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

Diagnosis: Digestive System/Gastrointestinal/Other/Acid Reflux.
Treatment: Diagnostic testing (other than radiology)/ upper endoscopy.

The health plan denied the requested upper endoscopy as not medically necessary. 
The health plan's determination is overturned.

The patient is a female. Per the provider letter, she has longstanding acid reflux at least 3 times per week with no improvement on Famotidine and Omeprazole, which she took for 5 to 6 months (she took Omeprazole 20 mg [milligram] daily initially, and then twice daily; she later added Famotidine 20 mg twice daily to this regimen). Per the provider letter, she had reflux symptoms with eating. An esophagogastroduodenoscopy showed Los Angeles grade A esophagitis, a 1 cm (centimeter) hiatal hernia, localized gastric inflammation characterized by erosions and erythema, and a normal-appearing duodenum; biopsies showed an unremarkable esophagus, mild chronic gastritis, and an unremarkable duodenum.
At issue is the medical necessity for an esophagogastroduodenoscopy with biopsies.

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

Yes, the request for esophagogastroduodenoscopy with biopsies is supported by the submitted documentation. Clinical guidelines (including the American College of Gastroenterology guidelines for the treatment of gastroesophageal reflux disease) recommend endoscopy for investigation of upper gastrointestinal symptoms when those symptoms are refractory to proton pump inhibitor taken properly for 4-8 weeks without response [1]. The most recent American Society for Gastrointestinal Endoscopy (ASGE) guidelines for appropriate use of endoscopy state that endoscopy is warranted if an appropriate empirical trial of therapy for a suspected benign digestive disorder has been unsuccessful [2]. Current medical literature continues to support these recommendations [3-6]. Biopsies can demonstrate pathology such as inflammation (esophagitis, gastritis, duodenitis) which can cause symptoms [1-4]. In this case, symptoms were reported to be refractory to proton pump inhibitor therapy for at least 4 weeks (as well as twice daily therapy and complaints-therapy with an H2 receptor antagonist). Investigation for pathology such as inflammation (esophagitis, gastritis, duodenitis, peptic ulcer disease) and Barrett's esophagus, which could be diagnosed by esophagogastroduodenoscopy with biopsies, was appropriate. For these reasons, coverage for esophagogastroduodenoscopy with biopsies is supported in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: psoriatic arthritis.
Treatment: Stelara.
The insurer denied Stelara SQ (subcutaneous) 90 mg. 
The health plan's determination is overturned.

The patient is a  woman with psoriasis and psoriatic arthritis. The patient has been on Stelara 90 milligrams (mg) every 8 weeks (w) and is stable. 

Stelara subcutaneous (SQ) 90mg is medically necessary for this patient.
The patient has psoriasis and psoriatic arthritis (PsA) and has been on Sstelara 90 mg every 8 w since. For patients with psoriasis who weigh <= (less than or equal to) 100 kg(kilogram), Stelara is usually started at 45 mg at 0 and 4 weeks, and then every 12 weeks thereafter. However, some patients may require doses of 90 mg or maintenance dosing every 8 weeks. Given that this patient has both psoriasis and PsA, it's medically necessary to continue Stelara 90mg every 8w. She was previously on 45 mg every 12w but her PsA was not as well controlled. She is stable on this dose and tolerating it well.

In 2019, the Journal of the American Academy of Dermatology published the joint guidelines of care for the management and treatment of psoriasis with biologics and stated that for patients with psoriasis who have had an inadequate response to Stelara (45 or 90mg every 12w), a trial of 90 mg for patients <=100 kg and/or maintenance therapy every 8 w is indicated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Ovarian cancer, low back pain.
Treatment:  Physical Therapy.

The insurer denied the Physical Therapy.  The determination is upheld.

The patient has a diagnosis of ovarian cancer. Records indicate she that was doing physical therapy for low back pain.  At issue is the medical necessity of physical therapy.

The requested health service/treatment of physical therapy is not medically necessary for this patient. The patient's therapy progress notes documentation does not support medical necessity for standards of practice for physical therapy. Transition to a home exercise program is appropriate. Skilled physical therapy is not necessary when the activities performed in therapy do not require the performance of a qualified health care provider. Documentation related to the sessions in question indicate these exercises (pelvic tilts, dead bugs, breathing, squats, use of band with pulling and squats) that would appropriately be included in a home exercise program for the patient to do safely. A therapy note documents patient with "decreased functional in strength again noted with stairs and sit to stand test" indicating this is a repeat finding.  The therapist also notes, "increased restricted tightness within paraspinals and gluts, most likely due to sitting for long periods of time."  The therapist documents that they provided instructions in "self soft tissue" which is an exercise that can be done independently.  The documentation does not provide information for which skilled therapy is the only option or that home exercises done independently would not be the appropriate treatment.  The activities described in the progress notes provided do not require the expertise, knowledge, and clinical judgement/decision making abilities of a physical therapist that patient cannot provide independently.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol intoxication
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a female with a past medical history remarkable for type 1 diabetes, seizure, and alcohol use, who was admitted after she was found unresponsive on the floor and foaming at the mouth. Review of system was positive for large volume of alcohol intake. The patient was admitted for alcohol withdrawal, hypoglycemia, and seizure due to Lantus overdose. Upon arrival, Emergency Medical Services (EMS) reported her finger stick to be 40. The patient was treated with intravenous (IV) fluids and dextrose. The patient was also treated with thiamine, folate, and monitored on Clinical Institute Withdrawal Assessment (CIWA) protocol for withdrawal symptoms. 

The inpatient admission was medically necessary. The care could not have been safely rendered at a lower level of care.

The documentation supports admission for alcohol withdrawal and seizures. The Diagnostic and Statistical Manual of Mental Disorders defines alcohol withdrawal as 2 or more distinguishing symptoms which develop within several hours to days following a significant decrease in alcohol consumption after a prolonged period of heavy drinking. These symptoms include nausea or vomiting, autonomic hyperactivity, insomnia, increased anxiety and agitation, tremor, perceptual disturbances, and seizure. In this case, patient had mild tachycardia, and no other signs of autonomic hyperactivity. The patient presented with hypertension, tachycardia, tongue fasciculations, tremors, and seizures. These are all active clinical signs that represent alcohol withdrawal which warranted inpatient admission for close monitoring and administration of the CIWA protocol.

The risks of worsening and severe withdrawal are usually dependent on the usual amount consumed, as well as duration of consumption. Patients who consume large amounts of alcohol on a regular basis, for long periods of time, are more likely to develop withdrawal requiring pharmacologic intervention and are at high risk for progression. Alcohol withdrawal delirium, commonly called delirium tremens (DTs), is a life-threatening complication of alcohol withdrawal and this occurs in approximately 3-5% (percent) of patients hospitalized with withdrawal symptoms. Mortality rates in cases of DTs without intervention can be as high as 20%, with death most commonly resultant from infection, cardiac arrhythmias, or respiratory collapse, and symptoms typically begin after 1-3 days of abstinence.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Skin Disorders/Psoriasis.
Treatment: Pharmacy/Prescription Drugs.
The health plan denied the requested prescription medication Taltz.
The health plan's determination is upheld.

The patient is a male with psoriasis. Body surface area affected is 30-35%. He has failed Triamcinolone 0.1% topically, Halobetasol, Prednisone, Cosentyx, Humira, Stelara, Otezla, and Enbrel.
The medication under review is Taltz 80mg/ml Auto Injectable.

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

According to the American Academy of Dermatology Psoriasis Guidelines and medical literature, the preferred medicines such as Skyrizi covered by the patient's insurance plan are effective treatments for the management of psoriasis [1-3].
Gu et al writes in "Risankizumab is a humanized IgG monoclonal antibody that binds to the p19 subunit of IL-23 (interleukin receptor) and inhibits its interaction with the IL-23 receptor. Clinical trials showed that Risankizumab was significantly more effective than Ustekinumab. Risankizumab was well tolerated" [2]. Reddy et al writes in "As the number of biologic agents used to treat psoriasis expands, newer medications provide promise of enhanced efficacy. In phase III trials conducted thus far, Risankizumab has proven to be both efficacious and safe in the treatment of plaque psoriasis. By specifically targeting the IL-23p9 (endothelial cell marker) subunit and thereby blocking the Th-17/IL-23 (pathway in inflammatory skin diseases), Risankizumab, when compared to other more non-specific agents, may have a lesser impact on normal immune function. The head-to-head phase III clinical trials discussed in this review have demonstrated that Risankizumab is superior to Ustekinumab and Adalimumab in efficacy, including time to visible clinical improvement, and comparable in its safety profile."[3]. The evidence-based literature is consistent. The preferred agents are appropriate agents for the treatment of the patient's psoriasis. The formulary medications should be tried and failed prior to approving Taltz.
There is no documentation provided that would justify the patient requiring treatment with Taltz prior to the formulary alternatives such as Skyrizi.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Home Health Care. 

The insurer denied Increase Home Care/Personal Care HHC-Level 2 Personal Care Services, per 15 minutes to 84 hours per week. 
The denial was upheld. 

The patient is a female with a past medical history significant for hypertension, heart failure, coronary artery disease, peripheral vascular disease, hyperlipidemia, diabetes mellitus type 2 with neuropathy, ataxia, seizure disorder, osteoporosis, and osteoarthritis. She has both physical and cognitive health decline secondary to her age and underlying medical conditions and dementia. The patient is requesting an increase in services. The increase in services was denied by her health plan based upon medical necessity. 

Services were denied by her health plan stating the patient was scheduled for 35 hours a week of services and there was an increase of services to 49 hours a week, 7 days a week times ()7 hours per day. The patient is requesting 12 hours a day 7 days a week for a total 84 hours a week of services. Services were partially increased at that time. However, her health plan stated she did not meet criteria for 12 hours a day 7 days a week, noting that the patient needs assistance with chores and assistance of daily living. Safety monitoring as part of the total care service hours for personal care are included. 

At issue is the medical necessity of Increase Home Care/Personal Care HHC-Level 2 Personal Care Services, per 15 minutes to 84 hours per week. 

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

The requested health service/treatment of Increase Home Care/Personal Care HHC-Level 2 Personal Care Services, per 15 minutes to 84 hours per week is not medically necessary for this patient. 

The patient is a female with progressive health problems including cognitive and physical decline. There was a noted decrease in the patient's functional capacity. This decrease in her abilities was accounted for by an increase in services from 35 hours a week to 49 hours a week. Time was allotted for her Instrumental activities of daily living (IADL)s, which was similar between the two evaluations, but there was a progression in time necessary for certain activities of daily living (ADL)s. The two areas of concern included the patient's cognitive decline along with incontinence. Services for incontinence are allotted for in a number of hours. Additional services must be demonstrated with a need for ADLs or IADLs above and beyond observation and preventing falls. Services for preventing falls and observation are included in the provided services. Specifically, the Personal Care Services must be performing a service such as in an ADL or IADL to be considered medically necessary. The documentation provided did not note why an additional 5 hours a day would be medically necessary other than for monitoring the patient. 

Therefore, the requested health service/treatment of Increase Home Care/Personal Care HHC-Level 2 Personal Care Services, per 15 minutes to 84 hours per week is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain and Shortness of Breath
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

This male patient was hospitalized for chest pain and shortness of breath. He presented to the hospital emergency department (ED) for evaluation of severe chest pain and shortness of breath (SOB). His past medical history was pertinent for cocaine abuse, hypertension (HTN), hyperlipidemia (HLP), smoking and obesity. 

The patient's vital signs were stable. The pain was reproduced on upper torso movement. Treatment included continuous intravenous (IV) morphine. There were no acute electrocardiogram (EKG) changes, arrhythmias or elevated troponin documented. Chest computed tomography angiography (CTA) was negative. This is an appeal of the denied claim that the requested acute inpatient hospital stay was medically necessary for this patient approved at the observation level of care.

No, the proposed inpatient admission was not medically necessary.
Based on the peer reviewed medical literature, there was not a medical need for the acute inpatient hospital stay, because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. Per the current published guidelines, criteria for inpatient hospital stay are not met, including hemodynamic instability, respiratory distress, pulmonary edema, acute myocardial infarction (AMI), angina with acute coronary syndrome (ACS), chest pain that is indicative of a serious cardiac condition like pulmonary embolism (PE) or aortic dissection, pneumonia, hypertension requiring inpatient hospitalization or any other medical condition, symptom or finding for which emergency and observation care have failed or are not considered appropriate. The care the patient received is routinely provided safely and effectively at a lower level of care, such as, at the Observation level of care. 

Therefore, the proposed treatment, inpatient hospital admission was not medically necessary, based on the submitted information and the current published medical standard of care.

Yes, the health plan act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: IBS (irritable bowel syndrome). 
Treatment: Formulary exception for Librax (Chlordiazepoxide-Clidinium). 

The insurer denied the Formulary exception for Chlordiazepoxide-Clidinium. 
The denial is overturned. 

The patient is a female with IBS (irritable bowel syndrome). She has failed OTC
(over-the-counter) medications, as well as dicyclomine, hyoscyamine sulfate and
hyoscyamine oral disintegrating tablets. She has done well with Librax
(Chlordiazepoxide-Clidinium). Her provider is requesting Librax. 

Yes, the health plan should cover the Formulary exception for Chlordiazepoxide-Clidinium. 

The patient has failed OTC (over-the-counter) medications, as well as dicyclomine, hyoscyamine sulfate and hyoscyamine oral disintegrating tablets. She has failed three preferred formulary alternatives. 

As the patient has failed 3 preferred formulary alternatives, the health plan should cover the Formulary exception for Chlordiazepoxide-Clidinium.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Foreign Body Ingestion. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the Inpatient Hospital Stay. 
The determination is upheld. 

The patient presented to the emergency room after swallowing a coin. She had dysphagia and increased salivation. She was admitted and underwent an upper endoscopy with foreign body removal. At issue is the medical necessity of an inpatient stay. 
The requested inpatient hospital stay was not medically necessary. 
This patient presented after swallowing a foreign body (coin). She had no respiratory distress or loss of consciousness. She was hemodynamically stable and well appearing on arrival to the emergency room. 
She required an urgent upper endoscopy, which was successful in removing the foreign body. No peri-operative complications were noted. The procedure and anesthesia were well tolerated. The procedure can be done at outpatient level of care. The patient's condition was stable and did not require postoperative care at inpatient level of care. There is no evidence that the admission was medically necessary to treat the patient's condition. There were no treatments given that were not possible at a lower level of care. The current literature and standards of care do not support inpatient management for uncomplicated gastrointestinal foreign bodies. 
Therefore, the medical necessity of the inpatient admission cannot be established.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neutropenia. 
Treatment: Inpatient Stay. 

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

This case involves a man with a history of schizoaffective disorder, opiate use on maintenance therapy, and cannabis use who presented to the hospital with a report of neutropenia. The patient has been treated with clozapine for six months and has to undergo weekly blood work. Per the last outpatient testing, it was noted to have a decreased white blood cell count and was instructed to stop the clozapine. However, the patient continued to take the clozapine while awaiting a follow-up appointment and subsequently presented to the emergency department, primarily for complaints of a sore throat for two days with no fevers, cough, or shortness of breath. Vital signs on arrival included a normal temperature, heart rate of 79, blood pressure 132/77, and respirations of 19. Oxygen saturations were normal. On exam, the patient is in no apparent distress. The cardiopulmonary exam is unremarkable. The abdomen is soft nontender. The rest of the exam is described as normal. 

The inpatient hospital admission is not medically necessary for this patient. The patient was experiencing a typical side effect reaction of this particular psychiatric medication. The patient was instructed to stop the medication, which he did not, and experienced neutropenia. The patient was completely asymptomatic with neutropenia and was directed to the hospital by his primary care physician because of an abnormal lab. However, neutropenia alone is not an adequate reason for inpatient hospitalization. The patient did not have febrile neutropenia, which is the clinical condition that warrants an inpatient hospitalization. The patient is neither febrile nor has a source of infection. The patient is not septic, and the peripheral blood smear shows no evidence of a malignant cell line. Therefore intravenous (IV) antibiotics were not clinically indicated, and this is supported by the infectious disease specialist. 

The patient was essentially monitored for improvement in the neutropenia after stopping the causative medication. This can be accomplished under a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe Crowding, ectopic eruption overjet and overbite. 
Treatment: D8080 braces. 

The insurer denied coverage for D8080 braces. 

The denial is overturned. 

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images as, well as narrative letters it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to severe crowding, ectopic eruption overjet and overbite in addition to manifestations of the patients underlying genetic syndrome. The orthodontist has completed the Handicapping labio-lingual deviations (HLD) index as required and arrived at a total point score of 28 points. 

Upon review of the submitted documentation, (study models were not provided for review), it is evident that the patient exhibits a malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, Handicapping Labiolingual Deviation Index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing 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 28 points on the HLD index. This reviewer concurs with the scoring from the orthodontist which supports comprehensive orthodontic care. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care. 

Reverse denial as the clinical circumstance as presented does substantiate medical/dental necessity of orthodontic care. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for D8080 braces is overturned. Medical Necessity is substantiated.