Persius/hicric huggingface dataset:
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lymphedema in the Legs
Treatment: Compression Stockings
The proposed treatment of compression stockings is deemed medically necessary. 

This is a male with a history of chronic lower extremity lymphedema since childhood. He has undergone extensive evaluations with numerous Vascular Specialists. The only medical treatment which has been found to be efficacious and useful for the patient is specialty lymphatic compression socks, knee high, which are custom fitted by a stocking specialist. For these reasons, the proposed treatment of compression stockings is deemed medically necessary for improved control of this condition.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cataract and open angle glaucoma

Treatment: Cataract surgery

The insurer denied coverage for cataract surgery. The denial was reversed.

This patient is a male diagnosed with primary open angle glaucoma and cataracts.  The clinical note indicated that the patient was having trouble driving at night especially on the left side.  This has worsened since the last visit.  The right eye was doing well following surgery.  The patient underwent a right eye extracapsular cataract extraction to the right eye with an intraocular lens implant and insertion of Cypass and the same to the left eye.

The medical literature indicates that treatment of cataracts includes surgical removal and replacement of the opacified lens from the eye in order to restore transparency of the visual axis.  Surgery is indicated if symptoms from the cataract interfere with the patient's ability to meet his or her needs of daily living.  The medical literature notes that the implantation of AcrySof toric intra ocular lens (IOL) and Hoya toric IOL is an effective choice to correct preexisting corneal astigmatism in cataract surgery.  This patient has a cataract and the treatment for a cataract is surgery.  A toric IOL is a good choice for someone with a cataract and a lot of corneal astigmatism.  Therefore, the requested cataract surgery (CPT code V2787 - Astigmatism correcting function of intraocular lens) performed was medically necessary and the prior determination is reversed.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The carrier's denial of coverage for cataract surgery (CPT code V2787 - Astigmatism correcting function of intraocular lens) performed is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: left epididymo-orchitis

Treatment: Inpatient hospital services

The insurer denied coverage for inpatient hospital services. The denial was upheld.

This patient is a male with no past medical history who presented to the Emergency Department (ED) with a complaint of left testicular pain worsening over the prior three weeks, radiating from the left testicle up to the abdomen.  ED evaluation by ultrasound revealed left epididymo-orchitis.  The white blood cell count was 18,800, then 21,000.  The patient was admitted.  He was started on intravenous antibiotics and was seen by Urology.  The patient appeared to recover well with this treatment.  He was feeling better and discharged home with outpatient Urology follow-up.  

The insurer has denied coverage for the inpatient hospital services not medically necessary.  The insurer noted that the patient was stable even though he presented to the ED with pain and an infection.  There was no severe kidney problem or blood infection.  The insurer maintained that the necessary care could have been provided at a lower level of care.

Per MCG Health (23rd Edition) Urologic Disease GRG, the patient fails to meet clinical indications for admission to inpatient care under subsection "Scrotal, testicular or epididymal disorder requiring inpatient care,"  as there was no scrotal edema or infection, orchitis or epididymitis not manageable with emergency or observation level of care. The patient also fails to meet clinical indications for admission to inpatient care under subsection "Urologic infection requiring inpatient care" (abscess requiring drainage, Fournier's gangrene, and hemodynamic instability).

The healthcare plan acted reasonably and with sound medical judgment and in the best interest of the patient. The inpatient hospital services were not considered medically necessary for this patient.

The carrier's denial of coverage for the inpatient hospital services is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Migraines
 
Treatment: Aimovig treatment

The insurer denied Aimovig treatment. The denial was reversed.

This is a female with a history of chronic migraine headaches, post-traumatic stress disorder (PTSD), anxiety and depression, bipolar disorder, intractable migraines, neuropathy, schizophrenia and status migrainosus.  The patient has had headaches since her youth and had tried multiple medications including steroids, Valproic acid, Nortriptyline, and Topiramate as preventives without relief, and Fioricet, Imitrex tablets and injections as rescue medications without success. A recent Neurologist note stated the patient presented with ongoing status migrainosus. She had a recent Botox injection which had helped, but it was not enough to allow her to enjoy a positive quality of life.  The patient responded well in the past to intramuscular Toradol, but Toradol is contraindicated with concurrent non-steroidal anti-inflammatory drug (NSAID) use.  The patient received an injection of Toradol in the office to break her current episode of status migrainosus, to be followed by a 5 day course of oral Toradol, while holding all other NSAIDs. She was to return for another injection of Botox, and wished to appeal for Aimovig. 

Aimovig is approved by the FDA for migraine.  FDA prescribing information does not mention any concomitant medication such as Botox as being a contraindication for Aimovig, or any other risks for drug interactions.  There does not appear to be any peer-reviewed literature specifically addressing the combination of Botox and Aimovig.  However, current clinical practice is to add a CGRP drug such as Aimovig to a migraine patient's current anti-migraine regiment. Aimovig injection for treatment of Migraine headache is medically necessary.  

This patient has intractable migraine.  Other medications have been ineffective.  Botox was incompletely effective.  The carrier's denial of coverage for Aimovig 140 mg/ml SC SOAJ is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

This patient is a male who is status post laparotomy for resection of a sarcoma.  He developed an upper abdominal ventral incisional hernia and underwent elective open repair of the ventral hernia on 12/20/18.  Comorbid health conditions included atrial fibrillation, hypertension, hyperlipidemia, GERD, hypothyroidism, and anxiety.  The operative dictation describes a robotic assisted ventral incisional hernia repair with mesh.  The hernia was 10-centimeter (cm) x 15-cm in size.  The anesthetic record documents hemodynamic stability during the operation.
Following surgery the patient was clinically stable, his diet was tolerated, and pain medications were converted to oral medications.  The following day the patient reported some soreness and nausea.  Vital signs were normal.  He was discharged from the hospital.
The health plan's determination is upheld.

This patient presented for elective ventral hernia repair.  The operation and post-surgical recovery period was uncomplicated.  The records support that inpatient care and treatment was not medically necessary.  This patient required provision of parenteral analgesic as is documented in the medical record.  However, the care and treatment provided could have reasonably been provided at a lower level of care status.  This patient did not require inpatient admission as provision of intravenous (IV) fluid, pain medications, and antiemetics could have been appropriately provided with a lower level of care status.  This level of care would have provided for regular clinical assessment, follow up assessment, and provision of the prescribed IV medications and fluid.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Schizophrenia, unspecified type
Treatment: Continued Acute Inpatient Mental Health Treatment for Adults 

The Continued Acute Inpatient Mental Health Treatment for Adults is medically necessary for this patient, in part. 

Specifically, the Continued Acute Inpatient Mental Health Treatment is medically necessary for an additional 16 days. Any dates of service beyond that point would require additional review and is not considered medically necessary at this time.

The patient's continued hospital stay for treatment of an exacerbation of a psychotic disorder (schizophrenia) does require the continued inpatient level services, structure, and monitoring. The patient's severity of symptoms, and inability to effectively participate in treatment at a lower level of care, persistent functional impairment, and treatment issues related to persistent symptoms of acute psychosis were clinical factors and treatment dimensions that necessitated continued acute inpatient hospital care, structure, and monitoring, as proposed. The medication treatment and safety monitoring, the support of functioning and the continued application of multimodal treatments, as well as assurance of medication adherence, were factors that did warrant the continued inpatient level treatment in view of the persistent symptoms of bizarre thought content and paranoid thinking; the patient could not have been effectively managed at a lower level of care. 

The patient's admission and continued treatment is reasonable and in the best interest of the patient. Any dates of service beyond that date require additional review. 

The patient had severe symptoms of psychosis complicated by a decline in functioning and safety issues together with a high risk for medication non-adherence due to persistent symptoms of psychosis. He had deteriorated to the point that he was a safety risk with disorganized and perceptual disturbance/paranoid thinking, and, poor insight and impaired judgment that persisted throughout his stay. Additionally, outpatient treatment had failed to prevent a relapse. Again, the patient could not have been safely or effectively managed at a lower level of care or in a less restrictive environment. The continued stay was necessary to develop a safe and clinically appropriate discharge plan and disposition that would effectively support his continued treatment.

These answers are consistent with the scientific literature and practice guideline, referenced below, as well as with instruction for this NY State mandated review and prevailing standards of medical practice.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Ulcerative Colitis 

Treatment: Entyvio

The insurer denied the Entyvio. The denial was reversed.   

This is a young female patient with a history of chronic idiopathic ulcerative colitis, Tenesmus and Factor V Leiden Deficiency. She was having episodes of abdominal pain and rectal bleeding. A calprotectin level was markedly elevated. She had multiple failed responses to other treatment medications. 
Milliman Care Guidelines (MCG) A-0731 evaluates vedolizumab for ulcerative colitis. An indication is having active disease with an inadequate response to steroids. This patient met the criteria of this guideline.

The American Journal of Gastroenterology March 2019 Volume 114 p 384-413 published an American College of Gastroenterology (ACG) guideline titled "Ulcerative Colitis in Adults." Among the recommendations given were that vedolizumab is recommended for induction of remission in patients with moderate to severe ulcerative colitis. It is also advised that if infliximab is used, combination therapy with a thiopurine should be given.

Vedolizumab is recommended as initial biologic therapy by both MCG and the ACG guideline. The patient has a concern that if she were to take infliximab, then an immunomodulator would be necessary. She does not want to take the risk of developing lymphoma. It is also correct as the physician has pointed out that a presentation at the European Crohn's and Colitis organization has shown in the VARSITY trial that Entyvio was superior to Humira in achieving clinical remission. The use of Entyvio as an initial biologic agent is well supported in the medical literature.

Based on the above, the medical necessity for Entyvio is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma
Treatment: Inpatient admission
The Inpatient admission was not medically necessary.

The patient is a female with history of asthma. She presented with worsening shortness of breath, found to be in asthma exacerbation. The patient received noninvasive ventilation in the emergency room, as well as frequent nebulizations and IV steroids. The patient was admitted to acute in hospital level of care for asthma exacerbation management.

The patient's asthma exacerbation improved significantly with emergency room care. The patient was hemodynamically stable, able to speak in full sentences. The patient was ambulating without assistance and did not require supplemental oxygen. The patient was discharged home after one day length of stay. The acute in hospital level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Exacerbation of Chronic Obstructive Pulmonary Disease and Asthma
 
Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld.

This is a female patient who presented to the Emergency Department with complaints of shortness of breath, wheezing, and a cough with greenish sputum along with some pleuritic pain. She has a history of brochial asthma, intubated 9 times in the past, chronic obstructive pulmonary disease, Mycobacterium Avium-Intracellulare (MAI), systemic lupus erythematosus (SLE), hypertension, diabetes mellitus, and seizure disorder and was immunocompromised. The patient had been hospitalized two weeks prior to this admission for a collapsed lung; a chest tube had been placed. On physical exam it was reported that the patient was in mild distress. She had bilateral wheezes. A chest x-ray was performed which was negative. She was started in intravenous steroids and bronchodilators. Oxygen therapy was in place. She was given intramuscular epinephrine and Terbutaline. She remained afebrile was discharged when medically stable. 

The patient remained stable after admission.  She was afebrile and hemodynamically stable.  Labs were stable and the patient was not hypoxic.  The patient did not need acute inpatient hospitalization.  She could have been placed in Observation status while diagnostic testing and treatment were initiated.  By the day after admission the patient had improved.  She was afebrile and hemodynamically stable.  There were no complaints. The patient was stable to be switched to oral steroids.  The patient could have been discharged on oral steroids and bronchodilators with close follow-up in an outpatient setting.  The prior denial is upheld.

The carrier's denial of coverage for the inpatient admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

The patient is a male with a history of diabetes.  He presented to the emergency room with chest pain, shortness of breath, and palpitations.  The physical exam and labs were non-contributory.  The electrocardiogram (EKG) was negative for ischemia.  The patient was admitted for further treatment and evaluation.  He was treated with his usual oral medications.  Monitoring and serial markers were unremarkable, and he was discharged.
The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld.

The requested inpatient stay was not medically necessary for this patient.  Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary.  Upon presentation, there was no objective evidence on physical exam, labs, or EKG of an imminently life-threatening cause of the patient's complaints.  The services provided - EKG monitoring, serial markers, oral medications - were not at the acute inpatient level of intensity.  The patient's care could have been safely and efficiently provided at a lesser level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Depression, Bipolar disorder
Issue under review: Continued inpatient admission

Determination:
The Continued inpatient admission was not medically necessary.

The patient's diagnoses included depression and bipolar disorder in addition to polysubstance abuse involving alcohol, marijuana, Xanax, and Percocet. His therapist sent him by ambulance to the emergency department after the patient expressed suicidal thoughts in the context of worsening depression and noncompliance with psychiatric medications.

From the time of admission and throughout the patient's stay, he consistently denied suicidality. At no time was there evidence of psychosis, behavioral dyscontrol, or other problems which would warrant continued acute inpatient care. The patient tolerated his medications without difficulties, and medication management could have been done safely and effectively in a less intensive setting. Therefore, continued stay for the dates of services under review was not medically necessary, and the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cross-bite of anterior teeth with clinical attachment loss and recession
 
Treatment: Orthodontic treatment

The insurer denied the orthodontic treatment. The denial was reversed.

This patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to Class III malocclusion, maxillary and mandibular crowding, and anterior cross-bite with gingival attachment loss (canines). The orthodontist completed the Handicapping Labio-Lingual Deviation (HLD) index and has chosen the automatically qualifying condition of cross-bite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. 

To assess for the medical/dental necessity for orthodontic care, New York State requires the use of the Handicapping Labio-Lingual Deviation Index Report (HLD). This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of the initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care, a total score of 26 points is necessary. 

In this case, the treating orthodontist claims an automatic qualifying condition of cross-bite of individual anterior teeth when clinical attachment loss and recession of the gingival margin is present. This reviewer finds that this automatically qualifying condition criterion is met and supports comprehensive orthodontic care. 

The Handicapping Labio-Lingual Index has been shown through scientific scrutiny in peer-reviewed journals to be a valid approach and a reliable determinant of need for orthodontic care.  As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.  

The braces were considered medically necessary for this patient. Based on the above, the medical necessity for Braces is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

The patient is a female with past medical history significant for peripheral artery disease (PAD), who presented to the emergency department with chief complaint of room spinning that was worse moving from lying to sitting and associated with gait imbalance.  She denied nausea, vomiting, chest pain, palpitations, focal neurologic deficits, falls, headache, fevers, chills, or other complaints.
On presentation to the emergency department, she was noted to have vital signs within normal limits.  Exam was otherwise significant for no neurologic deficits or other clear abnormalities.  Labs were notable for complete blood count (CBC), comprehensive metabolic panel (CMP), and troponin within normal limits.  Electrocardiogram (EKG) did not show evidence of acute ischemia or arrhythmia.  CT of the head showed no acute process.  Given concerns for benign positional vertigo versus cerebrovascular accident (CVA), the patient was subsequently placed in the hospital on inpatient status.  She was started on intravenous (IV) fluids, given meclizine, monitored on telemetry, and underwent CT-angiogram of the head and carotid ultrasound, which showed no evidence of significant stenosis or dissection.  The patient's symptoms were improving, and ultimately, she was felt to have peripheral vertigo and deemed stable for discharge.

The health plan's determination is upheld.

This patient presented with symptoms consistent with benign positional vertigo.  She did not have neurologic exam with focal deficits or imaging suggestive of CVA.  Her symptoms improved with IV fluids and meclizine, and she was able to be discharged within a reasonable time period of observation.  She did not have concomitant cardiac ischemia or other process complicating her course and requiring acute inpatient admission.  Acute inpatient admission was not medically necessary.  This patient presented with vertigo without other associated neurologic deficits, cardiac ischemia or arrhythmia, or infection.  Imaging was unremarkable.  Symptoms were consistent with likely benign paroxysmal positional vertigo (BPPV).  She improved quickly with treatment and did not have another process requiring care at the acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Acute cholecystitis
Treatment:  Inpatient stay 

Summary:
The inpatient admission was not medically necessary.

The patient is a female.  Her medical history included morbid obesity.  Her surgical history included laparoscopic gastric band.  She presented with a 48-hour history of right-upper-quadrant-abdominal pain and nausea. 
 
The patient was admitted at an acute inpatient level of care with a diagnosis of acute cholecystitis.  She was made nil per os [NPO], and provided with intravenous fluids, antibiotics, and analgesics.  She underwent laparoscopic cholecystectomy; surgery and recovery were uncomplicated. 

According to the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), "patients undergoing uncomplicated laparoscopic cholecystectomy for symptomatic cholelithiasis may be discharged home on the day of surgery" [SAGES].  Indeed, insofar as the patient did not demonstrate significant co-morbidities or physiologic derangements and insofar as surgery and recovery were uncomplicated, the patent could have been treated at a lower level of care, precluding the need for admission at an acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient presented with acute onset of vertigo that was position dependent, and she was suspected of having a TIA (transient ischemic attack) or stroke. Her work-up was negative, and her symptoms resolved within 24 hours. The diagnostic studies, clinical evaluation, treatment and monitoring could have safely and effectively been provided at a lower level of care.