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

Diagnosis: Right periorbital swelling, bruising, pain, lacerations to his right eyelid. 
Treatment: Inpatient Hospital Services. 

The insurer denied: Inpatient Hospital Services. 
The denial is overturned. 

The patient is an adult male for whom coverage of the inpatient level of care is the subject of review from an ophthalmologic perspective. The patient presented with right periorbital swelling, bruising, pain, headache and lacerations to his right eyelid after a fist fight while incarcerated. Computed tomography (CT) of the head revealed a fracture of the medial and inferior wall of the orbit with significant swelling and bruising noted. The patient's eyelid lacerations were evaluated, and it was noted that there was right subconjunctival hemorrhage and chemosis along with a mucosal opacity of the right maxillary and ethmoid sinus that may represent a traumatic hematoma. No intervention was recommended by oral and maxillofacial surgery (OMFS) for fractures. The patient was admitted with a plan of care including intravenous (IV) and oral pain control, oral antibiotics, and home medication. The patient was evaluated by ophthalmology, and it was recommended that the patient's laceration be repaired once soft tissue edema improved. Vision was 20/70 oculus dexter (OD; right eye) and 20/30 oculus sinister (OS; left eye). On day #2, lacerations were repaired with recommendations for continued pain control, wound care, antibiotics, and social worker referral for a safe discharge. The patient was discharged on the day after once treated with additional Toradol. 

The proposed inpatient hospital services were medically necessary. 

The records provided support that this patient had ocular injury or trauma requiring intravenous (IV) pain control beyond the scope of observation care which is generally considered no more than 48 hours. This patient required a three-day stay for which he was treated with antibiotics and wound repairs once edema decreased, and intravenous (IV) pain medication (Toradol) was required daily through the date of discharge.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diarrhea
Treatment: Full hospital admission
The insurer denied coverage for the full hospital admission.
The denial is overturned.

This patient is an adult patient with past medical history significant for hypertension, chronic obstructive pulmonary disease, and aortic dissection who presented to emergency department with complaints of shortness of breath, abdominal pain, and loose bowel movements. 

Vitals on presentation included: Temperature 102.1 degrees Fahrenheit, Blood Pressure 160/83, Heart Rate 111, Respiratory Rate 22, Oxygen saturation 98% on room air. Laboratory results showed: White Blood Count (WBC) 9.4, Hemoglobin (Hgb) 14.3, Hematocrit (Hct) 43.3, Creatinine 1.6, Glucose 103, Lactic Acid 2.4, Alkaline Phosphatase 248, and Troponin 82.1.

The patient was empirically started on antibiotics (Levaquin and metronidazole) for possible infectious diarrhea. A Computed tomography (CT) scan of abdomen/pelvis showed thickening of the ascending colonic and cecal wall, representing possible focal colitis. Cultures were negative. The patient improved clinically, remained afebrile, and hemodynamically stable. The patient was discharged to continue oral antibiotics as an outpatient. 

According to medical records, the patient presented with fever, diarrhea, and abdominal pain. Laboratory results were notable for elevated creatinine, alkaline phosphatase, and troponins. Based on the above findings, inpatient admission was medically necessary for administration of intravenous fluids, antibiotics, and cardiac evaluation. 

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 full hospital admission is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Systemic lupus erythematosus, inflammatory arthritis, malar rash, photosensitivity, oral ulcers and Raynaud's phenomenon
Treatment: Sildenafil 20mg (milligrams)
The insurer denied: Sildenafil 20mg (milligrams)
The denial is overturned

The patient is an adult female with systemic lupus erythematosus (SLE) and Raynaud's syndrome. She is currently treated with Benlysta infusions, Plaquenil, Celebrex and sildenafil 20 mg (milligrams) daily. For her Raynaud's symptoms, she failed treatment with the calcium channel blockers amlodipine and nifedipine, as well as topical nitroglycerin. Her Raynaud's symptoms have been successfully managed with sildenafil 20 mg (milligrams) daily since one and a half years ago, which was approved by her prior insurance. She held treatment with sildenafil after cholecystectomy and appendectomy and her provider now wishes to resume sildenafil in the setting of increased Raynaud's symptoms. Sildenafil was denied coverage by the health plan for this patient, because Raynaud's syndrome is not an FDA (United States Food and Drug Administration)-approved indication for sildenafil. The appeal is for sildenafil for the treatment of Raynaud's syndrome.

The health plan should cover the requested sildenafil for the treatment of Raynaud's syndrome.

This patient with SLE (systemic lupus erythematosus) and Raynaud's syndrome failed treatment with the calcium channel blockers amlodipine and nifedipine, as well as topical nitroglycerin. Her Raynaud's symptoms have been successfully managed with sildenafil 20 mg (milligrams) daily for a year and a half which was approved by her prior insurance. She held treatment with sildenafil after cholecystectomy and appendectomy and her provider now wishes to resume sildenafil in the setting of increased Raynaud's symptoms. Although sildenafil is not FDA (United States Food and Drug Administration)-approved for the treatment of Raynaud's syndrome, per Sildenafil: Drug information, Lexicomp, Raynaud's syndrome is an acceptable off-label indication for sildenafil. Per a recent UpToDate review, low-dose phosphodiesterase 5 (PDE) inhibitors such as sildenafil may be used in patients with uncomplicated Raynaud's phenomenon in whom calcium channel blockers are not tolerated. A meta-analysis of six randomized trials found that there was a modest benefit of PDE (phosphodiesterase) inhibitors (sildenafil, tadalafil and vardenafil) on the frequency and duration of Raynaud's phenomenon attacks. Therefore, resuming sildenafil for the treatment of Raynaud's phenomenon in this SLE (systemic lupus erythematosus) patient who failed treatment with amlodipine, nifedipine and as topical nitroglycerin is clinically appropriate and in accordance with standard of care in the medical community. Therefore, the health plan should cover the requested sildenafil for the treatment of Raynaud's syndrome.
The requested sildenafil for the treatment of Raynaud's syndrome is more beneficial than standard of care calcium channel blockers and topical nitroglycerin.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: collapsed left arch.
Treatment: Custom Shoe Inserts.
The insurer denied: Custom Shoe Inserts.
The denial is: Upheld.

The patient is a female who presented to her podiatrist's office complaining of pain and discomfort in the medial arch of her left foot. The patient has had pain for over 3 months. On exam, the patient is noted to have her left arch collapsed with calcaneovalgus deformity. The patient was diagnosed with posterior tibialis tendonitis. The patient was recommended icing and arch supports (custom inserts). The patient has modified her activities and done stretching. The subject under review is the medical necessity for the custom shoe inserts.

The health plan's determination is upheld.

The requested health custom shoe inserts are not medically necessary for this patient. The documentation does not support the medical necessity of the custom inserts. The patient has had pain for over three months and was diagnosed with posterior tibialis tendon dysfunction. The patient has tried stretching and modifying her activities. She has worn custom molded orthotics in the past. There is no documentation of objective findings of pain to the left foot. There is no documentation of a trial of anti-inflammatory or pain medications. There is no documentation of a trial of physical therapy. Thus, the requested custom molded orthotics are not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neck Pain.
Treatment: Inpatient Hospital Admission.

The insurer denied the Inpatient Hospital Admission.  The denial is overturned.

The patient is an adult male. The patient had complaints of neck pain and is status post cervical surgery. The patient had an inpatient hospital admission. The patient has a past medical history of bipolar disorder, depression, and substance abuse. The patient had a three-year history of posterior neck pain, which is worse on the left. The patient had radiation into the left biceps and posterior headaches. MRI (magnetic resonance imaging) of the cervical spine showed cervical kyphosis with stenosis present at C4-5 and C5-6 and increased T2 signal within the spinal cord at C4-5. The patient had a diagnosis of cervical spinal stenosis at C4-5 and C5-6 with myelopathy. The patient had surgery for anterior cervical diskectomy and fusion of C4-5 and C5-6 on the day of admission. The patient was seen by a nutritionist for a 17-pound weight loss on the few weeks leading up to surgery. The patient had been skipping meals recently. The patient participated in physical therapy and was cleared from physical therapy, and the Penrose drain was removed. The patient was discharged to home. This is a review for the inpatient level of care for this patient.

The Inpatient Hospital Admission was not medically necessary.

Inpatient admission would not be standard of care or clinically appropriate based upon the clinical circumstances for this case. This is an outpatient procedure. The patient did not have any complications or require additional treatments related to the surgery that would support the need for an inpatient level of care. Furthermore, the patient did not have any additional diagnoses that require additional treatments that would support a higher level of hospital care. Thus, based upon the information provided and the clinical course, the surgery postoperative care would not require inpatient services. As such, the Inpatient Hospital Admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Osteomyelitis.
Treatment: Continued sub-acute rehabilitation.
The insurer denied: Continued sub-acute rehabilitation.
The denial is: Overturned in part.

The patient is a male with past medical history significant for hypertension, uncontrolled hyperglycemia, Parkinson disease, diabetes mellitus, osteomyelitis, peripheral vascular disease and schizophrenia who was admitted secondary to sepsis and right foot abscess status post surgical treatment of his right hallux by amputation. The patient was treated with intravenous antibiotics, along with skilled physical and occupational therapies.
The subject under review is the medical necessity for continued sub-acute rehab services. This was denied by the health plan based on lack of medical necessity.

The health plan's determination is overturned in part. 

The requested continued sub-acute rehabilitation is medically necessary in part. 
This patient with multiple medical problems was admitted for diabetic ulcer, osteomyelitis, status post amputation for treatment of the ulcer initially with IV antibiotics, wound care physical and occupational therapy.
Services were denied by the patient's insurance stating the following, criteria are not met because a note show that you have gotten better with therapy. Clinical notes state that your condition has improved, however your doctor thought that your wound was re-infected and started antibiotics for you again. The medical notes show that you will complete the antibiotics. You need little help getting dressed. You can bathe with a small amount of help. You can feed self with a little help. You can get out of a bed or chair with a small amount of help. You need a small amount of help with walking 90 feet and you can climb 8 steps with little bit of help. The notes show that you can go home once your antibiotics are completed. You do not need to stay in skilled nursing facility for therapy. Based upon the notes, you can get skilled services and therapy safely in a lower level of care if needed.
The plan approved additional dates of service.
IV antibiotics for infected diabetic foot wound were restarted with vancomycin and Cefepime with the treatment duration of 1 week.
As per the documentation, the patient's physical status has improved especially in regard to physical and occupational therapy. The patient can function in an alternate location with mild assistance. Currently the patient lives with family members and has a home health aide 4 hours a day 5 days a week. He has several steps (less than [<]10) into his residence, which he should be able to navigate according to physical therapy (PT). Continued inpatient skilled care is medically necessary until the completion of antibiotics. Therefore, inpatient skilled care would not be medically necessary after this. The patient requires no other ongoing skilled services that cannot be provided in a lower level of care setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Altered mental status (AMS) and leukocytosis of unknown source
Treatment: Inpatient hospital admission 
The insurer denied coverage for the inpatient hospital admission.
The denial is overturned.

The adult patient, with a past medical history significant for severe developmental disabilities, presented to the emergency room with complaints of a change in behavior and altered mental status.

Vitals on presentation included: Temperature 97.3 degrees Fahrenheit, Blood Pressure 124/81, Pulse 126, Respiratory Rate 18, Oxygen saturation 99% (percent) on Room Air. Laboratory results included the following: White blood cells (WBC) 18.97, hemoglobin (Hgb) 13.2, creatinine 0.99, glucose 106, lactate 1.6.

Computerized tomography (CT) scan of the head showed no evidence of acute intracranial hemorrhage or acute territorial infarction. CT scan of abdomen/pelvis showed no acute findings. The patient was empirically started on antibiotics (Zosyn) and was treated with Droperidol and Ativan for agitation. The patient improved clinically, remained afebrile and hemodynamically stable. She was discharged to continue outpatient management.  

Based on above findings in a high-risk patient with severe underlying disabilities, hospital admission was required for monitoring and additional diagnostic management.   

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

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

Diagnosis: Language Disorder due to Apraxia of Speech
Treatment: Speech Generating Device
The insurer denied the speech generating device.
The determination is upheld.

The male patient has severe expressive language disorder due to Childhood Apraxia of Speech, and a mild receptive language delay. The speech therapist's letter describes that the patient is "functionally severe-profoundly delayed with regards to expressive communication." She performed an Augmentative and alternative communication (AAC) evaluation and recommended that he be provided with the E2510 Nova Chat 10, a speech generating device. The speech therapist's report was requested several times but was not received. At issue in this review is the medical necessity for a speech generating device.

The speech generating device is not medically necessary for this patient based on the information provided. The reviewer did not receive the requested speech therapy and AAC evaluation. The speech therapist's report was requested several times. The reviewer does not have the necessary information to determine the severity of the expressive language delay, nor his ability to effectively use an AAC device. 

If a patient has documented severe childhood apraxia of speech and has demonstrated the ability to learn how to communicate with a speech generating device, the device would be medically necessary. Oommen, et al [1] discusses that "In childhood apraxia of speech (CAS), children exhibit varying levels of speech intelligibility depending on the nature of errors in articulation and prosody. Augmentative and alternative communication (AAC) strategies are beneficial, and commonly adopted with children with CAS."

A Position Statement by the American Speech-Language-Hearing Association (ASHA) [2] states that "Eligibility policies and practices often preclude children and adults with severe disabilities from accessing needed communication services and supports." The authors continue "It is the position of the National Joint Committee for the Communication Needs of Persons With Severe Disabilities that eligibility for communication services and supports should be based on individual communication needs. Communication services and supports should be evaluated, planned, and provided by an interdisciplinary team with expertise in communication and language form, content, and function, as well as in augmentative and alternative communication (AAC)." However, the reviewer lacks the necessary speech therapy and AAC assessment necessary to determine the medical necessity of the requested health service/treatment of speech generating device for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Kidney stone
Treatment: Inpatient admission
The insurer denied coverage for the inpatient admission.
The denial is upheld.

The patient is an adult female who was admitted for worsening flank pain. She was found to have right kidney stone with hydronephrosis and was evaluated by urology. She was treated with intravenous (IV) antibiotics, fluid and pain medication and underwent cystoscopy with stone removal and stent placement. She was discharged in stable condition.

Inpatient admission was not medically necessary per evidence-based literature.
A systematic review and meta-analysis including 23 randomized controlled trials (2458 patients) found that outpatient therapy in addition of medical expulsive therapy (with alpha blocker) to extracorporeal shock wave lithotripsy (ESWL) in ambulatory settings in patients with renal or ureteral stones improved expulsion rates, reduced time to stone clearance, and reduced pain [1].

Analysis of a national database that included over 3.6 million visits to the emergency department for renal or ureteral stones found that 12% (percent) of patients required inpatient admission [2].

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 the inpatient admission services is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe Hyponatremia
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is overturned.

The patient presented with dizziness, diffuse weakness, and nausea and was afebrile with the vital signs stable. The abdominal exam was benign. The sodium was 118. Intravenous (IV) hydration with normal saline was given. Symptoms were felt to be related to dehydration. The following day the sodium went up to 124.

Clinical indications for admission for Dehydration per Milliman Care Guidelines (MCG M-123) include having severe electrolyte abnormalities. A sodium less than 130 that is not corrected to near normal after observation is an indication for admission.

MCG guideline lists indications for admission for Systemic or Infectious Conditions. Severe electrolyte abnormalities are an indication for admission. This is defined by a sodium less than 130 that is not corrected to near normal after observation.

This patient had severe hyponatremia and was symptomatic, the sodium was down to 118. Even by the next day, the sodium was only up to 124. This is significantly below the near normal range. The patient required close monitoring for the sodium of 118.  MCG criteria were met for admission for both Dehydration and Systemic or Infectious Conditions.

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: Overturned

Diagnosis: Chronic Low Back Pain. 
Treatment: Outpatient procedures (64483 x 1 and 64484 x 1). 
The insurer denied coverage for outpatient procedures (64483 x 1 and 64484 x 1). 
The denial is overturned. 

This adult gentleman has chronic low back pain with radiation to his left leg. He has had Physical Therapy and a trial of nonsteroidal anti-inflammatory drug (NSAIDs). His magnetic resonance imaging (MRI) shows a prior lumbar (L) 4-L5 hemilaminectomy, disc protrusions at L3-L4, L4-L5 and L5-S1. He had a transforaminal Epidural Steroid injection (TFESI) which gave him greater than 90% (percent) pain relief for almost a year. He had a repeat TFESI which gave him greater than 90% pain relief.  The Health Plan states that the 2nd injection was not medically necessary since it exceeded policy criteria. 

Evidence based clinical practice guidelines (1) support the use of epidural steroid injections without a one-year limitation.  Similarly, the utility of Epidural Steroid Injections is supported by a Cochrane review (2).  There is no evidence-based guideline that limits therapy months. The injection was medically reasonable and 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 outpatient procedures (64483 x 1 and 64484 x 1) services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever

Treatment is an inpatient admission. 

The insurer denied coverage for an inpatient admission. 
 
The denial is upheld.

The patient is an adult female with a benign past medical history who presented to the emergency department (ED) with complaints of subjective fevers, chills, and body aches. Vitals on presentation included a Temperature of 99.5 Fahrenheit, blood pressure 111/62, hear rate 68, respiratory rate 18, and oxygen saturation 97% (percent) on room air. Laboratory values were notable for a white blood cell (WBC) count of 2.4, hemoglobin 13.2, hematocrit 38.3, platelet 90, creatinine0.8, and a glucose of 91. The chest x-ray was negative.

The patient was admitted for evaluation of rash and fever. She was empirically started on antibiotics (intravenous Rocephin and oral doxycycline). Infectious Diseases was consulted, and their impression was possible tick-borne infection. The patient remained afebrile, hemodynamically stable, and clinically improved. She was discharged to continue outpatient management. 
 
According to documentation, the patient presented with subjective fevers and myalgia. Otherwise, she was afebrile, hemodynamically stable, with laboratory results suggestive of a viral syndrome including leukopenia. Their clinical impression was a viral syndrome versus a tick- borne etiology (e.g., Lyme disease). Based on above findings, the patient met criteria for observation level of care. The patient did not meet criteria for an acute hospital admission.

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

The insurer's denial of coverage for the full hospital admission is upheld. Medical necessity is not substantiated.