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

Diagnosis: Central Nervous System/Neuromuscular Disorder/Epilepsy
Treatment: Inpatient Hospital
The health plan denied the inpatient hospital stay as not medically necessary. 
The health plan's determination is upheld. 

At the time of her admission, the patient was a previously healthy young child brought to the emergency department (ED) by 911 the morning of admission after having a presumed seizure witnessed by mom who was sleeping beside her when she was awakened by her daughter having repetitive shaking movements involving the whole body. She was not responsive during the seizure, which mom estimated at 3-4 minutes duration, did not have incontinence, and afterward she was less responsive than usual. The day before, she had had the varicella vaccine. In the ED, she had one episode of vomiting but returned completely to baseline about three hours total after the seizure. She did not have a history of fever or illness but had a routine varicella vaccination the day before. There was a family history of seizures. In the ED, her vital signs were normal, electrocardiogram (EKG) and head computed tomography (CT) were normal. A urine toxicology screen was normal, blood work was normal. Pediatrics and pediatric neurology were consulted, which recommended admission for a video electroencephalogram (EEG) to expedite her workup of a new onset of afebrile seizures. The EEG showed frequent epileptiform spikes in the left centrotemporal region, prompting a magnetic resonance imaging (MRI) to rule out structural lesion, which was normal. She was discharged well with neuro follow up and a likely diagnosis of enign rolandic epilepsy. The health plan denied coverage at the acute inpatient level, which is the subject of this review.

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

No. The patient was brought by 911 to the ED after a witnessed seizure, without fever or illness, which had stopped by the arrival of the medics. There were no further seizures en route or in the ED, where history, physical, laboratory and radiographic evaluation were negative for identifiable causes of a seizure, such as metabolic derangement, toxin ingestion, infection, intracranial mass, intracranial bleeding, hypertension, hypoxemia. The patient was clinically normal upon admission, which was done to expedite obtaining an EEG, which could have been done as an outpatient since there was no indication that follow up would be challenging.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer/Breast Cancer
Treatment: Genetic Testing
The health plan denied the requested genetic testing due to no medical necessity. 
The health plan's determination is overturned.

This case involves a female of Jewish decent whose holistic medicine practitioner ordered a GeneDx assay to assist with management. The patient had undergone a magnetic resonance imaging (MRI) assisted biopsy of a left inner quadrant abnormality which failed to reveal any pathologic findings concerning for malignancy. Per report, the patient's mother was diagnosed with breast cancer at age 28. Denial of coverage for this service was stated by the patient's health care plan. Hence, an external appeal is requested.

I would recommend overturning the health care plan's determination of the denial of medical necessity in this case.

Per National Cancer Care Network Guidelines, a patient with a first-degree family member with a breast cancer diagnosis below 45 years of age, and who is of Ashkenazi decent, qualifies for genetic testing. Genetic testing is this context is consistent with standard of care medical care. Denial of coverage of this service is not consistent with the best interest of the patient.
While the specific assay requested by the patient's provider is not noted,  germline genetic testing for BRCA 1 and mutations among others is deemed medically necessary. Broad based whole exome sequencing, if performed here would not be necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope. 
Treatment: Inpatient admission. 

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

The patient is a male with hypertension, diabetes mellitus coronary artery disease, and prostate cancer who developed syncope at home. The patient was found to have acute renal failure as well as lactic acidosis. The patient was admitted to acute in-hospital level of care for the management of syncope and lactic acidosis. 

No, the proposed treatment was not medically necessary. 

The patient was admitted to acute in-hospital level of care for the management of syncope.  With intravenous fluid therapy, the patient's lactic acidosis improved. The patient also had pleural effusion which was evaluated by pulmonary.  The patient felt better with improved dizziness. Lactic acidosis improved. Acute renal failure improved. The patient was tolerating diet. Since the patient's condition improved significantly with intravenous fluid (IVF) hydration, the acute in-hospital level of care was not medically necessary. A lower level of care would be as safe and effective.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems/Overbite/Underbite.
Treatment: Dental/Orthodontic Procedure.
The health plan denied the request for orthodontic treatment (braces and monthly visits) as not medically necessary. 
The health plan's determination is upheld.

The patient is a female with a Skeletal Class III malocclusion with mild maxillary crowding and mild mandibular crowding, mild overjet and mild overbite. The subject to be determined is the medical necessity for braces and monthly visits.

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

Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 6 with no auto qualifiers. Auto qualifiers include cleft palate deformity or cranio-facial anomaly, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9-millimeter (mm) or greater and underbite 3.5 mm or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary. Thus, braces and monthly visits are not medically necessary for this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems- Missing Tooth/teeth
Treatment: Dental/Orthodontic Procedure-Braces
The health plan denied the service/treatment of Braces and monthly visits X 12 as not medically necessary. 
The reviewer has overturned in whole the health plan's determination.

The patient in question is presenting with a skeletal Class I malocclusion and mild spacing. She has a 50% deep bite. She is missing teeth 7, 10 and 13. Primary tooth C is retained. She is treatment planned for 24-30 months of orthodontics to address the spacing. The orthodontist is planning to extract primary tooth C, and set up space for prosthetic replacement of 7, 10 and 13. 

The patient's malocclusion will not correct itself; the only way to create the space for prosthetic teeth that will correct her bite is to do orthodontics. This treatment is medically necessary.
The patient presents with hypodontia. Hypodontia, or tooth agenesis, is the most prevalent craniofacial malformation in humans. Excluding third molars, the reported prevalence of hypodontia ranges from 1.6 to 6.9%, depending on the population studied. Hypodontia individuals often present a significant clinical challenge for orthodontists because, in a number of cases, the treatment time is prolonged, and the treatment outcome may be compromised.[1]
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System-Other-Pneumothorax
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

At the time of admission the patient was  brought to the emergency department (ED) with a day of anterior left chest discomfort and a sensation of bubbling. He appeared well. His vital signs were as follows: blood pressure (BP) 126/87, heart rate (HR) 96, respiratory rate (RR)18, and oxygen (O2) Sat 97% on room air. Examination was normal except for left sided chest wall tenderness. A chest x-ray (CXR) showed a small to moderate left apical pneumothorax. Labs and electrocardiogram (EKG) were unremarkable. He was admitted to the pediatric floor, where he appeared well, with normal vital signs. Diagnosis was spontaneous pneumothorax, and he was treated with oxygen. The next day, he felt better. A Thoracic surgeon saw him and explained the etiology was likely due to body habitus, and that the standard of care was to hold off on surgical intervention unless he has a second episode. He was discharged home. 

The inpatient stay was not medically necessary for this patient.
A lower level of care is the appropriate level of service for this patient, who had a clinically insignificant spontaneous pneumothorax. Moreover, lower level is the care he received. The oxygen therapy can be administered in this setting, and there is controversy about its efficacy in any event in this clinical setting.
Milliman Care Guidelines for pediatric pneumothorax indicate that admission is indicated for pneumothorax secondary to lung disease (e.g. cystic fibrosis, which he does not have), tension or traumatic pneumothorax, vital sign abnormality (e.g. low BP or oxygen saturation), altered mental status, difficulty breathing, identified infection requiring inpatient therapy, severe pain requiring inpatient treatment, or intervention required after observation period (e.g. chest tube placement).
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: Cancer; germ cell tumor
Treatment: Neulasta
The insurer denied Neulasta. The health plan's determination is overturned. 

This is a female with a relapsed, metastatic germ cell tumor. The patient is receiving carboplatin + (plus) vincristine after having previously progressed on multiple lines of therapy including a cytotoxic therapy, an autologous stem cell transplant, and immunotherapy. The patient received Neulasta as a component of her therapy. The use of Neulasta is under review.

Neulasta is medically necessary for this patient. 
The National Comprehensive Cancer Network (NCCN) recommends the use of primary prophylaxis with a granulocyte colony stimulating factor (G-CSF) when the patient is receiving a regimen with a 20% (percent) or more risk of febrile neutropenia or if the patient has one or more risk factors. The risk factors including prior chemotherapy, persistent neutropenia, bone marrow involvement by tumor, recent surgery and/or open wounds, liver dysfunction, renal dysfunction, or age > (greater than) 65. NCCN criteria for primary prophylaxis. These criteria are echoed by the authors of UpToDate and by ASCO (American Society of Clinical Oncology) Guidelines. For these reasons, medical necessity has been established for the use of Neulasta in this setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Xeljanz. 
The denial is upheld.

The patient is a female with rheumatoid arthritis with associated pyoderma gangrenosum. As stated in a letter of appeal, the patient is being treated with methotrexate and Plaquenil for her arthritis, and both topical tacrolimus under occlusion and intralesional Kenalog for her pyoderma gangrenosum. Only mild improvement of the patient's pyoderma gangrenosum was noted in a recent clinic note. The subject under review is the medical necessity for Xeljanz in this case.

The health plan's determination is upheld.

No, Xeljanz 5 milligrams (mg) is not medically necessary for this patient.
It should be emphasized that the requested Xeljanz is to be used for the patient's pyoderma gangrenosum, and not the patient's rheumatoid arthritis. Insufficient evidence exists for any safe or effective use of Xeljanz for the condition of pyoderma gangrenosum. Other medications are more supported by evidence to date to benefit this patient's pyoderma gangrenosum.
Xeljanz is Food and Drug Administration (FDA)-approved and literature-supported [1-5] not for pyoderma gangrenosum but is approved for rheumatoid arthritis in patients who have not responded to methotrexate alone. Methotrexate and Xeljanz can be used together for rheumatoid arthritis, but Xeljanz is at best investigational for pyoderma gangrenosum. Compared to the literature suggestive of benefit of patients to Xeljanz for pyoderma gangrenosum, the use of other agents are much more documented than Xeljanz. As such, Xeljanz is not medically necessary for this patient's treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fully edentulous
Treatment: D6010 Surgical Placement of Implant Body; Endosteal Implant #'s 3, 5, 6, 11, 12, 14
The insurer denied the D6010 Surgical Placement of Implant Body; Endosteal Implant #'s 3, 5, 6, 11, 12, 14
The denial is upheld. 

The patient is a male requesting dental benefits for implant placement of teeth #3, 5, 6, 11, 12, and 14.

The patient is fully edentulous--missing all upper and lower teeth.

No, the proposed treatment of implant placement of teeth # 3, 5, 6, 11, 12, and 14 are not medically necessary.
This patient presents fully edentulous---no remaining upper or lower teeth. There is no documentation supplied to explain why these six implants are to be placed. There is no documentation as to why implants are the only option for replacement of missing teeth for this patient.  There is no mention of any conditions that would necessitate only implant placement.

Implant placement is a major, complex process; there is no documentation regarding any other replacement options that are less invasive, any documentation that assesses the health of the bone where the implants are to be placed and the patient's overall health and prognosis of this treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tubo-ovarian abscess
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient presented to the emergency department (ED) with a complaint of left sided abdominal and pelvic pain. She had a history of pelvic inflammatory disease and a past chlamydial infection. The patient's exam was remarkable for abdominal tenderness and cervical motion tenderness. Her imaging showed a left sided adnexal mass of 6 centimeters (cm) with enhancing components on computed tomography (CT) scan consistent with a tubo-ovarian abscess. The patient was admitted for intravenous (IV) cefoxitin and doxycycline for two days, and then discharged to home with oral antibiotics. At issue is the medical necessity of an inpatient stay.

The inpatient admission in this case was medically necessary. While some cases of pelvic inflammatory disease can be managed as an outpatient, tubo-ovarian abscess is a well-established reason for inpatient management. This is a highly dangerous situation, because a tubo-ovarian abscess, if not resolved quickly, can lead to sepsis and death. Aggressive broad-spectrum IV antibiotics are necessary as well as monitoring for clinical instability with serial vital signs. Drainage can be helpful, but requires large pockets of fluid which were not available in the septated lesion found in this case. Therefore, antibiotic therapy was imperative for treatment in this case. Anything other than inpatient admission and aggressive therapy in this situation would not meet the standard of care. 
The patient met criteria for pelvic inflammatory disease with pelvic pain, abdominal tenderness, and cervical motion tenderness. Her history of past pelvic inflammatory disease and chlamydial infection supports this diagnosis as well. Her imaging showed a septated, rim-enhancing lesion in the left adnexa measuring 6 centimeters (cm), and was assessed by radiology as consistent with a tubo-ovarian abscess. Serial vital signs are necessary because if the patient were to become unstable, rapid surgical intervention to evacuate the abscess becomes necessary. Professional guidelines, including those from the Centers for Disease Control and Prevention (CDC), agree that tubo-ovarian abscess is an indication for inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems
Treatment: Dental/Orthodontic procedure

Diagnosis: Dental Problems-Teeth spacing problem
Treatment: Dental/Orthodontic procedure-Braces and Monthly visits
The health plan denied the Braces and monthly visits X12 as not medically necessary. 

The reviewer has upheld in whole the health plan's determination.

This patient has a Skeletal Class I occlusion. She has mild maxillary crowding and moderate mandibular crowding. She has mild overjet and mild overbite. 

Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 15 with no auto qualifiers. Auto qualifiers include cleft palate deformity or cranio-facial anomaly, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9 millimeter (mm) or greater and underbite 3.5mm or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary. Thus, braces and monthly visits are not medically necessary for this case.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Hypothyroidism.

Treatment: Formulary Exception for Tirosint 100 mcg [micrograms] capsule.

The insurer denied coverage for Formulary Exception for Tirosint 100 mcg [micrograms] capsule.

The denial is overturned. 

This is a female patient with a diagnosis of hypothyroidism. According to an office visit note, the patient has some symptoms of hypothyroidism.  She has previously taken Synthroid and had anaphylaxis.  A thyroid stimulating hormone (TSH) test was to be ordered. Her TSH level was 0.99.  The medication list included Tirosint 100 micrograms (mcg).  

The undated appeal letter by the patient states Tirosint is the only medication she can take.  She has Celiac disease and any gluten causes her reactions.

Based on the medical facts from the available records, claim documentation, and any additional information obtained from the treating provider, the requested medication Tirosint is medically necessary for this patient given her history of allergic reactions to Synthroid and Levothyroxine.  This also makes her have a high chance of allergic reactions to Unithroid and Levoxyl. Therefore, the formulary drug(s) are likely to cause the patient an adverse reaction.      

The formulary drugs Synthroid and Levothyroxine have been ineffective based on the patient's clinical history and this has been documented by her primary care provider. The requested drug Tirosint will be more effective as the patient has been on it for over a year with good control and no adverse reaction.  Given her history of allergic reactions to Synthroid and Levothyroxine the requested medication Tirosint is medically appropriate for this patient. Tirosint is a special gel capsule thyroid hormone that is gluten, starch, and dye free.  Tirosint also has better absorption. 

The carrier's denial of the Request for Formulary Exception for Tirosint 100 mcg [micrograms] capsule is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain.

Treatment: Current Procedural Terminology (CPT) code 74177- CT scan of the abdomen and pelvis with contrast.

The insurer is denied coverage for CPT code 74177- CT scan of the abdomen and pelvis with contrast.

The denial is upheld. 

This female patient has a history of abdominal pain and constipation. The gastroenterologist ordered a computed tomography (CT) scan of the abdomen and pelvis and the patient underwent testing.  Results showed apparent thickening without obvious inflammatory stigmata, possibility of infectious colitis, normal appendix, and no other gastrointestinal tract abnormality. A dominant 3 centimeter (cm) right ovarian cyst, likely functional was noted.  This could represent a recently ruptured corpus luteum cyst and could be the etiology abdominal pain.  No finding of inflammation or torsion was seen.

Milliman Care Guidelines (MCG) lists clinical indications for performing a computerized axial tomography (CAT) scan of the abdomen and pelvis.  These indications include aortic aneurysm, abdominal abscess, evaluation or staging of a neoplasm, abdominal mass, and certain indications for abdominal pain.  In cases of right upper abdominal pain a negative or equivocal ultrasound is needed.  There is no indication listed for epigastric pain.

The medical records submitted only indicate that the patient had epigastric and right upper quadrant (RUQ) discomfort.  The MCG requires that an abdominal ultrasound be obtained in this case.  Having colonoscopic polypectomies or gastritis is not an indication to have a CAT scan.  Gastric metaplasia should be followed endoscopically and not with a CAT scan.

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 the Current Procedural Terminology (CPT) code 74177- CT scan of the abdomen and pelvis with contrast is upheld.  The medical necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Hyperkalemia.

Treatment: Formulary Exception for Lokelma to treat hyperkalemia.

The insurer denied coverage for Formulary Exception for Lokelma to treat hyperkalemia.

The denial is overturned. 

This is a male patient with advanced chronic kidney disease secondary to hypertension. His condition was complicated with worsening hyperkalemia. He tried and failed Kayexalate and furosemide. His physician is requesting Lokelma to treat his condition. 

The patient tried and failed Furosemide and Kayexalate (sodium polystyrene sulfonate) and continued to have significant elevated potassium level. The requested drug is likely to produce a more clinically beneficial outcome.

The efficacy of zirconium cyclosilicate in hyperkalemic outpatients was evaluated in two nearly identical phase III, randomized placebo-controlled trials both showed Lokelma is safe and effective in treating hyperkalemia (Up to Date).

Kionex does not appear to be more effective in removing potassium from the body than laxative therapy. Although uncommon, cation exchange resins can produce severe side effects, particularly intestinal necrosis, which may be fatal (Up to Date).

Long term use of sodium polystyrene sulfonate (Kionex) is known to cause fatal gastrointestinal injury and should be avoided if possible. There is no evidence it is safe or effective in treating chronic hyperkalemia. Lokelma in clinical trials significantly decreases serum potassium levels without severe adverse events. Therefore, Lokelma is medically necessary to treat this member's hyperkalemia.

The insurer's denial of coverage for Formulary Exception for Lokelma to treat hyperkalemia is overturned.