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

This is a patient who presented to the emergency department (ED) with intermittent, non radiating, exertional left-sided chest pain. He described it as a heavy pulling-like sensation, associated with diaphoresis. The pain started 2 weeks ago. The pain initially was associated with heavy lifting. The pain was not positional. On the day of presentation, the pain was more intense and more frequent.
The patient had a past medial history of diabetes mellitus (DM) and poor compliance with his medications. He is a smoker.
There was no previous cardiac history. The patient was told two years ago, that his electrocardiogram (ECG) revealed a myocardial infarction (MI), but there was no cardiac work up done. 
The patient was under severe stress. Upon presentation to the ED, his blood pressure (BP) was 154/100 and heart rate (HR) was 93. Oxygen (O2) saturation was 99%. His physical examination was unremarkable, except for a distended abdomen.
His ECG revealed normal sinus rhythm at 92 beats per minute, left ventricular hypertrophy (LVH) with diffuse ST elevation. An ECG from the next day was interpreted as pericarditis.
 His chest x-ray (CXR) was unremarkable.
The patient was consulted by a Cardiology Fellow who ordered aspirin and colchicine for possible pericarditis.
The patient was admitted to the telemetry unit for a diagnosis of chest pain.
He underwent computed tomography (CT) coronary angiography with a calcium score of 1 in RA territory. There was mid left anterior descending (LAD) stenosis due to non-calcific plaque and D1 had minimal stenosis due to non-calcific plaque. The right coronary artery (RCA) also had minimal stenosis due to non-calcific palque in proximal part and minimal stenosis due to calcific plaque.
The patient also underwent an echocardiogram. His echocardiogam revealed ED of 57%. The rest of the findings were normal.
The patient was free of chest pain the day after admission. His troponin was normal. The patient was discharged on oral medications. He was educated about smoking cessation and compliance with medications.
The health plan's determination is upheld.
The patient presented with a new onset of chest pain, which could be interpreted as atypical chest pain versus unstable angina. He had several coronary risk factors, including diabetes and smoking.
His BP was modestly elevated, but it improved during the hospital stay. He did not have any cardiac arrhythmia. His ECG suggested pericarditis. However, there was no evidence of a pericardial effusion or cardiac tamponade, which would justify inpatient admission. His troponin was normal. His chest pain resolved. The patient was treated with oral medications.
The patient did not meet criteria for an inpatient admission. A lower level of care was more appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe feeding difficulty autism, developmental delay
Treatment: Day feeding program (92526 - 40 visits)
The Day feeding program (92526 - 40 visits) is medically necessary.

The patient is a boy with severe feeding difficulty autism, developmental delay, poor oral skills, and multiple allergies. He relies on PediaSure/purees for all nutrition and hydration. He demonstrated improvement of feeding skills after intensive day feeding treatment in past. Since that time, his growth has trended downward, and he does not feed himself. Over the past two years, he has not improved his eating behaviors. He has been denied coverage for re-enrollment in an intensive feeding program to try to normalize his food intake. 

The denial stated that growth charts were not included, but growth measurements and percentiles for age were noted in the two evaluation reports. The measurements indicate that the child's growth percentiles were trending downward over the 22-month interval: from weight 23.7 kg (94 percentile) to 27.2 kg (83.7 percentile), and height 116 cm (88 percentile) to 126.5 cm (79 percentile). BMI/age decreased from 93 percentile to 79 percentile. Additionally, the child's eating behaviors are significantly abnormal for his age and will be a major handicap/impairment as he ages. He reportedly benefited from the interdisciplinary feeding program in the past and has had some regression after developing an allergic reaction to several foods. 

Coverage should be provided for him to receive another course of Intensive Day Patient Feeding Therapy at this time.
Appeal type: Medical necessity
Decision: Upheld

Dental Problems - Overbite/Underbite
Dental/Orthodontic Procedure

The patient in question is a male with a Class I occlusion and slightly high overjet and overbite. The maxillary arch has 2 millimeter (mm) crowding, and the mandibular arch has 6mm crowding. He is treatment planned for 30 months of orthodontics to correct his malocclusion.

The health plan's determination is upheld.

There is no medical reason to correct his malocclusion with braces. The patient has some maxillary and mandibular crowding. His bite is slightly deep but there is no indication of damage to the incisors or the palate in the photographs, and his cephalometric radiograph show the lower incisors are contacting the maxillary teeth in occlusion, not the palate. There is no indication from the photographs there is severe soft tissue damage (or any soft tissue damage) on this patient.
The patient does have a deep bite, however, that alone is not a medical necessity to treat. There are many ways to correct patients with a deep bite, and there is strong evidence that one treatment is not better than another.  Furthermore, deep bites may be corrected in adulthood, so he will not lose the ability to correct the malocclusion should the patient choose to do so as an adult.
Appeal type: Medical necessity
Decision: Upheld

Overbite/underbite
Dental/Orthodontic procedure

This patient has a skeletal Class II malocclusion. Moderate overjet and moderate overbite. The proposed treatment is braces. The health plan determination of medical necessity is upheld in whole. Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 12 with no auto qualifiers. Overjet would score 4 points, overbite scores 5 points, and labio-lingual spread scores 3. Auto qualifiers include cleft palate deformity or cranio-facial anomaly, severe traumatic deviation, impacted permanent anteriors where extraction is not indicated, deep impinging overbite, anterior crossbite causing clinical attachment loss and recession of the gingival margin, overjet 9mm or greater and underbite 3.5mm or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bilateral posterior tendon insufficiency
 
Treatment: Inpatient hospital admission 

The insurer denied coverage for inpatient hospital admission. The denial is reversed. 

This patient is a female with multiple medical conditions. She is a diabetic and has hypertension. There is a history of cervical and lumbar radiculopathy. She had bilateral posterior tendon insufficiency. She was admitted to the hospital for hind foot reconstruction (multiple procedures). She also required an iliac crest bone graft. She also underwent a bunionectomy. She required multiple post-surgical dosages of intravenous (IV) analgesia. Subsequently she was discharged to home. 

The medical records demonstrate that a complex and extensive surgical procedure was performed. There were multiple components to several locations. The physician placed seven different incisions. The duration of the operation was almost four hours. The post-surgical course was complicated by severe pain requiring multiple dosages of morphine, despite previous use of a regional block. These procedures would be expected to have a significant amount of post-surgical pain- i.e. hip location for iliac crest graft by itself can be very painful. The patient underwent a bunion correction (great toe) and a calcaneal osteotomy (heel) which by itself is extremely painful.

The combination of underlying comorbidities, as well as the complexity and duration of the procedure would warrant the inpatient hospitalization. This type of surgery is not performed in an Ambulatory Surgery Unit (ASU) nor is it warranted for Observation status. The health care plan did not act reasonably or with sound medical judgment or in the best interest of the patient.

Based on the above, the medical necessity for the inpatient hospital admission is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary Artery Disease
 
Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld.    

This is a male patient with a medical history of coronary artery disease, systolic heart failure, hypertension, hyperlipidemia, and tobacco use. He presented with CCS Class III anginal symptoms.  He presented to the hospital for a staged percutaneous transluminal coronary angioplasty (PTCA). The patient was admitted to the hospital for post procedure monitoring. He experienced no post procedure complication. The patient was able to ambulate and tolerate oral intake. He remained medically stable and was discharged home. 

Inpatient admission status is not medically necessary for this patient.  Per MCG Angioplasty, Percutaneous Coronary Intervention ORG: M-52 (ISC), the clinical presentation and peri-procedural course were unremarkable and uneventful, and observational level monitoring was medically appropriate.  There were no extenuating circumstances in this case which warranted inpatient admission status following elective cardiac cath and stenting.  Despite the unique lesion characteristics of this particular procedure, namely chronic total occlusion, post-procedural observational level of care would have been appropriate. 

The health plan acted in the patient's best interests and with sound medical judgment.  

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

Diagnosis:  Edema and dyspnea on exertion
Treatment:  Inpatient admission

The Inpatient admission was not medically necessary.

The patient is a female with poorly controlled diabetes and hypertension.  She presented to the hospital with edema and dyspnea on exertion.  Labs demonstrated a potassium 5.5, bicarbonate 15, BUN (blood urea nitrogen) 55, and creatinine 3.4.  The chest x-ray showed no acute process and a renal ultrasound demonstrated no hydronephrosis.  The patient was afebrile with a blood pressure 144/75, oxygen saturation 100%, and pulse 87.  Intravenous diuretics were provided, amlodipine was discontinued (with diltiazem provided) and nephrology consulted.  Diuretics were changed to the oral route.  An echocardiogram demonstrated a normal ejection fraction with left atrial dilation and concentric left ventricular hypertrophy.  Proteinuria was measured at 13.9 g per day.  The creatinine on follow-up was 3.2 and 3.0.

The patient had lower extremity edema and dyspnea, but the chest x-ray showed no acute process.  There was no evidence of hypoxia, restrictive distress, or need for mechanical or noninvasive ventilation.  There was no evidence of hypertensive emergency.  The renal ultrasound demonstrated no hydronephrosis.  The patient had only mild hyperkalemia.  Renal function improved slightly during the hospital stay; the minimal improvement in the setting of poorly controlled diabetes and a very high degree of proteinuria was consistent with a substantial component of chronic kidney disease, without a significant acute component.  Dialysis was not required, and there was no evidence of overt uremic symptomatology.

In summary, inpatient admission was not medically necessary.  The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient in making its determination.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right nasolabial abscess
 
Treatment: Inpatient hospital admission

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

This patient is a male with a history of facial swelling in the right nasal labial area. He was seen previously at Urgent Care a few days before arrival, but had not taken any medication. A CT scan was obtained which revealed the right nasolabial area with swelling and an associated abscess. Incision and drainage of the right nasal labial abscess was carried out and purulent drainage was expressed. The abscess cavity was irrigated with Betadine and the patient was placed on intravenous antibiotics. He was discharged.

The peer reviewed literature notes the epidemiology of facial abscess are in the main candidates for outpatient antibiotics and early surgical drainage. The patient was seen by a medical facility some days before he arrived at the one in question.
During the period, he had no intervention. The peer reviewed literature notes the need for intravenous medication for facial abscess such as occurred for the patient.
The health care plan did act reasonably, and with sound medical judgment, and in the patient's best interest. This patient's management could have been accomplished during a period of observation. 

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned in Part

This is a patient who was admitted due to depression and suicidal ideation with a plan to hang himself in the context of an argument with his mother. The patient has a history of attention deficit hyperactivity disorder (ADHD) and pseudoseizures. The patient has no previous hospitalizations. The patient has attempted suicide in the past. The patient was noted to have chronic suicidal ideation since the age of 10 which intensifies with interpersonal conflict. The patient was calm and cooperative. He denied suicidal ideation at this time. The patient had no active suicidal ideation with plan, homicidal ideation with plan or command hallucinations. The patient was not physically aggressive, acutely manic or sexually inappropriate. The patient was not catatonic. The patient had no significant medical instabilities. The patient had no required emergency medications, restraints or seclusions. He was working on coping skills. The patient remained a chronic ongoing risk of impulsive behavior, even at the time of discharge. The health plan's determination is overturned in part. The patient did have suicidal ideation with a plan, a history of suicide attempts and was in an environment of stress and interpersonal conflict with his mother. Therefore, evaluation at an inpatient level of care on was appropriate for 1 day, however, after that treatment at a lower level of care was reasonable and in the best interest of the patient to treatment him at the least restrictive environment.  
The patient did have suicidal ideation with a plan, a history of suicide attempts and was in an environment of stress and interpersonal conflict with mom. Therefore, 24 hour evaluation at an inpatient level of care  was appropriate and medically necessary.
However, after that, the patient had no active suicidal ideation with plan, homicidal ideation with plan or command hallucinations. The patient was not physically aggressive, acutely manic or sexually inappropriate. The patient was not catatonic. He had no significant medical instabilities. The patient had no required emergency medications, restraints or seclusions. The interpersonal conflict was chronic and not acute. Treatment could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Metabolic alkalosis and hypokalemia
  
Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was reversed.   

This is a female patient with a history of an eating disorder, hydrocephalus, and substance abuse. She presented to the Emergency Department with complaints of weakness and forgetfulness for two days. It was reported that the patient had a past similar episode and was treated for hyperkalemia. Her presenting vital signs were; blood pressure of 103/69 with a pulse of 87 bpm, and respiration rate of 18. On physical examination it was noted that the patient was underweight. She had an electrocardiogram (EKG) that showed a normal sinus rhythm. Laboratory work up was performed revealing potassium level of 2.5 with CO2 at greater than 40, and a low osmolality of 271.  Patient's venous pH was 7.5 and PCO2 was 58.9. Urinalysis was performed that showed urine red blood cells, trace leukocyte esterace, and a cloudy appearance. The patient was treated with intravenous (IV) potassium and fluids. A repeat potassium level was drawn with an increase to 3.1. The patient was evaluated by psychiatry. The patient reported vomiting resulting in hypokalemia. The patient was medically stabilized and discharged home with recommendations to follow up with outpatient substance abuse programs. 

This patient was admitted for weakness and forgetfulness (altered mental status) over two days prior to admission. Though patient's vital signs were not of such degree that warranted hospital admission, the patient was noted to have metabolic alkalosis and hypokalemia that caused electrocardiogram (ECG) changes that supported inpatient admission   Patient's potassium level was 2.5 and bicarbonate level was 40. These electrolyte abnormalities were consistent with patient's history of eating disorder (bulimia). This low potassium of 2.5 with ECG changes meets the clinical criteria for hospital admission.  According to literature review, patients that need hospitalization are those with the following signs and symptoms:  Volume depletion/dehydration, altered mental status, significant rectal bleeding, prolonged symptoms (more than a week), severe abdominal pain, comorbidities such as diabetes and immunocompromised status, age >=65 years, recent hospitalization or antibiotics, pregnancy, or weight loss.   This patient's acid base status with ECG monitoring and assessments for altered mental status supported this hospital admission.  
 
The health place did not act reasonably with sound medical judgment in the best interest of the patient. 

The carrier's denial of coverage for the inpatient hospital admission is reversed.  The medical necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Idiopathic hypereosinophilic syndrome
Issue under review: Nucala (mepolizumab)

Determination:
The health plan should cover the Nucala (mepolizumab).

The patient is a female child with medical history significant for refractory seizure disorder on multiple medications. She recently developed hypereosinophilic syndrome, likely the result of one of the seizure medications. It was discovered during a hospitalization for complicated aspiration pneumonia. Unfortunately, per her allergist, because her seizure disorder is so difficult to control, none of the medications can be stopped. Instead, she remains on a prolonged course of systemic corticosteroids, with resultant aggression and insomnia. The steroids cannot be weaned without recurrence of the peripheral eosinophilia. The recommendation is to start treatment with mepolizumab as a steroid-sparing medication followed by possible alteration in her anti-seizure regimen.

Mepolizumab is an anti-interleukin-5 monoclonal antibody with glucocorticoid-sparing effects in patients with glucocorticoid-sensitive hypereosinophilic syndrome as well as treatment-refractory hypereosinophilic syndrome. It was originally intended for adults with atopic asthma, but its treatment efficacy has broadened to include a number of atopic disease processes. Studies have shown that mepolizumab is an effective and well-tolerated treatment choice for hypereosinophilic syndrome, in use since about 2005. It has also been found to be safe and effective in the pediatric population. 

This child has refractory seizures that require treatment with multiple anti-convulsants, one of which is responsible for her diagnosis of hypereosinophilic syndrome. Because her seizures are so difficult to manage and her current regimen is the best control she has had to date, her specialists determined that it would be best to place her on systemic corticosteroids as treatment of her hypereosinophilic syndrome. She responded well to steroids, decreasing her eosinophil count from 14K to 400. Unfortunately, she cannot be weaned off the steroids without resurgence of disease, and she is having unpleasant side effects. Mepolizumab has been shown to be safe and effective in pediatric patients with hypereosinophilic syndrome, and for this patient may actually be life-altering. Treatment with mepolizumab would certainly be more beneficial than her current treatment regimen, considered standard treatment for hypereosinophilic syndrome.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Idiopathic hypereosinophilic syndrome
Issue under review: Nucala (mepolizumab)

Determination:
The health plan should cover the Nucala (mepolizumab).

The patient is a female child with rare disorder - hypereosinophilic syndrome - secondary to medications that cannot be stopped.  The patient has severe seizure disorder, and seizure meds may be causing hypereosinophilic syndrome.  Systemic steroids were not doing well.  Mepolizumab is a steroid sparing agent - that is recommended in WHO management of idiopathic hypereosinophilic syndrome, and that is the reason for the AP's request.

The patient has a rare condition of idiopathic hypereosinophilic syndrome - and has had some response to steroids.  Research shows that in this situation, the patient is a good candidate for treatment with Mepolizumab. 

Interleukin-5 (IL-5) is a growth factor critical for eosinophil maturation and activation. Two anti-IL-5 antibodies, mepolizumab and reslizumab, have been evaluated in patients with platelet-derived growth factor receptor alpha (PDGFRA)-negative HES with promising results. These agents appear to be helpful in glucocorticoid-sensitive HES, including idiopathic HES, lymphocytic variants of HES (L-HES), and HES/eosinophilic granulomatosis with polyangiitis (EGPA) overlap. Although both agents are approved for the treatment of eosinophilic asthma by the US Food and Drug Administration (FDA), mepolizumab is not available for HES outside of clinical trials or the compassionate use program. This patient has shown steroid responsiveness and should be tried on a trial of mepolizumab to help decrease steroid use, which can cause severe side effects.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Idiopathic hypereosinophilic syndrome
Issue under review: Nucala (mepolizumab)

Determination:
The health plan should cover the Nucala (mepolizumab).

The patient is a female child with a history of idiopathic hypereosinophilic syndrome complicated with respiratory infection, seizure disorder, and complication with systemic oral steroids. The request is for mepolizumab.

The use of mepolizumab has been shown to target eosinophils, can result in corticosteroid-sparing for patients negative for FIP1L1-PDGFRA who have the hypereosinophilic syndrome in a recent international, randomized, double-blind, placebo-controlled trial.  The hypereosinophilic syndrome is a group of diseases characterized by persistent blood eosinophilia with end-organ involvement and no recognized secondary cause. Although most patients have a response to corticosteroids, side effects are common and can lead to considerable morbidity. The study showed that 95% of mepolizumab group achieve significant reduction on blood eosinophil count (less than 600 per microliter for 8 or more consecutive weeks) compared with 45% of patients receiving placebo.  

In an open-label extension study to examine the frequency of adverse events for mepolizumab, mepolizumab was well tolerated and effective as a long-term corticosteroid-sparing agent.