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

Diagnosis: Symptomatic Anemia.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a female who underwent a full acute hospitalization for symptomatic anemia. The patient had a history of coronary artery disease and prior recent stent placement.  

The patient presented with the complaint of chest pain. The patient was noted to have symptomatic anemia. The patient had a history of diabetes and hypertension. The presenting hemoglobin was 5.8. The patient received three units of blood. She underwent a negative colonoscopy. She did not evidence a cardiac event.

Yes, the proposed inpatient admission was medically necessary.
The patient had significant comorbid conditions and received three units of blood. This care is not appropriate for an observation level of treatment. The patient had a history of coronary artery disease and was so anemic she evidenced chest pain. She also required intravenous (IV) Lasix during the transfusions. She had also been maintained on blood thinners prior to presentation. As such a full acute admission was medically necessary and appropriate for the management of her presenting complaints and condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: chest pain.
Treatment: inpatient admission.
The insurer is denied coverage for inpatient admission.
The denial is upheld. 

This male patient has a history of hypertension, hyperlipidemia, and diabetes.

Full hospital admission was not necessary for this patient that presented with chest pain.  His pretest probability of coronary artery disease is intermediate.(Reference 1)  Utilizing the HEART [history, ECG anomalies, patient age, risk factors , and Troponin] score he was considered intermediate risk (4 points). (Reference 2) Risk assessment of patients presenting with chest pain and no significant ST changes on ECG(Electrocardiography) was reviewed by Hedayati et al. (Reference 3).  Using the HEART score risk stratification schema, this patient would have an intermediate risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death in the six weeks following presentation. These findings are concerning and warrant management and evaluation that includes serial troponin measurement, echocardiography and ischemia work up prior to discharge. However, numerous studies have demonstrated that work up can be performed in an observation unit without the need for hospital admission. Several investigators studied patients presenting to the hospital with chest pain and compared outcomes between those admitted to the hospital for short stay admissions and those that were placed in an observation unit at a lower level of care. (References 4,5)  They found no significant difference in outcome at 30 days between the two groups.  Fernando Bellolio et al. noted that patients presenting with chest pain, that were managed in an observation unit, had similar 30 day myocardial infarction rates as those admitted to the hospital. (Reference 5)  Admission to the hospital to treat an acute cardiac event was not medically necessary.  In conclusion, this patient could have been managed at a lower level of care.

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for inpatient admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for inpatient hospital admission. 

The denial is upheld. 

This patient presented to the hospital complaining of chest pain that awoke her from sleep.  Relevant past medical history included breast cancer status post lumpectomy, syncope and transient ischemic attack (TIA).  Upon arrival to the hospital, vital signs were stable blood pressure (BP) 106/73 and pulse 79. No significant abnormal findings were noted on physical examination. She was admitted to the hospital and monitored for an acute coronary syndrome.  No abnormalities were noted on 12 lead electrocardiogram and serum blood testing did not reveal findings consistent with acute myocardial infarction.  She was discharged home the following day.  

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

This patient presented with chest pain and a past history of TIA. Her pretest probability of coronary artery disease is low (Reference 1). Utilizing the HEART [history, ECG (electrocardiogram), age, risk factors, and troponin] score, she was considered low risk (Reference 2).  Utilizing the thrombolysis in myocardial infarction (TIMI) risk score, she also had a low risk of developing major adverse cardiac events in the subsequent 30 days (Reference 3).  Risk assessment of patients presenting with chest pain and no significant ST (interval on ECG) changes on ECG was reviewed by Hedayati et al. (Reference 3).  Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation.  Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, myocardial infarction (MI), and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation. 

In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary. This patient could have been treated at a lower level of care. 

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

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia

Treatment: Personal Care Assistant (PCA) services, Level II, 7 days per week, 24 hours per day, split shift

The insurer denied coverage for PCA services, Level II, 7 days per week, 24 hours per day, split shift.

The denial is overturned.

This case involves a female who has diagnoses including dementia as well as hypertension, osteoarthritis with severe deformity of toes and feet as well as insomnia, urge incontinence and gait impairment. She also suffers from ulcers and atrial fibrillation. She does have a history of falls and lives alone. She is incontinent and unable to ambulate independently. The documentation does indicate she currently receives personal care assistance (PCA) however the aide leaves at 3 pm (post meridiem). She does not receive care until the following morning at 9 am. Documentation indicates due to her worsening condition physically and mentally, she requires help with bathing as well as toileting, dressing, grooming, diaper changes, medical appointments, repositioning, and chores.

This is a female reported to have dementia, insomnia, and advanced degenerative arthritis, frequent falls due to gait impairment and urge incontinence. The clinic notes indicate that she has declined recently and has had frequent falls. She is also reported to need help with all her activities of daily living (ADLs) and help with getting to her doctor's appointments. Her current PCA service of 6 hours a day is grossly inadequate to cover her needs. The information provided is consistent with increased frailty, increased risk for falls with its attendant adverse outcomes. Due to insomnia and toileting issues, she will likely require almost as much help during the night as she would during the day and one provider providing care for both the day and night would not be able to provide this care in a safe manner.

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 requested Personal Care Assistance (PCA) Services, Level II, 7 days per week, 24 hours per day, split shift is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe Asthma

Treatment: Dupixent

The insurer denied coverage for Dupixent.

The denial is overturned.

The patient is a male with severe asthma, requiring frequent courses of oral steroids, previously on Cinqair, most recently on Dupixent with improvement. An appeal letter attestation by his doctor states that the patient has been on high dose inhaled corticosteroids (ICS)/ long-acting beta agonists (LABAs) and Spiriva as well and that the patient has developed diabetes mellitus type 2 (DM2) from steroid use. Per the patient's provider, the insurer denied Dupixent because the eosinophil count was less than 150. The patient was on oral steroids which decreased the eosinophils accordingly. A progress note states that the patient has had many hospitalizations and that the patient received his 2nd Dupixent dose 2 weeks prior and had improvement. Physical examination had wheezing bilaterally, on Wixela 500, Spiriva and montelukast. 

Although the Food and Drug Administration (FDA) approved dupilumab for the treatment of moderate-to-severe, eosinophilic asthma (eg, peripheral blood eosinophils >=150/microliters) in patients of preteen age and older, it is true certain patients do not have a baseline eosinophil elevation due to chronic oral steroid use. Finding an eosinophil before steroid use may be difficult if the patient is steroid dependent. Steroid induced reduction in eosinophils can persist for 2 weeks after steroids are stopped. Dupilumab has been used in steroid dependent severe asthma without using eosinophilia as an entry criteria and has been shown to reduce exacerbations and improve forced expiratory volume in 1 second (FEV1) while decreasing oral steroid use. 

It is reasonable to approve continuing dupilumab in this patient especially given the patient has already improved on initial treatment (at least 2 injections).

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

The insurer's denial of coverage for Dupixent for the treatment of asthma is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Cellulitis, foot
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.

The patient is an adult female.  She has a past medical history of uncontrolled type 2 diabetes recurrent foot infections with osteomyelitis and history of second toe amputation.  She presented with erythema, drainage and an open wound.  She had failed outpatient antibiotics and was admitted for right foot cellulitis.  The patient was admitted and placed on IV (intravenous) antibiotics. Consultation of infectious disease and podiatry was called.  She was started on IV (intravenous) vancomycin and Zosyn.  Cultures were taken.  An x-ray was performed as well, which showed erosive changes, questioning postop versus acute osteomyelitis.  She was seen by podiatric surgery and recommended discharge on oral antibiotics for 10 days and Dakin's solution dressing. Infectious disease recommended Levaquin 750 for seven days.

Yes, the inpatient admission was medically necessary.

Diabetic foot infections, especially high risk foot infections with question of osteomyelitis are typically admitted to the hospital.  The patient's condition required admission for IV (intravenous) antibiotics, evaluation by podiatric surgery, infectious disease, and frequent monitoring.  This inpatient hospitalization is the standard of care.  Failure to admit this patient would have resulted in possible worsening of the condition, limb loss, sepsis, or death.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Migraines

Treatment: Botox 200 unit

The insurer denied coverage for Botox 200 unit.

The denial is reversed.

The patient has complicated migraine with dysarthria and facial droop seen on video recorded by his girlfriend. He has migraines at least 15/30 days out of the month lasting 4 hours. It is documented that he has tried and failed verapamil and ibuprofen. He has also tried Botox (with benefit), occipital nerve block and samples of calcitonin gene-related peptide (CGRP) inhibitor. Botox was denied by his insurer.  

As noted in UpToDate, "the findings from two relatively large 24-week multicenter randomized controlled trials (PREEMPT 1 AND PREEMPT 2 [ Phase III REsearch Evaluating Migraine Prophylaxis Therapy 1]) suggest that botulinum toxin type A (OnabotulinumtoxinA, Botox) is effective for the treatment of chronic migraine [51,52]."

While it is true that he has not met the insurer's specific criteria for two prophylactic agents from different classes, he has in fact tried multiple agents, and there is no medical reason why he should have to try and fail additional agents before receiving the appropriate, effective, and Food and Drug Administration (FDA)-approved treatment of Botox for his migraines. 

Botox is medically necessary for this patient. It is FDA approved for this purpose and has already been shown to be effective in this patient.  

The health care plan did not act reasonably, with sound clinical judgment, or in the best interest of the patient.

The insurer's denial of coverage for Botox 200 unit is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dysphoria.
Treatment: Reduction Mammoplasty (CPT 19318).
The insurer denied the Reduction Mammoplasty (CPT 19318).
The denial is overturned.

The patient is a female to male transgender. He has been on hormone replacement therapy for two years.  He suffers from dysphoria due to his female breasts. Top surgery mastectomies are planned.

Yes, the requested Reduction Mammoplasty is medically necessary.

The requested Reduction Mammoplasty is medically necessary.

Per the World Professional Association for Transgender Health (WPATH) "Standards of Care for the Health of Transsexual, Transgender, and Gender- Nonconforming People" 7th Edition guidelines (7):

Criteria for Breast/Chest Surgery (One Referral)
Criteria for mastectomy and creation of a male chest in FtM (female to male) patients:

1) Persistent, well-documented gender dysphoria;
2) Capacity to make a fully informed decision and to consent for treatment;
3) Age of majority in a given country (if younger, follow the SOC [standard of care] for children and adolescents);
4) If significant medical or mental health concerns are present, they must be reasonably well controlled.
Hormone therapy is not a prerequisite.

Regarding chest surgery for adolescents, WPATH (World Professional Association for Transgender Health) guidelines are as follows: "Chest surgery in FtoM [female to male] patients could be carried out earlier, preferably after ample time of living in the desired gender role and after one year of testosterone treatment. The intent of this suggested sequence is to give adolescents sufficient opportunity to experience and socially adjust in a more masculine gender role, before undergoing irreversible surgery. However, different approaches may be more suitable, depending on an adolescent's specific clinical situation and goals for gender identity expression."

The patient meets the above guidelines. He has well documented gender dysphoria and has the capacity to make an informed decision. He has been on hormone therapy for 24 months. Mental health concerns are managed by his therapist.  His psychologist has recommended the mastectomies. The standard of care for adolescent top surgery is met.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain

Treatment: Hospital admission

The insurer denied coverage for hospital admission.

The denial is upheld. 

This female patient has a history of hypertension, diabetes, spinal stenosis, and a recent L (lumbar) 4-L5 laminectomy.

The patient presented with complaints of chest pain which was occurring at rest and lasting 5 minutes. Her symptoms were concerning for a cardiac etiology. The patient underwent appropriate initial evaluation in the ER (emergency room), which was unremarkable. This included an unremarkable physical exam, a normal EKG (electrocardiogram), and negative cardiac troponins. There were no other high-risk symptoms present to suggest acute coronary syndrome. As medically essential as it was to evaluate the patient's symptoms, inpatient admission was not medically necessary in this instance. The patient's care could have been provided under the observational setting, allowing for additional diagnostic testing. During the patient's initial evaluation and subsequent hospitalization, there was no objective evidence of hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions warranting acute inpatient level of care. Cardiac troponins remained negative.

The health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.

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

Diagnosis: COPD exacerbation.

Treatment: Inpatient hospitalization.

The insurer denied coverage for inpatient hospitalization.

The denial is overturned. 

This male patient has a history of chronic obstructive pulmonary disease (COPD) exacerbations, hypercapnia, chronic systolic congestive heart failure (CHF), essential hypertension (HTN), substance abuse, deep vein thrombosis (DVT) and pulmonary embolism.

The patient was admitted to hospital with COPD exacerbation, possibly secondary to pneumonia (PNA)/medication noncompliance and acute on chronic hypercapnic and hypoxic respiratory failure.

The patient was placed on bilevel positive airway pressure (BIPAP) due to worsening respiratory acidosis. The patient improved on BIPAP and other medications. Repeat ABG [arterial blood gas] PH [potential hydrogen] - 7.40, paCO2 [partial pressure of carbon dioxide] - 64, paO2 [partial pressure of oxygen] - 110, HCO3 [bicarbonate] - 39, oxygen saturation - 98% (percent).

The patient was noted to have bilateral wheeze. The patient was treated for COPD exacerbation and PNA. Was on Duonebs Q [every] 4 hours. The patient was non-compliant with BIPAP so was placed on 6 liters (L) nasal cannula. BIPAP at night. 

This patient needed close monitoring for his multiple medical issues including acute on chronic hypercapnic and hypoxic respiratory failure. He had a history of recent hospital discharge. Had retrocardiac infiltrate suggestive of PNA and also had other co morbidities - congestive heart failure (CHF) and polysubstance abuse. He was at a high risk of intubation hence not stable for observation status.

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

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

Diagnosis: Class I molar and Class I canine occlusion
Treatment: Braces (Comprehensive Orthodontic Treatment)
The insurer denied the braces (comprehensive orthodontic treatment).
The denial is upheld.

The patient is a male with a Class I molar and Class I canine occlusion. He has spacing between the upper front teeth.

No, the requested braces are not medically necessary.

The patient only scored a 7 on the handicapping index scale, which is nowhere near the 26 threshold. Although the provider noted there was palatal impingement from the patient's lower incisors against the palate behind the upper front teeth, the photos do not show this. The patient does not have a severely handicapping malocclusion, either. No medical necessity for braces is exhibited for this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a male. He presented to the hospital; Chief complaint was swelling of the left elbow, forearm, and hand. Several open areas with some purulent discharge were also reported by the patient. He had suffered a fall a few days earlier. Initially the patient visited the ER(Emergency Room) a few days prior. He was prescribed oral Bactrim twice a day. Despite the antibiotic, there had been worsening of swelling and pain in the involved area with extension distally in the forearm and hand.

On examination, the patient's temperature was 99.6 F(Fahrenheit). Reported symptoms and findings were confirmed by the clinician. The patient was hospitalized. Zosyn IV (intravenous) was initiated. X ray of the area showed no joint or bone involvement. CRP (C-reactive protein) was 91, ESR (erythrocyte sedimentation rate) 45. Infectious Disease consultant saw the patient and gram stain/culture the next day demonstrated Staph aureus. Improvement in clinical findings were noted. The patient was started on vancomycin IV (intravenous). Zosyn was stopped. Cefazolin was added. The following day, more improvement was noted and the patient was discharged home on oral Duricef and Bactrim for 7 days.

Yes, the Inpatient admission was medically necessary.
The reasons for inpatient treatment are as follows:

1) Progression despite more than 48 hours of Bactrim treatment in the outpatient setting.
2) Elevated ESR (erythrocyte sedimentation rate), CRP (C-reactive protein) (91) on presentation.
3) Elevated white cell count of 12,500 cells/mL (milliliter) on presentation with neutrophilia.
4) Worsening of cellulitis in the outpatient setting with involvement of a vulnerable area of the body - the forearm and hand.

These factors point to a moderately aggressive cellulitis with the need for immediate IV (intravenous) antibiotics and serial clinical monitoring anticipated and documented by the physician to require an overnight hospital stay.

Therefore, given the above, the inpatient admission was medically necessary.

The denial of inpatient services should not be based on commercially available criteria sets alone. Usual standard of care and unique patient circumstances also need to be accounted for in determining risk to the patient and anticipated duration as well as intensity of care in the hospital. The plan only used commercial criteria in rendering a denial.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bilateral hearing loss
Treatment: Hearing Aids (a total of two units), Pre-service
The insurer denied the Hearing Aids (a total of two units), Pre-service
The denial is overturned

The patient has severe hearing loss bilaterally demonstrated on audiogram.  Progression of hearing loss is noted versus study.  The patient was medically cleared for hearing aid evaluation and fitting.  The patient's hearing aids are noted to be in need of replacement because of use over time.  The patient previously had binaural hearing aids.

Yes, the proposed hearing aides (two units total) are medically necessary.
This patient has severe bilateral hearing loss and will benefit most medically from binaural hearing aids. The patient has had prior binaural hearing aids and has had progression of hearing loss. The new hearing aids are medically necessary to meet the patient's current needs of amplification given the current hearing profile.  The prior hearing aids are noted to not meet current needs because of use over time impacting their function.  Binaural hearing aids provide greater effective input for speech and discrimination.

This patient will have a best hearing outcome from aiding both ears. Especially with severe loss, binaural amplification is most likely to provide the best potential hearing profile.  There is no medical justification for not aiding both ears.