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

Diagnosis: Asthma Exacerbation
Treatment: Acute inpatient stay
The insurer is denied coverage for acute inpatient stay.
The denial is upheld.
This patient is a female with history of asthma who presented to the Emergency Department (ED) with complaints of shortness of breath, cough, and chest pain for about 2 weeks. The patient also complained of some fever, chills, and upper respiratory infection symptoms. The patient was initially seen at an Urgent Care center and was prescribed with antibiotics and steroids, prior to coming to the ED. In the ED, the patient's vital signs showed: Temperature 98.7 F, Blood pressure 117/66, Heart rate 96, and Oxygen saturation of 99% on room air. The patient was in no acute distress. On exam, the patient had decreased breath sounds but had an otherwise unremarkable exam. The patient was awake and alert. The patient had normal cardiovascular and neurological exams. The patient's white blood cell (WBC) count was 12.6 K, and her electrolytes and BUN/ Cr were within normal limits (WNL). The patient's arterial blood gas showed pH 7.47, pCO2 31, pO2 78 and oxygen saturation of 96%. The patient's chest x-ray showed no acute infiltrate. An influenza screen was done with negative results. The patient had elevated D-dimer but negative imaging for deep venous thrombosis (DVT) or pulmonary embolism. A computed tomography angiography (CTA) was performed with negative results for pneumonia. The patient was treated with steroids, bronchodilators, and received Lovenox in the ED. The patient was admitted for asthma exacerbation. Pulmonology was consulted with recommendations for treatment with inhaled corticosteroid/long-acting beta2-agonist (ICS/LABA) and long-acting muscarinic antagonist (LAMA) treatment, and tapering oral steroids. The patient remained afebrile and hemodynamically stable and was able to tolerate oral intake. 

Based on the review of the medical record and literature, inpatient admission was not medically necessary for this patient. This patient did not have pneumonia, pulmonary embolism, or congestive heart failure. The patient was clinically stable. The patient did not have hypoxia and did not require supplemental oxygen. The patient had mild leukocytosis that was likely due to this patient's steroid use. The patient's peak expiratory flow (PEF) was 400. The patient was tolerating oral intake and was not in acute respiratory distress or respiratory failure. The patient was not retaining CO2. The patient could have been placed in Observation status while diagnostic testing and treatment were initiated. The patient could have been discharged once pulmonary embolism was ruled out with computed tomography angiography (CTA) imaging of the chest. The patient was on oral medication and inhalers that could have been continued at home with close follow-up as outpatient.

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 acute inpatient stay is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Endometroid Adenocarcinoma
Treatment: Extended hospital stay
The insurer is denied coverage for extended hospital stay. 
The denial is upheld. 
This is a female patient who was admitted to the hospital for post-operative management following an exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, bilateral sentinel lymph node removal and repair of ileotomy. It was reported that the patient had a biopsy proven International Federation of Gynecology and Obstetrics (FIGO) Grade 1 endometrioid adenocarcinoma who underwent an There was an estimated blood loss of 400ml. Her postoperative course was uncomplicated. She was discharged home.

This patient underwent a laparotomy. Laparoscopies are ambulatory procedures, laparotomies are not. The standard of care is for patients who undergo an open procedure to stay in the hospital for 48 hours.

On post-operative day 1, the Foley catheter was removed, the patient was allowed to ambulate and the diet was advanced.

According to the progress note from postoperative day #2, the patient was
ambulating, vital signs were stable, wound was healing well, urine output was adequate and the pain was well controlled. The patient could have been discharged that day with outpatient follow-up.

The extended hospital stay is not considered medically necessary for this patient.

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

The carrier's denial of coverage for the extended hospital stay is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: History of epilepsy, gait ataxia, hypothyroidism and gastroesophageal reflux disease (GERD). 
Treatment: Increase in Personal Care Assistance to seven days per week, 12 hours per day; 84 hours per week. 

The insurer denied the Increase in Personal Care Assistance to seven days per week, 12 hours per day; 84 hours per week. The denial is overturned. 

The patient is a female with a history of epilepsy, gait ataxia, hypothyroidism and gastroesophageal reflux disease (GERD). Due to impairments related to these conditions, she requires assistance for completion of the majority of his/her activities of daily living (ADLs). 

Appeal review requested for potential approval of an increase in Personal Assistance Services to seven days per week, 12 hours per day; 84 hours per week to offer increased ADL support. 

Yes, the proposed treatment of an increase in Personal Assistance Services to seven days per week, 12 hours per day; 84 hours per week is deemed medically necessary. 

Recent documentation from the patient's Primary Care Provider indicates that the patient has demonstrated worsening cognitive impairment, gait ataxia and falls. Hence, the currently approved plan of seven days per week, eight hours per day; total of 56 hours per week is insufficient to meet the patient's current needs. For these reasons, the proposed treatment of an increase in Personal Assistance Services to seven days per week, 12 hours per day; 84 hours per week is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis.
Treatment: Siliq.
The insurer denied the Siliq. 
The denial is overturned. 

Yes, the proposed treatment is medically necessary.

This is a male with moderate to severe, widespread psoriasis for whom Siliq is requested. He has tried and failed topical steroids and methotrexate and Soriatane. He has been using Siliq with great results.

The patient had severe psoriasis that has been very well controlled with minimal residual disease and stable on Siliq. Although he still has skin lesions, the degree of improvement is excellent, and treatment should be continued. SILIQ injection is indicated for the treatment of moderate to severe plaque psoriasis in adult patients who are candidates for systemic therapy or phototherapy and have failed to respond or have lost response to other systemic therapies. Based on the documentation of failure of prior systemic therapies and good response to Siliq, it is appropriate and medically necessary for the patient to continue with this treatment for continuation of care. It is not medically appropriate to stop current therapy in order to try other therapies (such as other biologics). Additionally, stopping the current treatment with Siliq, on which he is stable, risks a disease flare. Therefore, continued use of Siliq is medically appropriate and necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Mental Health/ADHD.
Treatment:  Lab work/blood tests.

The insurer denied the lab work/blood tests.  The health plan's determination of medical necessity is upheld in whole. 

The requested health service/treatment of Genetic lab testing is not medically necessary for this patient.  At present, pharmacogenetic/pharmacogenomic testing for children being prescribed psychotropic medication is an emerging tool Wall et al. and Wehry et al. note that "The translation of pharmacogenomics to individualized/precision medicine in pediatric patients with attention deficit hyperactivity disorder (ADHD), anxiety and depressive disorders has accelerated; however, its application remains challenging given that there are numerous divergent pathways between medication/medication dose and clinical response and side effects."

Kiehling, et al. state "Despite an increasing number of associations reported, the identification of clinically relevant genetic predictors of treatment response remains a challenge.  At present, additional studies are required to allow for a shift from a trial-and-error approach to a more rational pharmacologic regimen that takes into account the likelihood of treatment effectiveness at the individual level."

Connelly, et al. describe that genomics are beginning to play a larger role in the elucidation of methods of action of traditional drug treatments for ADHD.  Recently, Wehry, et al. stated that "Significant advances have been made in the application of pharmacogenomic testing for the treatment of patients with psychiatric disorders.  Over the past decade, a number of studies have evaluated the utility of pharmacogenomic testing in pediatric patients with psychiatric disorders."  The authors concluded, "Evidence is accumulating for the inclusion of pharmacodynamic genes in these testing panels as well.  While there are definite limitations to pharmacogenetic testing in pediatric patients, testing has the potential to decrease morbidity, decrease treatment-emergent side effects, improve treatment response, decrease inpatient admissions and readmissions due to lack of efficacy or side effects, and cost of care for the patient and his or her family.  Ultimately, more research is needed to understand the contributions of pharmacogenomics testing to the clinical treatment of children and adolescents."

At present, there is insufficient evidence to support the use of pharmacogenomics in the clinical care of children with psychiatric disorders such as ADHD, depression, and anxiety.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Unspecified psychosis.
Treatment: Continued Inpatient Behavior Services.
The insurer denied the Continued Inpatient Behavior Services.
The denial is overturned. 

Yes, the Continued inpatient behavioral health services was medically necessary.

The patient is a male with a history of mental illness.

The patient has a chronic psychotic illness. He was initially brought in to the ER by the police after having acted in a bizarre and erratic manner in the community, including a violent assault on a police officer.  He received a chemical restraint due to his behaviors.  He was evaluated and noted to be paranoid and delusional.  He was medically cleared for hospitalization and was admitted.

The patient received treatment by a multidisciplinary team, including psychiatry, nursing, and therapy staff.  He received individual and group therapy.  He received a psychopharmacology evaluation, and Clozapine was re-titrated to 200mg PO (by mouth) BID (twice daily).  He attacked a peer and a staff member, and Haldol was used for agitation.  The patient was noted to have tested positive for COVID-19 and was kept in isolation at one point.  

It was explicitly noted by the patient's social worker "he remains in need of inpatient psychiatric treatment to address psychotic process that persists."  The patient was noted to have poor insight and limited judgement.  

The patient received Haldol as a prn (as needed) for agitation and was noted to have attacked two peers and a staff member over the prior weekend.  He was noted by the doctor to be "quite malodorous."  

The patient was discharged another facility.

The patient represented an acutely elevated risk of dangerous behaviors, and there was no less-restrictive treatment environment appropriate.  The acute risk factors of psychosis with the chronic risk factors of potentially dangerous behaviors suggest that the patient would have been at an acute risk of aggressive or self-injurious behaviors (including but not limited to suicide) were he to have been discharged from the inpatient hospital setting.  The patient was discharged from the inpatient psychiatric hospital setting as soon as a less-restrictive treatment setting was appropriate. Therefore, the treatment was medically necessary.  While the patient was not endorsing active suicidality or homicidally, the patient remained psychotic.  The patient had multiple static risk factors for potentially dangerous behaviors, including history of violence and diagnosis with a severe mental illness.  Therefore, the patient represented a chronic risk of potentially dangerous behaviors.  The fact that patient remained psychotic was an acute risk factor for dangerous behaviors.  Furthermore, the fact that there was no less-restrictive environment of care appropriate suggests that ongoing inpatient psychiatric hospitalization was medically necessary and should be covered by the patient's health plan.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Crossbite.
Treatment:  Braces.

The insurer denied the braces.  The denial is overturned. 

Yes, the Braces are medically necessary.

The patient is a female.  The request is for orthodontic benefits.

The patient has two lower canines that are in crossbite (reverse bite) with gingival attachment loss.  This is an automatic qualifier according to the handicapping index scale.  Orthodontic treatment is needed to correct these problems.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Overjet, Overbite, Ectopic Eruption and crowding

Treatment: D8080 (braces) and D8670 (monthly visit x 4)

The insurer denied D8080 (braces) and D8670 (monthly visit x 4).  The denial was upheld.   

This is a male patient who consulted an orthodontist for orthotic treatment. Diagnostic testing was performed that included lateral cephalometric radiograph, panoramic radiograph, and montage of extraoral and intraoral clinical images. It was determined that the patient had overjet, overbite, ectopic eruption and crowding; recommendations for orthodontic treatment was made. Handicapping Labio-Lingual Deviations (HLD) index was performed attaining 26 total points.

It is evident that the patient exhibits a malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, the use of a Handicapping Labiolingual Deviation Index is utilized.  This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 

In this case, the treating Orthodontist does not claim an automatic qualifying condition and completes the second portion of the index arriving at 26 points to justify orthodontic care.  This reviewer concurs with the index completed by the insurer attaining a total of 12 points on the HLD index (4 overjet, 5 overbite, and 3 labiolingual spread) which is below the threshold of 26 points to support orthodontic care.

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

Based on the above, the medical necessity for D8080 (braces) and D8670 (monthly visit x 4) is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholelithiasis

Treatment: Inpatient Admission

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

This is a patient with a history of gallbladder disease. She presented to the Emergency Department (ED) with complaints of upper quadrant abdominal pain associated with nausea and vomiting. It was reported that several weeks prior to presentation the patient had an episode of biliary colic complicated by an obstructing stone in the biliary duct. A magnetic resonance cholangiopancreatography (MRCP) was performed which was unremarkable. A physical exam was performed tenderness was reported in the right upper quadrant of the abdomen. Laboratory work up was performed revealing leukocytosis. An abdominal ultrasound was done that showed evidence of gallstones several were noted to be moderate-sized stones without evidence of acute cholecystitis. The common bile duct was dilated with concern for a bile duct stone. The patient was admitted to the hospital with surgical intervention as an option. The patient received intravenous (IV) fluids and antibiotics. The patient's symptoms resolved and she was able to tolerate a diet. The patient was medically stabilized and discharged home.

The Milliman Care Guidelines indicate that admission may be appropriate for patients who have a suspected acute intra-abdominal process with peritoneal signs, abdominal mass or similar findings or for severe pain requiring acute inpatient admission or when an emergency procedure is needed.  Additionally, guidelines indicate that for abdominal pain that is undiagnosed, admission may be appropriate for patients who have peritoneal signs such as severe abdominal tenderness, rebound tenderness, rigid abdomen, or involuntary guarding or when a procedure is needed that cannot be performed on an ambulatory basis.  The records submitted for review indicated that the patient had cholelithiasis. The patient was admitted for surgical intervention.  On admission, the patient was afebrile and hemodynamically stable.  The patient was given antibiotics every 12 hours and was to be given Tylenol as needed for pain. The patient did not have peritoneal signs and did not need a procedure that could not be performed on an ambulatory basis.  The patient was offered a cholecystectomy but the patient declined and the patient's symptoms improved without surgical intervention. The records failed to support that the patient could not have been treated at a lower level of care, such as observation.  Therefore, inpatient admission was not medically necessary to treat this patient's medical condition. 

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

The carrier denial of coverage for the inpatient hospital services is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite; gum loss 
Treatment: Comprehensive orthodontic treatment of the adolescent dentition 

The insurer denied the comprehensive orthodontic treatment of the adolescent dentition.
The denial is overturned. 

Yes, the proposed treatment - comprehensive orthodontic treatment of the adolescent dentition - is medically necessary. 

The patient is a male. The request is for orthodontic benefits.

The patient has a crossbite and gum loss between anterior teeth #'s 10 and 22. This is an automatic qualifying condition as per the handicapping index scale. Orthodontic treatment is needed to correct this problem.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic dermatitis 
Treatment: Dupixent (dupilumab) 300mg/2ml syringe 

The insurer denied the Dupixent (dupilumab) 300mg/2ml syringe. The denial is overturned. 

Yes, the treatment with Dupixent is medically necessary. 

The patient is a male with atopic dermatitis, treated with multiple topicals, including Eucrisa, steroids and Elidel and Protopic per documentation.  His provider is requesting Dupixent. 

Dupilumab is United States Food and Drug Administration-indicated for treatment of recalcitrant atopic dermatitis. Dupilumab is a novel interleukin-4 and interleukin-13 blocker, which inhibits the arm of the immune system responsible for atopic dermatitis. In clinical trials, after 12 weeks of monotherapy with dupilumab, 85% of patients had a greater than 50% reduction in eczema severity and pruritus scores decreased by 57.1%. In phase III clinical trials, dupilumab led to a 75% improvement in eczema severity, when compared to placebo, and decreased symptoms of anxiety and depression. It also led to a significantly decreased use of topical corticosteroids. The safety and efficacy were supported in a recent meta-analysis of all published dupilumab paper. 

Dupixent is now approved for ages 12 and up, and the patient has tried and failed the required topicals. Therefore, the requested Dupixent is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pregnancy/other
Treatment: Infertility treatment . 
The insurer denied IVF cycle, biopsy, and freezing of embryos. 
The denial is upheld in whole. 

The patient is a  gravida 0 who presents with over 12 months of primary infertility.

No, the requested treatment. IVF cycle, biopsy, and freezing of embryos is not medically necessary. The patient  with a normal AMH and antral follicle count. In addition,the patient   responded to stimulation with an adequate number of follicles and eggs. The patient  has one genetically normal euploid embryo frozen. The patient  does not have decreased ovarian reserve. There is no medical necessity for another embryo banking cycle at this time.
The patient  has an antral follicle count of 15 which is normal range. The stimulated and showed 8 mature follicles. 6 eggs were retrieved. Although patient  only ended up with 1 blastocyst, the paucity of embryos is not necessarily reflective of egg quality but more likely sperm quality. Based on  age, the use of biopsy and PGT-A is not warranted as 60% of the  embryos would be genetically normal. Therefore, the patient   is not at a risk for hyperstimulation and could have a fresh transfer. . the patient's  pregnancy rates at this time would be the same as it is now. There is no reason to proceed with an embryo banking cycle as the patient does not have decreased ovarian reserve. There is no medical necessity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain, fever 
Treatment: Inpatient admission 

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

No, the proposed treatment, inpatient services, was not medically necessary. 

The patient is a male. At the time of admission to the hospital, he had a past medical history significant for obesity, dyslipidemia and depression. The patient presented to the ER for sore throat, fever, and sharp left-sided chest pain of several days duration. The patient was seen in Urgent care and was referred to ER for an abnormal electrocardiogram (ECG). 

The patient was hemodynamically stable. ECG revealed diffuse non-specific ST elevations consistent with pericarditis. Troponin was negative. The patient underwent a chest computed tomography (CT), which revealed moderate pericardial effusion and was admitted for suspected pericarditis, pericardia effusion. The patient was seen in consultation by cardiothoracic (CT) surgery and cardiology. There was no evidence of tamponade, and a decision was made that no pericardial window or pericardiocentesis was required. The patient was started on Ibuprofen and colchicine for presumed viral pericarditis. Two-dimensional (2D) echo was obtained, revealing preserved left ventricular (LV) function and a small pericardial effusion. The patient was discharged home oral therapy with ibuprofen and colchicine with a plan for outpatient follow-up. 

The patient presented for evaluation of chest pain, fever and sore throat and was diagnosed with acute viral pericarditis with pericardial effusion. There was no pericardial tamponade. There was no evidence of acute myocardial infarction, acute coronary syndrome (ACS), decompensated congestive heart failure (CHFP), malignant arrhythmia or hemodynamic instability. There was no need for surgical intervention. 2D echo revealed a small pericardial effusion and the patient was treated with oral anti-inflammatory medications (ibuprofen and colchicine). Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission and the care required could have been provided at an observational level of care.