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

Diagnosis: Malocclusion

Treatment: Retainer

The insurer denied coverage for Retainer

The denial is overturned

 
The submitted documentation for review includes pre and postoperative intraoral and extraoral, montage of clinical images/photographs, panoramic and cephalometric radiographs and insurer correspondence. It appears that this patient underwent orthodontic treatment for management of a significant malocclusion. The patient is being treated by an orthodontist who initiated treatment years ago. The patient has completed years of orthodontic treatment and is ready for removal of the orthodontic appliances with retention to be maintained with a retainer. The insurer has denied the retainer prosthesis stating that there remain issues with the patient's occlusion that needs to be corrected prior to approval of a retainer. The orthodontist is appealing the decision stating that the malocclusion has been corrected and a retainer is necessary.

Upon review of the clinical and radiographic documentation, the patient exhibited a significant malocclusion prior to initiation of orthodontic care. As of the most recent clinical photographs provided for review it appears that this malocclusion has been corrected and that removal of the orthodontic appliance is indicated with maintenance of the corrected occlusion with a retainer. There did not appear to be any significant issues or residual malocclusion that would necessitate continued fixed orthodontic appliance care. This reviewer concurs with the orthodontist that the malocclusion has been corrected and the standard of care moving forward would be for a retainer as recommended.

Overturn the denial and approve coverage for a retainer as this would be the standard of care as the orthodontic care is complete and the malocclusion has been corrected.

Based on the above, the insurer's denial must be overturned. 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 a retainer is substantiated.
Appeal type: Formulary Exception
Decision: Upheld


Diagnosis: Diabetes Mellius.
Treatment: Januvia.
The insurer denied Januvia.
The determination is upheld.

The patient is a female diagnosed with Type 2 diabetes mellitus (DM) with hyperglycemia. This request is for Januvia. The provider states she cannot take Tradjenta due to interaction with her tacrolimus (required for transplant). She has done well on Januvia in the past. As issue is whether the formulary drug, Tradjenta, will be or has been ineffective, would not be as effective as the non-formulary drug, Januvia, or would have adverse effects.
The health plan's determination is upheld in whole.
The formulary drug, Tradjenta, would not be ineffective or less effective when compared with the nonformulary drug, Januvia. Januvia and tacrolimus have a recommendation to monitor therapy risk rating C that is identical to the interaction between tacrolimus and Tradjenta. Therefore, the patient can try the formulary alternative Tradjenta.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Rheumatoid Arthritis
Treatment: Cimzia starter kit
The insurer denied the Cimzia starter kit
The determination is overturned.

The is a female patient with rheumatoid factor (RF) positive, cyclic citrullinated peptide (CCP) positive rheumatoid arthritis (RA). Cimzia is being denied by the health plan. The reason for denial is that the patient has not tried formulary medications. Per a rheumatology office note, the patient has tried Plaquenil and prednisone. She had an intrauterine fetal demise at 20 weeks. She is trying to conceive again. At issue is whether the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug, Cimzia starter kit, or would have adverse effects.
The health plan's determination is overturned in whole.
The patient has rheumatoid arthritis (RA) and is trying to conceive. Tumor necrosis factor (TNF) inhibitors can be safely used in pregnancy. As per UpToDate, 'tumor necrosis factor (TNF)-alpha blockers may be used in women who require these medications for the maintenance or establishment of control of active inflammatory disease during pregnancy. Some expert guidance suggests these medications should be discontinued in the late second or early third trimester. However, use of these drugs can be extended, if necessary, to a later gestational age if benefits outweigh potential risks for an individual patient. Certolizumab is compatible for use throughout pregnancy. Only very limited information is available regarding golimumab'. As published in Semin Arthritis Rheum in 2019, 'managing RA during pregnancy is challenging, because treatment options are limited. Accumulating evidence shows the safety of Tumor Necrosis Factor inhibitors in pregnant RA patients and patients with a wish to conceive'.
Cimzia is the ideal treatment option given plans to try to conceive again as it can be safely used throughout the duration of pregnancy in all 3 trimesters. Rinvoq, Xeljanx and Kevzara are contraindicated as there is a lack of data with these drugs and pregnancy. In terms of Enbrel and Humira, these can be safely used during pregnancy; however, some expert guidance suggests these medications should be discontinued in the late second or early third trimester. This is why the non-formulary drug (Cimzia) is recommended, as it can be safely used throughout all 3 trimesters as placental transfer is minimal. The patient has RF positive (140) and CCP positive (greater than [&gt;] 250) RA and requires treatment beyond Plaquenil and prednisone, and Cimzia would be the first choice for the patient's RA at this time given the plans to conceive.
Appeal type: Experimental/Investigational
Decision: Overturned

Reviewer #2:

Diagnosis: Patent foramen ovale (PFO)

Treatment: procedure code 93580, transcatheter closure of a PFO using a cardiac occlusion device

The insurer denied coverage for procedure code 93580, transcatheter closure of a PFO using a cardiac occlusion device

The denial is overturned

This is the case of an adult with a history of recent thalamic stroke and symptoms of right face and arm weakness that occurred after straining on the toilet.  Work up revealed no evidence of atrial fibrillation on a thirty day monitor and no evidence of significant intracranial vascular disease. Transesophageal echocardiography (TEE) revealed a patent foramen ovale (PFO) with a right to left shunt. The patient was referred for PFO closure.

Closure of a PFO with right to left shunt in a patient with arterial embolic events (and no other etiology that clearly explains arterial emboli) would be considered more beneficial for this patient than any other therapy.  

It is the best available therapy for the patient at this time.  In a meta-analysis of 5 randomized clinical trials including over 1800 patients, patent foramen ovale closure reduced recurrent stroke or transient ischemia attack (TIA) compared with medical therapy (Reference 1) This patient suffered from a cerebral embolic event that occurred following Valsalva maneuver and is at high risk for recurrent cerebral emboli. 

Several randomized clinical trials support the use of transcatheter PFO closure in patients that have no other obvious etiologies that may cause thromboembolic events.  These trials have demonstrated a significant reduction in thromboembolic events and stroke in patients that undergo PFO closure as compared to those treated with anti-thrombotic medication alone. (References 2 - 4). 

This procedure is the best available treatment for the patient at this time.

In conclusion, the peer reviewed literature and multiple clinical trials support the use of transcatheter PFO closure in this patient. Current guidelines support the use of PFO closure in this setting and it is likely to be more beneficial than medical therapy alone for preventing recurrent stroke.(Reference 5 - 6)

The denial of procedure code 93580, transcatheter closure of a patent foramen ovale (PFO) using a cardiac occlusion device and coverage for the requested service/treatment should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Upheld

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

This is a male patient with a medical history of esophageal strictures with the most recent dilation, gastroparesis, prior alcohol abuse, diabetes mellitus type 2, neuropathy, hypertension, hyperlipidemia, deep vein thrombosis and pulmonary embolism on Eliquis, anxiety, and depression. He presented to the emergency department with the inability to swallow food or liquid for 2 days, with dysphagia, esophageal obstruction, and multiple episodes of vomiting and retching. Lab results showed a low potassium of 3.4 millimoles per liter (mmol/L). A gastroenterology consultation recommended nil per os (NPO), esophagogastroduodenoscopy with possible dilation, and hold anticoagulation. The esophagogastroduodenoscopy showed an esophageal stricture, which was dilated and biopsied. He was discharged upon tolerating a pureed diet, on Eliquis, pantoprazole, and sucralfate, with a plan for primary care and gastroenterology follow-up. At issue is the medical necessity for the inpatient level of care.

The inpatient level of care was not medically necessary. The patient presented with dysphagia and the inability to tolerate oral intake consistent with esophageal stenosis, which was confirmed on endoscopic visualization. Esophageal dilation was effective. Esophagogastroduodenoscopy is recommended for the evaluation of dysphagia, and dilation of stricture was appropriate [1-4]. However, there were no complications, such as esophageal perforation, mediastinitis, or severe bleeding. The care provided, including labs, monitoring, and esophagogastroduodenoscopy with dilation, could have been performed in sequence after presentation at a lower level of care than inpatient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rule out cerebrovascular accident (CVA)

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
This case involves an adult who presented to the emergency department (ED) reporting numbness to the nose, mouth, and the back of the ears and heaviness in the mouth described as a feeling like a Novocain injection was given.  Vital signs were relatively stable.  She had a body mass index of 33.  Glasgow coma score was 15.  The patient described an acute onset of left-sided numbness that began a few days prior that affected the top of her lip and some numbness to the back of the neck.  She stated that the day before she presented, she had an episode of double vision.  Initial telehealth assessment reported mild bilateral upper extremity drift and decreased sensation to light touch on the left side of the face, arm, and leg.  She reported feeling some decreased sensation to the right cheek as well.  The report said the patient was inconsistent with history, the symptoms have been occurring on and off since 4 days prior, but also claimed that symptoms worsened at times with no headaches, weakness, visual changes, nausea, or vomiting.  The neurological examination stated the patient was alert and oriented x3 with no facial droop.  She had decreased sensation to the left upper and left lower extremities as well as the right face, slightly decreased left hand grip compared to the right.  Showed a normal gait without assistance with normal skin.  Computed tomography (CT) of the brain was ordered and showed no evidence of abnormality.  The report stated that a stroke code was activated when the patient arrived to the emergency department with a blood pressure reading of 130/80.  The treatment plan was for telemetry monitoring, administration of aspirin, imaging, checking labs, and obtaining electrocardiogram (EKG) with troponins, echocardiogram, with neurological assessment.  The patient was admitted whereupon she underwent additional testing and assessment for the cause of her condition.  She remained in inpatient status in telemetry until discharge in stable condition.  

According to the Milliman Care Guidelines (MCG), the patient was not a candidate for inpatient admission based upon the provided documentation.  While she presented with complaints of numbness to the left side of the face and had findings of left-sided numbness to the extremities, she did not display any other significant signs or symptoms of neurological dysfunction to justify inpatient admission.  The patient's care to include examinations, testing/work-up, and treatment could have been rendered on an outpatient or observational basis.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: short stature
Treatment: Nutropin
The insurer denied Nutropin. 

The health plan's determination is overturned.

The patient is a male diagnosed with idiopathic short stature (ISS). His growth hormone (GH) stimulation test with glucagon and L-dopa (levodopa) peaked at 15. His mother's height is 162.56 cm (centimeters) as well as his father and his mid parental height is 169.06 cm (-1.09 SDS). Under review is the medical necessity of Nutropin AQ.

Nutropin AQ is medically necessary for this patient.
Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines. The Food and Drug Administration (FDA) approval for this indication is for "non-growth hormone-deficient short stature, defined by height standard deviation score (SDS) less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means."
The patient had a pretreatment height less than or equal to -2.25 SD. The patient's height velocity and bone age would not allow the patient to reach a normal adult height. The request therefore meets idiopathic short stature criteria. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Progressive Supranuclear Palsy (PSP). 
Treatment: Home Health Care. 

The insurer denied Consumer Directed Personal Assistance Program (CDPAP) Personal Care Services (PCS) - Housekeeping/Personal Attendant - Level One and Level 2: 56 Hours per Week. The health plan's determination is overturned. 

This is a case review for a female with medical history notable for progressive supranuclear palsy (PSP). The patient and her care team requested an increase to 56 hours per week, and this request was denied by the health plan. 

The requested Consumer Directed Personal Assistance Program (CDPAP) Personal Care Services (PCS) - Housekeeping/Personal Attendant - Level One and Level 2: 56 Hours per Week is medically necessary for this patient. 

The patient has a progressive and terminal neurodegenerative condition. She is now reliant on others for all activities of daily living (ADL) and her dementia has advanced. Her physician attested that additional home health hours are necessary to meet her personal care needs. She has been receiving a great deal of informal support from her family, but they have been documented to be reaching the limits of their support. The patient clearly has extensive personal care needs and additional care is appropriate to provide her with the requisite support.
Appeal type: Medical necessity
Decision: Upheld

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

This case involves a male admitted to the hospital with right lower extremity cellulitis. The symptoms began three weeks before this presentation, with an outpatient PCP (primary care provider) evaluation and initiation of treatment with Keflex. The symptoms did not improve, and the patient was limping. The previous assessment was a duplex study that was negative for a deep vein thrombosis (DVT). The leg edema persisted. Vital signs appeared normal in the emergency department (ED), except for elevated blood pressure of 171/100. On exam, the patient is obese, not ill or toxic appearing. He had 1+ pitting edema to the right foot and leg. The ED felt there was low suspicion of osteomyelitis.

The inpatient hospital admission was not medically necessary.
Based on the documentation from the emergency department, admission history and physical, and the discharge summary, the acuity of illness does not appear to satisfy inpatient admission criteria. The patient is described as nontoxic, not ill-appearing, with persistent leg edema. Imaging revealed no evidence of DVT (deep vein thrombosis). The patient had been treated with Keflex, typically a first-line cellulitis treatment, and did not fully improve. After receiving a dose of vancomycin and cefepime, an infectious disease specialist recommended one dose of dalbavancin and no further antibiotic therapy on discharge. There was no clinical evidence of an abscess, extensive wound, compartment syndrome, or sepsis. The patient was released within 24 hours to have an outpatient follow-up. Treatment of this condition can be managed at a lower level of care without the need for inpatient hospitalization.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroenteritis.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

The patient presented with abdominal pain and vomiting. The patient was afebrile (without fever), and the vital signs were stable. There was no abdominal rebound or guarding. The potassium was 3.1. The renal function was normal. An abdominal Compute Tomography scan showed inflammatory changes in the colon and mild mesenteric inflammation as well as a possible liver hemangioma. The patient was diagnosed with colitis. Intravenous (IV) hydration with potassium supplementation and antiemetics were given. Stool testing was ordered. The urine toxicology was positive for cannabinoids. The diet was able to be advanced and the patient signed out against medical advice (AMA). 

Medical necessity was determined using Milliman Care Guidelines (MCG) M-170 for Gastroenteritis. Clinical indications for admission include having a suspected severe infection such as bloody diarrhea, peritoneal signs, hemodynamic instability, severe vomiting, severe dehydration, persistent severe electrolyte abnormalities, and an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

This patient had gastroenteritis. IV hydration, proton pump inhibitor (PPI) therapy, antiemetics, and stool testing could have been done in the emergency room with observation status. The diet was able to be advanced. The patient did not meet MCG criteria for admission for Gastroenteritis. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient admission is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld


Diagnosis: Low back pain.

Treatment: procedure to treat low back pain (procedure codes 64628 &amp;64629).

The insurer denied coverage for procedure to treat low back pain (procedure codes 64628 &amp; 64629).

The denial is overturned.

This case involves an adult with a history of lupus and low back pain who is being considered for the Intracept procedure.  Magnetic resonance imaging (MRI) of the lumbar spine identified right paracentral disc herniation at lumbar (L)4-L5 causing right lateral recess stenosis and posterior displacement of the right L5 nerve root.  There was underlying spondylitic change with complete bone edema.  There was Modic type I endplate degenerative changes along with central disc herniation at L5-sacral (S)1 indenting the ventral epidural fat with no stenosis.  In addition, there was a broad disc herniation at L3-L4 with posterior annular fissuring and no stenosis.  The patient was seen regarding chronic low back pain that began after a motor vehicle accident.  She endorsed episodic pain radiating down the right lower extremity into the buttock and hamstring.  Pain also radiated down the left buttock and into the foot with some localized left groin pain that is tender to palpation.  She had left anterior thigh numbness with pain ranging in severity from 5-10/10 on the visual analog scale.  She was following with pain management and was started on gabapentin 300 milligrams (mg) 2-3 times a day reporting significant improvement in leg pain.  The patient also tried physical therapy, chiropractic treatments, massage, and multiple lumbar epidural steroid injections without any significant long-term relief.  On physical examination, the patient was neurologically intact distally.  She had positive left sacroiliac joint tenderness to palpation with positive compression and provocative testing in addition to paraspinal muscle spasms.  The physician stated there appeared to be no clear spinal etiology to explain the left leg pain.  Concerns were discussed that this may be a left sacroiliac joint related.  

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome.

The procedure to treat low back pain (procedure codes 64628 &amp;64629) has final approval from the appropriate regulatory bodies for this diagnosis.

The patient is a good candidate for the procedure to treat low back pain (procedure codes 64628 &amp;64629).

The procedure to treat low back pain (procedure codes 64628 &amp;64629) is one of the best available treatments for this patient at this time.

The adverse risks are not increased over standard treatment/services.

The requested service is likely to be as beneficial or more beneficial than any of the standard treatments/procedures for this patient.

In summary, the denial of procedure to treat low back pain (procedure codes 64628 &amp;64629) and coverage for the requested treatment should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.