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

Diagnosis: Epigastric pain.
Treatment: Inpatient admission.

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

This is a female patient with a history of hypertension who presented to the hospital with epigastric pain. The patient was afebrile and her vital signs were stable. On exam, there was no abdominal rebound or guarding. The patient's amylase was 198 and the lipase was 505. The patient's computed tomography (CT) scan showed a dilated pancreatic duct and pancreatic calcifications. It was felt to represent acute on chronic pancreatitis. The patient was treated with intravenous (IV) hydration. The patient's magnetic resonance cholangiopancreatography (MRCP) showed that she had chronic calcific pancreatitis but no inflammatory changes to suggest acute pancreatitis.

As per Milliman Care Guidelines (MCG), the clinical indications for admission for pancreatitis include for acute pancreatitis having 2 or more of the following: abdominal pain, serum amylase or lipase greater than 3 times the upper limit of normal and characteristic findings on abdominal imaging. In this case, the patient had epigastric pain. However, the patient did not have pancreatic enzymes greater than 3 times the upper limit of normal. The patient's CT scan showed largely chronic pancreatitis with only mild inflammation, and the patient's MRCP was negative for acute pancreatitis. The MCG guideline for acute or chronic pancreatitis is having inability to maintain oral hydration, evidence of infection, severe pain requiring inpatient management, hemodynamic instability, hypoxemia, acute renal failure, or a severe electrolyte abnormality. In this case, the patient did not have these conditions.

The patient had chronic pancreatitis. There was a component of a mild acute pancreatitis. However, IV hydration and pain medications could have been given in the Emergency Room (ER) with observation status. The radiological imaging could have also been done at this lower level of care. Thus, the inpatient admission is not considered medically necessary for this patient.

The health plan acted reasonably with sound medical judgement, 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: Overturned

Diagnosis: Allergic reaction and syncope
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a female with a history of Klippel-Trenaunay syndrome, UTI (urinary tract infection), depression, anxiety, and renal stones. She presented to the emergency room with allergic reaction and syncope after hair dying/rinsing. She also presented with difficulty breathing, hive, throat swelling, lightheadedness, nausea, weakness, diarrhea, flushing and syncope.

On presentation at the emergency room, the patient was found to be in distress with generalized hive, and laboratory finding of elevated white blood cell count from baseline.  She continued to have shortness of breath with oxygen supplementation as well as increasing white blood cell count despite IV (intravenous) fluid administration.

The patient was admitted based on the differential diagnosis of septicemia with leukocytosis and syncope/seizure.

Yes, the Inpatient admission was medically necessary.

The patient was presenting with symptoms of anaphylaxis with multiple organ involvements: neurological (associated loss of consciousness), gastrointestinal symptoms (nausea/diarrhea), pulmonary (shortness of breath), dermatological (generalized hive). The patient was symptomatic with respiratory distress requiring ongoing oxygen administration, as well as laboratory finding of increasing high level of white blood cell count suggesting sepsis.  The admission was necessary to monitor her respiratory response and well as to rule out sepsis with ongoing intravenous antibiotics and IV (intravenous) fluid.  These measures could not be accomplished on an observational or out-patient level of care.  Therefore, the level of care was medically necessary for the diagnosis of anaphylaxis and septicemia.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems (skeletal Class III hypoplastic maxilla, maxillary and mandibular crowding, anterior and posterior crossbite, and impacted maxillary canines). 

Treatment: Braces D8080 and D8670 monthly visit x12.

The insurer denied coverage for braces D8080 and D8670 monthly visit x12.

The denial is overturned. 

This patient is a female child who presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to skeletal Class III hypoplastic maxilla, maxillary and mandibular crowding, anterior and posterior crossbite, and impacted maxillary canines. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of impacted permanent anteriors where extraction is not indicated. 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 on the HLD index attaining only 9 points on review by their internal reviewers. 

It is evident that the patient exhibits a significant malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care the 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 qualify for orthodontic care, a total score of 26 points is necessary.

In this case, the treating orthodontist claims an automatically qualifying condition of impacted permanent anteriors where extraction is not indicated. This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care. In this case, the clinical circumstance does meet the insurer and the plan criteria to justify orthodontic care.

The coverage of D8080- comprehensive orthodontic treatment of the adolescent dentition and D9670 -monthly visit x 12 is 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 braces D8080 and D8670 monthly visit x12 is substantiated.  The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prostate cancer.

Treatment: Oncotype DX prostate Assay, Current Procedural Terminology (CPT)
 Procedure Code 0047U.

The insurer denied coverage for Oncotype DX Prostate Assay (CPT Procedure Code: 0047U). 

The denial is upheld.  

This is a male diagnosed with prostate cancer after his prostate-specific antigen (PSA) was found to be 5.6. The patient had Gleason 3+4 prostate adenocarcinoma; 16 positive biopsy cores. The patient's Oncotype DX assay was performed and the results indicated that the patient had intermediate risk prostate cancer. The insurer has denied coverage of the Oncotype DX test as not medically necessary. The insurer stated that there is insufficient medical evidence in the literature to show that this test is helpful for the patient's condition; thus, the test is not felt to be medically necessary. 

While it is true that the current National Comprehensive Cancer Network (NCCN) guidelines state that adult male patients with at least 10-15 years of life expectancy and a diagnosis of low risk or favorable intermediate risk prostate cancer consider the usage of genomic testing such as Oncotype DX testing, the NCCN panel also note the absence of randomized prospective trials for this test that show a clinical benefit. The American Urological Association (AUA) guidelines are more guarded regarding the usage of this test. As of this date, the impact of tissue based gene expression tests, such as Oncotype DX test, on clinical prostate and long term patient outcomes remains to be empirically demonstrated. Prospective studied of these yielding a true clinical benefit when implemented in clinical prostate are still lacking.

The coverage of Oncotype DX prostate Assay, Current Procedural Terminology (CPT)
 Procedure Code 0047U, 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 medical necessity for Oncotype DX Prostate Assay (CPT Procedure Code: 0047U) is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Hypertension, dyslipidemia, morbid obesity, and congestive heart failure.
Treatment:  Inpatient admission.

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

The patient, a male, had past medical history significant for hypertension, dyslipidemia, morbid obesity, and congestive heart failure (CHF). The patient presented to the emergency room (ER) with complaints of cough and mid-sternal chest pain and nausea.

The patient was hemodynamically stable. His oxygen saturation was 97% on room air. There were no acute ischemic changes on electrocardiogram (ECG). Troponin was negative. Chest x-ray revealed no evidence of cardiopulmonary disease. As per history, the patient had an outpatient nuclear stress test, which revealed low ejection fraction (EF) of 15%.

The patient was admitted to rule out acute coronary syndrome (ACS). Echocardiogram performed in the hospital revealed normal ejection fraction (EF) of 60-65%. The patient also complained of headache. Computed tomography (CT) scan of the head revealed no acute intracranial pathology. The patient underwent a cardiac catheterization, which revealed no obstructive coronary disease. He was discharged home with a plan for outpatient follow-up.

No, the proposed inpatient admission was not medically necessary.

This patient presented for evaluation of chest pain. The diagnosis of an acute myocardial infarct (MI) was ruled out by cardiac enzymes, which were negative. The patient had a history of an abnormal stress test as outpatient with findings of a low ejection fraction (EF). Echocardiogram in the hospital revealed normal ejection fraction (EF), and catheterization revealed no obstructive coronary disease. There was no evidence of acute myocardial infarction, acute coronary syndrome (ACS), decompensated congestive heart failure (CHF), malignant arrhythmia or hemodynamic instability. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission and the care required could have been provided at a lower level of care.
Appeal type: Formulary Exception
Decision: Upheld

Central Nervous System. 
Pharmacy/prescription drugs. 

Diagnosis: Migraine. 
Treatment: DHE (Dihydroergotamine) nasal spray. 

The insurer denied DHE (Dihydroergotamine) nasal spray. The health plan's determination is upheld. 

The patient is a woman with migraine headaches. Treatment with DHE (Dihydroergotamine) nasal spray is the subject of this review. The patient is treated with Botox and Topamax for migraine prevention. 

The formulary alternatives include DHE injection, almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan injection, sumatriptan nasal spray, sumatriptan tablet, zolmitriptan, Nurtec ODT, Zembrace Symtouch, and Zomig nasal spray. 
There is only documentation that the member has tried and failed Maxalt and Nurtec ODT. 

The remaining formulary alternatives have not been tried and failed and are likely to be as effective as the requested drug. The formulary options include triptans. Relatively few trials have compared the triptans head to head, making it difficult to decide whether to use one versus another. A meta-analysis of 53 clinical trials of the oral serotonin agonists that included over 24,000 patients concluded that all of the available oral drugs are effective and well tolerated. The highest likelihood of consistent success was found with rizatriptan (10 mg), eletriptan (80 mg), and almotriptan (12.5 mg). The findings of a subsequent network meta-analysis suggested that eletriptan was the most likely of all the triptans to produce short-term and sustained benefit. The member has only tried and failed one triptan but not other triptans which are considered highly effective such as eletriptan and almotriptan. 

Furthermore, the formulary options include the same medication, DHE as an injection. This medication has the same mechanism of action of DHE nasal spray.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems.
Treatment: Dental/Orthodontic Procedure.
The insurer denied treatment of braces. The denial is overturned.

The patient is a female with an anterior crossbite on teeth 6 and 7. She presented with a skeletal Class I malocclusion with minor crowding in the maxilla and minor crowding in the mandible. She is treatment planned for orthodontics to address the crowding and crossbite, but the treatment was denied due to lack of medical necessity. The subject under review is the medical necessity for the treatment of braces.

The health plan's determination is overturned.

The requested treatment of braces is medically necessary for this patient. This patient presents with an anterior crossbite on teeth 6 and 7, as well as crowding. 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. (1, 2, 3)
If left untreated, the damage that will likely occur to the patients teeth will be much more time consuming and difficult to correct than the patient's existing orthodontic problem. For this reason, treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Eucrisa 2% ointment. 
The denial was upheld.

The patient is a female with atopic dermatitis. The patient has tried and failed topical triamcinolone, 0.1%, as well as Fluocinonide, 0.05%, and Protopic 0.1%. The patient has responded to Eucrisa ointment samples. 
At issue is the medical necessity of Eucrisa 2% ointment.
The health plan's determination of medical necessity is upheld in whole.
No, the requested health service/treatment of Eucrisa 2% ointment was not medically necessary for this patient.
Six weeks of compliant and adherent use of combined Tacrolimus, 0.1% therapy and topical corticosteroids have not been sufficiently documented for this atopic dermatitis patient. Current medical literature reviews [1-4] acknowledge United States Food and Drug Administration (FDA) approval for moderate to severe atopic dermatitis, and likely greater relative effectiveness of Tacrolimus over Eucrisa. Eucrisa has an FDA approved indication only in mild to moderate atopic dermatitis and is relatively less efficacious compared to Tacrolimus. Tacrolimus is FDA approved for moderate to severe atopic dermatitis. The patient reported burning, but the side effects of Tacrolimus application are normally temporary and are often related to the extent and amount of skin disease for Tacrolimus to control. Accordingly, until such time that compliant and adherent use of both Tacrolimus and concurrent topical steroid therapy has been sufficiently demonstrated, Eucrisa is not medically necessary for this patient.
Therefore, the requested health service/treatment of Eucrisa 2% ointment for the treatment of Atopic Dermatitis is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: anterior crossbite 
Treatment: Braces/treatment visits
The insurer denied braces/treatment visits. 
The health plan's determination is overturned. 

The patient in question is a male with an anterior crossbite on tooth 10. He presents with a skeletal Class I malocclusion with crowding in the maxilla and in the mandible. He is treatment planned for 30-36 months of orthodontics with the extraction of a lower incisor to address the crowding and crossbite. Under review is the medical necessity of braces and treatment visits.

Braces and treatment visits are medically necessary for this patient.
This patient presents with an anterior crossbite on tooth 10, as well as significant crowding. 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.
If left untreated the damage that will likely occur to the patient's teeth will be much more time consuming and difficult to correct than the patient's existing orthodontic problem. For this reason, the requested treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back Pain.
Treatment: Injections (64483 x2, 64484 x2).
The insurer denied the Injections (64483 x2, 64484 x2).
The denial is overturned. 

The patient is a female with low back and radicular pain. She has MRI (magnetic resonance imaging) findings of a herniated disc causing radiculopathy. The patient underwent an ESI (epidural steroid injection) with greater than 50% relief for almost three months.

Yes, the Injections (64483 x2, 64484 x2) are medically necessary.

ESI (epidural steroid injections) are used to treat symptomatic radicular pain when conservative treatments have failed. The patient's MRI (magnetic resonance imaging) and exam are consistent with her symptoms. She has failed conservative treatment in the form of NSAIDs (nonsteroidal anti-inflammatory drugs) and home exercise.  ESIs (epidural steroid injections) are much less invasive than surgical treatments such as microdiscectomy or laminectomy.  The patient had greater than 50% relief for three months. Given the above, the requested repeat ESI (epidural steroid injection) is medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Migraine headache disorder.
Treatment: Formulary exception for Nurtec 75mg. 
The insurer denied the Formulary exception for Nurtec 75mg. 
The denial is upheld. 

The patient is a female with migraine headache disorder. She has tried and failed acetaminophen and rizatriptan for migraine abortive therapy. Her provider is requesting Nurtec for acute treatment of migraine.

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

The patient has only tried one preferred formulary medication, rizatriptan. There is no documented reason provided with regard to why the patient cannot be treated with the preferred formulary agents. All of the preferred agents are FDA (Food and Drug Administration)-approved for acute treatment of migraine headaches and are considered first line, standard of care, abortive agents (Thorlund et al.).  There are no high-quality clinical trials or standard of care guidelines supporting the preferential use or superiority of Nurtec relative to the preferred agents.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Heart Problem. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital admission for medical necessity. 
The denial was overturned. 

The patient is a male born with severe pulmonary valve stenosis and a small ostium secundum atrial septal defect (ASD). He underwent Balloon valvuloplasty of his pulmonary valve with excellent results. He has been followed with a small Secundum ASD. He recently was found to have pulse oxygen saturations in the low 90's along with bidirectional shunting on echocardiogram instead of the usual left to right shunting. It was therefore decided to take him to the cardiac catheterization laboratory to get hemodynamics and possible closure of the ASD.
In the cardiac catheterization laboratory, he was found to have a larger defect (10 millimeter (mm)) on balloon sizing. It was therefore decided to place a 27 mm Gore ASD occluder. He underwent the procedure without event and was admitted to the hospital and discharged the next day without any complications.
At issue is the medical necessity of the inpatient hospital admission.
The health plan's determination of medical necessity is overturned in whole.
Yes, the requested health service/treatment of inpatient stay was medically necessary for this patient.
It is routine clinical practice and the normal standard of care to admit a patient after a device closure in the cardiac catheterization laboratory for one day. This allows to watch for potential early complications such as dislodgement of the device. In addition, the patient had evidence of right to left shunting with low pulse oxygen saturations prior to device closure. This needed to be monitored after the ASD was closed to watch for dangerous complications. Also, per MCG guidelines, up to one day of a hospital stay is allowed after a device closure.
Therefore, the inpatient stay was medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion
Treatment: D8080 Braces And D8670 Monthly Visit x 12
The insurer denied the D8080 Braces And D8670 Monthly Visit x 12.
The denial is overturned. 

The patient is a male requesting orthodontic benefits.

Yes, the D8080 Braces And D8670 Monthly Visit x 12 are medically necessary. 

The patient has a crossbite between teeth #s 10 and 22 (lower left canine). This means the upper tooth is "inside" of the lower tooth, which is backwards to what it should be. According to the handicapping index scale, an anterior tooth in crossbite with gingival (gum) attachment loss is an "automatic qualifying" condition. This case, therefore, has medical necessity. The monthly follow up visits are also medically necessary to do any necessary adjustments to treatment as the case progresses.