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

Diagnosis: Urinary tract infection

Treatment: Inpatient admission 

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

This patient is a female with a past medical history significant for hypertension, pre-diabetes, and hypothyroidism who presented to the emergency department with complaints of lethargy. Vitals on presentation included: Temperature 98.1 F, blood pressure 146/65, pulse 57, respiratory rate 18, oxygen saturation 100% on room air. Laboratory values were notable for the following: WBC-8.4, Hgb-12.4, Hct-37.1, glucose-116, creatinine-1.0, and urinalysis was negative nitrites and large leukocyte esterase. The patient was admitted for possible urinary tract infection. She was empirically started on antibiotics (ceftriaxone). Chest x-ray was negative. Urine culture grew mixed flora. Doppler studies were negative for deep vein thrombosis (DVT). She remained afebrile, hemodynamically stable, and clinically improved. She was discharged on oral Keflex to continue outpatient management.

According to medical records, patient presented with findings consistent with an uncomplicated urinary tract infection. She was afebrile, hemodynamically stable; laboratory results were also unremarkable including a normal WBC.  She was able to tolerate oral intake and ambulatory with a cane (baseline). Based on above findings, the patient met criteria for observational level of monitoring. She did not meet criteria for acute inpatient admission. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient. Based on the above, the medical necessity for the inpatient admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rheumatoid arthritis
Treatment: Acthar Gel

The Acthar Gel is not medically necessary.

The patient is a female with seronegative rheumatoid arthritis (RA), diabetes and obesity. Per attached appeal, she has failed treatment with Humira, methotrexate, sulfasalazine, and intramuscular (IM) methylprednisolone. Per attached progress note, the patient's methotrexate dose was decreased to 15 milligrams (mg) weekly due to elevated liver function tests.  It is not clear whether she has actually been taking Humira, as the progress note history states "not given".  The attending physicain indicates that this patient is steroid-intolerant due to gastritis, and is concerned about steroid dysglycemia with her underlying diabetes.  Appeal is for Acthar Gel for the treatment of RA.

This patient with seronegative RA failed treatment with methotrexate, sulfasalazine and steroids. The attending physician (AP) indicates that this patient also failed treatment with Humira, but it is not clear whether Humira was ever taken by this patient per attached progress note.  Nonetheless, there are various other disease modifying anti-rheumatic drugs (DMARDs) (i.e., Plaquenil and Arava) as well as numerous other biologic therapy options that would be considered standard of care in the rheumatology community for this specific patient.  Per a recent UpToDate review as well as published 2015 guidelines for the treatment of RA, it would be appropriate to consider a non-tumor necrosis factor (TNF) biologic in this patient if she has indeed failed treatment with DMARDs and Humira. Furthermore, per attached Acthar Gel prescribing guidelines, "common adverse reactions of Acthar gel are similar to those of corticosteroids".  Thus, steroid-associated concerns regarding dysglycemia and weight gain (amongst others) in this obese, diabetic patient would render Acthar Gel an inappropriate therapy for her.  

Therefore, the proposed Acthar Gel for the treatment of RA in this patient is not clinically appropriate nor in accordance with standard of care in the rheumatology community, and thus is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: COPD; shortness of breath; chest pain
Treatment: Air ambulance
The air ambulance transportation was medically necessary.

The patient is a female with history of chronic obstructive pulmonary disease (COPD), tobacco use and other medical comorbidities.  The patient was admitted to the hospital for shortness of breath and chest pain.  Upon arrival out-of-town, the symptoms exacerbated and the patient was admitted to the hospital there for evaluation and treatment for chest pain, dyspnea, palpitations and diaphoresis.  Cardiology was consulted and performed a stress test for the heart and was it was abnormal.  Cardiac catheterization was schedule and the patient suffered a seizure and unresponsiveness.  Advanced cardiac life support (ACLS) was initiated and the patient was diagnosed with ventricular tachycardia and required defibrillation.  Cardiac catheterization demonstrated multivessel disease requiring multiple coronary stents.  The patient progressed to cardiogenic shock requiring pressors and ventricular assist devices and cardiac surgery consultation deemed her not a candidate surgery.  

Due to the severity of her cardiac failure and being unstable, she required to be transferred to a facility to be evaluated for cardiac transplantation and management of her cardiac failure.  She required air transportation for her transfer from the hospital to another hospital for her higher level of care.  The local heart transplant center was contacted and no physician answered to accept the patient.  Being in unstable cardiogenic shock, the next closer transplant center was the hospital that the patient was transferred to.

This patient suffered a life-threatening injury to the heart, rendering in cardiogenic shock.  The local hospital that admitted her and provided the initial care declared her not a candidate for cardiac surgery at their institution.  According to the note, it is described that the closest hospital to provide cardiac transplantation did not have an attending physician to accept the patient's care.  The next close institution to provide cardiac transplantation was the hospital that the patient was transferred to.  This patient was severely unstable requiring cardiotropic agents and poor cardiac performance.  The transferring center physicians decided that in the best interest and safety for this patient, air transport was the best way to transfer this patient to the other transplant facility.  This publication from 2019 by Sanchez-Salado JC et al demonstrated that the outcomes for patients in cardiogenic shock are much improved in centers that are highly specialized.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion

Treatment: Dental braces and monthly orthodontic visits

The insurer denied coverage for dental braces and monthly orthodontic visits. The denial was reversed.

This patient is a male that exhibited a significant malocclusion. The orthodontist recommended comprehensive orthodontics due to Class I malocclusion, Class II canines, maxillary crowding and mandibular crowding, excessive overjet and anterior crossbite with gingival attachment loss (mandibular canines).The orthodontist has completed the HLD index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. The insurer has denied coverage for orthodontic treatment as not medically necessary attaining only 19 points on review by internal reviewers.

It is evident that the patient exhibits a significant malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, a Handicapping Labiolingual Deviation Index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 
In this case, the treating orthodontist claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care.

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach.  This is confirmed by several studies. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care.  As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.  

Reverse denial as the clinical circumstance as presented does substantiate medical/dental necessity of orthodontic care. Based on the above, the medical necessity for the dental braces and monthly orthodontic visits is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tooth decay
Treatment: Core buildup and crown, teeth #s 2 and 30
The core buildup and crown, teeth 2 and 30 are not medically necessary.

Both teeth, 2 and 30, have two surface restorations on them. Decay is seen on the distal of tooth #30 in an x-ray. No decay is seen in tooth #2. Most other x-rays are of poor diagnostic quality. There are photos submitted, but it is unclear just what is being shown, as they are of poor quality as well. Good quality photos, showing how much tooth structure is missing, upon removing the existing fillings, would help to understand the need for the requested build ups and crowns. Absent those photos, there is no way to understand and corroborate the need for crowns and build ups, as the x-rays and photos do not show any need. Medical necessity for the crowns and build ups has not been established with the documentation provided.
Appeal type: Step Therapy
Decision: Upheld

This is a patient under management for ulcerative colitis. Phenotypically, she has moderate to severe pancolitis. The patient failed mesalamine and required steroids for disease management. The patient had an essentially normal colonoscopy. She started Xeljanz as part of a program through the manufacturer but apparently the manufacturer is no longer subsidizing this treatment.
The patient's provider has recommended continued treatment with Xeljanz 5 milligrams (mg) twice daily (BID), however, this was denied by the health plan as this is not on the list of preferred agents which include Humira and Simponi. The health plan's determination is upheld. The plan requires trial of a preferred drug, such as Humira or Simponi,  anti-tumor necrosis factor (TNF) drugs, as front line therapy for ulcerative colitis. The patient had a colonoscopy in 3/2019 and in 10/2019 which were essentially normal. There should be no barrier or deterioration in the colitis disease course upon switching over to Humira of Simponi. The standard of care currently is to not use Xeljanz as a first-line agent.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity; hypothyrodisim 

Treatment: Saxenda pen-injectors

The insurer denied coverage for Saxenda pen-injectors. The denial reversed.

This patient is a female that has diagnosis of obesity and hypothyrodisim based on data provided. She tried weight loss via diet and through what weight watchers would require. She also has a history of osteoarthritis of the knee, had a knee replacement surgery several years prior. She used different weight loss medication including contrive and belviq without success. When at a weight of 211 lbs. she took Saxenda and in few weeks she achieved a weight of 185lb, 26 pound weight loss.  That is very significant and when stopped taking it due to insurance coverage her weight went back to 201 lbs. Her BMI is 32. 

Saxenda was approved by FDA at a dose of 3mg/day for weight loss and comparative data suggest that weight loss with Liraglutide (Saxenda) is greater than that seen with Orlistat or Locaserin. (1) Based on the guidelines of Endocrine Society (2) if a patient responds well to weight loss medication and loses 5 percent or more of their body weight after 3 months the medication should be continued. Based on this guideline the patient lost on Saxenda more than 5% of her body weight in few weeks, so it is indicated to continue to use it for good response.

The most significant impact of obesity on musculoskeletal system is associated with osteoarthritis (OA) a disabling degenerative joint disorder, causing pain, decrease mobility and has negative impact on quality of life. (3) Due to all these reasons 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 the Saxenda pen-injectors is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Reported gap and fracture of tooth 
Treatment: D2750 White glass with high gold content crown, tooth #19

The D2750 white glass with high gold content crown, tooth #19 is not medically necessary.

According to the Panorex x-ray, tooth #19 has an existing crown on it. There is not any recurrent decay present or fracture of the crown showing, either of which would necessitate a new crown. There is a clear Panorex x-ray that does not show any gap on either side of this crown.  A periapical (PA) x-ray, with no overlapping of the teeth might show a gap as would an intraoral photograph.  No fracture can be seen on the Panorex and without a photo showing the questionable area, there is no reason to replace this crown as of now.  The existing crown is still functional.
Appeal type: Medical necessity
Decision: Upheld

Blood Clot
Inpatient Hospital

The patient is a male, with end stage renal disease on dialysis three times a week via left arteriovenous fistula, who was admitted for thrombosis in the superior vena cava on computed tomography and was started on heparin drip. During this stay, he had a normal chest X-ray, he had a negative electrocardiogram and cardiac markers for cardiac ischemia, carotid doppler was negative for significant stenosis, he was evaluated by nephrology and received routine dialysis, he was switched to oral anticoagulation and discharged in stable condition two days later.

The health plan denied the inpatient stay as not medically necessary. The health plan's determination is upheld. 

The inpatient stay was not medically necessary.  The patient was found to have thrombosis in the superior vena cava, however, he did not have an increased risk for complication such as bleeding before anticoagulation such as recent surgery (eg, within 3 months) or recent gastrointestinal (GI) bleeding or with contraindication to outpatient use of medication with rapid anticoagulation as defined by CHEST Guideline and Expert Panel report. His condition did not require an invasive or high-risk procedure as defined by the American Heart Association such as Thrombolysis (eg, catheter-directed) or pharmacomechanical thrombectomy. In addition, he was hemodynamically stable, with normal oxygenation, did not have significant electrolytes disturbance, did not have cardiac arrhythmias, no altered mental status or persistent nausea and vomiting with dehydration. There is no evidence-based literature that indicates his condition could not be treated safely under a lower level of care, therefore, inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Digestive System/Gastrointestinal - Appendicitis
Inpatient Hospital

The patient is a female who presented to the emergency department (ED) with a history of progressively worsening abdominal pain of 3-days duration. Her evaluation included physical exam, labs, and computed tomography (CT) scan. She was without fever at the time of presentation. The heart rate was 89/minute. Lab data identified a white blood cell (WBC) count of 5.4 thousand (K). CT scan yielded the diagnosis of acute appendicitis. Treatment was initiated with intravenous (IV) fluid and antibiotics. Surgical consultation was obtained.
The patient underwent laparoscopic appendectomy. The clinical notes and the anesthetic record indicate an uncomplicated appendectomy. The operative note describes an acute, non-perforated, appendicitis. She was provided IV fluid and perioperative antibiotics. The vital signs remained normal following surgery. She tolerated a diet and was discharged from the hospital the following day.

The health plan's determination is upheld.

Inpatient admission was not medically necessary for this patient. The records do not document hemodynamic instability, sepsis or toxicity, significant electrolyte imbalance, bleeding, gastrointestinal (GI) obstruction or surgical complications of the procedure that required inpatient care. In this case the patient tolerated oral hydration, diet and medication and pain was well controlled.
This patient presented to the ED with abdominal pain. The evaluation with examination, lab data, and CT scan confirmed the diagnosis of appendicitis without evidence of perforation. The initial treatment appropriately included nothing by mouth (NPO) status, IV fluid, IV antibiotics and appendectomy. The early post-surgical course was uncomplicated, and the patient was clinically stable. She was stable for discharge from the hospital.
The submitted clinical documentation does not support the need for inpatient admission for this patient. The patient required urgent surgical intervention for acute appendicitis, however, a lower level of care would have satisfactorily provided for the care provided and would have been consistent with the accepted standard of medical care. There was no documentation of hemodynamic instability, intra- or peri-operative complications, severe pain, or unstable comorbidities. The member tolerated oral hydration, diet and medication. Pain was well controlled.
The care and treatment provided could have appropriately been rendered with a lower level of care status. The patient was clinically stable at the time of presentation and remained so during the course of care. A lower level of care status would have provided for presurgical assessment, operative treatment and post-surgical monitoring. This lower level of care would have also allowed for overnight monitoring.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/ Musculoskeletal
Treatment: Consumer Directed Personal Care Assistance

The proposed treatment of consumer directed personal care assistance is not deemed medically necessary. 

This is a female who recently underwent a clinical assessment and demonstrated the ability to perform her activities of daily living (ADLs) including toileting, personal hygiene and walking independently. There are no other additional medical records noted in the file which indicate that the patient has sustained additional clinical/functional decline since the date of this last assessment. For these reasons, the proposed treatment of consumer directed personal care assistance is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multiple sclerosis

Treatment: Ocrelizumab (Ocrevus)

The insurer denied coverage for Ocrelizumab (Ocrevus). The denial was reversed.

This patient is a female who has previously been diagnosed with multiple sclerosis. The documentation indicated that the patient has been utilizing the requested medication for several years. The documentation detailed that the patient has previously utilized Tecfidera and Avonex.  The letter of medical necessity indicates that the patient requires treatment of the requested medication for relapsing remitting multiple sclerosis.  She has had a trial failure of Avonex due to disease progression on medication.  She also failed Tecfidera and has been doing well with Ocrevus. The most recent note dated mid-2019 indicated that the patient was seen for a follow-up.  At this visit, it was recommended to continue utilizing Ocrevus.  She was also recommended at this visit to undergo laboratory studies.  On exam, her 25 foot timed walk was completed in 6.5 seconds with no assistive device.  The patient was alert and responded appropriately. She also had 5/5 strength throughout and normal reflexes.  The physician again recommended continuation of Ocrevus.

The patient has had stable disease with Ocrevus--without side effects, having failed prior therapy with Avonex and Tecfidera.  Ocrevus is a cytotoxic recombinant humanized MAB that targets CD20 on circulating B-lymphocytes.  Clinical studies have shown that Ocrevus showed efficacy superiority over interferon Beta-1a.  Ocrevus has also shown a marked reduction in contrast enhancing lesions, as well as progression to disability.

As noted above, the patient has an advanced case of multiple sclerosis with failure of traditional front-line approaches.  It would be contraindicated medically to discontinue Ocrevus--which has shown robust efficacy in head to head trial versus Avonex--in the context of marked reduction in contrast enhanced magnetic resonance imaging (MRI) lesions and progression to disability.  Ocrevus is clearly medically necessary and there is no formulary alternative with Ocrevus' unique mechanism of action and robust clinical efficacy. Furthermore, as per the most recent guideline, "Multiple disease-modifying therapies [DMTs] are available for MS treatment. Switching therapies may be appropriate in people with MS who are experiencing adverse effects [AEs] or complications with a DMT."  This patient is clinically stable on her current regimen. 

Ocrevus is medically necessary. The health care plan did not act reasonably or with sound medical judgment or in the best interest of the patient. 

Based on the above, the medical necessity for Ocrelizumab (Ocrevus) is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Renal colic and vomiting
Treatment: Inpatient stay

Summary:
This is a female was admitted with right renal colic and vomiting. 

An acute inpatient level of care was not medically necessary.  Care could have been provided at a lower level of care.  The patient was afebrile and hemodynamically stable throughout the hospitalization.  There was no significant evidence for sepsis.  Following admission, there were no unstable vital signs reported.  She did not have a documented infection or kidney failure, solitary kidney or a kidney transplant, or need for an open surgery.  She did not have bilateral obstruction, acute renal failure, severe vomiting.   Pain control and IVF in a non-toxic patient can be provided at a lower level of care.