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

Diagnosis: Chest Discomfort and Palpitations 
Treatment: Inpatient admission 
The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a male who presented with palpitations and chest discomfort. He has a history of atrial flutter and ablation. The patient was seen in the emergency department, and his supraventricular tachycardia (SVT) was cardioverted with intravenous adenosine. The patient's exam was normal and post cardioversion the patient was asymptomatic with a normal electrocardiogram (EKG). The patient was admitted to telemetry. Troponin peaked at 0.6. After an uneventful stay, the patient was transferred to another institution for repeat ablation. 

No, the proposed inpatient admission was not medically necessary. 

Determination of level of care is primarily dependent on the actual care a patient receives and whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results, and highlighted in the orders for care. 

In this case, the symptoms were secondary to an arrhythmia and unlikely to be representative of acute coronary syndrome. Exam was normal and cardiac findings were normal post cardioversion. Electrocardiogram (EKG) showed no evidence of acute ischemia. Chest x-ray was normal. 

The physicians' treatment did not include medical therapy for acute coronary syndrome such as intravenous heparin, dual antiplatelet inhibitors, high dose beta blockers or intravenous (IV) nitroglycerin (NTG). He was transferred to another facility for ablation. He was in normal sinus rhythm (NSR), hemodynamically stable, and asymptomatic. 

The letter of appeal was carefully considered, but offered no evidence to support inpatient level of care. The only cardiac care provided was telemetry, frequently performed in a lower level of care. The patient was admitted for monitoring and subsequent tests and therapy did not require an inpatient level of care. There was no complex care that required inpatient care. This patient had no evidence of coronary artery disease (CAD). While there is always a potential for an adverse event (and in this case a low probability), one did not happen and no actual treatment was added. 

Milliman criteria requirements were not fulfilled as there was never any evidence of ACS (acute coronary syndrome) present nor any indication for inpatient level of care. 

All testing and therapy would be appropriate, safe and guidelines consistent to be in lower level of care. Thus, inpatient level of care was not medically necessary. 

The denial explanation was consistent with guidelines and usual community care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ulcerative Colitis

Treatment: Stelara (Ustekinumab)90 milligrams (mg) every 4 weeks

The insurer denied coverage for Stelara 90 milligrams (mg) every 4 weeks.

The denial is overturned.

The patient has had ulcerative colitis. She has failed treatment with 6MP (mercaptopurine), Remicade, Humira, and more recently Xeljanz. She was started on Stelara every 8 weeks and had a good response. However, a colonoscopy showed active colitis. Her physician has now advised to increase the Stelara to 90 milligrams every 4 weeks.

An article in Clinical Gastroenterology and Hepatology titled "Effectiveness of Ustekinumab Dose Escalation in Patients with Crohn's Disease." Data was studied from patients who initially received ustekinumab every 8 weeks and then had their interval shortened to every 4 weeks. The conclusion was that shortening the ustekinumab dose to every 4 weeks, in patients who did not respond to dosing every 8 weeks, improved clinical and biological indices of disease activity. The patients who don't respond to the standard dose of ustekinumab might benefit from dose interval shortening which was effective and safe.

This patient has had severe ulcerative colitis and has failed multiple biologic therapies. She has been on Stelara but remains with active colitis on the colonoscopy biopsies. The scientific literature supports the use of dose escalation in order to achieve a better clinical and pathological response. It has been shown to be effective and safe. The formulary drug dose has not been sufficiently clinically effective. It is likely that the increased dose of Stelara would be more effective since many patients with inflammatory bowel disease (IBD) benefit from dose escalation.

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

Based on the above, the medical necessity for Stelara is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sleep Apnea.
Treatment: Oral Device (code E0486).
The insurer denied the Oral Device (code E0486).
The denial is overturned.

The patient is a male with mild obstructive sleep apnea. The health plan's denial of an oral device was based upon AHI (apnea-hypopnea index) of 7 and no other symptoms. This is being appealed.

Yes, the oral device is medically necessary.
Patient had an AHI (apnea-hypopnea index) of 7.5, and 10.9 while supine. This is consistent with mild obstructive sleep apnea. The patient refuses CPAP (continuous positive airway pressure) therapy, as he is claustrophobic and cannot tolerate any restrictive movement during sleeping. An oral appliance for treating mild to moderate OSA (obstructive sleep apnea) is considered first-line treatment, especially if the patient cannot wear a CPAP (continuous positive airway pressure) device.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient. Please see the rationale, above.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Ureteral dilation for distal ureteral stricture and meatal stenosis

Treatment: hyperbaric oxygen therapy (HBOT) code G0277x40 with associated code 99183x10 before surgery and code G0277x80 with associated code 99183x20 after surgery

The insurer denied coverage for hyperbaric oxygen therapy (HBOT) code G0277x40 with associated code 99183x10 before surgery and code G0277x80 with associated code 99183x20 after surgery

The denial is overturned

This case involves a male who has a history of hypospadias repair in infancy with reoperation.  The documentation indicated the patient has been recommended to undergo hyperbaric oxygen treatment due to multiple failed surgeries besides skin graft failure with wound dehiscence and nonhealing wounds from a prior operation.  The documentation indicated the patient needs additional repair; however, without proper wound healing his risk for further complications are great and chances of a successful repair are minimal.  The documentation does include a chart note indicating he underwent an initial repair at an early age.  He then underwent an additional surgery at a later age.  The physician indicated he has battled distal stricture and meatal stenosis for years utilizing dilations however this is no longer effective.  He does indicate his erections are straight; however, he does admit he has some uncertainty.  The physical exam did include pictures showing abnormal appearing glandular meatus.  The scrotum was not well visualized.  The recommendation was made to undergo surgical intervention with the possibility of a graft contracture with lip distortion been discussed.  It was also indicated that he undergoes preoperative hyperbaric oxygen due to chronic nonhealing.

Evidence does support a result of improvement. It does have approval by the FDA [Food and Drug Administration]. He is a good candidate. This would be considered the most appropriate treatment. There are no increased risks.

This treatment per literature is considered appropriate as it is proven to improve graft take in reoperation. Bush and Snodgrass in as study involving patients with at least 3 failed repairs found that "Hyperbaric oxygen therapy improved graft take in hypospadias reoperations." Additionally hyperbaric oxygen treatment is a proven treatment to improve tissue healing. Therefore, given his history, the requested treatment is considered likely to be more beneficial than any other standard services. 

The carrier's denial of hyperbaric oxygen therapy (HBOT) code G0277x40 with associated code 99183x10, before surgery and code G0277x80 with associated code 99183x20 after surgery should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Ureteral dilation for distal ureteral stricture and meatal stenosis

Treatment: hyperbaric oxygen therapy (HBOT) code G0277x40 with associated code 99183x10 before surgery and code G0277x80 with associated code 99183x20 after surgery

The insurer denied coverage for hyperbaric oxygen therapy (HBOT) code G0277x40 with associated code 99183x10 before surgery and code G0277x80 with associated code 99183x20 after surgery

The denial is overturned

This is the case of a patient with a history of a hypospadias repair in infancy and a reoperation at a later age. His treating physicians are referring the patient for hyperbaric oxygen treatment due to multiple failed surgeries which has caused skin graft failure, ischemic skin flap, wound dehiscence, nonhealing wound from an operation and/or soft tissue damage or necrosis.

Several studies confirm the benefits of HBO [hyperbaric oxygen] for revision hypospadias repair. A study by Chang et al concluded: "The proposed treatment of combining NTG [nitrogycerine] and HBOT [hyperbaric oxygen treatment] appears to result in reversal of tissue hypoxia and improved wound healing. This preliminary report shows improved outcomes with less morbidity in a group of patients with multiple hypospadias surgical failures and it warrants further application in a larger number of patients."  A study by Neheman et al concluded: "Preemptive HBOT can be used safely in the hypospadias cripple pediatric population and can potentially reduce the expected high surgical failure secondary to graft contraction."  A meta-analysis concluded: "The present systematic review and meta-analysis significantly favor the administration of HBOT versus no HBOT in terms of graft failure rate and incidence of complications following urethroplasty. The available data also highlights the safety of HBOT in complicated cases of hypospadias."  HBO is an appropriate nonexperimental treatment for this patient's complex revision hypospadias surgery.

HBO is approved by the FDA [Food and Drug Administration].

This patient requires a complex revision of his hypospadias repair with oral mucosa grafting and is the ideal candidate for HBO.

Peer reviewed literature supports the benefits of this treatment vs no treatment.

Per the recent meta-analysis: "The present systematic review and meta-analysis significantly favor the administration of HBOT versus no HBOT in terms of graft failure rate and incidence of complications following urethroplasty. "HBOT is safe in this setting.

The requested service is most likely to be beneficial than standard treatment and is well supported by peer literature. The adverse risks are not increase over standard therapies.

The carrier's denial of hyperbaric oxygen therapy (HBOT) code G0277x40 with associated code 99183x10, before surgery and code G0277x80 with associated code 99183x20 after surgery should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Ureteral dilation for distal ureteral stricture and meatal stenosis

Treatment: hyperbaric oxygen therapy (HBOT) code G0277x40 with associated code 99183x10 before surgery and code G0277x80 with associated code 99183x20 after surgery

The insurer denied coverage for hyperbaric oxygen therapy (HBOT) code G0277x40 with associated code 99183x10 before surgery and code G0277x80 with associated code 99183x20 after surgery

The denial is upheld

This patient has a history of hypospadias repair in infancy and a reoperation. The patient has had years of ureteral dilation for distal ureteral stricture and meatal stenosis, with declining efficacy. His treating physicians are referring the patient for hyperbaric oxygen treatment due to multiple failed surgeries which has caused skin graft failure, ischemic skin flap, wound dehiscence, nonhealing wound from an operation and/or soft tissue damage or necrosis. The physicians also stated that the patient needs additional repair, but without proper wound healing, his risks for further complication are great, and his chances of a successful repair are minimal.  The patient underwent a repair with proximal urethrostomy, minor scrotoplasty, complex tissue rearrangement for ventral penile skin coverage and oral graft harvest of the lower lip. 

Per MCG (Milliman Care Guidelines) Health (25th) hyperbaric oxygen, hypospadias repair/ skin flap failure is not included in the clinical indications for procedure (HBOT). HBOT is included for compromised skin grafts / flaps only in the setting of radiation injury (delayed). While some articles describe HBOT improving graft take in staged hypospadias auto graft reoperations.

HBOT Code G0277x40 with associated code 99183x10 before surgery and code G0277x80 with associated code 99183x20 after surgery is considered not to be more beneficial for this patient's diagnosis.

-	No supported improvement in health outcomes
-	HBOT needs final approval from the appropriate regulatory bodies for this diagnosis 
-	Most studies regarding HBOT for hypospadias repair / augmented tissue healing are done with pediatric patients
-	HBOT is not the best available treatment at this time (before and after surgery) 
-	No adverse risks of HBOT over standard treatment / services, but not determined to be clinically beneficial.
-	HBOT is not likely to be more beneficial than any of the standard treatments/ procedure for this patient.

The carrier's denial of hyperbaric oxygen therapy (HBOT) code G0277x40 with associated code 99183x10, before surgery and code G0277x80 with associated code 99183x20 after surgery should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Back pain.
Treatment: Intracept Procedure (C9752, C9753, 22899).
The insurer denied the Intracept Procedure (C9752, C9753, 22899).
The denial is upheld.

The patient is a female with a history of chronic low back pain. Her pain has not responded to epidural steroid injections, medial branch blocks, radiofrequency ablation (RFA), physical therapy (PT). Her physical exam is unremarkable.

An Intracept procedure has been recommended. The procedure was denied by the health plan as experimental/investigational. This was appealed.

No, the health plan should not cover the Intracept procedure.
The patient is a female with a history of chronic low back pain. Her pain has not responded to epidural steroid injections, medial branch blocks, radiofrequency ablation (RFA), physical therapy (PT). Her physical exam is unremarkable.

The Intracept procedure (interosseous basovertebral nerve ablation) is not an intradiscal procedure. It is a new Food and Drug Administration (FDA) approved intraosseous nerve ablation for the treatment of chronic low back pain in the treatment of vertebrogenic related chronic low back pain. It is typically used in patients with significant Modic type I or type II vertebral endplate changes, typically in situations where conventional and typical options have been exhausted. The patient does have moderate spinal stenosis. Therefore other alternatives including decompression are viable. Alternatives, such as spinal fusion, do not have good long-term results in the literature for axial low back pain without instability. Spinal fusion is a very invasive procedure with high morbidity and poor outcomes, compared to the Intracept procedure. In fact most recent articles show less than 50 percent improvement for the treatment of chronic low back pain with spinal fusion.

However, the patient has not failed sacroiliac (SI) joint interventions which is common cause of axial low back pain, nor is it documented that she has considered surgical decompression. In situations where all non-invasive options have failed, epidural steroid injections could also be considered, although typically used in patients with radicular symptoms. Spinal cord stimulation is also an alternative, however has not been shown to have excellent results in primarily axial mechanical/discogenic type pain. Chronic opiates are not without risk, and can lead to addiction and overdose. Therefore, while the Intracept procedure is a reasonable option, it should be employed after all conventional and evidence proven alternatives have failed. In addition, while Modic changes are noted, it is not a given that this is the pain generator. One can have Modic changes and have no symptoms from this.  Given the above, the requested Intracept procedure is not medically appropriate.

No, the Intracept procedure is not more beneficial.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: lack of dentition.

Treatment: D6010 surgical placement of implant body.

The insurer is denied coverage for D6010 surgical placement of implant body.

The denial is upheld. 

This female patient has no documented history.

Upon review of the objective documentation which primarily consists of the panoramic radiograph, the patient exhibits oligodontia in both the maxilla and mandible. As regards endosteal implant placement, although implants are an acceptable treatment to restore edentulous spaces, an accepted standard of care in dentistry is not exclusively endosteal implants. Alternative appropriate treatment would include conventional removable dentures. Further the documentation provided does not support, justify, or substantiate the requested treatment. Therefore, as removable dentures remain a standard of care in general dental practice, and the medical documentation does not indicate a specific limitation precluding use of partial dentures aside from self-reported difficulty, the endosteal implants are considered elective and not medically necessary.

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

The carrier's denial of coverage for D6010 surgical placement of implant body is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: submandibular abscess.

Treatment: inpatient stay.

The insurer is denied coverage for inpatient stay.

The denial is overturned. 

This female patient has a history of right facial swelling, induration, erythema, and pain.

On examination she had a 10 by 5 centimeter indurated, erythematous, tender area over the submandibular area extending to the neck, with a "pustule on top of it". Computed tomography (CT) scan was done. The report is not very descriptive, it just indicates a submandibular abscess with bilateral cervical lymph nodes. However, the abscess was considered large enough for operative drainage, and the operative note describes copious amount of pus drained, irrigation done, and a counter incision made to facilitate drainage. The discharge note states that she had an obvious abscess, which for which surgical drainage was indicated on an emergency basis. 

The abscess was large, and it was clinically significant. In deep neck abscesses, swelling extended to the neck could indicate a risk of mediastinal extension. Moreover, the most important treatment modality in an odontogenic infection is the elimination of the infection by surgical drainage, with antibiotics as adjunctive therapy. If not done as soon as possible, the deep neck abscess could result in further regional spread of infection to other deep neck spaces, or hematogenous dissemination (bacteremia) which can seed native or prosthetic heart valves, or joints. (2) Initial intravenous antibiotic therapy in conjunction with the surgical drainage is part of the treatment, to reduce the risk of regional, mediastinal or bloodstream spread.

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

The carrier's denial of coverage for inpatient stay is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis Vulgaris

Treatment: Skyrizi

The insurer denied coverage for Skyrizi.

The denial is upheld.

This adult patient has psoriasis vulgaris. The provided documentation does not indicate a contraindication to alternative Food and Drug Administration (FDA)-approved formulary medications, such as Humira which has been shown to be an effective first-line therapy for psoriasis and psoriatic arthritis.

There is no medical and scientific literature and/or evidence-based clinical practice guidelines that strongly support the administration of Skyrizi for this patient's condition above reasonable alternatives as an accepted standard of practice in the U.S (United States). According to the American Academy of Dermatology Psoriasis Guidelines and dermatology literature, alternative effective treatments for the management of psoriasis are available and appropriate for this patient (1-3). Lanna et al (4) discuss the safety and efficacy of Humira in the treatment of psoriasis vulgaris.

As such, the health care plan acted reasonably in denying Skyrizi for this patient as numerous formulary options exist in the treatment of the patient's condition. The provided medical notes do not provide any evidence of an absolute contraindication for the use of available therapies or unique clinical situation which would specifically warrant Skyrizi.

The health care plan did act reasonably and with sound medical judgement and in the best interest of the patient.

The insurer's denial of coverage for Skyrizi is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sore Throat and Diabetes (type 2)
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

This is a female with type 2 diabetes. She presented with mouth and throat pain with 27-pound weight loss over the prior weeks, and hyperglycemia.

The patient's vitals were as follows: Temperature 98.3, heart rate 99, BP (blood pressure) 142/79, O2 (oxygen) 100%. The patient's glucose was 363 mg/dL (milligrams per deciliter), sodium 132, anion gap 17, beta hydroxy-butyrate 1.3, and A1C (glycated hemoglobin) 11.6%. CT (computed tomography) showed cervical lymphadenopathy and prominent bilateral lingual tonsils.

The patient was treated with intravenous fluids, insulin, nystatin, Dilaudid, and Zofran. She had oral ulcerations of unknown etiology. She was started on subcutaneous insulin therapy. She was seen by ENT (otolaryngology) who recommended BLM (Benadryl, Lidocaine, Maalox) mouthwash and cepacol lozenges.

No, the Inpatient admission was not medically necessary.
This patient presented with mouth and throat pain, weight loss, and hyperglycemia with ketosis. Her hyperglycemia improved with treatment and she was transitioned to subcutaneous insulin therapy, which can be administered and adjusted as an outpatient. She was seen by ENT (otolaryngology), who indicated acute ENT (otolaryngology) intervention was not required. She was treated with medicated mouthwash and lozenges, which can be given as an outpatient. She was hemodynamically stable. She was alert and oriented. She did not have an acute medical condition that required inpatient monitoring or treatment. She was discharged the day after admission. Therefore, no, the inpatient stay was not medically necessary.

Yes, the health plan act did act reasonably, with sound medical judgment and in the best interest of the patient.
The inpatient stay was not medically necessary and was appropriately denied by the health plan.