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

Diagnosis: Right knee osteoarthritis, knee replacement surgery.
Treatment: Inpatient Hospital Stay.
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

This is a female patient with a history of right knee osteoarthritis. She failed conservative management of this condition and opted to undergo elective right total knee replacement surgery. The surgery was successful with no documented complications. The patient was admitted to the hospital after surgery for postoperative care and supervised physical therapy. She was subsequently discharged to subacute rehabilitation. At issue in this case is the medical necessity of the inpatient hospital stay.

The provided records in this case document that this patient underwent elective right total knee replacement. The surgery was successful with no documented complications. The patient had normal vital signs and lab values following this operation. There was no documentation of postoperative infection or excessive bleeding. There were no signs of deep vein thrombosis after surely that would have necessitated a three-night inpatient hospital admission. The records indicate that the patient was accepted to a rehabilitation (rehab) center. There is no documentation in the records as to why the patient needed an additional night in the hospital until her discharge to rehab. Therefore, based upon the provided documentation, the inpatient hospital stay was not medically necessary in this case.
The current, peer-reviewed literature has found that a short hospital stay following elective joint replacement surgery is preferable. A recent article published by Kirkland and colleagues in the Journal of Arthroplasty in 2020 found that "Increased length of stay was associated with increased readmission risk. Patients with greater medical comorbidities stay longer to protect against readmission. Optimal length of stay (LOS) after total joint arthroplasty (TJA) is highly influenced by the patient's overall health. Despite a 300 percent (%) increase in TJA daily cost, readmission rate has changed minimally over the last 15 years." A second peer-reviewed article published by Leroux and colleagues in the Journal of Bone and Joint Surgery in 2020 concluded that "When comparing matched cohorts of patients who underwent short-stay and longer-stay total hip arthroplasty (THA) or total knee arthroplasty (TKA), we observed no difference in outcomes, suggesting that a short stay with a discharge home in the appropriately selected patient is safe following THA or TKA." Therefore, based upon the documentation in this case and the conclusions of this peer-reviewed research, the inpatient hospital admission in this case was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary Tract Infection
Treatment: Inpatient Admission

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

The patient is a child who presented to the emergency room (ER) with fever, left flank pain, abdominal pain, nausea, and sore throat. The patient was noted to have significant left flank pain on the exam as well as persistent fever (102.6 degrees Fahrenheit), tachycardia (130's), and tachypnea (30's). The urinalysis (UA) and urine culture were abnormal. 

The patient was treated as having pyelonephritis with intravenous (IV) fluids and IV antibiotics. The clinical status improved. The patient was discharged with oral antibiotics. The patient was treated with one antibiotic, and there was no need for multiple antibiotics. Also, even though the patient's heart rate (HR) was 135, that could be attributed to the fever and slight dehydration. There were also no clinical signs or symptoms of urosepsis. Also, there were no congenital urological abnormalities or nephrolithiasis, and the patient is greater than (>) 1 year old. No multidrug-resistant organisms were noted in the urine culture. The patient responded to first-line antibiotics, and there was no need to administer sequential or multiple antibiotics. The patient remained hemodynamically stable with a normal mental status and a Glasgow Coma Score (GCS) of 15. Due to the above facts, the patient could have been managed in observational status. 

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

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

Diagnosis: Dental Disorder
Treatment: Braces and monthly visits
The insurer denied braces and monthly visits.
The determination is overturned.

The patient is a female with an anterior crossbite on tooth 6. She presents with a skeletal Class I malocclusion with minor crowding in the maxilla and the mandible. She is treatment planned for orthodontics to address the crowding and crossbite, but the treatment was denied due to a lack of medical necessity. At issue is the medical necessity of braces and monthly visits.

This patient presents with an anterior crossbite on tooth 6. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular teeth that can lead to periodontal defects. (1-3) If left untreated, the damage that will likely occur to the patient's teeth will be much more time consuming to correct than the patient's existing orthodontic problem. For this reason, the treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: malocclusion		

Treatment: braces

The insurer denied orthodontic care

The denial is Overturned

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, dental treatment noted as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified anterior crossbite among other findings. The orthodontist has completed the Handicapping Labiolingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. The insurer has detailed coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the requirements of the HLD index needed to approve braces. Dr. Kuncio is appealing on behalf of the patient.

It is evident that the patient exhibits a significant malocclusion. However, to assess the severity of the malocclusion and therefore medical/dental necessity for orthodontic care, Handicapping Labiolingual 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 crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. 

This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does meet insurer and plan criteria to justify 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. 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. 

Reverse denial as the clinical circumstance as presented does meet and substantiate the medical/dental necessity of orthodontic care as it meets the accepted criteria for approval.

Based on the above, the insurer's denial must be reversed. 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 braces, monthly visit, and retainer services is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebral vascular accident
Treatment: Personal Care Aide (PCA) services: 10 hours/day, 7 days/week, total amount of 70 hours/week 
The insurer denied PCA services: 10 hours/day, 7 days/week, total amount of 70 hours/week.
The health plan's determination is overturned. 

This is a female patient with vascular dementia, history of a cerebrovascular accident (CVA) with left hemiplegia and hemiparesis, hypertension, unsteady gait, essential tremor, osteoporosis, depression, and urinary incontinence. 

Personal Care Aide (PCA) services: 10 hours/day, 7 days/week, total amount of 70 hours/week are medically necessary for this patient.

There is documentation in the Uniform Assessment System (UAS) of the patient requiring extensive assistance with toilet use and limited assistance with walking, locomotion, and transfer toilet. Therefore, the patient has unscheduled and unpredictable care needs that span a continuum of time and the plan failed to document a plan to meet these unscheduled and unpredictable care needs. A tasking tool should not have been used to calculate hours given that the patient has unscheduled and unpredictable care needs. There is documentation from the patient's PCP (primary care provider) of the medical necessity of increased PCA services.

The patient lives with her husband and therefore has informal support. However, it cannot be assumed that the informal support person can provide all needed care outside of the approved PCA hours as informal supports must be voluntary. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with activities of daily living (ADLs).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:	Chest Pain	

Treatment: 	Hospital admission

The insurer denied inpatient admission

The denial is overturned

This gentleman with a history of single vessel coronary artery disease, heart failure with reduced ejection fraction, hypertension, chronic kidney disease and active cocaine use presented to the hospital complaining of chest pain and near syncope with a fall.  Upon arrival, the patient reported no further chest pain. Vital signs were stable (Blood Pressure 140 over 101 (140/101), pulse 99).  Physical examination revealed no significant abnormalities aside from a superficial laceration of one finger.  12 lead electrocardiogram revealed normal sinus rhythm without ischemic ST or T wave abnormalities.  Serum blood testing revealed no elevation of troponin. Urine toxicology testing was positive for cocaine.  Computed tomography (CT) of the head and neck demonstrated no acute intracranial or cervical pathology. The patient was admitted to the hospital for observation and treatment.  Following a negative work up the patient was treated with guideline directed medical therapy and discharged home with follow up.

The health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.  This patient presented with intermittent chest pain in the setting of active cocaine use. His pretest probability of coronary artery disease is high. (Reference 1)  

Utilizing the Thrombolysis in Myocardial Infarction (TIMI) risk score he 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 changes on electro electrocardiogram (ECG) was reviewed by Hedayati et al. (Reference 2, 3).  

Using the HEART (History, Electrocardiogram, Age, Risk factors, and Troponin) 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.  However, this patient presented to the hospital with near syncope and head trauma.  Given the history of heart failure and a left ventricular (LV) ejection fraction of 25 percent (%), this patient falls into a high-risk category for syncope.  Moreover, this patient was actively using cocaine.  Investigators studying more than 300,000 hospital admissions for chest pain in the setting of cocaine abuse, found that patients over age 50, with concomitant heart failure and valvular disease had the highest risk of major adverse cardiac events and mortality. They concluded that such patients did require hospital admission. (Reference 4) In conclusion, admission to the hospital to treat an acute cardiac event was medically necessary in this case.

Based on the above, the insurer's denial must be reversed. 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 inpatient admission is substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Glaucoma
Treatment: Lumigan
The insurer denied Lumigan.
The health plan's determination is overturned.

The patient is an old male with severe stage primary open angle glaucoma (POAG) for whom coverage of Lumigan (bimatoprost) 0.01% (percent) is the subject of review. Reportedly, the patient has demonstrated an allergy to Alphagan, latanoprost, Travatan Z, and travoprost while he has used Lumigan successfully for over 4 years. 

A formulary exception in this case is indicated.
Li, T., et al. (2016) assessed the comparative effectiveness of first-line medical treatments in patients with POAG or ocular hypertension through a systematic review and network meta-analysis, and to provide relative rankings of these treatments. "The mean reductions (95% [percent] credible intervals) in IOP (intraocular pressure) in millimeters of mercury at 3 months ordered from the most to least effective drugs were as follows: bimatoprost 5.61 (4.94; 6.29), latanoprost 4.85 (4.24; 5.46), travoprost 4.83 (4.12; 5.54), levobunolol 4.51 (3.85; 5.24), tafluprost 4.37 (2.94; 5.83), timolol 3.70 (3.16; 4.24), brimonidine 3.59 (2.89; 4.29), carteolol 3.44 (2.42; 4.46), levobetaxolol 2.56 (1.52; 3.62), apraclonidine 2.52 (0.94; 4.11), dorzolamide 2.49 (1.85; 3.13), brinzolamide 2.42 (1.62; 3.23), betaxolol 2.24 (1.59; 2.88), and unoprostone 1.91 (1.15; 2.67)." Myers et al. (2014) found that reductions in IOP from latanoprost baseline were larger with bimatoprost 0.01% (percent) than with bimatoprost 0.03%(percent).
Therefore, all of the formulary drugs would be expected to be less effective than the requested Lumigan at lowering intraocular pressures, and the patient has already experienced adverse effects to latanoprost and travoprost.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Intermittent claudication of the right lower extremity 
Treatment: Vascular Procedure
The insurer denied Vascular Procedure.
The determination is overturned.

The patient is a male with coronary artery disease, chronic obstructive pulmonary disease (COPD), degenerative disc disease, hyperlipidemia, and hypertension, with bilateral lower extremity claudication who was seen in follow up where his computed tomography angiography (CTA) of the abdomen, aorta and runoff was reviewed.
The patient was noted to have an occlusion of the right distal superficial femoral artery (SFA) and 60 percent (%) stenosis of the distal left SFA.
The patient was diagnosed with atherosclerosis of native arteries of extremity with intermittent claudication, right leg. The provider recommended right leg angiogram with possible intervention. At issue is the medical necessity of vascular procedure (Current Procedural Terminology (CPT) 37220, 37221, 37224, 37226, 37228).

Yes. The requested health service/treatment of Vascular Procedure is medically necessary for this patient.
The patient has intermittent claudication of the right lower extremity requiring treatment. National practice guidelines are referenced below. (1,2)
The proposed treatment, right lower extremity angiogram with possible intervention, is the standard of care for the treatment of intermittent claudication.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Migraine
Treatment: Nurtec ODT
The health plan denied: Nurtec ODT
The determination is: Overturned

The patient is a female with acute migraine. Treatment with Nurtec orally disintegrating tablets (ODT) is the subject of this review. The drug was previously denied because there was no documentation that the member had tried and failed the required formulary alternatives. The clinical notes provided indicate that the patient has tried and failed sumatriptan and Ubrelvy.
At issue is the non-formulary drug Nurtec ODT.
The health plan's determination is overturned in whole.
The requested Nurtec ODT is for treatment of acute migraine. Therefore, the formulary drugs of Ajovy, Emgality, and Qulipta will not be effective for treatment of the patient's condition because these drugs are not Food and Drug Administration (FDA) approved for treatment of acute migraine. These drugs are only FDA approved for prevention of episodic and chronic migraine.
The only formulary alternative for acute treatment of migraine is Ubrelvy. The patient indicates that she has previously tried and failed Ubrelvy, and this medication was ineffective.
Appeal type: Medical necessity
Decision: Upheld


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

The patient is a male with a history of bipolar disorder, anxiety, and pars defect with spondylolisthesis who presented with 2 days of difficulty breathing, productive cough, and arm and leg edema two weeks after stopping smoking.
In the emergency department (ED), temperature was 98.2, blood pressure (BP) 139/75, heart rate (HR) 94, respiratory rate (RR) 24, and oxygen saturation 92% room air (RA). He was not in distress, heart was regular, breathing comfortably with clear lungs, and he was alert and oriented. A computed tomography (CT) thorax found no pulmonary embolism (PE) but did find emphysema and a trace right upper pneumothorax, as well as a 5 millimeter (mm) right lower lobe (RLL) nodule. 

The Inpatient hospital admission was not medically necessary. The patient presented with dyspnea and was found to have chronic obstructive pulmonary disease (COPD) and a tiny, right-sided pneumothorax (PTX) felt to be related to recent cough. He was not hypoxemic but was started on oxygen to manage the PTX. He was not felt to need any invasive intervention by thoracic surgery.
By the next day, the pneumothorax had resolved. He was seen by thoracic surgery, pulmonary, and cardiology and not felt to have any other active issues. His main active issue was the PTX. For a tiny PTX that does not need intervention, a short period of observation is needed as the risk of worsening is quite low, and no close monitoring is needed. As such, a lower level of care would've been appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Heart Failure.
Treatment: Inpatient Stay.

The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a male, who presented to the emergency department (ED) complaining of dyspnea and worsening lower extremity edema. He admitted to noncompliance with his prescribed diuretic regimen. His medical history was remarkable for nonischemic cardiomyopathy, heart failure with reduced ejection fraction, asthma, syphilis, and polysubstance abuse. In the ED, his blood pressure was 127/87, with a heart rate of 105 beats/minute. His respiratory rate was 28/minute with a room air oxygen saturation of 97 percent (%). His physical exam was remarkable for abdominal distention and lower extremity edema. His brain (or B-type) natriuretic peptide (BNP) level was 2827. His serum troponin level was normal. The urine drug screen was positive for cocaine. The patient received a dose of intravenous furosemide with improvement in his dyspnea. He was admitted to the hospital for management of decompensated heart failure. 

Based on the documentation provided, an inpatient hospital admission was not medically necessary.

This man presented with dyspnea and acute decompensated heart failure. He was hemodynamically stable and did not have high-risk features such as systolic blood pressure less than (<) 100; electrocardiographic changes consistent with ischemia; cardiac troponin elevation; serum creatinine level greater than (>) 3, or significant hyponatremia. Based on his Emergency Heart Failure Mortality Risk Grade score, his 7-day mortality risk was very low. His symptoms improved with a dose of intravenous furosemide. Studies have shown that observation is safe and effective in stable heart failure patients, such as this man, without high-risk features, with similar outcomes, including readmission, repeat emergency department visits, and 30-day mortality, compared to those treated as inpatients. 

Thus, inpatient admission was not medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Endocrine
Pharmacy/prescription drug

Diagnosis: diabetes
Treatment: Tradjenta
The insurer denied Tradjenta
The health plan's determination is upheld. 

The patient is a male diagnosed with T2DM (type II diabetes mellitus). Tradjenta is being requested. As per the visit note, the patient is on Januvia, Tradjenta and metformin hydrochloride (HCL) 1000 milligrams (mg).

The formulary drugs will not be ineffective or have adverse effects and will be as effective as the non-formulary drug requested. A formulary exception is not indicated in this case.
There are no studies showing superiority of one DPPIV (Dipeptidyl peptidase-4) inhibitor over another including linagliptin (tradjenta), saxagliptin(onglyza), vidagliptin (galvus), alogliptin (Nesina) or sitagliptin (Januvia).
There are no studies showing superiority of the requested medication over the formulary alternatives. There is no documentation of failure of any of the formulary alternatives. The patient is currently on Metformin and Januvia in addition to Tradjenta with no documentation of failure. The remaining formulary alternatives would be as effective as the requested medication. The patient can try the remaining formulary alternative options.