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

Diagnosis: Demyelination.
Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.  The denial is upheld. 

This is a female with a past medical history of human papilloma virus (HPV), eczema, migraines, and hemorrhoids status post hemorrhoidectomy.  The patient presented to the Emergency Department (ED) with subjective complaints of atraumatic bilateral leg numbness and tingling for 1 week.  The physical examination revealed a normal range of motion, no swelling, and no tenderness.  The patient was alert and oriented to person, place, and time.  There was no nystagmus, lid lag, or ptosis.  Cranial nerves II through XII were grossly intact.  There was facial symmetry with no slurred speech or drooping.  There was facial sensation bilaterally that was intact along the maxillary, ophthalmic, and mandibular joints.  The patient was able to smile, frown, push cheeks against resistance, and shrug shoulders.  Nose to finger and rapid alternating movement was intact bilaterally.  The patient had full range of motion with 5/5 strength.  Sensation was intact in the bilateral upper and lower extremities.  The patient ambulated with a steady gait. Neurology was consulted, and it was decided that the patient was to be admitted. The patient's magnetic resonance imaging (MRI) of the brain without contrast revealed an enhancing hyperintense lesion in the dorsal spinal cord at the C2-C3 (cervical vertebrae numbers 2-3) level compatible with active demyelination.  It was noted that these findings are nonspecific but could represent additional foci of chronic demyelination.  The patient was to be treated with intravenous (IV) steroids twice a day for 5 days.  The patient was advised to undergo a lumbar puncture but the patient refused because her brother had complications from having a lumbar puncture in the past.  The patient became agitated and left against medical advice (AMA).

Based on the review of the medical record and literature, inpatient hospital admission was not medically necessary for this patient.  While this patient was admitted and was to be treated with intravenous steroids twice a day for 5 days, she could have undergone this treatment as an outpatient.  Furthermore, the physical examination prior to admission revealed a normal examination.  The records did not include documentation of neurologic findings requiring inpatient care, or acute demyelinating disease requiring inpatient care as indicated by intracranial hypertension or intracranial mass or process causing acute neurologic signs or symptoms, severe neuropathy or neuromuscular disease, or neurologic trauma requiring inpatient care.  Observation level of care was appropriate for this patient.  Therefore, the inpatient hospital admission is not considered medically necessary for this patient.  The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

The medical necessity for the inpatient hospital admission is not substantiated.  The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Appendicitis

Treatment: Inpatient stay

The insurer denied coverage for inpatient stay

The denial is upheld 

The patient is a female with no significant past medical history who presented to the Emergency Department (ED) with a 2 day history of abdominal pain. There was no associated nausea or vomiting. The patient had a computed tomography (CT) scan that indicated acute appendicitis with free fluid in the pelvis. The patient was afebrile. White blood cell (WBC) count was 12.6. The patient underwent an uneventful laparoscopic appendectomy. The tip of the appendix was noted to be perforated. There were no documented complications. The patient was discharged home.

Based on clinical documentation, the patient had acute appendicitis. The patient presented to the ED. The patient was admitted and underwent an uneventful laparoscopic appendectomy and was discharged. There are no reported complications after the procedure, and no clinical evidence indicating that the patient was unstable for discharge. Outpatient appendectomy is as safe and effective, with complication rates, readmission rates, and satisfaction equivocal to those patients kept in observation [1-3]. 

The hospital admission was not medically necessary. Admission may be necessary for patients with severe systemic illness (e.g., sepsis), poorly controlled comorbidities (e.g., chronic obstructive pulmonary disease, chronic heart failure), or complications from the procedure (e.g., infection, bleeding) that require more than 24 hours of postoperative care [1-3]. According to clinical documentation, there is no documentation to support inpatient admission for this patient. There is no documentation indicating that the patient was unstable for discharge. Peer-reviewed literature also indicates that laparoscopic appendectomy can successfully be performed as an outpatient procedure in those with uncomplicated appendicitis [1-3]. Suitable criteria for same-day discharge include hemodynamic stability, tolerating liquids, and pain controlled on oral medications [4, 5]. Per clinical documentation, all same-day discharge criteria were met. Therefore, the requested hospital stay should be upheld. 

The health care plan acted reasonably and with sound medical judgment and in the best interests of the patient.

The insurer's denial of coverage for the inpatient stay is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Supraventricular Tachycardia
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female with a past medical history significant for preeclampsia. The patient presented to the emergency room (ER) with new onset supraventricular tachycardia (SVT). The patient initially had a heart rate (HR) in 170's, converted to sinus tachycardia, was given intravenous (IV) fluids in the emergency room (ER) and was started on metoprolol. The patient's blood pressure (BP) was stable. The patient underwent an echocardiogram, which revealed left ventricular (LV) function at 50-55%. The patient was offered an electrophysiology (EP) study and ablation, but a decision was made to treat her medically and she was discharged on metoprolol, with a plan for outpatient follow-up.

No, the inpatient admission was not medically necessary.

This patient presented for evaluation of rapid heart rate and was found to have supraventricular tachycardia (SVT). The diagnosis of an acute myocardial infarct (MI) was ruled out by cardiac enzymes, which were negative. The patient converted to sinus tachycardia with medical therapy and was given intravenous (IV) fluids. There was no evidence of acute myocardial infarction, acute coronary syndrome (ACS), decompensated congestive heart failure (CHF), malignant arrhythmia or hemodynamic instability. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission and the care required could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems (Skeletal Class II, excessive overjet and overbite, overcrowding and ectopically erupting teeth). 

Treatment: Comprehensive orthodontic treatment and periodic orthodontic treatment visits (codes D8080 and D8670).

The insurer denied coverage for comprehensive orthodontic treatment and periodic orthodontic treatment visits (codes D8080 and D8670). 

The denial is overturned. 

This patient is a female child who presented for evaluation for orthodontic care.  The orthodontist identified Skeletal Class II, excessive overjet and overbite, overcrowding and ectopically erupting teeth.  The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 28 total points.  The insurer has denied coverage for orthodontic treatment as not medically necessary, stating that the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements.

Upon review of the submitted documentation (study models were not provided for review) it is evident that the patient exhibits a significant malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, an HLD index is utilized.  This index provides 6 specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.

In this case, the treating orthodontist does not claim an automatic qualifying condition and completes the second portion of the index arriving at 28 points to justify orthodontic care.  This reviewer concurs with the index completed by this orthodontist attaining a total of 28 points on the HLD index (i.e., 5 overjet, 6 overbite, 6 ectopic eruption, 5 anterior crowding, 6 labiolingual spread) which is above the threshold of 26 points to support orthodontic care.

The comprehensive orthodontic treatment and periodic orthodontic treatment visits (codes D808 and D9670) are considered medically necessary for this patient.

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

The carrier's denial of coverage for comprehensive orthodontic treatment and periodic orthodontic treatment visits (codes D8080 and D8670) should be overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Transverse myelitis
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay.
The determination is overturned in part.

This is a patient with well-controlled type two diabetes mellitus, hypertension, hyperlipidemia, and obesity who presented to the emergency room with lower extremity weakness. The patient also reported shocking sensations that radiated from his back down into his feet. The weakness progressed to the point where he was unable to walk. He also reported some incontinence. During his hospitalization, he was diagnosed with transverse myelitis. The transverse myelitis was appreciated on magnetic resonance imaging (MRI). The patient also underwent spinal fluid analysis that showed oligoclonal banding. The patient was treated with a five day course of intravenous Solu-Medrol. There was interval improvement in his leg strength. He was subsequently discharged to a subacute rehabilitation facility. At issue is the medical necessity of an inpatient stay.

An acute inpatient stay for the diagnosis of transverse myelitis is medically necessary in part. Transverse myelitis (TM) is considered a neurologic emergency. Acute transverse myelitis is a rare acquired neuro-immune spinal cord disorder that can present with the rapid onset of weakness, sensory alterations, and bowel or bladder dysfunction. TM can occur as an independent entity, usually as a post-infectious complication, but TM also exists on a continuum of neuro-inflammatory disorders.

The patient presented to the hospital with bilateral leg weakness and sensory changes. In a neurologic examination, the patient had less than or equal to 3/5 strength in the legs and feet. An MRI of the spinal cord showed multifocal transverse myelitis. Guidelines recommend "urgent spine imaging". The patient was then treated with high-dose intravenous glucocorticoid treatment. Per guidelines, glucocorticoid treatment should be initiated as soon as possible; there are relatively few contraindications. Thus, a clinician does not need to wait for the workup to be complete before initiating therapy. The preferred regimens are methylprednisolone (30 milligrams (mg/kg) up to 1000 mg daily) or dexamethasone (120 to 200 mg daily for adults) for three to five days. There is only support for acute inpatient hospitalization from day one of admission through day five. While the patient was noted to have a pulmonary embolism, this finding was incidental. The patient was not hypoxic and did not have hemodynamic instability on account of the pulmonary embolism. The treatment of this incidental pulmonary embolism included anticoagulation, which can be accomplished with oral medications or injectable medications, such as Lovenox; this care does not require an inpatient level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left ureteral stone/renal colic.
Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.  The denial is upheld. 

This is a male patient with past medical history of renal stones and gastroesophageal reflux disease (GERD) who presented to the Emergency Department (ED) complaining of left flank-back pain for one day worsening over the past one hour.  The patient had been seen in the same ED earlier that day for the same complaint.  The patient was diagnosed with kidney stone as confirmed by his computed tomography (CT) scan.  The patient's pain returned after leaving the ED earlier that day.  The patient was given intravenous (IV) fluid bolus in the ED, and various IV medications.  The patient's CT scan showed left hydronephrosis due to 6 millimeter stone in the left mid ureter.  The patient was admitted for further management of the left ureteral stone/renal colic.  Urology consult was obtained, and possible stent placement was planned.  The patient improved and was cleared for discharge home with outpatient urology follow-up in one week.  

Per the clinical guidelines of Milliman Care Guidelines (MCG) Health (24th Edition) Renal Colic + Kidney Stones, the patient fails to meet clinical indications for admission to inpatient care.  These include hemodynamic instability, acute renal failure, bilateral obstruction, urinary tract infection (UTI), severe or persistent vomiting, etc.  However, the patient does meet guidelines for observation care for his insufficient pain relief in the ED setting. 

The inpatient hospital admission was not medically necessary.

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

The carrier's denial of coverage for the inpatient hospital admission should be upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain and Hypertension.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male. At the time of admission to the hospital he had a past medical history significant for hypertension (HTN), dyslipidemia, diabetes, and non-compliant with medical therapy. The patient presented for evaluation of elevated blood pressure and chest discomfort for two days duration.

The patient was hypertensive on admission with a blood pressure of 210/107. His troponin was 0.04 on serial measurements. The electrocardiogram (ECG) revealed no acute ischemic changes. The patient was admitted to telemetry. He was seen in consultation by cardiology specialist, and it was felt there is no evidence of acute myocardial infarction (MI), and his presentation was due to demand ischemia due to hypertension and non-compliance with medical therapy. He was started on oral antihypertensive medications and his blood pressure improved. Echocardiogram revealed normal left ventricular (LV) systolic function. He was discharged home the next day with a plan for outpatient follow-up.

No, the proposed inpatient admission was not medically necessary.

This patient presented for evaluation of chest pain and hypertension due to non-compliance with medications. There was no evidence of acute myocardial infarction, acute coronary syndrome (ACS), decompensated congestive heart failure (CHF), malignant arrhythmia or hemodynamic instability. The blood pressure improved with restarting of blood pressure medications. No further ischemic work-up in the hospital setting was planned and the patient was discharged home the next day. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission and the care required could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic Dermatitis.
Treatment: Dupixent.

The insurer denied the Dupixent.  The determination is upheld.

The patient has severe atopic dermatitis (over 70% body surface area involvement associated with flareups) of the face, extremities, and trunk. Methotrexate was tried but not tolerated due to diarrhea, nausea, and vomiting. The patient is currently on Claritin in the morning and Atarax in the evening, as well as topical Eucrisa, Protopic 0.03% ointment. The patient was previously using 2.5% hydrocortisone and 0.1% triamcinolone. Phototherapy has been avoided because of the patient's parents having severe neurologic medical problems that prevent frequent travel.

At issue is the medical necessity of Dupixent.

The Dupixent is not medically necessary.

Dupixent is only FDA-approved and literature-supported [1-4] for moderate to severe atopic dermatitis patients 6 years of age or older. Safety issues exist in younger patients (children and adolescents) with more severe atopic disease with respect to flaring of head/neck and ocular atopic symptoms, and insufficient evidence exists to conclude that Dupixent has favorable short-term and long-term outcomes and efficacy for patients less than 6 years of age. Other oral agents have not been used that--unlike Dupixent--have been reported for safe and effective treatment for this very young age. Phototherapy may be a challenge but is more time-tested than is Dupixent. Accordingly, other treatments that are better proven to benefit this patient have not yet been tried and are more the standard of care than Dupixent.

Dupixent is therefore not medically necessary for this patient's treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Pharmacy/Prescription Drug. 

The insurer denied: Stelara SQ 90 milligrams. 
The denial is upheld in whole. 

The patient is a female. She has a history of Crohn's disease (CD). She has mild anemia noted in her laboratory studies. No further treatment history provided. The requested service is Stelara dose escalation to 90 milligrams (mg) every 4 weeks. 

The health plan's determination is upheld. 

Stelara at 90 mg every 4 weeks is not medically necessary based on the provided records. Stelara is Food and Drug Administration (FDA) approved for the treatment of Crohn's disease and ulcerative colitis in adults. The use of Stelara is reasonable and appropriate in this case. The standard and FDA approved dose is 90 mg every 8 weeks. 
It is common for patients with inflammatory bowel disease to lose response to their biologic over time or to require higher than standard dosing. Dose escalation is recommended when patients fail to adequately respond to the standard dose. 
Per Ollech, Jacob E., et al: "Shortening the ustekinumab (UST) 90 mg dose interval to 4 weeks for patients with CD who did not respond to doses every 8 weeks improved clinical and biological indices of disease activity. Patients who lose response to the standard dose of ustekinumab might benefit from dose interval shortening, which was effective and safe." Per Cohen, Erica et al: "A majority of patients with moderate to severe CD benefited from UST dose escalation suggesting the clinical utility of optimizing dosing in the treatment course. 

However, the provided records do not indicate that this patient has tried and failed the standard dose of Stelara. Therefore, medical necessity of the requested dose cannot be established.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lyme disease.
Treatment: Polymerase Chain Reaction (PCR) Testing for Lyme Disease.
The insurer denied coverage for Polymerase Chain Reaction (PCR) Testing for Lyme Disease.
The denial is upheld. 

This is a male patient who was seen via telemedicine with malaise and tick bites to the abdomen. The patient was empirically treated with oral doxycycline.  Both standard serology for Lyme and Polymerase Chain Reaction (PCR) were ordered.  The Polymerase Chain Reaction (PCR) test is under review.

Per Centers for Disease Control and Prevention (CDC, 2019), "CDC currently recommends a two-step testing process for Lyme disease. Both steps are required and can be done using the same blood sample.  If this first step is negative, no further testing is recommended. If the first step is positive or indeterminate (sometimes called "equivocal"), the second step should be performed.  The overall result is positive only when the first test is positive (or equivocal) and the second test is positive (or for some tests equivocal)."

Per Eldin et al. (2019), "Lyme disease is a tick-borne bacterial disease with polymorphic clinical manifestations (cutaneous, rheumatological, and neurological)... All guidelines indicate that the diagnosis is currently based on a two-tier serology at all stages of the infection, except for the early localized dermatological presentation known as Erythema migrans.  One text of so-called guidelines has discordant recommendations when compared with the other guidelines, possibly explained by its low quality score.  Contrary to the intense debate taking place on the Internet and in the European and American media, our analysis shows that the great majority of medical scientific guidelines with a high quality score, agree on the clinical diagnostic methods of Lyme disease."      

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome. Polymerase Chain Reaction (PCR) Testing for Lyme disease does not have final approval from the appropriate regulatory bodies for this diagnosis. Thus, the patient is not a good candidate for Polymerase Chain Reaction (PCR) Testing for Lyme disease. The patient was seen for malaise and tick bites to the abdomen.  At this time, medical societies do not recommend the use of Polymerase Chain Reaction (PCR) blood testing for Lyme disease.  Polymerase Chain Reaction (PCR) blood testing for Lyme disease is not approved or accredited for diagnostic measures.  Standard serology is considered medically appropriate for this clinical scenario.  

The requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of coverage for Polymerase Chain Reaction (PCR) Testing for Lyme Disease should be upheld.