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

Diagnosis: Overactive Bladder. 
Treatment: Myrbetriq 50 mg or TB24. 

The insurer denied coverage for Myrbetriq 50 mg or TB24. 

The denial is overturned. 

This patient is a female with past medical history of glaucoma, hypertension, diabetes, and an overactive bladder (OAB). The patient had a tele-medicine urology visit.  The patient reported mixed incontinence. The patient's cystoscopy came back within normal limits (WNL).  The patient's urodynamic test revealed stress and urge leakage.  Based on this, the physician recommended a trial of Myrbetriq (mirabegron) for the next 2-3 months. 

Anticholinergic agents used for treatment of overactive bladder (OAB) are generally contraindicated for uncontrolled narrow angle glaucoma.  If it cannot be ascertained whether or not this patient suffers from uncontrolled narrow angle glaucoma, it is best to avoid the anticholinergic agents and plan to treat with the beta-3 agonist, mirabegron.  In general with a history of glaucoma and the patient with OAB, it is probably wise to avoid anticholinergics and treat with beta-3 agonist (i.e., mirabegron). The only exception would be a clearance note from the patient's ophthalmologist stating that this patient does not suffer from narrow angle glaucoma and is cleared to initiate treatment of her OAB with anticholinergic medications. This clearance is necessary to prevent this patient's risk of precipitating an acute ocular crisis caused by the initiation of any anticholinergic medications. In the absence of such a note from this patient's ophthalmologist, this patient's treatment of her OAB with beta-3 agonist such as Myrbetriq is considered medically necessary. 

Myrbetriq 50 mg or TB24 is considered medically necessary for treatment of this patient's overactive bladder, given her history of glaucoma and the inability to rule out narrow angle glaucoma for this patient at this time with the submitted medical record. 

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

The insurer's denial of coverage for Myrbetiq 50 MG or TB24 for the Treatment of Overactive Bladder is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left nasal obstruction. 
Treatment: Vestibular Stenosis Repair. 

The insurer is denied coverage for Vestibular Stenosis Repair. 

The denial is overturned. 

This female patient has a history of endometriosis, hypertension, and sinus headaches.  She presented to the plastic surgeon's office for an evaluation of left nasal obstruction.  Extensive prior medical management was provided with minimal response. The patient was noted to have nasal turbinate hypertrophy. 

Alar spreader grafts to treat vestibular stenosis are medically necessary for this patient and in her best interests.  This patient has nasal collapse with internal and external valve obstruction.  She has longstanding nasal obstruction despite previous sinus surgery.  Spreader grafts are necessary to open the internal nasal valves. Her obstruction is anatomic rather than allergic, and nasal sprays will not improve her symptoms.  The spreader grafts will improve function.  Collapse of the internal nasal valves is a well-recognized source of nasal obstruction. 

According to Grabb and Smith's Textbook of Plastic Surgery (8th Edition 2019), "The internal nasal valve is the angle formed by the junction of the nasal septum and the caudal margin of the upper lateral cartilage, and is usually 10 to 15 degrees. It can be responsible for up to 50% of the total airway resistance, and is the narrowest segment of the nasal airway. Occasionally, the head (anterior-most portion) of the inferior turbinate can be hypertrophied enough to cause further diminishment of the cross-sectional area of this region. Traditionally, a positive Cottle sign (lateral traction on the cheek leading to increased airflow) signals collapse of the internal nasal valve and indicates the need for spreader grafts to increase the valve angle and stent the airway open." This patient had a positive Cottle sign and collapse of the internal valves.  Spreader grafts are not used in cosmetic procedures.  The placement of spreader grafts will widen the nose, which is not a desired goal in aesthetic rhinoplasty.  The indication for spreader grafts is functional internal and external valve obstruction as was experienced by this patient. 

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 Vestibular Stenosis Repair is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Cardiac/Circulatory
Home Health Care

Diagnosis: transient ischemic attack 
Treatment: Personal Care Aide (PCA) Services
The insurer denied Personal Care Aide (PCA) Services: 7 Days x 8 Hours, Total 56 Hours. The health plan's determination is upheld.

The patient is a female with a past medical history significant for anxiety, depression, transient ischemic attack (TIA) and diabetes mellitus.
The patient is requesting personal care service hours 7 days a week 8 hours a day for a total 56 hours a week.  

Personal Care Aide (PCA) Services: 7 Days x 8 Hours, Total 56 Hours per Week is not medically necessary for this patient.
An increase in personal care service hours is not medically necessary.
According to the assessment done, there has been improvement in functional status documented, and the patient requires less assistance with activities of daily living. Due to improvement in personal functional status, she required decreased amount of personal care aid hours to meet functional needs. She was noted to require less assistance in the following areas: functional abilities related to bathing, toileting, incontinence care and transferring.
A review and comparison of the assessments done showed improvement in the patient's level of function. The patient had a fall and ankle fracture which impaired her ability to ambulate. However, she has successfully recovered from the fracture which gives her more mobility and greater independence in certain functional areas. She requires less assistance with ambulation, bathing, toileting and transferring. The less assistance is noted on the telephonic tasking tool which notes that the patient requires a total 42 hours a week. The patient currently has been approved for 49 hours a week which is sufficient to meet these needs. Additional needs on a tasking tool and UAS would necessitate additional services over 49 hours a week were not noted.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problem. 
Treatment: Dental/Orthodontic Procedure. 
The insurer denied comprehensive orthodontic treatment of the adolescent dentition (braces). 
The denial is upheld.

The patient in question is a female with a Class I occlusion with slightly deep overbite and appropriate overjet. She has maxillary and mandibular crowding. She is treatment planned for 36 months of orthodontics to correct her malocclusion. The subject under review is the medical necessity for the orthodontic treatment.

The health plan's determination is upheld.

The treatment is not medically necessary. The patient has crowding. Her overbite is slightly deep but there is no indication of damage to the incisors in the photographs. Her cephalometric radiograph shows the lower incisors are contacting the maxillary teeth in occlusion, not the palate. There is no indication from the photographs there is severe soft tissue damage (or any soft tissue damage) on this patient.
There is no medical reason to correct her malocclusion with braces. While the patient has crowded teeth, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence.1 This patient presents with none of those conditions. Aligning her teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion. If her teeth were aligned it would provide a minor esthetic improvement, but it would not create a medically significant improvement to the patient's health. For these reasons treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Possible stroke.
Treatment: inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

The patient is a woman with a history of human immunodeficiency virus (HIV), chronic obstructive pulmonary disease (COPD) and smoking who presented to the emergency department. She presented with loss of consciousness. She was found on the floor unresponsive by her husband. She appeared to have fallen out of the chair onto a hardwood flooring. After the fall, she was unresponsive to verbal stimuli. She denied chest pain and shortness of breath. Vital signs showed blood pressure 170/84, heart rate 60, temperature 99.3 Fahrenheit, and respiratory rate 18. On physical exam, the patient was somnolent, neck was supple, heart was regular, breath sounds were normal and the abdomen was soft. She had severe receptive aphasia but was only able to follow simple commands. Strength was normal in the upper extremities and decreased in the lower extremities. Labs showed glucose 67, potassium 3.6, lactate 1.7, and troponin negative. Coags were within normal limits. Head computed tomography (CT) was negative for acute stroke. The patient was admitted for syncope and suspected ischemic cerebrovascular accident (CVA) versus seizure. 

The inpatient admission was not medically necessary.

The patient presented with syncope and did require further evaluation. While she was in the emergency department, her mental status improved, and head CT imaging was negative for acute stroke. There were no other acute abnormalities such as evidence of sepsis, hemodynamic instability, recurrent seizure, overdose, or other acute abnormalities. She could have still received electroencephalogram and brain MRI at a lower level of care.
The patient did require further evaluation but inpatient level of care was not needed. The patient's labs were stable, head CT imaging was negative, and her mental status improved while she was in the emergency department. Brain MRI (Magnetic Resonance Imaging) and electroencephalogram were also performed but these do not need to be performed at the inpatient level of care for a stable patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neck/back pain.
Treatment: Inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

The patient is a male who had 4 weeks of worsening symptoms in his upper extremities and numbness that has progressed in the right side to include all 5 digits and extending up his arm with pain in the right arm also. He has trouble with finger dexterity on the right worse than the left. He has no problems with balance. He has previous evidence of cubital tunnel syndrome in bilateral hands. This was confirmed by an electromyography (EMG) study. He had an magnetic resonance imaging (MRI) which shows a disc herniation and spinal cord compression without any spinal cord signal change. He denies any bowel or bladder symptoms. He walks with a normal gait. He has normal cervical spine range of motion and 5 out of 5 strength throughout the upper extremities. There is dysesthesia in the ulnar 2 digits of his hands. Reflexes are 2+ and symmetric throughout upper extremities. There is no clonus, Hoffman's, or Babinski present. Spurling's maneuver is negative bilaterally. There is no inverted radial response present. Lhermitte sign is negative. Impingement test was negative bilaterally. His diagnosis is cervical myelopathy. He was admitted to the spine surgery service for surgical intervention.

The inpatient hospital admission was not medically necessary.
Based on the provided medical records, an acute inpatient hospital stay was not medically necessary per Milliman Care Guidelines, (Cervical Fusion, Anterior, ORG: S-320 (ISC)). Goal for length of stay, per guidelines, is ambulatory or 1 day postoperatively depending on patient comorbidities and the need for post-operative monitoring. Specifically, the floor to discharge and complete discharge planning criteria were met within 24 hours post procedure. The patient was hemodynamically stable, there was no evidence of infection or vascular compromise. Vital signs, respiration, voiding, and neurologic status were within normal limits. Pain was absent and the patient was ambulatory and tolerating p.o. (by mouth) medications and intake. Overall, the severity of disease, intensity of services provided, and documentation did not support an inpatient admission. The patient could have been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System/Asthma.
Treatment: Inpatient Hospital.
The health plan denied the requested inpatient hospital stay due to the lack of medical necessity. 
The health plan's determination is upheld.

This is a male who presented to the Emergency Department (ED) with a several days history of worsening shortness of breath and wheezing. He has a history of asthma, has taken his rescue inhaler multiple times without any relief. Upon evaluation in the ED, he was noted to have wheezing, tachypnea, and labored breathing. A chest x-ray did not reveal any acute process. An arterial blood gas (ABG) was performed showing a potential hydrogen (pH) of 7.552, a partial pressure of carbon dioxide (pCO2) of 21.9, and a partial pressure of oxygen (PO2) of 324.1 on a nonrebreather at 15 liters/minute of oxygen. The patient was reevaluated in the ED, was found to be dramatically improved, wheezing was improved, speech was clear, but was still on 6 liters/minute of supplemental oxygen. He was admitted to the hospital. A pulmonary consultation was obtained. He was continued on steroids and inhaled bronchodilators. He felt better the next day and was discharged home.
At issue is the medical necessity of the inpatient stay.

I uphold, in whole, the health plans determination of medically necessity.

The inpatient stay was not medically necessary. This admission was appropriate at an observational level of care. Upon presentation to the ED, he was noted to be in distress, but received steroids and bronchodilators. He did not require assisted ventilation. The ABG demonstrated good oxygenation. There was no hemodynamic instability or altered mentation. A chest x-ray was unremarkable. In the appeal it notes a sustained heart rate (HR) as a qualifying reason for an inpatient level of care. However, his HR had already dropped to the 90s according to ED physician notes. As such, given no evidence of hemodynamic instability, hypoxemia, altered mentation, need for ventilatory assistance, or other complications, an inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Quadriplegia
Treatment: Increase Personal Care Aide (PCA) Level 2 Services, For A Live-In Per Diem, 24 Hours Per Day, 7 Day(s) Per Week
The insurer denied the Increase Personal Care Aide (PCA) Level 2 Services, For A Live-In Per Diem, 24 Hours Per Day, 7 Day(s) Per Week
The denial is overturned.

The patient is a male with a history of Multiple Sclerosis and multiple CVAs (cerebrovascular accidents) rendering him quadriplegic. Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs). An appeal review was requested for potential approval of a Live-In Per Diem, 24 Hours Per Day, 7 Day(s) Per Week Personal Care Aide Services to offer increased ADL (activities of daily living) support.

Yes, the proposed treatment of a Live-In Per Diem, 24 Hours Per Day, 7 Day(s) Per Week Personal Care Aide Services is deemed medically necessary.

Recent correspondence from the patient's medical provider indicates that due to recent CVAs (cerebrovascular accidents) and resultant worsening weakness and worsening functionality; the currently approved plan of 84 hours/week Personal Care Aide Services is insufficient to meet the patient's current needs. Specifically, the provider states that due to the totality of the patient's neurologic deficits, he is now fully dependent on others for toileting, feeding, meal preparation and hygiene.

For these reasons, the proposed treatment of a Live-In Per Diem, 24 Hours Per Day, 7 Day(s) Per Week Personal Care Aide Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Motorcycle accident with pain to left wrist and
right ankle
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld. 

The patient is a female involved in a motorcycle accident. She reported pain to her left wrist and right ankle. She was admitted to hospital and diagnosed with a fracture to the distal radius. She also had a fracture to her right little finger.  She underwent operative intervention. Her post-surgical course was complicated by pain. She was discharged from hospital.

No, the Inpatient admission was not medically necessary.

The records show a non-complicated hospital course. The diagnosis was established, including all injuries (ankle, finger and wrist). The treatment record showed surgery was completed. A single operative procedure was required. The duration was approximately one hour. There were no post-surgical complications.

The woman was able to tolerate oral pain medication. Her vital signs were stable. There were no problems with the wound. There was no evidence of infection or bleeding. She did not require treatment for other body parts or for underlying comorbidities.

There were no extenuating circumstances to substantiate ongoing acute level hospitalization.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back pain. 

Treatment: Pain Injections (62323 x 1).

The insurer denied coverage for Pain Injections (62323 x 1).

The denial is overturned.

This is a male patient who has a history of morbid obesity, low back pain, and uncomplicated asthma.  The patient presented to the pain management clinic for an evaluation of his low back pain.  The pain was described as sharp and rated at a level of 7 out of 10.  The patient stated that he has had epidural steroid injections (ESI) in the past with good relief and better mobility.  The patient has received four epidurals in the past.  The patient has been repeatedly denied ESI.  The patient has a positive straight leg raising test and 2 levels of disc protrusions detected on his magnetic resonance imaging (MRI).

Helm et al. (2021) conducted a systematic review and a meta-analysis of the safety and efficacy of transforaminal epidural steroids and found: "There is Level I evidence for the use of transforaminal injections for radicular pain from disc herniations."

Vydra et al. (2020) surveyed a large number of interventional pain physicians and found: "Forty percent of physicians reported allowing four [epidural steroid injections (ESIs)] at a given spinal segmental level per year (cervical/thoracic/lumbosacral).  A small percentage of physicians reported allowing more than six ESIs annually (6%) and >10 injections annually (1%)."

Based on the literature review above, the patient has a clear indication for an epidural steroid injection (ESI) and the utilization figure used by the Health Plan is not evidence based.  The requested procedure is considered medically necessary for this patient.

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

The insurer's denial of coverage for the Pre-Service Request for Pain Injections (62323 x 1) should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Digestive System
Inpatient hospital

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

The patient is a woman who presented to the hospital with a chief complaint of abdominal pain and diarrhea. She reported massive diarrhea with no blood or melanoma. She was agitated and restless in the emergency department, requiring Haldol and ketamine. Her past history was notable for heroin abuse and cannabis use. Vital signs showed temperature 98.6 Fahrenheit, respiratory rate 20, heart rate 60, and blood pressure 165/105. On physical exam, heart was regular, breath sounds were normal, and the abdomen was diffusely tender and distended. There was no cranial nerve deficit. Labs showed white blood cell (WBC) 9.5, hemoglobin 12.3, platelets 262, sodium 140, calcium 10.1, magnesium 2.1, creatinine 1.11, and troponin negative. Imaging demonstrated distal small bowel thickening consistent with an infectious or inflammatory process. Electrocardiogram (EKG) showed sinus bradycardia with fusion complexes and inverted T-waves in precordial leads. The patient was admitted with acute enterocolitis. 

The inpatient hospital admission was medically necessary. 
The patient presented with multiple acute abnormalities, including agitation requiring administration of Haldol and ketamine, imaging evidence of enterocolitis, and electrocardiogram (EKG) abnormalities that were concerning for ischemia. The patient had a high complexity due to her presenting symptoms and history of polysubstance abuse. A patient with this degree of complexity would not normally be managed at the outpatient level of care.
The patient needed intravenous (IV) antibiotics for management of enterocolitis, and also needed simultaneous care for agitation/potential withdrawal, substance-abuse, and an abnormal EKG that was concerning for ischemia. She was at increased risk of developing sepsis, worsening agitation and possible delirium tremens, and acute cardiac ischemia with unstable cardiac arrhythmia.