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

Diagnosis: Bronchiolitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is overturned.

This is the case of a male infant with a history of a neonatal intensive care unit admission at birth for transient tachypnea of the newborn (TTN). He had been sick for 5 days with a fever, cough, and nasal congestion. His pediatrician started him on amoxicillin for rhinovirus and bilateral otitis media. On return to the pediatrician 2 days prior to admission, he was breathing with increased respiratory effort. The pediatrician administered 2 doses of albuterol and prescribed albuterol to be taken at home. The mother administered the albuterol at home but when his breathing difficulty did not improve, she brought the child to the emergency room (ER) for evaluation.

In the ER he was noted to have persistent respiratory distress with tachypnea with increased work of breathing. His heart rate was 150, respiratory rate 35 and oxygen saturation was 94 percent (%). Mom indicated that he had a decrease in oral intake and urine output. He was noted to be in respiratory distress with chest retractions and the presence of accessory use of respiratory muscles. There was right lung audible wheezing. A white blood count was elevated at 24,000 with a shift to the left with 78% neutrophils. A chest x-ray was unremarkable. He was started on cefdinir and albuterol. When his respiratory distress persisted despite treatment in the ER, he was admitted with a diagnosis of bronchiolitis and a plan to continue intravenous (IV) fluids and albuterol every 2 hours.

According to UpToDate article, Emergent evaluation and immediate management of acute respiratory distress in children: "Respiratory distress in children, particularly neonates and infants, must be promptly recognized and aggressively treated because they may decompensate quickly. Factors that contribute to rapid respiratory compromise in children include smaller airways, increased metabolic demands, decreased respiratory reserves, and inadequate compensatory mechanisms as compared to adults. Respiratory arrest is the most common cause of cardiac arrest in children and outcomes are poor for patients who develop cardiopulmonary arrest as the result of respiratory deterioration."

The patient was treated appropriately in the ER for respiratory distress with a rhinovirus infection. His elevated white blood count and respiratory distress with wheezing placed this child at an increased risk for respiratory failure since the child had not responded to outpatient therapy with albuterol and amoxicillin which had been prescribed by the pediatrician. The decision to admit for continued IV fluids and albuterol every 2 hours was consistent with the standard of care for a young infant with bronchiolitis.

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

The inpatient admission was medically necessary. 

The insurer's denial of coverage for the inpatient admission is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Surgical Services. 
The insurer denied liver biopsy.
The denial is upheld.

The patient is a female who underwent bariatric surgery (laparoscopic roux en Y gastric bypass and concomitant liver biopsy and mesh repair of an umbilical hernia) performed. The records support that she had a body mass index (BMI) of 35 kilograms per square meter (kg/m2). The operative dictation states that the surgeon obtained a wedge liver biopsy from the left lobe of the liver. The submitted records do not include any pre-surgical lab, imaging, or clinical data to indicate liver pathology. The pathology report provides the diagnosis of moderate steatosis. The subject under review is the medical necessity for the biopsy.

The submitted documentation does not support the medical necessity of concomitant liver biopsy at the time of roux en Y gastric bypass performed. There is no documentation of liver pathology as might be obtained by pre-operative imaging or lab data to warrant liver biopsy.
Accepted indications for liver biopsy include documentation of signs or symptoms of liver disease (abnormal liver function tests of unknown etiology, knowledge of a specific diagnosis that will likely alter the treatment plan, known liver disease where prognostic information about fibrosis may guide subsequent treatment, the presence of a mass or lesions or focal or diffuse abnormalities seen on imaging studies of unknown etiology). In this case there is no such documentation to warrant wedge liver biopsy. Routine liver biopsy is not an accepted or standard aspect of bariatric surgery.[1]
According to generally accepted criteria, routine liver biopsy is not medically necessary in conjunction with bariatric surgery. [1] Liver biopsy is indicated if there is a suspicious growth on the liver, if there is scarring of the liver or if there is a condition of the liver as indicated by pre-operative imaging or lab data that requires biopsy.
In this case the patient is morbidly obese with a body mass index of 35 kg/m2. Lab data and pre-operative imaging are not included with the review material. There is no description of clinical symptomatology to indicate liver pathology.

The Health plan's determination of medical necessity is upheld in whole.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis

Treatment: Humira Pen 40 milligrams per 0.8 milliliter (40 mg/0.8 ml) injector kit

The insurer denied coverage for the Humira Pen 40 milligrams per 0.8 milliliter (40 mg/0.8 ml) injector kit

The denial is overturned

This is a female patient with a history of psoriasis, obesity, arthritis, and fibromyalgia. She has severe psoriasis on 10 percent (%) of her body surface area (BSA). The dermatologist recommended starting laser therapy and Humira to treat psoriasis.

The patient has failed topical therapy and requires systemic therapy for control and management of her psoriasis diagnosis. Methotrexate is contraindicated given family planning and possibility of conception and due to a body mass index (BMI) greater than 40 which would place the patient at increased risk of liver toxicity from methotrexate. As such, Humira injections are a reasonable alternative which can be administered within the psoriasis care guidelines. 

The patient therefore has contraindications listed to other preferred treatment modalities which, in this case based on the provided documentation, would make the use of Humira medically more appropriate than the other options.  

The health plan did not act reasonably with sound medical judgment in the best interest of the patient. The requested service is medically necessary based on the provided medical records and the medical literature. 

The insurer's denial of coverage for the Humira Pen 40 milligrams per 0.8 milliliter (40 mg/0.8 ml) injector kit is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Foot pain
Treatment: Custom shoe inserts x2

The insurer denied custom shoe inserts x2.
The determination is upheld.

The patient was seen for evaluation on orthotics. He was complaining of pain on the bottom of both feet during activity for over 3 months. He was diagnosed with flat foot, calcaneovalgus and pain in the right and left foot. The patient has tried modified activities and stretching with no relief. He was given custom molded orthotics (CMO) many years ago. He has recently failed over-the-counter (OTC) inserts. The issue for review is the medical necessity of the custom orthotics.
The request for custom shoe inserts x 2 are not medically necessary for this patient. Though the patient was provided custom molded orthotics in the past, it had been about 10 years prior to his current visit and complaints. It appears he was diagnosed with plantar fasciitis in the past and currently is being diagnosed with flatfoot, calcaneovalgus, and foot pain. He has had the pain for about 3 months and has modified his activities and tried stretching. There is a comment in the notes that he had tried over the counter inserts which have failed. Custom molded orthotics are not considered first line treatment and other conservative measures should be tried first before proceeding with custom molded orthotics. The patient has not recently (since the current pain has started) tried physical therapy, strapping, or anti-inflammatory medications. Thus, the request for custom inserts are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pelvic Pain.
Treatment: Lupron depot 3.75 milligrams.
The insurer denied Lupron depot 3.75 milligrams.
The determination is upheld.


The patient has pelvic pain. She was seen in the emergency room for worsening pelvic pain. She had previously tried oral contraceptives and laparoscopic surgery, however, only Lupron has alleviated the pain. She was taking Lupron monthly. She had a gynecological visit with a normal physical exam. A previous ultrasound was reported as negative. She reported a history of endometriosis and planned on bariatric surgery. Of note, her bone density scan was normal with a T score of 1.5. At issue is the medical necessity of Lupron depot 3.75 milligrams (mg).

The requested health service/treatment of lupron depot 3.75 milligrams (mg) is not medically necessary for this patient.
Pharmacological treatment for endometriosis include progestins, danazol, extended-cycle combined oral contraceptives, nonsteroidal anti-inflammatory drugs (NSAIDs), and gonadotropin-releasing hormone (GnRH) agonists can be used for treatment of pain in women with suspected endometriosis. In women with a history of endometriosis who wish to preserve their fertility, non-steroidal anti-inflammatory drugs (NSAIDs) or combined oral contraceptives can be used to treat recurrent pain. Oral or depot medroxyprogesterone acetate is also effective. If none of these therapies is successful, progestins, gonadotropin-releasing hormone (GnRH) agonists, and androgens may be used. Use of the levonorgestrel-releasing intrauterine system (Mirena) also reduces pelvic pain associated with endometriosis. There is documentation that the patient has failed oral contraceptives and surgery, however, no other documentation of additional therapies exists. Therefore, chronic lupron is not recommended. In addition, Elagolix, a GnRH antagonist was approved by the United States (U.S.) Food and Drug Administration in 2018 for the treatment of endometriosis. Studies of leuprolide (Lupron) for endometriosis indicate that 6 months is an appropriate length for therapy. Because of a lack of safety data with long-term use, and because of concerns expressed in the available literature regarding effects on bone density, treatment after 6 months is typically not recommended.  Therefore, it is current standard of care to limit use to less than 12 months of use in the patient's lifetime.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Trauma. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient stay. 
The denial is upheld.

The patient is a male status/post (s/p) bicycle accident who presented to the emergency department for evaluation. He lost control of his bike and hit the curb causing him to fall. He was not hit by another vehicle. He arrived as a level I activation. Physical exam showed a Glasgow Coma Scale (GCS) level 14 (confusion), multiple lacerations involving left eyebrow, laceration of upper lip, full thickness laceration of lower lip. Computed tomography (CT) imaging revealed multiple facial fractures including bilateral maxillary sinus, pterygoid plates, nasal bone, and left orbit fractures with mild displacement. He was evaluated by plastic surgery who repaired with facial lacerations and ophthalmology. He was discharged. The subject under review is the medical necessity for the inpatient stay. 

The health plan's determination is upheld.

The inpatient stay was not medically necessary for this patient.
The patient was involved in a bicycle injury with facial lacerations and mild displacement of facial fractures. He was admitted to the floor. He was evaluated by the plastic surgeon who repaired his facial lacerations and discharged home thereafter.
The patient could have been treated at a lower level of care status. GCS was 14 as mentioned on trauma consult history of present illness (HPI). His altered mental status was not evident and was not severe/persistent.
Facial fractures did not need any monitoring beyond that warranted an inpatient level of care as the patient was discharged with outpatient follow up with plastic surgery.
CT of the head showed no intracranial injuries with no subarachnoid hemorrhage (SAH), subdural hematoma (SDH), epidural hematoma (EDH), intraparenchymal hemorrhage (IPH) or skull fractures.
According to Traumatic brain injury, non-surgical treatment, Milliman Care Guidelines (MCG) Health 25th edition,
Admission is indicated for 1 or more of the following:
1) Hemodynamic instability (Criteria not met)
2) Altered mental status that is severe or persistent (Criteria not met)
3) Post resuscitation or presenting GCS of less than 13 (Criteria not met)
4) Worsening of neurologic function post presentation (Criteria not met)
5) New signs of symptoms on neurologic examination (Criteria not met)
6) Evidence of increased intracranial pressure (Criteria not met)
7) New intracranial pathology on imaging that requires intervention or monitoring beyond the observation care time frame (Criteria not met)
8) Cerebrospinal fluid (CSF) leak (Criteria not met)
9) Recurrent seizures (Criteria not met)
10) Significant respiratory or cardiac abnormalities secondary to brain injury (Criteria not met)
11) Increased intracranial pressure or cerebral edema monitoring. (Criteria not met)
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congestive Heart Failure
Treatment: Home Health Care

The insurer denied Personal Care Aide (PCA) level 2 Services: Total Amount of 84 Hours per Week. 
The health plan's determination is overturned. 

The patient is a female with past medical history of progressive dementia, hypertension, coronary artery disease, congestive heart failure (CHF), diabetes mellitus type 2, gout, asthma, rheumatoid arthritis, osteoporosis, anxiety, depression, carotid artery disease, peripheral artery disease, chronic obstructive pulmonary disease (COPD), gastroesophageal reflux disease (GERD), urinary incontinence, obstructive sleep apnea, and osteoarthritis who had been assigned PCA (personal care aide) services per week based on assessment tool performed assessing the patient at total assistance with task of ordinary housework while maximum assistance with tasks of meal preparation, stairs, shopping, transportation, bathing, dressing lower body, walking, and locomotion. With tasks of personal hygiene, dressing upper body, transfer toilet, toilet use, and bed mobility, the patient was assessed at extensive assistance while set up only with tasks of managing finances and phone use. The patient was assessed as independent with task of eating.

Personal Care Aide (PCA) level 2 Services: Total Amount of 84 Hours per Week are medically necessary for this patient.
There is documentation from patient's providers that it is medically necessary to increase PCA services. The patient had increased assistance needs with tasks of managing medication, personal hygiene, and dressing upper body when comparing the recent assessments. The patient has no informal help. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) and Instrumental activities of daily living (IADL). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. 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, PCA services 84 hours/week are medically necessary for this patient. Personal care services are medically necessary 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: Central Nervous System/Neuromuscular 
Treatment: Pharmacy/Prescription Drugs
The health plan denied the requested prescription drug, Nurtec. The health plan's determination is overturned.

The patient is a woman with migraine headaches. Treatment with Nurtec ODT is the subject of this review. The patient has previously tried and failed Sumatriptan, Zolmitriptan, and Rizatriptan. These drugs were ineffective or caused intolerable side effects. Nurtec ODT was denied because the current outpatient notes do not document trial and failure of the triptans.
At issue is the medical necessity of the requested prescription medication, Nurtec ODT.

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

Nurtec ODT is medically necessary. The patient has acute migraines. Nurtec ODT is Food and Drug Administration (FDA) approved and is literature supported for the treatment of acute migraines. The primary efficacy analyses were conducted in patients who were treated for a migraine with moderate to severe pain. Nurtec ODT 75 mg. (milligrams) demonstrated an effect on pain freedom and most bothersome symptom (MBS) freedom at two hours after dosing, compared to placebo. As the patient has tried and failed multiple triptans, the use of an alternative medication, such as a Gepant, is appropriate. In this instance, triptans are ineffective and cause adverse side effects. An alternative therapy, Nurtec ODT, is indicated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crowding, crossbite
Treatment: D8080 Comprehensive Orthodontic Treatment, D8670 Monthly Visits
The insurer denied the D8080 Comprehensive Orthodontic Treatment, D8670 Monthly Visits.
The denial is overturned.

The patient is a male. The request is for dental benefits for orthodontic treatment (braces) and monthly visits.

Per the provider's dental clinical summary, the patient presents with a class I skeletal relationship, moderate maxillary crowding, severe mandibular crowding, anterior crossbite with gingival attachment loss (mandibular right Canine).

The health plan denied the claim because the patient did not score 26, the necessary value for braces approval per the Handicapping Labio-Lingual Deviation (HLD) Index Report.

The decision was appealed because per the dental clinical summary, the patient has an anterior crossbite with gingival attachment loss and this is asserted to be an automatic qualifier for braces treatment per the HLD Index Report.

Yes, the proposed treatment of orthodontic treatment (braces) and monthly visits are medically necessary.

As demonstrated in the x-rays and photos, and as stated in the dental clinical summary, the patient presents with extensive crowding in the upper and lower arches. There is also an anterior crossbite with gingival attachment loss (lower right canine).

The crowding and crossbite (mal alignment) can affect the patient's ability to chew food properly, proper speech, and the ability to maintain proper hygiene, and it can lead to gingivitis and gum disease.

Therefore, given the above, the braces and monthly visits are medically necessary.

The health plan did not act reasonably, with sound medical judgement, or in the best interest of the patient.

If these conditions are untreated, the complications of decreased proper function as it relates to chewing, speech, and compromised oral hygiene can only lead to more dental problems in the future.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: COPD. 
Treatment: Inpatient stay. 

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

The patient is a female with a past medical history remarkable for chronic obstructive pulmonary disease (COPD) /emphysema, who was admitted for bilateral lower extremity swelling. Review of system was positive for lower extremity swelling and chronic shortness of breath. 
The patient was afebrile (Temperature of 98.1), described as comfortable in stretcher, and in no acute distress. Her blood pressure was 112/66, pulse rate of 89, respiratory rate of 18, and oxygen saturation of 100% on room air. Physical examination was remarkable for 2+ (plus) pitting edema of the lateral ankles. The patient was admitted for bilateral ankle edema and rule out of right sided heart failure from underlying COPD and hyponatremia. 

The inpatient stay was not medically necessary. 

The care could have been appropriately rendered at a lower level of care. 

The patient was admitted for rule out of right sided heart failure since she has underlying COPD/emphysema. Clinically, the patient did not have hypoxemia (oxygen saturation of < 92%), crackles in the lungs, or any other clinical signs of heart failure. An isolated elevation of brain natriuretic peptide (BNP) does not represent acute heart failure without clinical symptoms of congestion. The patient's hyponatremia was in the setting of alcohol use and responded to intravenous (IV) fluids. A lower level of care would have been appropriate for monitoring of patient's sodium levels. The patient did not have evidence of COPD exacerbation. The patient also had chronic anemia and elevated liver enzymes which were deemed to be related to alcohol use. The documentation does not support inpatient admission for any identified clinical pathology that required inpatient treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hyperthyroidism.

Treatment inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.

The denial is overturned.

This is a female who presented to the emergency department and was admitted for hyperthyroidism and discharged later. The patient has a known history of hyperthyroidism. She also presented with left ear pain. She was not on any medications. Her heart rate was in the 120s. She had heat intolerance, palpitations, tremors. She had a large goiter on exam. Her thyroid stimulating hormone (TSH) was undetectable with a T (thyroxine) 4 of 6. However, the patient was not started on medications. Free T4 was greater than 6.99 and TSH was undetectable. The patient was admitted to the pediatric intensive care unit (PICU) for early thyroid storm. The Burch-Wartofsky score was 30. A score of 25 - 44 is consistent with impending thyroid storm and the recommendation is to consider intensive care unit (ICU) monitoring and symptom management. The patient also tested positive for 2019 Coronavirus. She was started on atenolol and methimazole and was observed for improvement in her symptoms and vital signs.

Admission to the hospital for telemetry, treatment and observation is necessary for any patient with a Burch-Wartofsky score of greater than 24 [1, [2, [3, [4, [5]. The patient had impending thyroid storm with a score of 30. Admission to the hospital is consistent with generally accepted standards of medical practice. The patient was appropriately treated with methimazole and atenolol. The patient was safely discharged once her symptoms and vital signs improved. The request is therefore medically necessary.

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

The insurer's denial of coverage for the inpatient hospital admission is overturned. Medical Necessity is substantiated.