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

Diagnosis: Atopic Dermatitis
Treatment: Rinvoq 15mg (milligram) ER (extended release) Tablet
The insurer denied: Rinvoq 15mg (milligram) ER (extended release) Tablet
The denial is overturned.

The patient is an adult female with atopic dermatitis as well as lichen planus. Her prior treatments include topical steroids, antihistamines, oral steroids, and Protopic. Her provider is requesting Rinvoq. The health plan requires use of traditional immunosuppressants and phototherapy as well as Dupixent or Adbry. The provider wishes to avoid Dupixent, given the patient's other diagnoses.

The requested Rinvoq is medically necessary.

The health plan prefers the use of traditional immunosuppressants and phototherapy as well as Dupixent or Adbry. Rinvoq (upadacitinib) was evaluated in a 16-week, double-blind, placebo-controlled, parallel-group, dose-ranging portion of this 88-week trial in eight (8) countries. Adults with moderate to severe disease and inadequate control by topical treatment were randomized 1:1:1:1, using an interactive 
response system and stratified geographically, to once-daily upadacitinib oral monotherapy 7.5, 15, or 30 milligrams or placebo. The trial showed a 74% (percent) improvement (achievement of primary end point) at the 30 milligram dose. Half of the patients receiving the 30 milligram dose of upadacitinib achieved clear or almost clear skin based on the IGA (Investigator's Global Assessment) score and an improvement of at least 90% in EASI (Eczema Area and Severity Index) at week 16. Improvements in signs and symptoms of AD (atopic dermatitis) were shown after the first week in those receiving upadacitinib (7.5, 15, 30 milligrams), with a significant reduction in pruritus as well as clinical efficacy end points. There was no correlation between the occurrence of adverse events and dose of upadacitinib. Therefore, there were no safety concerns to preclude further investigation of upadacitinib for AD (atopic dermatitis), and phase III trials are currently under way.
Rinvoq was compared to Dupixent in phase 3B randomized controlled trial. 924 patients were randomized to receive upadacitinib and 344 were randomized to receive dupilumab. At week 16, 247 patients receiving upadacitinib (71.0%) and 210 patients receiving dupilumab (61.1%) achieved EASI75 (75% reduction from baseline in the Eczema Area and Severity Index) (P = [equal] .006). All ranked secondary end points also demonstrated the superiority of upadacitinib vs dupilumab. Rates of serious infection, eczema herpeticum, herpes zoster, and laboratory-related adverse events were higher for patients who received upadacitinib, whereas rates of conjunctivitis and injection-site 
reactions were higher for patients who received dupilumab. During 16 weeks of treatment, upadacitinib demonstrated superior efficacy vs dupilumab in patients with moderate-to-severe AD (atopic dermatitis), with no new safety signals. Therefore, given the demonstrated superiority of Rinvoq, as well as the provider's assessment that Dupixent would be inappropriate, the request is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Difficulty Breathing
Treatment: Airway Clearance System (volara system) (E1399RRx3)
The health plan denied Airway Clearance System (volara system) (E1399RRx3). The denial is upheld.

The patient is a female child. The service under review is Airway Clearance System (volara system) (E1399RRx3).  This service was denied coverage by the health plan as not medically necessary, and this decision is being appealed. The patient's medical history includes bronchiectasis.

There are no applicable and generally accepted practice guidelines developed by the Federal government, national or professional medical societies, boards and associations that specifically deal with this device.

A search of the current medical literature using the PubMed search engine (United States National Library of Medicine at the National Institutes of Health) resulted in only a single publication using this device [ref 1]. This study included 419 elderly post-operative patients. There are no publications on the use of this device in a pediatric age group nor with similar underlying diagnosis.

Therefore, given the above, medical necessity of Airway Clearance System (volara system) (E1399RRx3) for this patient cannot be established.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient with a history of back pain, hypertension, atrial fibrillation, cardiac pacemaker, diabetes, cerebrovascular disease, and morbid obesity (status/post (s/p) bariatric surgery). He presented to the emergency room with a one-week history of right sided low back pain radiating to the front and side of the right leg along with urinary frequency and urgency. In addition, he complained of bilateral lower extremity numbness and tingling.
Upon admission, the patient was treated with oral medication, insulin, and a lidocaine patch. The MRI was completed showing severe central canal stenosis and clumping of the cauda equina nerve roots. Urgent low back surgery was recommended. However the patient simultaneously complained of a severe toothache. The dentist evaluated the patient and recommended antibiotics. The neurosurgical procedure was then cancelled. The remainder of the stay was clinically uneventful and the patient was discharged. At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient admission was not medically necessary for this patient.
Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or electrocardiogram (EKG) of an imminently life-threatening cause of the patient's complaints that required acute inpatient admission. There was a delay in service obtaining the magnetic resonance imaging (MRI), and the surgery was cancelled due to an apparent tooth infection. The services provided, oral medication, insulin, lidocaine patches, were not at the acute inpatient level of intensity. The patient was not observed to have urinary incontinence, bowel dysfunction, or saddle anesthesia, and his reflexes were present and symmetrical. Considering the contemporaneous tooth infection, the neurosurgeon did not feel that emergency back surgery was appropriate and ultimately sent the patient home with neurosurgical follow up plans. Therefore, based on the standard of care, as well as the peer reviewed literature and Milliman Care Guidelines (MCG) guidelines cited in the references, the acute inpatient level of care was not medically necessary and the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Endocrine/Metabolic/Nutritional
Pharmacy/Prescription Drugs (growth hormone)

Diagnosis: short stature
treatment: Norditropin
The insurer denied Norditropin. The health plan's determination is upheld. 

This is a young male diagnosed with idiopathic short stature (ISS). His growth hormone (GH) stimulation test with arginine and clonidine peaked at 25. His height velocity is reported to be 2.8 cm/yr (centimeters/year). 

Norditropin is not medically necessary.
Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines. Food and Drug Administration (FDA) approval for this indication is for "non-growth hormone-deficient short stature, defined by height standard deviation score (SDS) less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means."
The patient did not have a pretreatment height less than or equal to -2.25 SD. The patient therefore does not meet idiopathic short stature criteria. The request for Norditropin does not meet nationally accepted criteria for use of growth hormone. The request is therefore not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient admission.
The health plan denied inpatient admission. The denial is upheld.

The patient is an adult female with a past medical history of hypertension, hyperlipidemia, cerebral aneurysm, and Thalassemia. She presented to the emergency department for evaluation of chest pain.

On arrival to the ED (emergency department), she was afebrile and hemodynamically stable. She was saturating well on room air. She was admitted to the inpatient unit and was evaluated by cardiology. Troponins remained within normal limits. A nuclear stress test was performed, which did not demonstrate any evidence of ischemia. She was ultimately discharged with outpatient follow-up.

The patient was hemodynamically stable and was not hypoxic. There was no evidence of sepsis, no mental status changes and no end organ malperfusion. There was no evidence of acute coronary syndrome. Nuclear stress test did not demonstrate any evidence of ischemia. Consequently, based on the provided documentation, there is insufficient clinical data to support medical necessity for inpatient level of care. Observation level of care would have been appropriate in this case.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic Eustachian Tube Dysfunction. 

Treatment: Code 69705 an outpatient Nasopharyngoscopy surgical with dilation of eustachian tube (procedure done in the ear). 

The insurer denied coverage for code 69705 an outpatient Nasopharyngoscopy surgical with dilation of eustachian tube (procedure done in the ear). 

The denial is upheld. 

This is a patient with a history of chronic rhino sinusitis. All of the clinical information available did not document any otological abnormalities. There were no ear related symptoms noted in any of the medical documentation other than one mention not in an actual clinical report. 
	
The information available revealed that the patient's condition did not meet the criteria  necessary for eustachian tube dilatation. 

As there was no objective evidence of eustachian tube dysfunction, dilatation of the eustachian tube would be of no benefit.  

The Food and Drug Administration (FDA) has approved this. 

This patient is not a candidate for code 69705, an outpatient Nasopharyngoscopy surgical with dilation of eustachian tube (procedure done in the ear). 

Code 69705 an outpatient Nasopharyngoscopy surgical with dilation of eustachian tube (procedure done in the ear) is not the best available treatment for this patient at this time. 

The adverse risks are increased over standard treatment/services. 

The denial should be upheld as there was no objective evidence that the patient had eustachian tube dysfunction. 

In summary, the denial of code 69705 an outpatient Nasopharyngoscopy surgical with dilation of eustachian tube (procedure dine in the ear) and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risk are substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fracture bilateral mandibula

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned
 

Upon review of the submitted documentation which includes a narrative letter from the patient, comprehensive medical record inclusive of consult note and operative note in addition to Milliman Care Guidelines 26th edition head and neck disease criteria, and insurer correspondence it appears that this patient sustained bilateral mandibular fractures subsequent to trauma. The patient presented for evaluation and was recommended admission of the patient for surgical intervention which was to include bilateral mandibular open reduction internal fixation surgery to treat the fracture. The insurer has denied the inpatient admission stating that the patient was not unstable, and the clinical findings did not warrant inpatient admission as per Milliman Care Guidelines. The patient's mother is appealing stating the emergency nature of the surgery. 

Upon review of the submitted documentation it is evident that the patient sustained bilateral mandibular fracture subsequent to facial trauma. Based on the submitted documentation provided for review the clinical scenario meets the Milliman Care Guidelines (MCG) for hospital admission under sections "Severe trauma requiring inpatient medical treatment" as well as "Head or Neck Disease condition or findings for which observation care has failed or is not considered appropriate." Further, although recent literature suggests that some craniofacial fractures may be managed in an outpatient setting the standard of care remains surgical management in a controlled hospital setting. 

Reverse denial as a standard of care for bilateral mandibular fractures remains inpatient surgical management and this clinical scenario as presented in the documentation provided meets Milliman Care Guidelines criteria.

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 the inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Headache with right eye blurriness
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient with a past medical history (PMH) of psoriasis and osteoporosis who was admitted with complaints of (c/o) two weeks of a headache associated with right eye blurriness. Her vital signs were unremarkable. The physical exam was notable for decreased sensation in the right face, arm, and leg. Lab work was unremarkable. Imaging studies included computed tomography angiography (CTA) of the head which showed possible fibromuscular dysplasia. The patient was diagnosed with a migraine with aura and treated with intravenous (IV) divalproex and magnesium, which resolved the patient's symptoms within 2 hours. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.
The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with complaints of (c/o) a headache associated with right eye blurriness. She received a CTA scan in the ED that did not demonstrate any acute intracranial pathology. This patient did not have a life-threatening cause of the headache, evidence of increased intracranial pressure (ICP), tumor, hydrocephalus, intracranial bleed, acute or subacute cerebrovascular accident (CVA), acute central nervous system (CNS) infection (encephalitis, brain abscess) or bacterial meningitis. In addition, the patient did not require immediate surgical intervention, have a hypertensive emergency, acute alteration in mental status, co-existing seizures, nuchal rigidity, acute visual loss, new focal neurologic deficits, abnormal pupils, apnea, abnormal respiratory pattern, or significantly abnormal vital signs. The patient was diagnosed with a migraine with aura and treated with neurology consultation, IV divalproex, and magnesium, which resolved the patient's symptoms within 2 hours and discharged for outpatient follow-up, and these interventions could have been safely and appropriately provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

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

This patient is a man who presented with the condition of obstructive jaundice. He had been seen previously at the hospital with complaints of jaundice, abdominal pain, fatigue, and dark urine for the past one week, but left the hospital against medical advice. His evaluation at that time revealed a 1.4- centimeter (cm) mass of the pancreatic head. At the time of his re-presentation, he had normal vital signs. He had no reported comorbid health conditions. Lab data included a white blood cell (WBC) count of 6.2, hemoglobin of 12.1, elevated serum transaminases, alkaline phosphatase and bilirubin of 15. Prothrombin time (PT) international normalized ratio (INR) was 1.23. Gastroenterology consultation was requested and he underwent endoscopic retrograde cholangiopancreatography (ERCP) with stent placement.

Based on the submitted clinical documentation, an inpatient level of care was not medically necessary in this case. This patient was admitted to the hospital with the diagnosis of a pancreatic mass and obstructive jaundice. Vital signs and lab data were normal at the time of presentation. He underwent diagnostic evaluation that included endoscopic assessment with endoscopic retrograde cholangiopancreatography (ERCP), brushings and stent placement. The early post-procedure course was uncomplicated. The submitted medical records support that this patient's care and evaluation could have reasonably been performed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypercarbic respiratory failure
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is overturned.

This is a male patient with a history of asthma, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and polysubstance abuse. His presenting complaints were altered mental status and wheezing. Radiology was notable for a head CT scan without intracranial hemorrhage and a chest x-ray with mild pulmonary vascular congestion. The patient was given Narcan in the emergency department (ED) with some improvement in symptoms. He was started on bi-level positive airway pressure (BiPAP) and admitted to an inpatient level of care for treatment of hypercarbic respiratory failure due to either an opiate overdose, congestive heart failure (CHF) exacerbation, or chronic obstructive pulmonary disease (COPD) exacerbation.
At issue is the medical necessity of an inpatient stay.
The inpatient admission was medically necessary.
The patient presented with hypercarbic respiratory failure with a differential diagnosis that included CHF exacerbation, COPD exacerbation, and opiate overdose. The patient was still experiencing respiratory distress and continued to require BIPAP after receiving initial treatment in the ED. Given the serious nature of the patient's presentation with hypercapnia, confusion, and the need for BIPAP, an inpatient level of care was medically necessary. A lower level of care would not be appropriate to provide the patient with the close monitoring and continued respiratory support that he needed.
Appeal type: Medical necessity
Decision: Overturned

Endocrine
Surgical services

Diagnosis: obesity
Treatment: stomach surgery
The insurer denied stomach surgery
The health plan's determination is overturned

This patient is a woman under consideration for bariatric surgery. She was 1.676 meters tall and weighed 103.8 kg (kilograms). This corresponds to a body mass index (BMI) of 36.95. She has comorbid health conditions of obstructive sleep apnea and PCOS (Polycystic ovary syndrome). The patient has attempted weight loss with conventional exercise programs as are detailed in the surgical note. Unfortunately, she has not been successful with significant sustained weight loss.

Given this patient's diagnosis, her current health condition and generally accepted guidelines for patient selection, the proposed stomach surgery (laparoscopic sleeve gastrectomy) is medically necessary for this patient.
This patient has a body mass index (BMI) in excess of 35 with weight related comorbid health conditions that include obstructive sleep apnea and PCOS. These weight-related health conditions will respond favorably to the sustained weight loss associated with laparoscopic sleeve gastrectomy. She has successfully completed a multidisciplinary bariatric evaluation. She has had appropriate dietary counseling and has been cleared for bariatric surgery from a mental health standpoint. She has been granted medical (cardiology and pulmonary) clearance. She has participated with a supervised weight loss program over a period of 6-months with refractory medically complicated obesity.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Mobility issues. 
Treatment: Personal Care Aide (PCA) services for a total of 168 Hours per Week (split-shift). 
The insurer denied Personal Care Aide (PCA) services for a total of 168 Hours per Week (split-shift). 
The health plan's determination is overturned in part. 

This is a case review for a female with medical history notable for mobility issues, incontinence, bilateral leg amputation, and history of sacral decubitus ulcer. The patient's physician provided a letter of support for this appeal. The letter states that the patient has had sacral decubitus ulcers in the past. With her bilateral leg amputations it is difficult for her to sit herself up and rotate. She requires assistance with all activities of daily living. There were no specific recommendations provided. 

Personal care aide services for 24-hours per day (live-in) is medically necessary for the patient. 

The patient requires personal care assistance for all activities of daily living. She is also incontinent of urine and stool, and requires assistance with frequent changes of incontinence care products. Her husband has been providing informal assistance, but due to his own health problems, will not be able to do so in the future. Because the patient's personal care needs are expected to be continuous and unscheduled throughout the day and occasionally at the night time as well, 24 hour live in personal care assistance is medically necessary for the patient. 

There is insufficient evidence that the patient requires 24-hour split shift personal care. There are no night time logs which demonstrate that the patient requires care overnight. The physician letter does not state that the patient requires turning and repositioning and she does not have any evidence of active pressure ulcer. Therefore, personal care aide services for 24 hours per day (live-in) are medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Venous ulcer
Treatment: Ambulatory Surgery (ablation) (outpatient procedure-36475 x 1)
The insurer denied the Ambulatory Surgery (ablation) (outpatient procedure-36475 x 1).
The denial is upheld.

The patient is an adult female with venous insufficiency, lymphedema, and healing left ankle venous ulcer. The patient has good pulses distally and tolerates compression wrap. The patient has a smaller granulating ulcer with no signs of infection. The patient has a prior ankle fracture and chronic lymphedema.

The requested health service is not medically necessary.

Per the records, under impression, it is stated that patient has an improving ankle ulcer.  The plan is for compression pump and ablation. Venous duplex scan shows reflux in the left small saphenous vein. The patient does not meet the medical necessity criteria for the requested service since the patient has no evidence of persistent venous stasis ulcer. The patient has healing of the ulcer based on the documentation that is getting smaller. The patient has not failed compression therapy as well as wound care.