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

Diagnosis: Digestive System/Gastrointestinal-Cholecystitis/Inflammation of the Gallbladder
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 determination.

The patient presented to the hospital emergency department (ED) with upper abdominal pain. He had recently been admitted at another hospital with acute pancreatitis. Comorbid health conditions included recent pancreatitis, prior deep vein thrombosis (DVT), pulmonary embolism, gastroesophageal reflux disease (GERD), rectal cancer, and bipolar disorder. He was being treated with Eliquis. At the time of presentation the patient was without fever and vital signs showed a heart rate of 80 beats per minute and blood pressure of 130/86 millimeters of mercury (mmHg). He was tender in the upper abdomen. The white blood cell (WBC) count was elevated at 17.19 thousand (K). The complete metabolic panel identified normal serum transaminases. Bilirubin was normal. Amylase and lipase were normal. Ultrasound showed gallstones. A computed tomography (CT) scan identified findings of cholecystitis. He was initially treated with intravenous (IV) fluid and antiemetics. Surgical consultation was obtained. The WBC count was down to 10 K on the following day. The patient underwent laparoscopic cholecystectomy. The submitted records indicate an uncomplicated surgical procedure.
The patient was treated with post-surgical monitoring, IV fluid, and IV analgesia. The immediate post-surgical recovery was uncomplicated. Following the operation, the patient had stable vital signs. The diet was advanced. He was discharged from the inpatient setting. 

An inpatient level of care was not medically necessary in this case. This patient  presented to the ED with abdominal pain and nausea. Evaluation identified gallstones and cholecystitis. He was hemodynamically stable at the time of presentation. The WBC count was elevated at presentation but normalized the following day. Serum chemistries were normal. An uncomplicated cholecystectomy was performed The patient remained hemodynamically stable during the period of pre-surgical care, during surgery, and during the period of post-surgical monitoring. There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care at the time of presentation. There were no peri-operative complications or other clinical issues that mandated inpatient care. A lower level of care status would have allowed for overnight monitoring, confirmation of clinical stability, cholecystectomy as performed and post-surgical monitoring until discharge. This lower level of care would have been consistent with generally accepted standards of care.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male with a history of hammertoes who was admitted to the hospital. He presented to the emergency department from wound care for a postoperative infection. He underwent arthroplasty involving the fourth and fifth digits of the left foot with lateral mid hemi-phlagectomy. Two days prior to presentation, he developed pain and redness of the fifth toe. He also reported chills. Vital signs showed temperature 98 Fahrenheit, heart rate 78, and blood pressure 130/80. On physical exam, the left foot had sutures in place and was erythematous, but there was no draining. Labs showed white blood cell count (WBC) 7.1, hemoglobin 16.4, platelets 259, sodium 136, potassium 4.2, creatinine 0.8, and glucose 104. The patient was admitted for left foot cellulitis. 

The inpatient hospital admission was not medically necessary.
The patient was admitted with cellulitis and a postoperative wound infection. However, there was no evidence of a complicated infection. The infectious disease service did not note concern for necrotizing fasciitis, sepsis, involvement of deep tissues, or bacteremia. Treatment involved IV (Intravenous) antibiotics which were later converted to oral antibiotics. The patient needed further care, but the acuity was not consistent with the inpatient level of care.
The patient had a stable presentation with no evidence of sepsis, uncontrolled pain, complex infection involving abscess formation, or bacteremia. Further care with infectious disease consultation and podiatry consultation was appropriate but could have been safely and effectively provided at a lower level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder-pain in the left occipital region.
Treatment: Surgical Services. 
The insurer denied nerve stimulator. 
The denial is overturned. 

The patient is a male with a complex past medical history who is now complaining of severe pain in the left occipital region. He underwent a posterior fossa decompression for Arnold-Chiari malformation and subsequently underwent a revision decompression and placement of a ventriculoperitoneal shunt (VPS). He then had an occipital to cervical (C) fusion. After this surgery he experienced severe left occipital pain, that was diagnosed as occipital neuralgia (ON). He had a left occipital neurectomy which gave his several years of symptom relief, but the pain gradually recurred. A neuropsychological evaluation was undertaken and reported no issues that would negatively affect the outcome of a stimulator trial. The subject under review is the medical necessity of peripheral nerve stimulation (PNS) for occipital neuralgia.

The health plan's determination is overturned.

The nerve stimulator is medically necessary for this patient.
The information provided for review includes conservative treatments attempted by the patient as well as numerous imaging studies. This includes:
Documentation that the patient has tried numerous injections in addition to medications. They reassert that patient has had an occipital neurectomy already and that procedure cannot be repeated.

Multiple imaging reports of the brain and cervical (C) spine including magnetic resonance imaging (MRI) of the C spine, computed tomography (CT) of the C spine, MRI of the brain with and without contrast, CT scan of the brain  and dynamic cervical radiographs from  provided, all of which documents the prior posterior fossa decompression and intact occipital to C4 fusion without hardware issues, cervical instability or brain or spinal cord compression other than focal tenting of the left side of the spinal cord at C2, stable from a cervical MRI scan from. No mention of hydrocephalus is included in the reports. In addition, the recent shunt series  documents that the distal tubing of the shunt is disconnected and located in the pelvis, substantiating the patient's report that the shunt is non-functional and apparently has been for some time. 
At this point it does appear that the patient has indeed tried adequate conservative therapeutic attempts with the multiple injections and medication trials and does not have other complicating features such as cervical instability, recurrent cervical or craniovertebral compression, hydrocephalus or pseudarthrosis of the prior occipital to C4 fusion. Given that he had a good result from his occipital neurectomy but has recurrent pain without clear reconstitution of the occipital nerve on ultrasound that might be amenable to another neurectomy procedure, the request for an occipital region stimulator trial is both the most appropriate and least invasive, given its reversibility, procedure in the next step to try and provide this patient with symptomatic relief.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain and Palpitations.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.

The denial is upheld. 

The patient, a male, has a past medical history significant for stress induced tachycardia, psoriasis, obesity and tobacco abuse.  The patient presented for evaluation of tachycardia after shoveling snow.  

The patient was found to have sinus tachycardia. Electrocardiogram (ECG) revealed no ischemic changes. Initial troponin was 0.087, repeat troponins were normal. Chest x-ray (CXR) was unremarkable. The patient was treated with Verapamil for sinus tachycardia. No inpatient ischemic work-up was planned and the patient was planned for outpatient cardiology follow-up.

No, the proposed inpatient admission was not medically necessary.

The patient presented with sinus tachycardia. The blood pressure was stable. There was no evidence of acute myocardial infarction, acute coronary syndrome (ACS), decompensated congestive heart failure (CHF), malignant arrhythmia or hemodynamic instability. Although the initial Troponin level was mildly elevated, the repeat levels were normal. The patient improved clinically with intravenous (IV) fluids and verapamil and was discharged home with a plan for outpatient follow-up. 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 a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal-Knee problem/pain
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.

This is a case of an obese male patient admitted to the hospitalFebruary  for a diagnosis of acute onset left knee pain. The patient presented with chief complaint of acute onset left knee pain in the setting of trauma. Vital signs showed blood-pressure 127/77, pulse 79, temperature 98.1F, respiratory rate 22 and oxygen (O2) saturation 97% on room air. Physical exam showed lateral right foot tenderness to palpation and left knee without erythema, lesions, or deformities. X-ray of the right ankle showed no fracture or dislocation. X-ray of the right foot showed no fracture or dislocation. X-ray of the left knee showed an irregularity of the tibial plateau and posterior tibia with large suprapatellar joint effusion. Orthopedic surgery consult was requested. Orthopedic surgery and musculoskeletal radiology reviewed the computed tomography (CT) imaging of the knee and it was determined that there was no injury to bone, tendon, or ligament. The patient was recommended to be treated with a hinged knee brace and was scheduled to have outpatient follow-up with orthopedic surgery. 

Medical necessity of an acute inpatient admission has not been established. 
According to Up-to-date, 2019:
"Trauma - Trauma sufficient to cause joint pain and swelling is typically recollected by the patient. However, if a loss of consciousness (e.g., due to a drug overdose, motor vehicle accident, alcohol ingestion, or concussion) has occurred, the patient may not remember injuring the joint. Thus, if there is a history of joint injury or loss of consciousness, initial immobilization, and imaging studies to rule out a fracture or dislocation are appropriately obtained before proceeding with a thorough physical examination of the joint.
Intraarticular fractures, dislocations, ligamentous sprains, and complete tears (e.g., of the anterior or posterior cruciate ligaments of the knee), and meniscal damage are often associated with hemarthrosis. Intraarticular bleeding may also be related to coagulopathies, anticoagulation therapy, intraarticular tumors, and crystal disease, among other causes. (See "Overview of hemarthrosis".)"
The patient in this case did not have loss of consciousness, fracture, dislocation, or ligamentous sprain. There was no complete ligament tear or meniscal damage. There was no hemarthrosis, intra-articular bleeding, coagulopathy, anticoagulation therapy, intraarticular tumor, or active crystal disease.
Although the patient had needs best addressed in the hospital setting the monitoring, diagnostic workup and therapeutic interventions prescribed could have been safely administered at a lower level of care. Therefore, medical necessity of admission has not been established.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis.
Treatment: Consumer Directed Personal Assistance Services (CDPAP).
The insurer denied Consumer Directed Personal Assistance Services 49 hours a week. 

The health plan's determination is overturned. 

The patient is a female with past medical history of coronary artery disease, urinary incontinence, diabetes mellitus type 2, hypertension, gastroesophageal reflux disease (GERD), hypothyroidism, low back pain with sciatica, osteoarthritis, chronic knee pain, and osteoporosis who had been assigned Consumer Directed Personal Assistance Services 49 hours/week. The patient had seen his PCP (primary care provider) multiple times with notes stating the patient had a stroke, ambulated with a walker, and had severe intractable bilateral knee pain. The patient was trialed on Lyrica and diclofenac for pain. An office visit noted the patient had a fall and PT (physical therapy) had helped minimally. The patient's provider filled out DOH (Department of Health) 4359 stating the patient was dependent with activities of daily living (ADL) with a goal to keep her independent with ADLs. The completed form also stated the patient needs more hours and needs home physical therapy (PT) due to motor impairment, poor range of motion, and reduced stamina.

The Consumer Directed Personal Assistance Services: Total of 49 Hours per Week are medically necessary for this patient.

There is documentation of the patient's chronic progressive medical conditions of osteoarthritis, low back pain with sciatica, and cerebrovascular accident (CVA). The patient has tried multiple medications and therapies for her chronic pain as per notes from her PCP (primary care provider). The assessment tool provided by the insurer noted the patient requires at least extensive assistance with all activities of daily living (ADL) / Instrumental activities of daily living (IADL) except bed mobility and eating. The patient has unpredictable and unscheduled care needs over a continuum of time and the insurer failed to document a plan to meet those unpredictable and unscheduled care needs. The patient's care needs cannot be met with current hours and/or adaptive equipment and/or medical supplies. The patient's PCP has documented escalating pain and limited mobility with worsening osteoarthritis (OA) symptoms. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAP services 7 hours/day, 7 days/week, to total 49 hours/week are medically necessary for this patient. Personal care services are medically necessary under when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anterior crossbite of a lower canine.
Treatment: D8080 Braces and Monthly Visits, Pre-service.
The insurer denied the D8080 Braces and Monthly Visits, Pre-service.
The denial is overturned.

The patient is a female with an anterior crossbite of a lower canine.  The request is for orthodontic benefits.

Yes, the proposed braces and monthly visits are medically necessary.
The patient has an anterior crossbite (her lower canine) with recession of the gums and loss of attachment (gums). This is an automatic qualifier according to the handicapping index scale. This needs to be corrected with orthodontic treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status post anesthesia. 
Treatment: Inpatient admission. 

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

The patient is a female who underwent an exam under anesthesia, diagnostic and operative laparoscopy, resection of endometriosis, left ovarian cystectomy, insertion of a MIRENA intrauterine device (IUD), and dilation and curettage (D&C). The patient was admitted after the procedure and discharged to home the following day. 

No, the proposed treatment was not medically necessary. 

The proposed admission is not medically necessary given that the procedure is an outpatient procedure, the patient did not require conversion to laparotomy, and the surgery was uncomplicated.  In addition, after the procedure the patient had stable vital signs, a non focal exam, and was able to ambulate and tolerate an oral diet and oral medications. The patient did not have conditions that required inpatient level of care and the admission is not supported by peer reviewed data, it is not standard of care and it is not supported by professional organizations.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alopecia.
Treatment: Xeljanz (Pre-Service).

The insurer denied the Xeljanz (Pre-Service). The denial is overturned.

The patient is a female with severe alopecia areata that has failed topical, intralesional, and systemic steroids. She is severely depressed because of her condition. Xeljanz is requested.

The current literature reflects Xeljanz as being more effective than other treatments.

Alopecia areata (AA) is a relatively common disease, but no satisfactory treatment has yet been developed. Recently, research progress has been made in the pathogenesis of alopecia areata, revealing that autoreactive cytotoxic T cells are important and that the Janus kinase (JAK) pathway is involved. Therefore, the potential of JAK inhibitors as therapeutic agents for alopecia areata is attracting attention. There have been a number of case reports and small clinical trials reporting promising outcomes of JAK inhibitors tofacitinib, ruxolitinib and baricitinib for alopecia areata. The majority of the literature to date is based on small volume data, with a lack of definitive evidence or guidelines. 

A retrospective study of 90 adults with severe alopecia areata (at least 40 percent scalp hair loss, alopecia totalis, or alopecia universalis) who had stable or worsening disease for at least six months and received oral tofacitinib (five to ten milligrams twice daily) for at least four months (with or without adjuvant prednisone) supports benefit. Of the 65 patients with a duration of the current disease episode of ten years or less, 77 percent had a clinical response (at least six percent improvement in the Severity of Alopecia Tool [SALT] score) and 58 percent achieved greater than 50 percent improvement in the SALT score over four to 18 months of treatment. Patients with a disease episode longer than ten years appeared less likely to respond to treatment; the clinical response rate in this population was 32 percent (eight of 25 patients). No serious adverse effects occurred during treatment.

There is promising low-quality evidence regarding the effectiveness of JAK inhibitors in alopecia areata. Future large-sized randomized studies are required to confirm findings. However, of all the treatments reported to work in alopecia areata, JAK inhibitors have the most promising results to date. Because of the potential for serious adverse effects with JAK inhibitors, including infection and malignancy, a thorough discussion of risks and benefits is necessary before the initiation of treatment. This is an accepted off label use and dose for the treatment of alopecia areata based on the literature.

Therefore, given the above, Xeljanz is the best treatment option for this patient at this time.

The current literature reflects Xeljanz as being more effective than other treatments. Therefore, given the above, Xeljanz is the best treatment option for this patient at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems (tooth #18).
Treatment: Tooth colored cap (crown) for tooth #18 and other preventive services.

The insurer denied coverage for a tooth colored cap (crown) for tooth #18 and other preventive services. The denial is upheld. 

This is a female patient with a history of diabetes. She presented to the dentist for comprehensive care. The treating dentist recommended full coverage crown for tooth number (#) 18. The insurer has denied these services stating the there is a normal complement of teeth with posterior occlusion, and further there is no clinical/ radiographic evidence, such as traumatic injury or decay, provided to support the necessity of these services; therefore, the services do not meet medical necessity criteria. The patient is appealing.

The objective documentation provided for review is a copy of poor quality full mouth series radiographs. It appears that there is no evidence of fracture or other pathology specifically affecting tooth #18 based on the images provided for review. There does not appear to be any radiographic evidence of caries. The radiographs do not substantiate the requested dental services as enumerated above and therefore the crown is deemed not medically necessary.

Uphold denial of coverage for a tooth colored cap (crown) for tooth #18 and other preventive services as not medically necessary, as the documentation is insufficient to justify or substantiate the treatment.

The healthcare plan acted reasonably, with sound medical judgement and in the best interest of the patient.

The insurer's denial of coverage for a tooth colored cap (crown) for tooth #18 and other preventive services is upheld.  Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Symptomatic Anemia.

Treatment: Full Hospital Admission.

The insurer denied coverage for full hospital admission.

The denial is overturned.

The patient is a male with a past medical history of iron-deficiency anemia, gastrointestinal bleed, prostate cancer, and anxiety.  The patient presented to the emergency department with a chief complaint of anemia.  The patient's blood pressure was 123/59.  The patient complained of chills, malaise, and fatigue.  He complained of dyspnea, diarrhea, and melena.  His hemoglobin level was 4.7.  He was guaiac negative.  The chest x-ray was normal.  The patient was treated with intravenous fluids.  He was admitted with symptomatic anemia.  He was in stable condition on admission.  The admitting diagnosis was acute on chronic severe symptomatic anemia in the setting of likely gastrointestinal bleed.  The patient received 2 units of packed red blood cells.  The patient underwent a gastroenterology consultation.  The gastroenterologist recommended the patient undergoes a possible colonoscopy, endoscopy, or capsule endoscopy after his laboratory studies returned to normal.  He was given intravenous iron and fluids.  His repeat hemoglobin was 8.  The patient was subsequently discharged in stable condition.

The full hospital admission is considered medically necessary for this patient.

The patient had profound symptomatic anemia with history of small bowel arteriovenous malformations (AVMs) requiring intervention.  There was history of hematochezia just days prior to admission. He also had significant psychiatric co-morbidity in the form of suicidal ideation.

He needed packed red blood cell transfusion, evaluation, and treatment of the bleeding lesions as well as management of suicidal risk. These could not be achieved without inpatient admission.  The patient fulfills criteria for inpatient admission. 

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 the full hospital admission is reversed. Medical necessity is substantiated.