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

Diagnosis: Systemic Lupus Erythematosus (SLE)
Treatment: Formulary exception for Acthar Gel
The insurer denied the formulary exception for Acthar Gel
The denial is overturned.

The patient is a female with a history of systemic lupus erythematosus (SLE) (malar rash, arthritis and pleurisy) and rheumatoid arthritis (RA), as well as cystic lung disease with pulmonary Mycobacterium Avium Intracellulare (MAC) infection.

The patient was treated with a four-drug antibiotic regimen for pulmonary MAC and presented for infectious disease follow up with worsening pulmonary symptoms, radiographic progression and a positive AFB (acid-fast bacillus) sputum, suspicious for MAC recurrence and requiring re-treatment.  For SLE, she is treated with Plaquenil 400 mg (milligrams) daily and prednisone 5 mg daily.  She has also been treated with Acthar Gel 80 mg twice weekly, as she could not otherwise tolerate a decrease in her prednisone dosing.  The appeal is for continuation of Acthar Gel for the treatment of SLE.

Yes, the health plan should cover the formulary exception for Acthar Gel.

Acthar gel is FDA (United States Food and Drug Administration)-approved for "an exacerbation or as maintenance therapy in selected cases of systemic lupus erythematosus."  This patient with SLE and RA is being treated with Plaquenil 400 mg daily and prednisone 5 mg daily.  She has also been treated with Acthar Gel 80 mg twice weekly as she could not otherwise tolerate a decrease in her prednisone dosing.  Although there are other DMARDs (disease-modifying antirheumatic drugs) and biologic agents that may be used for the treatment of SLE, this patient also has a recurrence of her pulmonary MAC infection, as discussed above, and is thus not presently a candidate for additional immunosuppressive treatment.  She is at risk of SLE disease flare if her current therapy with Acthar Gel is discontinued.  Therefore, in this specific situation, continuation of Acthar Gel would be clinically appropriate and medically necessary. Therefore, the health plan should cover the proposed continuation of treatment with Acthar Gel.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems-Chest Pain.
Treatment: Inpatient Hospital. 

The health plan denied the inpatient hospital admission for medical necessity.  The denial was upheld in whole. 

This patient is a male with a medical history of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), obesity, pulmonary embolism (PE), asthma/chronic obstructive pulmonary disease (COPD), atrial fibrillation, and implantable loop recorder (ILR). He presented to the emergency room (ER) with stabbing chest pain, shortness of breath and palpitations. On presentation, the patient was hypertensive and tachycardic (sinus tachycardia up to the 120's). He was admitted for evaluation of PE and to rule out acute coronary syndrome (ACS).
The patient underwent a computed tomography (CT) scan, PE protocol that was negative, but the study was technically limited. During the course of the patient's hospitalization, the patient was tachycardic and intermittently hypoxic, with a pulse oxygen saturation at 91%, and febrile.
Cardiology service was consulted. ACS was ruled out by negative cardiac biomarkers, and there were no ischemic changes on his electrocardiogram (ECG). The ILR interrogation was normal. His fever workup was negative.
At issue is the Inpatient stay for medical necessity.
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of Inpatient stay was not medically necessary for this patient.
Given the patient's lack of objective evidence of myocardial ischemia and low risk Heart Score, an inpatient admission for evaluation for possible ACS was not medically necessary.
This patient presented with symptoms of chest pain, shortness of breath, and palpitations for 1 day. The patient's description of chest pain was consistent with atypical chest pain. The ECG monitoring was negative for ischemic changes, and the patient ruled out for ACS by negative cardiac troponin levels. Furthermore, the patient's calculated Heart Score was 1, a low risk for major adverse cardiac events. According to the clinically validated Heart Score pathway, this patient with a low Heart Score did not need an inpatient admission for further evaluation of ACS. (1, 2)
Also, according to the 2014 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines statement on the management of patients with non-ST-elevation (NSTE) acute coronary syndromes (ACS) (NSTE ACS include a clinical spectrum that ranges from unstable angina (USA) to NSTE myocardial infarction), given this patient had no objective evidence of myocardial ischemia, evaluation, and management under an inpatient level of care was not medically necessary. (3)
Therefore, the requested health service/treatment of Inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Pregnancy
Inpatient hospital

Diagnosis: Abdominal pain/Pregnancy
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

In this case, the patient is a pregnant female who presented at 33-1/7 weeks gestational age to rule out labor. The patient was noted to have abdominal pain. The pain was 10/10 and constant with movement and hip extension. She had 8/10 with rest and hip flexion. The pain was at the right lower quadrant and was associated with concurrent right upper quadrant pain. The patient had contractions that were perceived intermittently. She had no leaking of fluid or vaginal bleeding. There was good fetal movement. The right upper quadrant (RUQ) and right lower quadrant (RLQ) were reported as the primary areas of pain. There was no suprapubic tenderness. There was no dysuria. 

The inpatient admission was not medically necessary at the acute inpatient level of care status for this patient given the diagnosis of right sided abdominal pain with negative imaging for appendicitis by MRI (magnetic resonance imaging), CT (computed tomography) and ultrasound with stable vital signs and labs.

Based on review of the medical documentation and the Milliman Care Guidelines (MCG), there was no medical necessity for acute inpatient admission as the patient had no evidence of acute bleeding or worsening abdominal exam. In fact, the patient was noted to have normal vitals with a normal hemoglobin and hematocrit with a stable ultrasound, CT and MRI exam. There was no acute abdomen requiring surgical intervention. Given the stable vitals and afebrile status, this patient was not noted to have any source of infection. Thus, in conclusion, the care could have been provided at a lower level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pregnancy/Childbirth/Pregnancy-nausea and vomiting.
Treatment: Inpatient Hospital stay.

The health plan denied the inpatient hospital stay.  The health plan's determination is upheld.

This patient is a female, G1 P0 (gravida-para) who presented at 10-2/7 weeks by last menstrual period (LMP) consistent with an ultrasound at presentation with intractable nausea and vomiting that has been worsening over the past 2 days. The patient reports significant nausea and vomiting since she found out she was pregnant with up to 7 times per day. The patient reported that her vomiting worsened on the day prior, and she cannot tolerate any oral intake including fluids. She also had intermittent weakness and dizziness. She reported some blood-streaked emesis yesterday but no frank hematuria. Vomiting also was associated with epigastric pain but was not painful to palpation. This was painful during vomiting only. She denied chest pain or shortness of breath and denied fever and chills. The patient had a history of alcohol abuse and reported using up to a bottle of tequila every day for the past year.  The patient was admitted as a G1 P0 with nausea and vomiting of pregnancy after failed initial management in the emergency department. The patient was hemodynamically stable with normal vital signs and normal electrolytes. 

I uphold (in whole) the health plan's determination of medical necessity.

Based on review of the medical documentation and the MCG (Milliman Care) Guidelines, there was no medical necessity for acute inpatient admission, as the patient did not have a requirement of inpatient medical care, given the lack of the findings of any of the aforementioned criteria for admission to inpatient care. Based upon a review of each MCG Guideline criterion, the patient is noted to have no serious gastrointestinal pathology by lab assessment or physical exam. There was no necessity for inpatient admission rather than observation level of care based upon improvement noted in the first 24 hours of the admission. The patient had no tachycardia and was able to have intake. There was also no hemodynamic instability as the patient had normal vital signs. There was no vomiting that was severe or persistent documented. There were no severe electrolyte abnormalities noted, and her potassium was corrected to normal without difficulty. There was no acute renal failure and no altered mental status in this case. There was no fetal compromise at this gestational age. There was no suspicion of hydatidiform mole present given a normal ultrasound. The patient did not require treatment of monitoring that required inpatient admission. She had no need for excessive IV (Intravenous) fluids (> 3 liters per day) and only required an IV be placed. There was no need for parenteral nutrition in this case as the patient was on an oral diet and intake. Thus, there was no criterion that was met for inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left Knee Pain
Treatment: Euflexxa injections
The insurer denied the Euflexxa injections.
The determination is upheld.

The patient has a complaint of left knee pain. An office progress note documented that the patient had worsening left knee pain for 6 months and her pain failed to improve with a cortisone injection and physical therapy. Plain radiographs documented advanced left knee osteoarthritis. The patient was not interested in surgical intervention, so the provider requested authorization for a course of Euflexxa injections for the patient's left knee. At issue is the medical necessity of the requested Euflexxa injections for this patient's left knee.

The requested Euflexxa injections for the left knee are not medically necessary for this patient based on the records provided and the conclusions of the current, peer-reviewed literature.

The patient has pain from left knee osteoarthritis documented on x-ray. An office progress note documented that the patient had worsening left knee pain for 6 months and her pain failed to improve with a cortisone injection and physical therapy. A course of Euflexxa viscosupplementation injections was requested.

The current, peer-reviewed literature concluded that viscosupplementation injections are not an effective treatment for knee osteoarthritis. This is based upon recent articles published in the Journal of Bone and Joint Surgery and the clinical practice guideline published by the American Academy of Orthopedic Surgeons. A recent article published by Jevsevar and colleagues concluded that "Meta-analysis of only the double-blinded, sham-controlled trials with at least sixty patients did not show clinically important differences of hyaluronic acid treatment over placebo. When all literature was added to the analysis, the overall effect was greater but was biased toward stronger treatment effects because of the influence of nonblinded or improperly blinded trials." A second article published by Tammachote and associates concluded that "Triamcinolone acetonide provided similar improvement in knee pain, function, and range of motion compared with Hylan G-F 20 at the 6-month follow-up, with better pain control in the first week and better knee functional improvement in the second week." Lastly, the evidence-based treatment guideline published by the American Academy of Orthopedic Surgeons did not recommend viscosupplementation injections such as Euflexxa as an effective treatment for knee osteoarthritis. Therefore, the medical necessity of the requested course of Euflexxa in this case is not established.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiovascular/CHF
Treatment: Home Health Case/PCA
The health plan denied 84 hours of PCA as not medically necessary. The health plan determination is overturned in whole. The 84 hours of PCA are medically necessary for this patient.

The patient had been assigned 84 hours a week of personal care aide services based on assessment from August but according to the patient's primary care provider the patient continued to require assistance with walking, locomotion, toileting with transferring from commode and toilet as well as incontinence cares at the same level of assistance that was assessed from the August assessment tool indicating that the following January assessment underestimated the patient's PCA care needs in those areas. There was note from the January assessment that the patient's overall self-sufficiency had deteriorated. It was noted as well that the patient has had some episodes of stool incontinence based on the January assessment tool which was not noted in the previous assessment from August. The patient has multiple medical problems including diabetes mellitus type 2 which requires blood glucose monitoring 4 times a day with administration of insulin 3 times a day. The patient has congestive heart failure requiring diuretic therapy which would increase need for toileting, commode use and incontinence cares. The patient also requires the assistance of putting on and taking off compression stockings for the treatment of diastolic heart failure. Because of memory impairment the patient does have hallucinations, mainly overnight, requiring assistance with ambulation and locomotion to return to bed. The patient's medical provider has provided a letter citing medical necessity for 84 hours per week of personal care aide services. Again, the providers letter dated March, indicates that there was an underestimation of the patient's PCA needs for ADL's and IADL's from the January assessment tool.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems 
Treatment: Dental/Orthodontic Procedure 

The patient in question is a female. She is class II with a blocked out maxillary right canine (#6). The upper midline is shifted to the right and the maxillary left first molar (#14) is in crossbite. She has a functional shift to the left. She is treatment planned for orthodontics to correct her crossbite which was denied by the health plan on the basis that treatment is not medically necessary. The subject under review is the medical necessity of the treatment. 

The health plan's determination is overturned. 

The requested treatment with braces and monthly visits is medically necessary for this patient. This patient presents with crowding and partially blocked out #6. Most significant is the unilateral posterior crossbite on the patient's left side and corresponding mandibular midline shift to the left. There is strong medical evidence that early correction of unilateral posterior crossbites with a shift reduces the need for future treatment (1). The evidence shows if such a crossbite is not corrected before the patient reaches skeletal maturity, the ability to achieve orthopedic expansion is greatly reduced (2). Given the patient's age , and skeletal maturity in females usually occurs around 15-16 years old, she is nearing the end of the time that orthodontics alone can correct her crossbite. Therefore, the requested treatment is medically necessary at this time.
Appeal type: Medical necessity
Decision: Overturned

Dental Problems
Dental/Orthodontic Procedure

The patient is male with maxillary and mandibular spacing and several unerupted permanent teeth. #10 is delayed in its eruption and is impacted. There is a supernumerary (extra) tooth present incisal to tooth #6 and blocking its eruption. The patient was treatment planned for phase I orthodontics to remove the supernumerary tooth and expose #10 and bring it into the arch but the plan was denied due to lack of medical necessity.

The health plan's determination is overturned.

The request for braces is medically necessary. Impacted teeth indicate a strong medical need for orthodontic treatment. Most impacted incisor research is limited to central incisors, but the side effects described are applicable in this situation as well. Research shows that attempting to bring an impacted incisor is a long process that should be started as soon as possible. It is a generally accepted practice guideline to treat patients with impacted teeth, because if not handled properly it can lead to poor results for the patient. It is important to start orthodontics now and remove the supernumerary tooth before it causes damage to the permanent teeth.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Headaches, Dizziness, Nausea, Vomiting And Loss Of Appetite.
Treatment: Inpatient admission.
The insurer denied the inpatient admisssion.
The denial is upheld. 

The patient is a female with human immunodeficiency virus, hypertension, migraine headaches, asthma, and previous deep venous thrombosis/pulmonary embolism.  She presented with nausea, anorexia, lightheadedness, and headache since undergoing anal fissure repair with Seton placement four days prior.

The patient was afebrile with a pulse 62 and blood pressure 126/77.  Labs were notable for a creatinine 1.4, white blood cell count 5.3, calcium 7.9, potassium 4.1, and bicarbonate 29.  The chest x-ray showed no acute process.  Intravenous fluids were provided.  A renal ultrasound showed no hydronephrosis.  Meclizine was initiated.  The creatinine dropped to 0.4.

No, the Inpatient admission was not medically necessary.

The patient's nausea, headache, lightheadedness, and anorexia were not accompanied by syncope.  The patient was afebrile and hemodynamically stable.  There was no evidence of acute cerebrovascular accident, acute intracranial process, pulmonary embolism, or acute coronary syndrome.  There was no evidence of acute intra-abdominal process.  The white blood cell count was normal.  A renal ultrasound demonstrated no hydronephrosis.  The patient had only a mild degree of acute kidney injury, and renal function improved promptly with provision of intravenous fluids.  There was no intractable headache or need for frequent administration of parenteral analgesics.  Symptoms improved with conservative treatment.  In summary, inpatient admission was not medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Acne Vulgaris. 
Treatment: Formulary exception for adapalene-benzoyl peroxide gel (Epiduo, Epiduo Forte), Pre-service. 

The insurer denied the Formulary exception for adapalene-benzoyl peroxide gel (Epiduo, Epiduo Forte), Pre-service. 

The denial is upheld. 

The patient is a female with acne vulgaris for whom benzoyl peroxide (Epiduo gel) is requested. She has tried and failed minocycline, benzaclin, triamcinolone 0.05% cream, tretinoin, spironolactone 100 milligrams, Aczone, Spintec 0.25 milligrams, dapsone 7.5% gel and salicylic acid wash. 

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

The plan offers multiple alternatives that are interchangeable with the requested Epiduo gel, such as benzoyl peroxide and adapalene gel, the individual components of Epiduo gel, as well as clindamycin gel/solution, erythromycin sol, erythromycin-benzoyl peroxide, tazarotene, and tretinoin gel microsphere. The patient has tried and failed Benzaclin and tretinoin, so another formulary alternative can be tried before non-formulary medications are considered.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Plantar Fasciitis

Treatment: Pre-service request for custom shoe inserts (L3000 x2)

The insurer denied coverage for Pre-service request for custom shoe inserts (L3000 x2)

The denial is upheld 

The patient is a female who presented for evaluation of left heel pain. Per the records available, the patient was using custom orthotics and standing up to 18 hours a day. Furthermore, the progress notes indicate continued use of custom orthotics with met bars bilaterally. The patient presented again with complaints of heel and arch pain. She complained of daily pain that limits activity and noted orthotics were old. The patient was given a diagnosis of plantar fasciitis, as well as, bursitis. 

Based on the records, it appears the patient was only treated with custom orthotics and no other conservative treatment modalities were used to help with her heel pain. A review of the literature available regarding custom foot orthotics reveals that while many studies have been published, results have been found to be varied and often either inconclusive or negative in nature. (1) Furthermore, the role of over the counter orthotics in the relief of pain has been extensively researched. One study found that over the counter orthotics have been found to be effective in relieving patient foot pain. (2) As such, it is reasonable to have a patient try over the counter orthotics for the pain, as in the case of this patient, rather than immediately recommend custom orthotics. Furthermore, the records provided do not show any conservative measures that were done prior to the recommendation of the custom orthotics. If the patient tries other modalities and these fail then the orthotics may be needed.
	
As such, given the records available and an extensive review of the literature available with regard to this subject matter, this reviewer agrees with the decision to deny the orthotics based on a lack of medical necessity and not a covered benefit.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.

The insurer's denial of coverage for the pre-service request for custom shoe inserts (L3000 x2) is upheld. Medical necessity is not substantiated.