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

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital stay. 

The insurer denied inpatient hospital stay.  The denial is overturned in part.

The patient is a male who was admitted with a history of perforated diverticulitis status post colectomy with colostomy (Hartmann's Procedure). He also had comorbid health conditions of diabetes, hypertension, coronary artery disease, and sleep apnea
The patient underwent evaluation with transthoracic echocardiogram that revealed an ejection fraction of 36%. Cardiology and pulmonary consultations were obtained. Gastroenterology consultation was also obtained. He also underwent bowel preparation for colonoscopy that was performed. Pulmonary function tests and a stress test was also performed. Computed tomography (CT) scan of the abdomen and pelvis was performed. The patient underwent surgical reversal of the colostomy and removal of a diaphragm pacing wire. The patient was clinically stable. He was started on a clear liquid diet. He was also receiving supplemental intravenous (IV) fluid. Pulmonary and cardiology notes document stability on the first post-surgical day. The patient complained of knee pain for which orthopedic and rheumatology evaluations were requested. The diet was progressively advanced, and the patient was discharged from the hospital.

The inpatient stay was medically necessary in part.

The records support that this patient was admitted to the hospital and underwent a presurgical evaluation, as is detailed above. This pre-surgical assessment lasted until the patient underwent surgery to reverse a colostomy. The records document post-surgical care that include a period of nothing by mouth (NPO) status, provision of IV fluid and analgesia. There was also progressive advancement of diet during the return of bowel function.

The records support that the pre-surgical assessment did not require an inpatient level of care. This care could have been rendered at a lower level of care status. Inpatient care was necessary and appropriate for the date of surgery forward. Surgical reversal of a colostomy does require provision of parenteral fluid and analgesia. It is appropriately anticipated that this care would extend over a period of greater than 2-days. 

The records support that inpatient admission was medically necessary in part and consistent with standards of care and the submitted Milliman Care Guidelines (MCG). This patient underwent surgery to reverse a colostomy. This operation requires a laparotomy and creation of a colonic anastomosis. His post-surgical course was complicated by a knee effusion that was assessed by the orthopedic and rheumatology services. 

His condition as documented in the medical records support the need for parenteral fluid and analgesia and was reasonably and appropriately expected to last more than 2 days.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Other- Achalasia
Treatment:  Surgical Services

The patient with a history of achalasia requesting per oral endoscopic myotomy POEM. The patient has a history of dysphagia, regurgitation, painful swallowing.  An esophagogastroduodenoscopy (EGD) showed retained esophagus secretions, tight lower esophageal sphincter.  The patient subsequently underwent manometry, which showed 100% failed swallows, elevated pressures, all consistent with type 2 achalasia.
The health plans determination is overturned in whole.
The proposed health service or treatment Per-oral endoscopic myotomy (POEM) is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
This patient has definitive documentation of achalasia.  The barium swallow showed tightening of the distal esophagus and inability to pass a barium tablet.  The manometry showed failure of motility of the esophagus with distal esophageal tightening or failure of relaxation with swallowing.  The results are consistent with achalasia.  Botox is known to be a temporary procedure and does not afford long-term relief.  The literature supports the performance of a POEM procedure in this case.  This procedure is no longer considered experimental and has quality literature supporting its use.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Other- Achalasia
Treatment:  Surgical Services

The patient is diagnosed with achalasia.  The patient has had dysphagia, regurgitation, and odynophagia.  He has had inability to eat, trouble functioning at work, and unintentional weight loss.  Esophageal manometry with impedance showed elevated integrated relaxation pressure (IRP) of 34.2, 80% of swallows with pan esophageal pressurization, and 100% failed swallows; the results were consistent with Type II achalasia.  The Health plan's determination is overturned in whole. 
Yes, peroral endoscopic myotomy (POEM) is likely to be more beneficial than any standard treatment or treatments for the treatment of achalasia.
The American Gastroenterological Association best-practice guideline for peroral endoscopic myotomy (POEM) states that "if the expertise is available, POEM should be considered as treatment option comparable with laparoscopic Heller myotomy for any of the achalasia syndromes" (Kahrilas, et al).  The provider is a POEM expert (Friedel, et al).  The American Society for Gastrointestinal Endoscopy has recently published a statement based on available evidence, stating that POEM is a "a potential attractive option for the treatment of achalasia that offers a minimally invasive endoscopic approach to myotomy with the potential for a durable response to therapy" (ASGE PIVI Committee, et al).  Clinical studies and trials have shown comparable efficacy with surgery when expertise in POEM is available, and POEM is less invasive than the chest surgery required to treat achalasia (Barbieri, et al; Schlottmann, et al).
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Other- Achalasia
Treatment:  Surgical Services 

The patient with diagnosed achalasia.  This diagnosis was confirmed by barium esophagram along with esophageal manometry (manometry pattern was consistent with Type 2 achalasia). The patient has been highly symptomatic with dysphagia for solids and liquids. In July the patient underwent an esophagogastroduodenoscopy (EGD) with Botox injection into the lower esophageal sphincter (LES), which did not provide definitive relief, proton pump inhibitor (PPI) therapy along with a calcium channel blocker was also not beneficial. The health plans determination regarding the treatment is overturned in whole .

Laparoscopic Heller myotomy is the most commonly performed surgical myotomy procedure.  Peroral endoscopic myotomy (POEM) is the endoscopic equivalent of surgical myotomy and a newer technique for the management of achalasia [1].  POEM utilizes the principles of submucosal endoscopy to transform the submucosal layer in the esophagus and proximal stomach into a tunnel, through which esophageal and gastric myotomy are carried out using a flexible endoscope. In the past, pneumatic dilation was the primary endoscopic therapy for achalasia.  In a landmark randomized trial comparing peroral endoscopic myotomy (POEM) with pneumatic dilation in 133 patients with newly diagnosed achalasia, POEM was more successful at two years of follow-up (Eckardt score less than or equal to 3 and absence of severe complications or retreatment: 92 versus 54 percent) [2].
Based on this data and others, the American Gastroenterological Association (AGA) guidelines now consider POEM as first-line therapy for the treatment of achalasia [3].
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Swelling of the right eye
Treatment: Inpatient admission

The Inpatient admission was medically necessary.

The decision to hospitalize patients with cellulitis depends on age and extent (preseptal versus postseptal).  For example, the Wills Eye Manual recommends that children five years or younger with moderate-to-severe preseptal cellulitis be admitted to the hospital for IV antibiotics with conversion to oral antibiotics after significant improvement is observed. Other authors recommend hospitalization for patients less than 12 months or even six months of age who clearly only have preseptal cellulitis. For post septal (orbital) cellulitis, all authors would agree that children would be hospitalized for IV antibiotics with consultation for possible surgical involvement.  

According to Bae et al, "The mainstay of treatment is usually antibiotic coverage against S. aureus, the Streptococcus species, and anaerobes."

In this case, a patient with history of prior hospitalization for cellulitis returned with signs and symptoms concerning for preseptal versus orbital cellulitis. While CT scan showed minimal if any postseptal extraconal extension, Ophthalmology noted preseptal cellulitis of the right eye along with cellulitis of the right orbital region. The patient has demonstrated worsening over two days with more conservative management to the point that she could not fully open her eye. Therefore, as there was a diagnostic dilemma, it was medically necessary and within standard of care for this patient to be hospitalized for 48 hours to allow for administration of IV antibiotics prior to conversion to oral antibiotics and discharge to home.
Appeal type: Medical necessity
Decision: Overturned

This is a patient man who has had a left transfemoral amputation since 1987. The current prosthesis is in a condition that is beyond repair.  He has been using an Ottobock Genium microprocessor controlled knee unit.  The health plan's determination is overturned.

Per the documentation submitted, the patient is very active, both vocationally and recreationally.  He works full-time, travels to and from work via the city transportation system, exercises vigorously, and is active outdoors and is in and around water frequently. The patient is K functional level of 3, which indicates a high-level ambulator, walking on varying terrain and at various speeds, as an otherwise healthy adult would. The medical literature has many studies demonstrating the superior efficacy of the X3 knee unit compared to the C-leg, and it would likely place the patient at considerable risk of falls and injury were he to begin using a more rudimentary knee unit, such as the proposed C-leg unit.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Deep bite, crossbite.
Treatment: Braces and office visits.
The insurer denied the Braces and office visits.
The denial is overturned. 

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

The patient exhibits a class I skeletal relationship, class II canine, moderate maxillary and mandibular crowding, deep bite, moderate excessive overjet, moderate maxillary and mandibular incisor protrusion, and anterior crossbite with gingival attachment loss.  Standard orthodontic records were created (x-rays, photos, and treatment plan).

Yes, the proposed treatment of orthodontic therapy (braces) and monthly office visits are medically necessary.
As evident in the x-rays and photos, and as stated in the dental clinical summary, the patient presents with moderate excessive overjet / incisor protrusion and anterior crossbite in the area of the left maxillary lateral incisor.  The excessive protrusion of the maxillary front teeth makes them more prone to fracture and can also cause difficulty with speech and pronunciation. The crossbite can affect the ability to chew effectively.

The complications that can arise from the lack of treatment for the excessive protrusion and the crossbite can lead to more severe consequences as it relates to the patient's long-term dental health.  The corrective measures that would be needed can be more medically invasive.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a female.  The patient has a past medical history significant for dilated cardiomyopathy with severe systolic dysfunction status post automatic implantable cardioverter defibrillator (AICD) implantation.  The patient presented to the emergency room (ER) with complaints of chest pain, dizziness and palpitations. The patient was hemodynamically stable. Electrocardiogram (ECG) revealed lateral T-wave inversions. Her Troponin was elevated at 1.12. The patient was admitted to telemetry for suspected acute coronary syndrome (ACS), myopericarditis, due to elevated cardiac biomarkers. The patient was monitored, and AICD (Automatic implantable cardioverter-defibrillator) was interrogated, revealing no events. She was diagnosed with myopericarditis with type II myocardial infarct (MI) and was discharged home on anti-inflammatory medical therapy.

Yes, the proposed inpatient admission was medically necessary.

This patient with underlying severe cardiomyopathy status post automatic implantable cardioverter defibrillator (AICD), presented with new onset chest pain and was found to have elevated troponins, suggestive of myocardial damage. Presence of elevated cardiomarkers is consistent with increased risk of cardiac events. Given the presentation, elevated troponin, known pre-existing heart disease, she would not be an appropriate candidate for an emergency department chest pain observation unit, and it would be consistent with the current standard of care that this patient be managed in an inpatient setting, and therefore the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizures
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient was admitted to the hospital with a known history of seizures, being treated with levetiracetam (Keppra) 750 milligrams (mg) twice daily. She had a history of breakthrough seizures. She presented with seizures and feeling weak and tired. She was brought to the emergency department by ambulance after having two seizures at home and an additional seizure in the ambulance. In the emergency department, she complained of headaches but had a normal examination. She was provided with a Keppra load of 1500 mg, and her Keppra dose was increased from 750 mg twice daily to 1000 mg twice daily. A head computed tomography (CT) scan was performed as she had struck her head during one of her seizures. The head CT scan was negative. She was discharged. There was no other treatment provided. She was discharged on the higher dose of levetiracetam. At issue is the medical necessity of an inpatient stay.
The acute inpatient stay was not medically necessary.
The patient presented with repeated seizures. She had also struck her head during one of the seizures. The patient had normal mental status at the time of presentation. The appropriate standard of care would be to provide additional antiepileptic medication, and if necessary, perform a head CT scan. The patient had no seizures. After arriving in the emergency department, there was no need for intravenous medications or hydration. There was no need for epilepsy monitoring. The patient did not have status epilepticus. There was no evidence of any hemodynamic instability or the need to monitor for arrhythmia or other cardiac abnormalities. There was no evidence of any intracranial structural abnormality, such as a tumor, stroke, or infection. There was no evidence of any toxic metabolic etiology. She had a normal mental status at presentation to the emergency department and did not require monitoring for mental status changes. She had no focal deficit or any evidence of stroke. There was no abnormality on examination at the time of presentation. She previously had recurrent seizures that resolved. In the emergency department, she was provided with extra levetiracetam. Her home dose was also adjusted to 1000 mg twice daily. An outpatient seizure regimen could be established in the non-acute setting. There was no evidence of a subarachnoid hemorrhage or hydrocephalus requiring monitoring. There was no evidence of increased intracranial pressure. There was no cerebral edema. There was no medical necessity for intravenous medications. There was no indication for cardiac, neurologic, pulmonary, or hemodynamic monitoring. The patient could have been treated at a lower level of care, with discharge occurring once the patient had received extra levetiracetam and the home dose had been increased, and an intracranial structural abnormality had been ruled out on magnetic resonance imaging (MRI). Therefore, an acute inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male. His medical history included coronary-arterial disease, hypertension, and dyslipidemia. His surgical history included percutaneous coronary intervention with drug-eluting stent placement, "lumbar fusion and right knee surgery". 

The patient presented to an emergency room with a four-hour history of epigastric abdominal pain, nausea, and vomiting. His vitals were: temperature 36.5, pulse 77, blood pressure 200/103, respiration 20, oxygenation 96% on room air. Physical examination demonstrated tenderness to palpation of the right-upper-quadrant of the abdomen. Serum laboratories demonstrated a normal white-blood-cell count of 8.1. Ultrasound of the abdomen demonstrated: "No evidence of cholelithiasis or acute cholecystitis". Computed tomography of the abdomen demonstrated: "Findings.. suspicious for calculus acute cholecystitis". 

The patient was admitted at an acute inpatient level-of-care with a diagnosis of acute-on-chronic/sub-acute cholecystitis. He was made  nil-per-os [NPO]; and provided with intravenous fluids, antibiotics, analgesics, and anti-emetics. He underwent Cardiology Consultation for peri-operative risk assessment and optimization.

By the following day, because the patient's symptoms resolved and because the patient was anti-coagulated with Aspirin and Plavix, he was discharged home with prescriptions for oral antibiotics; with a plan to undergo future elective cholecystectomy; and with instructions for surgical follow-up.

No, the proposed inpatient admission was not medically necessary.

According to recommendations from the Tokyo Guidelines (the international, gold-standard, professional-society consensus statements on the evaluation and management of diseases of the biliary system), patients with acute cholecystitis may be treated either surgically (with cholecystectomy) or medically (with antibiotics) [TG18]. Both of these options may be provided on at a lower level-of-care; neither requires admission at an acute inpatient level-of-care. 
Therefore, this patient whether he underwent surgery or not, could have been evaluated and treated at a lower level-of-care.

Yes, the health plan acted reasonably, with sound medical judgment, and in the best interest of the patient. In accordance with recommendations from the Tokyo Guidelines [TG18], in the absence of unstable vital signs; significant anatomic or physiologic derangements; or complications, the patient could have undergone evaluation and treatment for cholecystitis at a lower level-of-care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Duchenne muscular dystrophy.  
Treatment: Emflaza.  

The insurer denied coverage for Emflaza.  

The denial is overturned.  

This patient is a male child who has been diagnosed with Duchenne muscular dystrophy (DMD).  The patient is no longer ambulatory.  The physician indicates the patient has been recommended to utilize the requested Emflaza.  The patient was initially diagnosed via genetic testing.  The patient has been recommended to begin treatment with the requested medication as soon as possible in order to effectively prolong independence as well as improved pulmonary function, and to delay the onset of cardiomyopathy.  

The patient has not had progression of weakness.  He was essentially wheelchair-bound however his arm strength was stable and there was no weakness in grip.  Most of the time he does not need help getting into a sitting position.  At home he will mostly sit on the floor and crawl to where he wants to go.  He does need help transferring from chair to toilet according to the patient's mother.  The documentation indicated the patient's brother typically will help him transfer however the brother can no longer be the patient's healthcare provider.  The patient discontinued the use of prednisone due to weight gain.  His contractures have progressed, particularly in his legs.  

The medical literature notes that Emflaza is a corticosteroid indicated for the treatment of DMD in patients above a certain age. According to current peer-reviewed literature, prednisone and deflazacort have similar efficacy with regard to improved muscle strength. Deflazacort, however, is associated with less weight gain when compared to prednisone.  

Children with DMD have a higher proportion of learning and academic challenges and adding prednisone would have a high likelihood of worsening his focus and learning.  

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 Emflaza is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems
Treatment: Dental/Orthodontic procedure

Diagnosis: Dental Problems-teeth spacing problem
Treatment: Dental/Orthodontic procedure-Braces and monthly visits
The health plan denied the treatment of Braces and monthly visits as not medically necessary. 
The reviewer has overturned in whole the health plan
determination.

The patient has maxillary and mandibular crowding. The orthodontist mentioned in the diagnosis that #27 is impacted. Tooth #11 is blocked out to the labial. The patient is treatment planned for 36 months of comprehensive orthodontics with extraction of first premolars to create room with possible canine exposure and ligation. 

It is in the best interest of patients to be referred to an orthodontist and oral surgeon when an impacted tooth is discovered.1 Studies have shown almost 65% of untreated impacted teeth will cause some kind of pathology.2 The two most common types of pathology causes are periodontal bone loss and root resorption of adjacent teeth.2 If left untreated the damage that can occur to the patient's teeth will be more time consuming and costly to correct than the patient's existing orthodontic problem. For this reason the treatment of braces and follow up visits is deemed medically necessary.