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

Diagnosis: Anemia. 
Treatment: Inpatient admission. 

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

The patient in this case is a female who has a history of sickle cell anemia and also prior deep vein thrombosis (DVT) and pulmonary embolism (PE).  She had been admitted for sickle cell pain crisis.  The patient presented to the emergency department with a two day history of right thigh pain. She had taken Dilaudid four milligrams (mg) at home without significant improvement. She had no other symptoms. 

The patient's physical examination was without significant abnormal findings other than some tenderness in the right thigh. Physical examination was notable for heart rate of 114. She had anemia which was stable and tachycardia was attributed to her pain.  She was admitted and treated with intravenous Dilaudid, but by the day after admission was able to switch back to her usual outpatient regimen.  She was discharged and other than pain no other active medical issues were documented. 

No, the proposed inpatient admission was not medically necessary. 

This patient had an uncomplicated sickle cell pain crisis.  She had pain requiring intravenous pain medication at the time of admission but by the following day was able to transition to her usual oral pain medication regimen.  She was treated with intravenous fluids but had no vomiting or diarrhea and no described limitation with regard to oral intake.  She had tachycardia but no hypotension or sign of infection.  Given these factors, she did not require acute care inpatient admission.  She was effectively transitioned to her usual oral mediation quickly and had no other significant active medical issues.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alopecia Universalis

Treatment Xeljanz 5 milligrams (mg)

The insurer denied coverage for Xeljanz 5 mg

The denial is overturned

The patient has a diagnosis of alopecia universalis.  He has failed therapy with Integrin-linked kinase (ILK), clobetasol solution, and tacrolimus ointment.  He was successfully treated with Xeljanz through a study with Pfizer without any documented side effects.  Since discontinuing Xeljanz, the patient has experienced recurrent hair loss.   

This patient has been successfully treated with Xeljanz for an extended period of time.  It would be medically inappropriate to deny coverage for a therapy shown in studies to improve the patient's condition following an extended use which has resulted in significant disease improvement without significant adverse effects.  

The use of xeljanz is medically necessary for use in the treatment of the patient's clinical circumstance. The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for Xeljanz 5 mg to treat alopecia universalis is reversed. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Total revision arthroplasty of the right knee. 
Treatment: Full hospital admission. 

The insurer is denied coverage for full hospital admission. 
The denial is upheld. 

This male patient has a history of anemia, arthrosis, hyperlipidemia, and osteoarthritis. 

The records demonstrate a non-complicated procedure was completed. There was limited blood loss. After the operation, there were no problems with the wound (ie. inspection after dressing change revealed no evidence of infection.) The vital signs were stable (ie. no fever.) Pain management was provided without need for intravenous (IV) administration. Gains were reported in physical therapy (PT) where the patient could walk 200 feet. There were no medical conditions to warrant additional care [body mass index (BMI) was taken into consideration.] 

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

The carrier's denial of coverage for the full hospital admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypogonadism. 
Treatment: Testosterone Gel 1% (25mg), Pre-service. 
The insurer denied the Testosterone Gel 1% (25mg), Pre-service. 
The denial is upheld. 

The patient is a male with a diagnosis of primary hypogonadism with symptoms of 
fatigue, brain fog, and loss of libido. 

The patient's free testosterone was 3.5 pg/mL (picograms per milliliter) (9.3-26.5), 
and his total testosterone 117.5 ng/dL (nanograms per deciliter) (264-916). 

Approximately 4 months later, the patient's free testosterone was 11.2 pg/mL (pictograms per milliliter) (9.3-26.5), and his total testosterone was 247.9 ng/dL (nanograms per deciliter) (264-916). 

The patient previously used anabolic steroids. The Request for testosterone gel 1% 
is under review. The prior request was denied, as approval required a diagnosis of 
primary hypogonadism, hypogonadotropic hypogonadism, or gender dysphoria. 

No, the Testosterone Gel 1% (25mg) is not medically necessary. 

The Endocrine Society guidelines recommend reserving testosterone replacement 
therapy for patients with confirmed symptomatic hypogonadism which is typically 
diagnosed by two low morning total testosterone levels [1], which is not 
documented in this case. The documentation includes two low total testosterone 
levels, but only one was drawn in the morning. Testosterone levels are typically 
lower in the afternoon. Laboratory reference ranges are established using morning 
testosterone levels. Measuring testosterone levels in the afternoon may 
inappropriately diagnose a patient with hypogonadism. Testosterone therapy has 
potential risks, including erythrocytosis. Therefore, no, the proposed testosterone 
gel 1% is not medically necessary. 

The health plan denied the testosterone gel 1%, which is not medically necessary, 
as outlined above. Therefore, yes, the health plan did act reasonably, with sound 
medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia, dizziness/giddiness, heart disease, and Parkinson's disease. 
Treatment: Increase Personal Care Assistance Services, Level II, Total of 84 Hours, Pre-service. 

The insurer denied the Increase Personal Care Assistance Services, Level II, Total of 84 Hours. 
The denial is upheld. 

The patient is a female. She has conditions including dementia, dizziness/giddiness, heart disease, and Parkinson's disease. The patient is appealing denial of personal care assistance service 84 hours per week. She was determined to require 47.58 total task hours per week based previous assessment. UAS (Uniform Assessment System) evaluation performed on most recently shows minimally impaired cognition and functional status: total dependence with housework; maximal assistance with meal preparation, managing finances and medications, shopping, bathing, lower body dressing, and toileting; extensive assistance with phone use, personal hygiene, upper body dressing, walking, locomotion, and eating; and limited assistance with bed mobility. She uses a walker for indoor locomotion and a wheelchair for outdoor. She has bowel and bladder incontinence. Compared to UAS (Uniform Assessment System) evaluation performed previously, there is no significant change in the patient cognition of physical functioning. 

No, the Increase Personal Care Assistance Services, Level II, Total of 84 Hours is not medically necessary. 

The requested health service is not medically necessary, because it is not consistent with standard of care. 

Personal Assistance Services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. This patient has multiple chronic conditions including dementia and Parkinson's disease. She is appealing denial of personal care assistance services 84 hours per week. 

UAS (Uniform Assessment System) evaluation performed most recently shows the patient requires assistance with will all ADLs/IADLs (activities of daily living/instrumental activities of daily living), and primarily requires extensive to maximal assistance with physical functioning. This evaluation shows no significant change when compared to the UAS (Uniform Assessment System) evaluation performed previously. Based on the previous evaluation, it was determined that the patient required 47.58 total task hours per week. There is no documentation to show that there has been a decline in the patient's functioning. The documentation is inadequate to support an increase in personal care assistance services to 84 hours per week. The proposed increase in personal care assistance services 84 hours per week is not medically necessary to meets this patient's need for assistance with ADLs (activities of daily living) and personal care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite.
Treatment: D8070 Braces, D8676  Monthly Visits, D8680 Retainer, Pre-service.
The insurer denied the D8070 Braces, D8676  Monthly Visits, D8680 Retainer, Pre-service.
The denial is overturned. 

The patient is a male. The request is for orthodontic treatment.

Yes, the braces, monthly visits, and retainer are medically necessary.
The patient has two anterior teeth in crossbite, teeth #s 11 and 27. Tooth #27 also has gingival attachment loss. This means that this is an automatic qualifier, according to the handicapping index scale.

Therefore, given the above, the braces, monthly visits, and retainer are medically necessary.

Having two anterior teeth in crossbite, especially when the teeth are canines, is problematic. Without those teeth in their proper positions, there can be no "canine guidance," which is a way the canines help guide the other teeth during the chewing cycle. Without canine guidance, the patient's other teeth will grind together and cause trauma and/or fracturing over time. This case has medical necessity to correct this problem, and it can only be corrected with orthodontic treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular 
Treatment: Durable Medical Equipment (DME)
The health plan denied the requested implantable durable medical equipment as not medically necessary. 
The health plan's determination is upheld.

This is a female who complained of falling asleep in daily activities, and vivid dreams. Narcolepsy was questioned. Her body mass index was 30.6. A sleep study revealed an apnea hypopnea index of 16.1 with no mixed or central events. She reported worsened fatigue with the use of continuous positive airway pressure (CPAP) along with an exacerbation of migraines, facial pain/bruising and nasal sores. Exam of the oropharynx revealed a Mallampati class 2 width 2+/4 tonsillar hypotrophy. A drug induced sleep endoscopy demonstrated grade 1 anteroposterior collapse at the level of the velum with no concentric collapse. Implantation of a hypoglossal nerve stimulator system for the treatment of obstructive sleep apnea (OSA) was recommended and is the service under review.

Based upon the clinicals provided, the health plan's determination of medical necessity should be upheld, in whole.

The requested health treatment implantation nerve stimulator is not medically necessary for this patient.
Hypoglossal nerve stimulator devices function by activating the genioglossus muscle, drawing the back of the tongue forward and improving the patency of the airway. The primary study for this device, the Stimulation Therapy for Apnea Reduction (STAR) clinical trial, is a prospective single-group cohort study of the Inspire upper-airway stimulation system developed by Inspire Medical Systems with results published in 2014. Study participants met eligibility criteria with moderate-to-severe OSA if they had difficulty adhering to CPAP treatment. The STAR trial (Strollo 2014) was funded by Inspire Medical Systems, the manufacturer of the technology and is an uncontrolled cohort study. The lack of control group limits the validity of the results of this study, and the cohort of 83% men. It is possible that the funding increased the possibility of bias. In addition, in the STAR trial study by Soose et al (2015), provided statistics based upon subjective self-reported data that was subjective not objective, including functional outcomes of sleep questionnaire and self/bed partner reports of snoring intensity. In a literature review by Certal et al (2015), according to the authors, the studies reviewed were based upon highly specific populations which may not be representative of the population with moderate to severe obstructive sleep apnea with the heterogeneity of comparing different devices. The authors concluded that based upon a limited number of case reports, which do not necessarily represent real world practice, and that more long-term data is required and further studies comparing hypoglossal nerve stimulation with conventional therapies are needed to definitively evaluate outcomes. Based upon the peer reviewed medical literature, the proposed treatment implantation of a hypoglossal nerve stimulator system is not medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Type 2 Diabetes Mellitus.
Treatment: MetFormin HCI ER(MOD) [(hydrochloride extended release)] 1000MG OR TB24, Pre-service.

The insurer denied the MetFormin HCI ER (MOD) [(hydrochloride extended release)] 1000MG OR TB24, Pre-service.  The denial is upheld. 

This is a female with type 2 diabetes on Trulicity, Basaglar, and metformin extended release. Request for metformin HCl ER (MOD) [(hydrochloride extended release)] is under review. The prior request for metformin HCl ER (MOD) [(hydrochloride extended release)] was denied as the patient has not tried and failed and does not have contraindication to metformin extended-release (generic Glucophage XR [extended release]).

No, the health plan should not cover the proposed treatment.

This patient does not have a documented trial of or contraindication to metformin extended-release. Both metformin extended-release and the requested metformin HCl ER (MOD) [(hydrochloride extended release)] are expected to be equally safe and effective in this clinical situation. The American Diabetes Association clinical guidelines do not recommend the use of metformin HCl ER (MOD) [(hydrochloride extended release)] over metformin extended-release. Therefore, the health plan should not cover the proposed treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Multiple Sclerosis. 
Treatment: Octagam. 

The insurer denied coverage for Octagam. 

The denial is upheld. 

This patient has been recommended to utilize Octagam to treat multiple sclerosis.  The documentation indicated the patient has trialed and failed Ocrevus as well as Copaxone, Betaseron, Rebif, Gilenya, and high-dose oral and intravenous steroids.  She continued to have clinical relapses and a progression of disease.  She was receiving IVIG [intravenous immune globulin] treatment with benefit.  Her condition was stable, and she has not suffered recent exacerbation.  The physician does indicate it is medically necessary to continue to receive IVIG therapy for her condition.  It was recommended she be treated with IVIG 40 g [grams] x [times] 2 days every 4 weeks. 

The documentation indicated she stated she felt stable utilizing IVIG.  She was being seen in a manual wheelchair.  She does have a stander that she utilizes at home and participates in physical therapy services 3 times a week.  She is a 1 person assist.  The physical examination did reveal decreased strength with decreased sensation to the left lower extremities.  It was noted she was wheelchair-bound.  She was recommended to continue medication and therapy participation. 

The patient presents with history of medically refractory multiple sclerosis with documented treatment failure with several immune modulating agents including Copaxone, Ocrevus, Betaseron and Gilenya. Treating physician is currently using IVIG. At issue is the medical necessity to continue with IVIG. As summarized in Up to Date "Although data are equivocal, there is no compelling evidence that intravenous immune globulin (IVIG) is effective for patients with RRMS [relapsing-remitting multiple sclerosis]. Some [206-209], but not all [210] early clinical trials reported beneficial effects for IVIG in RRMS. However, these trials generally involved small numbers of patients, lacked complete data on clinical and MRI [magnetic resonance imaging] outcomes, or used questionable methodology [211]. A later multicenter placebo-controlled trial of 127 patients with RRMS found that IVIG treatment conferred no benefit for reducing relapses or new lesions on MRI."(1)  

As per Up to Date, they note that when RRMS reaches the stage of secondary progressive multiple sclerosis (SPMS), a DMT (disease modifying therapy) is recommended. Of note, in the section dealing specifically with treatment of SPMS, no mention is even made of the use of IVIG. (2) 

A search of PubMed using the terms "secondary progressive multiple sclerosis" and IVIG found 14 papers. In the only referenced randomized trial by Hommes et al. involving 318 patients they concluded that "Treatment with IVIG in this study did not show any clinical benefit and therefore cannot be recommended for patients with secondary progressive multiple sclerosis." 

Therefore, the health plan acted reasonably with sound medical judgement in the best interest of the patient. 

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

Diagnosis: Impacted canine, Crowding, Overjet.
Treatment: D8080 Braces and D8670 Monthly Visit x 12 (Pre-service).
The insurer denied the D8080 Braces and D8670 Monthly Visit x 12 (Pre-service).
The denial is overturned.

The patient is a male. The request is for orthodontic treatment (braces) and monthly visits.

The orthodontic records created include x-rays and photos. The patient presents with a skeletal class I, moderate maxillary crowding, severe mandibular crowding, deep bite, slightly excessive overjet, impacted maxillary right canine, and over-retained primary canine.

Yes, the braces and monthly visits are medically necessary.

As evident on the x-ray, the patient's impacted canine does not have enough space to naturally erupt due to its position and the position of the adjacent teeth. Under these circumstances, surgical exposure of this tooth coupled with orthodontic treatment is the indicated corrective measure.

Additionally, the level of severe crowding on the lower arch and the degree of overjet/overbite can cause the patient difficulty with speech and chewing.

Therefore, given the above, the braces and monthly visits are medically necessary.

An untreated impacted canine can cause damage to adjacent teeth and cause their eventual loss. Furthermore, proper alignment and position of this tooth in the mouth is essential for chewing, functional guidance and aesthetics.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite
Treatment: Braces, Pre-service
The insurer denied the braces, pre-service.
The denial is overturned.

The patient is a male. The request is for orthodontic benefits.

Yes, the braces are medically necessary.

The patient's lower left and right permanent canines are in crossbite (reverse bite) with gingival attachment (gum) loss. This is an automatic qualifier, according to the handicapping index scale.

Therefore, given the above, the braces are medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Shortness of Breath and Chest Pain. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 

The denial is overturned. 

The patient is a female with a past medical history significant for asthma, anxiety, depression, and marijuana abuse. The patient presented to the emergency room for evaluation of dyspnea, chest pain and headache. The patient was hemodynamically stable and hypertensive. The electrocardiogram (ECG) revealed normal sinus rhythm with no acute ischemic changes. The patient's chest x-ray was unremarkable. The patient's laboratory data was significant for elevated high sensitivity troponin of 33.9. D-dimer was elevated. Due to suspicion of acute coronary syndrome (ACS) the patient was admitted to telemetry. Repeat troponin trended down, and the patient was referred for nuclear stress test, which revealed no evidence of ischemia, and the patient was discharged with a plan for outpatient follow-up. 

Yes, the proposed inpatient admission was medically necessary. 

The patient presented for evaluation of dyspnea and new onset chest pain. She was hypertensive. Her troponin was elevated, with suspicion for acute coronary syndrome. Given the presentation, uncontrolled hypertension, as well as clinical suspicion for an acute coronary syndrome/unstable angina, she would not be an appropriate candidate for an emergency department chest pain observation unit. It would be consistent with the current standard of care that this patient be managed in an inpatient setting. Therefore, the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Percutaneous coronary intervention (PCI)
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld. 

The patient is a male who underwent initial cardiac catheterization on for an ST-segment elevation myocardial infarction (STEMI). He had a successful intervention and the patient denied further chest pain, dyspnea, syncope, or other symptoms. He was compliant with medications. 

One month later, the patient was electively scheduled for staged percutaneous coronary intervention (PCI). This was performed successfully and without complications. The patient was admitted and observed.  The post cardiac intervention course was routine. He was discharged on optimal medical therapy after the uneventful procedure and recovery.

Admission and discharge diagnosis was atherosclerotic disease without angina.

No, the proposed inpatient admission was not medically necessary.
This was an elective, uncomplicated catheterization and percutaneous coronary intervention (PCI) that was scheduled for four weeks after successful intervention for an ST-segment elevation myocardial infarction (STEMI). There was a significant non culprit lesion that was staged. He was asymptomatic post initial intervention.

During the hospital stay, the patient was always hemodynamically stable, with normal vital signs; electrocardiogram did not show acute changes, and no significant ectopy. The only care that was given after the uncomplicated catheterization was monitoring, intravenous fluids (IVF), and routine medications. There was no indication for a higher level of care. 

Many institution's protocols include a same day discharge. Overnight stay for observation and telemetry does not change that determination. 

The letter of appeal was carefully considered, but it offered no evidence to support a higher level of care. The only care that was provided was telemetry; this does not require inpatient level of care. The patient was admitted for monitoring and routine post catheterization care; neither required an inpatient level of care. There was no "complex" care that was required in this patient's care, post catheterization. While there was always a potential for an adverse event, one did not happen, and no actual treatment was needed. 

Milliman criteria requirements for acute coronary syndrome (ACS) do not apply, as the patient does not meet criteria to support that diagnosis. Admitting and discharge diagnosis specified no angina present.   His electrocardiogram) showed no changes, and no acute medical treatment given for acute coronary syndrome (ACS). 

All of the testing and therapy that were provided did not require inpatient level of care.  Thus, inpatient level of care was not medically necessary. The denial was consistent with guidelines and usual community care. Post-cardiac care as described is routinely performed at a lower level of care.