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

The patient presented to the emergency department after sustaining a syncopal episode. Apparently, the patient was working on a ladder, stepped down and injured the right ankle. The patient also reported having one bout of diarrhea on that day. Following this episode, the patient continued to feel poorly and develop nausea, profuse sweats, and slurred speech. The patient walked to the car and felt very hot, to the point that the patient had to take his shirt off. The patient subsequently stepped out of the car and had a syncopal episode, which was witnessed by a woman who was standing nearby. She called 911. Apparently, initially, the patient refused care and didn't want to come to the hospital. Subsequently, the patient drove himself to urgent care, where apparently he had slurred speech. This prompted the patient to come to the emergency department where the patient was admitted.

The health plan's determination is upheld. The inpatient admission was not medically necessary. At the time of admission, the patient was afebrile, hemodynamically stable, had no significant electrolyte abnormalities or signs of acute kidney failure. The neurological exam, which was performed at the time of admission by admitting physician, was reassuring. The results of laboratory studies and diagnostic tests did not reveal evidence of serious medical conditions necessitating admission at the acute inpatient level of care.
Finally, the patient's condition significantly improved within a short period of time, and he was discharged from the hospital. The patient's symptoms were most likely related to dehydration due to some viral infection, which caused diarrhea, which was reported at the time of admission.
Taking into consideration all the facts, observation was definitely warranted. At the same time, neither the severity of the patient's condition nor the complexity of the services provided justified inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bilateral foot pain, hallux deformity
 
Treatment: Custom orthotic

The insurer denied the custom orthotic. The denial was upheld.

The patient is a male with bilateral foot pain, left greater than right. He noted that his feet hurt when the patient was on his feet at work all day with a pain level of 3-4/10 scale. On examination there was pain along the medial column of the left foot along the tibialis posterior tendon with arch collapse. X-rays demonstrated a cock-up hallux deformity. Treatment was discussed and a script was dispensed for custom orthotics. Stretching exercises were also recommended.

Per evidence-based medical literature, there are no high level randomized studies that compare custom orthotics to other surgical and non-surgical interventions for pes planus. In addition, this patient was not treated with other conservative or over-the-counter treatments prior to attempting custom orthotics. It is pertinent to attempt stretching, bracing, strapping, pre-fabricated orthotics, NSAIDs, physical therapy or other treatments and take a multimodal approach prior to administering a custom treatment. 

There is no evidence that would lead to the conclusion that the custom orthotics is medically necessary in this case. 

Based on the above, the medical necessity for the request custom shoe inserts L3000-Foot, insert, removable, molded to patient model, 'UCB' type, Berkeley shell, each is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Epilepsy
 
Treatment:  Epidiolex treatment

The insurer denied the Epidiolex treatment. The denial was reversed. 

This case involves a female currently diagnosed with localization-related epilepsy and epileptic syndromes with complex partial seizures with intractable epilepsy. The clinical note indicated that the patient had previously trialed Carbamazepine, Depakene, Oxcarbazepine, Onfi, Diastat, Tregretol XR, Topamax, Trileptal, Felbatol, Keppra, Vimpat, Zonegran, Lamictal, CBD, and vagus nerve stimulator (VNS). The patient was undergoing medication changes because she was poorly controlled.

A 2018 peer-reviewed publication 1 noted that "add-on [Cannabidiol] CBD can provide clinically meaningful and sustained reductions in the frequency of convulsive and total seizures across multiple epilepsy etiologies. The high proportions of patients achieving 
greater than or equal to 50% and greater than or equal to 75% reductions in seizure frequency were consistent at each visit window. Even in this highly treatment-resistant population, during each visit window, some patients reported 100% seizure reduction from baseline for the period since their prior visit."  

This patient, like the vast majority of patients in the 2018 study (and in clinical epilepsy practice) had "other" or "unknown" epilepsy syndrome.  Epidiolex appears to be effective for such patients, even though it is only FDA approved for patients diagnosed with certain rare epilepsy syndromes. This patient has intractable epilepsy and Epidiolex is one of the only medications for epilepsy the patient has not yet tried.  It is standard to try all appropriate available medications to try to control seizures.   Peer-reviewed medical literature 1 supports a trial of Epidiolex to attempt to control this patient's seizures. 

The carrier's denial of Epidiolex 100 mg/ml OR SOLN should be reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rule out dental abscess
 
Treatment: Inpatient admission, medication, monitoring

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

The patient is a female with a past medical history significant for hypertension. She presented to the emergency department with complaints of left side jaw pain, swelling, and erythema.  Vitals on presentation included: temperature 37.5 C, blood pressure 129/84, pulse 74, respiratory rate 18 and oxygen saturation 97% on room air. Laboratory results included: WBC-4.56, Hgb-13.2, Hct-40.2, glucose-100 and creatinine-0.68. The patient was started empirically on intravenous antibiotics. Panorex x-rays of her teeth were negative. CT scan of the neck showed parotitis and a hypodensity in the left interior parotid gland. Oral and Maxillofacial Surgery was consulted and deemed no odontogenic source of infection. Infectious Diseases also consulted; all cultures remained negative. The patient remained afebrile, hemodynamically and clinically stable. She was discharged to continue treatment as an outpatient.       

The patient was admitted to rule out a dental abscess. She was afebrile, stable hemodynamically, with no evidence for systemic toxicity. Laboratory values were unremarkable, including normal WBC.  Panorex x-rays were normal and CT scan showed parotid swelling that did not require any surgical intervention. The patient denied any fever, chills, bleeding, cough or difficulty swallowing. Based on the above findings, the patient did not fulfill criteria for acute inpatient admission. She was clinically stable to continue management as an outpatient, following evaluation in the emergency room. 

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse
 
Treatment: Inpatient substance residential treatment, medication, monitoring

The insurer denied continued inpatient substance residential treatment. The denial was reversed.

This is a male who was admitted to inpatient substance residential treatment after a 5 day hospital stay for altered mental status, acute hypokalemia, acute renal failure, and acute vomiting. He reportedly was using 5-10 bars of Xanax per day, drinking more than 6 drinks 1-3 times per week, smoking 2 grams of cannabis per day, and using MDMA 
0.3 grams 1-2 times per month. He was in treatment in a dual diagnosis partial hospital program 2 weeks prior to this admission. He had a past psychiatric hospitalization and had diagnoses of Major Depressive Disorder and Anxiety Disorder as well as Attention Deficit Hyperactivity Disorder (ADHD). His longest abstinence was 1 year. 

The APA Practice Guidelines for the Treatment of Patients with Substance Use Disorders indicates inpatient treatment is primarily for individuals whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. According to the LOCADTR, this patient met criteria for inpatient substance rehabilitation treatment as he continued to use multiple substances despite past recent substance rehabilitation treatments. He was unable to stop substance use without being in a sober and supervised therapeutic inpatient setting. Without this structured and supervised treatment he likely would have relapsed quickly.  

The National Institute on Drug Abuse: Principles of Addiction Treatment: A Research Based Guide reports the best treatment outcomes occur with longer durations of treatment. This patient required 24-hour residential treatment as he was at high risk to continue use without this treatment setting, and 2 weeks in this setting was not enough time for him to develop the necessary skills for abstinence. 

Based on the above, the medical necessity for Residential Substance Use Treatment is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hydronephrosis and kidney stone
 
Treatment: Inpatient admission, diagnostic intervention, medication

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

This is a female with a past medical history of hypothyroidism and right renal stone diagnosed late in 2018.  The patient presented to the emergency room (ER) with a two hour history of right flank pain, nausea and vomiting.  The patient had been scheduled for right extracorporeal shock wave lithotripsy the next day, but presented to the ER earlier due to the pain.  ER triage revealed a blood pressure of 127/90, a heart rate of 86, a temperature of 36.5C, a white blood cell (WBC) count of 14,090 and a urinalysis that was positive for blood.  A CT scan revealed a kidney stone.  While in the ER, the patient was treated with intravenous fluids, multiple doses of pain medications and antiemetics. She was admitted with diagnoses of hydronephrosis and kidney stone.  The patient remained stable with no acute issues.  She was taken to the operating room for a right ureteroscopy with laser lithotripsy, stent placement and stone extraction.  The patient tolerated the procedure well.  She was subsequently discharged home later that day.

Per MCG Health (23rd Edition) Renal Colic & Kidney Stones RRG, the patient fails to meet clinical indications for admission to inpatient care.  In addition, per MCG Health (22nd Edition) Urologic Surgery or Procedure GRG, the patient is noted to have met the General Recovery Course discharge parameter within 23 hours after the procedure.  As per the guideline, this procedure is normally designated for the ambulatory surgery setting. 

The inpatient admission is not considered medically necessary for this patient. The carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

The patient in question is a female with a chief complaint of crowding and anterior crossbite. She has severe maxillary and mandibular crowding and #7 and #10 are in crossbite with #22 and #27, respectively. She is treatment planned for 24-30 months of orthodontics with extraction of four first premolars to correct her malocclusion. The subject under review is the medical necessity of the treatment. 

The health plan's determination is overturned.

The patient has significant maxillary and mandibular anterior crowding, with #7 and #10 in crossbite. These teeth are at high risk for restorative problems in the future due to their traumatic occlusion with the mandibular teeth. Studies have shown that even the untreated dentition shows increased anterior irregularity with time, which will make treating this occlusion at a later time more difficult. Further labial movement of #22, #24 or #27 will likely lead to the need for future for periodontal grafting on this tooth. Orthodontic treatment now will likely prevent the need for future periodontal and restorative procedures. For these reasons orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Possible sepsis
 
Treatment: Hospital Admission 

The insurer denied coverage for Hospital Admission. The denial was reversed.

This patient is a male with a past medical history significant for splenectomy who presented to the Emergency Department with complaints of fever, chills, nausea, vomiting, and diarrhea. 

Vitals on presentation included a temperature of 101.6F, a blood pressure of 104/60, a pulse of 123, a respiratory rate of 32, and an oxygen saturation of 92% on room air. Laboratory values were notable for the following: a white blood cell (WBC) count of 10.73, hemoglobin of 15.4, a hematocrit of 45.4, glucose of 117, a creatinine of 0.99, and a lactate of 1.44.

The patient was empirically started on intravenous antibiotics (Zosyn and vancomycin) and intravenous fluid (IVF) hydration for possible sepsis. A CT scan of the abdomen/pelvis showed thickening of the jejunum. The documented plan included sepsis protocol, including an Infectious Diseases consult, aggressive fluid hydration and serial lactate monitoring.  The patient, however, opted to leave the hospital against medical advice on oral antibiotics.

According to medical records, the patient presented with fever and gastrointestinal complaints following a prior evaluation in Urgent Care and later in the Emergency Department. Despite outpatient intervention with oral antibiotics (cephalexin), his symptoms worsened with a fever (101.6), tachycardia (123), tachypnea (respiratory rate of 32), and leukocytosis. Clinically, the patient reported "vomiting almost 20 times." 

Based on these abnormal findings in a high-risk patient (history of a splenectomy) with documented failure of outpatient intervention, the hospital admission was medically warranted, despite his decision to leave against medical advice.

The prior determination of denial of inpatient admission has been reversed. The insurer did not act reasonably, or with sound medical judgment, or in the patient's best interest.

Based on the above, the medical necessity for the Hospital Admission is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

The patient has severe maxillary and mandibular crowding. Tooth #6 has erupted labial within the arch due to lack of space. The patient was treatment planned for comprehensive orthodontics with extraction of teeth 5, 12, 20 and 29 align the teeth and correct the bite. The medical necessity of Braces is under review. 

The health plan's determination is upheld. Braces are not medically necessary. While the patient has crowded teeth, there is no indication supplied of a functional impairment due to the position of his teeth. There is no evidence of wear or periodontal recession, and no narrative of potential tooth pain has been supplied. If his teeth were corrected it would provide an esthetic improvement but it would not create a medically significant improvement to the patient's health. Furthermore, Class II malocclusions may be corrected in adulthood, so there is not as if he will lose the ability to correct his malocclusion should he choose to do so as an adult. For these reasons, braces are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

The reviewer upholds the health plan determination that braces are not medically necessary for this patient. 

The patient has a skeletal Class II malocclusion with an overjet of 4
millimeter (mm), 80% overbite with severe maxillary crowding including an ectopic eruption of tooth #11 and moderate mandibular crowding. 

Using the Handicapping Labio-Lingual Deviation (HLD) index, this patient's malocclusion would score a 25 with no auto qualifiers.  The malocclusion in question does not meet criteria to be classified as handicapping, and treatment for this patient with braces would not be considered medically necessary.  Thus, under the standard of care and having the HLD score below a score of 26 makes braces for this patient not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite
Issue under review: Braces

Determination:
The Braces are medically necessary.

The patient has a crossbite between teeth #s 11 and 22. This is an "automatic qualifying" condition, where there is a crossbite of an anterior tooth with associated attachment loss. Tooth #22 needs to be in its proper position so that during the patient's chewing cycle, her teeth mesh together properly and do not bang together and traumatize (fracture and/or wear down) each other. If there is no orthodontic treatment to correct the problem, the teeth will suffer. There is also an increased possibility of problems (pain) with her TM (temporomandibular) joints due to increased pressure in them, which is caused by the malocclusion. This case has definite medical necessity for orthodontic treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient hospital admission
The inpatient admission was not medically necessary.

This patient is a male who presented to the ED with abdominal pain, vomiting and diarrhea in the setting of prior laparoscopic roux en Y gastric bypass that had been performed in 2005. The patient was clinically stable at the time of presentation and remained stable throughout the period of hospitalization.  The initial WBC count was normal.  Electrolytes and renal function was normal.  The patient was evaluated with imaging studies that included CT scan and endoscopy that identified a gastro-gastric fistula.  Other etiologies for his pain were excluded. Following this procedure the patient's diet was advanced and he was considered to be stable for discharge from the hospital with plans for short-term bariatric surgical follow up.

Based on the available medical record, the medical necessity of inpatient admission is not established.  The records support the health plan contention that this care and treatment provided could have been completed in the observational setting. This level of care would have allowed for provision of the medical treatment that was rendered in this case (including overnight observation).
Appeal type: Medical necessity
Decision: Upheld

The patient is a female with a medical history of pyelonephritis as a child, febrile seizures, and dysmenorrhea.  She presented to the emergency department with severe (9/10) abdominal pain, nausea. vomiting, and diarrhea following ingestion of fast food.  On that date, she also reported frequent urination with dysuria.  Vital signs were unremarkable.  Labs were notable for elevated white blood cell count of 19.98 K/uL with 89.6% neutrophils, elevated lipase of 56 U/L, and mildly elevated lactate of 1.7 mmol/L. Urinalysis was positive for 1+ glucose, 4+ ketones, 2+ blood, 2+ leukocyte esterase, 26 white blood cells, and 3 red blood cells.  An abdominal ultrasound showed an unremarkable gallbladder.  A computed tomography scan of the abdomen and pelvis showed mild pelvic free fluid but no gastrointestinal pathology.  She was treated with intravenous fluid bolus of 2 L normal saline, famotidine, ondansetron, metoclopramide, and ketorolac.  She did not tolerate oral intake in the emergency department.  She was admitted.  The recommendation was intravenous fluids, pantoprazole, ondansetron when necessary, and consider esophagogastroduodenoscopy and colonoscopy if symptoms persist.  She was discharged three days later.

The health plan has denied the inpatient admission as not medically necessary.  The health plan's determination is upheld. 

The admission is not supported as medically necessary at the acute inpatient level of care.  The patient had abdominal pain, nausea with vomiting, and diarrhea consistent with acute gastroenteritis.  However, there was no suspected or established complication, such as gastrointestinal perforation, pancreatitis, intra-abdominal abscess, toxic megacolon, bowel obstruction, ongoing gastrointestinal bleeding, peritonitis, sepsis, or other complications warranting inpatient level of care [1-3].  She was appropriately treated with intravenous fluids and supportive care, and her symptoms resolved [4].  Her urinary tract infection improved rapidly with antibiotics, which were administered appropriately [5-7].  The measures that were undertaken, such as observation, monitoring, labs, and intravenous fluid administration could have been performed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Anxiety
Inpatient hospital 

The patient is a man with a history of anxiety, alcohol abuse and polysubstance abuse who presented to the emergency department. He presented after being concerned about feelings of anxiety and not having his medications. He reported that his psychiatrist had died and he no longer had access to prior medications. He denied headaches, confusion, and lightheadedness. Review of systems was also negative for chest pain and shortness of breath. There was no homicidal or suicidal ideation. Vital signs showed temperature 97.3 Fahrenheit, blood pressure 121/82, respiratory rate 17, and oxygen saturation 97%. On physical examination, heart was regular, breath sounds were normal, abdomen was soft, and he had normal mood and affect. Labs showed alcohol level 75, white blood cell (WBC) 5.5, hemoglobin 13.1, platelets 217, glucose 76, creatinine 0.9, potassium 3.9, and calcium 9.2. Liver enzymes were normal. He was admitted for suspected alcohol withdrawal. The play Plan of care included intravenous (IV) thiamine, IV fluids, Clinical Institute Withdrawal Assessment (CIWA), benzodiazepines as needed, psychiatry consult, and referral to alcohol rehab. He was also seen by orthopedic surgery because of right elbow swelling and concern for bursitis. He was cleared by psychiatry for discharge home and discharged.

The health plan's determination is upheld. The patient was not having acute withdrawal symptoms. Based on the progress notes/ HPI, there was little documentation to support symptoms consistent with significant alcohol withdrawal. The patient did not have seizures, hemodynamic instability, respiratory failure, or Delirium tremens. Based on the documentation, the patient could have been safely and effectively managed at a lower level of care, in terms of management of mild alcohol withdrawal symptoms.