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

Diagnosis: Crohn's disease

Treatment: Inpatient admission and medication managment

The insurer denied inpatient admission. That denial was upheld

The patient had ulcerative colitis and previously underwent a total colectomy and ileostomy.  He subsequently had multiple bouts of pouchitis.  It was then determined that the disease was most likely Crohn's disease.  He did not respond to Humira.  He has had increased output from the ileostomy, abdominal pain, and nausea.

Clinical indications for admission for Inflammatory Bowel Disease (MCG M-565) include hemodynamic instability, abdominal abscess, fistulas, toxic megacolon, intestinal perforation, and intestinal obstruction.  The patient did not have these conditions.  He had dehydration, but it was not persistent and it responded to IV hydration.  He did not have a three-fold rise in serum creatinine.  There was no need for a drainage procedure, total parenteral nutrition (TPN), or urgent surgery.

This patient had increased output from his ileostomy.  There was a concern that he could have enteritis.  However, the dehydration and symptoms improved with IV hydration.  He had inflammatory bowel disease (IBD), but did not have obstruction or require any surgical intervention.  He did not meet MCG criteria for admission for Inflammatory Bowel Disease.  He could have been managed with Observation status.
Appeal type: Experimental/Investigational
Decision: Overturned

The patient with history of tobacco use presents with headache and chronic neck and right arm pain. The patient has had four cervical surgeries in the past including 3 anterior with fusion and 1 posterior surgery. Patient uses hydrocodone-acetaminophen 10-325 four times a day (qid) as needed (prn) and Cyclobenzaprine 5 milligrams (mg) three times a day (tid) prn. The patient has undergone a trial of physical therapy, chiropractic care, occipital nerve block and cervical injection therapy with no relief of symptoms. Request has been made for occipital nerve stimulator placement. The health plan's determination is upheld.

The patient has a very complex history of cervical surgery with multiple co-morbidities. The etiology of patient's symptoms including headaches are most likely multifactorial. The patient presents with headaches and neck and arm pain and does not represent the typical occipital neuralgia patient. Occipital nerve stimulator and generator placement has been used for intractable occipital neuralgia but systematic review of the literature by the Congress of Neurological Surgeons at best concluded it to be a level III recommendation. The procedure is an option for a select group of patients with intractable occipital neuralgia but would be considered experimental and investigational particularly in this patient. Review of the literature does not support the requested procedure.
Appeal type: Experimental/Investigational
Decision: Overturned

The patient has a history of postlaminectomy syndrome. The request is for an occipital stimulator trial for cervicalgia and paresthesia of skin. This was denied due to lack of information from well-designed studies in peer reviewed medical journals that show that the device improves long term outcomes. The health plan's determination is overturned. 
The occipital nerve stimulator would be more beneficial than any other standard treatment since for this patient who has failed an exhaustive course of conservative treatment. Studies show it is safe and effective for the patient's condition.
The Congress of Neurological Surgeons published an evidence-based guideline supporting the use of occipital nerve stimulation as a treatment option for patients with medical refractory occipital neuralgia. The patient population in the nine studies reviewed was small and there was a short duration of follow-up. Class III evidence: Level III recommendation (Evidence from case series, comparative studies with historical controls, case reports, and expert opinion, as well as significantly flawed randomized, controlled trials). 
The patient has occipital neuralgia from multiple cervical surgeries. The Congress of Neurological Surgeons concludes that occipital neurostimulation is a treatment option for patients with medically refractory occipital neuralgia.
Appeal type: Experimental/Investigational
Decision: Overturned

The patient has chronic migraines and has undergone over 100 injections and needle placements for migraines as well as many medications for pain. The patient also attempted physical therapy twice per week for 3 weeks without improvement. Pain follows the occipital nerve distribution. The patient takes opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and muscle relaxants for pain. Physical exam reveals 5/5 strength throughout. X-rays show trace retrolisthesis at C2-3. The patient was recommended occipital nerve stimulator. The health plan's determination is overturned.

The occipital nerve stimulator is likely to be more beneficial than any standard treatment for this patient.
The patient has occipital neuralgia which is a very difficult to treat disease process. It is extremely painful, can cause debilitating headaches, and can affect activities of daily living. The patient has attempted an adequate trial of multimodal therapy including PT, injections, among others. These have all failed to provide any benefit and it is unlikely that further treatments will provide a significant amount of improvement based upon history.

The use of occipital nerve stimulation has become more and more accepted and is considered within the standard of care for patients with refractory occipital neuralgia. The use of occipital nerve stimulator in this case is also supported by the literature. The patient's clinical symptoms correlate with neuralgia, and the proposed surgery has been shown to improve outcomes and therefore would be considered to be more beneficial than the standard treatments which the patient has already failed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain, past medical history of hypertension, diabetes
 
Treatment: Inpatient admission

The insurer denied the hospital admission. The denial was upheld

This woman was seen in another Emergency Department (ED) earlier that week for an upper respiratory and/or ear infection per records and was discharged on Levaquin.  On the morning of presentation she developed intermittent chest pressure associated with cough with clear sputum.  Emergency Medical Services (EMS) arrived at 16:00, with initial vital signs that included a blood pressure of 151/81, a heart rate of 79, a respiratory rate of 18, and an oxygen saturation on room air of 91%.  Vital signs in the ED triage area at 16:43 included a blood pressure of 164/102, a heart rate of 74, a respiratory rate of 18, an oxygen saturation of 94% and a temperature of 98.4F.  An EKG at 17:00 on Day 1 revealed normal sinus rhythm, with left axis deviation and small R waves in V2-4.  Laboratory test results included a white blood cell (WBC) count of 5.0, a hemoglobin of 15.3, a creatinine of 0.81, and a troponin of 0.00, with a subsequent troponin also 0.00 at 22:50. A CT scan of the chest and upper abdomen with contrast revealed only a small hiatus hernia.   A chest x-ray was also unremarkable.  Chest discomfort resolved by the time of admission, and she was seen by a Gastroenterology (GI) consultant who recommended an EGD (esophagogastroduodenoscopy) and barium swallow as an outpatient.  Prilosec was added to her regimen.

There was no evidence that this patient required an acute inpatient level of care to determine that her chest discomfort was not related to acute coronary syndrome.  This could have been completed in the ED or an observation level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:Chest Pain 

Treatment: Inpatient stay

Summary:
The medical records indicate that this patient was admitted to the inpatient medical service in stable condition where he received symptomatic management with prn analgesics and supportive care with IV fluids and continued cardiac monitoring. He responded well to the prescribed therapies and was subsequently discharged in stable condition. There is no evidence of intensification of services throughout the course of this patient's hospital stay. Hence, patient's care could have been safely furnished in a less intensive setting without adversely affecting patient's safety or outcome
Appeal type: Medical necessity
Decision: Upheld

The patient with history of (h/o) hypertension (HTN), hyperlipidemia (HLD), and a craniotomy for an aneurysm, was admitted after an episode of self-limiting resting chest pain. Vital signs were normal, troponins were negative, the electrocardiogram (ECG) was non acute with a QTc interval of 535 msec (reported as unchanged from prior ECG), and electrolytes were normal. A urine drug screen(UDS) was positive for cocaine and marijuana. An echocardiogram demonstrated a normal left ventricular ejection fraction (LVEF). The patient remained stable and was discharged.
The health plan's determination is upheld.

This patient presented with chest pain and remained stable. There was no congestive heart failure (CHF), respiratory distress, or ongoing symptoms suggestive of angina or angina equivalent. The patient was without severe arrhythmia, hemodynamic instability, or suspicion of another serious cause for chest pain, such as a pulmonary embolism (PE) or aortic dissection. The patient did not require prolonged intravenous (IV) medications or oxygen support, or introduction of high risk medications requiring ongoing in-hospital monitoring. There was a lack of supporting evidence for an acute coronary syndrome such as elevated cardiac biomarkers or an abnormal ECG. In the setting of this case an acute inpatient level hospitalization, compared to for example a lower level of care status, has not been established as standard of care towards improved cardiac outcomes. It is therefore considered not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: COPD
Treatment: Inpatient admission

The proposed treatment was medically necessary.

The patient was in moderate respiratory distress at the time of emergency room evaluation. The patient was hypoxic to 86% on room air, and tachypneic as well as tachycardic during emergency room care. At the time of admission, the patient was hemodynamically stable, but had diffuse wheezing on lung exam. The patient's blood gas revealed evidence of acidosis, with hypercapnia and hypoxia. The patient continued to have respiratory distress despite emergency room care. The patient was at high risk for impending respiratory failure due to severe COPD exacerbation. Since the patient had tried and failed emergency room care, and had high risk for impending respiratory failure, the acute in hospital level of care was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of a cerebrovascular accident (CVA) hypertension, remote history of heroin abuse, currently in remission with treatment on methadone, history of pulmonary embolus status/post (s/p) inferior vena cava (IVC) filter, who presented to the emergency department with nausea, nonbilious vomiting, and chest pain. The symptoms started while she was asleep, and had lasted for 2 hours prior to presentation to the emergency department.  The health plan's determination of medical necessity is upheld in whole. The patient presented to the hospital with chest pain for rule out acute coronary syndrome. Cardiac enzymes were negative. Thrombolysis in myocardial infarction (TIMI) score is 1. The echocardiogram showed no wall motion abnormalities. Typically a stress test would be performed for this type of presentation, and if negative, further outpatient follow-up. There was no indication for this patient, to be admitted under inpatient status based on the supplied documentation. It is the standard of care, to treat this type of presentation at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a past medical history significant for obesity, asthma, and tobacco dependence, who presented to the emergency department with a chief complaint of shortness of breath, mild chest pain, and a cough after a long car trip.
The health plan's determination of medical necessity is upheld. Acute inpatient admission was not medically necessary for this patient. This patient presented with shortness of breath and chest pain and CT angiogram with evidence of pulmonary embolism. She did have associated hypoxia or other hemodynamic instability, arrhythmias, concomitant bleeding making initiation of anticoagulation higher risk, require tPA or thromboectomy, or have other process requiring inpatient admission. Observing this patient in the hospital for arrhythmias, in addition to obtaining duplex of the lower extremities, TTE, and initiating her on anticoagulation was appropriate, but inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Systemic Lupus Erythematosus
Treatment: Pharmacy/Prescription Drugs 

Summary: This patient has a history of SLE (systemic lupus erythematosus) with features of RA (Rheumatoid Arthritis). She has an inflammatory arthritis with Raynaud's, for which she takes Procardia. She has positive antinuclear antibodies (ANA) and anti- deoxyribonucleic acid (DNA). She has used Enbrel, Imuran, sulfasalazine and Humira in the past. Xeljanz was stopped and Actemra was given. She is also on Rayos and Plaquenil. She had surgical closure of an atrial septal defect (ASD) in 2019. She stopped Rayos and began Acthar Gel twice a week in 2019. As of a visit in 2019, she was on Plaquenil, Actemra and Acthar Gel. She was noted to be doing much better and the plan is to increase Acthar to three times per week.
  
The insurer has denied coverage for Acthar injection 80 units every three days as not medically necessary. The denial was upheld. 

Acthar works by stimulation of production of endogenous steroids, and therefore a similar pattern of toxicity would be expected. Using Acthar does not prevent possible corticosteroid toxicity, including in a patient who has already been on oral steroids. It also has probable other mechanisms of action, as well. The labeling is non-specific and provides no criteria that help determine a "selected" case. An UptoDate search finds no reference to the use of Acthar in the treatment of SLE or RA. Large trials that clarify the benefit/toxicity of Acthar, or that clarify when to use it are not found. Acthar injections 80 units every 3 days are not medically necessary for this patient. The labeling and literature do not provide guidelines as to when Acthar is appropriate, and risk/benefits are not clear. Treatment guidelines do not address its use. There is no basis for determining that Acthar is any better/safer than a dose of corticosteroids adjusted for disease activity. There is no documentation that supports the use of Acthar Gel as a standard of care in the treatment of SLE. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic maxillary Sinusitis, Chronic ethmoidal sinusitis, Nasal turbinate hypertrophy and Nasal septal deviation 

Treatment: Inpatient admission for septoplasty, sinus surgery and inferior turbinate reduction. 

The insurer denied the coverage. The denial was upheld.

This female patient was admitted with current diagnosis of chronic maxillary sinusitis, chronic ethmoidal sinusitis, nasal turbinate hypertrophy, nasal septal deviation, and acute recurrent pansinusitis.  The patient had previously been treated with Singulair, Flonase, and had a poor reaction to antihistamines. The CT scan in late 2018 revealed an anterior nasal septum deviated to the right.  The maxillary crest was deviated to the left and the posterior nasal septum was deviated to the right.  There was a nasal septal spur seen deviating to the right and making no contact.  There was flattening of the tegmen ethmoidalis on the right.  There were no foci of abnormal mucosal thickening along the maxillary sinus ostium or ethmoid infundibulum.  There were no foci of abnormal mucosal thickening along the sphenoid ethmoidal recess.The patient underwent a nasal endoscopy and had been using a saline mist.  The patient had bilateral facial pressure, and nasal obstruction without anosmia.   

The medical literature supports that nasal obstruction caused by nasal septal deviation and hyperplastic turbinates is one of the most common Ear Nose & Throat (ENT) problems. Septoplasty with reduction of hypertrophic nasal turbinates is considered standard treatment. Septoplasty with bilateral sub-mucous diathermy (SMD) is effective and significantly improves patient symptoms.  The medical literature indicates that endoscopic sinus surgery in adults is considered medically necessary for patients with recurrent or chronic rhinosinusitis who have objective evidence of disease by endoscopic and/or CT imaging that is refractory to medical treatment which may include nasal saline, intranasal/oral steroids, oral/topical antimicrobials, and/or antibiotics.  The areas that are to be treated during the endoscopic sinus surgery depend on the areas of disease involvement. 

The insurer approved the patient for a septoplasty and turbinate reduction.  However, the records submitted for review failed to support the patient had objective findings, by physical examination and/or by CT scan to support the necessity for a total ethmoidectomy and maxillary antrostomy.  There was no disease noted in the ethmoids or maxillary sinuses by CT scan or examination.  If these procedures would have been appropriate, the stereotactic computer-assisted surgery would be appropriate.  If the surgical intervention in its entirety was approved, the patient may have been appropriate to undergo the debridement post-operatively.  The performance of debridement(s) would be dependent upon physical examination findings at the time of evaluation.
Appeal type: Medical necessity
Decision: Upheld

The patient presented to the ER with severe neck pain and right upper extremity pain. She was admitted for an anterior cervical discectomy and fusion. The health plan denied the inpatient hospital admission as not medically necessary. The health plan's determination is upheld. An inpatient hospital stay was not medically necessary as the patient could have been treated at a lower level of care as she did not have progressive or severe neurological deficits that would require urgent to emergent surgical intervention.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right lower extremity pain and swelling
Treatment: Inpatient admission
The proposed treatment of inpatient admission is not deemed medically necessary. 
This male patient presented to the ER for further evaluation/management of right lower extremity pain and swelling. Intake vitals were afebrile; the patient was hemodynamically stable with no evidence of febrile temperature, malignant hypertension, profound hypotension, severe tachycardia or hypoxemia on room air. Examination was notable for right lower extremity edema, erythema and skin breakdown. There were no other significant abnormalities noted including no evidence of acute cardiopulmonary abnormalities. Laboratory and ECG testing was without evidence of critical abnormalities including no evidence of acute end organ damage. 
The medical records indicate that this patient was admitted to the inpatient medical service in stable condition where he received treatment with broad spectrum IV antibiotics and supportive care with IV fluids and local wound care. He responded well to the prescribed therapies and was subsequently discharged in stable condition. There is no evidence of intensification of services throughout the course of this patient's hospital stay. Hence, the patient's care could have been safely furnished in a less intensive setting without adversely affecting patient's safety or outcome. Hence, the proposed treatment of inpatient admissionis not deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cross bite of her upper right canine
Treatment: D8080 - Braces, D8670 - monthly visit x 12

Summary:
Braces and monthly visits x 12 are medically necessary. 
The patient has a cross bite of her upper right canine. When there is a cross bite like this and there is clinical attachment loss (gum loss) and recession of the gingival margins, this is an "automatic qualifier" for benefits as stated on the HLD index report. With this type of cross bite, there will be continual trauma and fractures to the teeth on the right side due to the teeth banging into one another. The only way to correct this is with orthodontic treatment. This patient's need for orthodontic treatment is a medical necessity.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lingually erupting (ectopic) tooth 

Treatment: Comprehensive and periodic orthodontic treatment

Summary:
Orthodontic treatment is medically necessary. The patient has his upper right lateral incisor erupting severely palatally (behind) to the other upper front teeth. This will continue to be a hygiene problem forever since it will be difficult to keep all the teeth in that area clean. The gum between the teeth will always be inflamed because of this situation, which could lead to a periodontal problem. Orthodontic treatment is needed to re-position this tooth, #7, into its correct place.
Appeal type: Medical necessity
Decision: Overturned

The patient was  referred by his outpatient mental health providers for residential mental health treatment to address a longstanding behavioral disturbance in the context of mood and anxiety disorders associated with impaired functioning and suicidal behavior.The patient's admission to residential level mental health services had followed an acute psychiatric inpatient stay precipitated by a suicide attempt by overdose with subsequent outdoor behavioral health treatment (Wilderness Therapy) with immediate referral and admission for residential treatment The treatment plan included the goals of improved coping; breaking the cycle of self-destructive behaviors including anger issues and impulsive aggression; and, the development of healthy relationships and functioning.The health plan's determination of medical necessity is overturned.The requested health service/treatment of Mental Health Residential Treatment Services is medically necessary for this patient ,the patient could not have been safely or effectively managed in a less restrictive environment for the requested services.