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

Diagnosis: Parotid tumor.
Treatment hospital admission.
The insurer denied coverage for hospital admission.
The denial is upheld.

This patient has a parotid mass. The patient underwent surgery. The surgical diagnosis was left parotidectomy with biopsy of parotid tumor. Preoperatively the American Society of Anesthesiology (ASA) score equaled 1 and there were no indications of preoperative, operative or postoperative risk factors. The total anesthesia time was 4 hours 13 minutes, and the operative time was 3 hours and 23 minutes. 

His postoperative course was documented as uneventful. The patient is experiencing no pain and had a Aldrete score = 10. He maintained the status until discharge.

The Milliman care guidelines (MCG) inpatient and surgical care lists numerous reasons for prolonged inpatient stay. This includes:

"extensive(e.g, dissection far beyond usual scope procedure) or prolonged(e.g., well beyond usual timeframe) surgery.1"

The patient's total anesthesia time was 4 hours and 13 minutes which is within the expected time for this resection of the parotid gland to preserve the facial nerve. The nursing intraoperative report documents that four specimens were sent to surgical pathology. Two of this required frozen section. The need for two frozen sections and the time that it takes to have this processed and reported would substantially increase the operative time. This information would be congruent in evaluating the total operative in anesthesia time for the parotidectomy is being within the usual timeframe for this operative procedure. 

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. The patient had no postoperative complications and from the information available none of the MCG inpatient and surgical care criteria for admission were met.

The denial of coverage for hospital should be upheld as there were no conditions which would indicate that ambulatory care could not have been provided.

Based on the above, the medical necessity for the hospital admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Unstable Angina

Treatment: Hospital admission

The insurer denied coverage for hospital admission.

The denial is overturned.

The patient has a history of dyslipidemia, hypertension, pancreatitis, coronary artery disease (CAD) based on coronary computed tomography (CT) angiography as an outpatient and prior COVID (coronavirus) infection. The patient had been complaining of intermittent chest pain for several weeks prior to admission. He had a coronary CT angiogram as an outpatient which showed disease in the right coronary artery (RCA) and the left anterior descending artery (LAD). He was scheduled for elective intervention. However, he presented to the emergency department (ED) with chest pain. Prior to arrival, he took 325 milligrams (mg) of aspirin and nitroglycerin twice without relief. Physical examination in ED was unremarkable. Electrocardiography (ECG) showed evidence of inferolateral wall ischemia on the initial ECG. Initial troponin was normal. He was admitted with the diagnosis of unstable angina.

The patient underwent a cardiac catheterization with successful placement of drug-eluting stents in the RCA and the LAD. The patient was monitored uneventfully overnight and discharged.

The patient required inpatient care. This patient could not have been treated as an outpatient. The patient presented with chest pain with acute changes on ECG consistent with acute coronary syndrome (ACS). It was proper to monitor the patient and perform urgent diagnostic cardiac catheterization followed by coronary intervention. In view of the high probability of ischemic origin to the pain, careful monitoring on an inpatient unit was appropriate. After coronary intervention, it was appropriate to monitor the patient for at least 12-24 hours prior to discharge. Thus, the inpatient care period was appropriate based on the patient's presenting situation and the finding of multi-vessel disease warranting intervention.

In view of a diagnosis of ACS, hospital admission is accepted as standard treatment. The health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.

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

Diagnosis: Epistaxis

Treatment: Full hospital admission

The insurer denied coverage for full hospital admission.

The denial is upheld.

The patient is an adult female with a past medical history of chronic rhinitis, status-post balloon sinuplasty 1 month prior to admission. The patient presented to the Emergency Department (ED) with 5 days of intermittent epistaxis. The patient was packed and she bled through the packing. The patient had the packing replaced and she re-bled through the packing. She went to another ED and was admitted for an endoscopy procedure although they were unable to find the source of bleed. Overnight the patient had 2 episodes of bleeding with new packing placed. Her hemoglobin dropped overnight from 10.6 to 9.1. The patient left the hospital and went to another ED who removed the packing and sprayed Afrin. She had no active bleeding since that time but presented to the current facility to be evaluated by Ear, Nose and Throat (ENT) services. The patient reported fatigue, lightheadedness, and generalized weakness. She was sent for discharge but began bleeding again. Per the ENT, the patient was to be kept until the following morning. The patient underwent a computed tomography angiography (CTA) to evaluate for active arterial bleed. She was taken to the Operating Room (OR) and underwent an embolization procedure. The patient was subsequently discharged in stable condition.

This patient would have been appropriate for observation status after the embolization. She did not require extended observation and was not noted to have recurrent, severe epistaxis with a drop in her hemoglobin and hematocrit to support the need for full hospital admission. 

The health care plan acted reasonably, with sound medical judgment, and in the best interest of the patient. 

The full hospital admission is not considered medically necessary for this patient. 

The insurer's denial of coverage for the full hospital admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multiple Sclerosis

Treatment Kesimpta

The insurer denied coverage for Kesimpta

The denial is overturned.

This case involves a patient diagnosed with relapsing remitting multiple sclerosis who has been recommended to utilize the requested medication.  The recommendation was made for the patient to utilize the requested Kesimpta (ofatumumab) as Aubagio (terflunomide) is a pregnancy category X (possible fetal abnormalities) medication that can pass through semen.  Given the patient is a man of childbearing age he should not utilize the above medication.  The physician also indicated Kesimpta has been shown to be superior to Aubagio.  

Hauser et al. in a randomized trial showed that "Among patients with multiple sclerosis, ofatumumab was associated with lower annualized relapse rates than teriflunomide." The documentation indicated the patient has previously trialed Ocrevus infusions however had a severe reaction.  He was seen complaining of tingling in his legs.  He was initially seen after developing a fever with dizziness and loss of consciousness.  After months he had a change in sensation with bowel movements and leg numbness.  He was admitted with a magnetic resonance imaging (MRI) showing an enhancing lesion at the T7 (thoracic) level with other non-enhancing brain lesions.  A cerebral spinal fluid (CSF) test did have an elevated immunoglobulin (IgG) index.  The documentation indicated at the time of presentation he had ongoing tingling in his legs that exacerbated with walking.  The physical examination revealed he was well-appearing in no acute distress.  The physician indicated he has relapsing remitting multiple sclerosis based on clinical events.  There was recommendation made to switch to kesimpta due to the prior response to Ocrevus.

The patient has a clinical history of multiple sclerosis who has a severe form of the disease as evidenced by lesions involving the spinal cord which would be consistent with an aggressive form of the disease with high propensity for gait dysfunction and disability. Immune modulating agents such as Ocrevus and Kesimpta are reserved for patients who have a more aggressive form of the disease. Kesimpta in clinical trials has demonstrated efficacy in severe, refractory forms of the disease with improved control of the disease, improved imaging characteristics on MRI, and a reduced trend towards disability. Given the severe, aggressive form of multiple sclerosis the patient has, the use of Kesimpta is warranted, within standard of care and medically necessary. 

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

The insurer's denial of coverage for Kesimpta for the treatment of multiple sclerosis is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma, hypertension, hypothyroidism, and peripheral neuropathy

Treatment admission to a Skilled Nursing Facility for subacute rehabilitation services

The insurer denied coverage for admission to a Skilled Nursing Facility for subacute rehabilitation services

The denial is upheld

This is the case of an adult male patient with chronic medical problems including asthma, hypertension, hypothyroidism, and peripheral neuropathy. He was admitted to the hospital for evaluation and treatment of progressive weakness, altered mental status and weight loss over the past several months. Under review is the medical necessity for requested admission to a skilled nursing facility (SNF) for subacute rehabilitation services.

Based on the clinical records made available for review, the patient is not an appropriate candidate for subacute rehabilitation at a SNF (1, 2, 3). His reported symptoms have gradually progressed over the past year. The patient lives at home under the care of his spouse and home health aide. He has been in the hospital for well over a month.  Of particular note is the limited physical and occupational therapy services provided; specifically, while awaiting SNF placement. Only one week of occupational and physical therapy notes made available for review, respectively, documenting a level of function at essentially the minimal assistance level. Subsequent physical and occupational therapy notes were not included for review. Given the chronic nature of his condition and pre-hospital level of care; returning home under the care of spouse and home health aide with home physical therapy is the most appropriate level of care for this patient at this time.  

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.  (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations.  All decisions are evidence-based).

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, admission to a SNF for subacute rehabilitation services is not medically necessary.

The insurer's denial of coverage for the requested admission to a Skilled Nursing Facility for subacute rehabilitation services is upheld. Medical necessity is not substantiated
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Migraines

Treatment Ubrelvy (ubrogepant)

The insurer denied coverage for Ubrelvy (ubrogepant)

The denial is overturned

This case involves a patient who was seen for neurologic follow-up.  The documentation indicated she continues to have several headaches a month.  They are prolonged lasting an entire day and are associated with significant discomfort as well as photosensitivity and nausea/emesis.  She has received samples of Ubrelvy and finds this medication particularly helpful as abortive treatment.  She has had difficulty however filling her medication.  She has no significant findings on physical examination.  The patient has previously undergone imaging of the brain.  The physician indicated she should continue with Ubrelvy as an abortive medication given medications are somewhat limited given comorbidities.  The physician indicated they will avoid triptan medications given her history of basilar artery stenosis as well as concern for autoimmune vascular disease.  A letter indicated the patient was recommended to utilize the requested medication and is unable to utilize triptan medications due to basilar artery stenosis.

The submitted documentation indicated the patient was recommended to utilize the requested medication given she cannot utilize the formulary options as she has comorbidities that include basilar artery stenosis as well as concern for autoimmune vascular disease.  The current literature does indicate triptan use may be associated with serious adverse vascular events.  

Therefore, the formulary drug may cause the patient to have an adverse reaction and therefore she cannot trial at least 3 formulary medications.  The requested drug is likely to be more effective given the above.

The insurer's denial of coverage for Ubrelvy (ubrogepant) is overturned.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Erectile Dysfunction
Treatment: Caverject 20mcg KIT, Pre-service
The insurer denied the Caverject 20mcg KIT, Pre-service.
The denial is overturned. 

The patient is male with some major neurologic issues for which he is slowly recovering (request form states cauda equina syndrome) and obesity and hypertension. He has tried Viagra and Cialis with no significant success with some side effects. The patient does not wish to use vacuum device or have penile surgery. Caverject 20mcg is prescribed.

Yes, the health plan should cover the proposed treatment.

This patient was denied the Caverject 20mcg (micrograms) per the nonformulary medication exception - pharmacy 69, which indicates that the patient must have had serious side effects of drug failure from ALL formulary alternatives consistent with the drug class. Formulary alternatives include sildenafil, tadalafil and vardenafil. This patient has tried sildenafil (Viagra) and tadalafil (Cialis), both of which were noted to be ineffective and had some side effects. In addition to the cauda equina syndrome, this patient also has diabetes mellitus and hypertension, all of which contribute to erectile dysfunction. Although oral PDE-5 (phosphodiesterase-5) inhibitors have been reported to be successful in men with neurogenic erectile dysfunction, they tend to be young men without other contributing factors such as diabetes mellitus and hypertension. 

In one series tadalafil 10mg (milligrams) seemed to be more effective than sildenafil 50mg, although all PDE 5 (phosphodiesterase-5) inhibitors seem to be effective. For PDE 5 (phosphodiesterase-5) inhibitors to be effective nerve innervation must be present, patients with lesions below T10 (tenth thoracic vertebra), have a poor response to PDE 5 (phosphodiesterase-5) inhibitors and patients with complete lesions at S2-4 (sacral spinal nerve 2-4) experience the worst failure rate. This patient has cauda equina syndrome, which is lower than T10 (tenth thoracic vertebra) and in addition has diabetes and hypertension, which contribute to vascular factors in addition to the neurologic. As such, the likelihood of a third PDE 5 inhibitor working after 2 (including tadalafil) did not, is unlikely as supported in the literature. One study demonstrated that of those Neurogenic ED (erectile dysfunction) patients who failed oral PDE 5 (phosphodiesterase-5) inhibitors 76% responded to intracorporeal injection therapy. Adverse effects of Caverject include penile pain and prolonged erection. Prolonged erection is also a side effect of PDE 5 (phosphodiesterase-5) inhibitors.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Constipation

Treatment: coverage for Procedure Code 72195 - Magnetic Resonance Imaging (MRI) of the pelvis, without contrast (dye)

The insurer denied coverage for coverage for Procedure Code 72195 - Magnetic Resonance Imaging (MRI) of the pelvis, without contrast (dye)

The denial is upheld.

This is the case of an adult female with a past medical history of gastroesophageal reflux disease (GERD), first degree hemorrhoids, pelvic and perineal pain, constipation, retention of urine, and midline cystocele. The patient had a telephone consult with Gastroenterology and Internal Medicine specialist for follow-up on constipation. 

Up-To-Date has an article titled "Etiology and Evaluation of chronic constipation in adults." The article addresses the use of defecography. It states that "defecography is most helpful when looking for potential anatomic causes of symptoms or when findings of manometry are at variance with the balloon expulsion test." It also states that "defecography is operator dependent and has poor reliability." It should be used as an adjunct to manometric assessment. Tests such as magnetic resonance imaging (MRI) and dynamic MR-defecography "are expensive and have uncertain added clinical value compared to standard defecography."

The patient presented with constipation, decreased appetite and weight loss. An upper gastroenterology (GI) series with small bowel follow- through was normal. She has also developed left lower quadrant abdominal pain. A colonoscopy was negative except for hemorrhoids. A computed tomography (CT) scan of the abdomen and pelvis showed fecal retention. A lipase of 357 was found. The patient's doctor has advised further workup of the constipation with MRI-defecography.

Based on the review from up-to-date, the use of MRI-Defecography does not have clinical value in this case. The requested MRI of the pelvis without contrast is not medically necessary treatment for the patient's condition.

The healthcare plan acted reasonably and with sound medical judgment and in the best interest of the patient. 

The insurer's denial of coverage for Procedure Code 72195 - Magnetic Resonance Imaging (MRI) of the pelvis, without contrast (dye) is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion

Treatment braces and monthly visits

The insurer denied coverage for braces and monthly visits

The denial is upheld.

According to the documentation submitted, this is the case of a male patient who was evaluated for orthodontic treatment.

The patient has a malocclusion. To determine the severity of the malocclusion a Handicapping Labiolingual Deviation (HDL) index is utilized. To support the need for braces one needs to have an automatic qualifier or reach a score of 26.

The provider states that the patient automatically qualifies as there are impacted anterior teeth. The documentation shows that the upper cuspids have inadequate space for eruption but are not impacted but erupting to the facial.

The insurance review indicated that the HLD score is 19. This reviewer concurs with a score of 19 which is below the threshold for approval. Therefore, as the HLD is below 26, the guidelines for braces and monthly visits were not met. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for braces and monthly visits is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Thigh pain
Treatment: 93925 - Duplex scan, a special kind of picture of the lower extremity arteries (legs), Pre-service
The insurer denied the 93925 - Duplex scan, a special kind of picture of the lower extremity arteries (legs), Pre-service
The denial is overturned. 

The patient is a female with complaints of thigh pain while walking. She has a history of deep vein thrombosis (DVT), smoking, pulmonary hypertension, inferior vena cava (IVC) filter, and morbid obesity. She has mildly depressed left ventricular (LV) function and heart failure with reduced ejection fraction (HFrEF).

Based on the patient's symptoms a duplex scan, (93925 - duplex scan, a special kind of picture of the lower extremity arteries [legs]) was ordered. It did indicate an abnormal ankle-brachial index (ABI).  The ankle-brachial index showed mild distal ankle popliteal disease. Her ankle-brachial index was 0.91, bilaterally.

Yes, the proposed 93925 - duplex scan was medically necessary.
In a patient with these risk factors, in particular smoking and heart failure, it is appropriate to evaluate for peripheral artery disease causing low extremity symptoms. The least invasive and most valued procedure would be a Doppler examination to look for obstructive arterial disease.  If result were negative, then it is unlikely that peripheral artery disease is the cause of her symptoms.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Crohn's disease.

Treatment: Apriso (brand).

The insurer is denied coverage for Apriso (brand).

The denial is upheld. 

This male patient has a history of Crohn's disease.

The American College of Gastroenterology has published a clinical guideline "Management of Crohn's Disease in Adults" (American Journal of Gastroenterology April 2018- vol 113 pages 481-517). For mild disease, sulfasalazinc has been shown to be effective. Oral mesalamine has not been consistently shown to be effective in either inducing remission or achieving mucosal healing. "Oral mesalamine has not consistently been demonstrated to be effective compared with placebo for induction of remission and achieving mucosal healing in patients with active Crohn's disease and should not be used to treat patients with active Crohn's disease (strong recommendation, moderate level of evidence)."  Budesonide is also a recommended treatment. 
"Controlled ileal release budesonide at a dose of 9 mg once daily is effective and should be used for induction of symptomatic remission for patients with mild-to-moderate ileocecal Crohn's disease (strong recommendation, low level of evidence)."

This patient has Crohn's disease and has remained with symptoms. Mesalamine is a treatment but is often not effective for Crohn's Disease. There is no recommendation that Apriso is more effective than generic mesalamine. If the patient is doing poorly on mesalamine, there are other treatment options available. The Formulary option is not likely to cause an adverse reaction. The formulary drug has been reported to be less effective than the brand name. However, there is no scientific evidence that Apriso is more effective than generic mesalamine for Crohn's disease. The requested drug would not be more effective than the formulary.

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the Apriso (brand)  is upheld.  The medical necessity is not substantiated.