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

Diagnosis: Hyponatremia
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The health plan's determination is overturned.

This is a male patient with a past medical history (PMH) of diabetes insipidus who was admitted with complaints of (c/o) syncope while having a bowel movement (BM) associated with nausea, vomiting, dizziness, and decreased by mouth (PO) intake. His vital signs were unremarkable. The physical exam was unremarkable. Lab work was notable for a sodium of 117. Imaging studies included a chest x-ray (CXR) which showed no acute pathology. An electrocardiogram (EKG) showed normal sinus rhythm (NSR) without acute ischemia. The patient was diagnosed with symptomatic hyponatremia and syncope and treated with intravenous fluids (IVF) and desmopressin, every six hour (q6h) basic metabolic panel (BMP), and expert consultations. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

Yes, the hospital stay was medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with c/o syncope while having a BM associated with nausea, vomiting, dizziness, and decreased PO intake. The patient was found to have a sodium level of 117, and thus, the patient presented with severe and symptomatic hyponatremia. In addition, the patient was at risk of seizures, obtundation, coma, and respiratory arrest, as well as the severe complication of osmotic demyelination and/or cerebral edema. Overall, this patient presented with symptomatic hyponatremia, which required close monitoring to ensure there was no over-correction, neurological checks, and expert consultation, and could not have been safely accomplished at a lower level of care while the patient was receiving treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal/Stomach Pain
Treatment: Inpatient hospital admission
The health plan denied the inpatient hospital admission.
The determination is overturned.

The patient is a male with past medical history of bilateral inguinal hernias who was admitted with complaints of left groin pain. His vital signs were unremarkable. The physical exam was notable for no apparent distress and a large, tense, and very tender left-sided inguinal hernia. The lab work was unremarkable. Imaging studies, including a chest x-ray (CXR) showed no focal consolidation. The patient was diagnosed with incarcerated left inguinal hernia and was treated with open inguinal hernia repair with mesh. The patient was discharged in stable condition.

At issue is the medical necessity of the inpatient hospital admission.

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

The requested health service/treatment of inpatient hospital admission was medically necessary for this patient. This patient with known past medical history of inguinal hernias presented to the emergency department with complaints of left groin pain. The patient was diagnosed with an incarcerated hernia and underwent an urgent surgical evaluation and was ultimately brought to the operating room (OR) for an urgent hernia repair. Incarcerated hernias require admission for urgent surgical intervention as these are considered a surgical emergency. In addition, this patient required close clinical monitoring to assess for complications such as peritonitis, surgical site infection, or severe pain. Overall, this patient required an acute inpatient stay for safe surgical and medical treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class I Occlusion 
Treatment: Braces 
The insurer denied braces. 
The health plan's determination is upheld. 

The patient in question is a young female with a Class I occlusion with 4 millimeter (mm) overbite and 3 mm overjet. She is in the middle-mixed dentition phase with many primary teeth remaining. She has maxillary and mandibular spacing. She is treatment planned for braces to correct her malocclusion. 
Braces are not medically necessary. 
While the patient has spacing, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. However, this patient presents with none of those conditions. Aligning her teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion. The patient's overjet is slightly more than ideal, but her overjet would not affect oral health related quality of life unless it was greater than 6 mm. If her teeth were aligned, it would provide a minor esthetic improvement but it would not create a medically significant improvement to the patient's health. Therefore, braces are not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Central Nervous System
Home health care

Diagnosis: Parkinson's Disease
Treatment:  Personal Care Aide (PCA) Services: 12 Hours per Day, 7 Days per Week -and- 12 Hours per Day, 7 Days per Week (Split Shift) total 168 hours per week.
The insurer denied Personal Care Aide (PCA) Services: 12 Hours per Day, 7 Days per Week -and- 12 Hours per Day, 7 Days per Week (Split Shift) total 168 hours per week. The health plan's determination is overturned. 

The patient is a male with medical history notable for Parkinson's disease and Lewy body dementia. The patient and his care team requested an increase to Personal Care Aide (PCA) Services: 12 Hours per Day, 7 Days per Week -and- 12 Hours per Day, 7 Days per Week (Split Shift) total 168 hours per week and this request was denied by the health plan.
The patient's neurologist provided a letter of support for this appeal. The letter states that the patient's condition is progressive and incurable, and will result in both cognitive impairment and significant physical limitations. For this reason, the physician recommends 24 hour personal care to meet his needs.

The requested health service of Personal Care Aide (PCA) Services: 12 Hours per Day, 7 Days per Week -and- 12 Hours per Day, 7 Days per Week (Split Shift) total 168 hours per week is medically necessary for this patient.
The patient has end-stage dementia secondary to Lewy body disease and has severe functional limitations secondary to his Parkinsonism and dementia. He is incontinent and bed bound. His limitations appear to be more severe than represented by the Uniform Assessment System (UAS) on the basis of the testimony by the patient's physicians and his son. Given that he is bedbound and needs assistance with toileting and repositioning, he will have personal care needs that can be expected to be continuous and unscheduled in nature. Therefore, the requested services are medically necessary and appropriate for the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary artery disease

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
Asked to review the case of an adult with a history of multivessel coronary artery disease, diabetes mellitus, and hypertension that presented to the hospital for elective cardiac catheterization and intervention to the proximal and mid left anterior descending artery.  Several weeks prior to presentation he underwent successful revascularization of the right coronary artery.  He underwent successful rotational atherectomy and drug eluting stent placement via a right radial artery approach. He was observed on cardiac telemetry overnight.  No periprocedural complications were noted and the patient was discharged the following day. 

This patient presented for elective percutaneous revascularization.  He underwent an uncomplicated procedure and stents were placed in the proximal and mid left anterior descending artery. He was discharged the following day.  Several investigators have studied the safety surrounding same day discharge following percutaneous intervention and demonstrated no difference between patients that are discharged on the same day as compared to patients admitted to the hospital.(Reference1-4)  Current expert consensus from the society of cardiovascular angiography and interventions support treatment at a lower level of care. (Reference 4)  

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

The medical necessity for inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Periodontal disease.
Treatment: Partial Lower Denture (D5212).

The insurer denied the partial lower denture.  The denial has been overturned. 

The proposed treatment is medically necessary.

The patient is a male requesting benefits for a lower partial denture.  Five lower teeth will be extracted prior to treatment. The prior denial was due to plan documents limiting partial dentures to cases that had no periodontal disease, which this patient does have.

Although the patient has periodontal disease around multiple lower teeth, those teeth are going to be extracted. With those teeth missing, there will be no periodontal disease. The patient will have three lower teeth left, numbers 22, 27 and 28. These teeth have enough bone left to support a lower partial denture, which will fit up against the new full upper denture the patient is treatment planned to get. The lower partial denture (once the diseased teeth are extracted) is medically necessary to allow this patient to properly chew his food.   

The health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Premature ventricular contractions

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned.

This case involved an adult who presented to the hospital for an elective electrophysiologic study with ablation of symptomatic premature ventricular contractions. Past medical history was significant for aortic stenosis, mechanical aortic valve replacement, Coronary artery bypass graft (CABG), and hypertension. On presentation to the hospital, vital signs were stable and physical examination revealed no significant abnormalities. 12 lead electrocardiogram revealed normal sinus rhythm with frequent monomorphic premature ventricular contractions (PVCs). PVC configuration was right bundle extreme right axis. Electrophysiologic study and ablation were performed via transeptal puncture. PVCs were mapped to the anterolateral papillary muscle and targeted with radiofrequency energy. The procedure was without complications and the patient was observed overnight. Recurrent PVCs were noted the following day and the patient was discharged home on antiarrhythmic therapy.

Acute inpatient hospital admission was medically necessary. Catheter ablation of PVCs is associated with a 3% (percent) rate of major adverse cardiac events and a 1.2% rate of moderate adverse events (1). In one registry study, including more than 400 patients undergoing catheter ablation for PVCs, the median length of hospital stay post procedure was 3 days (2). A third study, analyzing the United States National Inpatient Sample Database, recorded outcomes of over 1200 patients undergoing catheter ablation for ventricular arrhythmia demonstrated that the average length of hospital stay was 4.7 days (3). In this case, the patient underwent ablation without complications. However, recurrent PVCs were noted the following day. Inpatient hospitalization for close monitoring and treatment is indicated and in the best interest of the patient. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left great toe ulcer
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

The patient is an adult with past medical history significant for benign prostatic hyperplasia, coronary artery disease, diabetes mellitus type 2, hyperlipidemia, right 4/5th toe amputation, and hypertension who presented to the emergency department with complaints of a left great toe ulcer. 

Vitals on presentation included: Temperature 98.2 degrees Fahrenheit, Blood Pressure 138/68, Pulse 102, Respiratory Rate 18, oxygen (O2) saturation 100% (percent) on Room Air. Laboratory results included the following: white blood cell (WBC) count 9.7, Hemoglobin (HGB) 11.0, Hematocrit (HCT) 34.4, creatinine 1.57, glucose 111.

The patient was started empirically on intravenous antibiotics (vancomycin and Zosyn) for left big toe cellulitis. X-ray of the left foot showed no fracture, no bony erosions. Vascular surgery consulted; their impression was paronychia. Infectious Diseases consulted and recommended oral antibiotics. the patient remained afebrile, hemodynamically stable, and clinically improved. He was discharged to continue oral antibiotics as an outpatient.

According to documentation, patient was admitted for a possible left toe cellulitis. Otherwise, he was afebrile and hemodynamically stable. Laboratory results were unremarkable, including a normal WBC and inflammatory markers. There was no evidence of a disseminated infection, no surgical intervention was required, and the patient was not immunocompromised. Based on these findings, the patient met criteria for observation level of care. He did not fulfill criteria for acute care.

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

The medical necessity for the inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hernia
Treatment: Inpatient Hospital
The insurer denied the inpatient hospital stay.
The health plan's determination is overturned.

The patient is a male (body mass index (BMI) 40 kilograms per meters squared (kg/m2) who presented to the hospital with multiple ventral herniae. He has a history of prior gastric bypass surgery. The records indicate that this was a scheduled hernia repair procedure. The patient underwent open retrorectus repair of the incarcerated incisional hernia with a 20 by 30 centimeter (cm) mesh and an extensive lysis of adhesions. Two surgical drains were placed. The operative procedure took approximately 2 hours.
The records indicate that the patient was receiving intravenous (IV) fluids and was nothing by mouth status (NPO). He was receiving IV narcotic medication (Dilaudid) every 4 hours for pain management. His vital signs were normal. The white blood cell count (WBC) count was elevated to 12. The urinary catheter was removed the day after surgery and on the third post-operative day he was started on a liquid diet. The drain had serosanguinous output. The WBC count normalized to 7.7. The patient's pain management included oral narcotics. He was discharged from the hospital with the surgical drains in place and with home health arrangements.

The health plan, in its determination of medical necessity, did not act reasonably, with sound medical judgment and in the best interest of the patient.

The inpatient admission was medically necessary. This patient had an incarcerated abdominal wall hernia. He required an open abdominal operation for this condition. The operation involved the retrorectus repair of the incarcerated incisional hernia with a 20 by 30 cm mesh and an extensive lysis of adhesions. Two surgical drains were placed at the time of surgery. He also had a presenting body mass index of 40 kg/m2.
While the goal length of stay is ambulatory, an extended inpatient stay may be required for emergent surgery (strangulated hernia), significant peritoneal adhesions complicating surgery, surgical complications, obturator hernia, open repair of large recurrent or incarcerated ventral or incisional hernia, parastomal hernia, post op ileus, morbid obesity, active comorbidities.
The records support that this patient had a large ventral hernia and required an extensive lysis of adhesions. He was also morbidly obese with a BMI of 40 kg/m2. Based on these clinical conditions it was reasonably anticipated that an inpatient level of care would be required. He was initially NPO after surgery. He was receiving parenteral narcotics for pain management. He was started on a liquid diet on the third post operative day and once he tolerated a diet and pain management was achieved with oral medication, he was discharged home with home health.
A lower level of care would not have been consistent with his presenting condition, intra-operative findings and post-surgical needs in this case. This patient had a large ventral hernia as supported by the need for a retrorectus hernia repair with a 20 by 30 cm mesh.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis
Treatment: Otezla 30MG (milligrams) OR (Oral) Tabs
The insurer denied Otezla 30MG (milligrams) OR (Oral) Tabs.
The denial is overturned.

The patient is an adult male with psoriasis, ten percent body surface area (BSA) to the extremities, face, and scalp, treated with topical steroids and calcipotriene. The provider is requesting Otezla. The health plan requires a trial and failure to phototherapy and systemic immunosuppressant therapy. The patient has no other past medical history.

The proposed treatment is medically necessary.

Otezla is an appropriate medication for this patient Otezla (apremilast) is a phosphodiesterase inhibitor, and therefore its mechanism of action is different from injectable biologics. Apremilast (Otezla) works intracellularly to modulate pro- and anti-inflammatory mediators. The ESTEEM trial (randomized, double-blind) documented favorable response to apremilast over placebo at week 16. Side effects were generally mild and did not result in discontinuation. Seventy-five percent or greater improvement in the Psoriasis Area and Severity Index (PASI75) from baseline was seen in 33% of patients, and a fifty percent reduction in the Psoriasis Area and Severity Index (PSAI50) in 60%. Efficacy has been demonstrated in psoriatic arthritis as well, and it was first Food and Drug Administration (FDA) approved for spondyloarthropathies. There are no studies to date comparing the efficacy of Otezla to other systemic medications for psoriasis. It is an oral therapy and requires less medication monitoring (current data do not indicate a need for laboratory monitoring) and is not immunosuppressive. Otezla is now among 
the growing number of systemic therapies for psoriasis. Currently, there are no evidence based medical guidelines indicating which therapy is best or delineating a stepwise approach to psoriasis. The Guidelines of care for the management of psoriasis state that each patient requires individual tailoring, and a stepwise approach is not recommended. No evidence-based literature could be found to support the use of other therapies before Otezla.
In addition, phototherapy would not be appropriate given the facial/scalp involvement.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Poor memory, anxiety, hypertension, osteoarthritis, rheumatoid arthritis, osteoporosis, GERD (gastroesophageal reflux disease), depression, and brain aneurysm
Treatment: Medical Day Care 2 Days Per Week
The insurer denied: Medical Day Care 2 Days Per Week
The denial is upheld

The patient is an elderly female. She has history of poor memory, anxiety, hypertension, osteoarthritis, rheumatoid arthritis, osteoporosis, GERD (gastroesophageal reflux disease), depression, and brain aneurysm. Denial of medical day care 2 days per week is being appealed. The health plan denied coverage of the service due to lack of supporting documentation for recertification and lack of attendance for the past 5 months. Uniform Assessment System evaluations from last year are provided. There is a statement from the Medical Director of the Adult Day program that notes that the patient had a CVA (cerebrovascular accident) in August with residuals. The patient has been in the program for over a year with benefit from ongoing PT (physical therapy) and OT (occupational therapy). 
Continuation in the program is recommended to further her strength and functionality. A letter from the patient's provider notes it would be beneficial to receive maximum amount of home health aide hours.

The requested Medical Day Care 2 Days Per Week is not medically necessary.

Adult day centers offer a heterogeneous group of services. This patient had been receiving medical day care after a stroke that occurred 8 months ago. The health plan denied the service due to lack of supporting documentation for recertification and lack of attendance for the past 5 months. There is an appeal statement from the medical director of adult day program recommending continuation of treatment.
Documentation for recertification from the patient's provider has not been received. In addition, documentation addressing lack of attendance for the past 5 months has not been provided. The information is inadequate to support the medical necessary for medical day care 2 days per week. The requested medical day care is not medically necessary.