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

Diagnosis: Dental Problems.
Treatment: Emergency Care/Emergency Room.
The insurer denied: Emergency room services.
The denial is: Overturned in whole.

The patient is a female who presented to the hospital with the complaint of 9 out of 10 dental pain and facial swelling. Her vital signs were all normal, with a blood pressure of 124/84, pulse of 93, respiratory rate of 16, and temperature of 98.0 degrees Fahrenheit. Her pulse oximetry reading on room air was also normal at 98%. She was seen by the emergency room physician who documented that the patient was having gradually worsening left upper premolar pain with some mild facial swelling. She denied any fever, sinus symptoms, chest pain, shortness of breath, ear pain or visual disturbance. She had no neurological symptoms either. She denied any past medical history. He reported that she appeared alert and awake. Her dental exam was significant for left upper premolar tenderness to percussion but negative for any abscess or fluctuance. She had no submandibular or submental neck swelling, tongue elevation, or exudates. Her neck was nontender and without crepitus. She received 600 milligrams (mg) of ibuprofen and 300 mg of clindamycin orally. She was discharged home with a prescription for clindamycin and hydrocodone-acetaminophen 5-325 and advised to follow-up with a dentist in the morning. The subject under review is the medical necessity for the emergency room services.

The health plan's determination is overturned in whole.

The question at hand is whether the emergency room services are medically necessary for this patient and the answer is yes. Failure to treat this dental infection could have resulted in significant morbidity and mortality. The patient presented with severe 9 out of 10 dental pain and facial swelling, which is indicative of infection. While her exam did not reveal abscess, facial cellulitis, or fever, left untreated, her dental infection could have led to significant morbidity, and even mortality. Complications could include deep head and neck space infection/abscess, as well as hematogenous spread of bacteria with seeding of native heart valves and subsequent endocarditis (1). Her condition required prompt treatment with antibiotics to prevent the complications listed above, and subsequent dental follow up for definitive care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Angiogram and angioplasty
Treatment: Inpatient admission
The insurer denied the inpatient admission. 
The denial is upheld. 

No, the Inpatient admission was not medically necessary.

The patient is a male. He has a past medical history significant for HTN (hypertension), DL (dyslipidemia), PAD (peripheral arterial disease) with claudication. He presented to the catheterization lab for an elective peripheral angiogram and angioplasty of the right iliac CTO (total occlusion). Ipsilateral access was obtained and PTA (percutaneous transluminal angioplasty) of the proximal right iliac lesion with stent placement was performed. 

The patient was hemodynamically stable. There was no evidence of bleeding, infection or shock. A bruit was auscultated over the right femoral access site and a Doppler ultrasound study was obtained, which revealed no evidence of pseudoaneurysm. The patient was observed post procedure and was discharged home with a plan for outpatient follow-up.

This patient was admitted for an elective peripheral angiography, and an uncomplicated PTA or right common iliac artery was performed. There were no peri-procedural complications documented. The standard of care for patients post elective PTA is observation. Usually, no acute inpatient admission is required, unless there is evidence of a bleeding or thrombotic complication, hemodynamic instability or infection. Although there was a concern of a bruit over the right femoral access site, a Doppler ultrasound was performed, ruling out a pseudoaneurysm. There was no fever. There was no evidence of hemodynamic instability. There was no report of uncontrollable pain. Therefore, the services provided did not require acute inpatient stay and could have been rendered at a lower level of care setting.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Uterine Fibroid
Treatment: Inpatient admission
The insurer is denied coverage for inpatient admission. 
The denial is partially overturned.

This is a female patient with a history of symptomatic fibroid uterus. She was admitted to the hospital for a scheduled laparoscopic hysterectomy, bilateral salpingo-oophorectomy and cystoscopy. She underwent the procedure and experienced a blood loss of 800cc.  Patient's hematocrit dropped from 33 to 26.7 Hct to 22.6 to 22.8.
She was ambulating, tolerating regular diet and voiding without difficulty. She remained afebrile with normal vital signs. She received a dose of IV iron. She was medically stable and was discharged.

There are many ways of doing a hysterectomy. The trend has been towards less invasive procedures. Conventional and robotic laparoscopy share similar advantages over laparotomy, including decreased morbidity, rapid recovery, and improved aesthetics of incisions. Laparoscopic hysterectomies are outpatient procedures unless a complication arises. Admission becomes necessary if the patient is febrile, hypotensive, bleeding, has difficulty breathing, or the severity of the pain is such that admission is necessary.

According to MCG, Inpatient and Surgical Care, Laparoscopic Hysterectomy, a laparoscopic hysterectomy is an ambulatory procedure. Inpatient stay may be needed for:
1) Surgical complications (bladder ureter or bowel injury or hemorrhage)
2) Conversion to abdominal hysterectomy
3) Complex surgery (staging of endometrial cancer)
4) Wound complications
5) Comorbidities
This patient did not have any of these criteria. Her procedure was uncomplicated. There was no evidence of any injury to other organs. Post operatively, the patient was stable. However there was concern about the significant drop in her hematocrit (as low as 22.6). Even though the patient was asymptomatic for anemia and was ambulating, admission for observation and iron infusion was necessary. However the patient has received her iron therapy. There was no evidence of more bleeding and the patient could have been discharged that day.

Based on above, the inpatient hospital admission was medically necessary. However continuous admission was not.  The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient with regard to the admission, did with regard to the continued stay.

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

Diagnosis:  Tachycardia, Fever.
Treatment:  Inpatient admission.

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

The is a female patient who presented to the Emergency Room (ER) with complaints of a productive cough, post-tussive vomiting, and fever of 105 two days prior to presentation.  She also had complaints of right ear pain and headache.  It was reported that the patient had recently returned from a 4-month trip to Bangladesh where she had been sick with a right-sided pneumonia and fever requiring hospitalization.  In the ER the patient was noted to have tachycardia, a bulging tympanic membrane with a discharge in the ear canal.  There was some crackles audible upon the examination of her lung.  The patient was treated with Tylenol, intravenous (IV) fluids and an antibiotic.  The patient's blood testing showed an elevated white blood count of 21, an ESR of 31 and a low HCO3 of 19.  The patient's chest x-ray was normal.  Infectious Disease was consulted.  The patient's quantiferon Gold TB assay was negative.  The patient's electrocardiogram (EKG) was unremarkable except for tachycardia.  The patient was admitted to the hospital to rule out possible endocarditis.  Her medical treatment included intravenous (IV) fluids, IV antibiotics, cardiac monitoring, and Tylenol.  The patient was medically stable and discharged home the next day.

Based on the review of the medical record and the literature, the patient was treated appropriately in the Emergency Room (ER) and was diagnosed with an acute otitis media and a clinical pneumonia.  The patient did not have persistent fever since the initial temperature of 105 degree fever two days prior to this ER visit, and the patient was not in any respiratory distress.  Although the history of a prolonged illness during her travel to Bangladesh was important information in the medical history, this patient's clinical condition when seen in the ER did not require hospitalization.  The patient could have been treated with an oral antibiotic to treat her ear infection and a clinical pneumonia, and the patient could have followed up with the pediatrician in 24 - 48 hours as outpatient.  The clinical condition of this patient did not support the need for intravenous (IV) antibiotics.  The patient could have been discharged safely on oral antibiotics with appropriate outpatient follow up.  Thus, inpatient admission was not medically necessary for this patient.

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

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

Diagnosis:  Neck Pain.
Treatment:  Magnetic Resonance Imaging (MR).

The insurer is denied coverage for Magnetic Resonance Imaging (MRI).  The denial is upheld. 

This is a male patient who was evaluated by his physician for complaints of neck pain.  He reported clicking, cracking and spasms.  The progression was worsening with a visual analog scale (VAS) score of 9/10.  His physical examination reported supple neck and no focal deficits.  A magnetic resonance imaging (MRI) of the lumbar spine was performed that showed diffuse bulge measuring 0.2 cm at L4-L5 and diffuse bulge measuring 0.3 cm at L5-S1, with no evidence of central spinal canal or neural foraminal stenosis.  Trigger point injections were also provided.

MRI is of benefit if additional information assists in establishing a diagnosis.  The scientific literature describes MRI should be recommended if conservative treatment has not been beneficial. The diagnosis can alter the decision, prognosis and plan of care.  The necessity for more invasive procedures (surgical treatment) can be assessed.

The performance of the MRI should have an impact on a patient's treatment regimen.  If diagnostic tests are not clinically useful, they are not medically necessary.

If imaging is considered necessary as per Up to Date, cervical spine AP and lateral views can be performed.  "If cervical spine radiography is normal or shows only for age-appropriate degenerative changes and the clinical evaluation does not reveal an appropriate indication for MRI, no further imaging is necessary."

The medical record and appeal correspondence do not report evidence of conservative
treatment. The patient did not receive bracing, or therapy.  He did not have evidence of "red flags".  There were no focal findings on physical examination.  The facts were he was evaluated and the study ordered.  No X-ray was completed either.  These findings do not substantiate the necessity for an MRI to cervical spine at this time.

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

The medical necessity for Magnetic Resonance Imaging (MR) of the neck without contrast is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Concussion
Treatment: Inpatient admission
The insurer is denied coverage for the inpatient admission.
The denial is upheld.

This is a male patient with a history of hypertension and hyperlipidemia. The patient presented to the Emergency Department (ED) after sustaining a fall off of a six step ladder. He reported not hitting his head as per his ring video. His presenting complaints were right arm and right shoulder pain, and a right elbow laceration. The patient's wife reported that the patient was acting confused; the patient denied a loss of consciousness. The x-ray was negative for fracture. The right elbow laceration was repaired by the Emergency Department. The patient was admitted for observation given the symptoms of a likely concussion. A computed tomography (CT) of the head was done that showed a slight periventricular white matter chronic ischemic type change, ventricular prominence, and cortical atrophy. There was no evidence of acute intracranial hemorrhage or an acute appearing territorial infarction. The patient was stabilized and subsequently discharged.

The inpatient admission was not medically necessary. The patient presented to the hospital after a fall from a ladder. Documentation indicates that a video of the incident did not show him hitting his head. Following the fall, the patient had right-sided pain and confusion. A CT scan of the head did not show any acute process. The patient was diagnosed with a possible concussion despite no evidence of head trauma or hitting his head on the video capture. He was observed in the hospital overnight with resolution of his symptoms and then discharged home the next day. None of the care provided required an acute inpatient admission. The patient did not have an injury that required inpatient care. The neurologic complaints of confusion did not warrant acute inpatient care. There was no neurologic deficit such as aphasia, weakness, or inability to ambulate. There were no significant laboratory abnormalities. There were no significant EKG abnormalities. There were no significant imaging abnormalities. The patient did not require acute nursing services. The patient did not require rehabilitation on discharge. All of the care provided could have been performed at a lower level of care.

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

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

Diagnosis: Palpitations, Premature Ventricular Contractions (PVC)
Treatment: Inpatient admission
The insurer is denied coverage for inpatient admission.
The denial is upheld. 

This is a female patient with a history of palpitations, dizziness, and premature ventricular contractions (PVCs). She began feeling the symptoms from her PVCs in the form of palpitations, shortness of breath, and chest tightness over the past year and they had progressively worsened. It was reported that the patient had recently been prescribed metoprolol following a recent hospitalization for symptomatic PVCs; the dose was subsequently increased. She presented to the hospital for an elective electrophysiology PVC ablation procedure under intravenous (IV) sedation with local anesthesia. The patient successfully underwent the procedure without complications. She was admitted to the hospital post procedure where she remained clinically and hemodynamically stable. The patient medically stable and was discharged home.

The inpatient admission was not medically necessary. The patient underwent an uneventful electrophysiology study with ablation and had no complications. She remained hemodynamically stable, was ambulatory, and was tolerating oral intake. There were no hemodynamic or clinical complications or concerns noted.

Per MCG 23rd Edition Guideline for Electrophysiologic Study and Intracardiac Catheter
Ablation, this procedure is an outpatient one, with allowance of one night in the hospital at an observational status. The insurer acted reasonably, with sound medical judgment, and in the patient's best interest.

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

Diagnosis: Anxiety 
Treatment: Brand Xanax 

Summary: 
The patient is a female. The physician writes that the patient has been taking Xanax. He writes that the generic form "failed." He also writes that Ativan, clonazepam, and diazepam did not alleviate the patient's anxiety. 

The provider does not provide any details regarding the reported "failure" of the proposed generic formulation. There is no evidence regarding dosage, specific symptoms, clinical description of patient response, duration of treatment, etc. There is no adequate clinical description that would meet generally accepted criteria. 

Thus, the health plan's requirements that the patient must have had a severe reaction to the generic drug, that switching to the generic agent would worsen the patient's condition and require urgent medical care, or that the patient might require additional medical treatment as a result, are reasonable and are not met.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Psoriasis
 
Treatment: Taltz autoinjector

The insurer denied coverage for Taltz autoinjector. The denial is upheld. 

This patient is a male who has requested Taltz for psoriasis located to elbows, lower legs and flanks. The patient has a diagnosis of psoriasis located to elbows, lower legs and flanks. The patient has tried and failed clobetasol. The preferred agents are topical steroids, disease-modifying antirheumatic drug (DMARDS) and Humira, Otezla, Stelara, Skyrizi, Tremfya, Enbrel, and Cosentyx.
The formulary drugs will not cause harm or adverse reaction based on information provided. Topicals are ineffective for such a large surface area affected but the more potent systemics have not been trialed. There are no head to head studies to compare efficacy and safety other than Enbrel and Stelara, which Taltz demonstrated a better resolution. However, the data indicates that Skyrizi has the highest Psoriasis Area and Severity Index (PASI) reduction in psoriasis, better than Taltz (Armstrong et al 2020). For this patient's clinical scenario, there are available preferred medications the patient has not tried and failed. 

Taltz is an acceptable safe medication as reported by Syed et al. 2017, stating "Phase 3 UNCOVER trials in this patient population, ixekizumab was superior to placebo or etanercept in terms of the proportion of patients achieving a 75% reduction from baseline in the Psoriasis Area and Severity Index and in those achieving a static Physician Global Assessment score of 0 or 1, after 12 weeks of induction treatment. "

Taltz (ixekizumab) has been tested against ustekinumab (Stelara): "At week 12, IXE (n = 99, 728%) was superior to UST (n = 70, 422%) in PASI 90 response (response difference 321%, 975% confidence interval 198-445%, P < 0001). Response rates for PASI 75, PASI 100 and sPGA (0, 1) were significantly higher for IXE than for UST (adjusted P < 005). "(Reich et al. 2017)

In a study that looked at other medications, there was considerable psoriasis improvement with multiple biologics: including Taltz improvement over Humira, apremilast, and Stelara. But not Skyrizi, "Sixty trials meeting all inclusion criteria were included. At weeks 10 to 16, the highest PASI 90 rates were seen with risankizumab-rzaa (71.6%; 95% credible interval [CrI], 67.5%-75.4%), brodalumab (70.8%; 95% CrI, 66.8%-74.6%), ixekizumab (70.6%; 95% CrI, 66.8%-74.6%), and guselkumab [TALTZ] (67.3%; 62.5%-71.9%). At weeks 44 to 60, the treatments with the highest PASI 90 rates were risankizumab-rzaa (79.4%, 95% CI, 75.5%-82.9%), guselkumab (76.5%; 95% CI, 72.1%-80.5%), brodalumab (74.0%; 95% CI, 69.3%-78.1%), and ixekizumab (73.9%; 95% CI, 69.9%-77.5%). Findings were consistent for short-term and long-term PASI 75 and 100 responses." (Armstrong et al. 2020).                                                          

Based on the above, formulary exception for Taltz autoinjector is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems 
Treatment: Inpatient hospital 

This is a female with history of migraine headache and spinal surgery who presented to the emergency department (ED) with a complaint of dizziness. The patient also complained of nausea as well as right facial tingling with radiation into her right arm. The patient also developed a chest crushing sensation upon arrival to the ED. Vital signs were Temp 97.9 F, pulse 80, respirations 18, blood pressure (BP) 162/ 82, and pulse oximetry 98% on room air. Physical examination showed a lethargic female with horizontal nystagmus. Laboratory values, chest x-ray and brain computed tomography (CT) were unremarkable. The patient was admitted for further monitoring and testing. The inpatient admission is under review. 

The health plan's determination is upheld. The inpatient stay was not medically necessary. This patient did not have evidence of bacterial labyrinthitis, brain ischemia or hemorrhage, hemodynamic instability, severe or persistent vomiting or arrhythmias. There were no new neurological findings or signs/symptoms that were severe or persistent. The patient did not require intravenous medications. The clinical presentation and documentation reviewed does not meet criteria for inpatient admission. In addition, the Milliman Care Guidelines (MCG) criteria for dizziness were not met. This patient did not have any clinical needs that would have required an inpatient admission. This patient could have been monitored with further testing at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems 
Treatment: Dental/Orthodontic Procedure 

The patient in question is a male. He has a Class II malocclusion with severely crowded arches. Tooth 10 is in anterior crossbite. He is treatment planned for 24-30 months of orthodontics with extraction of teeth 5, 12, 21, and 29 to correct the crowding and crossbite. The medical necessity of braces is under review. 

The health plan's determination is overturned. Braces are medically necessary. Tooth 22 is already developing recession, and if his bite is not corrected with orthodontics the recession will get worse. Additionally, tooth 22 is being pushed labially in the dental arch and is developing recession. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. These problems are much more time consuming and difficulty to correct than the patient's current orthodontic problem.