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

Diagnosis: cerebrovascular accident 
Treatment: Skilled Nursing facility admission
The insurer denied the skilled nursing facility admission. The health plan's determination is overturned. 

The patient is a female who was admitted to the skilled nursing facility (SNF) from the hospital after being hospitalized for a right thalamic hemorrhagic cerebrovascular accident requiring a right frontal external ventricular drain placement with eventual removal. She is currently undergoing physical, occupation and speech therapy with steady improvement.
Under review is the medical necessity of Skilled Nursing Facility Admission.

Skilled Nursing Facility Admission is medically necessary for this patient.
This patient was admitted to the skilled nursing facility (SNF) from the hospital after being hospitalized for a right thalamic hemorrhagic cerebrovascular accident requiring a right frontal external ventricular drain placement with eventual removal. Per the most recent notes, she was working with physical therapy and the patient is making consistent gains towards the goal of returning home. Per the occupational therapy notes, the patient exhibits good rehabilitation potential with training for activities of daily living and therapeutic functional activities. Per the speech therapy notes, the patient is making steady gains in phonation and dysphagia. She is able to eat full meals chopped solids with thin liquids, no longer relies on a white board for written communication but can elicit phonation for up to 10 seconds. Therefore, with the ongoing benefit from therapy (physical/occupational/speech), the requested Skilled Nursing Facility Admission is medically necessary for this patient.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Anaplastic oligodendroglioma.
Treatment: Formulary Exception for Tibsovo.
The insurer denied coverage for the Formulary Exception for Tibsovo.
The denial is overturned.

This is a male patient with a history of oligodendroglioma.  An office note from the patient's Neuro-Oncologist indicates the patient had a resection and then had chemotherapy, followed by a second resection.  The patient also has a patent foramen ovale and atrial septal aneurysm.  He has been having constant pressure headaches and forehead swelling.  He has tried Tylenol and oxycodone. The isocitrate dehydrogenase-1 (IDH1) drug Tibsovo (ivosidenib) has been prescribed for the patient.

This patient has a rare type of tumor of oligodendroglioma. The patient has an IDH1 mutation in his tumor and has failed his standard of care, but he remains in good condition. The provider would like to provide the patient with the best likelihood for continuing care. The insurer coverage policy approves Tibsovo for patients with acute myeloid leukemia (AML) or cholangiocarcinoma. 

The patient was diagnosed with anaplastic oligodendroglioma. He had recurrent anaplastic oligodendroglioma grade III, IDH mutant. Initially reported to glioblastoma multiform (GBM) status post resection, RT/TMZ [radiotherapy with concurrent temozolomide], PCV [procarbazine, lomustine, and vincristine] x 3 stopped 3rd cycle due to rash. Then, the patient was transitioned to adjuvant TMZ [temozolomide] status post 6 cycles, status post second resection with pathology showing recurrent anaplastic oligodendroglioma. Magnetic resonance imaging (MRI) of the brain showed new left occipital cortical lesion. As the patient experienced severe headaches, the plan was to increase steroids and likely to start TMZ and to order Foundation medicine. Hence, the application to obtain IDH inhibitor. The progress note stated, in the assessment and plan, that the patient has cryptogenic silent strokes. Genomic test findings showed IDH1 R132H mutation. Hence, the request for this drug. 

The formulary drug would be likely to cause an adverse reaction. Genomic test findings showed IDH1 R132H mutation. Hence, the use of an IDH inhibitor is expected to derive clinical benefit. The patient has failed standard treatment.    
  
The formulary drug was being utilized with the last recurrence, but the patient still had progression reoccurrence, based on provided documentation.     

Given the evidence of the IDH mutation in this patient, Tibsovo will be more effective than the formulary options and provide a more clinically beneficial outcome to the patient.

The insurer's denial of Request for Formulary Exception for Tibsovo is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems-deep cleaning. 
Treatment: Dental Services- deep gum cleaning on upper right (UR), lower right (LR), upper left (UL) and lower left (LL).
The insurer denied coverage for Dental Services- deep gum cleaning on upper right (UR), lower right (LR), upper left (UL) and lower left (LL).
The denial is upheld. 

This is a male patient who presented for evaluation for dental services and periodontal therapy.  The dentist reported periodontal chartings indicating 2-5 millimeters (mm) of generalized periodontal pocketing.  The recommended treatment was scaling and root planing in all four maxillary and mandibular quadrants.  The insurer has denied the service as the information provided does not show evidence of moderate to severe periodontal disease or other clinical or radiographic criteria to justify the services and therefore does not meet clinical criteria to support scaling and root planing.  The patient is appealing.

Upon review of the submitted documentation, the only objective documentation provided for review was the periodontal chartings.  Based on the reported periodontal probing depths, there would appear to be minimal if any loss of alveolar bone height affecting these teeth.  The increased pocket depths likely represent pseudo pocketing due to superficial calculus accumulation and poor oral hygiene.  There is minimal significant periodontal probing with no periodontal probing over 5mm depth.  And there is no documentation of any bleeding on probing. 

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

The coverage for dental services - deep gum cleaning on upper right (UR), lower right (LR), upper left (UL), and lower left (LL) is not considered medically necessary for this patient.

The insurer's denial of coverage for Dental Services- deep gum cleaning on upper right (UR), lower right (LR), upper left (UL) and lower left (LL) is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute otitis media. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for the inpatient hospital admission. 

The denial is upheld. 

This is a female patient with a past medical history of anxiety disorder who presented to the Emergency Department (ED) with 3 days of left ear pain.  The patient's pain was associated with mild left sided temporal headache and decreased hearing on the left.  In the ED, the patient appeared non-toxic and was afebrile.  On examination, she had decreased hearing to the left side mastoid and tragal tenderness.  Her left tympanic membrane was perforated. Computed Tomography (CT) of the head with contrast showed partially opacified middle ear and left mastoid cells, mild blunting of the left scutum, and circumferential inflammation of soft tissues along the external auditory canal.  The patient was admitted as an inpatient to Pediatrics for left sided mastoiditis with left otitis media with perforation.  

The patient's white blood cell (WBC) count was 11,000 and her oral temperature was 97.4. The patient remained afebrile, and her WBC stayed the same throughout her entire hospital stay.  She had at least one episode of having some pain associated with her ear.  At no time was there any aural discharge. 

There have been numerous guidelines published by national pediatric medical societies concerning the care of acute otitis media. The patient's medical condition meets the criteria for acute otitis media in all of these guidelines.  The guidelines all state that when acute otitis media does not resolve spontaneously it should be treated with antibiotics as is the case with the patient.  Her CT is also compatible with the diagnosis of acute otitis media. The patient had neither signs nor symptoms of intracranial involvement nor of an acute mastoiditis. 

The healthcare plan did act reasonably and with sound medical judgment and was in the best interest of the patient. The patient needed only antibiotic therapy and did not require inpatient hospitalization for five days. 

The hospital admission was not considered medically necessary for the patient's acute otitis media which international guidelines have stated should be treated just with antibiotics. The patient exhibited neither symptoms, signs, nor quantitative clinical examinations, for example, temperature, white blood cell count, computed axial tomography (CAT) scan of any complication which would have created the need for the admission. 

The denial should be upheld as the patient should have been treated as an outpatient. Per the provided information available, there was no reason for five days of inpatient care. 

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

Diagnosis: Hypoglycemia
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned

The patient is a female. She has history of diabetes, CVA (cerebrovascular accident), hypertension, hyperlipidemia, status post recent left nephrectomy due to a renal mass found to be a real cell carcinoma. The patient has a history of DVT (deep venous thrombosis). The patient presented to the emergency department via EMS (emergency medical services) with hypoglycemia. The patient's blood sugar in the field was 24. EMS (emergency medical services) administered glucagon 1 mg (milligram), and the repeat glucose was 40. The patient was last seen four hours prior to being found lethargic diaphoretic and difficult to arouse.

On arrival to the ED (emergency department), the patient had altered mental status. Her blood glucose in the emergency room was 31. She received 1 amp of D50 (50% dextrose). The repeat blood glucose was 107, and following that was 56. She was started on D10 (10% dextrose) continuous intravenous fluids. The patient is on insulin at home. She takes 38 units in the morning and 18 units at night. Her creatinine was elevated. Her initial creatinine was 1.36, and then it rose to 1.7. On admission, the patient was also severely hypertensive and was treated for her hypertension.

Yes, the Inpatient admission was medically necessary.
The standard of care regarding admission to the hospital in patients with hypoglycemia due to insulin therapy is that patients who are unresponsive to treatment with dextrose should be hospitalized until their glucoses stabilize (1-5). The patient had multiple attempts at treatment of her hypoglycemia both in the field and in the emergency department, which either resulted in no response, or an improvement of her glucose followed by recurrent hypoglycemia. The initial request for admission is consistent with generally accepted standards of medical practice and is therefore medically necessary. The patient had acute renal insufficiency as well as severe hypertension that was being monitored and treated. The entire hospitalization is consistent with generally accepted standards of medical practice and is therefore medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Paroxysmal atrial fibrillation, tachy-brady syndrome.
Treatment: Hospital stay.
The insurer denied coverage for the hospital stay.
The denial is overturned.

This is a female patient with a history of paroxysmal atrial fibrillation, tachy-brady syndrome, asthma and gastroesophageal reflux disease (GERD) who presented to the hospital for left atrial catheter ablation with cryoballoon therapy.  Her post-operative course was complicated by recurrent paroxysmal atrial fibrillation and left sided upper extremity numbness and weakness as well as bilateral lower extremity numbness.  A full neurological work up was performed.  The patient's arrhythmia was treated with Flecainide and beta blocker therapy.  Brain magnetic resonance imaging (MRI) was unrevealing, and the patient was ultimately diagnosed with a transient ischemic attack (TIA). 

This patient presented to the hospital for an elective electrophysiologic study and ablation. According to hospital records, ablation of paroxysmal atrial fibrillation was successfully performed.  Observation overnight, following the ablation was complicated by both recurrent paroxysmal atrial arrhythmia and new onset left upper extremity numbness/weakness along with lower extremity numbness.  Atrial fibrillation with rapid ventricular rate up to 150 beats per minute was treated with metoprolol and flecainide therapy.  Neurology consult recommended a complete neuro work up and MRI of the brain revealed no acute stroke. The patient was diagnosed with a transient ischemic attack (TIA) and observed until deemed stable for discharge.

In a study of patients undergoing almost 40,000 ablation procedures, 7% of patients had perioperative complications.  Cardiac complications were noted in 1.15% (not including tamponade) and 0.31% of patients had complications of stroke or TIA.  The average length of hospital stay was 2.63 days.(1)  In two multicenter registry studies looking at healthcare utilization after electrophysiological (EP) study catheter ablation, more than 80% of patients undergoing ablation were hospitalized for a single day, regardless of age or co-morbidity.(1)  However these patients had an uncomplicated operative course and did not require additional observation.  Another study demonstrated that patients undergoing atrial fibrillation ablation procedures could be safely discharged on the same day only when procedures were without complication.(3)  Inpatient hospital admission was medically necessary in this case due to recurrent rapidly conducted atrial fibrillation and TIA post procedure.  

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

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

Diagnosis: Skin Disorders-Acne
Treatment: Pharmacy/Prescription Drugs-Tretinoin cream
The health plan denied the Tretinoin 0.1% cream as not medically necessary and the health plan considers the diagnosis of acne vulgaris cosmetic. The reviewer has overturned in whole the health plan's determination. 

The patient is a male with severe acne, for which the patient has tried topical clindamycin, benzoyl peroxide cream wash, and 0.05% tretinoin gel. On physical examination at a clinic visit, the patient was noted to have inflammatory papules, especially on the forehead and a few on the chin.

Tretinoin 0.1% cream is medically necessary for this patient.

Acne is not a cosmetic condition, particularly when inflammatory papules exist that can lead to both pain and permanent scarring for patients. Topical retinoids (such as the requested 0.1% tretinoin cream) have both an anti-inflammatory and comedolytic action that reduces the lesions and potential permanent scarring associated with those lesions in acne patients. Topical retinoids are a mainstay of therapy for acne, both for acne associated with comedones, and those associated with inflammatory papules (such as with this patient), and are strongly recommended by all dermatology associations as a medical and not cosmetic condition (acne). All current literature to date [1-5] supports the use of topical retinoids, and for medically necessary purposes, in teenagers associated with acne (particularly ongoing and chronic inflammatory acne).

Tretinoin and other retinoids are a fundamental part of the treatment of acne for both comedolytic purposes (opening comedones prevents subsequent pustular, papular, nodular, and cystic/scarring that can occur as acne lesions progress without treatment) and direct anti-inflammatory purposes. The patient has already tried and failed topical antibiotics, and also a lower concentration of tretinoin (0.05%). The requested tretinoin, 0.1% cream is therefore medically necessary and consistent with current dermatology literature [1-5] and associated standards of care.
Appeal type: Medical necessity
Decision: Overturned

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

The patient has a past medical history (PMH) of bipolar disorder type I (BPI d/o), hepatitis C, human immunodeficiency virus (HIV) and hypertension (HTN) and was admitted with complaints of (c/o) a cough associated with fevers and chills. The vital signs were notable for a pulse of 114, respiratory rate (RR) 24, peripheral capillary oxygen saturation (SpO2) 94%. The physical exam was unremarkable. Lab work was notable for a white blood cell count (WBC) of 18.3 and lactate 2.2. A chest x-ray (CXR) showed large airspace consolidation in the right middle lobe (RML). The patient was diagnosed with community-acquired pneumonia and treated with intravenous (IV) antibiotics, biochemical work-up, and blood cultures. The Pneumonia Severity Index (PSI) score was class III. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient stay.

The hospital stay was medically necessary at an acute inpatient level of care.

This patient presented to the emergency department (ED) with c/o a cough associated with fevers and chills. He had multiple co-morbidities, including hepatitis C and HIV and was considered PSI class III. In addition, the patient's CURB-65 (Confusion, urea, respiratory rate, blood pressure, age greater than or equal to 65) score was 2. Given these two validated risk scores and the patient's co-morbidities and immunocompromised state, an inpatient level of care was required. In addition, this patient's clinical status was further shown to be tenuous given the elevated WBC count, tachypnea, lactic acid elevation, tachypnea and borderline oxygenation/SpO2 and new oxygen requirement. The patient also met systemic inflammatory response syndrome (SIRS) criteria. Overall, this patient's illness severity and risk for complications indicates that an inpatient level of care was medically necessary for the patient's close monitoring and treatment and that a lower level of care would not have been medically appropriate for aggressive clinical monitoring and treatment with IV antibiotics.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right Foot Cellulitis 

Treatment: Inpatient Admission 

The insurer denied coverage for inpatient admission

The denial is upheld

The patient is a male with a past medical history significant for diabetes mellitus, neuropathy, peripheral vascular disease, and status post left foot amputations, who was referred to the Emergency Department for possible osteomyelitis.  The patient complained of right groin tenderness and subjective fevers. Vitals on presentation included: Temperature 99.6 Fahrenheit, Blood Pressure 138/80, Pulse 98, Respiratory Rate 17, and Oxygen saturation 95 percent on room air.  Laboratory results included the following: White blood cell count-12.3, hemoglobin-12.6, hematocrit 39.1, creatinine-0.83, and glucose-106.  The patient was admitted for possible osteomyelitis.  He was empirically started on intravenous antibiotics (vancomycin and Unasyn). X-ray of the left foot showed no evidence of acute fracture, no radiographic evidence of osteomyelitis.  Right foot x-ray was suggestive of gouty arthropathy of the first metatarsophalangeal joint.  Culture remained negative.  He underwent a bedside debridement of the left 1st and 2nd toe.  He remained afebrile and hemodynamically stable.  The patient was discharged to continue oral antibiotics (Bactrim) as outpatient.

According to documentation, the patient was admitted for possible cellulitis versus osteomyelitis.  Otherwise, he was afebrile, hemodynamically stable.  Laboratory results showed only a mild elevated white blood cell count, which resolved the following day.  The patient had no evidence of acute osteomyelitis or a disseminated infection.  The patient underwent a bedside debridement.  Based on the above findings, the patient met criteria for observation level of management.  He did not meet criteria for acute hospital admission.  

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

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

Diagnosis: Dental Problems-Abscess/Infection
Treatment: Inpatient hospital stay
The health plan denied the inpatient stay as not medically necessary. The reviewer has overturned in whole the health plan's determination.

The patient presented with a dental abscess. He was well until 2 days prior to admission, when he developed swelling of the right side of his face as well as fever. He also had poor oral intake. His mother had noted that he was having some difficulty breathing due to his asthma, and had given him a nebulized treatment of albuterol at home. After that she noticed his lips started to swell, as well as his eye. His temperature went up to 100.6 Fahrenheit the night prior to presentation and he continued to refuse to eat. The following day they called their primary doctor, who recommended evaluation in the emergency department.

On physical examination in the emergency department he was noted to have a bluish staining pattern to his teeth that was thought to be related to a recent dental visit, as well as facial swelling up to the lower eye.

An ultrasound was performed which showed a 1.9 centimeter (cm) x 0.5 cm dental abscess. He was initially treated with Augmentin. Maxillofacial surgery was consulted and advised admission for intravenous antibiotics and reevaluation for possible incision and drainage the next day.

He was admitted to the hospital and started on intravenous clindamycin. By the following day, his blood cultures were negative, he had improved, and no incision and drainage was felt to be needed. He was discharged home on oral clindamycin with follow-up as an outpatient.

The requested inpatient stay was medically necessary for this patient.

This is a young boy who presented with a dental abscess, with fever and refusal to eat. He had significant facial swelling and a dental abscess diagnosed by ultrasound. The maxillofacial surgeon recommended admission with parenteral antibiotics, with a blood culture pending.

The decision making at the time of admission for this patient was consistent with his young age, the presence of a dental abscess and poor oral intake, and the need for prompt initiation of treatment with parenteral antibiotics along with close monitoring for potential deterioration of clinical status.

Suppurative dental infections may cause significant morbidity. They can extend to potential fascial spaces in the orofacial area or deep in the head and neck. If not properly treated, they can also cause osteomyelitis of the jaw or bacteremia. This patient had a significant abscess and poor oral intake, and required prompt and appropriate treatment with parenteral antibiotics in an inpatient setting to prevent potentially serious complications.