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

Diagnosis: Gastroenteritis, Urinary Tract Infection 
Treatment: Inpatient Admission 

The insurer denied the inpatient admission. The denial was reversed. 

This patient is male child who presented to the Emergency Department (ER) with complaints of vomiting for three days with poor oral intake. A laboratory work up was performed revealing a white blood cell (WBC) count was 20.5, a carbon dioxide level (CO2) of 7 and severe acidosis with bicarbonate level of 7. A urinalysis was obtained which was suspicious for urinary tract infection. The patient received intravenous (IV) fluids, IV antibiotics, and IV anti-emetics. The patient was medically stabilized and discharged home. 

While literature indicates that most gastroenteritis cases do not require inpatient care, patient who develop severe dehydration and require intravenous hydration require hospital care. Per Banyai, K., et al. (2018) "For treatment of dehydration caused by gastroenteritis viruses, the administration of reduced-osmolality oral-rehydration solutions (5060 mmol/L sodium) is the first line of therapy.  Profuse vomiting, worsening dehydration with altered consciousness, or severe acidosis, hypovolaemic shock, abdominal distension, and ileus are indications for intravenous rehydration". Articles such as Hartman S1 et al (2019) and Vega and Avva (2019) emphasize the risk of high morbidity and mortality of dehydration in infants and young children, and that proper rehydration should be prioritized for proper care. 

This patient's clinical signs and symptoms of dehydration and acidosis were particularly concerning because of this patient's inability to rehydrate orally. The patient's vomiting and poor oral intake indicated that this patient required intravenous rehydration, in order to restore this patient's urine output and prevent cardiovascular collapse in the setting of an infection. The patient was noted to have gastroenteritis, likely viral and a suspicion for urinary tract infection on his urinalysis. 

The plan did not act reasonably with sound medical judgement and in the best interest of the patient. 
                            
The carrier's denial of coverage for the inpatient hospital services is reversed. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Transient Ischemic Attack

Treatment: Inpatient Admission  

The insurer denied the inpatient admission. The denial was upheld. 

This is a female patient with a history of hypertension and diabetes.  The patient presented to the Emergency Department (ED) with complaints of intermittent numbness in her left arm and leg, dizziness, and right-sided neck pain. The patient also reported having the sensation of a clogged ear. Neurology and Cardiology were consulted. An electrocardiogram (EKG) was performed that revealed a normal sinus rhythm. Magnetic resonance angiography (MRA) of the neck and magnetic resonance imaging (MRI) of the brain were performed with negative results. A computed tomography (CT) of the head was done which was negative for acute processes. The patient was admitted to the hospital with transient ischemic attack (TIA). Intravenous fluid bolus was administered and aspirin 81 mgs. The patient's symptoms resolved and she was discharged home after a period of medical stability.  

Based on the review of the Milliman Care Guidelines for transient ischemic attack, this patient's clinical presentation and diagnosis of transient ischemic attack could have been managed at an observation level of care. Inpatient admission was not medically necessary because there was no clear evidence of acute change in the patient's neurological examination, or acute motor, sensory, or visual deficits that suggested as acute stroke. The patient did not present with hemodynamic instability, new focal neurological signs, clinical signs and symptoms of cardiovascular compromise or acute prolonged metabolic decompensation or seizure. Based on the MCG criteria for inpatient admission, this patient's transient ischemic attack presentation did not meet the medical indication and necessity for inpatient level of care.

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

The carrier denial of coverage for the inpatient hospital services is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain  
Treatment: Inpatient hospital services  

The insurer denied coverage for inpatient hospital services. The denial is upheld.  

This patient is a woman with a history of HTN, asthma and ischemic heart failure with reduced ejection fraction (LVEF of 40%).  The patient presented to the hospital complaining of chest pain, bilateral facial numbness and nausea/vomiting.  On physical examination, BP was 152/96, heart and lung sounds were clear and without abnormality.  ECG revealed sinus rhythm with left ventricular hypertrophy (LVH) and lateral T wave inversions, septal Q waves consistent with old septal myocardial infarction (MI) were also noted.  Serum troponin levels were not elevated and B type natriuretic peptide was elevated.  The patient was admitted to the hospital for additional monitoring and therapy.  The patient was discharged the following day after serial serum troponin levels were negative.  

This patient has a known history of heart disease and previous coronary stents.  The patient presented with atypical chest pain and nausea.  ECG was unchanged from baseline and serial serum troponin studies were normal.  The patient has documented coronary artery disease and was managed on appropriate medical therapy including beta blockers and antiplatelet therapy.  Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati, et al.  Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as MI, need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation.  Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation.  In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary.  This patient could have been treated at a lower level of care.  

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.  Admission to the hospital was not medically necessary.  

Based on the above, the medical necessity for the inpatient hospital services is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Anovulation.
Treatment:  Intrauterine Insemination (IUI) Cycle.

The insurer denied the Intrauterine Insemination (IUI) Cycle.  The denial is upheld. 

The patient is a female with a diagnosis of anovulation.  Hysterosalpingogram (HSG) was normal.  Semen analysis was normal except for three percent normal morphology.  The patient did conceive following a cycle of induction of ovulation and intrauterine insemination (IUI).  The patient is appealing the denial of IUI.

No, the proposed treatment is not medically necessary.

This patient's diagnosis is anovulation.  In other words, she is unable to conceive because of inability to release an egg.  The treatment of infertility due to anovulation is to induce ovulation.

A randomized controlled trial was performed to compare the efficacy of IUI versus timed intercourse as first-line treatment for anovulatory infertility associated with polycystic ovarian syndrome (PCOS).  Based on the scientific literature, ovulation induction with clomiphene citrate or Letrozole and timed intercourse is as effective as that with intrauterine insemination for achieving pregnancy in polycystic ovary syndrome.  Addition of IUI does not appear to improve pregnancy rates.  Therefore, adding IUI in women without male factor infertility undergoing ovulation induction is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Duchenne Muscular Dystrophy
Treatment: Vyondys 53 (CPT code J3490)
The insurer denied the Vyondys 53 (CPT code J3490). 
The denial is overturned. 

The patient is a male with medical history significant for Duchenne muscular dystrophy (DMD) due to out-of-frame deletion of exons 49-52 in the DMD gene complicated by the following: generalized anxiety treated with Zoloft; compression fractures treated with Zometa to prevent worsening osteoporosis; obesity followed by Nutrition; delayed puberty; and severe restrictive lung disease treated with BiPAP (bilevel positive airway pressure) and cough assist. His treatment regimen also includes deflazacort, lisinopril, fibrinogen study medication, and GI (gastrointestinal) protection. He is non-ambulatory and wheelchair-bound, with increasing difficulty lifting his arms and holding a glass, but still able to feed himself. He has been prescribed Vyondys 53 (golodirsen) as an FDA-approved treatment to increase dystrophin production in skeletal muscle with the goal of slowing progression of symptoms.

Yes, the treatment with Vyondys 53 is medically necessary.

Duchenne muscular dystrophy is a progressive degenerative disease of skeletal muscle caused by mutations in the DMD gene, affecting about 5,000 male births worldwide. The genetic mutation disrupts dystrophin production, resulting in progressive muscle wasting and eventual death. Phosphorodiamidate morpholino oligomers (PMOs) bind to messenger RNA (ribonucleic acid) in such a way that the targeted exon is skipped and excluded from mature messenger RNA, restoring the reading frame and allowing production of functional protein. The first PMO approved in the US for DMD with confirmed mutations was eteplirsen (exon 51 skipping). Golodirsen is a new PMO that hybridizes to exon 53 and ultimately restores the dystrophin messenger RNA reading frame. Golodirsen is used to facilitate production of a functional dystrophin protein, slowing the progression of the disease. Golodirsen was granted accelerated FDA approval in December 2019. It also received orphan drug designation. Ongoing trials regarding clinical benefit are underway. Per the FDA, Vyondys 53 (golodirsen) has been approved to treat DMD patients with confirmed mutation of the dystrophin gene amenable to exon 53 skipping. No further restraints were placed on the approval. 

This male with Duchenne muscular dystrophy has been managed with the standard of care for the entirety of his life. The current standard of care includes use of phosphorodiamidate morpholino oligomers if the appropriate genetic abnormality is present. This boy has the genetic mutation that is amenable to exon 53 skipping, so that administration of golodirsen is considered standard of care and medically necessary for his condition. The limitations of ambulation and age (under 16 years) are not found within the FDA approval language or the literature and should not be considered limitations in this case.
Appeal type: Medical necessity
Decision: Upheld

Trauma/injuries
Skilled Nursing Facility

Diagnosis: Traumatic brain injury
Treatment: Continued Skilled Nursing Facility Admission 
The insurer denied the Continued Skilled Nursing Facility Admission. The health plan's determination is upheld. 

The patient is a male with past medical history significant for traumatic brain injury with resulting frontal and temporal lobe gliosis, seizure disorder, astrocytoma status/post (s/p) partial resection who was admitted to skilled nursing facility with generalized and left upper extremity weakness and decreased activity tolerance, strength, coordination, safety awareness and balance resulting in impaired ability to complete functional mobility, transfers, toileting, Instrumental activities of daily living (IADL) and dressing. Under review is the continued skilled nursing facility admission.

The continued skilled nursing facility admission is not medically necessary for this patient. The patient is a male who recently underwent partial resection of a brain tumor. While he has a past medical history significant for traumatic brain injury and seizure disorder, the level of functioning at time of admission was appropriate for a lower level of care. 
Documentation noted that the patient lived with his mother and brother in an apartment prior to admission. Prior level of functioning was significant for independent with bathing, toileting, upper and lower body dressing, toiling, hygiene/grooming and self-feeding. Initial therapy evaluation noted that the patient only required contact guard assist (CGA) for bathing and lower body dressing. Stand by assist (SBA) for toileting. Setup for upper body dressing and self-feeding and was supervision for hygiene/grooming. In addition, despite therapy noting a Tinetti score of 23/28 (which places patient at risk of falls), therapy also documented that the patient was ambulating 200' with rolling walker at supervision which for this reviewer does not correlate. Additionally, he was independent with transfers and bed mobility on initial physical therapy evaluation. Lastly, a review of medications and nursing orders did not contain any skilled nursing needs. Nursing noted "Ok to shower - no lotions, creams, powders on the incisions. Sutures will be removed. Resident ambulating with no assist and no assistive device." Therefore, skilled nursing facility admission was not medically necessary for this patient and his needs could have been met at a lower level of care.
Appeal type: Step Therapy
Decision: Upheld

Central Nervous System
Pharmacy/Prescription Drugs

Diagnosis: Migraine
Treatment: Ajovy
The insurer denied Ajovy. The health plan's determination is upheld. 

This is a male with a history of migraines. He was prescribed Ajovy. According to a letter of medical necessity, he had previous trials and failures of propranolol, nadolol, tizanidine, and sumatriptan, and experience for migraines per month meeting the criteria for episodic migraines. Office notes indicate that the patient presented with episodic migraine and was provided with nadolol without improvement in symptoms. Emgality was not approved, and he underwent a vitamin B12 injection. The use of Ajovy is under review.

There is no medical indication for Ajovy in this patient. Ajovy is a CGRP (Calcitonin gene-related peptide) targeting medication utilized for migraine prophylaxis. There is no evidence in the medical literature that Ajovy is superior in efficacy or has a superior adverse effect profile to any and all formulary medication. The patient has failed beta blockers. There are no contraindications to the FDA-approved medications, divalproex (Depakote) and topiramate (Topamax). There are no contraindications to the evidence-based tried antidepressants, amitriptyline and venlafaxine. There is no evidence that any of these medications would have greater side effects.
The rationale provided by the provider was that these medications were not FDA-approved (though, divalproex and topiramate are FDA approved) and would have more side effects than Ajovy. Anticipation of an adverse effect is not predictive of its occurrence. Anticipation of lactic lack of efficacy does not predict a lack of efficacy. There is no rationale why the patient cannot be treated with oral migraine prophylactic medication, which would have the same efficacy as Ajovy or any other CGRP agent, and there is no specific medical necessity for the use of Ajovy in this patient.
There is no contraindication to any of the available formulary medications (topiramate, divalproex, amitriptyline, venlafaxine).
There is no evidence in the peer-reviewed medical literature that any of these medications are ineffective or less effective than fremanezumab based on a lack of head to head comparisons.
The patient has utilized beta blockers without efficacy (nadolol). There is no documentation of the use of any antiepileptic (topiramate, divalproex) or antidepressant (venlafaxine, amitriptyline).
There is no current use of any CGRP agent, including Ajovy.
There is no evidence that the patient would be noncompliant with treatment. There is no evidence that the patient had any adverse reactions to any and all of the formulary medications. There is no evidence that any other medications would worsen the patient's clinical condition, and there is no evidence that the patient would not respond to any and all of the formulary medications.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Congestive heart failure on home supplemental oxygen therapy, diabetes
mellitus, coronary artery disease and hypertension.
Treatment:  Increase of Personal Care Services to eight hours per day, four days per week and six hours per day, three days per week; total of 50 hours per week.

The insurer denied the Increase of Personal Care Services to eight hours per day, four days per week and six hours per day, three days per week; total of 50 hours per week.  
The denial is overturned.

The patient is a male with a history of congestive heart failure on home supplemental oxygen therapy, diabetes mellitus, coronary artery disease and hypertension.  Due to impairments related to these conditions, the patient requires assistance for completion of the majority of his activities of daily living (ADLs).  Appeal review requested for potential approval of 50 hours/week Personal Assistance Services to offer increased ADL support.

Yes, the proposed treatment of 50 hours/week Personal Assistance Services is deemed medically necessary. 

This is a male with a history of congestive heart failure on home supplemental oxygen therapy, diabetes mellitus, coronary artery disease and hypertension.  Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs).  Recent documentation received from the patient's provider, indicates that due to progressive functional decline, the patient has worsened mobility, requires increased assistance with activities of daily living, and is experiencing worsening nocturia and disrupted sleep, resulting in frequent unscheduled nighttime bathroom trips.  Due to his gait ataxia, shortness of breath and weakness, he is at a high risk for falls.  For these reasons, the currently approved plan of 38 hours per week is insufficient to meet the patient's current needs.  For these reasons, the proposed treatment 50 hours/week Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Febrile Syndrome.

Treatment: Inpatient admission.

The insurer denied the inpatient admission.

The denial was upheld.  

This is a female patient with gastroesophageal reflux.  The patient presented to the hospital on with complaints of fever for the past three days, maximum temperature 104 F, rhinorrhea, decreased oral intake and crying more than usual.  It was also reported that the patient had multiple episodes of emesis and diarrhea.  The patient was admitted to the hospital for an acute febrile syndrome. On examination, the patient was alert, with normal skin turgor and capillary refill and no focal findings. The patient's bloodwork showed a normal complete blood count (CBC), chemistry and C-reactive protein (CRP). The patient's urinalysis (UA) was also within normal limits. The patient was medically stabilized and discharged home with outpatient follow up instructions.

Based on the review of the medical record, the patient's immunizations were up-to-date.  The likelihood of her having bacteremia in the absence of a urinary tract infection (UTI) was very low.  Prior to Prevnar and Hib vaccination, pneumococcal bacteremia in an otherwise well-appearing febrile infant, so called "walk-in" or occult  bacteremia, used to be grounds for blood culture and consideration of empiric antibiotics.  However, this is not the case for this patient. The patient had no leukocytosis (white blood cell (WBC) 9.5)). The patient's admitting diagnosis was "acute febrile syndrome", which could have been managed with initial intravenous (IV) fluids and follow-up as an outpatient. There is no documentation that the patient had ongoing fluid losses from vomiting or diarrhea, or clinical signs of significant dehydration. The patient's care could have been managed at an observational level of care. Thus, inpatient admission was not medically necessary for this patient.

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

The carrier's denial of coverage for the inpatient admission should be upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anterior open bite
Treatment: Braces. 
The insurer denied Braces. 
The health plan's determination is Overturned. 

Summary:
The proposed braces are medically necessary.
The patient has an anterior open bite, meaning her front teeth do not touch and she can stick her tongue through them when her bite is closed. This will lead to multiple problems. First, it will be difficult to pronounce certain words. It will be hard or impossible to incise her food properly which could lead to poor digestion. There is no anterior or canine guidance. This means that during the chewing cycle, the patient's teeth do not mesh properly and the back teeth will bang into each other in ways that can cause traumatic fracturing of the teeth. Also, since the jaws don't align properly, there is a higher probability of temporomandibular joint (TMJ) issues over time. This patient needs orthodontic treatment to correct these problems.

In the health plan's denial letter, there are 3 "bullet points" explaining the point system that both the provider used (which adds up to a total of 33 points on the handicapping index scale), and the point system that the reviewer used (which is exactly the same and also adds up to 33 points). Since 33 is higher than the 26 point cutoff, the case merits orthodontic benefits.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease; traumatic brain injury (TBI).
Treatment: Personal Care Aide 7 Days x(2) 12 Hours Split Shift.
The insurer denied the Personal Care Aide 7 Days x(2) 12 Hours Split Shift.
The denial is overturned.

The patient is a female with a history of advanced dementia, coronary artery disease, osteoarthritis and gait ataxia with frequent falls. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). An appeal review was requested for potential approval of 7 days x 2 (12) hours split shift Personal Assistance Services to offer increased ADL support.

Yes, the proposed treatment of 7 days x 2 (12) hours split shift Personal Assistance Services is deemed medically necessary. 

The patient is a female with a history of advanced dementia, coronary artery disease, osteoarthritis and gait ataxia with frequent falls. Due to impairments related to these conditions, she requires assistance for completion of the majority of his/her activities of daily living (ADLs). Recent documentation from the patient's physician indicates that the patient has demonstrated progressive functional and cognitive decline, rendering her with grossly limited cognitive, psychological, physical and social functional abilities making her dependent on assistance for completion of all of her activities of daily living. In addition, she requires 24/7 overnight supervision for assistance with toileting, dressing changes and bed mobility. 7 days x 24 hours live-in PAS is insufficient to meet the patient's current needs. For these reasons, the proposed treatment of 7 days x 2 (12) hours split shift Personal Assistance Services is deemed medically necessary.