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

Diagnosis: hyperglycemia
Treatment: inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

The patient is a male. He has a past medical history of diabetes mellitus, polysubstance abuse, hypertension, chronic obstructive pulmonary disease (COPD), arthritis and alcohol abuse. He presented with chest pain and generalized weakness. Vital signs showed a blood pressure of 145/86, pulse 86, temperature 98.3, respiratory rate 18 and oxygen saturation 98%. Labs showed a sodium 132, potassium 4.2, creatinine 1.2, glucose 538, bicarbonate 23 and blood urea nitrogen (BUN) 10.

The Inpatient Hospital Admission is not medically necessary for this patient. Care could have been provided at a lower level.
The patient presented with chest pain and generalized weakness in the setting of medication noncompliance. He was started on intravenous fluids (IVF) and insulin. There was no acute kidney injury (AKI) or severe electrolyte derangements. In addition, there was no acute coronary syndrome or diabetic ketoacidosis requiring an insulin drip.
Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS, also known as hyperosmotic hyperglycemic nonketotic state [HHNK]) are two of the most serious acute complications of diabetes. In DKA, metabolic acidosis is often the major finding, while the serum glucose concentration is generally below 800 and often in the 350 to 500 mg/dL. In HHS, there is little or no ketoacid accumulation, the serum glucose concentration frequently exceeds 1000, the plasma osmolality (Posm) may reach 380, and neurologic abnormalities are frequently present. He did not have any of the above in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: malocclusion with crowding
Treatment: Braces
The insurer denied: Braces
The denial is: Overturned.

The patient is a female with a Class II malocclusion with minor crowding and protrusive maxillary incisors. She has a 6-millimeter (mm) overjet and 6mm overbite. She is treatment planned for orthodontics to correct the crowding and protrusion. Treatment was denied by her health plan based on lack of medical necessity. The subject under review is the medical necessity for braces for this patient.

The health plan's determination is overturned.

Braces are medically necessary for this patient. There is strong medical evidence that that correction of patients with prominent maxillary front teeth can reduce the risk of incisor trauma.[1]  Teeth #(number) 8 and #9 are protruding forward within the dental arch. This makes them more prone to trauma. Evidence shows orthodontic treatment will reduce the chances of damage to the maxillary incisors and the associated complications and morbidity of repairing these teeth. Furthermore, there is scientific evidence that oral health quality of life is reduced in patients with 6+mm overjets, which this patient has.[2]  For these reasons braces are deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skin Disorders- Abscess.
Treatment: Skilled Nursing Facility-Long-term custodial care.
The health plan denied the treatment of long-term custodial case as not medically necessary. 
The reviewer has overturned in whole the health plan's determination. 

This is a case review for an adult male with medical history notable for type 2 diabetes, coronary artery disease (CAD), chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), human immunodeficiency virus (HIV), hypertension, weakness, anemia, and perianal abscess. The patient was receiving long term custodial care from for treatment of perianal abscess.
A letter of support was provided from the case manager at the custodial care facility. The letter states that the patient is having "increased difficulty with bed mobility, transfers, and ambulation. Patient also with impaired activities of daily living (ADL) independence." The physician caring for the patient at the facility also provided a letter of medical necessity. The physician states that the patient has "significant debility interfering with ADL requiring Skilled Nursing Facility (SNF) care and rehabilitation. He is also homeless with no income." The facility is assisting the patient with Supplemental Security Income (SSI) applications in hopes of facilitating a safe discharge plan. A separate letter from the patient's case manager states that once SSI is approved, he can be transferred to an Assisted Living Facility (ALF), and that a discharge back to homelessness would be unsafe for him.
Progress notes from the facility were provided and reviewed in detail.
A Hospital and Community Patient Review Instrument (HC-PRI) functional assessment was completed. It states that he requires intermittent supervision and assistance for eating, requires one person for transfer, and is continent of bowel and bladder but requires constant supervision and assistance with toileting.

The requested health service/treatment of Long-Term Custodial Care is medically necessary for this patient.
The denial was based in part by a claim that he is able to perform activities of daily living independently; however, the appeal included a physician attestation to the contrary, explicitly stating that he does need assistance with ADL's. The request was also denied due to the patient being able to receive ongoing care on an outpatient basis or at an alternate site, which would be true if the patient were not homeless. He has medical attestation for decreased functioning with activities of daily living and needs support, which the patient cannot get in the community without a stable housing situation. Until safe discharge arrangements can be put in place, it remains medically necessary for the patient to stay in the custodial care facility to receive proper medical care and assistance with ADL's.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Personal care aide (PCA) hours; 7 days/week 2-12 hours/day (split-shift) 
The insurer denied PCA hours; 7 days/week 2-12 hours/day (split-shift). 
The determination is overturned.

The patient has a medical history notable for dementia, congestive heart failure with chronic hypoxic respiratory failure on oxygen, and poor functional status. The patient and her care team requested 24 hours/day (2-12 hour split-shift) personal care services. This request was partially denied, with the health plan approving 24-hour live-in personal care.

A letter of support for this appeal was provided by the patient's granddaughter. The letter states that the patient yells throughout the night due to "being in the same position or she needs her diaper changed." Similarly, in the appeal the patient's son states that she is "totally bed bound. Cannot reposition herself in bed. Cannot change diaper-urinary and fecal incontinence. Does not sleep at night, yelling nonstop."

A statement of medical necessity for increased services was provided by the treating physician. The letter states that due to the patient's "very poor functional status" she has been bed bound. She wears diapers for urinary and fecal incontinence that need to be changed throughout the day and night. The physician recommended multiple daily and nighttime changes of the diaper to prevent skin breakdown and infection.

A Uniform Assessment System (UAS) was completed and was available for review. She exhibited impaired cognition. Evaluation showed worsening functional status from a prior evaluation consistent with the testimony above. She now requires total dependence for bathing, hygiene, dressing upper/lower body, walking, locomotion, toilet transfer, toilet use, and bed mobility. She also requires total dependence for instrumental activities of daily living (IADLs) including meal preparation, housework, and managing finances. She is frequently incontinent of urine and occasionally incontinent of stool.

At issue is the medical necessity of personal care aide (PCA) hours; 7 days/week 2-12 hours/day (split-shift). 

The requested health service/treatment of PCA hours; 7 days/week 2-12 hours/day (split-shift) is medically necessary for this patient.

The patient is bed bound and requires total dependence for all activities of daily living(ADLs), including positioning in bed. Her physician recommended split-shift care for incontinence care overnight as well. Live-in personal care aides require a minimum of 5 hours/night of uninterrupted sleep. This would mean that the patient would be left in the same position in a potentially soiled diaper for up to 5 hours every night. This is not optimal and could lead to skin breakdown, ulceration, and/or infection. This establishes medical necessity for split-shift services overnight. The patient's needs cannot be met through the use of durable medical equipment as she requires total dependence for all of her functional needs.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back Pain
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is upheld.

The patient has a history of back pain, hypertension, depression and gastroesophageal reflux disease. His body mass index (BMI) is 44.23. His American Society of Anesthesiologists (ASA) score is 3.

He was admitted for an elective lumbar laminectomy lumbar (L) 5-sacral (S) 1 via a minimally invasive approach after failing conservative treatment. His diagnoses are degenerative disc disease, radiculopathy and spinal stenosis. There were no postoperative complications. He required additional pain medications and Zofran for nausea.

He reported improvement in his legs. He was not walking a lot but stated he walked the prior evening and his bilateral hips started to bother him a bit. His pain was controlled. His right Hemovac put out 5 milliliters (ml) and a left Hemovac put out 20 ml overnight. His exam is normal. The plan stated that given his size and complexity of the surgery, they would leave the drains in until he was up and ambulating more. They would remove the drains that afternoon and he could be discharged home. Nursing documentation noted 5 ml output for each drain.

A discharge note states that he underwent an uncomplicated decompressive lumbar laminectomy of L5-S1. He tolerated the procedure well and recovered in general care. He was monitored closely throughout the hospitalization. His diet was advanced as tolerated. He was placed on Hydrocodone and Valium for pain control. He was evaluated by physical and occupational therapy and was eventually cleared for discharge. His exam was normal. His Hemovacs were discontinued. He was hemodynamically stable.
At issue is the medical necessity of an inpatient hospital stay.

The inpatient hospital stay was not medically necessary. The patient underwent a simple lumbar decompression at L5-S1 without complications, neurological deficits or hemodynamic instability. Given his Hemovacs, his obesity and ASA score of 3, his care could have been provided at a lower level. The InterQual Inpatient List notes that a one level lumbar laminectomy is an outpatient procedure. (1) This study reports a lower overall complication rate in the 30-day postoperative period following 1- and 2-level lumbar laminectomy performed in an outpatient versus inpatient setting. Significant risk factors for complications included body mass index (BMI) greater than (>) 30 kilograms per square meter (kg/m2), age greater than or equal to 55 years, a functional status of partially dependent, chronic obstructive pulmonary disease (COPD), chronic steroid use, American Society of Anesthesiologists (ASA) class 3 or 4, and operative time > 90 minutes. (2)
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis:  Psoriasis.
Treatment:  Sotyktu 6 milligrams (mg) per day.

The insurer denied coverage for Sotyktu 6 mg per day.  The denial is upheld.

The patient is an adult female with a history of psoriasis. The patient has failed topical triamcinolone and hydrocortisone 2.5% (percent) ointment as well as topical Vtama and tacrolimus. The patient has 15% Total Body Surface Area (TBSA) involvement. The requested medication is Sotyktu tablets. 

Based on the submitted documentation and the standard of care, Sotyktu is not medically necessary. The patient has failed topical therapy but has no true contraindications to numerous appropriate available formulary treatment modalities. There are no definitive, comparative, controlled head-to-head studies showing that Sotyktu has a superior efficacy or safety profile to reasonable alternatives such as Humira, Enbrel, Cosentyx, Stelara, Tremfya, or phototherapy. According to the American Academy of Dermatology Psoriasis Guidelines and dermatology literature, alternative effective treatments for the management of psoriasis are available and appropriate for this patient. 

There is no documentation to suggest that Sotyktu would be more effective than available formulary alternatives or that the patient has an absolute contraindication to a preferred medication which would specifically necessitate Sotyktu. 

The carrier's denial of request for formulary exception for Sotyktu 6 milligrams per day is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic low back pain.
Treatment: Pain injections (64483 x 1, 64484 x 1).

The insurer denied coverage for pain injections (64483 x 1, 64484 x 1).  The denial is overturned.

This patient has chronic low back pain. The patient takes Ultracet and Motrin and has done Physical Therapy. Physical exam is notable for positive straight leg raising test as well as cross straight leg raising text.  The patient had a transforaminal epidural steroid injection which produced years of pain relief. The request is to repeat the injection. 

The American College of Radiology (ACR) practice parameter (1) states the indication for an epidural steroid injection includes: "Radicular pain: single symptom of pain that can arise from one or more cervical, thoracic or lumbar spinal nerve roots which are inflamed and irritated...."  The patient has no contra-indication.

Similarly, the American Society of Interventional Pain Physicians (ASIPP) (2) has published evidence-based guidelines on epidural steroid injections. The evidence recommendations are as follows: "Disc herniation: Based on relevant, high-quality fluoroscopically guided epidural injections, with or without steroids, and results of previous systematic reviews, the evidence is Level I."

There is no evidence to support a time limit in performing epidural steroid injections. The practice parameters suggest between 4 and 6 per rolling 12-month period. An epidural steroid injection is medically reasonable and necessary for this patient.

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

The insurer's denial of coverage for pain injections (64483 x 1, 64484 x 1) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ulcerative Colitis
Treatment: Stelara 90 milligrams (mg) every 4 weeks
The insurer denied Stelara 90 milligrams (mg) every 4 weeks. The health plan's determination is overturned.

This patient is a male with a history of ulcerative colitis (UC). He has tried and failed numerous therapies, including mesalamine and infliximab. He was started on Stelara at the standard dose, 90 milligrams (mg) every 8 weeks. However, he did not respond adequately. His Stelara drug level was noted to be low. 

Stelara 90 milligrams (mg) every 4 weeks is medically necessary for this patient. Stelara is Food and Drug Administration (FDA) approved for the treatment of Crohn's disease and ulcerative colitis in adults. Despite the lack of FDA approval for pediatric patients, there are many peer reviewed publications supporting the efficacy and safety of Stelara in children with inflammatory bowel disease.

This patient has a history of refractory ulcerative colitis and has failed anti-tumor necrosis factor alpha and conventional therapy. The patient also failed to respond to Stelara standard dose (90 mg every 8 weeks) and is experiencing disease activity. Stelara drug level was noted to be low.
There are no other treatment alternatives. Therefore, escalation of Stelara to 90 mg every 4 weeks is appropriate and medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders/Other/Hyperhidrosis of Axilla
Treatment: Pharmacy/Prescription Drugs/Botox 200 Unit injectable solution reconstituted (IJ SOLR)

The health plan denied the Pharmacy/Prescription Drugs/Botox 200 Unit injectable solution reconstituted (IJ SOLR).  The health plan's determination is upheld.

The patient is a female with hyperhidrosis of the axilla. The patient also has acne and alopecia. The prescriber is a dermatologist.
The medication under review for medical necessity is Botox 200 Unit IJ SOLR.

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

The requested health service/treatment of Botox 200 Unit injectable solution reconstituted (IJ SOLR) is not medically necessary for this patient. Based on the evidence-based literature, the Botox 200 units is not medically necessary.

There are no comparative, controlled studies showing that Botox has a superior efficacy or safety profile to all the conventional alternatives. One such example is the conventional treatment Oxybutynin, which has been shown to be effective for hyperhidrosis. [1-3] Within the peer-reviewed literature, Schollhammer et al. writes in the paper "Oxybutynin as a treatment for generalized hyperhidrosis: a randomized, placebo-controlled trial," that "Treatment with low dose Oxybutynin is effective in reducing symptoms of hyperhidrosis in generalized or localized forms." [2] Wolosker et al. writes in "A randomized placebo-controlled trial of Oxybutynin for the initial treatment of palmar and axillary hyperhidrosis" that "Treatment of palmar and axillary hyperhidrosis with Oxybutynin is a good initial alternative for treatment given that it presents good results and improves quality of life." [3]

The conventional agents are appropriate agents for the treatment of the patient's hyperhidrosis. The conventional medications should be tried and failed prior to initiating Botox. After review of the documentation provided, there is no documentation provided that would justify the patient requiring treatment with Botox prior to the conventional alternatives, such as Oxybutynin.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Falls.
Treatment:  Inpatient admission.

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

This is a patient with chronic medical problems including peripheral neuropathy, status post a right below the knee amputation. He presented to the hospital for readmission due to multiple falls. Under review is the medical necessity of inpatient hospital admission.  

The enclosed clinical information does not support a level of medical acuity or complexity that warranted an acute inpatient hospital admission. There were no specific acute medical issues supporting the patient readmission. In an appeal letter it is noted that the patient underwent a recent below the knee amputation and subsequent discharge home. It was indicated that the patient was unable to safely manage at home and had returned to the hospital for further management and rehab placement. In the hospital Discharge Summary note the physician assistant also noted that the patient was readmitted for rehab placement.  However, the most clinically appropriate level of care and treatment would have been provided at a lower level of care such as a skilled nursing facility with subacute rehabilitation, rendering admission to the hospital not medically necessary.

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

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary tract infection (UTI).
Treatment:  Inpatient admission.

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

This patient has a history of cardiovascular disease (CV), hyperlipidemia (HLD), and recurrent urinary tract infections (UTI's). The patient presented to the emergency department (ED) with complaints of intermittent hematuria and a UTI. The patient was treated with Macrobid for his urinary tract infection (UTI) and later developed recurrent dysuria and hematuria. A computed tomography (CT) scan revealed left renal duplication but no calculi or hydronephrosis or perinephric fluid collection. 

The patient was admitted for further management by Infectious Disease (ID) and Urology. An outpatient urine culture was positive for extended-spectrum beta-lactamases (ESBL) Escherichia coli (E. coli) urinary tract infection, and the patient was started on intravenous meropenem in the emergency room. The patient's symptoms improved, and he was discharged. 

The insurer has denied coverage for the inpatient admission as not medically necessary. They noted the patient was in no acute distress, had no serious medical comorbidity, or metabolic reason for an acute level of care (LOC). The medical care could have been provided in the observation setting. The appeal on behalf of the hospital is noted and read in detail. 

Per MCG (Milliman Care Guidelines) Health (25th Ed.) guidelines

I.	UTI-RRG; the patient fails to meet indications for admission. There was no hemodynamic instability, no presentation or worsening of clinical findings despite observation care, no altered mental status, no ureteral obstruction (stone)

II.	Urologic Disease GRG- the patient fails to meet guidelines for an admission under subsection "gross hematuria requiring inpatient care."

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient admission services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain.
Treatment: Inpatient stay.

The insurer denied the inpatient stay. The health plan's determination is upheld.

This is a case of a male admitted for a diagnosis of chest pain. The patient presented with symptoms of chest pain and had been previously evaluated for similar symptoms. Troponin was minimally increased and an electrocardiogram (EKG) had new T-wave inversions. He was planned to undergo cardiac catheterization, but left against medical advice. Vital signs demonstrated blood pressure 153/96, pulse 74, temperature 98.9F, respiratory rate 19, and O2 (oxygen) saturation 99%. Physical exam showed no acute distress or altered mental status. Sodium was 132 with creatinine kinase 205. Troponin was 0.06. Brain (or B-type) natriuretic peptide (BNP) was 67. 

The inpatient admission was not medically necessary. The patient in this case was admitted for symptoms of chest pain but did not have a life-threatening cause identified such as acute coronary syndrome, dissection, pulmonary embolism, pneumothorax, tamponade, or mediastinitis. He was found to have a mildly elevated troponin during this admission but was also admitted for chest pain and troponin elevation the week prior. His troponin during this current visit was actually lower than the week prior (0.06 versus 0.1). He was evaluated by cardiology who felt that he required treatment for hypertensive urgency. He was not diagnosed with hypertensive emergency.

He did not have hemodynamic instability or hypoxia. He also was evaluated for right lower extremity tenderness and ultrasound showed a fluid collection. He was evaluated by vascular surgery, and they determined he did not require procedural intervention. There was no fever or leukocytosis and so he was simply treated with ibuprofen. There was no deep vein thrombosis of the lower extremity.

Although the patient required services in the hospital setting the monitoring, diagnostics testing and therapeutic interventions prescribed could have been rendered at a lower level of care.