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

Diagnosis: Right basal ganglion hemorrhage; left hemiplegia.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female with history of right basal ganglion hemorrhage with left Hemiplegia. She was admitted to acute inpatient rehabilitation. The patient's relevant past medical history includes hypertension, diabetes mellitus, hyperlipidemia, etc.

Prior to admission, the patient lived with her son in an apartment on the second floor. She was independent with ADLs (activities of daily living) and ambulation.

The patient was ambulating without assistive device under supervision 150 feet x 4 and 50 feet x 2, able to navigate stairs/steps with supervision, required supervision and minimal assistance for most ADLs (activities of daily living) and requiring wheelchair as needed.

The patient's clinical conditions were stable.

No, the continued inpatient admission was not medically necessary.
The patient did not meet all the criteria for acute rehabilitation care INTERQUAL Criteria for Acute Rehabilitation in a patient with General Debility. She was clinically stable. She was ambulating without assistive device under supervision 150 feet x 4 and 50 feet x 2, able to navigate stairs/steps with supervision, required supervision and minimal assistance for most ADLs (activities of daily living) and requiring wheelchair as needed.

The patient's clinical conditions, including hypertension and Diabetes Mellitus, were well under control. The plan is to discharge her to live with her son in his apartment with support from others.

Based on the above, the patient has not met the criteria for continued intensive acute inpatient rehabilitation for the remaining six days of admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertensive emergency

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is overturned

The patient presented to the emergency department with chest pain, dyspnea on exertion, pedal edema, and poorly controlled blood pressure (198/128). On further questioning, the patient reported paroxysmal nocturnal dyspnea.  Past medical history was significant for hypertension, but the patient was not taking his previously prescribed medications. Upon arrival to the emergency department (ED) the patient was markedly hypertensive with Blood Pressure (BP) 198/128.  Physical exam was significant for a body mass index (BMI) of 40 and bilateral 1+ [positive] pedal edema. Serum blood testing revealed hypokalemia (K-3.0), a mild elevation in Troponin (0.084 ng/ml [nanogram per milliliter), Creatinine (1.11) and an elevated B type natriuretic peptide (BNP) level (1160).  Electrocardiogram (EKG) revealed bilateral enlargement with ST-T (interval on EKG) wave inversions in the inferior leads, unchanged from baseline.  The corrected QT (interval on EKG) interval was prolonged at 540 milliseconds. The patient was admitted to the hospital for observation and treatment.  Blood pressure was controlled with nifedipine, lisinopril, and hydrochlorothiazide and plans were in place for ischemia work up.  The patient signed out against medical advice (AMA) and was given a follow up appointment. 

The health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.  Hypertensive emergency is defined as BP>180/120 with target organ damage. (Reference 1) This patient presented with paroxysmal nocturnal dyspnea, pedal edema and elevated BNP and troponin levels. These findings are consistent with left ventricular dysfunction and target organ damage.  In addition, the patient was hypokalemic and the corrected QT interval on Echocardiogram (ECG) was greater than 500 milliseconds.  The goals of treatment of hypertensive emergency are to minimize progressive or additional target organ damage while preventing consequences of rapid BP correction. (Reference 2) Admission to the hospital for aggressive blood pressure management was necessary. In fact, American Heart Association guidelines recommend admission to the ICU (intensive care unit) for management of hypertensive emergencies. (Reference 1) In conclusion this patient should have been managed at a higher level of care. Inpatient hospital admission was medically necessary.

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

Diagnosis: alopecia universalis

Treatment: Xeljanz

The insurer is denied coverage for Xeljanz.

The denial is overturned. 

This female patient has a history of alopecia universalis and subclinical hypothyroidism

The patient is a female with a history remarkable for hypothyroidism who has a diagnosis of alopecia universalis.  She has failed systemic therapy with methotrexate 15mg a week along with folic acid. The patient has failed topical therapy with clobetasol.  The patient has also failed systemic steroid pulse therapy with dexamethasone.  Based on the provided documentation the patient requires systemic therapy and has exhausted reasonable available options.  Xeljanz has been shown to decrease the inflammation leading to hair loss and has been shown safe and effective in the pediatric population based on case reports (1-8).  It would be medically inappropriate to deny coverage for a therapy shown in studies to improve the patient's condition when reasonable systemic therapies have been tried and found to be insufficient.  

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

The carrier's denial of coverage for the Xeljanz is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: retinal lesion bilaterally

Treatment: CPT code 67210, treatment of eye lesion with laser - right side, 1 visit and CPT code 76210, treatment of eye lesion with laser - left side

The insurer is denied coverage for CPT code 67210, treatment of eye lesion with laser - right side, 1 visit and CPT code 76210, treatment of eye lesion with laser - left side.

The denial is overturned. 

This male patient has a history of diabetes, type ll with ocular complications including vitreous hemorrhage in the right eye (OD), proliferative diabetic retinopathy (PDR) in both eyes (OU), clinically significant macular edema (CSME) OU, pseudophakia OU, chronic neurovascular glaucoma (NVG) OU, diabetes, type ll with ocular complications.

The American Academy of Ophthalmology indicates symptomatic retinal breaks constitute a category of retinal breaks for which intervention is generally indicated. These are characterized by the perception of increased flashers or floaters that usually occur due to increased vitreoretinal traction exerted during an acute posterior vitreous detachment. Retinal breaks with persistent vitreous traction at the edge yield retinal detachments 50% of the time, and should be treated with immediate laser retinopexy, which reduces the risk of retinal detachment to less than 5%. The patient had complaints of blurred vision left greater than right, and flashes bilaterally. Examination noted clear vitreous bilaterally, neovascular retina on the right, sclerotic vessels on the left, scattered dot/blot hemorrhages in the macula bilaterally with no edema. There was preretinal hemorrhage on the right. The patient has proliferative retinopathy with retinal hemorrhages. This is an indication for laser. As such, the request for CPT code 67210 is medically necessary.

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

The carrier's denial of coverage for the CPT code 67210, treatment of eye lesion with laser - right side, 1 visit and CPT code 76210, treatment of eye lesion with laser - left side is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Unspecified Psychotic Disorder. 
Treatment: Inpatient Hospital Admission. 

The insurer denied coverage for inpatient hospital admission. 

The denial is overturned. 

This female was admitted to the pediatric medical unit on due to psychotic symptoms including paranoid delusions and delusions of reference including feeling as if others communicate via telepathy, derogatory auditory hallucinations, preoccupations with cleanliness and compulsive behavior including excessive sanitizing and showering.  She reportedly had a toxic ingestion of rubbing alcohol, Listerine, vinegar, and lemons. The patient reported obsessions that there were bad bacteria in her stomach. She reportedly had an irritable mood, was suspicious and had depressive and anxiety symptoms. It was reported that she was eating only a few raw vegetables due to her obsessional thinking. The patient had medical conditions including renal issues, hypertension and sleeping problems. She had a metabolic work up which revealed no organic etiology for acute psychosis. The patient had a diagnosis of Unspecified Psychotic Disorder. She reportedly continued to have psychotic symptoms and was transferred to the psychiatric unit. 

The American Psychiatric Association (APA) Practice Guidelines for the Assessment and Diagnosis of Patients with Schizophrenia Spectrum and Other Psychotic Disorders reports that patients with hallucinations, delusional thinking, disorganized thinking or behavior, severe agitation, aggression, suicidal or homicidal intent or plan, or inability to adequately care for basic needs need hospital treatment. 

This patient had severe psychiatric symptoms interfering with the ability to care for her basic needs. Symptoms included paranoid delusions and delusions of reference including feeling as if others communicate via telepathy, derogatory auditory hallucinations, preoccupations with cleanliness and compulsive behaviors including excessive sanitizing and showering. She reportedly had a toxic ingestion of rubbing alcohol, Listerine, vinegar, and lemons. It was reported that her symptoms became even more severe over the next 3 days and she reportedly had more irritable mood and delusions of persecution and reference, worsened sleep, and continued derogatory auditory hallucinations. 

The patient had severe psychiatric symptoms during the denial period which interfered with her ability to adequately care for her basic needs, so she required 24 hour hospital treatment. The medical records provided enough specific evidence to support that inpatient hospital treatment was medically necessary. 

It did not appear that the health care plan acted reasonably, had sound medical judgment, or acted in the best interests of the patient. 

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

Diagnosis: OSA (obstructive sleep apnea)

Treatment hypoglossal nerve stimulation

The insurer denied coverage for hypoglossal nerve stimulation.

The denial is overturned.

This was an adult male with a history of obstructive sleep apnea (OSA). The chart documented that he could not tolerate continuous positive airway pressures (CPAP) or bilevel positive airway pressure (BIPAP), he had a body mass index (BMI) of 29.8 and the sleep induced endoscopy, which revealed:

"The vellum was clearly seen to collapse in an anterior posterior direction without significant mobility of the lateral walls. This view was documented using a recording device. Additionally, there was no evidence of tongue base hypertrophy or other contributing factors. Next, the endoscope was advanced further to evaluate the patient's bilateral tongue base, piriformis sinuses, molecular, vocal cords and other structures of the super robotic region. There were no lesions, masses or ulceration seen."

There is only one sleep study which was performed which showed an apnea hypopnea index (AHI) of 71.2.

There is extensive literature showing the efficacy of hypoglossal nerve stimulation and the treatment of obstructive sleep apnea (1-7). The use of hypoglossal nerve stimulation has been approved by international and national professional societies (8-12). The Food and Drug Administration (FDA) has twice approved the use of hypoglossal nerve stimulation for the effective treatment of obstructive sleep apnea (13,14). 

The patient fulfilled two of the three of the FDA requirements for the uses of hypoglossal stimulation which included (1) AHI of greater than 15 and less than 65; his was out of range at 71.2; (2) who have been confirmed to fail or cannot tolerate positive airway pressure (CPAP), this has been documented; and (3) who do not have a complete concentric collapse at the soft palate level, which was documented by the endoscopy. 

As noted in the two FDA approvals and the peer-reviewed literature documented that in two different studies, all of patients with AHIs greater than 65 were cured of their obstructive sleep apnea as was noted with postoperative AHIs of less than or equal to five. 

Use of hypoglossal nerve stimulation for the treatment of obstructive sleep apnea is medically necessary for this patient. The scientific evidence in peer-reviewed literature does support a result of improvement in health outcome. Although the patient's AHI was greater than what had been approved by the FDA, at least two different peer-reviewed reports found that all their patients who had AHI's greater than 65 were cured with the criteria that postoperatively their AHI were all less than 5.

The health care plan did not act reasonably, with sound medical judgment or in the best interest of the patient as the cases in the peer-reviewed literature have shown that the use of hypoglossal nerve stimulation in patients with AHIs greater than 65 is efficacious.

The insurer's denial of coverage for a hypoglossal nerve/ upper airway stimulator device to treat obstructive sleep apnea (OSA) is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

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

The patient is a female with history of obesity. Under review is the medical necessity for Saxenda. The medication was denied by the health plan because the patient did not meet medical necessity criteria.
Per office note, the patient has been unable to lose weight. Body mass index (BMI) is 36.5. She has been unable to lose weight despite limiting calories and exercising 3-4 times weekly - prior weight described 203lbs (pounds). The provider recommended for her to start Saxenda.

Saxenda is medically necessary for treatment of this patient's obesity.
The Endocrine Society 2015 guidelines recommend pharmacotherapy in BMI > (greater than) 27 with comorbidity or BMI >30 without comorbidities and use of bariatric surgery in patients with BMI> 35 with comorbidity or BMI over 40. Saxenda in clinical trials after 1 year was able to produce about 8 kg (kilograms) of weight loss (Khera et al. 2016, Food and Drug Administration (FDA) label).
This patient was unable to lose meaningful weight after 6 months of regimented diet and exercise. Her BMI is over 30. She would benefit from Saxenda.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory Problems. 
Treatment: Home Health Care. 
The insurer denied 6 skilled nurse home care visits. 
The denial is upheld.

The patient is a male with a past medical history significant for chronic thrombotic pulmonary hypertension, orthostatic hypotension, congestive heart failure, proximal atrial fibrillation, chronic obstructive pulmonary disease (COPD), hypoxia, schizophrenia, depression, coronary artery disease, obesity and chronic use of long-term anticoagulants.
This review is for the medical necessity of 6 nursing home skilled visits. The patient requested 9 visits, 3 visits were approved and 6 were denied. Services were denied based upon lack of medical necessity.

The requested 6 skilled nurse home care visits are not medically necessary for this patient. The patient is a male with the past medical history noted above. The patient is in his chronic state of health with multiple medical and psychiatric diagnoses. He did have a fall in May requiring medical attention noted to be secondary to static hypotension.
Statement of denial from his insurance company: You were receiving home care visits because you have a chronic/long-term thromboembolic pulmonary hypertension causing scar like tissue that narrowed blood vessels in your lungs, orthostatic hypotension and congestive heart failure. The request to increase his services partially approved because you do not meet the criteria to fully approve the request. We are currently arranging for pharmacy to do pre-package medications, thus eliminating a nurse to prepare medications each week. Oxygen needs and knee pain are chronic and ongoing.
The patient is in his chronic state of health, nursing visits were for monitoring signs and symptoms of heart failure and also pulmonary hypertension/respiratory failure along with medication management. The issue of medication management has been addressed with prefilled medication through the pharmacy. The question is whether ongoing nursing services are medically necessary for monitoring for signs and symptoms of heart failure and respiratory failure. There were no signs of progressive heart failure or respiratory failure as noted in the last nursing assessment provided. The patient's blood pressure and other vital signs are stable. His oxygen level was 93% on 4 liters (L) of oxygen.
The patient's medical status is chronic in nature. There does not appear to be any acute exacerbations or changes in his health status which would require additional skilled services for assessment and management. Skilled services for assessment and monitoring without an underlying change in his medical status or progression of disease would not be considered medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back pain; Leg pain.
Treatment: Pain Injections Into The Spine, Pre-service.
The insurer denied the Pain Injections Into The Spine, Pre-service.
The denial is upheld.

The patient is a female with low back and left leg pain. She has done PT (physical therapy), continues with home exercise, and various medication.  An ILESI (interlaminar epidural steroid injections) has been recommended.

No, the pain injections are not medically necessary.

The patient is a female with low back and left leg pain. She has done PT (physical therapy), continues with home exercise, and various medication.  An ILESI (interlaminar epidural steroid injection) has been recommended. Her physical exam reveals some numbness on the left Lower extremity.  Her MRI (magnetic resonance image) is essentially normal.

The requested procedure is not medically necessary.  There is no objective evidence to support lumbar radiculopathy.  The presence of numbness in the left LE (lower extremity) with associated pain is concerning, but does not confirm the diagnosis of lumbar radiculopathy.  In general, it is not recommended to proceed with an ESI (epidural steroid injection) in the setting of a normal MRI (magnetic resonance imaging) without further evidence of radiculopathy, such as EMG (electromyelogram) confirmation.  Multiple etiologies can result in numbness and pain in the LE (lower extremity).  An etiology to these symptoms should first be made, especially in the setting of a normal MRI (magnetic resonance image), prior to the consideration of an ESI (epidural steroid injection). Given the above, the requested ESI (epidural steroid injection) is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.

The patient is a female with a history of advanced left knee osteoarthritis. She failed conservative treatment for this condition and opted to undergo elective left total knee replacement. The surgery was successful with no documented complications. The patient remained in the hospital until she was discharged home with home health and home physical therapy. The subject under review is the medical necessity for an inpatient stay.

The health plan's determination is upheld.


The inpatient hospital stay was not medically necessary for this patient. The rationale for this determination is based upon the provided medical records and the recommendations of the current, peer, reviewed orthopedic literature. First, the medical records in this case document that this patient underwent elective left total knee replacement surgery. There were no documented complications of the operation and the patient had normal vital signs and lab values after the operation. The patient did not require any blood transfusion and there was no documentation of post-operative infection. Based upon the provided documentation in the medical records, the medical necessity of the inpatient hospital stay is not supported. In addition, the records contain an orthopedic progress note which stated that there were no acute events overnight and there were no signs of distress or complaints of pain from the patient. The patient was stable for discharge.
Second, the recent, peer-reviewed literature, including articles published by Rutherford and colleagues in Orthopedic Clinics of North America and by Edwards and associates in the Journal of Knee Surgery has documented the safety and efficacy of both short stay and outpatient total knee replacement surgery.
Therefore, based upon the provided medical records and the recommendations of the peer-reviewed literature, the medial necessity of the inpatient hospital stay in this case is not established. The patient could have been managed at a lower level of care status.
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 male with diabetes who presented to the emergency room with cough and fevers. The patient was found to have pneumonia. The patient was treated at a different hospital in Florida within one week. The patient was admitted to acute inpatient hospital level of care for the management of pneumonia with intravenous (IV) antibiotics. 

The acute inpatient hospital admission is denied because the patient left against medical advice. The denial is being appealed.

No, the proposed inpatient hospital admission was not medically necessary.
The patient was not in any distress. The patient was not on any supplemental oxygen as the oxygen saturations were above 90%. The patient was able to speak in full sentences and able to take oral medications. The patient's CURB-65 (confusion, uremia, respiratory rate, blood pressure, age greater than or equal to 65 years) score was one which suggests outpatient therapy is likely safe and effective. Thus, the requested acute inpatient hospital level of care for pneumonia is not medically necessary.

The patient had multifocal pneumonia and was started on intravenous (IV) antibiotics. At the time of admission, the patient was not in any distress. The patient was not on any supplemental oxygen as the oxygen saturations were above 90%. The patient was able to speak in full sentences and able to take oral medications. The patient's CURB-65 (confusion, uremia, respiratory rate, blood pressure, age greater than or equal to 65 years) score was one which suggest outpatient therapy is likely safe and effective. Thus, the requested acute inpatient hospital level of care for pneumonia is not medically necessary.