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

Diagnosis: Cellulitis.

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld.  

This female patient has a past medical history of diabetes mellitus and presented to the Emergency Department (ED) with complaints of pain and swelling to right side of the face. The patient's vital signs on presentation included: Temperature 37.5 Celsius, Blood Pressure 115/72, Pulse 78, Respiratory Rate 17, and Oxygen (O2) Saturation 99% on Room Air. The patient's laboratory values were notable for the following: white blood cell (WBC) count 6.6, hemoglobin 15.5, hematocrit 44.5, creatinine 0.53, and glucose 368. The patient was empirically started on intravenous (IV) antibiotics (i.e., Vancomycin and Zosyn) for facial cellulitis. The patient's computed tomography (CT) scan of facial bones showed soft tissue swelling on right lateral subcutaneous cheek and adjacent soft tissue swelling. The patient's chest x-ray was negative. Ear Nose & Throat (ENT) consulted and no surgical intervention was required. Infectious Diseases specialist recommended de-escalation of antibiotics to Unasyn. The patient remained afebrile, hemodynamically stable and clinically improved. The patient was discharged to continue oral antibiotics (i.e., Augmentin) as an outpatient. 

According to documentation, the patient presented with a right-sided facial cellulitis. Otherwise, the patient was afebrile, hemodynamically stable, and described as in no acute distress. Moreover, the patient's laboratory results were unremarkable including a normal WBC count. The patient's glucose level was elevated reflecting her history of chronic diabetes. The ENT evaluated the patient and deemed no surgical intervention was necessary. Based on the above findings, the patient did not meet criteria for acute inpatient hospitalization. 

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.

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

Diagnosis: Dental Problems (Class II canines, overjet, overbite, open bite, anterior mandibular crowding).
Treatment: Comprehensive orthodontic treatment of the adolescent dentition (code D8080).

The insurer denied coverage for comprehensive orthodontic treatment of the adolescent dentition (code D8080).  The denial is upheld. 

This is a female patient who presented for evaluation for orthodontic care.  The orthodontist identified several clinical findings including Class II canines, overjet, overbite, open bite, anterior mandibular crowding and has recommended orthodontics.  The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 28 total points to support orthodontic care.  The insurer has denied coverage for orthodontic treatment as not medically necessary, stating that the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements.

Upon review of the submitted documentation (study models were not provided for review) it is evident that the patient exhibits a malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care a Handicapping Labio-Lingual Deviation (HLD) Index is utilized.  This index provides 6 specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to quality for orthodontic care a total score of 26 points is necessary.

In this case, the treating orthodontist does not claim an automatic qualifying condition and completes the second portion of the index arriving at 28 points to justify orthodontic care.  This reviewer concurs with the index completed by the insurer attaining a total of 19 points on the Handicapping Labio-Lingual Deviation (HLD) index (i.e., 7 overjet, 4 overbite, 5 anterior crowding, 3 labiolingual spread) which is below the threshold of 26 points to support orthodontic care.

Comprehensive orthodontic treatment of adolescent dentition (code D8080) is not considered medically necessary for this patient.

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

The carrier's denial of coverage for comprehensive orthodontic treatment of the adolescent dentition (code D8080) should be upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute cholecystitis.

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld. 

This is a female patient who presented to the Emergency Department (ED) with a one-day history of abdominal pain. There was associated nausea and vomiting. The patient also had a history of gastroesophageal reflux disease (GERD). The patient's vital signs in the ED were within normal limits. The patient had a computed tomography (CT) scan that indicated "cholelithiasis within an overdistended gallbladder with mild gallbladder wall thickening." The patient's liver function tests were normal. The patient was taken to the operating room for a laparoscopic cholecystectomy. There were no reported complications. The patient was evaluated that night by the surgery team and it was noted that the patient's pain was well-controlled and diet was being advanced.  

Acute cholecystitis is 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, ambulatory laparoscopic cholecystectomy is safe and feasible. [5] 

According to clinical documentation, the patient was treated under observation standards. Peer-reviewed literature indicates that laparoscopic cholecystectomy can successfully be performed as an outpatient procedure. The patient's care could have been safely provided at a lower level of care, such as observation status. Inpatient admission is thus not considered medically necessary for this patient.

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

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

Diagnosis: Chronic pancreatitis. 
Treatment: Inpatient admission. 

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

This is a female patient with a history of chronic pancreatitis. The patient presented to the Emergency Department (ED) with epigastric pain, nausea, and vomiting. A recent workup revealed pancreatic calcifications and mild biliary duct dilatation. The patient's magnetic resonance cholangiopancreatography (MRCP) showed dilatation of the pancreatic duct and a pancreatic cyst. The patient was afebrile and her vital signs were stable. There were no peritoneal signs on exam. The patient's lab work showed normal amylase and lipase values. The patient was given intravenous (IV) hydration and pain control. The patient's pain was controlled and the nausea and vomiting resolved. 

Clinical indications for admission for pancreatitis according to Milliman Care Guidelines (MCG) include indications for patients with both acute and chronic pancreatitis. These include the inability to maintain oral hydration, evidence of infection, severe pain not responding to medication, hemodynamic instability, hypoxemia, acute renal failure, and severe electrolyte abnormalities. The patient did not have these conditions. 

In this case, this patient had chronic pancreatitis. The patient required intravenous hydration and pain control. This could have been given in the Emergency Department (ED) with observation status. The patient did not meet the MCG criteria for admission for pancreatitis. Inpatient admission was not medically necessary for this patient. 

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

The medical necessity for the inpatient admission is not substantiated.  The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status asthmaticus. 
Treatment: Inpatient Hospital Admission. 

The insurer denied coverage for the Inpatient Hospital Admission. 
The denial is overturned. 

This is a male patient with a history of moderate persistent asthma who has had multiple hospitalizations for asthma.  He has required 3 courses of steroids for asthma in the past year.  He has been on Flovent twice per day (BID) as a preventive asthma medication but lost his aerochamber one month prior to this admission.  He has allergies and eczema and there is exposure to a dog in the home to which he is known to be allergic.  There is also cigarette smoke and mice infestation in the home.  He was sick for two days with shortness of breath and a cough and has been receiving albuterol on four occasions during this illness with no improvement in his cough. The mother contacted the Pediatrician who had agreed to see the child but the mother reportedly decided to seek care in the Emergency Room (ER). 

In the ER he was noted to have increased work of breathing with abdominal retractions.  He was tachypneic and his pulse oximeter was low at 92%.  On physical exam he had bilateral wheezing with decreased air entry.  He was treated with multiple inhalations of DuoNeb, magnesium sulfate and methyl prednisolone.  He also was administered a bolus of normal saline by intravenous (IV).  When his wheezing and increased work of breathing did not improve with treatment in the ER the decision was made to admit the child to the hospital with a diagnosis of status asthmaticus for continued treatment with albuterol every 2 hours. 

The patient was treated appropriately in the ER for an acute episode of wheezing and difficulty breathing.  The child has a history of poorly controlled asthma with multiple hospitalizations and need for treatment with steroids.  The medical record indicates that he has been followed by allergy and the asthma specialist at a clinic and that he was compliant with his prescribed Flovent preventive therapy.  Despite his preventive therapy he was experiencing status asthmaticus which did not respond to frequent outpatient albuterol in the home.  When he did not respond to treatment in the ER he was appropriately admitted to the hospital with a diagnosis of status asthmaticus.  He was not stable enough to be safely discharged since he required albuterol every 2 hours. 

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

The medical necessity for the Inpatient Hospital Admission is substantiated.  The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gynecological-Endometrial Hyperplasia. 
Treatment: Genetic Testing-Invitae Common Hereditary Cancers Panel. 

The health plan denied the requested genetic testing. 
The health plan's determination is upheld. 

This is a female with no personal history of malignancy. The patient had been previously tested for breast cancer antigen (BRCA); this was negative. The patient is not of Ashkenazi Jewish descent. Her mother is reportedly BRCA positive (felt to be about 10 years ago). Additional family history is not available. Expanded testing was obtained and she was found to have a (ATM) heterozygous pathogenic variant of uncertain significance; testing is under review. 

At issue is the medical necessity of the requested genetic testing. 

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

The provided documentation does not indicate that this patient meets National Comprehensive Cancer Network (NCCN) criteria for expanded testing. The patient has previously been tested for a BRCA mutation (per her family history), which was negative. This is the approach taken by both the NCCN and by the authors of UpToDate. Endometrial hyperplasia is a benign condition and is not associated with an increased risk of breast cancer nor any of the hereditary breast-ovarian cancer syndromes. 
An expanded panel was performed on this patient, which is what is under review. It is documented that based on family history; this patient was previously only tested for BRCA; this test was negative. The NCCN recommends expanded testing in appropriate patients; this includes testing for genetic mutations (CHEK2, PALB2, ATM), as 4-7% of patients have a pathogenic variant in another gene with probable breast and ovarian cancer associations - but this is not an appropriate test for this patient, given her family history. Lacking guideline support or recommendations in the literature, medical necessity cannot be established for this service.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: High Blood Pressure. 
Treatment: Inpatient admission. 

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

The patient is a G2 P2002 (pregnancies  2 - term births 2, pre-term births 0, abortions 0, living children 2) who was admitted to the hospital on postpartum/post-operative day #7 for postpartum preeclampsia.  The pregnancy was complicated by preeclampsia and the patient had a Cesarean section. 

On presentation to the hospital, the patient's blood pressure was 186/60 and she had a headache.  In the hospital, her blood pressures were extremely elevated as high as 204/93. She received magnesium sulfate (MgSO4) for seizure prophylaxis and intravenous (IV) labetalol and subsequently oral (PO) labetalol and Procardia.  Her hypertension and headache resolved and she was discharged home on hospital day #4. 

The health plan contends that the hospitalization was not medically necessary because the patient did not have blood pressure greater than 180/120, end organ damage, aortic dissection, heart failure, shortness of breath, mental status changes, severe headache, nausea or vomiting, or need for parenteral antihypertensive or invasive monitoring. The facility contends that the hospitalization was medically necessary but does not cite any specific criteria. 

Yes, the proposed inpatient admission was medically necessary. 

The patient presented with a very typical classic presentation for postpartum preeclampsia with severe features as evidenced by her extremely high blood pressure greater than (>) 160/110 and headache in the postpartum period. Suspicion would be even higher in this case due to the history of preeclampsia with the prior pregnancy.  Postpartum preeclampsia is associated with potentially life threatening complications including eclamptic seizures, intracranial bleeding, liver failure, renal failure, disseminated intravascular coagulation, pulmonary edema, hemolysis - elevated liver enzymes - low platelet count (HELLP) syndrome, posterior - reversible - encephalopathy - syndrome (PRES) syndrome, cortical blindness, and death. For these reasons intravenous magnesium sulfate (MGSO4) infusion, intensive clinical and laboratory monitoring, and titration of antihypertensives are absolutely required.  This cannot be accomplished on an outpatient basis. Therefore, the admission was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alopecia Universalis. 
Treatment: Xeljanz, Pre-service. 

The insurer denied the Xeljanz, Pre-service. 
The denial is overturned. 

The patient is a man with alopecia universalis who has failed oral, topical, and intralesional steroids. He also experienced severe eye irritation due to lack of eyelashes. He started taking Xeljanz and is now having regrowth: 90% of the scalp and all eyelashes and eyebrows have regrown. This is a request for continuation of treatment. 

Yes, the proposed treatment with Xeljanz is medically necessary. 
Regrowth of hair during treatment with tofacitinib (a small molecule selective Janus kinase [JAK] 1/3 inhibitor) has been documented in patients with alopecia areata. Patients are typically treated with five to ten milligrams (mg), twice daily. 

A retrospective study of 90 adults with severe alopecia areata (at least 40 percent scalp hair loss, alopecia totalis, or alopecia universalis) who had stable or worsening disease for at least six months and received oral tofacitinib (five to ten milligrams twice daily) for at least four months (with or without adjuvant prednisone) supports benefit. Of the 65 patients with a duration of the current disease episode of ten years or less, 77 percent had a clinical response (at least six percent improvement in the Severity of Alopecia Tool [SALT] score) and 58 percent achieved greater than 50 percent improvement in the Severity of Alopecia Tool (SALT) score over four to 18 months of treatment. Patients with a disease episode longer than ten years appeared less likely to respond to treatment; the clinical response rate in this population was 32 percent (eight of 25 patients). No serious adverse effects occurred during treatment. 

This is an accepted off label use and dose for the treatment of alopecia areata based on the literature and represents continuation of therapy for the patient. 

Given this patient's diagnosis and history, treatment with Xeljanz would be considered to be reasonable and consistent with the current standard of care in the dermatology community.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: macular degeneration with legal blindness (vision)
Treatment: Personal Care Worker (PCW) services (Home Health Care)

The insurer denied Personal Care Worker (PCW) services. 
The health plan's determination is overturned. 

The patient is a female with past medical history of dementia, anxiety, depression, insomnia, hallucinations, gastrointestinal (GI) bleeding, macular degeneration with legal blindness, urinary incontinence, osteoarthritis, chronic kidney disease stage III, atrial fibrillation, coronary artery disease, hypertension, severe aortic stenosis, hyperlipidemia, and hypothyroidism who had been assigned Personal Care Worker (PCW) services following an assessment. At that assessment, the patient was assessed total assistance with tasks of meal preparation, ordinary housework, managing finances, and shopping while maximum assistance with tasks of managing medication, phone use, stairs, transportation, equipment management, bathing, dressing upper/lower body, and toilet use. With tasks of personal hygiene, walking, locomotion, transfer toilet, bed mobility and eating the patient was assessed at extensive assistance. Notes from this assessment stated the patient was unable to express goals and had moderate cognitive impairment. The patient had a recent hospitalization with GI bleeding and her anticoagulant was discontinued and due to risk of adverse outcome the patient's family decided not to pursue upper endoscopy unless there were further sign/symptoms of bleeding.

Personal Care Worker (PCW) Service to 7 Days per Week, 24 Hours per Day [Continuous Care by More than One Person] is medically necessary for this patient.
The patient has documented chronic and progressive medical conditions of aortic stenosis, coronary artery disease, chronic kidney disease, dementia, and macular degeneration with blindness. The patient has overnight needs that are unscheduled and unpredictable and the patient needs turning and repositioning every 2 hours as documented by her PCP (primary care provider). Due to the patient's care needs an aide would be unable to obtain at least 5 hours of uninterrupted sleep. The patient requires at least some assistance with all ADLs (activities of daily living)/IADLs (instrumental activities of daily living). An increase in PCW hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs. 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, Personal Care Worker (PCW) Service to 7 Days per Week, 24 Hours per Day [Continuous Care by More than One Person] 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: Upheld

Diagnosis: Metastatic Prostate Cancer.
Treatment: Cabometyx.
The insurer denied the Cabometyx.
The determination is upheld.

The patient has metastatic prostate cancer. The patient has previously received radiotherapy and multiple lines of systemic therapy but has progressed. Cabozantinib plus nivolumab has been recommended; cabozantinib (Cabometyx) is under review for medical necessity.

The Cabometyx is not medically necessary. This is a patient with metastatic prostate cancer. The use of cabozantinib in the treatment of patients with prostate cancer remains the subject of multiple ongoing trials. Its use in this clinical scenario is not recommended by the authors of UpToDate nor by the National Comprehensive Cancer Network (NCCN) Guidelines due to the lack of outcomes data demonstrating a benefit to patients with the use of this agent. To date, findings would indicate a potential role based on bone scan response, but whether this role would be as a combination or single agent and in what line of therapy remains unclear.
Without supporting literature, medical necessity for this agent in this setting has not been established.