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

Diagnosis: Clostridium difficile.
Treatment: Inpatient admission.
The insurer denied coverage for inpatient admission.
The denial is upheld.

The patient is an adult with a past medical history significant for clostridium difficile (C. diff.), hypertension, obesity, and scoliosis who presented to the emergency room with complaints of diarrhea and fever. 

Vitals on presentation included Temperature 97.6 degrees Fahrenheit, blood pressure 146/75, pulse 97, respiratory rate 14, and oxygen saturation 98% (percent) on room air. Laboratory results included white blood cell count (WBC) 13.56, hemoglobin 12.9, hematocrit 40.7, potassium 4.4, creatinine 0.67, and a glucose of 120.

The patient was started on intravenous fluids and evaluated by Infectious Diseases for possible refractory C. diff. infection. The patient had recently been hospitalized and discharged home on oral vancomycin. A Computed Tomography scan of the abdomen/pelvis showed pancolitis. The patient was started on fidaxomicin. 

The patient improved clinically, remained afebrile and hemodynamically stable. The patient was discharged to continue outpatient management.

According to the documentation, the patient presented with diarrhea despite treatment with oral vancomycin. Otherwise, the patient was afebrile, and hemodynamically stable. Laboratory was notable only for a mildly elevated WBC. The patient was described as comfortable, no distress, and no signs of systemic toxicity. Severity of C. Diff. can be assessed based on clinical and laboratory findings. "Non-severe C. Diff." includes WBC < (less than) or = (equal to) 15,000 cells/milliliter and serum creatinine <1.5. Additionally, the patient did not have evidence of shock, hypotension, or megacolon. Based on above findings, the patient met criteria for observation level of management.

Prior determination of denial of inpatient stay is upheld.

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 is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Decreased mobility
Treatment: Personal Care Worker (PCW) Services: 7 Days per Week, 12 Hours per Day - Total of 84 Hours per Week. 
The insurer denied Personal Care Worker (PCW) Services: 7 Days per Week, 12 Hours per Day - Total of 84 Hours per Week. 
The health plan's determination is upheld. 

This is a case review for a female with medical history notable for mobility issues and incontinence. The patient's physician provided a brief note for this appeal. The letter lists the patient's medical conditions, which include gait difficulty, frequent falls, leg edema, chronic pain, and multiple orthopedic conditions. She has had several hospitalizations within the past year. The letter then requests to "please give her whatever consideration you can." There is no discussion of unmet personal care needs.

Personal Care Worker (PCW) Services: 7 Days per Week, 12 Hours per Day - Total of 84 Hours per Week is not medically necessary for this patient.

The patient has mobility issues related to multiple orthopedic conditions. Her personal care needs are greatest for her Instrumental activities of daily living (IADL). She does require some assistance for activities of daily living (ADL). The notes discuss issues with toileting at night, but this need was apparently supposed to be addressed with the aid of durable medical equipment (DME) to allow her to toilet at night without hands-on assistance. There is no clear documentation regarding which personal care needs, if any, are not being met at the current allotment of daytime hours. Her Uniform Assessment System (UAS) did not demonstrate any significant interval decline in functioning. Her current hours are greater than that recommended by the task tool.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a female patient with a past medical history (PMH) of major depressive disorder (MDD) and attention deficit hyperactivity disorder (ADHD) who was admitted with c/o (complaints of) left foot pain and swelling after suffering a puncture wound on a beach. Her vital signs were notable for a pulse of 113. The physical exam was notable for mild distress, left foot erythema. Lab work was notable for a white blood cell count (WBC) of 16.2. Imaging studies included a left foot radiograph which showed moderate dorsal forefoot swelling, a left lower extremity (LLE) ultrasound (US) which showed no deep vein thrombosis (DVT). The patient was diagnosed with LLE cellulitis and was treated with intravenous (IV) antibiotics and observation. The patient received 23 hours of antibiotics without improvement and was admitted to inpatient. Magnetic resonance imaging (MRI) demonstrated a possible foreign body, and the patient underwent an operative removal of the foreign body. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

The hospital stay was medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with c/o (complaints of) LLE (left lower extremity) swelling and erythema associated with a puncture wound. Given the patient's presentation, she met sepsis criteria with tachycardia and leukocytosis, met the Infectious Diseases Society of America (IDSA) definition of severe cellulitis, and the expected length of stay was greater than 48 hours. In addition, the patient was initially admitted to observation but did not clinically improve with appropriate antibiotics and eventually underwent an invasive surgical procedure for a foreign body removal. Overall, this distressed patient presented with cellulitis associated with a retained foreign body, suggesting that the patient required immediate treatment for her infection with intravenous antibiotics and acute surgical intervention and that an inpatient level of care was require for safe medical evaluation and treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Appendicitis. 
Treatment: Inpatient Admission. 
The health plan denied: Inpatient Admission. 
The determination is: Overturned. 

The patient is a male who presented to the emergency room (ER) with complaints of right lower quadrant (RLQ) abdominal pain. His white blood cell (WBC) count was 14.8. A computed tomography (CT) scan revealed acute uncomplicated appendicitis. The patient was made nothing by mouth (NPO) status and supported with intravenous fluids (IVF) and intravenous (IV) antibiotics. A decision was made to proceed with a laparoscopic appendectomy. Surgical intervention was not possible until late the next day, which was uncomplicated. The patient was able to tolerate oral intake, with stable vital signs, pain controlled with oral medications, and was discharged home the day after surgery. 

At issue is the medical necessity of the inpatient admission. 
The health plan's determination of medical necessity is overturned in whole. 
The requested health service/treatment of inpatient admission was medically necessary for this patient. In general, acute uncomplicated appendicitis can be considered in an ambulatory or observation setting. This patient was unable to be accommodated in the operating room (OR) despite being added on until the late evening on the second day. The patient was supported with IVF, IV antibiotics (which would also have been the treatment for non-operative management), and IV pain medications. Surgical appendectomy was not able to be performed within a 23-hour window, and 2 acute inpatient days were required to provide IVF, IV antibiotics, and pain medication to support this patient. The patient, however, could not have been discharged to home or a lower level of care.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Pelvic varices
Treatment: vascular embolization or occlusion
The health plan denied the vascular embolization or occlusion.
The health plan's determination is upheld.

This is a female patient with a history of diverticulitis, fibroids, and an ovarian cyst who presented with several weeks of left sided pelvic pain. A magnetic resonance (MR) study showed an 8-millimeter (mm) left ovarian vein with pelvic varicosities. The provider wishes to perform ovarian vein venography with possible ovarian vein embolization. At issue is whether the vascular embolization or occlusion is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The vascular embolization or occlusion is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. There is a lack of peer-reviewed literature supporting a better outcome with ovarian vein embolization as a treatment for pelvic pain compared with other standard medical treatments.
The body of evidence in the peer-reviewed medical literature regarding embolization of the Ovarian Vein or Internal Iliac Veins for the treatment of pelvic congestion syndrome (PCS) is insufficient and poor quality. While some studies suggest favorable results of embolization for the treatment of PCS, additional well-designed randomized controlled trials are necessary to establish the relative safety and efficacy of the embolization procedure.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Pelvic varices
Treatment: vascular embolization or occlusion
The health plan denied the vascular embolization or occlusion.
The health plan's determination is overturned.

This is a female patient with sharp left sided pelvic pain that limits standing and walking. She has followed up with a gynecologist (GYN). Imaging shows a dilated left ovarian vein and prominent pelvic veins. At issue is whether the vascular embolization or occlusion is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The vascular embolization or occlusion is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. There is no other reasonable diagnostic or treatment option other than pelvic/ovarian venography and embolization, given the patient's symptoms and imaging findings. There are numerous studies showing a greater than 80 percent (%) symptom improvement rate. Larger studies have shown greater than 90% symptom relief.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Pelvic varices
Treatment: vascular embolization or occlusion
The health plan denied the vascular embolization or occlusion.
The health plan's determination is overturned.

This is a female patient with history of symptomatic pelvic varices. There is a request for treatment authorization for the performance of a bilateral pelvic venogram with embolization. She is in reasonable overall health. Medications were reviewed. Treatment was reviewed. The past medical history noted lifestyle limiting and debilitating pain especially at the left pelvis, diverticulitis, fibroid uterus and an ovarian cyst. She had a previous cardiac ablation for trigeminy, chronic venous insufficiency symptoms. Previous imaging reports were reviewed. The past surgery history was reviewed and included abdominal surgery. Lab work was noted. Repeat imaging of the pelvis with magnetic resonance imaging (MRI) was planned. The current treatment plan would be pelvic bilateral venography and venous embolization as requested. At issue is whether the proposed health service or treatment vascular embolization or occlusion is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The proposed health service or treatment, bilateral gonadal vein vascular embolization or occlusion is likely to be more beneficial than any other standard treatment or treatments for the insured's life threatening or disabling condition or disease, namely symptomatic pelvic varices.
The patient's condition is quite disabling for her and other treatment options are not reasonable. An expected alternative treatment plan of hysterectomy is not reasonable. The alternative of hormone therapy or other medication therapies or other conservative approaches can be contraindicated by side-effects. Venous embolization is the best alternative. The minimally invasive procedure would be low risk with high expected success and with few complications.
The proposed treatment of embolization with venography is recommended as being safe, effective, with little risk or morbidity. The benefit would be control of the patient's symptoms by shrinkage of the varicosities. The proposed treatment would be expected to provide a positive effect on this member's condition and wellbeing.
Pelvic varices are a disabling diagnosis and a medical problem that requires a meaningful treatment attempt. Ovarian and pelvic venous embolization can help this patient's symptoms and thereby improve her health and is likely to be more beneficial to the patient.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Psoriasis

Treatment: Vtama 1% (percent) cream

The insurer denied coverage for 

The denial is overturned.

 
The patient is an adult with a diagnosis of psoriasis vulgaris. The patient has failed therapy with topical high potency steroids, halobetasol as well as tacrolimus ointment. The patient has failed numerous other topical agents, including clobetasol and betamethasone. The request is for Vtama 1% cream.

Vtama 1% cream is an aryl hydrocarbon receptor agonist indicated and Food and Drug Administration (FDA) approved for the topical treatment of plaque psoriasis in adults. Based on the submitted documentation Vtama is medically necessary for the topical treatment of the patient's psoriasis. The patient has failed numerous high potency topical steroids, including clobetasol and halobetasol. The patient has also failed therapy with the non-steroidal calcineurin inhibitor, tacrolimus ointment. The patient would likely not receive benefit from calcium analogues or tazarotene given the failure of topical steroids and the lack of hyperkeratosis as documented by the provider. The use of Vtama is a reasonable next medical treatment based on its FDA approval for psoriasis. The decision is overturned and the use of Vtama is approved for topical use under the supervision of the providing physician.

The formulary drugs are not expected to cause adverse effects. 

The formulary drugs were not tried, and the patient did not have an adverse reaction or contraindication.

The formulary drug is expected to be ineffective.

The non formulary drug is expected to be more effective than the formulary alternatives.

The carrier's denial of Request for Formulary Exception for Vtama 1% Cream to treat psoriasis is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Triple Negative Breast Cancer.
Treatment: AR2420953 New Century Health Regimen (Avastin, cyclophosphamide, gemzar, leucovorin, fluorouracil, irinotecan and carboplatin).
The insurer denied AR2420953 New Century Health Regimen (Avastin, cyclophosphamide, gemzar, leucovorin, fluorouracil, irinotecan and carboplatin).  
The denial is upheld.

The patient in this case is an adult female who has metastatic triple negative breast cancer. She is being treated with a combination of chemotherapy agents including Avastin, cyclophosphamide, gemcitabine, leucovorin, 5-fluorouracil (5-FU), irinotecan and carboplatin. 

An appeal letter states that the patient has derived significant benefit from this treatment based on reduction in breast cancer tumor markers and improvement in her cancer on positron emission tomography (PET) / computed tomography (CT).

The proposed treatment was not medically necessary.

The combination of agents this patient is receiving has not been shown to improve health outcomes in any published clinical trial. This combination is also not endorsed as a standard treatment for metastatic triple negative breast cancer by the National Comprehensive Cancer Network (NCCN) guidelines. Given these considerations, this treatment is not medically necessary. It is not proven effective and is not in accordance with generally accepted standards of medical practice.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Herniated discs. 
Treatment: Outpatient services 63030 x 1, 69990 x 1. 
The insurer denied coverage for outpatient services 63030 x 1, 69990 x 1. 
The denial is upheld. 

This case involves an adult under review for lumbar spine surgery. The patient's visit information from the hospital indicated the patient had been seen for sciatica as well as right foot drop. A magnetic resonance imaging (MRI) of the lumbar spine noted disc herniation at lumbar (L)4-5 with minimal central canal stenosis. There was also disc herniation at L3-4 with mild mass effect on the thecal sac. Photos were only partial copies of the MRI and full pathology is unknown. 

Current scientific literature supports lumbar decompression surgery when there is evidence of spinal cord and/or nerve root impingement causing neurological deficits unresponsive to conservative measures. 

In this case, it was noted that the patient had previously been seen for sciatica and right foot drop. There was also evidence of disc herniations on the MRI. However, the submitted records were photographs of partial reports. Therefore, the full extent of pathology is unknown. In addition, there is no documentation of a comprehensive physical examination to assess neurological findings. There is also a lack of documentation of an adequate course of conservative care. 

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 outpatient services 63030 x 1, 69990 x 1 is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism Spectrum Disorder.
Treatment: applied behavioral analysis (ABA) therapy-8 hours per week of direct ABA therapy, 2 hours per week of supervision, 1 hour per week of parent training, 1 hour per week of treatment planning, and 3 hours for reassessment.
The insurer denied applied behavioral analysis (ABA) therapy-8 hours per week of direct ABA therapy, 2 hours per week of supervision, 1 hour per week of parent training, 1 hour per week of treatment planning, and 3 hours for reassessment.
The determination is overturned.

This is a female patient diagnosed with autism spectrum disorder.  In addition to autism the patient also has a diagnosis of obsessive-compulsive disorder. She has noted deficits in communication, frustration, tolerance and adaptive behaviors. It is noted in the clinical documentation that patient is functionally non-verbal. The following review is evaluating the medical necessity of continued ABA therapy. At issue is the medical necessity of continued applied behavioral analysis (ABA) therapy-8 hours per week of direct ABA therapy, 2 hours per week of supervision, 1 hour per week of parent training, 1 hour per week of treatment planning, and 3 hours for reassessment.

Yes, the ABA therapy as requested is medically necessary. The patient has a valid diagnosis of autism spectrum disorder. She continues to have deficits in communication and adaptive behaviors and struggles with frustration tolerance that leads to aggressive outbursts. She has responded well to ABA which is the gold standard treatment for autism. The treatment is based on evidence (Kodak and Bergmann, 2020) and is recommended by the patient's therapist as well as medical doctor. While it is acknowledged that the patient is an adult. she is responding to treatment and is improving with care and intervention. The patient has been receiving the services without issue and has been improving steadily. She is essentially non-verbal and unable to participate in other types of therapies due to her autism. ABA therapy is the gold standard treatment for autism spectrum disorders and it has been shown that increasing frequency of ABA interventions leads to optimal outcomes with appropriate supports and reinforcement ( Linstead et al., 2017). ABA therapy is not being done for the convenience of the patient or her physicians. Given the above, the use of ABA therapy as requested is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
The patient was admitted for chest pain and missed dialysis. The patient had missed her last hemodialysis session and therefore needed inpatient dialysis. On admission, she had no acute distress with normal cardiac and respiratory exams. Electrocardiogram demonstrated normal sinus rhythm with no ST or T wave abnormalities. Chest radiograph demonstrated no acute cardiopulmonary process. She was evaluated by nephrology and underwent dialysis. 

An evidence-based specialty society guideline concludes that patients identified as low-risk via a validated clinical decision pathway (i.e., HEART score 1 to 3, and 2 serial troponin levels below the 99th percentile) can be discharged from the emergency department without further testing or risk stratification, as such low-risk classification has a greater than 99% negative predictive value (NPV) for 30-day incidence of a major adverse cardiac event.[1]

Two other evidence-based specialty society guidelines conclude similarly that low-risk patients who have been ruled out for myocardial infarction (MI) (e.g., as per HEART score and negative troponins) can forgo immediate diagnostic testing (coronary computed tomography (CT) angiography, stress testing, myocardial perfusion imaging) and be discharged from the emergency department directly[2]

A database analysis including 809,873 adult patients presenting to the emergency department with chest pain found, after excluding 4.4% of patients who were admitted with a length of stay of 3 days or more (i.e., diagnosed with a more severe condition), that 58% of patients were discharged from the emergency department[3]

A study including 13,445 patients who presented to an emergency department with chest pain found that 48% were discharged from the emergency department, with a 30-day MACE (major adverse cardiac event) rate of less than 1%. In the same study, of those patients with a low-risk HEART score (3 or less), 85% were discharged from the emergency department.[4]

In addition, she did not have persistent severe hyperkalemia, no signs of severe volume overload or hypoxia, no documentation of severe uremia such as encephalopathy or uremic bleeding.  She had established dialysis access and did not require emergent vascular intervention.

Her condition could have been treated safely under a lower level of care.

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 is not substantiated.