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

Diagnosis: Dizziness
Treatment: Inpatient admission
The Inpatient admission was not medically necessary.

The patient is a female. She has a past medical history significant for diabetes mellitus type 2, HTN (hypertension), TIA (transient ischemic attack), ASD (atrial septal defect), s/p (status post) repair. She presented for evaluation of dizziness, associated with nausea, vomiting and diarrhea of two days duration. 

The patient was hemodynamically stable. Her dizziness was reported to be positional. Her neurological examination was normal. Her cardiac enzymes were negative. Laboratory data were significant for mild elevation in WBC (white blood cell) count to 13.6. A head CT scan was negative. A CTA of the head and neck was also obtained and was unremarkable. Recent echocardiogram revealed EF (ejection fraction) 61-65%, diastolic dysfunction and s/p ASD closure. 

The patient was treated with IV fluids and meclizine and admitted for monitoring. Neurology consultation was obtained and the patient underwent an MRI and MRA of the head, with no acute findings. Working neurological diagnosis was Meniere's disease, triggered by viral infection. Her medications were continued. The patient was noted to have vascular congestion on the CXR (chest x-ray), and one dose of IV Lasix was given. Cardiology consultation was obtained and the patient was advised to obtain a coronary CT, which she chose to do as outpatient. She was discharged home with a plan for outpatient follow-up.

The patient presented for evaluation of dizziness. The patient was hemodynamically stable. The diagnosis of an acute MI (myocardial infarction) was ruled out by cardiac enzymes, which were negative. There was no evidence of acute myocardial infarction, ACS (acute coronary syndrome), malignant arrhythmia or hemodynamic instability. There was no evidence of acute CVA (cerebrovascular accident) or intracranial bleeding. There was no evidence of vertebral or carotid artery dissection. There was no plan for any invasive vascular or neurological procedure. There was no report of increase intracranial pressure, hydrocephalus, cerebral bleeding, or seizure activity. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission, and the care required could have been provided at an observational level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lower back pain

Treatment: Inpatient hospital admission

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

This patient is a female gravida 3 para 1 at 6 weeks gestation with a history of chronic lower back pain who presented to the Emergency Department (ED) with a complaint of progressively worsening sharp lower back pain that became acutely worse after she tried stretching her low back. Her vital signs were stable. On admission, she was treated with acetaminophen, lidocaine patches and hot/cold ice packs. No opiates were used after admission. A nurses' note indicates that of a specified date the patient was noted to be walking "occasionally but for short distances."

This patient presented with severe back pain which was refractory to regular treatment. However, evaluation by MRI did not reveal any progressive condition that warrants immediate intervention like surgery. So the basis for the admission was to offer the patient pain medication and physical therapy.

Both physical therapy and pain control can be performed as an outpatient. Once the providers had ruled out any acute process that warranted immediate intervention like an infectious process, tumors, fractures and significant neurologic deficits, the patient could have been sent home on physical therapy and pain medication.

The admission was not medically necessary. The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. The inpatient hospital admission from is not considered medically necessary for this patient.

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

The patient is a male with psoriasis, treated with topicals, Humira and Taltz. The provider is requesting Tremfya. This was denied by the health plan.

The health plan's determination is upheld. The health plan requires a trial and failure to preferred products, which include Humira, Taltz, Otelza, Skyrizi, and Stelara. The patient has not tried Otezla, Skyrizi, and Stelara. These are also appropriate, safe and effective therapies for psoriasis and would also be highly appropriate for this patient. No evidence based medical literature supports the superiority of Tremfya over these preferred agents. Therefore, Tremfya is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Altered mental status; aphasia
Treatment: Inpatient admission
The inpatient admission was not medically necessary. 

The patient's acute inpatient admission was not medically necessary. The patient is status post meningioma resection, with known epilepsy related to his meningioma. The patient's Keppra was discontinued about one months ago prior to the emergency room visit, which led to a seizure presenting with altered mental status. The patient's antiseizure medication was reinstated, and his condition improved. This could be accomplished at a lower level of care; the patient could have been managed at a lower level of care. Acute inpatient admission was not medically necessary.

The patient had a breakthrough seizure and improved with appropriate medical management, namely reinstating his Keppra.  The inpatient admission was not medically necessary; the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ulcerative colitis
Issue under review: Stelara every four weeks

Determination:
The Stelara every four weeks is medically necessary.

The patient is an adult female with ulcerative colitis. She had failed treatment with mesalamine and steroids, and then developed encephalitis and disseminated zoster with Humira, and was a primary non-responder to Remicade and Entyvio. The patient was started on Stelara, and had some but not a complete response to Stelara. The attending physician is requesting to increase Stelara to 90 milligrams (mg) every four weeks. 

The patient has ulcerative colitis that has been refractory to anti-tumor necrosis factors (TNFs) and Entyvio. She has had some but not a complete response to Stelara. Stelara is FDA approved and standard of care in the treatment of ulcerative colitis. In patients who do not respond to FDA approved dosing, Stelara has been shown to be safe and effective at doses as high as 90 mg every four weeks. 

Results from a retrospective cohort study of patients with Crohn's disease (CD) reported that among 122 patients on ustekinumab, 21 (17%) patients on every eight week maintenance dosing required dose intensification (frequency increased to every four weeks [n=11], every six weeks [n=5], or a combination of intravenous (IV) booster and frequency increase to every six weeks or every four weeks [n=5]). A total of 11 patients (52%) had clinical response after dose escalation (two [18%] were primary nonresponders to induction while nine [82%] had poor initial clinical response). 

A multicenter, retrospective, open-label cohort study of adults with moderate to severe CD was conducted to evaluate the long-term maintenance efficacy of ustekinumab therapy. During the maintenance therapy, dose escalation was required in 16.3% (17/104) patients and a combination strategy of re-induction and dose escalation was required in 6.7% (7/104) of patients. The most common escalated maintenance dosing was 90 mg subcutaneous (SC) every four or six weeks. Clinical response was regained in 52.9% (9/17) of patients who had dose escalation, and 57.1% (4/7) of patients who had combined re-induction and dose escalation. 

Results from a retrospective, multicenter, open-label study of patients with refractory CD receiving ustekinumab, demonstrated that, among 11 patients who required a dosing interval reduction (includes 90 mg SC every eight weeks to every four weeks [n=8], 90 mg SC every eight weeks to every six weeks [n=1]), clinical improvement was seen in 73% (8/11) of patients.  

Results from a retrospective, open-label, observational study of ustekinumab for the treatment of anti-tumor necrosis factor (anti-TNF) resistant CD patients, demonstrated that, among patients who achieved clinical response at the last followup, dose escalation was required in 35% (7/20) of patients who received ustekinumab 90 mg SC every eight weeks.

Therefore, the requested Stelara 90 mg every four weeks is medically necessary and should be covered by the health plan.
Appeal type: Medical necessity
Decision: Upheld

Digestive System/Gastrointestinal - Abdominal Pain
Inpatient Hospital

This patient is a male who presented to the emergency room with complaints of abdominal pain. Vital signs were stable. Labs were within normal limits. Computed tomography (CT) scan revealed some mildly dilated loops of bowel consistent with ileus or possible small bowel obstruction (SBO). The patient was made nothing by mouth (NPO) and supported with intravenous fluids (IVF). The patient improved clinically with resolution of abdominal pain and passage of flatus. The patient was able to tolerate a regular diet and was discharged home. Decision to proceed with surgical treatment was not required.

The health plan's determination is upheld.

The patient presented with abdominal pain that resolved without need for surgical intervention. He was made NPO status and was supported with IVF. The patient continued with stable vital signs, and resolution of abdominal pain. He was able to tolerate a regular diet with passage of flatus and was discharged the following day. Acute inpatient level of care is not determined to be medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Other
Surgical Services

The request is for an endoluminal gastric pouch plication 4 years after the gastric bypass in a patient who has regained 40 pounds after initially losing 100 pounds. Current body mass index (BMI) is approximately 31, and no comorbid conditions were noted by the requesting provider. Also, there is no evidence that the patient has undergone an intensive behavioral management program after the weight regain or that pharmacotherapy has been attempted. In this patient with Class 1 obesity the procedure to plicate her gastric pouch is based on the patient's concern about weight regain and not due to recurrence of obesity-related medical issues or after failure of other modalities. The HP determination is upheld in whole. It is possible, for a patient such as this, with Class 1 obesity, to have insulin resistance or some other obesity-related comorbidity, but no documentation for such has been submitted. The best data available in patients with Class 1 obesity do not necessarily support ROSE over intensive behavioral/lifestyle modification or pharmaco-therapy, or other standard treatments. In fact, one study in the peer reviewed literature states explicitly that "Durability at 1 year remains questionable due to weight recidivism." (2) Another large series demonstrates that 20% of patients will need the procedure repeated in the first year. (3)
The American Society for Metabolic and Bariatric Surgery (ASMBS) guideline for patients with low body mass index (BMI) (in this case 31) suggests that an intervention can be offered for patients with Class 1 obesity and an obesity-related comorbidity after other interventions have failed, however in this case, there seems to be no comorbid condition and no attempt at other interventions, according to the documentation submitted for review. Lastly, the data for the long-term effectiveness of ROSE is scant. Not the ASMBS, Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), or American Society for Gastrointestinal Endoscopy (ASGE) has a position statement advocating for its use. Therefore, the treatment of ROSE is not likely to be more beneficial than any standard treatment for this patient's condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Other
Surgical Services

This patient is status post roux en Y gastric bypass surgery performed in for morbid obesity. Patient was successful with initial weight loss of 100 pounds (lbs.). Recently, the patient has experienced weight gain of 40 lbs. Presently, the patient is 67 inches tall, and weighs 197 lbs. (body mass index (BMI) approximately 31 kilograms per square meter (kg/m2)). The endoscopy was performed showing a gastrojejunal stoma of approximately 25- millimeters (mm) and a gastric pouch of 7- centimeters (cm) in length. The anastomosis appeared healthy.

Following this evaluation the physician has offered endoscopic suturing to provide additional restriction, induce satiety, and promote weight loss. The health plan's determination is upheld in whole. No, based on the submitted clinical data and the current status of peer reviewed literature, the proposed health service of ROSE is not likely to be more beneficial than any standard treatment for the patient's condition. The endoscopic evaluation by the treating surgeon showed an essentially normal and expected post gastric bypass anatomy and does not support revisional surgery (either open or endoscopic). Restorative endoscopic obesity surgery (ROSE) procedure has been described as a means to decrease pouch and stoma size to recreate a restriction to encourage weight loss. This technique does not require surgical incisions. Rather, an endoscopic suturing device is introduced through the mouth like an upper endoscopy. Sutures are placed in the stomach pouch to reduce its size and around the stoma to reduce its diameter. By eliminating outside incisions, the ROSE procedure is proposed to provide important advantages to patients, including reduced risk of infection and associated complications, less post-operative pain, faster recovery time, and no scarring. However, the current body of peer-reviewed literature does not yet establish this therapy as proven effective for the condition of weight gain s/p gastric bypass. Endoscopic suturing of the gastrojejunal anastomosis to induce additional weight loss is not a proven therapy. 

Standard alternative therapy for patient's like this patient, who underwent gastric bypass surgery and were initially successful with weight loss, would be strict and earnest participation with a supervised weight loss program to include nutritional counseling, exercise and behavioral modification to promote adherence to the prescribed diet program. There is no documentation of recent earnest participation with a supervised diet program or nutritional counseling.
Appeal type: Experimental/Investigational
Decision: Upheld

Other
Surgical Services

This patient has a history of morbid obesity who underwent Roux-en-Y (RYGP). The patient is currently 67 inches tall, weighs 197 pounds giving this patient a body mass index of 30.9 kilograms per square meter (kg/m2). The patient was noted to have an enlarged gastric outlet and pouch. The health plan's determination is upheld in whole. The proposed ROSE procedure is not likely to be more beneficial than any standard treatment for the patient's condition. The procedure is a Food and Drug Administration (FDA) approved procedure for reduction of a gastric outlet. It is safe and results in short term weight loss but there is a paucity of literature to support durable weight loss which are in the form of single case series. There are no randomized controlled trials (RCTs) documenting durable weight loss of 5 or more years. This patient currently documents a body mass index (BMI) of < 35 kg/m2. There is no documentation of reintroduction of a multidisciplinary team evaluation and support for other options for ongoing weight loss.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Glaucoma
Treatment: Rocklatan

The health plan should cover the proposed treatment, formulary exception for Rocklatan.

The patient is a male with severe stage glaucoma for whom a formulary exception for Rocklatan (netarsudil and latanoprost ophthalmic solution) is requested. His provider reports that the patient is on many drops to lower his eye pressures which are still not at target.  Reportedly, the patient needs Rocklatan, has had good response, and is tolerating it well. The provider also states that there is no substitution for Rocklatan, and he would not want to jeopardize the patient's stability. Upon appeal, it is identified that the patient has tried brimonidine (Alphagan), Travatan Z and dorzolamide-timolol (Cosopt), and brimonidine-timolol (Combigan). Rocklatan was started approximately four months ago. A note dated approximately three months ago documents Alphagan being added to Rocklatan. As of the beginning of the month, the patient was using Rocklatan and Cosopt.  

In this case, coverage of Rocklatan is requested for a patient with severe stage chronic angle closure glaucoma who has tried and failed brimonidine (Alphagan), Travatan Z and dorzolamide-timolol (Cosopt), and brimonidine-timolol (Combigan).

Rocklatan 0.02%/0.005% is a fixed dose combination of a Rho kinase inhibitor and a prostaglandin F2alpha analogue FDA approved for the reduction of elevated intraocular pressure (IOP) in patients with open-angle glaucoma or ocular hypertension.

Coverage was previously denied as it was not documented that the patient had taken or had a poor response to medications on the preferred drug list which include apraclonidine, betaxolol, Betimol, Betoptic-s, carteolol, levobunolol, metipranolol, pilocarpine, Azopt, Simbrinza, dorzolamide, dorzolamide-timolol, Travatan-a, latanoprost, and bimatoprost 0.03% drops. 

As the patient has already tried and failed medications from four drug classes (beta-blockers, alpha-agonists, carbonic anhydrase inhibitors, and prostaglandin analogues) and the patient has had a good response to Rocklatan, the requested Rocklatan would be established as medically necessary in this case per standard of care.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with hypercholesterolemia, hypertension, and Parkinson's disease who complained of several months of exertional chest pain. Her stress test showed moderate anterior and anterolateral ischemia. She was referred for elective cardiac catheterization. She was found to have an 80% mid left anterior descending (LAD) stenosis for which underwent successful drug eluting stenting without complications. She was admitted, observed uneventfully overnight, and discharged the following day. At issue is the medical necessity of an inpatient admission.
The health plan's determination is upheld. The patient had an elective uncomplicated catheterization and coronary intervention. It was appropriate to monitor the patient post-procedure for several hours but that could have been performed at a lower level of care than inpatient. It was expected that discharge would have been accomplished within 24 hours in this low risk patient. Inpatient hospitalization was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Substance Abuse/Addiction
Substance Abuse: Inpatient

The patient is a male who was admitted to inpatient substance abuse level of care related to use of heroin, cocaine, and alcohol. The patient also reportedly was using 10 milligrams (mg) of Xanax per day and 20 mg per day of non-prescribed methadone 1 to 2 times per week. The patient was reported to have signs of tremors, joint pain, anxiety, irritability, and diarrhea. The patient had an initial Clinical Institute Withdrawal Assessment (CIWA) score of 12 and Clinical Opiate Withdrawal Scale (COWS) score of 10. The patient was treated with a methadone taper for opioid detoxification. The patient was treated with Librium for alcohol and benzodiazepine detoxification. Under review is the inpatient substance abuse treatment level of care.

The health plan's determination is overturned. The Inpatient Substance Abuse Treatment was medically necessary for this patient. The patient did not require immediate hospitalization for a severe life-threatening medical or psychiatric crisis. The drug with the most potential to cause harm to self or others was sedatives. Documentation indicated use of up to 10 mg of Xanax per day. The patient clearly met criteria for multiple substance use disorders including for sedatives, opiates, and cocaine. The patient was not in full remission from his substance use disorder. Patient did not have serious medical symptoms that needed to be managed in an inpatient setting. Patient did not have serious psychiatric symptoms that needed to be treated in an inpatient setting. The patient was not noted to be using in hazardous situations or in amounts or frequencies likely to be imminently dangerous to self or others. The patient had problems maintaining relationships and employment. The patient had serious medical symptoms in the form of withdraw from benzodiazepines and con current use of opiates that required management in an inpatient setting. The potential for withdraw from benzodiazepines while also being at risk for needing opiates put the patient at significant immediate risk. The patient needed management in a 24 hour medical setting. The patient did not exhibit predatory behavior. The patient had strong and unmanageable cravings that required stabilization with medical oversight.
Because the patient was using 10 mg per day of xanax and 1 pint of alcohol, he was at high risk for complicated alcohol withdrawal. Being also addicted to opiates complicated further this issue given the need to closely monitor concurrent use of benzodiazepines and opioids for withdrawal. The patient required inpatient care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion
Treatment: Braces, Monthly Visit,  Retainer

Summary:
The patient is a male. The request is for orthodontic benefits.
The D8080 - Braces, D8670 - Monthly visit, and D8680 - Retainer are medically necessary.

This patient has a "deep impinging overbite with soft tissue damage." This is an "automatic qualifier" according the handicapping index. The orthodontic treatment is necessary to correct this malocclusion.
Appeal type: Medical necessity
Decision: Upheld

Chronic Obstructive Lung Disease/COPD
Skilled Nursing Facility

The patient is a male with a medical history of smoking (26 pack years), morbid obesity, hypertension, hyperlipidemia, diastolic heart failure and depression who was admitted to LTACH (Long-Term Acute Care Hospital) after a hospitalization for an acute on chronic hypercapnic and hypoxic respiratory failure due to undiagnosed obesity hypoventilation syndrome (OHS) and an acute diastolic heart failure exacerbation. 

The health plan's determination is upheld. The Inpatient Long-Term Acute Care Hospital (LTACH) Admission is not medically necessary for this patient. On admission the patient is hemodynamically stable, neurologically stable, not on any continuous intravenous medications and is on oral feeding. Also, there is no documentation that his wounds would require more than minimal wound care or require daily physician supervision due to necrosis or need for debridement. In addition, there is no indication from the clinical notes that the patient needs frequent nursing care >6.5 hours per day or daily physician assessments. As per the physical & occupation therapy documentation, the patient is able to participate in physical therapy and would benefit from continued skilled inpatient rehabilitation 3-5 times per week. Although the patient required continued physical therapy, nocturnal BIPAP, supplemental oxygen and diuretics for his heart failure, this does not require an LTACH level of care.