Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Glaucoma. 
Treatment: Current Procedural Terminology (CPT) code 66174, transluminal dilation of aqueous outflow canal; without retention of device or stent. 

The insurer denied coverage for CPT code 66174, transluminal dilation of aqueous outflow canal; without retention of device or stent. 

The denial is overturned. 

The patient has a history of glaucoma and diabetes. This patient presented to the ophthalmologist's office for the evaluation of glaucoma. The patient has tried and failed conservative measures to treat glaucoma. He had laser therapy years ago. The patient had a transluminal dilation of aqueous outflow canal; without retention of device or stent recently. 

The peer-reviewed scientific literature does support a result in improvement outcome.
CPT code 66174 is a Category III code and is neither investigational nor experimental and by definition does not require Food and Drug Administration (FDA) approval.  CPT code 66174 has been around as a category I code for many years. It is a new device to perform the same procedure. It is a mainstream glaucoma procedure that has received final approval from US (United States) FDA for the Omni System for Canaloplasty (micro-catheterization and transluminal viscodilation) followed by Trabeculotomy, to reduce intraocular pressure in adults with primary open angle glaucoma. 

It is apparent that this patient was a good candidate for CPT 66174, having tried and failed at maximum topical medications and selective laser trabeculoplasty (SLT) laser procedure. 

CPT code 66174 is the best, safest and most appropriate treatment for this patient at this time. The adverse risks that are referenced to other surgical procedures are far greater than those considered in CPT 66174 procedure. 

The procedure performed on this patient, CPT 66174, is more beneficial, has less surgical risks and has a long history, clearly noted in the robust peer-reviewed scientific literature than any of the other more invasive glaucoma surgical procedures. 

It is consistent with the performed and dictated surgical procedure. The procedure, 66174, has abundant support in the peer-reviewed literature. It has in fact been performed over 5,000 cases a year on Medicare beneficiaries and a similar number on non-Medicare patients. CPT 66174 is a mainstream glaucoma procedure, considered as Standard of Care for glaucoma management and generally accepted as a societal standard. 

The carrier's denial of current procedural terminology (CPT) code 66174, transluminal dilation of aqueous outflow canal; without retention of device or stent performed should be overturned.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Plaque Psoriasis.
Treatment: Formulary exception for Taltz Autoinjector (2 pack) 80mg/ml (milligrams/milliliter).

The insurer denied the Formulary exception for Taltz Autoinjector (2 pack) 80mg/ml.  The denial is upheld. 

The patient is a male with severe palmoplantar psoriasis for whom Taltz is requested. He has failed topical and systemic steroids and Otezla. Formulary medications include: topical steroids (betamethasone, clobetasol, halobetasol, mometasone, triamcinolone, etc.), calcipotriene, methotrexate, cyclosporine, acitretin, Humira (requires prior authorization), Otezla (requires prior authorization), Stelara (requires prior authorization), Skyrizi (requires prior authorization), Tremfya (requires prior authorization), Enbrel (requires prior authorization), Cosentyx (requires prior authorization), Cimzia (requires prior authorization).

No, the health plan should not cover the Formulary exception for Taltz.

The patient has severe psoriasis, for which systemic therapy is indicated. In the era of biologic therapies for psoriasis, use of methotrexate, cyclosporine or acitretin is not the most appropriate first line treatment, because their long term safety and efficacy are inferior to biologic therapies.

Biologics show superior results to conventional systemic therapies (70% improvement versus 40% improvement) for the treatment of patients with moderate to severe psoriasis, as measured by decrease in simple-measure for assessing psoriasis activity (S-MAPA) (physician global assessment [PGA] multiplied by body surface area) at week 24. These results were observed despite the fact that patients on biologics had a greater baseline severity and had a greater number of previous treatments.

The plan offers multiple formulary options for biologic therapies that are on par with the efficacy and safety of Taltz, such as Skyrizi, Cosentyx, and Tremfya, none of which have a black box warning, and all of which have reported excellent efficacy data from clinical trials.

Based on the above data, the requested Taltz is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Creatinine clearance of 18.
Treatment: Kidney Transplant.
The insurer denied the Kidney Transplant.
The denial is overturned.

This patient is a male who is being evaluated for a possible renal transplant. This patient had a creatinine clearance of 18. This is a review for a renal transplant.

Yes, the proposed treatment is medically necessary.
According to Bunnapradist S, et al., O'Coonor K, et al., Tonelli M, et al., Azzi J, et al.Breda A, et al., Marroquin C, et al., MCG criteria Huang H, et al., and Rossi A, et al. the only absolute requirement to be United Network for Organ Sharing (UNOS) approved for listing for a cadaveric renal transplant in this country and to be considered as a candidate on the waiting list and accrue time towards deceased-donor kidney transplantation at any time after a diagnosis of irreversible kidney disease is made is to have documented a glomerular filtration rate (GFR) decreased to 20 milliliters per minute (mL/min) or to be on some form of dialysis which would be considered as the standard of care.  Glomerular filtration rate can be determined by any modality including direct measurement or using any of the available estimating equations including creatinine clearance. 

As per the submitted medical records, this patient has not started dialysis; he has a creatinine clearance documented of only 18. It is then up to each Renal Transplant Center to make sure that a given patient meets that Transplant Center's Set of Selection Criteria for renal transplant listing. This patient has had an extensive pre-transplant evaluation including cardiac evaluation, psychosocial/psychological evaluation, dental, infectious disease, tuberculosis (TB), standard cancer screening for age and sex including prostate specific antigen (PSA), and colonoscopy. This patient has been previously presented, reviewed, and approved by the local Renal Transplant Selection Committee, and there not any obvious contraindications for this patient to be United Network for Organ Sharing (UNOS) approved renal transplant listed at this time.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
A pre-transplant evaluation needs proper up-to-date documentation which has been supplied at this time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: acute cholecystitis
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned.

The patient is a male who presented with abdominal pain. He was well until 2 weeks prior to presentation when he developed abdominal pain and was seen in the emergency department. He was monitored overnight at that time, and was discharged home. Afterwards, he continued to complain of abdominal pain and developed vomiting. He returned to the hospital again and was admitted for 5 days. During that admission, an ultrasound revealed gallstones. He had a follow-up with the gastroenterology specialist for eosinophilic esophagitis, and was referred to pediatric surgery for possible cholecystectomy. However on the day of presentation, he again returned to the emergency department with persistent abdominal pain that was localized to the right upper quadrant, and vomiting.

Inpatient Hospital Admission was medically necessary for this patient.
This is a young boy who presented with significant abdominal pain and vomiting as a result of acute cholecystitis. He had been previously seen and hospitalized, but his pain had continued. He required hospital admission for prompt initiation of intravenous antibiotics, intravenous fluids, and pain control pending surgical intervention, with subsequent post operative care.
Cholecystectomy is the mainstay of treatment for acute calculous cholecystitis. Patients diagnosed with acute cholecystitis should be admitted to the hospital and provided with supportive care including intravenous hydration, pain control, and intravenous antibiotics. This patient required intravenous antibiotics and pain control as well as intravenous fluids in preparation for needed surgical intervention and for post-operative care.
The decision-making at the time of admission for this patient was consistent with his young age, the presence of significant and persistent abdominal pain with vomiting, and the need for parenteral therapies and intravenous fluids as well as prompt surgical intervention for acute cholecystitis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure
Treatment: Inpatient admission

The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female with chronic obstructive pulmonary disease (COPD), thyroid disease, hypertension and seizures who was admitted for possible seizures. With these episodes, she shakes and nearly passes out but is conscious. Episodes were occurring more frequently over the last two weeks.  The patient did not have fevers, chills, shortness of breath, or chest pains. The patient was admitted for 72 hour video electroencephalography (EEG).

No, the proposed inpatient admission was not medically necessary.
The inpatient hospital stay was not medically necessary. The patient did not meet Milliman Care Guidelines (MCG) guidelines for inpatient criteria as she was not in status epilepticus. The reason for admission was for a 72 hour video EEG. An EEG can be done on an ambulatory basis and if indicated, an epilepsy monitoring unit stay could be arranged. For these reasons, the inpatient hospitalization was not medically necessary.

Yes, the health plan acted reasonably, with sound medical judgement and in the best interest of the patient.
The patient did not have episodes that were consistent with status epilepticus and did not meet Milliman Care Guidelines (MCG) for inpatient admission. Furthermore, the EEG could have been done on an ambulatory basis or done at an epilepsy monitoring unit if indicated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tooth decay; fracture
Treatment: D2750 CROWN; PORC. TO GOLD D2950 CORE BUILDUP INCLUDING PINS

The insurer denied the D2750 CROWN; PORC. TO GOLD D2950 CORE BUILDUP INCLUDING PINS.
The denial is overturned.

The patient is a female. The request is for benefits for dental services for D2750 CROWN; PORC. TO GOLD ; D2950 CORE BUILDUP INCLUDING PINS on tooth #30.

Per the provider's dental clinical summary, the patient presents with an existing occlusal composite filling, heavy decay on the disto-occlusal decay involving the line angle and a vertical fracture on the distal of tooth #30.

The health plan denied the claim because they believed that the information reviewed does not show that the decay present cannot be restored with a routine filling.

The provider and patient are appealing because of the condition of the tooth and the steps taken to correct the defect.

Yes, the requested core build-up and crown on tooth #30 are medically necessary.
Based on the documentation submitted, tooth #30 exhibits substantial decay on the disto-occlusal aspect of the tooth in addition to the existing occlusal filling. Taking both of these contiguous areas into consideration, the area affected accounts for more than 50% of the tooth.

The standard of care calls for a build-up and complete coverage (crown) when 50% or more of the tooth structure is compromised. This coverage restores structure and function and protects against possibility of future fracture of the tooth.

The photos and the x-rays display the area compromised as 50% or more of the tooth structure on the disto-occlusal and lingual aspect of the tooth.

No, the health plan did not act reasonably with sound medical judgement and in the best interest of the patient.
If the patient does not have the option to have the optimal treatment of full coverage (crown), she runs the risk of having compromised function and the possibility of further fracturing the tooth and may eventually lead to loss of that tooth.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Idiopathic short stature (ISS)
Treatment: Norditropin

The insurer denied coverage for Norditropin.
The denial is upheld.

This patient is diagnosed with idiopathic short stature (ISS). This request is for Norditropin. As reported; she underwent puberty at an early age. The patient has central precocious puberty (CPP). Height velocity is reported to be 8.2 centimeters per year (cm/yr). Growth hormone (GH) stimulation test with clonidine and arginine peaked at 11.60. Her breasts and pubic hair were at tanner 3. Months ago, her bone age was 1 year and 7 months older than her chronological age (CA); more recently her bone age was 11 months older than her chronological age (CA). Her insulin-like growth factor binding protein (IGFBP) 3 was 4508; Insulin Like Growth Factor 1 (IGF1) was 354. Her recent weight and height were at +0.01 SDS (standard deviations score).

Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines  [4, [5, [6, [7, [8, [9]. Food and Drug Administration (FDA) approval for this indication is for "non-growth hormone-deficient short stature, defined by height SDS less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means."

The patient does not have a pretreatment height less than or equal to -2.25 SD (standard deviation). The patient therefore does not meet idiopathic short stature criteria. 

There are no studies showing safety or efficacy of growth patients with central
precocious puberty. The request does not meet any nationally accepted criteria for
use of growth hormone. The health plan acted reasonably with sound medical
judgment in the best interest of the patient.

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

Diagnosis: Total knee replacement
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is overturned.

This is a female with a history of osteoarthritis of the right knee, tendonitis, gastroesophageal reflux disease (GERD), and hypertension. She presented to the hospital for a right total knee replacement (TKR). The patient was admitted for postoperative care. Neurovascular and compartment checks were done. She was assessed by physical therapy (PT). Pain medication was given as ordered. The patient's condition improved, and she was discharged three days later. 

The medical record demonstrated ongoing problems after total knee replacement. The hospital course was complicated. The patient was unable to be mobilized without dizziness. She was seen on several occasions by rehabilitation staff who stated, "tolerated poorly". She was also reported to be "pallor in color". There were limitations to her ambulation where attempts were made to walk. She could not tolerate the treatment and had to be placed back into chair/bed.  She also had nausea and vomiting which required a Scopolamine patch. The records showed ongoing pain with visual analog scale (VAS) scores of 7-8. 

Based upon her inability to ambulate, nausea, dizziness and continued pains, additional hospitalization would thus be warranted. She would require the inpatient admission and length of stay that was provided. 

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

The inpatient admission is considered medically necessary for this patient.

The insurer's denial of coverage for the inpatient is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Possible Nipple Necrosis

Treatment: Inpatient stay

The insurer denied coverage for the inpatient stay

The denial is overturned

The patient is an adult female with past medical history significant for a recent mastopexy with breast augmentation surgery who presented to the emergency department with complaints of left breast pain, nipple discharge and fever.   
Vitals on presentation included: temperature 99.4, blood pressure (BP) 104/68, heart rate (HR) 112, respiratory rate (RR) 20, oxygen (O2) saturation 97 percent (%) on room air. Laboratory results included the following: white blood cell (WBC) 18.9, hemoglobin (Hgb) 10.6, hematocrit (Hct) 33.9, creatinine 0.7, glucose 89.  The patient was empirically started on intravenous (IV) antibiotics (Unasyn) for a possible breast abscess following a recent augmentation procedure. She underwent an incision and drainage procedure with implant removal. She tolerated the procedure well. Cultures remained negative. The patient remained afebrile, hemodynamically, and clinically stable. She was discharged to continue antibiotics as an outpatient.  

According to documentation, the patient presented with a breast wound infection and possible nipple necrosis. She had low-grade fever, was tachycardic with leukocytosis on laboratory findings. Moreover, emergent surgical intervention was required including removal of the infected implant. Based on above findings, hospital admission was medically necessary for administration of intravenous antibiotics and surgical intervention.

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 inpatient stay is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholelithiasis

Treatment inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is upheld

Per the submitted clinical documentation, this adult patient presented to the emergency department (ED) with a one day history of right upper quadrant abdominal pain. Vital signs in the ED were within normal limits. The patient was afebrile. An ultrasound demonstrated cholelithiasis without definite gallbladder wall thickening. The patient was scheduled for an elective cholecystectomy. Liver function tests were not performed. The patient underwent a laparoscopic cholecystectomy. There were no reported complications. The patient was discharged.

Acute cholecystitis and biliary complaints are a common inpatient diagnosis. Acute cholecystitis is also estimated to attribute to millions of ambulatory visits each year and is a leading cause of hospital admissions [1]. Studies have shown that ambulatory laparoscopic cholecystectomy is safe and avoids an overnight hospital stay [2, 4, 5]. Factors that contribute to admission after laparoscopic cholecystectomy include drain placement, conversion to open surgery, persistent abdominal pain, nausea, and vomiting [3]. In patients without abnormalities of the bile duct or abnormal liver function tests (elevated alkaline phosphatase and total bilirubin), ambulatory laparoscopic cholecystectomy is safe and feasible [5, 8]. A 50% increase in the liver function tests can be labelled as mild elevation and is considered negligible by many [9]. Ambulatory and/or outpatient laparoscopic cholecystectomies reduce hospital costs without compromising patient outcomes [6].

Peer-reviewed literature and MCG (Milliman Care Guideline) criteria indicate that inpatient admission was not necessary for this patient. Per the provided clinical documentation, an inpatient admission was not medically necessary. An observation stay would be more appropriate.

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

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

Diagnosis: Chronic Idiopathic Constipation. 
Treatment: Trulance (plecanatide). 

The insurer denied coverage for Trulance (plecanatide). 

The denial is overturned. 

The patient has chronic idiopathic constipation. The physician's letter states that she has tried both Linzess and Amitiza without achieving a benefit from these medications. She has also been on MiraLax 2-3 times a day. She has had success on Trulance. Her physician has advised not to go back to Amitiza since it did not work in the past. 

UpToDate has an article titled "Management of Chronic Constipation in Adults." The article discusses pharmacological therapy for severe constipation. An option for treatment is plecanatide. This drug has been approved by the FDA (Food and Drug Administration) for chronic idiopathic constipation. The safety and efficacy of plecanatide was evaluated in 2 placebo-controlled trials involving 2683 patients. Patients treated with plecanatide were more likely to experience improvement in the frequency of complete spontaneous bowel movements as compared to placebo. 

This patient has chronic idiopathic constipation and is responding to plecanatide. According to her physician, she has already failed the formulary drugs of Amitiza and Linzess. Therefore, it is likely that the formulary drugs will be ineffective. Since the patient is having a good response to plecanatide and has failed treatment with the formulary drugs, giving Trulance is likely to be more effective in treating this patient's condition. 

The insurer's denial of coverage for Formulary Exception for Trulance (plecanatide) is overturned.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Cerebral Infarction
Treatment: Formulary exception for Eliquis
The insurer denied the formulary exception for Eliquis.
The denial is upheld.

The patient is a male with a history of stroke. He tried and failed ticagrelor. He has been treated with apixaban. The provider has requested continuation of treatment. This was denied coverage as he has not tried and failed the preferred agent, rivaroxaban.

No, the health plan should not cover the formulary exception for Eliquis.

There is no documented reason the patient cannot be treated with the preferred formulary agent. Rivaroxaban is considered appropriate oral anticoagulation for secondary stroke prevention. There are no high quality clinical trials or standard of care guidelines supporting the preferential use or superiority of apixaban relative to the preferred rivaroxaban in this clinical context.