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

Diagnosis: Cardiac Amyloidosis
Treatment: Vyndamax
The insurer denied coverage for Vyndamax.
The denial is overturned.

This case involves a geriatric patient with a history of systolic congestive heart failure, left bundle branch block, and significant left ventricular hypertrophy (LVH) on echocardiogram. The patient underwent pyrophosphate scan that was positive and consistent with a diagnosis of amyloidosis. Genetic testing was consistent with a diagnosis of cardiac amyloidosis. The patient was prescribed tafamidis (Vyndamax).

Tafamidis (Vyndamax) has been demonstrated to be efficacious in treating cardiac amyloidosis (wild-type transthyretin amyloidosis [ATTR wt] and hereditary amyloid transthyretin [ATTRv]) [1]. This patient presents clinically with a diagnosis of early amyloid cardiomyopathy. Early treatment is the only treatment that is effective. Waiting for the patient to develop severe symptoms of congestive heart failure is not best practice. Moreover, treatment with tafamidis has been associated with a reduction in both mortality and functional decline [2].

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

The medical necessity for Vyndamax is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Overweight
Treatment: Wegovy
The health plan denied the requested medication, Wegovy, as not medically necessary.
The health plan's determination is upheld.

This is a case review for a female being prescribed Wegovy for the diagnosis of overweight. The medical necessity for this medication was denied by the health plan, and this denial is the subject under review.

The request is for initiation of therapy. The medication will not be used in combination with any other products. The patient is currently on a reduced calorie diet and exercise program. The prescribing physician wrote that the request for review for medical necessity was done for the reason of "patient request." No office visit notes or supporting documentation were provided for review.

The patient's health plan denied coverage. They state that Wegovy is considered medically necessary to promote weight loss only if the patient is obese (defined as body mass index [BMI] of at least 30) or overweight with a BMI of at least 27 and one or more serious disease or two or more risk factors for serious disease. The health plan was unable to establish documentation of the patient's current body mass index. They also were not able to verify that she is currently enrolled in a qualified weight management program for at least 3 months, which is another requirement for approval.

Of note, the request for the medication was associated with the diagnosis of overweight (BMI 25-29.9). Elsewhere in the documentation, it states that the patient is obese (BMI over 30). There is no office visit note with recent calculation of actual BMI available for this review.

The patient provided a letter of support for this appeal on her own behalf. It states that she has had therapeutic trials of Wellbutrin and Topamax that had to be stopped due to medical contraindication. She also had a trial of Phentermine that was stopped due to increased heart rate. She discusses concerns with "high numbers" for blood pressure and possible fertility problems, but there has not been a workup or diagnosis for either symptom.

At issue is the medical necessity for the requested health service/ treatment of Wegovy.

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

The requested health service/treatment of Wegovy has not been demonstrated to be medically necessary for this patient.

The health plan has very specific criteria which must be met before Wegovy (semaglutide) will be prescribed for the medical management of weight loss. The case review does not include any medical record documentation of her most recent BMI and any other obesity-related comorbid conditions. There is no documentation that she met the health plan's requirement for at least 3 months of enrollment in a qualified comprehensive weight plan. Therefore, there is insufficient evidence that the patient meets the health plan's criteria regarding the medical necessity of Wegovy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Influenza.

Treatment: inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

The patient is an adult with benign past medical history who presented to the emergency department with complaints of fever, cough, congestion, and myalgias.

Vitals on presentation included temperature 103.0 degrees Fahrenheit, blood pressure142/84, pulse 108, respiratory rate 20, oxygen saturations at 94% on room air.  Laboratory results showed white blood cell count of 7.79, hemoglobin 14.1, hematocrit 42.0, creatinine 0.82, glucose 94, procalcitonin 0.12, influenza A positive. 

According to medical records, the patient presented with upper respiratory infection-like symptoms and tested positive for influenza A. The patient was hemodynamically stable with normal oxygen saturation. Laboratory results were unremarkable including a normal white blood cell count and procalcitonin. There was no evidence of a disseminated infection, chest x-ray was normal. Based on above findings, the patient met criteria for observation level of care.  

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

Diagnosis:  Obstructive Sleep Apnea.
Treatment:  Home Sleep Testing.
The insurer denied the home sleep testing.
The health plan's determination is overturned.

The patient is a female, who is seeking approval for a home sleep study. The patient was seen for a video visit. There was snoring present. The patient has a history of obesity with a body mass index (BMI) of 38 and eosinophilic esophagitis. The laboratory studies were unremarkable. A home sleep study was ordered. The sleep study showed no obstructive sleep apnea (OSA) present.

The health plan in its determination of medical necessity, did not act reasonably, with sound medical judgment and in the best interest of the patient. 

The home sleep testing is medically necessary for the patient. The patient met criteria for home sleep apnea testing as she had multiple risk factors such as sleepiness, obesity, and loud snoring. The patient gets 7 hours of sleep and is sleepy during the day. The patient's sleepiness scale (Epworth) is 8. Her screens for obstructive sleep apnea (STOP BANG) score is 4.  According to Kushida et al., (2005), Epstein et al., (2009), and Collop et al., (2007), the patient had major risk factors for OSA and required testing. It was reasonable and medically necessary for the home sleep study.

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

Diagnosis: Uterine fibroids.
Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is upheld.
 
The patient with a diagnosis of symptomatic fibroids who underwent a scheduled robotic assisted laparoscopic hysterectomy, left salpingo-oophorectomy, right salpingectomy and cystoscopy and lysis of adhesions. Blood loss was minimal. The procedure was reported as uncomplicated.  Postoperatively, the patient was stable. Pain was well controlled. 

There are many ways of doing a hysterectomy. The trend has been towards less invasive procedures. Conventional and robotic laparoscopy share similar advantages over laparotomy, including decreased morbidity, rapid recovery, and improved aesthetics of incisions. Laparoscopic hysterectomies are outpatient procedures unless a complication arises. Admission becomes necessary if the patient is febrile, hypotensive, bleeding, has difficulty breathing or the severity of the pain is such that admission is necessary.

According to Milliman Care Guidelines (MCG), Inpatient and Surgical Care 26th Edition, Laparoscopic hysterectomy, a laparoscopic hysterectomy is an ambulatory procedure. Inpatient stay may be needed for:  1) Surgical complications (bladder ureter or bowel injury or hemorrhage), 2) Conversion to abdominal hysterectomy, 3) Complex surgery (staging of endometrial cancer), 4) Wound complications, or 5) Comorbidities.

This patient did not have any of these criteria. Her procedure was uncomplicated. There was no evidence of any injury to other organs. Blood loss was minimal. Post operatively, the patient was stable. Nothing in the submitted clinical information suggested any serious problem that warranted admission. Please note that laparoscopic hysterectomy is an outpatient procedure and includes appropriate postoperative monitoring and an overnight stay if required.

The length and the complexity of the surgery did not warrant hospital admission.

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

Diagnosis: Alcohol withdrawal
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

The patient is a female with a past medical history (PMH) of polysubstance abuse, diabetes mellitus type 2 (DM2), and bipolar disorder who was admitted after feeling unwell and falling. The vital signs were unremarkable. The physical exam was notable for no apparent distress (NAD). The laboratory evaluation was unremarkable. The imaging studies included a computed tomography (CT) of the head, which showed no acute findings. The patient was diagnosed with mild alcohol withdrawal and treated with intravenous fluids (IVF) and a banana bag. The patient was discharged in stable condition. At issue is the medical necessity of the inpatient stay.

The health plan, in its determination of medical necessity, acted reasonably, with sound medical judgment and in the best interest of the patient.

The requested health service/treatment of inpatient admission was not medically necessary for this patient.

The patient did not have an acute co-morbid illness requiring inpatient treatment, high risk for delirium tremens, history of withdrawal seizures, long-term intake of large amounts of alcohol, serious psychiatric condition (suicidal ideation, psychosis), or severe alcohol withdrawal symptoms. This patient was found to have mild alcohol withdrawal and was treated with Clinical Institute Withdrawal Assessment (CIWA), benzodiazepines (BZDs), intravenous fluids (IVF), and telemetry. These interventions could have been safely and appropriately provided at an alternate level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned.
 

This is an adult male who presented to the hospital complaining of abdominal and chest pain, associated with nausea and increased with exertion.  Past medical history was relevant for hypertension, myocardial infarction, systolic congestive heart failure and diabetes mellitus.  He also had a history of previous percutaneous coronary intervention. On presentation vital signs were stable. Physical examination revealed no significant abnormality.  

12 lead electrocardiogram demonstrated normal sinus rhythm with right bundle branch block and inferior wall myocardial infarction- age undetermined.  Serum blood testing demonstrated a mild elevation in creatinine kinase-myocardial bands (CK-MB) 5.1 and no elevation of troponin at 0.003. The patient was admitted to the hospital for monitoring and treatment.  Coronary angiography revealed an ulcerated thrombotic stenosis at 80% (percent) in the mid right coronary artery within a previously stented segment.  A drug eluting stent was placed to open the occlusion. Antiplatelet therapy was changed from Brilinta to Effient prior to discharge.

This patient presented with chest pain and had a past medical history of coronary artery disease and percutaneous intervention. Electrocardiogram (EKG) on admission revealed right bundle branch block and an inferior wall myocardial infarction.  This patient had chest pain and a high pretest probability of significant coronary artery disease. This patient had an elevated HEART score and appropriately underwent cardiac catheterization with drug eluting stent placement prior to discharge. Acute inpatient admission was medically necessary in this case.

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 hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Perirectal Abscess
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient with a recent visit for groin pruritis who presented with a new complaint of right buttock pain that had begun 2 days before. The patient reported swelling associated with this. His vital signs were within normal limits. The examination demonstrated a 3x2 centimeter (cm) area of induration/fluctuance consistent with an abscess. The white blood cell count (WBC) was 11.8. A computed tomography (CT) scan was ordered which demonstrated a right perirectal abscess that was 9x27 millimeters (mm). The patient underwent right perirectal abscess drainage without complications. He was hospitalized overnight. The next day the patient was found to be doing well. He was discharged home. At issue is the medical necessity of an inpatient stay.

The inpatient stay was not medically necessary. The patient was identified to have a rectal abscess which was drained surgically and the patient did well after the procedure. There is no evidence that additional complex testing or therapy other than the surgery was performed. There is no evidence that a complicating event occurred before, during, or after the procedure that required a higher level of care. There is no documentation that the treating team identified conditions or problems specific to the patient that would have required inpatient care. The patient did not have significant dehydration, hemodynamic instability, severe pain requiring frequent or high doses of narcotics, signs of intestinal obstruction, peritonitis, or bacteremia. The provided documentation does not support the medical necessity of inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic Dermatitis
Treatment: Dupixent 300mg (milligrams)/2ml (milliliters) SC (subcutaneous) SOPN (Solution Pen Injector)
The insurer denied the request for Dupixent 300mg/2ml SC SOPN.
The health plan's determination is overturned.

The patient is a female who has a diagnosis of atopic dermatitis. Dupixent is being requested for the treatment of atopic dermatitis.

The requested health service/treatment of Dupixent medically necessary for this patient. Per the Food and Drug Administration (FDA) label, Dupixent (Dupilumab) is indicated for the treatment of patients aged 6 months and older with moderate-to severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable. This recommendation was based on trial results showing significant improvement in symptoms of atopic dermatitis in participants who were randomized to Dupixent (plus topical steroids) compared to those randomized to placebo (plus topical steroids). Several phase 3 clinical trials have demonstrated the efficacy of Dupilumab in patients ranging from 6 months of age to adults with atopic dermatitis. Dupixent can be used with or without topical corticosteroids.

The patient has had atopic dermatitis since she was an infant. She has tried and failed Mometasone, Triamcinolone, Eucrisa and Tacrolimus. The patient was given samples of Dupixent which improved her atopic dermatitis. The patient meets the FDA approved indication for the use of Dupixent for atopic dermatitis that is not adequately controlled by topical therapy. Medical literature does not suggest that a patient needs to have trialed and failed Tacrolimus for 12 weeks prior to using Dupixent for atopic dermatitis. The standard duration of approval is recommended.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion

Treatment: Braces and monthly visits

The insurer denied coverage for braces and monthly visits

The denial is overturned

Upon review of the submitted documentation (study models were not provided for review) it is evident that the patient exhibits a significant malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after the Handicapping Labiolingual Deviation Index. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used which utilize a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 

In this case, the treating orthodontist claims that an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care. 

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. This is confirmed by several referenced studies (1, 2, 3). Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. This is an accepted methodology that has been determined to represent an appropriate approach for assessing orthodontic need. 

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 braces and monthly visits is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Gastroesophageal reflux disease
Treatment: Outpatient LINX Reflux Management System
The insurer denied Outpatient LINX Reflux Management System.
The denial is Overturned.

The patient is an adult male with GERD (gastroesophageal reflux disease) and small hiatal hernia. Esophageal pH monitoring showed a DeMeester score of 31.8. Manometry was normal. The patient is on pantoprazole.

The health plan should cover the LINX procedure. 

The LINX procedure is beneficial. Per ACG (American College of Gastroenterology) guidelines for the management of GERD (gastroesophageal reflux disease), magnetic sphincter augmentation is evidenced to be a safe and effective alternative to laparoscopic fundoplication. Clinical outcomes of the 2 (two) procedures are similar, and both have unique advantages and disadvantages. The minimal surgical dissection required for MSA (magnetic sphincter augmentation) results in greater technical ease, shorter operative times, and shorter durations of hospital stays than for fundoplication. MSA (magnetic sphincter augmentation) is also easier to reverse, and MSA (magnetic sphincter augmentation) may result in less gas-bloat and greater ability to belch and vomit than fundoplication. This patient has failed standard therapeutic options for GERD (gastroesophageal reflux disease), including proton pump inhibitor therapy, necessitating the LINX procedure.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary Tract Infection

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld
 

Patient is an adult with a past medical history significant for hypothyroidism who presented to the emergency department with complaints of diffuse abdominal pain radiating to right flank, with nausea and vomiting. 

Vitals on presentation included: Temperature 97.3 degrees F, Blood Pressure 139/77, Pulse 80, Respiratory Rate 22, oxygen (O2) saturation 99%.

Laboratory results included the following: white blood cell count (WBC) 10.79, Hemoglobin (Hgb)-13.4, Hematocrit (Hct)-40.4, creatinine-0.79, glucose-122, urinalysis showed positive nitrite and moderate leukocyte esterase. 

Patient was started on intravenous fluids and empiric antibiotics (Zosyn) for possible urinary tract infection. Computed tomography (CT) scan of abdomen/pelvis showed ureteral mucosal hyperemia with mild stranding to the proximal right ureter. Blood cultures were negative and urine culture grew Escherichia coli. Patient remained afebrile and hemodynamically stable. She was discharged to continue outpatient follow-up on oral antibiotics. 

According to documentation, patient was admitted for urinary tract infection. Otherwise, patient was afebrile, hemodynamically stable with unremarkable laboratory findings including normal WBC. The decision to admit patients with acute complicated urinary tract infection (UTI) should be individualized. The decision is usually clear when patients are septic or otherwise critically ill. Otherwise, general indications for inpatient management include persistently high fever (e.g., >38.4C/>101F) or pain, marked debility, or inability to maintain oral hydration or take oral medications. Additionally, inpatient management is warranted when urinary tract obstruction is suspected or there are concerns regarding patient adherence. Generally, outpatient management is acceptable for patients with acute complicated UTI of mild to moderate severity who can be stabilized, if necessary, with rehydration and antimicrobials in the emergency department or observation unit.  Based on above findings, patient met criteria for observation level of management.

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 inpatient admission is not substantiated.