Persius/hicric huggingface dataset:
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.

This is a male patient with an anterior crossbite on teeth 7 and 10. He presents with a skeletal Class I malocclusion with moderate mandibular crowding. He is treatment planned for 24 months of orthodontics to address the crowding and crossbite. At issue is the medical necessity of braces and monthly visits.

This patient presents with an anterior crossbite on teeth 7 and 10, as well as significant crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. (1,2,3)
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: Chronic Low Back Pain

Treatment: Pain management (pain injection 64483) DOS (date of service) TBD (to be determined)

The insurer denied coverage for pain management (pain injection 64483) DOS (date of service) TBD (to be determined)

The denial is overturned

This patient has chronic low back pain. The patient has tried Aquatherapy, Physical therapy, Chiropractic therapy and transcutaneous electrical nerve stimulator (TENS). The patient's current medications include: Flexeril, Gabapentin, Tylenol #3, Duloxetine, Methacarbamol and Tramadol.  The patient also uses medical marijuana. The patient has had trigger Point injections. The Health Plan states that the patient does not have physical exam signs or imaging that support the use of an Epidural Steroid Injection, which is incorrect.

The patient's magnetic resonance imaging (MRI) shows a disc bulging into the right L (lumbar) 4-L5 foramen. Electromyelogram (EMG)/Nerve Conduction Velocity (NCV) shows mild right L4-L5 radiculopathy. The patient's pain scale is 6/10.

The patient has failed conservative therapy.  The patient's physical exam findings and imaging support the performance of an epidural steroid injection.

Clinical practice guidelines (1) and meta-analysis (2) support an epidural steroid injection in this patient, and it is medically reasonable and necessary.

L. Manchikanti and others (et al) published clinical practice guidelines (1) which state:

"Disc herniation: Based on relevant, high-quality fluoroscopically guided epidural injections, with or without steroids, and results of previous systematic reviews, the evidence is Level I".

Helm et al (2) conducted a meta-analysis and concluded: "Eleven randomized controlled trials dealt with various aspects of transforaminal injections for radicular pain owing to disc herniation. Based on these studies, there is Level 1 evidence supporting the use of transforaminal injections for radicular pain owing to disc herniation. A meta-analysis showed that at both 3 and 6 months, there was highly statistically significant improvement in both pain and function with both particulate and nonparticulate steroids."

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 pain management (pain injection 64483) date of service (DOS) to be determined (TBD) is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Other- Small intestinal bacterial overgrowth
Treatment: Xifaxan tablets 550MG Milligram (42 per 14 days)
The health plan denied: Xifaxan tablets 550MG (42 per 14 days)
The determination is: Overturned 

The patient is a female with a history of a small intestinal bacterial overgrowth (SIBO). She tried and failed ciprofloxacin. The requested service is Xifaxan, which was denied.
At issue is the medical necessity of Xifaxan.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of Xifaxan is medically necessary for this patient. It has been shown in many peer reviewed literature reports to be effective and safe for the treatment of SIBO.
Per Uday C et al: "Though in the past, tetracycline, doxycycline, co-trimoxazole, fluoroquinolones have all been used in the treatment of SIBO, in most of the recent studies among patients with irritable bowel syndrome (IBS), rifaximin has been the preferred antibiotic".
Per V Giorgio et al: "Rifaximin is safe and seems to be effective in SIBO eradication and symptoms improvement of IBS pts".
According to Scarpellini, E., et al: "Rifaximin was effective and safe in SIBO treatment and IBS symptoms improvement in childhood."
Finally, there is evidence that Xifaxan is more effective than Metronidazole. Per Lauritano, E. C., et al": Rifaximin showed a higher SIBO decontamination rate than metronidazole".
This member has a history of SIBO, confirmed via breath test. She has tried and failed ciprofloxacin. Therefore, using Xifaxan in this case is appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Upper Gastrointestinal Bleeding

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

The patient presented after vomiting blood. The patient was taking Motrin after having a fracture from a fall. The patient was afebrile and the vital signs were stable. The abdominal exam was benign. The hemoglobin was 10.9. An endoscopy revealed multiple small gastric erosions with no sign of active bleeding. The patient was discharged on Nexium and was able to tolerate a diet. 

Medical necessity was determined based on Milliman Care Guidelines (MCG) guideline M-180 for Upper Gastrointestinal Bleeding. Clinical indications for admission include hemodynamic instability, ongoing active bleeding, peptic ulcer with high risk endoscopic features, severe coagulopathy, severe anemia, bowel obstruction, peritoneal signs, or an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

This patient had taken Motrin which resulted in developing gastric erosions. However, the patient was not actively bleeding and there were no high risk endoscopic features. The endoscopy could have been performed with observation status. Afterwards, the patient was stable to have been discharged on proton-pump inhibitor (PPI) therapy. The patient did not meet MCG criteria for admission for Upper Gastrointestinal Bleeding. The healthcare plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary. 

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

Diagnosis: Left Leg Weakness and Swallowing Difficulty. 
Treatment: Inpatient Admission. 

The insurer denied: Inpatient Admission. 
The denial is upheld. 

The patient is an adult female. She presented to the emergency ward with the complaint of left upper extremity numbness and weakness and dysphagia. At presentation, CT (computed tomography) brain showed no acute pathology, and neurological examination was normal. She was admitted for possible stroke. 

The Inpatient Admission was not medically necessary. 

The patient presented with subjective neurological symptoms for one day. She had a normal examination and normal diagnostic studies. She was not a candidate for acute intervention. The NIH (National Institutes of Health) stroke scale score was 2 or less (Mendelson and Prabhakaran, 2019). There were no complicated co-morbid condition present that would warrant acute inpatient admission. She could have been safely and effectively treated at a lower level of care (Mendelson and Prabhakaran, 2019).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting, diarrhea and decreased oral intake
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is a toddler male. He presented with vomiting, diarrhea and decreased oral intake for three days. He was hospitalized for 2 days. A brief summary of the hospital stay is as follows:
Per the ED (emergency department) note and admission H&P (history and physical), the patient was seen in the ED (emergency department) for vomiting, diarrhea and decreased oral intake for three days, likely acute gastroenteritis. The plan was to admit for dehydration; IV (intravenous) fluids; clear liquid diet.
Per the discharge summary, the patient experienced no vomiting overnight and only one episode of diarrhea; he tolerated PO (by mouth). The patient was discharged to home.

The Inpatient Hospital Admission was not medically necessary.

As documented in clinical notes, this patient had acute nausea, vomiting and oral intolerance prior to this hospital admission. The patient was diagnosed with acute gastroenteritis. During hospital stays, the patient received IV (intravenous) fluids and oral intakes. The patient stopped vomiting after admission and tolerated oral intake. There was no documentation of any other acute events such as high fever, respiratory distress and cardiovascular instability. Acute gastroenteritis may require IV (intravenous) fluids for dehydration and can be managed at observational level of care (1-3). Thus, the proposed acute inpatient care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain.
Treatment: Acute inpatient level of care.

The insurer denied Acute inpatient level of care.  The denial is upheld.

This patient is an adult male, who presented to the emergency room with abdominal pain and watery diarrhea for one week. The patient had associated nausea, vomiting, chills, and fatigue. The patient had a history of dental infections and was on a seven-day course of Keflex. The white blood cell count was 19.64. A computed tomography (CT) scan of the abdomen / pelvis showed thickening of the sigmoid colon. The patient was treated with intravenous (IV) hydration, intravenous Rocephin, intravenous Flagyl, intravenous Reglan, and intravenous acetaminophen. The patient was started on clear liquids. 

On day #2, the patient's abdominal pain improved, and the white blood cell count decreased to 14.42. His potassium was 3.3, requiring oral replacement. On day#3, the patient's abdominal pain and diarrhea improved. The white blood cell count was 11.11. Gastroenterology recommended advancing diet, twice daily proton pump inhibitor, monitoring white blood cell count, and obtaining stool studies. The sample was positive for Clostridium difficile, and oral Vancomycin was started. The patient was discharged the following day.

The proposed treatment was not medically necessary.

An inpatient level of stay was not medically necessary. The patient did not require any procedural or surgical intervention, did not require to be nothing by mouth for a prolonged duration of time, and did not require prolonged treatment with intravenous hydration or intravenous medications. The patient did not have acute kidney injury and did not have any complications such as intra-abdominal abscess or a surgical abdomen. The medical records do not support that the acute inpatient admission was medically necessary. The patient did not require services of such intensity that could have been safely and effectively provided only on an inpatient level of service. The health, safety, and medical condition of the patient would not have been threatened by providing the care given in a lower level of care setting.

Therefore, based on review of the submitted medical records, the requested inpatient level of care was not medically necessary for the dates of service in question, as it exceeded in scope and intensity the level of care necessary to provide safe, adequate, and effective treatment for this patient's condition.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease
Treatment: Manual wheelchair
The insurer denied: Manual wheelchair
The denial is overturned.

The patient is an elderly female with a medical history of Parkinson's disease. Home health therapy documentation indicated that the patient has hypertension, Alzheimer's disease, dementia, stroke, arthritis and asthma. The patient was noted to have an unsteady gait with decreased step length. A manual wheelchair was recommended. The patient was noted to have impaired mobility and her wheelchair was non-functional. The patient was modified independent with mobility and performing daily activities. A community health assessment report performed last year indicated that the patient has dementia and lives with her daughter. The patient requires maximum assistance for daily activities, including bathing and dressing. She requires extensive assistance for transfers and mobility. The manual wheelchair 
was denied; this decision is being appealed.

The requested manual wheelchair is medically necessary.

The patient is an elderly female with a medical history of Parkinson's disease. Home health therapy documentation indicated that the patient has hypertension, Alzheimer's disease, dementia, stroke, arthritis and asthma. The patient was noted to have an unsteady gait with decreased step length. A manual wheelchair was recommended. The patient was noted to have an impaired mobility and her wheelchair was non-functional. The patient was modified independent with mobility and performing daily activities. A community health assessment report performed last year indicated that the patient has dementia and lives with her daughter. The patient requires maximum assistance for daily activities, including bathing and dressing. She requires extensive assistance for transfers and mobility. The patient has Parkinson's disease with decreased strength and coordination and is at high risk for falling. She requires a manual wheelchair for mobility and significant assistance for mobility and performing mobility related activities of daily living. She is functionally non-ambulatory and 
her current wheelchair is no longer working. She was assessed by a therapist regarding her mobility and durable medical equipment needs.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumonia. 
Treatment: Inpatient admission. 
The insurer denied the inpatient admission. 
The health plan's determination is overturned. 

This case involves a woman seen in the emergency department and subsequently admitted to the hospital with fever, cough, nausea, vomiting, and abdominal pain. Despite three days of Levaquin, prescribed at the urgent care center, the patient continued to have fevers of 105 and was admitted to the hospital for further assessment. Admission vital signs included a temperature of 99.5, blood pressure of 104/61, and heart rate of 122. Oxygen saturations were normal. Laboratory studies showed a normal white blood cell count of 9.5, hemoglobin of 12, and platelets of 237. There were no abnormalities of the electrolytes or renal function. Lactic acid was 1.1. Procalcitonin was 0.88. Imaging studies included a chest x-ray which showed right middle lobe and left lower lobe pneumonia. 

The inpatient hospital admission was medically necessary. The patient received appropriate antibiotic treatment for pneumonia in the form of Levaquin for three days before coming to the hospital, with persistent fevers, nausea, and vomiting. As a result, this is considered a failure of outpatient treatment. The vital signs improved after appropriate intravenous (IV) fluid hydration and broadening the antibiotic spectrum to cover methicillin-resistant staphylococcus aureus (MRSA). A computed tomography (CT) of the chest showed multifocal pneumonia, and the medical team felt there was a clinical indication for outpatient IV antibiotics, instead of an oral regimen, due to the severity of the illness. Therefore, an inpatient hospital admission was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back abscess
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial is overturned.

This patient is an adult male with a large back abscess. The patient had symptoms for four days and started developing fevers at home. His white blood cell (WBC) count was 19. He was hemodynamically stable. A computed tomography (CT) scan of the chest showed a large abscess on the back. The patient went to the operating room for incisions and drainage. Wound care was performed. The patient was discharged with his wife after wound care was taught.

The requested health service was medically necessary.

This patient was admitted for leukocytosis, fever, and large abscess of the back region. This patient required wound care and needed to go to the operating room for drainage. The abscess was large and, given the fevers and leukocytosis, intravenous antibiotics were needed as well. Inpatient admission was necessary given the sepsis picture with fevers, leukocytosis, need for intravenous antibiotics and wound care, and source of infection. Therefore, the requested health service is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female with a history of hypertension, chronic left-sided frontal headaches, and a previously resected left cerebellar pontine angle schwannoma, as well as comorbidities including obesity, hyperlipidemia, and asthma, who presented to the hospital. She was referred from the Neurosurgery clinic due to worsening chronic left-sided headaches with suspicion of a hypertensive emergency.
Upon arrival in the Emergency Department, her blood pressure was measured at 253/116. The patient reported regular self-monitoring of her blood pressure at home, with an average systolic blood pressure exceeding 200. She was taking only Losartan 25 milligrams as her home antihypertensive medication. Initially in the emergency department (ED), she complained of intensifying left-sided headaches and chest pain. However, during the interview, she described her headache as consistent with her chronic headaches and denied chest pain, new visual changes, palpitations, shortness of breath, sweating, nausea, vomiting, abdominal pain, or extremity edema.

The inpatient admission was not medically necessary in this clinical case since the patient did not have a real hypertensive emergency. The patient had hypertensive urgency, a condition that could be treated at the lower level of care. 

Based on the data available in this clinical case, the patient had a hypertensive urgency and not an emergency. Even though the patient had severely elevated blood pressure which was likely chronic, there was no definitive end-organ damage. The patient did not really have true acute coronary syndrome requiring intervention. The elevation of troponin was likely due to severe hypertension and did not represent true acute coronary syndrome requiring intervention.
Therefore, admission at a lower level of care was appropriate given the clinical circumstances.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis. 
Treatment: SILIQ 210 MG (milligram) /1.5 ML (milliliter) SYRINGE (procedure code C9399). 
The insurer denied coverage for the SILIQ 210 MG /1.5 ML SYRINGE (procedure code C9399). 
The denial is overturned. 

The insurer has denied coverage for the prescription drug SILIQ 210 MG (milligram) /1.5 ML (milliliter) SYRINGE. In their Final Adverse Determination letter, they write that this treatment is considered medically necessary when the following criteria are met: the individual is 18 years of age or older, has chronic moderate to severe plaque psoriasis (with either of the following; plaque psoriasis involving greater than three percent body surface area, or plaque psoriasis involving less than or equal to three percent body surface area (BSA) involving sensitive area or areas that significantly impact daily function such as palms, soles of feet, head/neck or genitalia, and the individual did not get better with other treatments or cannot use other treatments (has had an inadequate response to, is intolerant of, or has a contraindication to phototherapy or other systemic therapy (such as acitretin, cyclosporine, or methotrexate). For this reason, they consider this medication not medically necessary. 

The patient's provider is appealing. In an appeal letter it is noted that the patient has sharply demarcated, scaly plaques throughout the body, body surface area (BSA) 30%. The condition is very itchy and significantly impacting the patient's health-related quality of life. The patient has tried and failed numerous treatments including cosentyx, tremfya, vtama, betamethasone, taclonex, clobetasol, and calcipotriol. Siliq is the only agent in its class and works via a completely different mechanism from all other medications. 

The patient has a diagnosis of psoriasis affecting 30% total body surface area (TBSA). The patient has tried and failed systemic biologic therapy with Cosentyx and Tremfya as well as topical therapy with betamethasone, calcipitriol, vtama, zoryve, taclonex, and clobetasol. The request is for Siliq. 

Based on the submitted documentation, Siliq is medically necessary for the treatment of the patient's psoriasis vulgaris. The patient has failed numerous therapies, including Cosentyx and Tremfya. The patient requires systemic biologic therapy for appropriate disease management. Siliq is Food and Drug Administration (FDA) approved for moderate-severe psoriasis and is a reasonable alternative for the patient. The joint American Academy of Dermatology - National Psoriasis Foundation (AAD-NPF) psoriasis guidelines list Brodalumab with a strength of recommendation of "A" as monotherapy for adults with psoriasis. The use of Siliq is approved. The decision is reversed. 

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 the prescription drug SILIQ 210 MG (milligram) /1.5 ML (milliliter) SYRINGE is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Mental Health 
Pharmacy/prescription 

Diagnosis: attention deficit hyperactivity disorder
treatment: Methylphenidate SR 30 mg Capsules, Additional Quantities (over 90 Capsules per Month of Ritalin LA 30 mg) 

The insurer denied Methylphenidate SR 30 mg Capsules, Additional Quantities (over 90 Capsules per Month of Ritalin LA 30 mg). The health plan's determination is upheld. 

The patient is a male with history of attention deficit hyperactivity disorder. He has been in treatment for the treatment of his attention deficit hyperactivity disorder (ADHD) since 2013. He has been on 60 milligrams (mg) twice a day of Ritalin long acting but due to supply shortages was switched to 30 mg (2 pills/twice a day). He has been on the same regimen for 9 years without any side effects.

Methylphenidate SR 30 mg Capsules, Additional Quantities (over 90 Capsules per Month of Ritalin LA 30 mg) is not medically necessary for this patient.

Doses over 60 mg daily is above the Food and Drug Administration (FDA) recommended use. In addition, there are many other standard medications within FDA guidelines that can be used to treat the patient's condition. The patient is requesting a dose twice the FDA maximum. Therefore, the requested medication is not medically necessary.