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

Diagnosis: Shortness of Breath and Wheezing
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient is a female with a history of asthma and alcohol abuse. She presented complaining of shortness of breath, cough and wheezing for two days.

The patient had a runny nose and fever of 102. She was treated with a nebulizer x 1 in the emergency department. The patient's Vital Signs included Temperature = 37.1, Pulse = 107, Respiratory Rate = 19, Blood Pressure = 146/81, Pulse oxygenation 98%. Her exam was remarkable for wheezing. The patient's labs included White blood cells (WBC) = 3.99, Hemoglobin/Hematocrit (H/H) = 11.1/33.5, Platelet (Plt) = 97, Sodium (Na) = 142, Potassium (K) = 3.9, Bicarbonate = 21.7, Blood urea nitrogen/Creatinine (BUN/Cr) = 5/.6. The patient's EKG (electrocardiogram) revealed normal sinus rhythm. Her chest x-ray revealed no acute disease.

The patient was admitted with asthma exacerbation and monitoring for alcohol withdrawal. Plan of care included nebulized breathing treatments every 6 hours, prednisone, PO (oral) antibiotics, and CIWA (clinical institute withdrawal assessment).

The patient's vital signs were stable. Her CIWA (clinical institute withdrawal assessment) was 3. The plant was to continue current management. She was cleared for discharge.

No, the Inpatient admission was not medically necessary.
The patient was admitted with asthma exacerbation. She was hemodynamically stable and afebrile. She had normal oxygenation. She does not have a history of intubation. She did not have pneumonia. She did to require ventilatory support. She was clinically stable at time of admission and remained stable during hospital stay. She had not failed a lower level of care, because she was only treated with one nebulizer before admission. The inpatient admission was not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia, arthritis, lower extremities weakness and low back pain, lung cancer and urinary incontinence.
Treatment: Increase personal Care Services to 84 Hours Per Week.

The insurer denied the Increase personal Care Services to 84 Hours Per Week.  The denial is overturned.

The patient is a female. The request is for Increase personal Care Services to 84 Hours Per Week.

The health plan's reason for prior denial was that requested service is not medically necessary.

Yes, the requested Increase personal Care Services to 84 Hours Per Week is medically necessary.

Patient has history of alzheimer's dementia, arthritis, lower extremities weakness and low back pain, lung cancer and urinary incontinence. Over the last year her symptoms have been getting worse.

Patient can not change her diapers and has been developing urinary tract infections. She needs more help for her ADLs and changing diapers frequently. She does not remember taking her medications. She needs help with meals and feeding. Patient will need 84 Hours Per Week to ensure more help safety, help with diaper changes, taking her medications and meals. She is otherwise at risk of frequent hospitalizations.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.

The patient has underlying dementia and has significant decline in her cognition and cannot perform her ADLs (activities of daily living). An increase in home services is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status post MVA (motor vehicle accident) / Electrocution. 
Treatment: Physical Therapy. 

The insurer denied the physical therapy. 
The denial is upheld. 

The patient is a male with past history of MVA (motor vehicle accident) approximately two years ago. He also experienced an electrocution, and he sustained cervical spine injuries with spinal cord injury, leading to cervical laminectomy status post fusion C3-C7 (third cervical spine vertebra to seventh cervical spine vertebra). Also, he sustained C5 (fifth cervical spine vertebra) and C6 (sixth cervical spine vertebra) nerve root injuries. He continued to experience neck pain and stiffness while still experiencing weakness. These have affected his ADLs (activities of daily living). 

The patient has had many previous PT (physical therapy) sessions. This is a request for further sessions to improve his strength. 

Having completed recent sessions in the current year, he has not shown any tangible progress after the most recent PT (physical therapy) sessions up to this date. 

No, the requested additional physical therapy visits are not medically necessary.
The patient sustained a neurological injury. After rehabilitation he has undergone PT (physical therapy) sessions. There was no evidence of any tangible improvement in muscle strength, ADLs (activities of daily living), etc. The PT (physical therapy) sessions are more of maintenance nature in this regard. Therefore, the additional physical therapy sessions are not medically necessary. 

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient. 

Continued PT (physical therapy) is not medically necessary, as explained above, and unlikely to be more beneficial than any standard treatments, which will be home exercise program in this instance. The patient sustained a neurological injury. After rehabilitation he has undergone PT (physical therapy) sessions. The most recent consisted sessions during which there was no evidence of any tangible improvement in muscle strength, ADLs (activities of daily living), etc. The PT (physical therapy) sessions are more of maintenance nature in this regard.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity.
Treatment: Wegovy 0.5mg/.5ml Pen Injector.
The insurer denied the Wegovy 0.5mg/.5ml Pen Injector.
The denial is overturned.

The patient is a female who reportedly has obesity. Wegovy is requested for approval. The reason for prior denial was that medication is not medically necessary and patient does not meet plan criteria.

Yes, the proposed treatment is medically necessary. 

The patient has obesity with a body mass index of 30 with high cholesterol and high blood sugar, and has already lost weight.  She is tolerating the medication well and is happy with the results. She is actively following with the doctor at Medical weight loss of New York for weight loss program. She uses optifast as apart of weight management program. She also has membership at planet fitness for exercise program. Patient is able to maintain weight loss with the requested medications.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
The patient has been responding very well to Wegovy with significant weight loss. She is happy with the results. She has obesity, hyperlipidemia and high glucose which are health risks without approval of the requested medication. 
She meets criteria for approval. Therefore, the proposed treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female with hypertension and hyperlipidemia. The patient presented to emergency room with flu like symptoms. The patient was found to have COVID-19 infection a few days prior to arrival to the emergency room. In the emergency room (ER), the patient received intravenous (IV) steroids, intravenous (IV) antibiotics, and intravenous (IV) fluids and electrolyte replacements.

The patient was admitted to acute in hospital level of care for further management. The patient was started on intravenous (IV) remdesivir and finished a three day course. The patient was also treated with amoxicillin for strep pharyngitis. The patient was admitted to acute in hospital level of care. This length of stay (LOS) is denied due to lack of medical necessity. This denial is being appealed.

No, the proposed treatment, inpatient hospital admission was not "medically necessary."

The patient was being treated for diarrhea and mild hypoxia due to COVID-19 infection. The patient's electrolytes improved with intravenous fluid (IVF) resuscitation.

The patient' condition improved significantly within 24 hours. The patient finished the three day remdesivir treatment. The patient was also on intravenous (IV) antibiotics for over seven days and was receiving oral steroids.

During this length of stay, the patient was hemodynamically stable. The patient was not requiring supplemental oxygen. The patient was not in respiratory distress. The patient was tolerating an oral diet. The entire admission was not medically necessary.

Given the patient's signs and symptoms due to COVID-19 pneumonia had good response with emergency room (ER) treatment, it would not have been reasonable to expect prolonged hospitalization for the administration of intravenous medications to see significant improvement in this patient. The patient's treatment course would have been expected to be safe and effective at a lower level of care.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Given the patient's signs and symptoms due to COVID-19 pneumonia had good response with emergency room (ER) treatment, it would not have been reasonable to expect prolonged hospitalization for the administration of intravenous medications to see significant improvement in this patient. The patient's treatment course would have been expected to be safe and effective at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyponatremia. 
Treatment: Inpatient Admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a female with diabetes and hypertension who presented to the hospital with constipation spanning a week, nausea and vomiting with decreased oral intake. The patient's sodium was noted at 125 and improved to 128 after getting salt tablets and Lasix. The patient was treated with stool softeners, laxatives and enemas for constipation with plan for continued outpatient gastrointestinal (GI) workup. 

No, the proposed inpatient level of care was not medically necessary. 

The requested inpatient level of care was not medically necessary as it was provided primarily for convenience of the patient or the practitioner, nor was it the least intensive and/or most appropriate alternatives among diagnostic and treatment options. 

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

The patient had constipation, nausea and vomiting with decreased oral intake and was noted with low sodium. The patient was treated with Lasix, salt tablets and water restriction. Based on available data, there was no documentation of altered mental status that was severe or persistent, cerebral edema, diffuse, generalized edema (e.g., anasarca) or other neurologic abnormalities (e.g., tremor, hypertonia or hypotonia, hyperreflexia, gait abnormalities) or hemodynamic instability requiring inpatient level of care. There were no specific treatments or therapies that required at an inpatient level of care and therefore, the patient could have safely and effectively been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pregnancy.
Treatment: Inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is overturned.

The patient is a female who is 34 0/7 weeks pregnant. She is diamniotic - dichorionic twin gestation, with Vertex / Breech presentation. She presented with complaints of decreased fetal movement x 12 hours (improved over the last 8 hours) and contractions.

The Inpatient Hospital Stay was medically necessary for this patient.
Based on provided clinical information, the patient's pregnancy was high - risk, due to advanced maternal age, cervical shortening, prior episode of preterm labor and advanced cervical dilatation to 3 centimeters. The patient presented with decreased fetal movement x 12 hours and contractions with cervical change from prior exam: the cervix was 4-5 centimeters on admission with 90% effacement. The patient was contracting every 1-2 minutes. Given gestational age, tocolytics were noted appropriate for the patient; but admission with monitoring for labor progress (with cesarean section if further progress of preterm labor noted, as presentation was vertex / breech) and continuous electronic fetal monitoring was absolutely appropriate (given decreased fetal movement) and consistent with literature and generally accepted standards of practice.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Migraine Headache
Treatment: Emgality
The insurer denied the Emgality.
The denial is overturned.

The member is a female with migraine headache disorder. She is currently treated with topiramate and Emgality for migraine prevention. The provider is requesting continuation of Emgality.

Yes, the requested Emgality is medically necessary.

The patient has tried and failed a reasonable trial of topiramate for migraine prevention. She cannot be treated with divalproex sodium, as she is a female of childbearing age. She cannot be treated with amitriptyline or venlafaxine, as she is currently treated with escitalopram. She cannot be treated with a beta-blocker (Danesh and Gottschalk), as the medical records indicate relative bradycardia (heart rate 58 and 67 at two encounters). Therefore, she has either tried and failed or has a contraindication to all of the preferred agents (Burch).

Therefore, given the above, the requested Emgality is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Deep impinging overbite.
Treatment: Comprehensive orthodontic treatment.
The insurer denied coverage for comprehensive orthodontic treatment.
The denial is upheld. 

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to deep impinging overbite, among other findings. The orthodontist has completed the HLD (Handicapping Labio-Lingual Deviation) index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage to support orthodontic necessity. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet this specified handicapping malocclusion medical necessity requirement on the HLD Index Report index. 

Upon review of the submitted documentation, (study models were not provided for review), it is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires, as of September 1, 2012, the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. In this case, the treating orthodontist claims an automatic qualifying condition of deep impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of soft tissue damage severe or otherwise and does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does not meet insurer and peer criteria to justify orthodontic care.

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.

Comprehensive orthodontic treatment is not considered medically necessary for this patient.

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

The insurer's denial of coverage for comprehensive orthodontic treatment is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bipolar. 
Treatment: Acute mental health inpatient treatment. 

The insurer denied inpatient Mental Health Treatment. 
The health plan's determination is overturned. 

This case involves an adult male admitted for acute inpatient psychiatric treatment with a diagnosis of bipolar mood disorder, manic phase with psychosis. The patient was brought into the emergency department from jail with onset of delusions and erratic behaviors. He had been arrested for running in the street and threatening others with a machete. He had threatened his girlfriend's brother accordingly. He indicated that he was being persecuted and was at risk for harm. Additionally, he was not sleeping and had become increasing agitated in the 72 hours prior to his arrest. The patient had a history of a depressive disorder treated with Zoloft in the past, and a history of attention deficit hyperactivity disorder (ADHD) treated with Adderall in the past. He had no history of psychiatric hospitalization or suicidal behavior. 

Inpatient Mental Health Treatment was medically necessary for this patient. 

The continued inpatient services served to provide intensive treatment in a patient with high risk for relapse, and severe symptoms of bipolar disorder including psychotic features and poor insight and control of impulses. Thus, the continued acute inpatient level care was necessary in order to continue a safe and clinically appropriate treatment with monitoring and address any psychosocial stressors and other issues that could result in medication non-adherence. Moreover, the patient presented with safety issues with delusional thinking and erratic behavior, and had remained anxious with illogical and disorganized thinking and mood disturbance and sleep disturbance. There were continued safety concerns, residual mood disturbance, and paranoid thinking together with continued risk of impulsive behavior. 

Only by the date of discharge did the patient exhibit calm demeanor without evidence for delusions or with clear thinking that would support a discharge to the community under the care of his grandparents with a clear discharge plan.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bilateral Osteoarthritis of Knee.
Treatment: Euflexxa (series of injections to bilateral knee).
The insurer denied the Euflexxa (series of injections to bilateral knee).
The denial is overturned.

The patient is a male diabetic with diabetic neuropathy. He has bilateral knee OA (osteoarthritis) described as moderate to severe (antalgic gait, reduced range of motion, stiff knee pattern). He has a past surgical history of arthroscopic partial meniscectomy right.

The patient's provider performed steroid injections, which gave short-lived relief, however with exacerbation of elevated blood glucose level. Referral to the requesting provider led to activity modification, home program for functional recovery followed by Hyaluronic Acid intra-articular injections for 2-injection pulsed cycle bilateral, with patient reported outcome of very good relief for 8 weeks followed by slow return to referral baseline level.

Yes, the requested Euflexxa is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
The patient has impacting co-morbidities (diabetic, bilateral knee involvement) with documented compliance with care plan and results from a staged approach for OA (osteoarthritis): NSAIDs (nonsteroidal anti-inflammatory drugs) IACS (intra-articular corticosteroids), IAHA (intra-articular hyaluronic acid). The request is for advancement to Euflexxa intra-articular injection within the appropriate time frame.

The treatment of Knee Osteoarthritis (KOA) in the age group of this patient has evolved to the algorithm which routinely deploys the use of intra-articular viscosupplementation. The current data suggest that > [greater than] 10% of all newly diagnosed KOA (knee osteoarthritis) will undergo such a treatment this year.

The policy acknowledges the FDA (United States Food and Drug Administration)-approval for viscosupplementation, however limits its use to Medicare Advantage population. The current medical plan/policy excludes the population of patients under age 65 with moderate to severe KOA (knee osteoarthritis) with desire to delay or contraindication to surgical arthroplasty.

Recent society Guidelines and literature support the use of viscosupplementation. The initiation of IHA (hyaluronic acid) injection regimen is a commonly deployed strategy used in daily practice for these unique situations. It has been shown to potentially reduce NSAID (nonsteroidal anti-inflammatory drug) use and opioid prescriptions, yielding a safe, efficacious, and effective regimen.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain (s/p [status post] surgery)
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

The patient is a female. She was admitted to the hospital on post-operative day 
# (number) 2 after laparoscopic cholecystectomy for gallstone pancreatitis. The patient had recurrent severe abdominal pain, and CT (computed tomography) evidence of a postoperative fluid collection in the gallbladder fossa.

The patient was admitted for her abdominal pain. She was hydrated and discharged the next day.

No, the Inpatient admission was not medically necessary.
The documentation does not justify a hospital admission. The patient had severe abdominal pain after cholecystectomy that, per documentation, was treated with IV (intravenous) fluids. There is no other supporting documentation that she improved other than in the appeal letter. This does not support the need for inpatient treatment unless there is supporting documentation. Records attached do not reflect any treatment other than NPO (nothing by mouth) and hydration after the laparoscopic cholecystectomy. There is no documentation of reasoning for observing vs (versus) working up the fluid in the gallbladder fossa. There is no documentation about the patient improving after being admitted.

Therefore, given the above, the inpatient admission was not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
The documentation provided does not justify an inpatient stay. Patient was evidenced to improve very quickly. Based on the documentation provided, she was discharged the next day. The patient could have been treated in a lower level of care, while assessing her symptoms.