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

Diagnosis: Abdominal pain.
Treatment: Inpatient admission.

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

The patient is a male. He had presented to the emergency department of the facility filing the appeal with the report of several days of intermittent abdominal pain. The patient was pain-free at the time of his presentation. The pain was noted to start in the left lower quadrant, and then it radiated to the right upper quadrant, peaked and then abated. The patient denied any bleeding or diarrhea or emesis. The patient had no relevant medical history.

The patient's vitals on presentation were normal, and there was no temperature. The white count was normal. The ultrasound showed no acute intra-abdominal pathology. A CT (computed tomography) scan of the abdomen also showed no acute intra-abdominal pathology. A GI (gastroenterology) consultant did not deem the patient as evidencing significant gallbladder pathology. An endoscopy was recommended by the surgical consultation to evaluate for gastritis.

No, the inpatient admission was not medically necessary.

While the services as provided are medically appropriate, the level at which the services were provided was not medically necessary.

Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had abdominal pain, yet he did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for a prolonged NPO (nothing by mouth) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission. As such, the care could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute/chronic/recurrent venous thromboembolism (VTE) of the extremity. 
Treatment: Inpatient admission. 

The insurer denied coverage for Inpatient admission. 
The denial is upheld. 

The patient is a male with past medical history of venous thromboembolism (VTE) who presented to the Emergency Room (ER) with complaints of leg swelling. An ultrasound (US) showed recurrent venous thromboembolism (VTE) versus persistent VTE. The patient was admitted to the hospital for acute VTE. The patient was placed on a heparin drip. Hematology evaluated the patient and recommended increasing Xarelto to 20mg daily with a repeat ultrasound in 4 weeks. The patient was discharged. 

As per Khatib et al. (2020), "Increasing evidence supports the safety and effectiveness of managing low-risk deep vein thrombosis (DVT) or pulmonary embolism (PE) in outpatient settings. [This study] performed a systematic review to assess safety and effectiveness of managing patients with DVT or PE at home compared with the hospital [and]...indings indicate that low-risk DVT patients had similar or lower risk of patient-important outcomes with home treatment compared with hospital treatment. In patients with low-risk PE, there was important uncertainty about a difference between home and hospital treatment." 

Based on the review of the medical record and literature, hospital admission was not medically necessary for this patient. Acute/chronic/recurrent venous thromboembolism (VTE) of the extremity does not warrant acute level care. Multiple studies have demonstrated safety and efficacy of outpatient management of VTE. Patients with VTE who require acute level admission are patients with hemodynamic instability, massive pulmonary embolism (PE), and/or risk of bleeding. In this case, none of these conditions were present. In this case, the patient could have been placed and managed on observational status while awaiting hematology evaluation. In conclusion, the patient could have been managed at a lower level of care and did not inpatient level of care. 

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

Based on the above, the medical necessity for the Hospital Admission is not substantiated.  The insurer's denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Gastroesophageal reflux disease (GERD). 
Treatment: Esophageal sphincter augmentation device (Procedure code 43284) and inpatient stay. 

The insurer denied coverage for the esophageal sphincter augmentation device (Procedure code 43284) and inpatient stay.  The denial is upheld. 

This is a male patient with a history of gastroesophageal reflux disease (GERD) with abnormal reflux episodes. The patient was noted to have an abnormally elevated DeMeester score of 17. There was no evidence of Barrett's esophagus on an esophagogastroduodenoscopy (EGD) performed in the past. Esophageal manometry was noted to be normal. There was no hiatal hernia noted on an esophagram. Mild GERD was noted. 

The patient has not had resolution of symptoms with conservative medical treatment consisting of proton pump inhibitors and antacids. As per literature review, Linx Reflux Management System should be standard of care in the management of this patient's chronic GERD. 

The reviewed record notes a diagnosis of Barrett's esophagus. While a recent retrospective study supports the use of Linx in patients with GERD and Barrett's esophagus, most studies have in fact excluded such patients, so that the role of Linx in such patients remains unclear (Dunn et al.). 

It appears that the diagnosis of Barrett's esophagus may have come from the endoscopist and/or the patient. From the EGD note, it seems as if the endoscopist thought that the Z-line looked abnormal and similar to Barrett's, so they biopsied it. It appears that they added "Barrett's esophagus" as a diagnosis in the patient's chart after the procedure. Once the final pathology returned, it actually wasn't Barrett's. This may be an instance of when a diagnosis is added, it stays with the patient until someone removes it or edits it in the medical chart. For those suspected of Barrett's, upper endoscopy is sometimes repeated every 6-12 months. 

Without clarification of the patient's Barrett's status, it cannot be stated that this procedure is likely to be more beneficial than any other standard procedure. 

The carrier's denial of the requested esophageal sphincter augmentation device (Procedure code 43284) and inpatient stay should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic skin wounds and substance abuse. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for the inpatient hospital admission. 

The denial is upheld. 

This is a male patient with past medical history significant for polysubstance abuse, bipolar disorder, and methicillin resistant staphylococcus aureus (MRSA) infection who presented to the Emergency Department (ED) with complaints of chronic wounds to his buttocks and legs. 

Vitals on presentation included: Temperature- 36.8, Blood Pressure- 119/79, Pulse- 80, Respiratory Rate- 18, and Oxygen (O2) saturation- 99% on Room Air. Laboratory results included the following: White blood cell (WBC) count- 7.0, hemoglobin (HGB)- 14.4, hematocrit (HCT)- 43.5, creatinine- 1.07, and glucose- 122. 

The patient was started empirically on intravenous (IV) antibiotics (vancomycin and Zosyn) for possible rash/cellulitis/chronic wound. The patient was monitored for withdrawal precautions. Cultures remained negative. The patient was offered detoxification, which he refused. The patient remained afebrile and hemodynamically stable. The patient was discharged on oral antibiotics (Bactrim) to follow-up as an outpatient. 
 
The patient presented with chronic skin wounds and substance abuse. Otherwise, he was afebrile, hemodynamically stable, with unremarkable laboratory results including normal WBC. The patient did not have any evidence for a disseminated infection and no surgical intervention was required. Based on these findings, the patient met criteria for observation level of care; 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 hospital admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic Dermatitis.
Treatment: Dupixent.

The insurer denied the Dupixent.  The determination is upheld.

The patient has with atopic dermatitis. There are paid claims for Fluocinonide ointment and Triamcinolone. The patient's dermatologist reports the trial and failure of Tacrolimus, Triamcinolone, and Clobetasol. At issue is the medical necessity of Dupixent.
Dupixent is not medically necessary.

The patient has insufficient to no documented treatment failure with, or true medical contraindication to, either topical calcineurin inhibitors, or standard, first-line oral medications such as Methotrexate or Azathioprine. Dupixent is not proven to be superior to all other formulary alternatives as per comparative, controlled studies.  Methotrexate, Cyclosporine, and Azathioprine are not contraindicated due the potential risks and side effects for hepatotoxicity and hematologic toxicity. Monitoring is necessary for these medications, which are normally very well-tolerated and have been proven highly effective for a host of autoimmune and immune-related conditions for years to decades, provided they have blood monitoring on a regular basis. Such monitoring is indicated for all medications (some more than others) with respect to laboratory and clinical side effects and is also true for the requested Dupixent. The warnings therefore are for potential side effects, and until such time that medical contraindication can be proven for this patient (which has not occurred to date), these medications are to be as presumed safe and effective as they have been for countless patients with atopic dermatitis and other conditions as much as they have been for decades.

Atopic dermatitis (AD) is a common chronic inflammatory skin disease that predominantly affects children. However, it can persist in adulthood and/or start at older ages. Due to its chronic nature and frequently occurring relapses, AD has a substantial effect on patients' quality of life, often requiring long-term systemic treatment, especially in adult patients, who are more frequently refractory to adequate topical treatment with mid- to high-potent corticosteroids and/or calcineurin inhibitors. Therefore, treatment with systemic therapies is often needed to take control of the disease, prevent exacerbations and improve quality of life. However, data regarding systemic treatment effectiveness and long-term safety in adult patients with AD are insufficient. Indeed, standardized international guidelines are lacking, and the treatment approach widely differs among diverse countries. This review focuses on the use of systemic treatments in adult AD patients analyzing published literature. [2] Many AD patients respond satisfactorily to topical or systemic treatments, but for those patients who do not respond or have contraindications, new biologic agents appear to be promising therapies [4].

 Therefore, consistent with current medical literature [1-4], the requested Dupixent is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 
The insurer denied braces and monthly visits. 
The denial is overturned.

The patient in question is a female. She has a Class II malocclusion with crowding and protrusive maxillary incisors. She has an 8 millimeter (mm) overjet and 6mm overbite. She is treatment planned for 24-30 months of orthodontics to correct the crowding and protrusion. The subject under review is the medical necessity for the treatment of braces and monthly visits.

The health plan's determination is overturned. 

The requested treatment is medically necessary for this patient.

Teeth #8 and #9 are protruding forward within the dental arch. This makes them more prone to trauma. There is strong medical evidence that that correction of patients with prominent maxillary front teeth can reduce the risk of incisor trauma.1 Orthodontic treatment can make the teeth significantly less protrusive. If orthodontic treatment reduces the protrusion, it will reduce the chances of damage to the maxillary incisors and the associated costs and morbidity of repairing these teeth. Additionally, there is scientific evidence that oral health quality of life is reduced in patients with 6+mm overjets, which this patient has.2 For these reasons orthodontic treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Moderate maxillary crowding, mild mandibular crowding, anterior crossbite with gingival attachment loss on the mandibular left canine.
Treatment: Braces and monthly visits.
The insurer denied the braces and monthly visits.
The denial is overturned.

The patient is a female.  The request is for dental benefits for orthodontic therapy (braces) and monthly visits.  Dental clinical exam reveals a skeletal class I relationship, class II canine, moderate maxillary crowding, mild mandibular crowding, an anterior crossbite with gingival attachment loss on the mandibular left canine.  Diagnostic x-rays and photos were taken.  

The Health plan denied the claim because patient scored a 23 on the Handicapping Labio-Lingual  Deviation (HLD) index; a score of 26 is needed for approval.  The provider is appealing the case because the health plan did not consider the anterior crossbite condition of the patient.

The proposed treatments of orthodontic therapy (braces) and monthly visits are medically necessary.
The photos and the x-rays show that the lower left canine is 100 percent in crossbite, meaning that this tooth should be inside or lingual to the upper opposing tooth but it is outside or labial to that tooth.  In addition, the patient also exhibits a class II canine--that is where the distal surface of the mandibular canine is mesial to the maxillary canine.  This shows how out of alignment the patient's teeth are.  The crossbite can affect the patient's ability to chew effectively and can also interfere with the ability to have proper speech.

The health plan did not consider and indicate the crossbite on the Handicapping Labio-Lingual Deviation (HLD) index form that they used to deny the claim.  The Handicapping Labio-Lingual Deviation (HLD) index states that a crossbite is an automatic qualifier for orthodontic therapy (braces).  The Provider's reasoning for the appeal is that the health plan did not consider the anterior crossbite that is exhibited on the lower left canine.   This condition is quite evident on the photos.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, urinary incontinence, depression, colon cancer and diabetes mellitus.
Treatment: Increase Consumer Directed Personal Assistance Program (CDPAP) Service Hours from 52 Hours per Week to 80  Hours per Week.
The insurer denied the Increase Consumer Directed Personal Assistance Program (CDPAP) Service Hours from 52 Hours per Week to 80  Hours per Week.
The denial is overturned.

The patient is a female with a history of dementia, urinary incontinence, depression, colon cancer and diabetes mellitus. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). 

Appeal review requested for potential approval of 80 hours per week Personal Assistance Services to offer increased activities of daily living (ADL) support.

Yes, the proposed treatment of 80 hours per week Personal Assistance Services is deemed medically necessary.
This is a female with a history of dementia, urinary incontinence, depression, colon cancer and diabetes mellitus. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Recent correspondence was received from the patient's physician states that due to progressively worsening cognitive impairment, confusion, incontinence and insomnia, the currently approved plan of 52 hours per week Personal Assistance Services is insufficient to meet the patient's current needs. For these reasons, the proposed treatment 80 hours per week Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease. 
Treatment: Personal care services. 

The insurer denied Personal Care Services (PCS): 24 Hours per Day, 7 Days per Week (Split-Shift) for a Total of 168 Hours. The health plan's determination is overturned. 

The patient is a female with past medical history of Alzheimer's disease, urinary incontinence, bowel incontinence, seizure disorder, cataracts, constipation, and permanent pacemaker who had been assigned PCA (personal care assistant) services 8 hours/day, 6 days/week, and 7 hours/day, 1 day/week to total 55 hours/week. The patient's PCP (primary care provider) provided a letter stating the patient's medical diagnoses, current PCA hours and stated the patient's health and mental state had rapidly declined and it was medically necessary that the patient be approved for a minimum of 7 day a week 24 hour care with split shift of 12 hours, as the patient requires assistance with activities of daily living (ADL). 

Personal Care Services (PCS): 24 Hours per Day, 7 Days per Week (Split-Shift) for a Total of 168 Hours are medically necessary for this patient. 

The patient has documented progression of chronic medical condition of Alzheimer's dementia. The recent assessment stated the patient was supervision with walking and locomotion but further stated the patient does not walk on her own. The patient requires assistance with all activities of daily living (ADL) and the daughter felt the patient required more than supervision with task of transfer toilet. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these needs. Because the patient had 24 hour care needs, the plan improperly utilized the task assessment tool to calculate PCA hours. The patient's care needs cannot be met with current hours and adaptive equipment or medical supplies. The request to increase PCA hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs/ Instrumental activities of daily living (IADL). The plan assumed the patient has informal/formal support outside of the PCA hours provided which was incorrect. According to her medical providers, the patient was unsuccessfully treated for insomnia and was not able to participate with physical therapy (PT) due to her dementia. The patient wears diapers and has urinary and bowel incontinence requiring attention and assistance in the overnight hours. 

Due to the patient's medical conditions and overnight care needs a PCA would not be able to obtain greater than five hours of uninterrupted sleep. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 24 hours/day, split-shift, 7days/week, to total 168 hours/week are medically necessary for this patient. Personal care services are medically necessary under when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: Braces and monthly visit
The insurer denied the braces and monthly visit.
The determination is overturned.

The patient has a skeletal Class II subdivision right malocclusion with maxillary and mandibular spacing. She has an anterior open bite. She is treatment planned for orthodontics to address the open bite. At issue is the medical necessity of braces and monthly visit.

The braces and monthly visit are medically necessary. Patients with an anterior open bite are among the most difficult patients to treat. (1) One side effect of an anterior open bite is reduced maximum bite force with less muscle activity while chewing than patients without an open bite. (2)
Orthodontic treatment is medically necessary for this patient due to the side effect described above, and the fact that this is not something that will self-correct without orthodontic intervention.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right cerebellopontine angle schwannoma. 
Treatment: Proton beam radiation therapy for primary CNS (central nervous system) neoplasms (tumors). 
The insurer denied proton beam radiation therapy for primary CNS (central nervous system) neoplasms (tumors). 
The determination is upheld. 

This patient has a right cerebellopontine angle schwannoma post subtotal resection. Radiation therapy is recommended to this surgical bed to attempt long-term control and the proton beam approach is requested. At issue is the medical necessity of proton beam radiation therapy for primary CNS (central nervous system) neoplasms (tumors). 

The requested treatment of proton beam radiation therapy for primary CNS neoplasms is not medically necessary for this patient. 

The recommended proton beam radiation therapy for this patient with a low grade schwannoma of the right cerebellopontine angle of the brain is not medically necessary. There are a lack of any significant studies published in peer reviewed journals supporting the benefits and safety of proton beam radiation as compared to conventional intensity modulated radiation therapy (IMRT) photon radiation. There are ongoing clinical trials to determine the benefits and safety of proton radiation as compared to photon beam approach. Until these studies mature and are published in peer reviewed journals showing the efficacy and safety of proton beam radiation, this would not be medically necessary. The few studies that are published are with small numbers of patients and nonrandomized and state the need for additional studies to be performed to assess the benefits over photon beam radiation.