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

Diagnosis: Ulcerative Colitis (UC).
Treatment Xeljanz 10mg (milligrams).
The insurer denied coverage for Xeljanz 10mg.
The denial is overturned.

The patient has a long history of ulcerative colitis (UC). She has been treated with xeljanz 10mg twice a day. She was not responding to 5mg twice a day.

The Journal of Crohn's and Colitis article titled "Dop75 Efficacy of tofacitinib dose escalation to 10mg BID [twice a day] in patients with UC after completing maintenance therapy in remission and losing response: Data from long term extension study" concludes that for patients with moderate to severe disease on tofocitinib 5mg BID but flared and were escalated to 10mg BID, response was recaptured in the majority of patients. Safety in this subpopulation was generally consistent with that observed in the overall tofacitinib UC program.

This patient did not respond well to the lower dose of xeljanz but has responded to the dose of 10mg twice a day. Dose escalation of biologic agents is supported in the scientific literature. The initial dose was not successful in controlling the patients' symptoms. The increased dose of xeljanz is likely to be more effective based on the patient's response and the data from the OCTAVE [ongoing study] long term extension study. 

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 Xeljanz is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Decreased muscle strength, balance, activity
tolerance, and functional mobility
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned. 

The patient is a male with general debility secondary to COVID pneumonia and shortness of breath. He was admitted to inpatient acute care. His relevant past medical history includes End-Stage Renal Disease (failed Renal Transplant), Type 2 Diabetes Mellitus, Foot ulcer, Enterocolitis, chronic anemia, Hypertension, Anxiety disorder, Hypercholesterolemia, CVA (cerebrovascular accident), GERD (gastroesophageal reflux disease), vitamin deficiency, urinary retention, gastroparesis, testicular abscess, osteomyelitis, interstitial pulmonary edema, pulmonary arterial hypertension, etc.

The patient was readmitted to Sub-acute Nursing Facility (SNF) with decreased muscle strength, decreased balance, decreased activity tolerance and decreased functional mobility. His prior admission was to Nursing facility. He requires oral Vancomycin for Clostridium difficile enterocolitis.

Prior to admission, the patient had been in and out of acute inpatient admission and SNF (skilled nursing facility)

Yes, the Inpatient admission was medically necessary.

The patient was able to ambulate 30 feet with support, required supervision for feeding. He was minimum assistance for transfers with 2 person-support, for dressing, maximum assistance for most ADLs (activities of daily living), including toileting, personal hygiene, bathing, etc.

He was on regular solid with thin liquid diet.

Therefore, the readmission to stay in SNF (skilled nursing facility) was medically necessary, as the patient had multiple medical issues, including need for oral antibiotics for Clostridium difficile enter-colitis, hemodialysis, general debility with increased fall tendency. Further stay in SNF (skilled nursing facility) was reasonably expected to be health beneficial for the patient, as the patient was prone to falls and increased general debility without the continued stay in SNF (skilled nursing facility).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Withdrawal

Treatment hospital admission

The insurer denied coverage for hospital admission

The denial is overturned

This is the case of an adult male who was admitted to this hospital due to critically low potassium of 2.6 and he also reportedly had low magnesium. He had fever, lethargy, and was put on a clinical institute withdrawal assessment for alcohol (CIWA) protocol due to drinking 1 pint of liquor per day with last use the day of admission. He was also put on seizure precautions and telemetry. He received potassium and magnesium supplementation. He reportedly was referred by his primary care physician due to low potassium (K). He had low K despite oral supplementation. He left against medical advice (AMA). 
  
The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. It also states that patients with past complicated or life-threatening withdrawal symptoms including withdrawal seizures or delirium tremens are in need of inpatient hospital treatment for the management of withdrawal and reports that patients with comorbid medical condition that complicate the management of withdrawal are also candidates for inpatient detoxification. 

This patient could not safely be treated in a less restrictive detoxification treatment level of care as he was at risk for severe, complicated, and life-threatening withdrawal due to large amounts of daily alcohol use. He had multiple active medical issues due to alcohol use including critically low K and low magnesium requiring supplementation and this put him at high risk medically, so he was in telemetry and had seizure precautions. He was put on a CIWA protocol but left AMA. 

The reviewer disagrees with the decision to deny coverage for inpatient hospital treatment as the medical records provided enough specific evidence to support that he required hospital treatment. It did not appear that the health care plan acted reasonably or in the best interests of the patient.

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

Diagnosis: E-cigarette or vaping product use-associated lung injury (EVALI)

Treatment: inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is overturned.

This is a teenage male with a one-day history of chest pain, nausea, and shortness of breath. He had a fever and complained of difficulty taking a deep breath, so his parents arranged for an ambulance to transport him to the Emergency Room (ER) for a medical evaluation. In the ER he was noted to be anxious and in respiratory distress with intercostal retractions. He had a documented fever of 101.8 degrees. The patient reported smoking marijuana and vaping daily. There was also a history of a 14-pound weight loss in a period of 2 weeks. The patient was treated with 2 liters of oxygen, an intravenous (IV) fluid bolus and antibiotics. A chest x-ray was normal but a computed tomography (CT) scan of the chest which was performed to rule out a pulmonary embolism demonstrated ground glass opacities and mediastinal lymphadenopathy. His white blood count, C-reactive protein (CRP), lactic dehydrogenase (LDH) and D dimer were all elevated. When the patient was taken off oxygen supplementation, his pulse oximeter dropped to 90 and oxygen was therefore continued. Based on the ongoing need for oxygen, the history of vaping, the abnormal findings on blood testing and the CT scan, the decision was made to admit the patient with a diagnosis of possible sepsis, pneumonia and possible diagnosis of e-cigarette or vaping product use-associated lung injury (EVALI) for ongoing treatment with antibiotics, steroids and IV fluids. 

EVALI can be rapidly progressive and life threatening, and it was appropriate for the ER staff to perform a CT scan in view of the patient's chronic history of vaping. The consultation with Pulmonary, Hematology and Infectious Disease were also appropriate. In view of the risk for rapid progression to life-threatening respiratory failure for which treatment requires mechanical ventilation, hospital admission was consistent with the standard of care and was considered medically necessary treatment for the patient's condition.

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

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

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

The patient is a female patient who has a history of gastroesophageal reflux disease (GERD), gastritis and diverticulitis. The patient presented to the emergency department of the facility with nausea, emesis and severe abdominal pain for two days prior to arrival. 

A computed tomography scan showed choledocholithiasis and common bile duct (CBD) dilation. The patient was found to have focal pancreatitis. The lipase was elevated at 219. The liver function tests (LFTs) and bilirubin were significantly elevated. The patient was admitted to an acute setting. 

Yes, the proposed inpatient admission was medically necessary.
The patient had an elevated lipase, a computed tomography confirmation of acute pancreatitis, and abdominal pain.  Therefore, the patient had acute pancreatitis with symptoms and chemical evidence of such.  The patient required admission for management of pain and hydration.  The literature supports admission with labs, x-ray, and pain evidencing acute pancreatitis with need for hydration and pain management.  This patient received supportive care including intravenous fluids and pain medication.  An acute admission with 'nothing by mouth' (NPO) status was appropriate given these findings.

A magnetic resonance cholangiopancreatography (MRCP) performed showed improvement. The patient was stabilized and discharged home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status Asthmaticus

Treatment: Hospital admission

The insurer denied coverage for hospital admission.

The denial is overturned.

The patient is a male with a history of asthma. He was seen in the emergency department (ED) for a cough and wheezing. He was sick with a cold virus for 2 days. He had received 3 treatments with albuterol at home with no improvement in his symptoms. When his shortness of breath persisted and he developed a fever to 101.4 degrees, he was brought to the ED for further therapy.

On physical examination, the patient was noted to be in respiratory distress with wheezing, nasal flaring, retractions and tachypnea. His pulse oxygen reading was low at 89% and he was started on supplemental oxygen by face mask. He was treated with 3 doses of Combivent and 2 doses of prednisone. Covid (coronavirus) 19, influenza and respiratory syncytial virus (RSV) testing were normal. After treatment in the ED, he was reevaluated and was noted to have persistent wheezing and subcostal retractions. The decision was made to admit the patient with a diagnosis of status asthmaticus for ongoing treatment with albuterol every 2 hours.  

This patient was treated appropriately in the ED for a cough, wheezing and respiratory distress. He had been taking albuterol for 2 days at home and following treatment in the ED, he continued to have ongoing respiratory distress with persistent wheezing and increased work of breathing. Based on review of the medical record, it was appropriate and consistent with the standard of care to admit the patient to the hospital for ongoing treatment with albuterol every 2 hours with a diagnosis of status asthmaticus. He had failed outpatient management of his asthma and was not stable enough to be sent home.

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

The insurer's denial of coverage for the hospital admission is reversed. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crowding, overjet, open bite.
Treatment:  D8080 Braces and D8670 Periodic Orthodontic Treatment Visits.
The insurer denied the  D8080 Braces and D8670 Periodic Orthodontic Treatment Visits.
The denial is overturned. 

The patient is a female. The request is for dental benefits for orthodontic treatment (braces), monthly visits. Orthodontic records have been created, and include clinical consultation, x-rays and photos.

The patient presents with a class I skeletal relationship, Class III canines, mild maxillary spacing, mild mandibular crowding, moderate excessive overjet and a severe open bite.

The health plan denied the claim because the patient did not score a 26 on the Handicapping Labio-Lingual Deviation (HLD) Index Report--the score necessary to be approved for orthodontic treatment.

The Provider appealed the case on the basis of the clinical diagnoses, especially the anterior open bite.

Yes, the requested orthodontic therapy (braces) and monthly visits are medically necessary.
As stated on the HLD (Handicapping Labio-Lingual Deviation) index Report, and as evident in the photos, the patient presents with a severe open bite of 5mm (millimeters).

An open bite occurs when the upper and lower teeth do not come in contact when the mouth is closed. The seal that is made when the anterior teeth comes together is critical for swallowing, proper speech (enunciation of certain letters--patient may develop a lisp.), proper chewing function and maintaining proper alignment of the teeth in each arch.

Orthodontic treatment is medically necessary to correct this.

When a severe open bite is left untreated they typically become worse over time. Patients may develop flaring of the teeth, speech problems, difficulty chewing, premature posterior teeth wear, inability  to swallow effectively.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: pulmonary embolism

Treatment: hospital admission

The insurer is denied coverage for hospital admission

The denial is upheld. 

This female patient has a history of asthma, deep vein thrombosis, schizoaffective disorder, and anxiety.

This patient did not need acute inpatient hospitalization. She could have been placed in Observation status while diagnostic testing and treatment were initiated. The patient was afebrile and hemodynamically stable. She was not hypoxic, and she was saturating well on RA (Room air). Observation period could be for up to 48 hours during which her diagnostic testing and treatment could have been completed. The patient remained stable on PO (by mouth) meds. She could have been discharged home after a period in observation on PO meds with close follow up in outpatient setting.

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: Upheld

Diagnosis: End-stage renal disease on hemodialysis, cirrhosis, gout, diabetes, and hypertension.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male with end-stage renal disease on hemodialysis, cirrhosis, gout, diabetes, and hypertension.  He was admitted with right knee pain and swelling.  The patient had recently been treated with a corticosteroid taper for a gout flare.  The patient was afebrile with the blood pressure 137/74 and pulse 76.  The examination demonstrated bilateral lower extremity edema with tenderness to palpation around the right knee.  Labs were notable for white blood cell count 6.7, hemoglobin 9.2, brain natriuretic peptide 7200, uric acid 10.3, potassium 4.9, and bicarbonate 28.  The chest x-ray demonstrated pulmonary vascular congestion.  Lower extremity Dopplers demonstrated a cystic mass in the right popliteal fossa and no deep venous thrombosis.  Hemodialysis was performed with ultrafiltration.  Knee arthrocentesis was performed with an intra-articular corticosteroid injection.  Oral steroids were provided.

No, the proposed Inpatient Hospital Admission is not medically necessary.
The patient's knee pain was due to a gout flare and was not accompanied by inability to ambulate or severe pain requiring frequent intravenous analgesics.  The patient did not require intravenous corticosteroid therapy.  There was no evidence of septic joint or musculoskeletal injury.  The patient remained hemodynamically stable and afebrile.  There was no evidence of fracture.  Laboratory indices were compensated.  Although the brain natriuretic peptide was elevated, there was no evidence of acute heart failure or pulmonary edema.  In summary, inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: missing multiple teeth

Treatment: braces

The insurer is denied coverage for braces

The denial is upheld. 

This female patient with no documented medical history.

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, a Handicapping Labia-Lingual Deviation (HLD) 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 submit an HLD index as required. Furthermore, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care. This reviewer concurs with the HLD index of the insurer attaining 8 points (8 points open bite).

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach.

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 braces is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autoimmune Autonomic Ganglionopathy.

Treatment Gammagard.

The insurer denied coverage for Gammagard.

The denial is overturned.

This is the case of an adult female patient whose past medical history includes attention-deficit/hyperactivity disorder (ADHD), anorexia, anxiety, depression, decreased vision, cardiomyopathy, congestive heart failure, interstitial nephritis, pyelonephritis, and systemic lupus erythematosus (SLE). The patient has been diagnosed with autoimmune autonomic ganglionopathy and Neurology Specialist is requesting coverage for Gammagard. 

Autonomic disorders can be the result of autoimmunity. The classic, well-characterized example is autoimmune autonomic ganglionopathy (AAG), in which antibodies against the ganglionic nicotinic acetylcholine receptor impair autonomic transmission, causing autonomic failure, which responds to immunotherapy. About half of cases of idiopathic subacute autonomic failure are seronegative for ganglionic acetylcholine receptor (gAChR) antibodies. Seropositive cases are more likely to have prominent cholinergic failure and pupillary abnormalities. Response to immunotherapy has been reported in seronegative cases.

Treatment of AAG is directed at the antibody-mediated pathology. Due to the rarity of the disease, evidence is limited to case reports and series; antibody depletion via plasma exchange (PE) or modulation with intravenous immunoglobulin (IVIG) appears to be beneficial and is considered first-line therapy per the current medical literature. Combination therapy with immunosuppressant medications may yield an additional benefit. 

Given that per the current medical literature, IVIG is generally regarded as first-line therapy, the request for IVIG for treatment of this member's condition is medically necessary and should be approved.

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

The insurer's denial of coverage for Gammagard for the treatment of autoimmune autonomic ganglionopathy is overturned. Medical necessity is substantiated
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope.

Treatment inpatient hospitalization.

The insurer denied coverage for inpatient hospitalization.

The denial is upheld.

This case involves a patient who presented to the emergency department due to a witnessed syncopal episode.  The documentation indicated she does have a past history of anemia and depression.  She has a possible history of a seizure as a child as well as an eating disorder.  She stated she felt lightheaded and then had the above-noted episode.  There was urinary incontinence with shaking activity with postictal phase.  The physical examination revealed the patient is 5-feet-tall weighing 105 pounds.  Oxygen saturation was 100% (percent).  She was alert and oriented and in no apparent distress.  There was an abrasion noted.  She had normal strength to her extremities and her Glascow coma scale is 15.  The physician indicated the claimant should undergo laboratory diagnostic studies.  Laboratory studies revealed pressure of carbon dioxide (PCO2) of 51.6 with partial pressure of oxygen (Po2) 30.  Venous oxygen saturation was 53.  Urinalysis revealed small leukocyte esterase.  The patient also underwent an electrocardiogram (ECG) revealing a sinus rhythm at 66 beats per minute (bpm).  The physician indicated she had a non-focal neurologic examination.  She was not hypoglycemic.  Given her eating habits there was some concern for metabolic derangement.  She does have low blood pressure and the physician indicated it was recommended she undergo a neurological consultation.  The documentation did indicate she was admitted for inpatient services for further evaluation and treatment.  A neurological work-up was non-diagnostic.  She also underwent a magnetic resonance imaging (MR)I as well as electroencephalogram (EEG).  She did not have any further significant adverse events or findings while hospitalized.  She was discharged with instruction to follow-up.

This case involves a patient with a syncopal workup with a non-focal exam, and normal computed tomography (CT), in an otherwise healthy female is an outpatient workup. Admission was not medically necessary in this clinical scenario. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for inpatient hospitalization is upheld. Medical Necessity is not substantiated.