Persius/hicric huggingface dataset:
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis:  Attention Deficit Hyperactivity Disorder.
Treatment:  Quillivant XR (methylphenidate ER).

The insurer denied Quillivant XR (methylphenidate ER).  The health plan's determination is upheld.

This is the case of a young male with attention deficit hyperactivity disorder (ADHD) prescribed Quillivant XR (methylphenidate ER [extended release]) 8ml (milliliters) daily.

The provided documentation indicates the patient has been on the requested medication for 5 years with good effect. He has previously tried Ritalin 5 milligrams (mg) which was ineffective. The Provider also notes shortages/unavailability of certain medications.

A formulary exception is not indicated in this case. Based on the documentation provided, including the plan formulary alternatives, there is insufficient evidence that the formulary drugs will be ineffective or have adverse effects, compared to the non-formulary drug. The patient has ADHD and has been on Quillivant XR liquid for 5 years. The only documented other medication that was trialed and ineffective was Ritalin. There are multiple available formulary medications, which would be expected to be effective, and which can be opened and sprinkled for administration.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Head injury
Treatment: Inpatient Hospital Stay.
The insurer denied Inpatient Hospital Stay.
The determination is overturned.

 
The patient is a female who had no past medical history. She presented to the emergency room where she was admitted to the inpatient service.
Two days prior to admission, she was riding on the handlebars of a bicycle being ridden by her friend when she fell off, hitting the right side of her head on concrete. She had no loss of consciousness or seizure activity, but she vomited after the fall, and had further vomiting. She complained of a headache, which was persistent, and she had increased sleepiness. She complained of fullness in the right ear. Her parents were away from home at the time of the accident, and she did not inform them about the incident until their return home.
In the emergency room, she was noted to be alert and oriented. Her temperature was noted to be elevated at 101.9 degrees Fahrenheit (F), but vital signs were otherwise normal. Her neurological examination was documented to be normal, but she had right sided parietal soft tissue swelling with subcutaneous emphysema.
She was evaluated by the trauma service, and also by the neurosurgery and neurology teams. 
A computed tomography (CT) scan of the head was performed, which was abnormal, showing a nondisplaced fracture of the right temporal bone extending through the mastoid air cells. 
She was given acetaminophen for pain, and intravenous fluids were administered, with diet as tolerated given her persistent vomiting. A repeat computed tomography (CT) scan and CT angiogram were performed. The studies did not show evidence of venous sinus thrombosis.
She was discharged home with neurology and neurosurgery follow-up, and recommendations for a follow-up computed tomography (CT) scan or magnetic resonance imaging (MRI). She was to return to the emergency room if she had deterioration in her symptoms.
At issue is whether full hospital admission was medically necessary.

The requested health service/treatment of full hospital admission was medically necessary for this patient. She had a head injury two days prior to admission. She had persistent symptoms, with vomiting, a headache, increased sleepiness, and complaints of fullness of the right ear. She had an elevated temperature of 101.9 degrees F, a sign of a possible infection. Her CT scan was abnormal, showing a non-displaced fracture of the right temporal bone extending through the mastoid air cells. There was a small amount of mastoid fluid as well as air within the right transverse sinus, and minimal air in the left transverse sinus.
The finding of air in the transverse sinuses mandated the need for close observation and follow-up imaging with CT and CT angiogram, looking for infarct or venous sinus thrombosis. Schlimp et al. describes that: "Cerebral venous air embolism (CVAE) is reported more frequently and may be associated with poor neurological outcome or even mortality." Evaluation for cerebral venous thrombosis or infarct was medically necessary, as if found, anticoagulation or surgical intervention may have been indicated [3].
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis
Treatment: Inpatient Admission

The insurer denied coverage for inpatient admission.  The denial is upheld. 
 
The patient has a past medical history significant for gastric sleeve, status-post gastric sleeve revision, esophageal stricture, gastroesophageal reflux disease (GERD), anxiety disorder, panic attacks, and opiate dependence who presented to the emergency department with complaints of drainage from the percutaneous endoscopic gastrostomy (PEG) site.

Vitals on presentation included: temperature (T) 97.6 Fahrenheit (F), blood pressure (BP) 109/84, pulse (P) 69, respiratory rate (RR) 18, oxygen (O2) saturation 99% on room air (RA). Laboratory results included the following: white blood cell (WBC) count 9.1, hemoglobin (Hgb) 11.1, hematocrit (Hct) 38.3, and glucose-101.

The patient was started empirically on intravenous antibiotics (Vancomycin and Zosyn) for possible cellulitis around the gastrostomy tube (G-tube). A computed tomography (CT) scan showed mild subcutaneous stranding around the G-tube, but no fluid collection/abscess. Bariatric surgery consulted and recommended that no surgical intervention was required. They noted, "doubt utility of antibiotics...". The patient remained afebrile and hemodynamically stable. The patient decided to leave the hospital against medical advice (AMA).

According to documentation, the patient presented with possible cellulitis from the G-tube site. Otherwise, the patient was afebrile and hemodynamically stable, with unremarkable laboratory results, including a normal WBC. The patient had no evidence of a disseminated infection, and a surgical intervention was unnecessary. Based on the above findings, the patient met the criteria for an observation level of management. 

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 the full the hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male with a medical history of hypertension and hyperlipidemia. He presented to the emergency department with nausea, vomiting, diarrhea; he had nausea for several days and hypotension. His vital signs were notable for a low blood pressure of 81/46 millimeters of mercury (mmHg). The physical examination was notable for a soft, nontender, nondistended abdomen with hyperactive bowel sounds. Lab results showed an unremarkable complete blood count, low sodium of 133, low potassium of 3.0, elevated blood urea nitrogen of 57 milligrams per deciliter (mg/dL), elevated creatinine of 3.0 mg/dL, and elevated lactate of 3.3. A computed tomography scan of the abdomen and pelvis showed no bowel obstruction or inflammatory process, and two hyperenhancing areas in the left renal upper pole. He was treated with intravenous fluids (including a bolus of 4 liters), ciprofloxacin, metronidazole, and potassium. He reported ongoing diarrhea; he was tolerating a diet well. He felt significantly better. He was discharged on  ciprofloxacin and metronidazole. He was assessed to have viral gastroenteritis during the stay, but a culture ultimately found Salmonella. 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 nausea, vomiting, diarrhea, and hypotension initially assessed as having viral gastroenteritis, with a finding of Salmonella on stool pathogen testing. He was appropriately maintained on antibiotic therapy with supportive care [1-4]. However, there was no persistent hypotension (which responded to fluid resuscitation), gastrointestinal bleeding, severe diarrhea, or other severe complications of infectious colitis. The care provided, including monitoring, labs, imaging, and empiric and then directed antibiotic therapy, could have been provided without the inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion

Treatment: D8080 braces, D8670 monthly visit, and D8680 retainer

The insurer denied coverage for D8080 braces, D8670 monthly visit, and D8680 retainer

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 overjet, open bite, posterior crossbite and anterior crowding among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 32 total points. 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 requirement on the HLD index attaining 16 points by internal reviewers. The patient's orthodontist is appealing the decision on behalf of the patient.

Upon review of the submitted documentation (study models were not provided for review) it is evident that the patient exhibits a significant malocclusion. However, to access for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York requires, as of September 1, 2012, the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program), modeled after Handicapping Labiolingual Deviation Index. 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 32 points to justify orthodontic care. This reviewer concurs with the index completed by the orthodontist which remains above 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. 
 
The healthcare plan did not act reasonably and with sound medical judgement and in the best interest of the patient.

D8080 braces, D8670 monthly visit and D8680 retainer is considered medically necessary for this patient.

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 D8080 braces, D8670 monthly visit, and D8680 retainer is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain and diarrhea
Treatment: Inpatient Admission
The insurer denied: Inpatient Admission
The denial is upheld.

This is an adult female patient who presented to the emergency room with worsened abdominal pain and diarrhea for four days. The patient had an episode of blood mixed with stool. She had a history of B12 deficiency. Her hemoglobin was 6.7. She was transfused one unit of packed red blood cells (RBCs). She was admitted and given vitamin B12 intramuscularly times one (x1) and then 1000 micrograms (mcg) orally. Gastrointestinal (GI) was consulted and noted a history of elevated calprotectin. Gastrointestinal recommended outpatient evaluation with 
capsule endoscopy and computed tomography (CT) or magnetic resonance (MR) enterography. The patient's abdominal pain and diarrhea resolved.

The requested health service was not medically necessary.

The patient did not have hemodynamic instability, severe pain requiring acute inpatient management, or peritoneal signs. The patient did not require identification of etiology or finding; or evaluation requiring the patient to not eat or drink for extended period (e.g., more than 24 hours). The patient did not have inability to maintain oral hydration (e.g., needs intravenous fluid support) that persists after observation care; and did not have suspected toxic megacolon. The patient did not have bacteremia. The patient did not require a procedure that could not have been performed on an ambulatory basis. Therefore, the requested health service was not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Idiopathic scoliosis. 
Treatment: Spinal Surgery (Procedure code 0657T). 
The insurer denied the Spinal Surgery (Procedure code 0657T). 
The health plan's determination is overturned. 

The patient is a male with progressive adolescent idiopathic scoliosis. Because of curve progression and skeletal immaturity, surgical intervention was recommended. Curve pattern, flexibility and skeletal immaturity allowed the patient to be a candidate for Vertebral Body Tethering. 

The Spinal Surgery (procedure code 0657T) performed is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. This device is indicated for skeletally immature patients that require surgical treatment to obtain and maintain correction of progressive idiopathic scoliosis, with a major cobb angle of 30 to 65 degrees whose osseous structure is dimensionally adequate to accommodate screw fixation, as determined by radiographic imaging. Patients should have failed bracing and/or be intolerant to brace wear. This procedure is currently considered standard of care in the discussion of treatment options for progressive scoliosis in skeletally immature adolescents with scoliosis.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Idiopathic scoliosis. 
Treatment: Spinal Surgery (Procedure code 0657T). 
The insurer denied the Spinal Surgery (Procedure code 0657T). 
The health plan's determination is upheld. 

The patient is a male with adolescent idiopathic scoliosis (AIS). He was taken to the operating room (OR) for anterior vertebral body tethering T (thoracic) 6-L (lumbar) 2 for a diagnosis of AIS. No intraoperative complications were reported. 

The Spinal Surgery (procedure code 0657T) performed is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. 
Unfortunately, the only clinical information provided is the operative report. There is no description of the magnitude of the curve, the flexibility of the curve, or the progression of the curve provided. The Risser stage is unknown. While there is substantial support within the orthopaedic literature for vertebral body tethering, given the lack of clinical information provided in this case example, the procedure is not indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Idiopathic scoliosis. 
Treatment: Spinal Surgery (Procedure code 0657T). 
The insurer denied the Spinal Surgery (Procedure code 0657T). 
The health plan's determination is upheld. 

The patient is a young male with adolescent idiopathic scoliosis and a curve of unknown magnitude. The extent of skeletal maturity of the patient is unknown. An orthopedic surgeon recommended and performed a thoracoscopic anterior vertebral body tethering procedure. 

The Spinal Surgery (procedure code 0657T) is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. 
Although beneficial results have been achieved with the vertebral body tethering procedure in properly-selected patients, there is insufficient information provided in the records to determine whether the patient would be an appropriate candidate for this procedure. There is no reason, given the information provided, to believe that vertebral body tethering would be more beneficial than other forms of surgical treatment for adolescent idiopathic scoliosis, such as posterior spinal fusion with instrumentation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope, Seizures
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

This is a female patient who initially presented to the emergency department with concerns for lightheadedness and a fall. The pertinent history included a seizure disorder, schizoaffective disorder, diabetes mellitus, and chronic obstructive pulmonary disease.  An electrocardiogram (EKG)was without acute ischemic changes or significant conduction abnormalities. Musculoskeletal radiographs were relatively unremarkable. A chest radiograph was unremarkable. A computed tomography (CT) scan of the head was unremarkable. The patient was admitted to the hospital with an impression of syncope versus near syncope versus breakthrough seizures. Orthostatic vital signs were negative. The treatment plan included telemetry, home medications, and monitoring for falls. The patient was discharged with a couple of adjustments to home medications. At issue is the medical necessity of an inpatient admission.
Based on the clinical documentation provided, evidence based literature and standards of care, acute inpatient level of care was not medically necessary for the entire admission. Evaluation and management could have been performed at a lower level of care.

The patient had a history of a seizure disorder and schizoaffective disorder who presented with recurrent falls and associated lightheadedness. Initial examination documented the patient as alert, oriented, hemodynamically stable, and without focal neurologic deficits. Initial evaluation including laboratory testing, electrocardiography, and CT imaging was relatively unremarkable. Treatment plan was primarily observation and adjustment of home medications. Physical medicine and rehabilitation (PM&R) consulted and documented the patient was safe to discharge to home. There was no observed syncope, seizure, arrhythmias or other significant events during the hospital stay.
The clinical indications for admission to inpatient care were not met. The patient did not have hemodynamic instability, altered mental status, pacemaker or automatic implantable cardioverter defibrillator (AICD) malfunction, or severe or persistent dehydration. The patient also did not have a cardiac disease or finding (eg, results of echocardiogram or cardiac monitoring perform in observation care) that indicates necessity of immediate (eg, not elective) intervention (eg, AICD placement, electrophysiology study, surgery, or prolonged telemetry monitoring) as indicated by outflow tract obstruction, ventricular dysfunction, cardiomyopathy, significant valvular disease, subclavian steal syndrome, aortic dissection, cardiac tamponade, acute myocardial ischemia, sustained or symptomatic ventricular tachycardia, symptomatic conduction systemic disease, bradycardia or sinus pauses, atrial fibrillation with rapid ventricular response with outpatient medication titration inappropriate, or supraventricular tachycardia with outpatient medication titration inappropriate.[2]
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: dementia
Treatment: home health care
The insurer denied Personal Care Worker (PCW) Services: 7 Days per week, 12 Hours per Day - Total of 84 Hours per Week.
The health plan's determination is overturned.

This is a case review for a female with medical history notable for Alzheimer's dementia, mobility issues, and incontinence. The patient's neurologist provided a letter of support for this appeal. The letter states that the patient has Alzheimer's disease and is in progressive neurodegenerative decline. She requires hands-on assistance and prompting for all activities of daily living. She requires assistance with ambulation, toileting, transfers, bathing, medication management, and eating. 

The Personal Care Worker (PCW) Services: 7 Days per week, 12 Hours per Day - Total of 84 Hours per Week are medically necessary for this patient.
The most recent assessment was completed approximately 5 months ago. As detailed in the notes by the patient's care team, her condition has been dramatically declining over the course of the year. The patient's medical team provided documentation of a more accurate picture of her current level of functioning. As outlined in the letters, the patient requires personal care assistance with essentially all tasks throughout the day. She requires assistance both in completing tasks and also with cueing/prompting given her advanced dementia. The requested increase in hours is medically necessary to meet the patient's personal care needs. Failure to provide support for the patient's personal care needs could result in injury, skin breakdown, and/or infection.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Diabetes. 
Treatment: Insulin lispro Kwik pen unit (u) -100, 100 milliliter (ml) insulin pen. 
The insurer denied coverage for Insulin lispro Kwik pen unit (u) -100, 100 milliliter (ml) insulin pen. 
The denial is upheld. 

This is an adult diagnosed with Type 1 diabetes mellitus over 10 years ago. This request is for Insulin lispro Kwik pen unit (u) -100. As per the appeal letter, the patient has been well-controlled for the past few years. Insulin lispro Kwik pen allows for calculations based on the patient's blood glucose and insulin-to-carbohydrate ratio (ICR). The patient's most recent hemoglobin A1c (test of average 2 to 3 months of blood sugar control) was 6.1 %. 

There are no studies demonstrating the superiority of one rapid-acting insulin analog over another. 
There was no evidence of a previous trial of the formulary alternative Humalog. 

The formulary drug is not expected to cause adverse effects. 

The formulary drug was not tried, and the patient did not have an adverse reaction or contraindication. 

The formulary drug is not expected to be ineffective. 

The non-formulary drug is not expected to be more effective than the formulary alternatives. 

The carrier's denial of a request for a Formulary Exception for Insulin lispro Kwik pen unit (u) -100, 100 milliliter (ml) insulin pen to treat diabetes is upheld.