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

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

The patient is a woman who presented to the emergency department (ED) complaining of three days of nausea, vomiting and diarrhea. Her medical history was remarkable for hypertension, hyperlipidemia, diabetes, gastroparesis and cigarette smoking. She reported noncompliance with her prescribed medical regimen. In the emergency department (ED), her blood pressure was 191/125 with a heart rate of 94 beats/minute. Her respiratory rate was 18/minute. An electrocardiogram showed sinus rhythm without acute changes. Her troponin T level was 0.220 and was 0.189 when re-measured. Her serum creatinine level was 3.65; her baseline level was not documented. Chest X-ray and computed tomography (CT) scan of the abdomen and pelvis showed no acute pathology. The patient was treated with aspirin, intravenous labetalol, intravenous fluid and nifedipine and was admitted to the hospital with diagnoses of hypertensive emergency, acute on chronic kidney injury and hypovolemia. 

Based on the documentation provided, an inpatient hospital admission was medically necessary. 
This patient was markedly hypertensive upon presentation and was found to have significant kidney injury that was thought to be acute, at least in part, and due to her uncontrolled hypertension. Hypertension with acute end-organ damage is classified as hypertensive emergency and is associated with a substantial risk for major adverse events, including stroke, myocardial infarction and death, both from uncontrolled hypertension and from hypoperfusion due to overly rapid blood pressure lowering. Careful monitoring of vital signs and clinical status is indicated and requires an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Osteoarthritis. 

Treatment:  Inpatient admission. 

The insurer denied coverage for inpatient admission.  The denial is upheld. 

This adult female patient underwent a robotic right hip arthroplasty. The facts were although her blood pressure was low after surgery, she received fluids and did not require a transfusion. The condition stabilized. There were no signs of bleeding. Her wound was satisfactory. The report of unable to be discharged without clearance from physical therapy (PT) has no merit. She was evaluated and reported to be tired and declined some attempt at PT. There were visits reported by PT showing "independence". She was able to tolerate oral pain medications. 

The Social Work record reported discharge (DC) planning was completed. There were "no concerns". The nursing progress record notes "disposition planning and social work (SW) involved". 

The physician record noted pain was controlled with recommendation of discharge home when cleared. The DC summary noted no significant events. 

There were no medical records showing a complication or delay to require the acute level of care. The criteria were not met. The medical records did not substantiate the necessity for acute level inpatient services. 

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 a full hospital admission is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

 Diagnosis: Irritable Bowel Syndrome with Constipation

Treatment: Ibsrela 50 milligram (mg) tablet to treat irritable bowel syndrome with constipation

The insurer denied coverage for Ibsrela 50 milligram (mg) tablet to treat irritable bowel syndrome with constipation

The denial is upheld 

The patient has a diagnosis of irritable bowel syndrome - constipation (IBS-C). The patient's physician writes that the patient has failed treatment with MiraLAX, Metamucil, lactulose, Linzess, and Trulance. The patient was given samples of Ibsrela which helped the constipation greatly. 
UpToDate has an article titled "Treatment of Irritable Bowel Syndrome in Adults." The article discusses treatment of IBS-C. The recommendation is that if patients fail soluble fiber such as psyllium, polyethylene glycol (PEG) should be given. If there is persistent constipation after treatment with a PEG preparation, the patient should be treated with lubiprostone, linaclotide, or plecanatide. 

Lubiprostone is a locally acting chloride channel activator that enhances chloride-rich intestinal fluid secretion. 

Tenapanor (Ibsrela) is given for patients who have failed the other constipation treatments. 

This patient has failed several of the advised IBS-C treatments. However, the patient has not failed lubiprostone. As per the UpToDate recommendations, it is appropriate treatment to give a trial of lubiprostone prior to starting lbsrela. 

As the formulary drug lubiprostone has not been tried, it has not been determined whether it would cause an adverse reaction. 

As the formulary drug lubiprostone has not been tried, it is unknown if the patient would have an adverse reaction; there is no known contraindication.

Since the formulary drug lubiprostone has not been tried, it has not been shown to be ineffective.

It is possible that Ibsrela may work better than lubiprostone. However, a trial of lubiprostone should be given before the Ibsrela is prescribed. 

The carrier's denial of a request for a Formulary Exception for Ibsrela 50 milligram (mg) tablet to treat irritable bowel syndrome with constipation is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Upper Gastrointestinal Bleeding

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld
 

The patient was having melena and vomited coffee grounds. She was started on Protonix and Sucralfate 2 days earlier. At the hospital her vital signs were stable. There was no abdominal rebound or guarding. The hemoglobin was 5.7. She was given 2 units of packed red blood cells (PRBC) and treated with Protonix. The hemoglobin went up to 8.3. There was no bleeding while in the hospital. She remained hemodynamically stable. An endoscopy revealed a duodenal ulcer that was not bleeding and was clean based. 

Medical necessity was determined based on Milliman Care Guidelines (MCG) M-180 for Upper Gastrointestinal Bleeding. Clinical indications for admission include hemodynamic instability, ongoing active bleeding, peptic ulcer disease with high-risk endoscopic features such as a visible vessel, severe coagulopathy, severe anemia with signs of cardiac ischemia, peritoneal signs, and an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

This patient had a duodenal ulcer which had bled but was no longer bleeding while in the hospital. She had a severe anemia but was not having signs of cardiac ischemia and the hemoglobin rose to 8.3 after the transfusions. The transfusions could have been given with observation care. Afterwards, the endoscopy could have been performed as an ambulatory procedure. There was no evidence of any bleeding during the procedure and the ulcer was clean based. She did not meet MCG criteria for admission for Upper GI Bleeding. 

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

Diagnosis: Accidental cannabis ingestion. 
Treatment: Inpatient admission. 
The insurer denied coverage for inpatient admission. 
The denial is overturned. 

This child reportedly had marijuana intoxication after ingesting 87.5 milligrams (mg) of edible cannabinoid candies and was admitted for inpatient hospital treatment. It was reported that while the patient's father showered the child ate his cannabinoid candies. It was reported that the patient had an elevated heart rate of 119 beats per minute, hypotension with a blood pressure of 94/52, fever, had body shaking, altered mental status including screaming, had leukopenia, hyperbilirubinemia, and elevated alkaline phosphatase (AP) of 276. It was reported that poison control was contacted, and they recommended that the patient be hospitalized until their neurological status was back to baseline. The patient was on neurological checks every 2 hours, was given intravenous (IV) fluids, and was nothing per mouth (NPO). 
  
The medical records provided enough specific evidence to support inpatient hospital treatment. The Milliman Care Guidelines (MCG) Drug Ingestion/Overdose criteria states that one of the following need to be met: hemodynamic instability, dangerous arrhythmia, respiratory abnormalities, hypertension requiring inpatient treatment, specific finding indicating severe and prolonged drug toxicity, or inpatient admission is required other than observation care. In this case this patient had an overdose of marijuana as they reportedly ingested 87.5 mg of cannabinoid candies. The patient reportedly had altered mental status and was agitated, screaming, and had medical consequences to the ingestion including had elevated heart rate, hypotension, fever, body shaking, altered mental status including screaming, had leukopenia, hyperbilirubinemia, and elevated alkaline phosphatase (AP). It was reported that the accidental overdose of marijuana put the patient at high risk medically so until they were at their baseline medically and with their mental status, the patient was considered a medical risk and in need of 24-hour hospital treatment. This patient could not safely be treated in a less restrictive setting. 

The Milliman Care Guidelines (MCG) Substance Related Disorder criteria reports that if one has acute toxicity or instability from substance use requiring inpatient treatment and a lower level of care is not feasible, or one is an imminent danger to self or others then they meet criteria for inpatient hospital treatment. This patient was a child considered at risk medically and had altered mental status due to this ingestion and overdose of marijuana. Once her mental status and medical status improved, she was discharged. 

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 inpatient hospital admission is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Nasal airway obstruction
Treatment: Low-dose radiofrequency intranasal tissue remodeling (30469)
The insurer denied: Low-dose radiofrequency intranasal tissue remodeling (30469)
The denial is overturned.

According to the clinical records, the patient is an adult female who presented with nasal obstruction. The patient has a chronic history of blocked nasal breathing. Medical management was trialed without benefit. Examination revealed evidence of internal valve narrowing and dynamic nasal obstruction. The recommendation was made for an in-office procedure to assist with improvement in the nasal airway. The prior denial reason was that the procedure was deemed investigational or experimental, given not enough evidence regarding benefit. The reason for appeal is to overturn this decision based on medical appropriateness and supporting evidence in the medical literature.

The health plan should cover the proposed treatment.

The medical literature supports the usage of this device for treatments of nasal valve collapse and obstruction. A prospective study found, "The study involved 31 patients presenting from 1st September 2017 to 1st May 2018 with symptoms of nasal obstruction and snoring. In all patients, an improvement was observed in nasal breathing measured by NOSE score, sleep quality by SOS questionnaire and quality of life as measured by EQ-5D and SNOT-22." (1)
Another study stated, "Clinically significant improvement from baseline in NOSE Scale score change demonstrated at 6 months (mean, 55.9; standard deviation [SD], 23.6; p < 0.0001) was maintained through 24 months (mean, 53.5; SD, 24.6; p < 0.0001). Responders (>=15-point improvement) consisted of 92.3% of participants at 6 months and 97.2% at 24 months. Responses to the QoL questions also showed improvement in patients' QoL." (2)
A third study concluded, "A total of 108 patients received active treatment (77 as index active treatment, 31 after crossover). The mean (SD) age of patients was 48.5 (12.3) years; 66 (61.1%) were women. The combined group of patients receiving active treatment had a mean baseline NOSE Scale score of 76.3 (95% CI, 73.6-79.1). At 12 months (n = 88), the responder rate was 89.8% (95% CI, 81.7%-94.5%). The NOSE Scale score improved from baseline (mean change, -44.9 [95% CI, -52.1 to -37.7]). No device/procedure-related serious adverse events were reported." (3) 
Therefore, the health plan should cover the proposed treatment.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Nasal airway obstruction
Treatment: Low-dose radiofrequency intranasal tissue remodeling (30469)
The insurer denied: Low-dose radiofrequency intranasal tissue remodeling (30469)
The denial is overturned.

This patient is an adult female with prior (septo) rhinoplasty as a teenager and chronic nasal congestion refractory to fluticasone nasal steroid and ipratropium. Physical exam shows deviated septum with bilateral edematous turbinates consistent with turbinate hypertrophy. Nasal endoscopy had similar findings. Computed tomography (CT) scan of the sinuses shows deviated septum without spurring or chronic sinusitis.

The health plan should cover the proposed treatment.

Treatment options include the gold standard septoplasty, turbinate reduction, and nasal valve repair as well as in office ablation of the inferior nasal turbinates. The patient has a history of prior rhinoplasty that may have included septoplasty. Septoplasty is required for cartilage graft for nasal valve repair via different types of splinting (batten, spreader, etc). Given that the donor site may have a paucity of cartilage, as the Provider pointed out, the patient may require an alternative site for cartilage graft such as the ear/conchal cartilage. For a patient wishing to avoid a second incision, conservative treatment with low-dose radiofrequency intranasal remodeling is accepted and is very reasonable. Therefore, the health plan should cover the proposed treatment. 
The requested health service or treatment is likely to be more beneficial than any standard treatment for the insured's condition or disease. This patient has not responded to prior (septo) rhinoplasty and an appropriate course of nasal steroid. She does not want more invasive surgery with nasal valve repair with conchal cartilage graft. Given that radiofrequency intranasal tissue remodeling avoids general anesthesia, is less invasive, and has a low complication rate, this procedure is very reasonable in a stepwise treatment of nasal obstruction. The attending physician has provided a reference list that contains multiple studies in respected journals supporting the use of radiofrequency intranasal tissue remodeling in nasal obstruction (2-10). In addition, the meta-analysis by Casale et al. supports this procedure (1).
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Nasal airway obstruction
Treatment: Low-dose radiofrequency intranasal tissue remodeling (30469)
The insurer denied: Low-dose radiofrequency intranasal tissue remodeling (30469)
The denial is upheld.

The patient is an adult female with a nasal obstruction that did not respond to medical therapy. She has a history of prior septorhinoplasty. On exam, the patient is noted to have a narrow nasal valve due to alar cartilage resection and enlarged turbinates. After discussion with her surgeon, VivAer radiofrequency ablation procedure was recommended. This was denied by her insurer and an appeal was submitted. The prior review concluded that coverage for this surgery should not be approved as this procedure is considered investigational. This represents a second level review of this case.

The health plan should not cover the proposed treatment.

There is not enough clinical evidence to prove the safety and efficacy of low dose radiofrequency intranasal tissue remodeling. The studies that are available offer low patient numbers, are of poor quality, and have short follow-up duration. Therefore, the health plan should not cover the proposed treatment. 
The data that is available on radiofrequency tissue ablation for nasal airway remodeling is of low quality, with low patient numbers and short duration follow-up. The majority of the available studies are sponsored by the medical device manufacturer. Many of the studies concluded that more research is needed on a large scale to confirm results. Septorhinoplasty is the current standard of care and has been found to offer durable symptomatic improvement in structural nasal obstruction. Therefore, the requested health service or treatment is not more beneficial than any standard treatment for the insured's condition or disease.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis:  Angiofibromas.
Treatment:  Sirolimus powder (compound).

The insurer denied coverage for Sirolimus powder (compound).  The denial is upheld.

The patient is a child with angiofibromas.  Clinical notes are not provided to determine whether these lesions are associated with tuberous sclerosis, nor is there an indication of the number of lesions and their actual distribution.  The request is for Sirolimus powder as a compounded topical treatment.

Based on the limited clinical information provided, including lack of any clinical documentation, the use of Sirolimus topical is not medically necessary.  Angiofibromas are benign vascular papules, which rarely require treatment.  The first line treatment would be laser destruction or electrocautery destruction. The use of Sirolimus cream is indicated for congenital vascular malformations, not angiofibromas.  In the setting of a diagnosis of tuberous sclerosis, in which multiple angiofibromas form, the use of sirolimus cream may be warranted and clinically necessary.  In this case, there is no documentation to this effect.  As a result, and due to a lack of clinical notes which clearly would establish the extent of involvement and whether the diagnosis is isolated benign angiofibromas or the more severe case associated with tuberous sclerosis, the clinical necessity for the use of sirolimus cream has not been established.  Sirolimus cream is not Food and Drug Administration (FDA) approved for the treatment of angiofibromas and is not clinically indicated for isolated angiofibromas not associated with tuberous sclerosis.  

The carrier's denial of a request for a Formulary Exception for Sirolimus powder (compound) is upheld.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis:  Attention deficit hyperactivity disorder (ADHD)
Treatment: Vyvanse
The insurer denied Vyvanse.
The determination is overturned.

This patient is a female with a history of attention deficit hyperactivity disorder (ADHD) requesting coverage for Vyvanse 40 milligrams (mg) capsules. According to the appeal letter written by her provider, the patient has tried and failed dextroamphetamine/amphetamine extended release, amphetamine/dextroamphetamine salts, and methylphenidate. The medical records submitted for review document these trials. At issue is whether the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.

At least three formulary drugs have been found to be ineffective and therefore would not be as effective as the non-formulary drug Vyvanse. The plan stipulates that a non-formulary medication will be approved if the patient has tried and failed three similar formulary preferred agents. The records indicate that the patient has tried and failed at least three similar formulary drugs. Therefore, based on the standard of care, as well as the peer reviewed literature and guidelines cited in the references, the non-formulary medication Vyvanse should be approved.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental issues. 
Treatment: Crown and Core Buildup on Tooth Number 16. 
The insurer denied Crown and Core Buildup on Tooth Number 16. 
The health plan's determination is upheld. 

This is a female who has been denied a core buildup and a crown for tooth #16 because there was no documentation of a significant loss of tooth structure that would require a crown restoration. 

The Crown and Core Buildup on Tooth Number 16 is not medically necessary for this patient. There is no clinical documentation supplied that supports the need for a buildup and a crown for tooth #16. 
The indications for a crown include: 
-	Large, previously placed restorations. When a tooth appears to require an intracoronal preparation that exceeds one-half of the facial-lingual cusp tip-to-cusp tip distance, placement of an intra-coronal direct or indirect restoration is a questionable procedure. Cusps often break off during service, in spite of the placement of "bonded" restorations. 
-	Cracked-tooth syndrome. 
-	Asymptomatic cracks in teeth. 
-	Endodontically treated, heavily restored teeth. 
-	Broken cusps. 
-	Hemisected teeth. 
-	Mobile teeth requiring splinting and 
-	Need for esthetic upgrading. 
There is no documentation of any of the above indications. The radiograph shows a small occlusal restoration and mesial caries. A build up is not necessary without approval of the crown. In addition, build ups are indicated when more than one-half of the coronal tooth structure on a full-crown tooth preparation is absent.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Oropharyngeal and supraglottic squamous cell
carcinoma
Treatment: Inpatient admission stay
The insurer denied Inpatient admission stay.
The denial is overturned.

The patient is an adult male who presented to the emergency room via transfer from outside facility for profuse bleeding from the nose, mouth, and tracheostomy. He has a known history of 
squamous cell carcinoma of the supraglottis and has a tracheostomy and was on Plavix. He had a computed tomographic angiography (CTA) that showed active extravasation of blood from an oropharyngeal tumor. His red blood cell counts were low upon presentation, and he was tachycardic and his white blood cell counts were elevated. He was admitted to the surgical intensive care unit. He was treated with intravenous medications and fluids and received tranexamic acid via nebulizer. Once stable, he was transferred to an outside facility that had capability of interventional radiology embolization. The hospital stay for the date of service under review was denied by his insurer based on need for a change in the doctor's plan, worsening of his condition, or new or worsening symptoms that required additional care. The medical necessity of this inpatient stay is under review. 

The requested health service is medically necessary.

This patient has known history of oropharyngeal and supraglottic squamous cell carcinoma. He presented with active bleeding from this tumor in his airway as confirmed on computed tomographic angiography. On initial presentation, he was actively bleeding from his airway and had low red blood cell counts and tachycardia indicating a clinically significant amount of blood loss had occurred. His bleeding was temporized by using tranexamic acid, but his bleeding had not been definitively controlled. Tranexamic acid has a half-life of only two hours and is not definitive treatment. This patient required intensive care setting to monitor for recurrent bleeding until definitive embolism of the bleeding vessel could be accomplished. Therefore, inpatient 
admission to the Surgical Intensive Care for the date of service under review is medically necessary.