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

Diagnosis: Breast Cancer with Metastasis
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is overturned.


The patient is a female with a history of breast cancer. She had a laparoscopic bilateral salpingoophorectomy, conversion to laparotomy and repair of sigmoid colon. She was admitted after surgery as an inpatient and progressed postoperatively well. She was discharged. At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient hospital admission is medically necessary for this patient.
The patient was scheduled for a laparoscopic procedure; however, she had a complication of bowel injury and the procedure was converted to an open (laparotomy) incision for repair. This includes a large incision into the peritoneum and has a high risk for surgical complications including hemorrhage, infection and inappropriate fluid shifts. Inpatient admission for 1-3 days is standard of care for an open laparotomy and therefore the inpatient admission is medically necessary. Nursing care for monitoring, urine output, ambulation, pain control and oral intake is essential and standard of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
Treatment: Inpatient substance abuse treatment 
The insurer denied inpatient substance abuse treatment 
The determination is overturned.

The patient presented for detoxification and substance-related services. He has a history of multiple detoxification treatment episodes. He was using 1 pint of liquor plus beer on a continuous daily basis together with up to $500 worth of crack cocaine daily. He was tobacco dependent with one pack per day use.
The patient has a co-occurring psychiatric disorder best characterized as schizophrenia or schizoaffective disorder with one remote history of hospitalization and no recent treatment. The patient was homeless and unemployed.
The patient has comorbid general medical conditions with hyperlipidemia and hypertension. 
The patient was admitted for inpatient treatment with the detoxification protocol using a Librium taper with vitamin replacement therapy and availability of nicotine replacement, as well as comfort medications. 
The requested health service and treatment is medically necessary for this patient. The admission and the continued inpatient level treatment through discharge could not have been safely or effectively provided with lower-level services.
The patient was using large quantities of alcohol and crack cocaine on a daily continuous basis that did warrant the admission and the continued inpatient level detoxification and withdrawal management and monitoring. The patient's social environment was not conducive to an effective detoxification, and the patient had a history of treatment with relapses. The patient had associated clinical features that included remote history of a co-occurring psychiatric disorder and general medical comorbidities including hypertension. 

The health plan's determination of medical necessity is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Low back pain

Treatment: outpatient surgery (0275T x 1)

The insurer denied coverage for outpatient surgery (0275T x 1)

The denial is overturned.

 
This patient has chronic low back pain and neurogenic claudication. The patient has had medication trials, Physical Therapy (PT), home exercise, Epidural Steroid Injections (ESI), and facet injections. The patient has spinal stenosis shown by radiographic imaging. The request is for the minimally invasive lumbar decompression (MILD) procedure. 

There are two prospective randomized controlled trials (1,2) that support this procedure.

In a Cleveland Clinic study (3), a review of a case series found: "Seventy-five patients received mild during the protocol-defined time period and were included in the study. Only 9 out of 75 patients required lumbar surgical decompression during the 5-year follow-up period. Subjects experienced statistically significant pain relief and reduction of opioid medications utilization at 3, 6, and 12 months compared to baseline. Based on our analysis, the mild procedure is durable over 5 years and may allow elderly patients with symptomatic lumbar spinal stenosis to avoid lumbar decompression surgery while providing significant symptomatic relief."

This procedure is more beneficial than the standard treatment for this patient. The procedure is medically reasonable and necessary.

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 outpatient surgery (0275T x 1) is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Uterine Fibroids
Treatment: Uterine Artery Embolization
The insurer denied: Uterine Artery Embolization.
The denial is overturned.

The patient is an adult female with menorrhagia and uterine fibroids. The request is for a uterine fibroid embolization (UFE), also called a uterine artery embolization (UAE).

The Uterine Artery Embolization is medically necessary. 

A search of the peer-reviewed medical literature on PubMed.com finds many articles regarding uterine fibroid embolization (UFE), also called uterine artery embolization (UAE). The radiology and gynecology societies recommend this procedure to treat symptomatic uterine fibroids. UFE (uterine fibroid embolization) is considered standard of care and had been demonstrated to be as efficacious in comparison to surgery. A review paper by Bulman, notes that "Uterine fibroid embolization (UFE) has become established as an accepted minimally invasive treatment for uterine fibroids and should be considered a treatment option for patients with symptomatic uterine fibroids." It is less invasive with improved recovery time in comparison to surgery. The criteria from the Standards Division of the Society of Interventional Radiology, Patient Care and Uterine Artery Embolization for Leiomyomata, were fulfilled. The definition of medical necessity is fulfilled. The requested service is safe; effective; generally accepted national standard of medical practice; not provided primarily for convenience of the patient or the practitioner; the least intensive and/or most appropriate alternatives among diagnostic and treatment options; and provided in the most effective setting and no other treatment would provide a clinically appropriate benefit at a lower intensity.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Hypopituitarism 

Treatment: Sogroya for use in the treatment of Hypopituitarism

The insurer denied coverage for Sogroya for use in the treatment of Hypopituitarism

The denial is overturned

This is a patient diagnosed with growth hormone deficiency (GHD). The request is for Sogroya. The patient's magnetic resonance imaging (MRI)  showed an ectopic posterior pituitary gland. The patient started growth hormones (GH) and testosterone therapy. The patient has done well on Norditropin; however, it is on a national back order. Norditropin and Genotropin are unavailable due to a nationwide shortage. The patient's most recent insulin-like growth factor 1 (IGF1) was 210. 

The formulary alternatives are not likely to cause the patient an adverse reaction.

The formulary alternatives have not been ineffective for the patient. The patient was being treated with Norditropin with excellent results. However, the provider has reported that both formulary alternatives are currently on shortage.

The requested drug will not be more effective that the formulary alternatives; however, the request is medically necessary since both formulary alternatives are reported by the provider to be on shortage.

The requested medication Sogroya has been shown to be safe and effective for the treatment of growth hormone deficiency [5, 6]. The study using the medication shows that the medication is clinically equivalent (noninferior) to daily injections of growth hormone in terms of efficacy and safety. The study showed a slight advantage of the Sogroya of being a weekly medication. Other than the convenience of weekly administration, the requested medication is not superior to daily growth hormone. 

The patient was being treated successfully with Norditropin. The provider reported shortage on both formulary alternatives: Norditropin and Genotropin. Continuation of treatment is necessary.

The carrier's denial of a request for a Formulary Exception for Sogroya for use in the treatment of Hypopituitarism is reversed.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Atopic Dermatitis.
Treatment:  Opzelura 1.5% (percent) cream.

The insurer denied Opzelura 1.5% cream.  The determination is upheld.

The patient is a male with atopic dermatitis. He has failed triamcinolone and hydrocortisone. Per the appeal letter, he has also failed topical tacrolimus. The prescriber is a dermatologist. The medication under review is Opzelura 1.5 percent (%) cream. At issue is whether the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.

The formulary drug Eucrisa will not be ineffective. The formulary drugs would be as effective as the non-formulary drug. The formulary drug Eucrisa would not have adverse effects.
According to the American Academy of Dermatology Atopic Dermatitis Clinical Guidelines and dermatology literature, the preferred medications, such as crisaborole, are effective treatments for the management of atopic dermatitis (1, 2).
According to Paller et al., "Crisaborole demonstrated a favorable safety profile and improvement in all measures of efficacy, including overall disease severity, pruritus, and other signs of AD." (3).
It is noted that the patient has tried and failed topical steroids. However, the patient has no true contraindications to the other preferred, formulary medications which have been shown to be effective for the treatment of atopic dermatitis. The evidence-based literature is consistent and in line with the patient's medical policy. The preferred agents, such as Eucrisa (crisaborole), are appropriate agents for the treatment of the patient's atopic dermatitis. The formulary medications should be tried and failed prior to initiating Opzelura.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ulcerative Colitis

Treatment: Medication Stelara

Insurer denied dose escalation of Stelara.

The denial is reversed.

This is an adult with a history of ulcerative colitis, which was diagnosed in 2021. The patient was previously treated with Entyvio but failed to respond. The patient has been treated with Stelara every 8 weeks since nine months ago. There was initial improvement, but this was followed by increased flare ups. A colonoscopy performed five months ago showed active disease. The Stelara trough levels were low, and the colonoscopy showed that the disease was not controlled. The physician is now requesting to increase the frequency of Stelara dosing to every 4 weeks. 

The Journal of Clinical Medicine article titled "Update on Therapeutic Drug Monitoring with Ustekinumab, Vedolizumab, and Tofacitinib in Inflammatory Bowel Disease" evaluates ustekinumab treatment in ulcerative colitis. Serum concentrations were correlated with clinical, biochemical, and histological remission. At week 8 post induction concentration of 3.7 ug/ml (microgram per milliliter) was associated with a response to the drug. A maintenance concentration of 1.3 ug/ml was correlated with increased rates of clinical remission. It was advised that experts agree to target ustekinumab concentrations of at least 3-7 ug/ml at week 8 and 1-3 ug/ml during maintenance for both Crohn's disease and ulcerative colitis. 

Taxonera et al., did a meta-analysis of 19 studies involving 3786 patients treated with ustekinumab for ulcerative colitis. Over 92% (percent) had been previously treated with a biologic. Of note, "Almost 30% (percent) of the patients needed dose escalation, which was effective in 40% (percent) of these patients."

Ylisaukko-Oja et al., in a nationwide study, found that dose escalation was noted in 70% (percent) of patients with ulcerative colitis.  They concluded that dose escalation is common clinical practice.

The scientific literature supports the use of dose escalation for ustekinumab when there is not an adequate response or when trough levels are low. This patient has already failed multiple biologic therapies, so it is important to optimize the ustekinumab treatment. Medical literature supports the use of dose escalation and optimization of treatment with Stelara in patients with irritable bowel disease.

Based on the above, the insurer's denial is 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 Stelara, dosed every 4 weeks for the treatment of ulcerative colitis is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion
Treatment: Braces and Monthly Visits
The insurer denied: Braces and Monthly Visits
The denial is overturned.

The patient is a teenage female. The request is for orthodontic benefits with monthly visits. The health plan denied coverage of the request due to the patient having a handicapping index score of 23. The denial is being appealed.

The requested Braces and Monthly Visits are medically necessary.

The patient has bilateral posterior crossbites. This means that her upper back teeth on both the left and right sides are inside of her lower teeth. This is backward to what it should be. The patient's upper left and right canines are not touching her lower canines. This means that there can be no "canine guidance" during the chewing cycle. Instead of her lower canines gliding along the backs of her upper canines and allowing for smooth disarticulation of all the back teeth, there will be banging together of all her back teeth in a traumatic fashion. The trauma will ultimately lead to fracturing and/or loosening of multiple teeth. The bilateral posterior crossbites, with the teeth being in the wrong positions, will exacerbate the trauma to all the teeth. It will most probably cause temporomandibular joint (TMJ) issues over time also by placing excess stress on the temporomandibular joints. This case has medical necessity and needs orthodontic treatment to correct all the problems. The monthly visits are needed to make sure treatment is properly progressing.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pancreatitis with Pseudocyst

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

The patient has a history of pancreatitis and a pseudocyst. The patient presented with abdominal pain and vomiting. The patient has had multiple admissions with the same complaints where they have signed out against medical advice (AMA). The patient was afebrile and the vital signs were stable. The physical exam in the emergency room (ER) revealed a soft abdomen with no abdominal tenderness. The patient's lipase was 210 (normal to 83). A computed tomography (CT) scan showed pseudocysts and mild pancreatitis. 

Medical necessity was determined based on Milliman Care Guidelines (MCG) guideline M-250 for Pancreatitis. Clinical indications for admission include having acute pancreatitis along with 2 of the following: abdominal pain, serum lipase greater than 3 times the upper limit of normal, and imaging findings indicative of acute pancreatitis. In this case, the patient did not have abdominal tenderness, the lipase was not 3 times greater than the upper limit of normal, and the CT scan findings were more consistent with chronic pancreatitis as there was a pseudocyst and only mild pancreatic inflammation. The patient also did not have evidence of infection, hemodynamic instability, severe dehydration, acute renal failure, altered mental status, or a severe electrolyte abnormality. 

This patient has had recurrent episodes of mild pancreatitis and now pseudocysts. The patient did not require any acute interventions. Intravenous (IV) hydration and pain medications could have been given with observation care. The patient did not meet MCG criteria for admission for Pancreatitis. 

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 an inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: pyelonephritis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

 
Patient is an adult female with past medical history significant for recent vaginal delivery who presented to the emergency room with complaints of fever, chills, and flank pain.

Vitals on presentation included: Temperature-103 degrees Fahrenheit, Blood Pressure -107/67, Pulse -99, Respirations -32, oxygen saturation 100%. Laboratory results included the following: White blood cells (WBC)-18.4, Hemoglobin (Hgb)-11.8, Hematocrit (Hct-34.9), creatinine-0.90, glucose-106, urinalysis showed leukocyte esterase.

The patient was started on intravenous (IV) fluids and empiric antibiotics (ceftriaxone). Urine culture grew Escherichia coli (E coli). Computed tomography (CT) scan of abdomen/pelvis showed mild right perinephric fat stranding. Patient remained afebrile, hemodynamically stable, and clinically improved. She was discharged to continue outpatient follow-up on oral antibiotics. 

According to documentation, patient presented with a fever (103 F), with tachycardia (99), tachypnea (respiratory rate -32) and laboratory results were notable for leukocytosis (WBC-18.4). Urine culture grew E coli and CT scan was suggestive of right sided pyelonephritis. Based on above findings, hospital admission was medically necessary for administration of intravenous antibiotics in a high risk post-partum patient.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cirrhosis. 

Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

The patient has asthma, sleep apnea, congestive heart failure (CHF), and cirrhosis. There is a history of polysubstance abuse. The patient presented with shortness of breath (SOB) and abdominal distention. The patient was hemodynamically stable and the oxygen saturation was 94%. During a recent admission, a paracentesis was done and 5.7 liters of fluid were removed. Intravenous (IV) Lasix was given in the emergency room (ER). Potassium and magnesium replacement were given. A computed tomography (CT) scan showed end stage cirrhosis. The total bilirubin was 1.4. The troponin was negative. The international normalized ratio (INR) was 1.2. A paracentesis was performed and 6.4 liters of fluid were removed. After the paracentesis the patient's symptoms improved. 

Medical necessity was determined based on Milliman Care Guidelines (MCG) guideline M-570 for Liver Disease. Clinical indications for admission include having acute liver failure as manifested by both an INR over 1.5 and hepatic encephalopathy or cirrhosis as manifested by a bilirubin of 5, an INR over 1.5, and acute onset ascites or encephalopathy. The patient did not have these conditions. The patient also did not have infected ascites, hepatorenal syndrome, or acute respiratory failure. 

This patient has cirrhosis and required a paracentesis and diuretic therapy. This treatment could have been given with observation status. The sleep apnea and asthma were chronic problems that were amenable to outpatient treatment. The patient did not meet MCG criteria for admission for Liver Disease. The health care 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 inpatient hospital is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Local Infection of the Skin and Subcutaneous Tissue. 
Treatment: Inpatient Hospital Admission. 
The insurer denied: Inpatient Hospital Admission. 
The denial is overturned. 

The patient is an adult male with relevant past medical history of intravenous drug use (IVDU) and bilateral forearm fasciotomies secondary to compartment syndrome who presented to the emergency room for pain associated with chronic left-hand dorsum wound with exposed third and fourth metacarpophalangeal joints (MCP) of 6 months. The patient stated that he had an infection of the hand earlier this year and was treated with Levofloxacin for 6 weeks. He had hand clinic appointments prior also earlier this year. The patient reported subjective fevers. On exam, he had an open wound on the left-hand dorsal aspect with exposed muscle, bone and tendon. In the emergency room, x-ray of the left hand showed septic arthropathy and the patient was started on Vancomycin and Zosyn. Labs showed a white blood cell (WBC) count of 11.7 and 
elevated C-reactive protein (CRP). Magnetic resonance image (MRI) of the hand was obtained that showed osteomyelitis of the left wrist and hand. The patient was continued on intravenous antibiotics during the hospital stay. The patient was evaluated by surgery - hand surgery - and advised continuation of antibiotics and evaluation by plastic surgery. The patient signed out against medical advice on day #5. 

The inpatient admission for the above duration was medically appropriate and medically necessary. 

The clinical presentation of the patient was concerning for infection, rule out septic arthropathy rule out acute osteomyelitis. In view of this, the patient needed to be started on intravenous antibiotics and he was started on Vancomycin and Zosyn. The patient underwent magnetic resonance image of the left hand and that showed osteomyelitis. X-ray of the left hand was concerning for septic arthropathy. In view of above, the patient needed continuation of intravenous antibiotics and also needed follow up inpatient evaluation to see if the wound continues to stabilize - improve and an evaluation - plan to be made by plastic surgery for possible surgical treatment to obtain permanent closure of the hand wound. The patient's clinical needs on presentation were not just administration of intravenous antibiotics, but also needed continued inpatient evaluation in view of the finding of osteomyelitis to ensure appropriate response to the antibiotics and also evaluation - follow up with plastic surgery to finalize plan for permanent closure of the hand wound. These treatments would not be achieved in a lower level of care and so inpatient level of care is appropriate for the above duration.