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

Endocrine/Metabolic. 
Inpatient hospital. 

Diagnosis: Acute kidney injury.
Treatment: Inpatient stay. 

The insurer denied the inpatient stay. The health plan's determination is overturned.

The patient is a woman with history of anemia who was admitted to the hospital. She was sent to the urgent care center because of an elevated creatinine. She had been diagnosed with hypertension two months earlier and started on an ACE (Angiotensin-converting enzyme) inhibitor and hydrochlorothiazide. She denied chest pain, shortness of breath, headaches and hematuria. Review of systems was negative for fevers and chills. Vital signs showed blood pressure 161/88, heart rate 88, temperature 98.4 Fahrenheit, and respiratory rate 16. On exam, heart was regular, mental status was intact, and the abdomen was soft. Labs showed white blood cell (WBC) 9.6, hemoglobin 7.7, platelets 327, sodium 136, potassium 4.5, creatinine 3.4, and Glucose 114. The patient was admitted for acute kidney injury and uncontrolled hypertension. The plan of care included intravenous (IV) fluids, follow up urine studies, abdominal ultrasound, uric acid testing, monitor kidney function, start calcium channel blocker, and monitor hemoglobin. The renal team was consulted and their assessment was that the patient's acute kidney injury was likely due to nonsteroidal anti-inflammatory drugs versus glomerulonephritis versus diuretics. 

The inpatient stay was medically necessary. The reason is the combination of the severity of the patient's kidney injury and her concurrent poorly controlled hypertension. Kidney injury at that severity must be monitored closely and typically requires assistance from the renal consult service, which was provided. Patients with this severity of kidney injury can progress to require dialysis, particularly if the underlying process causing the injury has not been interrupted. This patient had a relatively uneventful post admission Hospital course but it was still appropriate to manage her at the inpatient level of care in the absence of certainty.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis
Treatment: Otezla 30MG Tablet (Pre-Service)
The insurer denied the Otezla 30MG Tablet (Pre-Service).
The denial is upheld. 

The patient is a female with psoriasis for whom Otezla is requested. She is mildly itchy and has worsening lesions on the hands and feet. She has had psoriasis for over six months. It has improved a little bit with topical Clobetasol. The psoriasis affects greater than five-percent of her body surface area. The patient has been using Otezla for the past five months with significant improvement.

No, the proposed Otezla is not medically necessary.

Medical chart notes document improvement with Otezla over the past five months; however, the documented body surface area has not changed and there is no description of the lesions that would support that. The patient has only used topical steroids and, even though various treatments were discussed, there is no documentation of inadequate response or intolerance to phototherapy or other systemic psoriasis therapy such as acitretin, cyclosporine, or methotrexate. There is also no indication the patient has tried biologic therapies or that she has intolerance or medical contraindications to any of them. Current preferred biologics include - Cosentyx (secukinumab),  Enbrel(etanercept), Humira (adalimumab), Skyrizi (risankizumab -  rzaa), Stelara (ustekinumab) or Tremfya (guselkumab).

The current treatment guidelines that are in accordance with nationally accepted standards of medical practice for moderate to severe plaque psoriasis recommend typical first line treatments such as topical corticosteroids and calcipotriene followed by typical second line treatments such as ultraviolet phototherapy, oral systemic treatments (methotrexate, acitretin, cyclosporine) or biologics. The patient has only tried topical corticosteroids.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male. The patient has a history of small cell lung cancer. He presented to the emergency department with a one month history of shortness of breath.  This had worsened in the few days before presentation.  His other symptoms included cough, fatigue and leg swelling.

The patient's physical examination was notable for tachycardia and irregularly irregular heartbeat.  He had mild edema in both legs. Vital signs noted heart rate in the 130s and blood pressure of 102/70.  He had a known history of atrial fibrillation. Records note that he had been on chemotherapy treatment, but had not followed up with his oncologist.  He was noted to be actively using tobacco, alcohol and heroin. Chest x-ray revealed enlargement of his known left lung mass and also revealed an area of atelectasis vs consolidation.

Lasix was given to the patient, as there was evidence of fluid overload. He had been non-compliant with outpatient medications and was started on his usual dose metoprolol at the time of admission.

The patient had improved, and oxygen saturation was 95% on room air.  However, his oxygen saturation was 95% on room air at the time of admission as well. Heart rate had also improved. Antibiotics were stopped, and he remained afebrile.

No, the Inpatient admission was not medically necessary.

This patient presented with shortness of breath that had been present for one month.  He had elevated heart rate, but he had normal blood pressure. He had worsening cancer without clear sign of infection.  There was a new opacity on his chest x-ray, but he was afebrile, not hypoxic and not noted to have significant productive cough.  He had chronic atrial fibrillation without significant worsening, and for that, he was treated only with oral metoprolol.  He had a good oxygen saturation (95%) on room air.  Based on these considerations, he did not require acute care hospital admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Non-epileptic seizures 
Treatment: Rehab treatment- treatment in an acute rehabilitation facility 

The insurer denied Rehab treatment- treatment in an acute rehabilitation facility. 
The determination is upheld. 

The patient was admitted to the hospital, transferred to the hospital's inpatient psychiatry unit and then returned to the hospital due to increased frequency of non-epileptic seizures and parental concern for his safety at home during these episodes. At issue is whether the requested health service/treatment of rehab treatment-treatment in an acute rehabilitation facility is medically necessary. 

The requested health service of acute inpatient rehabilitation is not medically necessary for this patient. The patient is medically stable, he is already at a contact guard assistance (CGA) to supervision level for transfers and over 2 weeks ago he was walking a few steps with CGA and occasional minimum assistance (MINA). Although his non-epileptic seizures are very disturbing for the patient as well as his family, there is not support for close, 3 times (x)/week, physician oversight or aggressive physical/occupational therapy. 

The patient has diagnoses significant for pelvic floor dysfunction, chronic abdominal and pelvic pain and non-epileptic seizures (conversion disorder with pseudo seizures). He has received an extensive medical workup with a video electroencephalogram (vEEG) within normal limits with multiple captured episodes. In addition, magnetic resonance imaging (MRI) did not show any evidence of an osteitis pubis (further workup for pelvic pain). He remains medically stable. While the information does support that the patient can participate in a minimum of 15 hours of therapy/week, the rehabilitation goals could be met at a lower level of care. The patient was independent with bed mobility, required CGA to supervision for transfers and was ambulating 12 feet (') with CGA and occasional MINA. In addition, while the patient continues to have non-epileptic seizures, frequent physician visits, 3x/week or more, are not supported as the patient is medically stable and treatment revolves around psychiatric care with additional rehabilitation, both of which can be provided at a lower level of care.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems-heart disease.
Treatment: Pharmacy/Prescription Drugs.
The health plan denied the benefit plan exception request for a non-formulary medication Edarbyclor  as it did not meet the criteria. 
The reviewer has upheld in whole the health plan determination.

The patient has a history of diabetes, hypertension, and hyperlipidemia. While on valsartan and chlorthalidone, his blood pressure was 116/70 millimeters of mercury(mmHg). The valsartan and chlorthalidone were discontinued and he was started on Edarbyclor (azilsartan-chlorthalidone) 40-12.5 milligrams (mg) daily. The indication for the change was not documented in the medical record. The patient has remained on Edarbyclor with good blood pressure control.

The formulary alternatives include candesartan, candesartan-hydrochlorothiazide, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, and valsartan-hydrochlorothiazide.
Based on the records provided, the patient has had a trial of valsartan in combination with chlorthalidone, which controlled his blood pressure well. Edarbyclor is a combination of azilsartan, an angiotensin receptor blocker (ARB), and chlorthalidone, a diuretic. There are multiple formulary options that include an ARB and a diuretic, hydrochlorothiazide (HCTZ); none include azilsartan or chlorthalidone. In some studies azilsartan has been shown to achieve better 24 hour blood pressure control than other commonly used angiotensin receptor blockers (ARBs). However, this patient was previously treated with valsartan (along with chlorthalidone) with good blood pressure control. Moreover, in a large cohort of 73,225 adults with hypertension, there was no significant difference in incidence of acute myocardial infarction (AMI), hospitalized heart failure, stroke or the composite outcome of AMI, hospitalization for heart failure, ischemic or hemorrhagic stroke, and sudden cardiac death in patients treated with chlorthalidone versus HCTZ. However, treatment with chlorthalidone was associated with a significantly higher risk of hypokalemia, hyponatremia, acute renal failure, chronic kidney disease and type 2 diabetes mellitus. There is no documentation that this patient has not responded to treatment with any of the formulary ARB-HCTZ combinations and that they would be likely to be ineffective in this particular case, or that they would be more likely than Edarbyclor to have adverse effects.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Endocrine/Metabolic/Nutritional-Diabetes/hyperglycemia
Treatment: Inpatient stay
The health plan denied the inpatient stay as not medically necessary. 
The reviewer has upheld in whole the health plan determination.

This is a patient with hypertension, diabetes, and dyslipidemia who was referred to the emergency department for hyperglycemia. She had left upper abdominal pain after being hit by her special needs son. She denied dizziness, headache, nausea, or vomiting. She reported not taking insulin at home as she does not like to take insulin. She was alert and oriented. Heart rate was 114. The carbon dioxide (CO2) 26, potential hydrogen (pH) 7.428, creatinine 1.33, and (The A1C test result reflects your average blood sugar level for the past two to three months) A1C 14.2%. She was treated with intravenous insulin and then transitioned to subcutaneous insulin. Glucose improved to 264 mg/dL after intravenous fluids and 18 units of Regular insulin intravenous push. She had mild congestion on her chest x-ray. She was seen by endocrinology and switched to oral medications only due to patient request. 

This patient presented with hyperglycemia and dehydration in the setting of known diabetes. She had not been taking her insulin therapy. She had mild tachycardia and mildly elevated creatinine that resolved with hydration. She was hemodynamically stable. She did not have evidence of sepsis or infection. She had hyperglycemia but her pH was 7.428. Therefore, she did not have acidosis to support a diagnosis of diabetic ketoacidosis. She did not have altered mental status to support a diagnosis of hyperglycemic hyperosmolar state. Her glucose quickly improved with hydration and insulin therapy. Therefore, the requested inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right-lower-quadrant abdominal pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a man. His medical history included hypertension. His surgical history was negative. He presented to an emergency department with a one-day history of right-lower-quadrant abdominal pain, loss-of-appetite, nausea, and diarrhea. His vitals were as follows: temperature 98.6, pulse 67, blood pressure 146/62, respirations 16, oxygenation 97%. Serum laboratories demonstrated leukocytosis to 14.53. Computed tomography was negative.

The patient was admitted at an acute inpatient level of care with a diagnosis of acute appendicitis. He was made nil per os [NPO]; provided with intravenous fluids, antibiotics, analgesics, and anti-emetics. The patient underwent laparoscopic appendectomy. Surgery confirmed "acute purulent appendicitis." The procedure and recovery were uncomplicated.

Having returned to his baseline health and function, the patient was discharged home in good and stable condition with outpatient surgical follow-up and prescriptions for anti-hypertensives and analgesics.

No, the Inpatient admission was not medically necessary.

According to several studies, the majority of patients with uncomplicated appendicitis who undergo laparoscopic appendectomy can be treated effectively and safely on outpatient or observational status [Gilliam et al; Cross et al; Cosse et all. In fact, most patients can be discharged from the post-anesthesia care unit -- the recovery room --, precluding the need for inpatient admission, even on observational status [Mitchell et al; Dubois et al; Cash et all. Therefore, for this patient, there was no need for admission at an acute inpatient level of care; this patient could have been treated at a lower level of care.

According to peer-reviewed medical literature, patients with uncomplicated appendicitis who undergo laparoscopic appendectomy can be treated effectively and safely on outpatient or observational status; most patients can be discharged from the recovery room. Therefore, this patient could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems (overjet, overbite, open bite, anterior crowding, mandibular protrusion, ectopic eruption). 
Treatment: Orthodontic treatment (braces).

The insurer denied coverage for orthodontic treatment (braces).
The denial is upheld. 

This is a female patient who presented for evaluation for orthodontic care.  The orthodontist identified several clinical findings including overjet, overbite, open bite, anterior crowding, mandibular protrusion, ectopic eruption and has recommended orthodontics.  The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 26 total points to support orthodontic care.  The insurer has denied coverage for orthodontic treatment as not medically necessary, stating that the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements.  

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 HLD index is utilized.  This index provides 6 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
20 points on the HLD index (3 overjet, 4 overbite, 10 anterior crowding, 3 labiolingual spread) which is below the threshold of 26 points to support orthodontic care.

Regarding the validity of the HLD index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach.  This is confirmed by several studies.
 
Peer reviewed articles conclude that this index is a valid and reliable determinant of need for orthodontic care.  As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.

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

The orthodontic treatment (braces) is not considered medically necessary for this patient.

The carrier's denial of coverage for orthodontic treatment (braces) is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overbite. 
Treatment: Braces. 

The insurer denied the braces. 
The denial is overturned. 

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

Yes, the braces are medically necessary. 

The patient has a deep, impinging overbite with soft tissue damage to her palate. This is an automatic qualifier according to the handicapping index scale. This case has medical necessity for orthodontic correction.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ovarian cancer.
Treatment: Inpatient admission.

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

The patient is a female with Stage IIIC ovarian cancer. She is status post debulking surgery.  She was admitted for management of a small bowel obstruction requiring laparotomy and lysis of adhesions. She was discharged.

No, the continued Inpatient Admission was not medically necessary.

The patient was afebrile, with stable vital signs, and able to ambulate, tolerate an oral diet and oral medication during the days in question. Thus there was no acute medical condition that would render inpatient level of care medically necessary. Inpatient level of care was not medically necessary, it is not consistent with standard of care practice, and not supported by peer-reviewed data or professional organizations.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure like activity.
Treatment: Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

The patient had several paroxysmal events in the course of a single week. The first event occurred when she was laying in the grass. She slowly laid backward, rolled onto her stomach, and briefly appeared dazed. She then returned quickly to her normal baseline. The second event occurred several days later. She was sitting, leaned forward onto one arm, then toppled to her abdomen. She screamed and cried, then had a dazed look on her face, which resolved after a short period of time. The third episode occurred several days later. She was walking and fell to the ground. She screamed and her face turned red. When she was picked up, her body went limp for a brief period of time. She was taken to the emergency room, where she was at her normal baseline and vital signs were stable. She underwent testing with a complete blood count (CBC), comprehensive metabolic panel, head computed tomography (CT) scan, and electrocardiogram (EKG), all of which were normal. Her physician suspected that her paroxysmal events might have been epileptic seizures. She was then admitted to the hospital, where she underwent continuous electroencephalogram (EEG) monitoring and continuous pulse oximetry, both of which were normal. She remained clinically stable throughout the hospitalization and was discharged. At issue is the medical necessity of an inpatient stay.
The inpatient stay was not medically necessary.

The patient was clinically stable in the emergency room. That week, she had had several breath-holding spells, which are common and benign. An inpatient stay for their evaluation was not medically necessary. Even if they were epileptic seizures, which her physician suspected, an inpatient stay at the acute level of care would not have been medically necessary.
Breath holding spells are paroxysmal events that happen to young children. They are not epileptic in nature but are an involuntary physiologic reflex that occurs in response to an event that the child interprets as adverse. They consist of cessation of breathing, often accompanied by paleness or cyanosis. They are brief and self-resolving. Breath-holding spells do not require hospitalization. They are diagnosed clinically and are treated by reassuring the parents. The spells that the patient had were breath-holding spells. No hospitalization was required. The patient's physician suspected that the spells were epileptic seizures. It is common to mistake breath-holding spells for seizures. However, even if the spells had been epileptic seizures, hospitalization at the acute level of care would not have been medically necessary. The patient was clinically stable in the emergency room. Her vital signs were stable and normal. She did not require administration of any fluids or medications. She was admitted for a video EEG and pulse oximetry. However, both of these tests could have been done at a lower level of care. 

She did not require hospitalization at the acute level of care.