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

Diagnosis: Substance Abuse

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This adult male reportedly was admitted to the inpatient hospital due to alcohol withdrawal including a likely withdrawal seizure. He reportedly had acute disorientation, a fall, and had generalized shaking with seizure like activity in the context of heavy alcohol consumption. He reportedly was drinking 3 pints of vodka per day for the past week due to the stressor a divorce. He reportedly also had elevated heart rate of 108, agitation, and low magnesium of 1.8. He had a positive toxicology for benzodiazepine and alcohol. He reportedly had multiple past admissions for alcohol withdrawal. He was given Librium for alcohol detoxification treatment and given intravenous (IV) fluids, thiamine, and folic acid. He reportedly had a medical history significant for myocarditis, degenerative disc disease, severe right shoulder pain, and early cirrhosis. He was discharged.
  
The medical records provided enough specific evidence to support that the patient required this level of care. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. It also states that patients with past complicated or life-threatening withdrawal symptoms including withdrawal seizures or delirium tremens are in need of inpatient hospital treatment for the management of withdrawal and reports that patients with comorbid medical condition that complicate the management of withdrawal are also candidates for inpatient detoxification. 

He did require 24-hour inpatient medical hospital treatment for alcohol detoxification, and it was considered unsafe for him to be treated for detoxification in a less restrictive level of care then. He reportedly was using a very large amount of alcohol including 3 pints of vodka per day and had a positive toxicology for benzodiazepines and alcohol and reportedly was drinking more due to the stressor of a divorce. He was considered a high risk medically and in need of 24-hour hospital treatment including as he continued with detoxification medications. 

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 the inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetic Ketoacidosis. 
Treatment: Inpatient Hospital Admission. 

The insurer denied: Inpatient Hospital Admission. 
The denial is upheld. 

The patient is a young adult male with type 1 diabetes. He presented with generalized weakness. He had not taken insulin for two days and developed weakness and nausea. The patient's BP (blood pressure) was 102/58, heart rate 91, respiratory rate 18, temperature 97.5, O2 (oxygen) 97%. pH 7.24, glucose 426, bicarbonate 13, lactic acid 2.9, sodium 130, potassium 5.2, small serum ketones, beta-hydroxybutyrate 7.2, white blood cell count 17,280. He was treated with normal saline and intravenous regular insulin. He was admitted to the intensive care unit. His glucose and acidosis improved, and he was transitioned to subcutaneous insulin and discharged home. The inpatient stay is under review. 

The Inpatient Hospital Admission was not medically necessary. 

This patient presented with known type 1 diabetes with moderate diabetic ketoacidosis due to missed insulin doses. His hyperglycemia and ketoacidosis responded quickly to insulin therapy. 

Patients with diabetic ketoacidosis can be safely managed in observation units unless they present with severe alteration of mental status or with critical illness such as sepsis, which is not documented in this case. This patient did not have alteration in his mental status. He was hemodynamically stable. The documentation does not support a trial and failure of a lower level of care. He was discharged the same day. Therefore, no, the patient's admission was not medically necessary for the inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stroke/cerebral vascular accident (CVA), left-sided hemiplegia.

Treatment: increase in personal care assistance (PCA) services to 7 days x 12 hours per day (84 hours per week).

The insurer denied coverage for increase in personal care assistance services to 7 days x 12 hours per day (84 hours per week).

The denial is overturned.

This is an elderly woman with multiple medical problems including stroke with left hemiplegia, osteoarthritis and depression.  She is also prescribed anticoagulation medication (Coumadin) for history of deep vein thrombosis (DVT).  The insurer approved personal care assistant (PCA) 49 hours/week, and the request is an increase to 7 days x 12 hours per day (84 hours per week).

The Uniform Assessment System (UAS) report was reviewed. The patient's cognition is described as "Minimally impaired."  She requires maximal assistance for bathing and lower body dressing.  Extensive assistance is needed for personal hygiene, upper body dressing, and toilet transfer/use.  She is frequently incontinent of bladder and occasionally incontinent of bowel.  Limited assistance is need for bed mobility and eating.  The patient was observed ambulating "25 feet with contact guard assistance and close contact guard using a 2 wheeled walker, gait slow and unsteady."  The patient's condition and functional deficits are at a level and unpredictable as to require the requested PCA 84 hours/week.  Of particular concern is her poor balance, difficulty ambulating and significant risk for falling resulting in serious injury while prescribed the medication Coumadin.  The patient may actually require additional monitoring that is more than the requested 84 hours/week.  However, safety monitoring under PCA does not include monitoring an individual (e.g., with dementia) when no other Level I or Level II personal care services task is being provided.  Based on the enclosed documents reviewed, the patient's health and safety can be appropriately provided and maintained by the increasing PCA services, 84 hours/week.  

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 increase in personal care assistance services to 7 days x 12 hours per day (84 hours per week) is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bitten by Dog, Initial Encounter.
Treatment: Hospital Stay.
The insurer denied coverage for hospital stay.
The denial is upheld.

This child presented to the emergency department (ED) in the evening with a total of 7 centimeters of dog bite lacerations to the face. The child was clinically stable in no acute distress and was admitted to the hospital for wound closure because nothing by mouth (NPO) status did not allow immediate wound closure in the operating room.  The child was clinically stable. Wound closure was performed. The procedure was uneventful as was the patient's hospital course. Per the notes, the infectious disease consultant recommended continuing intravenous (IV) antibiotics. The patient was otherwise clinically stable.  

The records do not document any clinical conditions that required inpatient care.  According to Milliman Care Guidelines (MCG) General Admission Criteria: General Criteria Observation Care: "Observation is not a location within the hospital, but rather a short period when the same active diagnostic and therapeutic services used during an inpatient hospitalization are provided to gather more information and assess the response of the patient. Typically, it is 48-hours or less, but can be up to 72-hours in certain situations."  

This patient was medically stable and received only additional analgesic medication and IV antibiotics. Hospitalization for antibiotics was not indicated. Guy and Zook reported a wound infection rate of 1.4% (percent) following primary closure of 145 head and neck dog bite wounds without administration of antibiotics (1). A review of 734 dog bite injuries managed as outpatients found only a 2.5% incidence of infection (2).  Morgan et al recommend oral antibiotics following surgical closure of dog bite injuries and with IV antibiotics and hospital admission indicated only for children, the elderly and immunodeficient patients (3).  

In a comprehensive review of dog bite injuries to the head and neck, Stefanopoulos and Tarantzopoulou recommend oral antibiotic prophylaxis following primary repair of facial dog bite injuries with amoxicillin-clavulanate as the preferred agent (4).  Recent studies by Quinn et al and Dendle and Looke question the role for antibiotics following animal bites.  The medical literature indicates that this patient could have been safely managed as an outpatient with oral antibiotics.  

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the hospital stay at an acute medical surgical level of care is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pain in back that goes down to legs
Treatment: Inpatient lumbar laminectomy/diskectomy and fusion 
The health plan denied the requested inpatient lumbar laminectomy/diskectomy and fusion as not medically necessary.
The health plan's determination is upheld.

This is a male with a history of low back and leg pain. He has had injections and medications without relief. He is a current smoker. The neurologic exam shows decreased sensation in L (lumbar) 4-5. The lumbar magnetic resonance imaging (MRI) shows bilateral pars defects at L4 and L5, with spondylolisthesis at L4-5 and foraminal stenosis. At L5-S (sacral) 1 there is marked stenosis due to lipomatosis. The provider has recommended an L4-S1 fusion.

At issue is the medical necessity for the requested health service/treatment of an inpatient lumbar laminectomy/diskectomy and fusion.

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

The procedure is not medically necessary.

The patient is a current smoker, which has a negative impact on lumbar fusion. The patient would need to be tobacco free for approximately 6 weeks prior to lumbar fusion. Martin, et al cite "current smoking is associated with a small but significant increase in systemic morbidity and wound complications following elective lumbar spine procedures. Increasing pack year history was also associated with wound complication risk, suggesting a dose-related effect." Berman, et al cite "it has been clearly demonstrated from both a biochemical and clinical perspective that smoking increases the rate of perioperative complications for patients undergoing spinal fusion surgery, particularly pseudoarthrosis. It has also been shown that there are certain approaches that can reduce the risk of morbidity."

The patient would be a candidate for lumbar fusion with spondylolisthesis at L4, and pars defects at L4 and L5. This is supported in the literature. Surgery for symptomatic isthmic spondylolisthesis has been shown to be very effective for pain relief. Lian, et al cite "for the adult isthmic spondylolisthesis without degenerative disease in adjacent level, single segment of posterior lumbar interbody fusion (PLIF) with pedicle screw fixation is an effective and safe surgical procedure regardless of whether additional reduction had been conducted or not." Schulte, et al cite "surgery appears to be better than conservative treatment in adults with isthmic SL (spondylolisthesis) (poor evidence) and also in adults with degenerative SL (good evidence). Instrumented fusion with decompression appears to be more successful than decompression alone in adults with degenerative SL and spinal stenosis (poor evidence). Reduction and instrumented fusion does not appear to be more successful than instrumented fusion without reduction in adults with isthmic or degenerative SL (moderate evidence)."
Appeal type: Medical necessity
Decision: Overturned

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

The patient is a female presenting with a skeletal Class I malocclusion and minor crowding. She has an anterior open bite. She has treatment planned for 24 to 30 months of orthodontic treatment to address the crowding and anterior open bite, but the treatment was denied.

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

The requested health service and treatment of braces is medically necessary for the patient. Patients with an anterior open bite are among the most difficult patients to treat. One side effect of an anterior open bite is a reduced maximum bite force with less muscle activity while chewing than patients without an anterior open bite. Orthognathic surgery or permanent tooth extractions are often the choice of treatment to treat patients with an anterior open bite. This is not something that will self-correct without orthodontic intervention.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Migraine
Treatment: Botox (onabotulinumtoxinA) injection
The insurer denied the Botox (onabotulinumtoxinA) injection.
The determination is overturned.

The patient has chronic migraine. She is prescribed Botox. The drug was denied because the patient has not tried and failed a second oral preventative medication. The patient has tried and failed topiramate and is currently treated with venlafaxine extended release (ER) and propranolol. These medications have been ineffective thus far. Additionally, the patient has tried and failed Emgality and Qulipta for migraine prevention. At issue is the medical necessity of Botox.

Botox is medically necessary for treatment of this patient. The patient is diagnosed with chronic migraine. Botox is Food and Drug Administration (FDA) approved and literature supported for prevention of chronic migraine. There are no requirements in the peer reviewed literature or prescribing information that require a patient to try and fill off label oral preventative medications in order to receive treatment with Botox However, the documentation indicates that the patient has tried and failed anticonvulsants, antidepressants, and beta-blockers for prevention of migraine. The patient has also tried and failed Emgality and Qulipta. The record demonstrates that the member has chronic migraine and has failed standard therapies prior to the request for Botox.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Glioblastoma
Treatment: Balversa
The insurer denied Balversa.
The determination is upheld.

This is a patient with a history of glioblastoma who has received many lines of therapy in past including surgical resection, multiple rounds of radiation therapy, temozolamide, regorafenib and pembrolizumab. He now has further progression of disease. Tumor genomic profiling revealed fibroblast growth factor receptors-transforming acidic coiled-coil containing protein 3 (FGFR-TACC3) fusion. The treating oncologist is requesting erdafitinib (Balversa) for treatment as there are no other standard of care options for treatment of his disease. At issue is the medical necessity of the Balversa.

The requested treatment is not medical necessary. Erdafitinib is not Food and Drug Administration (FDA) approved for treatment for glioblastoma. Erdafitinib (erda) is an oral selective pan-FGFR tyrosine kinase inhibitor approved to treat locally advanced or metastatic urothelial carcinoma (UC) in adults with susceptible FGFR3/2 alterations (alt) who have progressed during or after greater than or equal to (>=) 1 line of platinum containing chemotherapy. There are no available therapies for patient who has received many lines of treatments for glioblastoma.
The current data, although limited phase II results, has shown efficacy of edrafatinib in glioblastoma with fibroblast growth factor receptor (FDFR) alterations. However, the phase II trial (RAGNAR) is still ongoing for final analysis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Giant cell arteritis. 
Treatment: Increase in Personal Care Services to 24 hours a day, 7 days a week (Split-shift), totaling 168 hours per week. 

The insurer denied: Increase in Personal Care Services to 24 hours a day, 7 days a week (Split-shift), totaling 168 hours per week. 

The denial is upheld. 

This is a case review for a female with medical history notable for heart failure, atrial fibrillation, chronic kidney disease stage 3, giant cell arteritis, and history of thoracic compression fracture secondary to long term steroid use. The patient is approved for 7 hours per day, 7 days per week (49 hours per week) of personal care services. The patient and her care team requested an increase to 24 hours per day (split-shift) 7 days per week (168 hours per week). 

A Uniform Assessment System (UAS) was completed and was available for review. Cognition is independent. She is alert and oriented times three and has 3/3 recall at five minutes. She is able to perform procedural tasks. From a functional status standpoint, she requires total dependence for meal preparation, housework, and managing finances. She requires maximal assistance for managing medications, stairs, shopping, and transportation. For her activities of daily living (ADL's), she requires maximal assistance for bathing. She requires extensive assistance for dressing lower body, walking, and toilet transfer. She requires limited assistance for locomotion and bed mobility. She is independent in hygiene, dressing upper body, toilet use, and eating. She was observed transferring from the bed to a wheelchair without assistance. She needs assistance with getting on and off the toilet. She is continent of urine and stool, although she does wear adult diapers. She has no pressure ulcer. Her family is overseas, and no one is available for informal support. An Hours Evaluation for Paraprofessional Support (HELPS) assessment tool recommended 29 hours per week over 7 days to address her functional needs. 

The requested Personal Care Services 24 Hours a day,7 days a week (Split-Shift), totaling 168 hours has not been demonstrated to be medically necessary for this patient. 
The patient is self-directing and independent in cognition. She requires assistance with many instrumental activities of daily living (IADL's). She requires some assistance with ADL's, but is independent in many areas. She was observed to safely make transfers by herself. The HELPS assessment recommended 29 hours per week to address her needs, and the health plan approved 49 hours per week. They recommended splitting this into two shifts per day to accommodate for some unplanned needs. She is continent of urine and stool and does not require turning and positioning in bed. There is no evidence provided of medical necessity for personal care services to be provided on a continuous 24-hour basis. The patient has many medical problems and has had frequent hospitalizations. She may have skilled nursing needs or safety monitoring needs which would be beyond the scope of personal care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Acquired absence of the kidney, kidney stones, diverticulosis, dysphagia, hypertension.
Treatment:  One indoor stairlift.

The insurer denied coverage for one indoor stairlift.  The denial is overturned.

This is an elderly female with chronic medical problems including glaucoma, dystonia and cerebellar ataxia.  She lives alone in a private residence.  Under review is the medical necessity for a requested stair lift.

The clinical records support the medical necessity of the requested stair lift.  The insurer's reasons for denial include "authorized ambulette 2-man assistance transportation services which provide safe transport up and down the stairs" is insufficient to deny the patient need to routinely ascend/descend stairs.  According to the Uniform Assessment System (UAS-NY) report, the patient's cognitive status is "Modified independence."  However, she requires extensive assistance for locomotion and ambulation.  Her functional ability has declined over the prior 90 days.  The patient's treating physician recommended a stair lift and her underlying medical conditions (cerebellar ataxia and dystonia) support the medical necessity of the requested home stair lift.  The physical therapist also submitted a letter recommending a stair lift for the patient.  He indicated "Stair negotiation, which is an area of focus in physical therapy, is becoming extremely difficult for the patient and is now unsafe for her to perform on her own.". 

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty based on the enclosed clinical records, the requested stair lift is medically necessary.  

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 one indoor stairlift services is substantiated.