Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Ulcerative Colitis.
Treatment: Stelara 90mg/ml syringe every 4 weeks.
The insurer denied the Stelara 90mg/ml syringe every 4 weeks.
The denial is upheld.

The patient is a male who has the diagnosis of inflammatory bowel disease. Specifically, the patient has ulcerative colitis. The patient received Stelara as treatment for this condition. As the patient evidenced increasing symptoms attributable to their condition, the provider has requested the provision of Stelara at a decreased dosing interval of every 4 weeks. This is the subject of this review.

No, the health plan should not cover the Stelara every 4 weeks.
The provider has requested Stelara at a dosing not approved by the FDA (United States Food and Drug Administration). A review of the literature indicates that there have been no significant studies to date demonstrating the safety and efficacy of Stelara dose escalation to every 4 weeks in Ulcerative Colitis disease. The reports are anecdotal and involve small numbers of patients. As such, the usefulness, efficacy and safety of dose escalation of Stelara in patients with refractory disease requires further study and would not be considered medically appropriate. Despite the patient's presentation and history, there is no cogent medical literature or society guidelines to recommend dosing Stelara at an interval of every 4 weeks for maintenance. There is no medical literature to show that this dosing frequency has a positive effect on healthcare outcomes. The formulary medications, including Stelara at a dosing of every 8 weeks for maintenance, is as effective and without more adverse side effects than the requested non-formulary medication.

Therefore, the request is denied and not medically appropriate for this patient.

No, the Stelara every 4 weeks is not more beneficial.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Convergence Insufficiency

Treatment: vision therapy

The insurer denied coverage for vision therapy

The denial is overturned.

The patient has a diagnosis of convergence insufficiency. The patient's doctor requested nine months of neuro-developmental therapy.

The doctor indicated that the patient had significant difficulty changing focus from one distance to another.  Developmental lenses were recommended to reduce visual stresses of close work and bring focus and positioning of the eyes into balance.  Nine months of weekly office sessions supplemented by daily home therapy was recommended.

In-office vision therapy can improve visual function for patients with convergence insufficiency.  Results from the Convergence Insufficient Treatment Trial (CITT) showed that office-based vision therapy to be the most effective treatment for improving convergence and ameliorating symptoms and the treatment effects are long-lasting (CITT-ART [Convergence Insufficient Treatment Trial - Reading and Attention Trial] Investigator Group 2019).

Vision therapy is medically necessary for this patient.  The patient has convergence insufficiency.  Current research shows that office-based therapy with home reinforcement is more effective than home-based therapy (Scheiman 2020).  Randomized studies also show that office-based therapy helps alleviate symptoms associated with convergence insufficiency and the effects are long-lasting (CITT-ART Investigator Group 2019).  Scheiman et al. in a Cochrane analysis concluded that "Current research suggests that office-based vergence/accommodative therapy with home reinforcement is more effective than home-based pencil/target push-ups or home-based computer vergence/accommodative therapy for children."

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 the vision therapy is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: hematuria and sepsis.

Treatment: continued skilled nursing facility admission.

The insurer is denied coverage for continued skilled nursing facility admission.

The denial is upheld. 

This male patient has a history of aneurysmal subarachnoid hemorrhage, migraines, hemiplegia, and aphasia.

The patient  was initially an appropriate candidate for subacute rehabilitation.  He has functional (mobility, activities of daily living and communication/swallowing) deficits that were potentially amenable to comprehensive rehabilitation.  Unfortunately, after several weeks of rehabilitation therapy, there was limited, if any functional improvement.  According to the physical therapy notes, he continued to require maximal assistance to fully dependent for functional mobility including bed mobility and transfer activities (Hoyer lift).  A similar lack of improvement was documented by the occupational therapist.  The patient remained essentially at the maximal assistance to fully dependent level for activities of daily living including dressing, bathing and toileting.  According to the speech language pathologist the patient continued to have severe expressive and receptive communication deficits.  

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 continued skilled nursing facility admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Pancreatitis. 
Treatment: Emergent admission. 

The insurer denied coverage for emergent admission. 

The denial is upheld. 

The patient had a history of chronic pancreatitis and a pseudocyst. He presented with abdominal pain, nausea, and vomiting. He was hospitalized about 1 week earlier with similar complaints. He was afebrile and the vital signs were stable. There were no peritoneal signs. The white blood count (WBC) count was 10.9. The lactate was 2.2. The lipase was 34. A computed axial tomography (CAT) scan was read as changes consistent with chronic pancreatitis. The impression of the radiologist was that there was no evidence for acute pancreatitis in this study. Intravenous [IV] hydration and pancreatic enzymes were given. 

Clinical indications for admission for Pancreatitis include having acute pancreatitis as manifested by pancreatic enzymes greater than 3 times the upper limit of normal or characteristic findings on imaging studies. In this case, the lipase was normal and the CAT scan was read as chronic pancreatitis and not acute pancreatitis. For chronic pancreatitis, indications for admission include having evidence of infection such as fever or an abscess, hemodynamic instability, hypoxemia, acute renal failure, severe electrolyte abnormalities, or an inability to maintain oral hydration. The patient did not have these conditions. 

This patient had chronic pancreatitis. Intravenous (IV) hydration, antiemetics, and pain control could have been given in the emergency room (ER) with observation status. He did not meet MCG [Milliman care guidelines] criteria for admission for Pancreatitis. The healthcare plan acted reasonably and with sound medical judgement. An inpatient admission was not medically necessary. 

Based on the above, the medical necessity for the emergent is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory System 
Treatment: Inpatient Hospital 
The insurer denied the inpatient stay. 
The denial is overturned. 

This is the case of a minimally immunized (1 dose of DTaP [diphtheria, tetanus, pertussis]) male who presented to the emergency department (ED) with complaint of fever and rash. He had previously been diagnosed with otitis media and started on amoxicillin as an outpatient, which was switched to cefdinir after 2 days. He presented to the ED with continued symptoms.

Vital signs were temperature 101 degrees Fahrenheit (F), heart rate (HR) 123, respiratory rate (RR) 20, blood pressure (BP) 102/62. Physical exam noted a maculopapular rash and bilateral acute otitis media (AOM). The patient was given a dose of Augmentin in the ED and shortly afterwards developed lip swelling and increased work of breathing. He was treated with epinephrine, diphenhydramine, and dexamethasone which controlled the symptoms. After vital signs were deemed stable, he was transferred to the inpatient floor. Infectious disease consult was obtained and recommended oral linezolid given recent treatment failures and suspected allergy. The patient was discharged home the following day on oral linezolid and Epi Pen Jr. At issue is whether this inpatient stay is considered medically necessary.

The health plan's determination is overturned.

The inpatient stay is medically necessary. This patient failed outpatient therapy for AOM. He presented to the ED with fever and rash, and proceeded to have an anaphylactic reaction to Augmentin in the ED.

This is a patient with bacterial infection (AOM) whose symptoms persisted, despite imperfect treatment with amoxicillin and cefdinir as an outpatient. In addition, the patient had an anaphylactic reaction to Augmentin which was given in the ED. Therefore, the patient required additional monitoring and consultation to ensure his symptoms improved and to determine best course of treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Genitourinary/Kidney Disorder. 
Treatment: Inpatient Hospital. 
The insurer denied Inpatient Stay. 
The denial is overturned in whole. 

This patient is a female with a past medical history of ketamine abuse characterized by ketamine bladder syndrome. She presented with abdominal pain and vomiting. The preliminary work-up revealed normocytic anemia, hyponatremia, dehydration, azotemia, and acute kidney injury with acid base disturbance. She also had transaminitis. Urinalysis on examination was suggestive of a urinary tract infection.
She was empirically started on intravenous (IV) fluids, IV antibiotics for coverage of vancomycin-resistant enterococcus (VRE), and an infectious disease consult was requested. Nephrology was consulted for abnormal renal indices in the setting of ketamine bladder syndrome. Nephrology recommended oral hydration, pain control, and continuing Zyvox outpatient while waiting for the urine culture.  She received Protonix 40 milligrams (mg) twice daily, IV analgesics for pain, and IV antiemetics for nausea. She was discharged home after the urine culture was negative.
At issue is the medical necessity of the Inpatient Stay.

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

The requested health service/treatment of Inpatient Stay was medically necessary for this patient.
This is a complex patient with a history of ketamine drug abuse complicated with ketamine-induced bladder syndrome, who presented with abdominal pain, nausea in the setting of a complicated urinary tract infection (UTI), anemia, transaminases, and azotemia with acute kidney injury (AKI) in the setting of chronic hydronephrosis. She has significant comorbidities . Her clinical presentation required IV fluid, IV antibiotics, and urgent nephrology and Infectious disease consultation because of her history of (h/o) ketamine abuse and ketamine-induced bladder syndrome. She required inpatient care, including IV fluid, IV anti emetics, IV acid suppression, IV antibiotics and serial labs. The patient required urgent and prudent medical evaluation and management to prevent the potential complication of urosepsis, leading to increased mortality and morbidity.
Therefore, the requested health service/treatment of Inpatient Stay was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse/Addiction. 
Treatment: Substance Abuse Inpatient. 
The insurer denied inpatient stay. 
The denial is overturned.

The patient is a male who presented to the emergency department and was evaluated and subsequently admitted to acute inpatient level services for detoxification and withdrawal management of stimulant (cocaine), sedative-hypnotic-anxiolytic (benzodiazepine/clonazepam) and alcohol use disorders. The subject under review is the medical necessity for the inpatient stay. 

The requested inpatient stay was medically necessary for this patient.
The patient in this case presented with a diagnosis of severe alcohol, opioid, sedative-hypnotic-anxiolytic and stimulant use disorders with history of severe alcohol and drug withdrawal in the past. The patient also has severe psychosocial stressors with limited support and functional impairments. The presenting clinical features and history and risk for withdrawal seizures and other complications of alcohol/anxiolytic and opioid and stimulant use disorders did warrant the admission and continued inpatient level services with medical monitoring in this case scenario. The proposed inpatient services could not have been safely and effectively provided at a lower level of care. 
Medical necessity for the admission and the continued inpatient services, is met in this case, and is consistent with prevailing standards of medical practice, published practice guidelines, and American Society of Addiction Medicine (ASAM) Criteria, referenced below. This answer and determination are consistent with the appropriate application of the NY (New York) State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria and Guidelines, referenced below.
Appeal type: Medical necessity
Decision: Upheld

Dental Problems
Dental Procedure

Diagnosis: Dental Disease
Treatment: implant placement (D6010) for teeth #2, 3, 4, 5, 6, 18 and 30.
The insurer denied implant placement (D6010) for teeth #2, 3, 4, 5, 6, 18 and 30. The health plan's determination is upheld. 

The patient is a female who presents for evaluation and treatment of teeth # (number) 2, 3, 4, 5, 6, 18, and 30. Provided for review are previous letters of appeal and denial, a narrative from the provider, a full mouth panoramic radiograph from an unknown date, one page of American Dental Association (ADA) claim forms, a health history, and clinical notes.
In question is the medical necessity of implant placement (D6010) for teeth #2, 3, 4, 5, 6, 18 and 30.

Implant Placement for Teeth 2, 3, 4, 5, 6, 18 and 30 is not medically necessary for this patient.
There is nothing in the documentation that indicates that the patient has had a partial denture provided and then that the partial denture did not function correctly. There is nothing in the provided documentation that shows that the patient uses a partial denture currently. Further based on the provided documentation, the teeth do not appear to have been prepped for a partial denture in the past. There has been no evaluation of any current prosthesis by the doctor. The need for implants has not been established. Hence the treatment of implant placement (D6010) for sites #2 ,3, 4, 5, 6, 18 and 30 is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Liver disease, bilateral lower extremity edema.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

This is a female patient with alcoholism, obesity, and gastric bypass who presented to the emergency room for evaluation of abnormal labs with persistent bilateral lower extremity edema, worsening functional status, and frequent falls.  The patient had an increase in alcohol intake for a few months and had been drinking 15 to 20 drinks per day.  The patient had an overnight stay at another hospital and since then, she had experienced poor appetite, extreme weakness, inability to ambulate without assistance.  The patient had seven falls due to weakness and unsteadiness.  She had bilateral lower extremity edema for the last three months.  In the emergency room, the patient had jaundice and scleral icterus.  She had abdominal distention and ascites.  Labs showed an alanine transaminase (ALT) of 31 and an aspartate transaminase (AST) of 92.  Total bilirubin was 5.0.  The patient was started on intravenous (IV) thiamine.

Magnetic resonance cholangiopancreatography (MRCP) was ordered but the patient refused.  The patient was started on Lasix and lactulose three times per day.  On day two, the patient reported persistent generalized weakness for several days.  The patient denied abdominal pain or back pain.  On day three, the patient reported persistent generalized weakness for several days.  The edema improved mildly. 

No, the proposed inpatient admission was not medically necessary.
The medical records do not support that the acute inpatient admission was medically necessary. The patient did not require services of such intensity that could have been safely and effectively provided only on an inpatient level of service. The health, safety, and medical condition of the patient would not have been threatened by providing the care given in a lower level of care setting.

A lower level of care would have been a more efficient setting, since the patient did not require any procedural or surgical intervention, did not require to be nothing by mouth for a prolonged duration of time, did not require prolonged treatment with intravenous hydration or intravenous medications, did not have acute kidney injury, did not have electrolyte derangement needing intravenous replacement, did not have fevers, did not have an elevated white count, was not being considered for liver transplant, did not have acute gastrointestinal bleeding, did not have acute liver failure, and did not have any complications such as intra-abdominal abscess or a surgical abdomen.

Yes. the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetic Foot Ulcer.
Treatment: Topical Oxygen Therapy, Pre-service.
The insurer denied the Topical Oxygen Therapy, Pre-service.
The denial is upheld.

The patient is a female who is status post right first metatarsal head resection approximately two years prior. She presented with a wound on the right foot an ulceration measuring 25 x 24 x 4 mm (millimeters).  This was on the right foot.  This was under the fourth metatarsal head.  This was debrided and treated with wound care.  The wound care consisted of dry sterile dressing with Santyld. She was also status post metatarsal head resection 2, 3, and 4 approximately three years prior.  This was done for osteomyelitis. Additional evaluation found that her nutrition was optimized. She was properly offloaded in diabetic shoes.  Due to the nonhealing nature, topical oxygen therapy was recommended.

No, the Topical Oxygen Therapy is not medically necessary.
Diabetic foot ulcers can become chronic for several factors.  There are multiple treatment strategies to try to improve wound healing.  One of the strategies in a non-healing chronic ulcer is to utilize hyperbaric oxygen therapy. This increases the oxygen concentration within the tissues, promotes neovascularization, promotes wound healing from chronic to acute among other benefits.  Topical oxygen is not equivalent to hyperbaric oxygen (1).  Topical oxygen has not been proven to help diabetic wounds heal (2).  Therefore, the treatment is not medically necessary.

Yes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Trauma

Treatment assistant surgeon for Current Procedural Terminology (CPT) code 15004 (Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 square (sq) centimeters (cm) or 1 percent of body area of infants and children)

The insurer denied coverage for assistant surgeon for Current Procedural Terminology (CPT) code 15004 (Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 square (sq) centimeters (cm) or 1 percent of body area of infants and children

The denial is upheld

This is the case of a patient with a history of multi-trauma following a multivehicle accident (MVA). The patient had facial scars associated with the MVA. The patient underwent: Epidermal overgrafting of glabellar scar; Epidermal overgrafting of right mid-forehead scar; Left forehead scar revision by excision and closure. At issue is the need for an assistant surgeon.

The records document that the surgeon performed a scar revision of the face and then over grafted two facial scars. The graft was harvested from the retro-auricular scalp. The grafts were secured with tie-over bolsters. The operative area was confined to the patient's face and scalp. Due to the small operative field, the surgeon and assistant could not sew in grafts at the same time. A scrub tech or the medical student who was present would have been sufficient to help with hemostasis and the securing of the tie over bolster dressings. The records do not document any specific roles or tasks for the assistant that could not have been performed by the scrub tech or medical student. The records do not provide compelling documentation that an assistant was required or medically necessary for these procedures. 

The health plan acted reasonably with sound medical judgement in the best interest of the patient.

Based on the above, the medical necessity for the assistant surgeon for Current Procedural Terminology (CPT) code 15004 (Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 square (sq) centimeters (cm) or 1 percent of body area of infants and children) is not substantiated. The insurer's denial is upheld.