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

Diagnosis: Gastroesophageal reflux disease (GERD)

Treatment: transoral incisionless fundoplication (TIF) procedure using EsophyX (code 43210) and associated inpatient stay

The insurer denied coverage for transoral incisionless fundoplication (TIF) procedure using EsophyX (code 43210) and associated inpatient stay

The denial is overturned

This case involves a female seen for follow-up of reflux esophagitis. The physician indicated prior imaging showed extensive reflux and sliding scale hiatal hernia. There was evidence of a 3 centimeter (cm) healed hiatal hernia with gastritis and small duodenal erosions. Esophageal pH (acid level) monitoring was negative; however, there was good correlation with heartburn. The patient was utilizing a proton pump inhibitor (PPI) twice a day and citalopram. She indicated that they helped; however, she continued to have symptoms. The major reported gastrointestinal (GI) symptoms were burning and chest pain. The physical examination revealed no significant findings. The physician indicated the patient could respond to surgical intervention; however, she should first undergo a 24-hour impedance test. The 24-hour ambulatory monitoring study revealed a DeMeester score of 17.6. The request has been received for transoral incisionless fundoplication (TIF) procedure using EsophyX (code 43210) with associated inpatient stay.

The scientific evidence in peer-reviewed literature does support a result of improvement in health outcome; there is an improvement in quality of life.

Transoral incisionless fundoplication (TIF) procedure using EsophyX (code 43210) does have final approval from the appropriate regulatory bodies for this diagnosis.

The patient is a good candidate for transoral incisionless fundoplication (TIF) procedure using Esophyx (code 43210).

Transoral incisionless fundoplication (TIF) procedure using EsophyX (code 43210) is the best available treatment for this patient at this time.

The patient has documented reflux with inadequate response to standard treatment. Her esophagitis is mild, and she does not have Barrett's esophagus. These clinical conditions make her an appropriate candidate for the procedure.

The carrier's denial of the transoral incisionless fundoplication (TIF) procedure using EsophyX (code 43210) and associated inpatient stay should be overturned.
Appeal type: Medical necessity
Decision: Overturned

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

The patient is a female with past medical history of hypothyroidism, fatty liver and Sjogren's syndrome, who was admitted for severe epigastric pain for 2 weeks duration. The patient was admitted for persistent epigastric pain and acute transaminitis. The patient's pain was thought to be related to possible pancreatitis. The patient was treated with intravenous (IV) fluids. Her pain was not controlled on Tylenol and Toradol therefore, she was treated with IV Ketamine and Dilaudid. A magnetic resonance cholangiopancreatography (MRCP) showed mild hepatic steatosis and no cholecystitis or biliary obstruction. The patient also underwent an esophagogastroduodenoscopy (EGD) which revealed nonbleeding gastric ulcer. 

The inpatient hospital admission was medically necessary. The patient presented with persistent and severe epigastric pain that had progressed since a prior recent admission. The patient meets indication for inpatient admission for severity of pain requiring IV opioids and poor tolerance to oral intake. Additionally, since imaging did not reveal the cause of the patient's pain, the patient necessitated an endoscopic procedural intervention and expert consultation with a gastroenterologist. The patient was unable to accommodate the procedure on an ambulatory basis due to worsening and progressive pain. Inpatient admission was indicated for the management of severe pain (refractory to Tylenol and Toradol), poor tolerance to oral intake and need for procedural intervention. Upper endoscopy is indicated for patients with epigastric pain that do not respond to treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial Fibrillation

Treatment: Full Hospital Admission

The insurer denied coverage for full hospital admission.

The denial is upheld.

The patient has a history of persistent atrial fibrillation (AF), hypertension, obesity and thyroid cancer.  Following a failed attempt at restoring sinus rhythm with direct current (DC) cardioversion, the patient was scheduled for an elective left atrial catheter ablation.  Pulmonary vein isolation with cavotricuspid isthmus ablation was performed without complication and the patient was discharged the following day.

The health plan did act reasonably, with sound medical judgment and in the best interest of the patient.  This patient presented to the hospital for an elective electrophysiologic study and ablation.  According to hospital records, the ablation was successfully performed without complication.  Observation following ablation was unremarkable and no post-operative issues were noted.  The patient was discharged home the following day.  In this case, there were no clinical reasons for hospital admission and the patient could safely be managed at a lower level of care.  In two multicenter registry studies looking at healthcare utilization after electrophysiological (EP) study and catheter ablation of atrial fibrillation, more than 80 percent (%) of patients undergoing ablation were hospitalized for a single day, regardless of age or co-morbidity. [1]  Several other investigators have demonstrated safety and feasibility of same day discharge or observation following AF ablation. [2,3]  Creta, et al studied more than 2600 patients undergoing ablation for atrial fibrillation.  In their study over, 700 patients were safely discharged on the same day as their procedure.  Only 0.7% of the study population required hospitalization for more than one day. [2]  The current standard of care in an uncomplicated atrial fibrillation ablation is to manage patients at a lower level of care.  Full hospital admission was not medically necessary.  The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.

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

Diagnosis: Tooth Decay
Treatment: White glass of metal crown - tooth #10
The insurer denied the white glass of metal crown - tooth #10.
The denial is overturned.

The patient is a male requesting a new crown on tooth number (#) 10.

Yes, the white glass of metal crown - tooth #10 is medically necessary.

The x-ray provided shows decay around the margin (edge) of the crown on tooth #10. The tooth will require a new crown once the decay is removed. Therefore, the white glass of metal crown - tooth #10 is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholecystitis

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

The patient presented to the emergency department with emesis and noted she had been losing weight.  The patient had nausea and vomiting for 2 weeks.  The pain was associated with right epigastric pain and anorexia for fear of vomiting and a weight loss of 25 pounds in the same period.  The vomitus was intermittent and related to after eating.  The patient mentioned that she either vomited or had to make a bowel movement after eating.  The physical examination revealed mild right-sided epigastric pain.  The assessment was, given the examination, the patient likely had cholecystitis or gallstone pathology.  There was a consideration for pancreatitis.  It was unlikely appendicitis, given the location.  The patient underwent an ultrasound indicating thick-walled gallbladder containing calculi likely due to cholecystitis.  The patient was admitted for a laparoscopic cholecystectomy.  The patient signed out against medical advice, as she wanted to transfer care to a different hospital with surgeons she was more familiar with.

The health care plan acted reasonably, with sound medical judgment, and in the best interest of the patient.  The inpatient hospital admission is not considered medically necessary for this patient. 

The patient's symptomatology was chronic and as such, the acute presentation did not reveal to be one that needs inpatient evaluation.  Her labs, imaging studies and clinical parameters did not indicate any acute condition or severe acuity that needed intervention. 

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

Diagnosis: Acute gastroenteritis

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is overturned. 

This male patient has a history of hypertension, hyperlipidemia, asthma, hypogonadism, and alcohol abuse.

Clinical indications for admission for Milliman Care Guidelines (MCG) Gastroenteritis (M-170) include having a suspected severe infection such as bloody diarrhea or being immunosuppressed. This patient was immunosuppressed and was on medications for his condition. The cluster of differentiation 4 (CD4) count was 90 a couple of months earlier. He previously had a severe cytomegalovirus (CMV) colitis and the D-Dimer (fibrin degradation product) was now markedly elevated. He had abnormal renal function. 

In view of the patient being immunosuppressed, he has met MCG criteria for admission for gastroenteritis. The healthcare plan did not act with sound medical judgement. An inpatient admission was medically necessary.

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

The carrier's denial of coverage for the inpatient hospital admission is overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male with a history of hypertension who presented to the emergency ward with the complaint of vertigo that was intermittent and worse with movement, improved with rest. At presentation he was noted to have asymmetrical nystagmus. Computed tomography (CT) at presentation was negative. The patient was admitted to the acute inpatient service. He improved and was discharged to home.

No, the proposed inpatient admission was not medically necessary.
The patient presented with position dependent vertigo consistent with benign positional vertigo. There were no concerning features on examination or history of present illness.  He was treated conservatively and his symptoms resolved. The diagnostic studies, clinical evaluation, monitoring and treatment could have been safely and effectively provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient stay
The insurer denied the inpatient stay.
The health plan's determination is upheld. 

The patient is a woman with history of atrial fib, hypertension, diabetes, dyslipidemia, chronic kidney disease, asthma, psoriasis, coronary artery disease (CAD), peripheral vascular disease, right foot cellulitis, osteomyelitis, and right third toe amputation due to gangrene, who presented to the hospital with a chief complaint of left-sided chest pain. She denied cough, fever, shortness of breath, headache, nausea and vomiting. She was taking Eliquis for anticoagulation. She rated the chest pain as eight out of 10 in severity. She also reported a mechanical fall four days earlier. She had a history of a recent cardiac cath that was abnormal. She had previously been offered percutaneous coronary intervention (PCI) for invasive obstructive coronary artery disease, but she refused and instead chose to pursue optimal medical management. Vital signs showed blood pressure 198/75, heart rate 72, and respiratory rate 18. On physical exam, heart was regular, breath sounds were normal, and the abdomen was soft and nontender. Labs showed white blood cell (WBC) count 4.4, hemoglobin 10.3, platelets 312, sodium 137, potassium 7.6, creatinine 2.57, and Troponin 0.08.

The patient was admitted for suspected acute coronary syndrome (ACS), mechanical fall, hypertension with diastolic heart failure, and atrial fibrillation.

The inpatient hospital stay was not medically necessary. The patient did present with concerning symptoms of chest pain with suspected ACS in the setting of elevated blood pressure. However, blood pressure improved with antihypertensive therapy and cardiac enzymes were negative. There was also no evidence of electrocardiogram (EKG) changes consistent with acute ischemia, no invasive intervention was recommended by cardiology given her previously stated preference for optimal medical management, and there were no other acute abnormalities. She needed further care but it could have been safely provided at a lower level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle Cell Crisis.
Treatment: Inpatient admission.

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

The patient in this case is a female with sickle cell disease. She was admitted to the hospital with a vaso-occlusive sickle cell crisis. She had presented to the emergency department with a complaint of generalized body pain involving chest, back and legs. She had also noted itching.  Symptoms had been present for two days before admission.  She had been taking Percocet at home with minimal relief.  At the time of admission she had normal vital signs and was not in any distress, eating pizza based on provided records.  Physical examination was notable for tenderness in the chest and also leg tenderness.  Laboratory studies were notable for hemoglobin of 6.6 grams per deciliter (g/dl).   Her creatinine was 1.8.   She was treated initially with Toradol, and due to continued pain she received two doses of intravenous (IV) Dilaudid along with Benadryl.  She had continued pain.  She also had a urine test done that revealed evidence of urinary tract infection.  She was admitted to the hospital for continued treatment of pain. As her transfusion threshold was noted to be 7.0 g/dl, transfusion was given.  

Day 2, the patient was sleeping and did not wake.  She was being treated with Percocet as needed for pain. She also had just been given Dilaudid and Benadryl before she was seen by the physician and was sedated and unable to carry on a conversation.  Given that, intravenous (IV) Dilaudid was stopped.  She was continued on antibiotic treatment for urinary tract infection.

Day 3, the patient signed out against medical advice.

No, the inpatient admission was not medically necessary.

This patient presented with pain but had normal vital signs, no respiratory compromise and also no evidence of active infection requiring hospital admission.  She had been diagnosed with urinary tract infection, but that did not require inpatient treatment.  She had no other acute medical condition documented in medical records. Furthermore, there was no documentation that she had severe pain requiring intravenous pain medications, as she is depicted as being comfortable when given pain medications and notably had excess sedation with use of intravenous (IV) pain medication that necessitated stopping intravenous pain medication and switching to oral pain medications.  There is no documentation provided that indicates this patient required acute care inpatient admission.  She could have been managed without hospital admission and treatment with oral pain medications.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute myopericarditis. 

Treatment: Acute inpatient hospital stay. 

The insurer denied coverage for acute inpatient hospital stay. 

The denial is upheld. 

This patient had no significant past medical history and presented to the emergency department (ED) with a 3-day history of intermittent chest and upper shoulder discomfort, radiating to his back, lasting a few minutes at a time, and worse with movement and certain positions.  Initial vital signs included blood pressure (BP) 117/72, heart rate 74, respiratory rate 16, oxygen saturation on room air 99% [percent], and temperature 98.6 Fahrenheit.  Laboratory test results included white blood cell (WBC) count 4.59, hemoglobin 14.4, creatinine 0.88, D dimer <150, and troponin 0.512, with subsequent troponin levels 0.577 and 0.592.  Electrocardiograms (EKG) were described as normal sinus rhythm, incomplete right bundle branch block, and with no acute ST-T wave abnormalities.  Chest X-ray was normal.  He was seen by cardiology, who recommended discharge to home if the initial troponin was normal, then again after the initial troponin level was noted to be mildly elevated.  Cardiology noted that symptoms were more consistent with musculoskeletal origin, but also noted that the elevated troponin may be related to myopericarditis.  No echocardiogram report was included, but there is a notation that it was unremarkable.  He was discharged on ibuprofen and omeprazole for outpatient follow-up. 

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

There is no evidence that this patient required an acute inpatient level of care to determine that his chest discomfort was not related to acute coronary syndrome or to initiate treatment for acute myopericarditis.  This should have been completed in the ED or at an observation level of care. 

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

Diagnosis: Psoriasis
Treatment: Skyrizi
The insurer denied the Skyrizi.
The determination is upheld.

The patient has moderate to severe psoriasis of the scalp, trunk, and extremities. The patient has tried and failed topical triamcinolone, clobetasol, and ketoconazole shampoo, as well as oral Otezla (no improvement for over a year, and with severe gastrointestinal (GI) side effects). At issue is the medical necessity of Skyrizi.

The Skyrizi is not medically necessary. The patient has no documented treatment failure with, or true medical contraindication to, standard, first-line systemic therapies such as either methotrexate or cyclosporine. These medications are as appropriate for a patient with a history of only topical therapy, as is the requested Skyrizi. Both methotrexate and cyclosporine can be monitored for patients with fatty liver and elevated cholesterol. Cholesterol elevation can be treated with statins to both allow for treatment response and to improve the likelihood of clinical improvement for any systemic therapy.

Modern dermatology literature [1-4] supports use of the health plan preferred medications as similarly efficacious to the requested Skyrizi, particularly for a patient with a limited history of systemic psoriasis therapy previously utilized and recommends use of these preferred agents as appropriate for this patient's clinical scenario. Therefore, as per current medical standards of care, Skyrizi is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hairy cell leukemia
Treatment: ZELBORAF (vemurafenib), Pre-service
The insurer denied the ZELBORAF (vemurafenib), Pre-service.
The denial is upheld.

The patient in this case is a man diagnosed with hairy cell leukemia. The diagnosis was based on bone marrow biopsy results. He was treated with pentostatin. He had six cycles, finishing that treatment. He was subsequently found to have slowly worsening neutropenia and thrombocytopenia. Bone marrow biopsy was done and revealed recurrent hairy cell leukemia. His physician has recommended treatment with rituximab plus vemurafenib. This was based on a recent publication in the New England Journal of Medicine that found this combination was associated with a 91% remission rate.

No, the treatment with ZELBORAF (vemurafenib) is not medically necessary.

The combination of vemurafenib and rituximab was shown to be active in a recently published phase 2 trial that enrolled 30 patients who had received multiple prior therapies. There is no evidence in any larger studies and no evidence comparing this regimen to standard treatment options in the second-line treatment setting. At the present time, this combination is not considered a routine standard second-line treatment option for patients with hairy cell leukemia. The NCCN (National Comprehensive Cancer Network) does not endorse it as a standard second-line treatment. It is not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems (crowding, cross bite, and deep impinging overbite). 
Treatment: D8080 braces; D86702 monthly visit x12. 

The insurer denied coverage for D8080 braces; D86702 monthly visit x12.  The denial is upheld. 

This is a male patient, who presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to crowding, cross bite, and deep impinging overbite. The orthodontist has completed the Handicapping Labio-Lingual (HLD) index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage to support orthodontic necessity. The insurer has denied coverage for orthodontic treatment as not medically necessary, as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining 17 points on review by internal reviewers. 

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 Labia-Lingual Deviation Index is utilized. This index provides six 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 automatic qualifying condition of deep
impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition criterion is not met, as there is no evidence of soft tissue damage and does not support comprehensive orthodontic care. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care. This reviewer concurs with the HLD index of the insurer attaining 17 points (3 points overjet, 6 points overbite, 5 points anterior crowding and 3 points labiolingual spread).

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach.  This is confirmed by several studies. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care.  As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.

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

The insurer's denial of coverage for D8080 braces; D86702 monthly visit x12 is upheld. Medical Necessity is not substantiated.