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

Diagnosis: Nonfamilial Hypogammaglobulinemia

Treatment: Healthcare Common Procedure Coding System (HCPCS) J1559 Hizentra 1 gram/5 milliliters (mL) syringe, 30 grams by injection every 2 weeks for one year = 300 HCPCS units per dose for a total of 7800 HCPCS units

The insurer denied coverage for Healthcare Common Procedure Coding System (HCPCS) J1559 Hizentra 1 gram/5 milliliters (mL) syringe, 30 grams by injection every 2 weeks for one year = 300 HCPCS units per dose for a total of 7800 HCPCS units.

The denial is upheld.

The patient has a diagnosis of common variable immunodeficiency (CVID) associated with inflammatory bowel disease and a history of chronic sinusitis. Her then dose of Hizentra was 15 gm (gram) every 2 weeks. Immunoglobulin G (IgG) level was 1446 milligrams per deciliter (mg/dL). Her IgG was 1100 mg/dL. She has protective titers for streptococcus pneumococcus but her lymphocyte immunophenotypes show some abnormalities. She was previously on Remicade. According to the note from allergy/immunology her "CVID [Common variable immunodeficiency] by itself is rather mild with no major infections low dose SCIG [subcutaneous immunoglobulin G]". The rationale for higher Hizentra dosing appears to be for an "anti-inflammatory dose" related to her inflammatory bowel disease.  

According to UpToDate, "On other disorders in CVID - Gastrointestinal infections and/or complications are relatively unaffected by immune globulin replacement, for reasons that are not well understood. Immune globulin replacement therapy may exert a protective effect in those with autoimmune disease, although it is not known to alter the development of malignancy or to impact granulomatous disease [3,12]."

The patient appears to have a reasonable treatment dose for common variable immunodeficiency without evidence of poor trough IgG levels or breakthrough infections. The argument for a high Hizentra dosing for her bowel disease is not supported by current literature.

Based on the above, the medical necessity for the Healthcare Common Procedure Coding System (HCPCS) J1559 Hizentra 1 gram/5 milliliters (mL) syringe, 30 grams by injection every 2 weeks for one year = 300 HCPCS units per dose for a total of 7800 HCPCS units prescribed for the diagnosis of D80.1 (nonfamilial hypogammaglobulinemia) is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain. 
Treatment: Inpatient admission. 

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

The member is a female who underwent an inpatient hospital admission. The member had a history of obesity, GERD (gastroesophageal reflux disease), cervical cancer, biliary colic and gallstones. The member reported severe abdominal pain with nausea and emesis. Gallstones and the suggestion of a porcelain gallbladder were noted. The member received intravenous (IV) pain medication. The member was admitted with the differential of gastritis versus acute cholecystitis. The member received supportive care and improved and was discharged the following day. 

No, the care as provided was medically appropriate but the level at which the care was provided was not medically necessary. 

Despite the member's presentation the care as provided could have been rendered in its entirety at a lower level of care. The member had a abdominal pain; yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for NPO (nothing by mouth) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission.  As such the care could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity
Treatment: Weight reduction surgery (procedure code 43775) and inpatient stay
The insurer denied coverage for weight reduction surgery (procedure code 43775) and inpatient stay.
The denial is upheld. 

This female patient has a history of anxiety, depression, fibromyalgia, Hashimoto's disease, hypothyroidism, migraines, peptic ulcer disease, and obesity.

The insurer has denied coverage for weight reduction surgery (procedure code 43775) and inpatient stay (date of service to be determined) as not medically necessary. They stated in a final adverse determination letter that the records tell us that the ratio of your height and weight (BMI) is less than 40. The patient also has sleep apnea. Medical studies have shown that weight loss surgery improves patient outcomes in patients with a BMI of 35-40 if they also have (life threatening) medical problems (complications of obesity). Those medical problems can include high blood pressure, diabetes, and severe sleep apnea (AHI [apnea-hypopnea index] scores over 30). Because weight loss surgery for patients with a BMI of 35-40 and no (life threatening) medical problems has not been proven to improve your health, it is not medically necessary for you. Because they cannot approve the operation, they cannot approve a hospital admission. They based this decision on the health plan clinical guidelines (CG), Surgery for clinically severe obesity (CG-Surg-83).

This patient has a BMI of 37 approximately and does not have obesity hypoventilation syndrome as she has only mild obstructive sleep apnea (OSA) with an AHI of 6.6 and oxygen (O2) saturation of 88%. There is also no evidence that the patient demonstrated reliable participation in preoperative multidisciplinary behavior modification program (for example, preparation for postoperative diet and exercise regimens). Thus, the patient does not meet MCG (Milliman Care Guidelines) criteria.

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

The carrier's denial of coverage for the weight reduction surgery (procedure code 43775) and inpatient stay is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic venous insufficiency, factor V (mutation of clothing in the blood)  Leiden, left calf deep vein thrombosis and phlebitis

Treatment endovascular ablation therapy of incompetent extremity veins

The insurer denied coverage for endovascular ablation therapy of incompetent extremity veins

The denial is overturned

This case involves a male who was seen for a follow-up regarding a longstanding history of chronic venous insufficiency as well as left calf vein deep vein thrombosis (DVT) and phlebitis.  He was being seen with recurrent bilateral lower extremity edema and left leg phlebitis.  He has factor V Leiden positive and does utilize daily aspirin.  He reported he has had a several week history of leg discomfort and edema.  He does utilize compression stockings with minimal relief and has previously undergone a reflux study demonstrating chronic thrombus to the small saphenous vein.  The physical examination revealed clotted varicosities to left medial calf.  The physician indicated the patient has left leg phlebitis after travel which is resolving.  He has chronic lipodystrophy changes and edema causing him discomfort despite compression.  He is a candidate for a left greater saphenous vein radiofrequency ablation.  Duplex indicates there is 5.2 seconds of reflux at the saphenofemoral junction (SFJ).  The physician indicated there is evidence of left great saphenous vein reflux from the saphenofemoral junction to the knee.  There was chronic thrombus to the gastrocnemius veins and small saphenous vein.

This patient with Factor V Leiden deficiency, left calf DVT to the small saphenous vein(SSV), and phlebitis, who also has chronic left leg venous insufficiency.  He has tried compression stocking therapy and conservative management without improvement.

Venous reflux study is an essential part of the workup and it revealed clear evidence of reflux at the left SFJ and entire greater saphenous vein (GSV) visualized. The left SSV is chronically occluded as the history provides.

The left SFJ and GSV reflux is a classic indication for ablative therapies such as the requested left GSV thermal ablation is medically indicated and necessary.
The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for endovascular ablation therapy of incompetent extremity veins is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Symptomatic Fibroids
Treatment: Inpatient hospitalization
The insurer denied coverage for inpatient hospitalization.
The denial is upheld.

The patient is an adult female with a history of symptomatic fibroids who underwent a laparoscopic hysterectomy. The patient tolerated the surgery well and the procedure was uncomplicated. Blood loss was 100 cubic centimeters (cc). The patient was stable post-operatively.

Laparoscopic hysterectomies are outpatient procedures unless a complication arises. Admission becomes necessary if the patient is febrile, hypotensive, bleeding, has difficulty breathing or the severity of the pain is such that admission is necessary. According to Milliman Care Guidelines (MCG), Inpatient and Surgical Care 24th Edition, Laparoscopic Hysterectomy, a laparoscopic hysterectomy is an ambulatory procedure. An inpatient stay may be needed for surgical complications (bladder ureter or bowel injury or hemorrhage), conversion to abdominal hysterectomy, complex surgery (staging of endometrial cancer), wound complications or comorbidities.

This patient did not have any of these criteria. Her procedure was uncomplicated. There was no evidence of any injury to other organs. Postoperatively, the patient was stable. Nothing in the operative report or the progress notes suggested any serious problem that warranted admission. Please note that laparoscopic hysterectomy is an outpatient procedure and includes appropriate postoperative monitoring and an overnight stay if required.

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

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

Diagnosis: Rheumatoid Arthritis and Atopic Dermatitis

Treatment: Rinvoq 15 milligrams (mg)

The insurer is denied coverage for Rinvoq 15 milligrams (mg).

The denial is overturned. 

This case involves a female who has a history of undifferentiated connective tissue disease manifesting with seronegative rheumatoid arthritis as well as patchy alopecia and sicca disease.  The documentation indicated she has been previously treated with methotrexate and Enbrel.  She has also been treated with Dupixent for atopic dermatitis; however, she discontinued use given the ineffectiveness.  She did report pain as well as swelling and stiffness to her hands, back, and neck which have worsened since therapy was discontinued.  The physician indicated she also has increasing elevations in inflammatory markers.  A biologic is required for treatment of her condition given the severity of disease and prior robust response to biologic therapy.  The documentation indicated there was also no evidence that the recommended medication Kevzara would be effective in treating atopic dermatitis which is why the requested Rinvoq is a better option.

Based on the medical records available the patient has inflammatory arthritis manifested by seronegative rheumatoid arthritis and atopic dermatitis, the requested Rinvoq is appropriate because there is good pre-liminary data indicating that Rinvoq will address both conditions.

The reviewer is aware that the Food and Drug Administration (FDA) has not approved Rinvoq for atopic dermatitis.  However, preliminary evidence is very promising and as such that would appear appropriate to offer this medication to this patient. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for Rinvoq 15 milligrams (mg) for the treatment of rheumatoid arthritis and atopic dermatitis is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia
Treatment: Consumer Directed Personal Assistance To 37 Hours Per Week
The insurer denied the increase in consumer directed personal assistance to 37 hours per week.
The denial is upheld.

This female has conditions including dementia, insomnia, and depression.  She is appealing denial of increase in consumer directed personal assistance to 37 hours per week.  She has been approved for 27 hours per week.  There is a reported social change as friends are not able to help as usual.  

An appeal letter from the provider notes the patient has significantly declined cognitively and functionally.  Ambulation is minimal.  Increased fall risk.  Cognitively unable to be alone.  Requires home attendant due to increasing dementia.  Must be supervised constantly.  Appeal statement form the patient notes loss of vision in both eyes.  States cognitively can't be alone because not safe.

No, the proposed treatment is not medically necessary.

Personal assistance services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs), health maintenance activities, and routine support services.  This patient has dementia.  She is appealing denial of increase in consumer directed personal assistance to 37 hours per week due to reported social change, as friends are not able to help as usual.  She has been approved for 27 hours per week.  Appeal letters note the patient has declined cognitively and functionally.  Notes the patient requires constant supervision due to cognitive impairment.  There is inadequate documentation supporting increased needs for physical functioning.  Personal assistance services are not indicted when no tasks are being performed.  Personal assistance services are not indicated for supervision.  The proposed increase in consumer directed personal assistance to 37 hours per week is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overjet, Overbite, and Anterior Crowding.

Treatment D8080 braces and D8670 monthly visit x (times) 6.

The insurer denied coverage for D8080 braces and D8670 monthly visit x 6.

The denial is overturned.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical. images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified overjet, overbite, an anterior crowding. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 26 total points. 

Upon review of the submitted documentation 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, an HLD 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 completes the second portion of the index arriving at 26 points to justify orthodontic care. This reviewer concurs with the index completed by the orthodontist attaining a total of 26 points on the HLD index (6 overjet, 5 overbite, 10 anterior crowding, 5 labiolingual spread) which meets the threshold of 26 points to support orthodontic care.

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 the 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 health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The clinical circumstance as presented does meet and substantiate the medical/dental necessity of orthodontic care as it meets the accepted criteria for approval.

The insurer's denial of coverage for D8080 braces and D8670 monthly visit x 6 is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atypical chest pain. 
Treatment: Inpatient stay. 

The insurer denied coverage for inpatient stay. 

The denial is upheld. 

The patient presented to the hospital with chest pain.  Relevant past medical history included hypertension and thyroid cancer.  Upon arrival to the Emergency Department (ED) vital signs were stable (blood pressure (BP) 141/80 and pulse 66).  No significant abnormalities were noted on physical examination.  Twelve-lead electrocardiogram (ECG) revealed no acute ischemic changes and serial serum troponin levels were within normal limits (below 0.05 ng/ml [nanogram per milliliter]).  Echocardiogram revealed a normal left ventricular ejection fraction at 55-60% [percent] and concentric left ventricular hypertrophy.  She underwent cardiac catheterization and non-obstructive disease was noted. She was discharged home on medical therapy with a diagnosis of atypical chest pain. 

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.  This patient presented with atypical chest pain and no significant past medical history. Her pretest probability of coronary artery disease is low. (Reference 1) Utilizing the HEART (History, ECG, Age, Risk factors, Troponin) score she was considered low risk. (Reference 2) Utilizing the thrombolysis in myocardial infarction (TIMI) risk score she also had a low risk of developing major adverse cardiac events in the subsequent 30 days. (Reference 3) Risk assessment of patients presenting with chest pain and no significant ST (interval on ECG) changes on ECG was reviewed by Hedayati et al. (Reference 3).  Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation.  Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation.  In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary. 

In conclusion, this patient could have been treated at a lower level of care. The health plan acted reasonably with sound medical judgment in the best interest of the patient. 

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

Diagnosis: Status post anterior cervical discectomy with fusion at C5-C7. 
Treatment: Inpatient admission. 

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

The patient is a female who was admitted for anterior cervical discectomy and fusion at C5-7(cervical).  Surgery went uneventfully.  The patient had a drain placed intra-operatively and was monitored overnight.  Pain management was consulted. She was discharged home the following day. 

No, the proposed inpatient hospital admission was not medically necessary. 

A one- and two-level anterior cervical discectomy and fusion can typically be performed as an outpatient procedure. An observation level of care is appropriate if a drain is placed, although drains are usually not indicated and there is no good data to support better outcomes with drains. The patient did not have any complications requiring an inpatient stay and the patient was comfortable on an oral pain medication regimen. The patient did have a drain, but this did not require inpatient admission. There was no indication for an inpatient stay. 

This procedure is typically performed as an outpatient procedure and at the most an observation level of care. An inpatient stay is rarely required unless there is a complication or if the patient has multiple medical comorbidities.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: A20 Haploinsufficiency With Recurrent Fever. 
Treatment: Kineret. 

The insurer denied the Kineret. 
The denial is overturned. 

This case involves a female with a rare autoinflammatory disease known as A20 haploinsufficiency (HA20).  Her disease is characterized by recurrent episodes of fever lasting up to two weeks that are debilitating.  There is no Food and Drug Administration (FDA) approved treatment specifically indicated for HA20.  Her board-certified pediatric rheumatologist has requested to use anakinra (Kineret). 

Yes, the proposed treatment with anakinra is medically necessary. 

This patient has a rare genetic autoinflammatory disease known as A20 haploinsufficiency (HA20), characterized by a mutation in the TNFAIP3 (TNF Alpha Induced Protein 3) gene leading to recurrent fevers.  There is no Food and Drug Administration (FDA) approved medication that is specifically indicated for HA20.  There is literature available that demonstrates safe and effective use of the interleukin-one (IL-1) recombinant antagonist anakinra in patients with HA20 (A20 haploinsufficiency). 

Therefore, anakinra should be considered medically necessary for this patient. 

Anakinra has been proven to be a safe and effective medication for treatment of patients with HA20 (A20 haploinsufficiency) (see references below).  There are no FDA approved therapies specifically indicated for HA20 (A20 haploinsufficiency).  Therefore, the denial of anakinra for this patient should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: vomiting, an inability to tolerate PO intake, and ketosis.

Treatment: inpatient hospital admission

The insurer is denied coverage for inpatient hospital admission

The denial is overturned. 

This female patient has a history of asthma and cannabinoid hyperemesis.

Clinical indications for admission for Vomiting- Milliman Care Guidelines (MCG) 370 include having vomiting that is severe or persistent. This is defined as having continued vomiting after appropriate antiemetic treatment in observation care. In this case, by day 3 of the hospitalization the patient had only minimal oral intake while receiving multiple doses of IV antiemetics.

This patient had persistent vomiting while on antiemetic treatment. This met Milliman Care Guidelines (MCG) criteria for inpatient admission.

The health plan did not act reasonably with sound medical judgment, and 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.