Persius/hicric huggingface dataset:
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Parkinson's disease

Treatment Ongentys capsule 50 milligram (mg)

The insurer denied coverage for Ongentys capsule 50 milligram (mg).	

The denial is upheld.

This is a patient who was prescribed Ongentys (opicapone) 50 milligrams (mg), by his treating provider.  A New York State external appeal application indicates that the patient was taking carbidopa/levodopa and entacapone. He did not benefit from entacapone, as he continued to have wearing off between the carbidopa/levodopa doses.

An office note indicated a diagnosis of Parkinson's disease. The patient first became symptomatic a few years ago. He was most recently treated with a combination of carbidopa levodopa (immediate and extended release) and was started on entacapone because of wearing off after about 3 to 4 hours. However, he did not benefit and entacapone was stopped at that time. His doctor prescribed Ongentys (opicapone). There was no documentation why tolcapone could not be utilized.

There is no indication that the formulary drugs would be likely to cause the patient an adverse reaction. The patient has already tried and failed entacapone. Tolcapone is available as a formulary medication. The patient tolerated entacapone, and there is no reason to believe he would not tolerate or have an adverse reaction to tolcapone, the available formulary catecholamine O methyltransferase (COMT) inhibitor.

Literature data showed the absence of relevant safety concerns of tolcapone when strict adherence to hepatic function monitoring is respected. Given its high efficacy on motor fluctuations, tolcapone is probably an underutilized tool in the therapeutic PD [Parkinsons Disease] armamentarium." (Artusi, C. A. et al.).     
 
The formulary drug entacapone was ineffective. However, based on the clinical history, the available formulary drug, tolcapone, has not been ineffective, as the patient has not previously been treated with tolcapone.  
   
There is no evidence in the peer-reviewed medical literature that Ongentys (opicapone) is superior in efficacy to tolcapone. Opicapone would therefore not be more effective than the available COMT inhibitor, tolcapone.

"Tolcapone is a catechol-O-methyltransferase (COMT) inhibitor. Levodopa, a common medication used for Parkinson disease, is normally metabolized by decarboxylase in the periphery to dopamine." (Willman, C., & Tadi, P.

"Treatment with a 50-mg once-daily dose of opicapone was associated with a significant reduction in mean daily off-time in levodopa-treated patients with PD and motor fluctuations, and this effect is maintained for at least 1 year. Opicapone was safe and well tolerated." (Lees, A. J. et al).       
  
The insurer's denial of Formulary Exception for Ongentys capsule 50 milligram is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain and Nausea.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld

This is a female with the diagnoses of abdominal pain and nausea (status post laparoscopy appendectomy).

The proposed inpatient admission was not medically necessary.
As per the submitted InterQual Criteria: A procedure can not be considered for an Acute Inpatient Admission if it not designated as an Inpatient admission procedure. 

As per the Milliman Care Guidelines (MCG) National Criteria: The Expected LOS (Length of Stay) for an uncomplicated laparoscopic appendectomy is Ambulatory. In keeping with this expected LOS (and in agreement with the health plan letter), all the medical care that this patient did receive postoperatively including vital signs monitoring, intravenous fluids, pain and nausea control, voiding, ambulation, and oral diet all could have been safely, effectively, and efficiently provide as Observation Care not requiring an Acute Inpatient admission especially since this patient only had a one over-night stay.

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

An acute inpatient admission was not indicate.  All of the medical care could have been safely, effectively, and efficiently provided as Observation Care. This would have been more consistent with the expected LOS (Length of Stay) following an uncomplicated laparoscopic appendectomy as ambulatory.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Infertility
Treatment: IVF (in vitro fertilization), ICSI (intracytoplasmic sperm injection), and PGT-A (preimplantation genetic testing for aneuploidies)
The insurer denied the IVF, ICSI, and PGT-A.
The denial is overturned, in part.

The patient is a female with a diagnosis of infertility due to decreased ovarian reserve and a male factor. She has failed three prior IUI (intrauterine insemination) cycles.

The provider plans to proceed with in vitro fertilization (IVF). However if the patient does not develop an adequate number of follicles, the IVF cycle will be converted to an insemination cycle.

The request is for IVF, ICSI (intracytoplasmic sperm injection) and PGT-A (preimplantation genetic testing for aneuploidies).

The requested health service is medically necessary, in part.

This patient has a diagnosis of infertility and has failed three insemination cycles. The next step is to proceed with IVF. While the patient has decreased ovarian reserve with decreased odds of conception, because of her young age, her odds of conception and live birth are still acceptable (greater than 5% [percent]).

Note that ICSI is warranted due to the presence of a male factor. Note, however, that PGT-A is not medically necessary as the patient is not documented to be the carrier of any chromosomal anomaly or genetic condition with the risk of passing it to a fetus.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient, in part.

The health plan erred in denying IVF and ICSI. However, the decision to deny PGT-A was reasonable and within the standard of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle cell pain crisis.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female with hemoglobin SS (sickle cell) disease with past history of acute chest, AVN (avascular necrosis), CVA (cerebrovascular accident) with a recent TIA (transient ischemic attack) (left AMA [against medical advice] three days prior). She presented to the ER (emergency room) with an uncomplicated sickle cell pain crisis.

The patient's LDH (lactate dehydrogenase) was 700. Her other labs were at baseline. She was afebrile. She was placed on IV (intravenous) Dilaudid and IV (intravenous) hydration. UA (urinalysis) and CXR (chest x-ray) were negative.

The Inpatient admission was not medically necessary.
This individual presented with an uncomplicated acute sickle cell pain crisis.  She had no evidence of infection, no evidence of acute chest syndrome, or CVA (cerebrovascular accident) symptoms.  She was not in aplastic crisis. Uncomplicated pain crisis are expected to improve within several days.

As this patient had a condition that could reasonably be expected to be stabilized within 24 hours, observational status would have been appropriate.

"Generally a person is considered to be in inpatient status if officially admitted as an inpatient with the expectation that he or she will remain at least overnight. The severity of the patient's illness and the intensity of services to be provided should justify the need for an acute level of care. An inpatient admission solely because the patient has been kept in observation status over 23 hours would not be considered medically necessary." (American Health Information Management Association).

"Observation was meant to be a short period of time for providers to assess whether patients required admission for inpatient care, or could be discharged. Typically, this was meant to last fewer than 24 hours and only rarely spanned more than 48 hours." (Society of Hospital Medicine).

"In summary, hospital case managers are a crucial resource for making admission decisions. Hospitalists should be familiar with Medicare criteria for inpatient versus observation status. Patients who are likely to require 24 hours or less for a disposition decision should be assigned observation status. When in doubt, admit to observation since conversion to inpatient status is a simple process." (Pinson, R.).

The health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hip pain/hip surgery
Treatment: Skilled Nursing Facility
The insurer denied the skilled nursing facility stay.
The determination is upheld.

The patient has a diagnosis of "s/p [status post] hip surgery" who received care in a skilled nursing facility (SNF). Per the clinical documentation, the surgery was a left hip revision open reduction internal fixation (ORIF). This surgery was necessary due to a left periprosthetic femur fracture on the left lower extremity. Other diagnoses per the physician progress notes include peripheral vascular disease, lumbar disc herniation, alcoholic hepatitis, and hypertension.

Available records include a physical medicine and rehabilitation evaluation, medication administration record, nursing assessment and notes, nutrition assessment and notes, occupational and physical assessment and notes, social services/psychology assessment and notes, and physician progress notes.

At issue is the medical necessity of continued care in the skilled nursing facility (SNF).

Based on the available documentation and the diagnosis being treated, continued skilled nursing facility stay is not medically necessary to achieve health and functional goals. The patient can continue to work toward his health and functional goals in the home or outpatient setting.

The therapy note documents the patient as independent in grooming, feeding, wheelchair (wc) mobility. The patient's function on upper body dressing is independent and lower body is minimal (min) assist on therapy assessment. At this level of function, the patient is appropriate for in home services. He was contact guard on transfers of wheelchair to commode, wheelchair to tub, toileting, bed mobility, and minimal assist with lower body dressing. He ambulated 75 feet with a rolling walker with contact guard. According to the physical therapy evaluation, his prior level of function was ambulation with a rolling walker. The patient lives alone in an apartment with 5 steps to enter, right handrails, main floor setup, bathroom with tub with curtain and shower chair. According to therapy documentation, patient did not perform stairs with therapy due to weight bearing status of the left lower extremity. The number of stairs in home environment is not incorporated in Skilled Nursing Facility (SNF) qualification guidelines. The patient had an over the toilet commode from the prior left total hip replacement 8 months prior. He was independent with activities of daily living (ADLs), bed mobility, transfer. There is no documentation of the patient requiring intravenous antibiotics at the time in question, enteral feeds, or complex wound care.

Therefore, the requested services are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizures. 
Treatment: Inpatient Admission. 

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

The patient is a male who was admitted due to recurrent witnessed seizures in the setting of K2 (Synthetic Cannabinoids) and marijuana. It is unclear if he returned to baseline between the seizures. The second seizure was aborted by benzodiazepines. He was assessed in the emergency room and loaded on Keppra. The computed tomography (CT) of the head was unremarkable. The patient was also noted to have a creatinine level of 135 and a creatine kinase (CK) of 529. He underwent neurological consultation. 

The hospital admission was deemed not medically necessary by the Health Plan as there was no evidence of an electroencephalogram done within 24 hours and neurological assessment done at least six times in 24 hours. 

No, the proposed Inpatient Hospital Admission was not medically necessary. 
The patient did not meet the requirement for inpatient admission.  As based on the InterQual, he did not get an electroencephalogram (EEG) within 24 hours or have neurological checks at least six times in 24 hours. 

Furthermore, the patient did not meet Milliman Care Guideline (MCG) criteria for inpatient hospitalization as there was no evidence that he was in status epilepticus (defined as recurrent seizures without return to baselined). It was unclear if the patient returned to baseline between the two seizures. 

In addition, the patient did not have rhabdomyolysis. His creatine kinase (CK) was 529. Rhabdomyolysis is defined as five times the upper limit of normal which usually starts around 1500. 

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient as the admission did not meet InterQual or Milliman Care Guidelines.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Endocrine/Metabolic/Nutritional/Obesity.
Treatment: routine liver biopsy in conjunction with bariatric surgery .
The health plan denied the  routine liver biopsy in conjunction with bariatric surgery.
The health plan's determination is upheld.

The patient is a woman who underwent bariatric surgery (laparoscopic roux en Y gastric bypass and concomitant liver biopsy). The operative dictation states that the surgeon obtained a wedge liver biopsy from the left lobe of the liver. The submitted records do not include any pre-surgical lab, imaging, or clinical data to indicate liver pathology. The pathology report provides the diagnosis of no significant fatty infiltration or hepatocellular degeneration.
The provider submitted current procedural terminology (CPT) code 47379 (liver biopsy, wedge). The health plan rationale for denial of coverage for liver biopsy is that there is no documentation of objective signs or symptoms of liver disease to warrant liver biopsy. Per this letter, guidelines on the use of liver biopsy in clinical practice do not mention routine biopsy of the liver with bariatric surgery.
At issue is the medical necessity of the performed surgical procedure.

The health plan's determination of medical necessity is upheld, in whole.

No. The submitted documentation does not support the medical necessity of concomitant liver biopsy at the time of roux en Y gastric bypass. There is no documentation of liver pathology as might be obtained by pre-operative imaging or lab data to warrant a liver biopsy.
According to generally accepted criteria, routine liver biopsy is not medically necessary in conjunction with bariatric surgery. A liver biopsy is indicated if there is a suspicious growth on the liver, if there is scarring of the liver or if there is a condition of the liver as indicated by pre-operative imaging or lab data that requires biopsy.
Lab data and pre-operative imaging are not included with the review material. There is no description of clinical symptomatology to indicate liver pathology. While the operative dictation does describe a fatty liver per the surgeon, this is not substantiated by preoperative clinical data. Furthermore, if a liver biopsy is deemed necessary by the treating surgeon, this can be accomplished by tru-cut needle biopsy (CPT 47000 ) and does not require a wedge liver biopsy (CPT 47100 or 47379). [1.2,3]
Accepted indications for liver biopsy include: Documentation of signs or symptoms of liver disease (abnormal liver function tests of unknown etiology, knowledge of a specific diagnosis that will likely alter the treatment plan, known liver disease where prognostic information about fibrosis may guide subsequent treatment, the presence of a mass or lesions or focal or diffuse abnormalities seen on imaging studies of unknown etiology). In this case there is no such documentation to warrant wedge liver biopsy (47100 or 47379 liver biopsy, wedge).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems- Broken/cracked Tooth
Treatment: Dental/orthodontic procedure-Root canal therapy
The health plan denied the root canal therapy as not medically necessary. 
The reviewer has overturned in whole the health plan's determination. 

The patient  presents to the office of her provider for evaluation and treatment of tooth #20 with root canal therapy. Provided for review are previous letters of appeal and denial, a narrative from the patient's provider explaining the need for root canal therapy on tooth #20 due to tooth fracture, full mouth panoramic radiographic images from, one page of American Dental Association (ADA) claim forms, and health plan language.

Yes, based on the provided documentation, tooth #20 suffered a fracture and loss of the majority of the clinical crown which required a post and buildup for retention and replacement of the lost tooth structure. In order to place a post, the root canal space is required to be occupied by the post. Also, as a result of the fracture, pulpal exposure did occur, which is another indicator for the need for root canal therapy as the pulp is instantly infected with bacteria in the oral environment and there is no other therapy to remove pulpal infection. Thus, the treatment of root canal therapy (3320) for tooth #20 is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a history of ruptured appendicitis who presented to the emergency department with left lower quadrant abdominal pain at the site of the previous drain. The patient's vital signs were essentially within normal limits. The patient was noted to have left lower quadrant tenderness on exam. The white blood cell count (WBC) was 7.9. A pelvic ultrasound demonstrated a fibroid uterus. A computed tomography (CT) scan demonstrated circumferential thickening of the cecum with adjacent inflammation extending to the left lower quadrant; slightly complex fluid is seen within the left paracolic gutter without drainable fluid collection. General Surgery saw the patient and admitted her to surgery for observation. They planned to treat her with antibiotics, givernher regular diet and perform serial abdominal exams and trend her lab work. Her pain was noted to have improved. The patient was seen by gynecology (GYN) in regards to endometriosis. They felt there was a possible endometriosis implant at the drain site. They recommended continuing her oral contraceptive. The patient was still doing well, with improved but persistent pain. The patient was discharged home later that afternoon.
At issue is the medical necessity of an inpatient stay.

No, the inpatient stay was not medically necessary.

The patient had left lower quadrant pain and a CT scan demonstrating inflammation. The patient improved quickly over the first 24 hours. There is no evidence that additional complex testing or therapy other was performed. She appears to have been monitored briefly and then discharged without significant additional workup or intervention during the hospital stay. There is no evidence that a complicating event occurred during the hospitalization that required a higher level of care. There is no documentation that the treating team identified conditions or problems specific to the patient that would have required inpatient care. The patient did not have significant dehydration, hemodynamic instability, severe pain requiring frequent or high doses of narcotics, signs of intestinal obstruction, peritonitis, or bacteremia. The patient did not utilize complex testing, therapy, or intense monitoring that would have required an inpatient level of care.
The provided documentation does not support the medical necessity of inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Home Health Care
The insurer denied Personal Care Services: 8-9 Hours per Day, 7 Days per Week (Total of 56-63 Hours). 
The health plan's determination is overturned. 

The patient is a female with past medical history of vascular dementia, urinary incontinence, hypertension, diabetes mellitus type 2, peripheral vascular disease, osteoporosis, osteoarthritis, major depressive disorder, anxiety, and panic disorder who had been assigned PCA (personal care assistant) services. There was a request to increase PCA services and the patient underwent an assessment tool via telephone assessing the patient at total assistance with task of ordinary housework while maximum assistance with tasks of meal preparation, stairs, shopping, bathing, dressing lower body, transfer toilet, and toilet use. The patient was assessed that extensive assistance with tasks of managing finances, managing medication, personal hygiene, dressing upper body, walking, and locomotion while limited assistance with tasks of phone use, bed mobility, and eating. Notes from the assessment noted the patient lived alone. The assessment also stated the patient wore pull-ups and was unable to change her pull ups on her own. The patient had informal help from a relative.

Personal Care Services: 8-9 Hours per Day, 7 Days per Week (Total of 56-63 Hours) are medically necessary for this patient.
There is documentation from the patient's PCP that the patient has had worsening physical functioning and cognitive functioning with an increased need for assistance with activities of daily living (ADL) and Instrumental activities of daily living (IADL). The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The patient requires assistance with ADLs and IADLs when she has no informal help and the patient's niece who is her informal helper is not available at all times outside of the current PCA hours. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies.
Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 8-9 hours/day, 7 days/week, to total 56-63 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental problems
Treatment: Crown tooth 20
The insurer denied a crown on tooth 20. 
The health plan's determination is overturned.

The patient is a female who presents for evaluation and treatment of tooth # (number) 20. Provided for review are previous letters of appeal and denial, a narrative from the treating provider explaining necessity of treatment for #20, full mouth panoramic radiographic images, bitewing images, American Dental Association (ADA) claim forms, and health plan language.

A crown on tooth 20 is medically necessary. Based on the provided documentation, tooth #20 suffered an extensive loss of tooth structure resulting in the loss of an entire cusp. In order to restore the tooth to its original structure and function, there was need for retention in the form of a post and buildup followed by a crown to replace the missing tooth structure. There is a clear medical necessity for the crown on tooth 20.