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

Orthopedic
Orthotics

Diagnosis: bilateral foot pain
Treatment: custom orthotics
The insurer denied custom orthotics. The health plan's determination is overturned. 

The patient is a boy with hypermobility, genu valgus, pes planus, and bilateral foot pain. He is able to run and participate in track events, but often complains of foot pain. His symptoms have been present for a couple of years. He was given exercises to do. He had previously been prescribed foot orthoses and felt that they benefited him. The orthopaedic surgeon prescribed new custom orthotics to treat his pain.

Custom shoe inserts are medically necessary for this patient.
Although flat feet may be considered normal and are generally not symptomatic, sometimes patients do have pain in the foot and ankle. This is particularly true in children who have other conditions that may accentuate the pressures on the foot. This patient has genu valgus and hypermobility, which can increase the pressure on the ligaments and joints of the foot and contribute to pain. Support of the longitudinal arch can maintain the foot in a more normal weight-bearing position, which can improve the shock-absorbing function of the joints and ligaments of the foot and decrease pain. To gain adequate support of the foot, an orthotic must be sized or contoured to provide sufficient corrective force; over-the-counter, non-custom orthoses are not able to do this. The orthosis supports the foot and treats the pain; it is not designed to change the anatomic shape of the foot. The custom orthotics should be considered medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Respiratory System/Pneumonia
Inpatient Hospital/Inpatient Hospital Admission
The health plan denied the inpatient hospital admission as not medically necessary. The health plan's determination is overturned.

The patient is a male who was admitted to the hospital for pneumonitis and a heart attack. He has a history of substance abuse. On presentation, the patient was found unresponsive and cyanotic. He was given Narcan and was transferred to this facility. He abuses amphetamines, Ketamine, and Xanax. He had crackles and tachycardia with an elevated troponin. His white blood cell count (WBC) was 14.6. A urine drug screening (UDS) and positive for cocaine and amphetamines. An electrocardiogram (EKG) noted ST elevation. He was stated on Rocephin and Azithromycin in addition to Lovenox. The patient's mental status quickly improved and he was eventually discharged in stable condition.
At issue is the medical necessity for the inpatient hospital admission.

The health plan's determination of medical necessity is overturned, in whole.

The requested service/treatment was medically necessary.
The patient in question does meet medical necessity for the acute inpatient level of care per current literature and standard of care. The patient had possible airway compromise due to overdose and developed pneumonia. The patient was at high risk of decompensation and death secondary to the overdose and developing pneumonia. Due to the acuity of presentation, an alternate level of care would not have been appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back Pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

The patient is an adult female with history of sudden onset low back pain radiating to the left leg with associated numbness, tingling and weakness that was progressive and presented in the emergency room (ER). Prior to presenting in the emergency room, the patient saw other physicians and had a magnetic resonance image (MRI) of the lumbar spine to rule out spinal cord compression; she saw an orthopedic surgeon who prescribed steroids to no avail after which she decided to go to the emergency room. The patient's relevant past medical history included lumbar five/sacral one (L5/S1) laminectomy and revision four years ago, lumbar herniated disc, and obesity. She tried Medrol dose pack, naproxen, Topamax, gabapentin, etc.
In the emergency room, the patient was found to have decreased sensation and weakness of the left lower extremity (muscle strength 3/5) with paraspinal tenderness in the cervical and lumbar spines. In addition, the patient was in extreme pain at ten out of ten (10/10) with tachycardia at 109-110. The patient's lab work showed elevated white blood cells, elevated neutrophils, and urine was positive for ketones, blood and leucocyte esterase. Treatment was started in the emergency room before transfer to the inpatient floor for continued care where her pain was managed with intravenous Morphine, intravenous Decadron, intravenous Dilaudid, Tramadol, lidocaine patch, Flexeril, Lyrica, etc. She had tachycardia at 118 beats per minute. The patient 
was discharged on day #4 when she was hemodynamically stable, and pain was better controlled.

The proposed inpatient hospital admission was medically necessary.

The acute inpatient admission for severe acute low back pain radiating into a the left lower extremity with associated weakness numbness and tingling; difficulty in ambulation; tachycardia to upper rate of 118 beats per minute; lab work showing elevated white blood cells/neutrophils; and urine with blood, ketones and leucocytes esterase was medically necessary. Because of the above clinical presentation and a past history of lumbar five/sacral one (L5/S1) laminectomy/fusion and a revision, the 
patient was admitted to the floor from the emergency department. She required intravenous Morphine, intravenous Decadron, intravenous Dilaudid, Tramadol, lidocaine patch, Flexeril, Lyrica, etc. The need for admission was met because at 
presentation, as stated above, it was clinically prudent to admit the patient especially with her weakness, lab work findings, and tachycardia for a period of time when she was hemodynamically stable. Pain improved while on intravenous medications before discharge.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary tract infection. 
Treatment: Inpatient admission. 
The insurer denied coverage for inpatient admission. 
The denial is upheld. 

Patient is an adolescent female with benign past medical history who presented to the emergency department with complaints of fever and flank pain. 

Vitals on presentation included: Temperature 103.4 degrees Fahrenheit, Blood Pressure 97/42 mmHg, Pulse 152 beats per minute, Respiratory Rate 20 breathes per minute, oxygen (O2) saturation 100% on room air. 
Laboratory results included the following: white blood cell count (WBC)10.30, Hemoglobin (Hgb) 13.8, Hematocrit (Hct) 40.7, Creatinine 0.8, Glucose 94, C-reactive protein (CRP) 7.7, urinalysis showed positive nitrite and leukocyte esterase 3+ (level 3). 

The patient was started on intravenous fluids and empiric antibiotics (ceftriaxone) for possible urinary tract infection. Computerized Tomography (CT) scan of abdomen/pelvis was unremarkable. Blood cultures were negative and urine culture grew gram negative rods. The patient remained afebrile and hemodynamically stable. She was discharged to continue outpatient follow-up on oral antibiotics (Augmentin). 

According to documentation, the patient was admitted for urinary tract infection and had fever and tachycardia. Laboratory results were unremarkable including a normal white blood cell (WBC) count. Computerized Tomography (CT) scan was negative. The decision to admit patients with acute complicated Urinary Tract Infection (UTI) should be individualized. The decision is usually clear when patients are septic or otherwise critically ill. Otherwise, general indications for inpatient management include significant pain, marked debility, or inability to maintain oral hydration or take oral medications. Additionally, inpatient management is warranted when urinary tract obstruction is suspected or there are concerns regarding patient adherence. Generally, outpatient management is acceptable for patients with acute complicated Urinary Tract Infection (UTI) of mild to moderate severity who can be stabilized, if necessary, with rehydration and antimicrobials in the emergency department or observation unit. 
Based on the above findings, the patient met criteria for observation level of management, not inpatient 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 an inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Multiple sclerosis, fibromyalgia, arthritis, epilepsy, and asthma.
Treatment:  Additional Personal Care Assistance (PCA) Hours (8 hours a day x 6 days per week for a total of 48 Hours Per Week).

The insurer denied Additional PCA Hours (8 hours a day x 6 days per week for a total of 48 Hours Per Week).  The denial is overturned.

The patient is an adult female. Her medical conditions include multiple sclerosis, fibromyalgia, arthritis, epilepsy, and asthma. Denial of additional PCA (personal care assistance) hours of 8 hours a day x 6 days per week for a total of 48 hours per week is being appealed. The health plan approved 8 hours per day x 5 days per week and 4 hours per day on 1 day per week, for a total of 44 hours per week. The patient lives with her uncle and disabled mother. The patient's Uniform Assessment System evaluation completed three months ago shows modified independent cognition and functional status: total dependence with stairs; maximal assistance with managing medications and personal hygiene; and extensive assistance with eating. She uses a motorized scooter. She is incontinent of bowel and bladder. An appeal statement from the patient's provider notes the patient has pain and weakness. She is non-ambulatory. She requires assistance 24 hours per day. She had been receiving informal support from her uncle, who is unable to continue providing support for 8 of 24 hours on Saturdays. She takes multiple medications and needs reminders.

The requested PCA (personal care assistance) Hours (8 hours a day x 6 days per week for a total of 48 Hours Per Week) is medically necessary.

Personal Assistance Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. Denial of additional PCA (personal care assistance) hours of 8 hours a day x 6 days per week for a total of 48 hours per week is being appealed. The health plan approved 8 hours per day x 5 days per week and 4 hours per day on 1 day per week, for a total of 44 hours per week. This patient has limited mobility due to multiple sclerosis and fibromyalgia. Uniform Assessment System evaluation completed three months ago shows modified independent cognition and functional status: total dependence with stairs; maximal assistance with managing medications and personal hygiene; and extensive assistance with eating. She is incontinent of bowel and bladder. Appeal statements support her need for assistance with ADLs (activities of daily living). She has been receiving informal support from her uncle. He is unable to continue providing support for 8 of 24 hours on Saturdays. This loss of informal support supports the additional PCA (personal care assistance) hours from 44 to 48 hours per week. The requested increase to PCA (personal care assistance) hours of 8 hours a day x 6 days per week for a total of 48 hours per week is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: benign neoplasm of long bones of the left lower limb

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
According to the documentation submitted, this is the case of a patient with a history of rheumatoid arthritis, benign polyps and benign neoplasm of long bones of the left lower limb. The patient presented to the hospital for excision of left lower extremity neoplasm and removal of left lower extremity hardware. The medical records show the surgery performed was not complex or extensive. The facts were the hardware that was removed was a single screw. It was  in the proximal tibia, easily accessible". The bone graft provided filled the cavity. The femoral portion of the procedure was a small bone window, biopsy and filling with allograft. There was also removal of synovium posteriorly. The duration of anesthesia was approximately 3 hours. The blood loss was 100 cubic centimeters (cc). 

The post-surgical course showed pain level of 0. There were no drains. Physical therapy (PT) was delayed and the physician recommended 50 % weight bearing. There were no problems with bleeding, no infection, stable vital signs and no ongoing acute medical problem. The report of constipation for 5 days would be insufficient to substantiate necessity of hospitalization. Delays in PT would be expected and mobilization with associated services could be provided as an outpatient. There was no evidence "the patient required continuous medical management prior to safe discharge." There were no extenuating circumstances to support the admission with length of stay.

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

Diagnosis: Right fifth toe infection. 
Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

Patient is an adult female with past medical history significant for anxiety, bipolar disorder, and prediabetes who presented to the emergency department with complaints of right fifth toe infection. 

Vitals on presentation included: Temperature 99.0 degrees Fahrenheit, Blood Pressure 114/68 millimetre(s) of mercury (mm Hg), Pulse 72 beats per minute, Respiratory Rate 19 breaths per minute, oxygen saturation 98 percent on room air. Laboratory results included the following: white blood cells (WBC) 3.3, hemoglobin 10.3, erythrocyte sedimentation rate 115, C-reactive protein 5. 

The patient was started empirically on intravenous antibiotics (vancomycin and cefepime) for right foot infection in the emergency department. X-ray of the foot showed degenerative changes of the first metatarsophalangeal joint. Computed tomography (CT) scan and magnetic resonance imaging (MRI) of the foot, done outside of hospital was positive for osteomyelitis. Infectious Diseases recommended holding any further antibiotics as "patient is not acutely ill and also increase the likelihood of positive culture from bone biopsy."  

The patient underwent a bone biopsy and antibiotics were started 3 days later. Bone biopsy was negative. Patient remained afebrile, clinically, and hemodynamically stable. She was discharged to continue antibiotics as an outpatient. 

According to documentation, the patient presented with a right big toe infection concerning for osteomyelitis. Otherwise, she was afebrile, hemodynamically stable with unremarkable laboratory results including a normal white blood cell (WBC) count. Empiric antibiotics were held since the Infectious Diseases consultant felt "patient was not acutely ill" and plan was for diagnostic bone biopsy. Moreover, the patient had no evidence of a disseminated infection. Based on the above findings, she did not fulfill criteria for acute care hospitalization. She was medically stable for diagnostic procedures as an outpatient. 

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

Diagnosis: Impacted upper right canine. 
Treatment: D8080 Braces and D8670 Monthly Visit. 

The insurer denied: D8080 Braces and D8670 Monthly Visit. 
The denial is overturned. 

The patient is an adolescent female. The request is for orthodontic benefits with monthly follow up visits. The patient has a Class II skeletal malocclusion, mild maxillary and mandibular crowding, deep bite and an impacted upper right canine. The prior denial was due to a handicapping index score of 19. 

The proposed treatment is medically necessary. 

The patient has an impacted upper right permanent canine (tooth #6) which is not to be extracted. This is an automatic qualifier according to the handicapping index scale. This case has medical necessity and orthodontic treatment is needed to correct this problem. The monthly visits are to make sure the treatment is progressing properly.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity
Treatment: Wegovy 
The insurer denied Wegovy. 
The health plan's determination is overturned. 

This patient is a male diagnosed with obesity. As per the records, he has a history of HLD (hyperlipidemia) and hypertension (HTN). He has been unsuccessful in losing weight despite changing lifestyle factors including diet and exercise. 

Wegovy is medically necessary for this patient. 

Semaglutide (Wegovy) is a GLP1R (glucagon-like peptide-1 receptor) agonist that is Food and Drug Administration (FDA) approved in the treatment of type II diabetes and obesity. Recent studies published in major peer reviewed medical journals have shown the safety and efficacy of semaglutide for the treatment of obesity. This medication is now available for the treatment of obesity in the form of Wegovy. 

The standard of care requires that the patient is participating in lifestyle modification. It also requires that the patient has a body mass index (BMI) of 30 or greater or a BMI of 27 or greater with comorbidities such as hypertension, hyperlipidemia. 

The patient has a BMI of 36 and is reported to be participating in lifestyle modification. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vasovagal syncope
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient with a past medical history (PMH) of cerebrovascular accident (CVA), hypertension (HTN), diabetes mellitus type 2 (DM2), congestive heart failure (CHF), cirrhosis, and diabetes mellitus type 2 (DM2) who was admitted with complaints of (c/o) fatigue and syncope since a prior hospital discharge; the patient was supposed to go to rehabilitation (rehab) after that admission but declined. Her vital signs were unremarkable, with normal orthostatics. The patient was diagnosed with likely vasovagal syncope and treated with clinical monitoring, radiological and biochemical work-up, physical therapy (PT) / occupational therapy, and expert consultations. Cardiology was evaluated for a pericardial effusion, which they stated was not the cause of syncope, and no evidence of tamponade. Gastroenterology (GI) was consulted, and they recommended continuing lactulose and rifaximin. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient stay.
The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with c/o syncope associated with fatigue. The patient did not have any history of dilated cardiomyopathy, hypotension, family history of sudden cardiac death, aortic stenosis, hypertrophic cardiomyopathy (HCM), left ventricular outflow disease, pre-excitation syndrome, or Brugada syndrome. The patient did not have subarachnoid hemorrhage, pulmonary embolism, acute GI bleed, malignant arrhythmia, sustained bradycardia, supraventricular tachycardia (SVT) or ventricular tachycardia (VT), confirmed acute coronary syndrome (ACS), evidence of heart failure, cerebrovascular accident (CVA), shock, coma major trauma or cardiac arrest, or exertional syncope. The patient was felt to have vasovagal syncope and fatigue, and observation provides an ideal setting for care coordination and discharge planning and an opportunity for assessment by a physician, physical therapist, social worker, and care manager for these types of patients. These patients received focused interventions in mobility, gait training, and functional status improvements. Overall, this patient had neither severe acute pathology nor the need for acute surgical intervention. The patient was diagnosed with vasovagal syncope and treated with clinical monitoring, radiological and biochemical work-up, PT/OT, and expert consultations. Overall, this patient could have been safely treated at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity
Treatment: Duodenal switch and inpatient hospital admission
The insurer denied Duodenal switch and inpatient hospital admission.
The determination is overturned.

This is a patient who is seeking surgical treatment for the condition of morbid obesity. The patient has a current body mass index of 48 kilograms per square meter (kg/m2) (70.25 inches, 338 pounds (lbs)).

The patient consulted for the condition of refractory morbid obesity. He was enrolled in a multidisciplinary bariatric program. He participated with a nonsurgical weight loss program. This program included a reduced calorie diet, exercise, and behavioral modification. He has consulted with a registered dietician and has received nutritional counseling and education. He did complete a mental health assessment and was cleared for the proposed bariatric operation. His thyroid stimulating hormone (TSH) is normal. He has completed imaging with a chest x-ray and contrast upper gastrointestinal (UGI) imaging and diagnostic lab data. At issue is the medical necessity of duodenal switch and inpatient hospital admission.

The submitted records do support the medical necessity of the proposed procedure and the associated inpatient admission for this patient.

In this case, the proposed procedure is a medically necessary treatment for the documented condition of morbid obesity with a body mass index (BMI) of 48 kilograms per square meter (kg/m2) and is supported by the most recent guidelines published by the American Society for Metabolic and Bariatric Surgery.[1]

This patient has the diagnosis of morbid obesity with a BMI in excess of 40 kg/m2. He has successfully completed a comprehensive multidisciplinary bariatric evaluation with medical, mental health, nutritional, and surgical evaluations. There is no medical or mental health contraindication to the proposed procedure for this patient.

SADI (single anastomosis duodenoileostomy) with sleeve gastrectomy is a generally accepted treatment for the condition of medically complicated morbid obesity as is documented to exist in this case. It is effective as supported by multiple peer reviewed publications. It is not part of any ongoing clinical trial. The published guidelines of the American Society for Metabolic and Bariatric Surgery (ASMBS) support the safety and efficacy of the SADI/sleeve gastrectomy procedure for a patient such as this patient. The anticipated weight loss associated with this procedure will be health beneficial for this patient.

The proposed treatment in this case is the loop duodenal switch procedure also known as the single anastomosis duodenal switch or single anastomosis duodenoileal bypass with sleeve gastrectomy. This procedure is proposed as a bariatric operation to achieve weight loss and ameliorate comorbid health conditions.
An inpatient level of care is consistent with the standard of care regarding performance of this bariatric operation.