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

Diagnosis: Ingested foreign body

Treatment: Inpatient admission

The insurer is denied coverage for inpatient admission

The denial is upheld. 

This female patient has a history of bipolar disorder, schizoaffective disorder, borderline personality disorder, and substance abuse disorder.  The patient presented to the Emergency Room (ER) with complaints of hearing voices telling her to hurt herself and ingesting 2 plastic spoons.  The patient reported being recently discharged from the psychiatric unit and being noncompliant with her medication regimen.  The patient also recently swallowed something and presented to the hospital. At that time she signed out against medical advice (AMA) before the esophagogastroduodenoscopy (EGD) could be done.  The patient was hemodynamically stable in the ER.  The patient was admitted to the Medicine service with an ingested foreign body.  The patient's EGD was done and the 2 spoons were removed from the second portion of the duodenum. There was some macerated tissue and a nonbleeding duodenal ulcer.  The patient tolerated the procedure well.  The patient was initially kept on nothing-by-mouth (NPO), and her diet was advanced as tolerated with no problems.  During the hospital course, there was no abdominal pain, nausea, vomiting, and diarrhea, bleeding, or witnessed swallowing events.  The patient was discharged after a period of medical stability.  

Milliman Care Guidelines (MCG) clinical indications for admission for Gastroenterology (MG-GAS) include having severe dysphagia.  This needs to be manifested by perforation, severe dehydration, and inability to manage secretions, hemodynamic instability, severe electrolyte abnormalities, or acute renal failure.  The patient did not have these conditions.

This patient required an endoscopy for foreign body removal.  MCG guideline ACG: A-0203 lists indications for this procedure.  Dysphagia is an indication for an endoscopy.  However, the procedure is listed as an ambulatory care procedure.

Based on the review of the medical record and literature, inpatient admission was not medically necessary for this patient. The patient was stable to have had the endoscopy and foreign body removal done on an outpatient basis.  The patient had psychiatric disorder but no complications were reported from the endoscopy.  There was some trauma noted from the foreign body but no perforation.  The patient could have been followed after the procedure with observation status.  

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 inpatient hospital admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prostate cancer. 
Treatment: Genetic testing of prostate tissue with Oncotype DX for prostate cancer (code 0047U).

The insurer denied coverage for the genetic testing of prostate tissue with Oncotype DX for prostate cancer (code 0047U).  The denial is upheld. 

This is a male patient with diagnosis of early prostate cancer. His prostate specific antigen (PSA) was 2.8, and on biopsy he had Gleason 3+4 prostate cancer and clinical stage T1c. After the biopsy results, the urologist ordered an Oncotype Dx Prostate Cancer (PCA) test for further evaluation to assist with risk stratification and help with formulating an individualized treatment decision. The Genomic Prostate Score (GPS) stated that the patient's prostate cancer was intermediate risk. There was a 35% risk for adverse pathology, a < (less than) 1% risk for prostate cancer death within 10 years and 4% risk of cancer within 10 years. 

The insurer has denied coverage for Oncotype Dx GPS as not medically necessary. The insurer noted that while this test has a validation study published that shows potential of assisting in decision making for potential treatment options for this cancer, there was a lack of any significant randomized trials in peer reviewed medical literature that show a significant benefit or difference in outcomes of patients with prostate cancer by utilization of this test. 

While it is true that both the National Comprehensive Cancer Network (NCCN) and the American Society Clinical Oncology (ASCO) guidelines state that usage of Oncotype Dx GPS can be considered for patients with low risk and favorable intermediate risk prostate cancer and at least a 10-15 year life expectancy; they also note the lack of randomized prospective trials. The American Urological Association (AUA) guidelines (2018) are more pessimistic regarding the clinical utility if this test, stating that "tissue based genomic biomarkers tests (such as Oncotype) have not shown a clear role in active surveillance for localized prostate cancer, and all not necessary for follow-up". Currently there is no level 1 evidence supporting use of genomic biomarkers in clinically localized prostate cancer. The most common result of a genomic biomarkers test is no change in the clinical risk profile. While genomic testing likely affects decision making, it is unknown yet whether these decisions are ultimately better or worse in terms of long-term oncologic outcomes when compared to decision making using existing pathological and clinical data. Prospective studies of these tests yielding a true clinical benefit when implemented in clinical practice are still lacking. 

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

The carrier's denial of coverage for the genetic testing of prostate tissue with Oncotype DX for prostate cancer (code 0047U) is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems (anterior crowding, overjet and overbite).

Treatment: D8080 Braces and D8670 Monthly Visit x12.

The insurer denied coverage for D8080 Braces and D8670 Monthly Visit x12.

The denial is upheld. 

This patient is a male child who presented for evaluation for orthodontic care.  The Orthodontist identified several clinical findings including anterior crowding, overjet and overbite and has recommended orthodontics.  The Orthodontist has completed the Handicapping Labiolingual Deviation (HLD) index attaining 20 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 six specific conditions that automatically qualify for orthodontic care.  Additional criteria are required 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 20 points to justify orthodontic care.  This reviewer concurs with the index completed by the insurer attaining a total of 14 points on the HLD index (3 points overjet, 4 points overbite, 5 points anterior crowding, 2 points Iabiolingual spread) which is below the threshold of 26 points to support orthodontic care.  Of note in this case, is that the patient's own Orthodontist does not attain 26 points on the HLD index as required for orthodontic approval.

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.  This is confirmed by several studies.

Each of these peer reviewed articles concludes 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.

Recommendation:  Uphold denial as the clinical circumstance as presented does not substantiate the medical/dental necessity of orthodontic care as it does not meet the accepted criteria for approval.

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

The medical necessity for D8080 Braces and D8670 Monthly Visit x12 is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Neurofibroma Tremor, Major Neurocognitive Disorder, Aphasia, Spinal Stenosis, Back Pain, Gait Ataxia and frequent falls. 
Treatment: Increase Personal Care Services Level II to 12 Hours per Day, 7 Days per Week - a Total of 84 Hours per Week. 

The insurer denied the Increase Personal Care Services Level II to 12 Hours per Day, 7 Days per Week - a Total of 84 Hours per Week. 

The denial is overturned. 

The patient is a female with a history of Neurofibroma Tremor, Major Neurocognitive Disorder, Aphasia, Spinal Stenosis, Back Pain, Gait Ataxia and frequent falls. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). An appeal review was requested for potential approval of 84 hours/week Personal Assistance Services to offer increased activities of daily living support. 

Yes, the proposed treatment of 84 hours per week Personal Assistance Services is deemed medically necessary. 

The patient is a female with a history of Neurofibroma Tremor, Major Neurocognitive Disorder, Aphasia, Spinal Stenosis, Back Pain, Gait Ataxia and frequent falls. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). An in-home assessment of the patient's functionality and ability to perform activities of daily living was completed and revealed that the patient requires extensive assistance with bathing and limited assistance with personal hygiene, dressing upper body, dressing lower body, toilet transfer and toilet use. 

However, recent correspondence from the patient's medical provider indicates that due to progressive cognitive impairment, the patient now requires extensive assistance with all activities of daily living including toileting, dressing and personal hygiene. In addition, she requires assistance with meal preparation, eating, transfers and ambulation. 

For these reasons, the currently approved plan of 40 hours per week Personal Assistance Services is insufficient to meet the patient's current needs. Hence, the proposed treatment of 84 hours per week Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alopecia Universalis.
Treatment: Dupixent.
The insurer denied the Dupixent. 
The denial is upheld. 

The patient is a female with alopecia universalis for whom Dupixent is requested. She has tried and failed topical and intralesional steroids. She's trying to get pregnant and cannot take cyclosporine and Janus kinase (JAK) inhibitors.

No, the proposed treatment with Dupixent is not medically necessary.

Alopecia areata (AA) is an autoimmune condition that affects up to 2% of the general population. Currently available treatment options for alopecia areata are of limited efficacy and can be associated with adverse effects. The advancement in understanding of the genetic and molecular mechanisms of alopecia areata has led to the development of novel treatment options, with the Janus kinase (JAK) inhibitor class of drugs at the forefront of ongoing clinical trials. Platelet-rich plasma, fecal transplants, and cytokine-targeted therapy with ustekinumab and dupilumab have also been shown to regrow hair in patients with alopecia areata in individual case reports or small studies. However, case studies have also reported dupilumab inducing alopecia areata in patients treated for atopic dermatitis. Its safety and efficacy for this condition has not been established and it is not considered an accepted off label use of this medication. Therefore, it is not considered medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital admission for medical necessity. 
The denial was overturned. 

The patient is a male with diabetes requiring insulin and recurrent pancreatitis related to hypertriglyceridemia (likely familial), with prior admissions related to similar complaints. He presented to the emergency department (ED) with complaints of abdominal pain for the prior 3 days. He reported compliance to his diabetes treatment but poor adherence to his diet and fish oil/gemfibrozil.

His vital signs in the ED were unremarkable and the exam was unremarkable except for abdominal tenderness. His lab work showed a normal lipase, elevated Hemoglobin at 19, a white blood cell (WBC) count to 13, and an elevated blood glucose (BG) at 269 with mild anion gap at 17. His triglycerides (TGL) level was noted at 1575. A computed tomography (CT) scan of the abdomen showed mild acute pancreatitis.

He was admitted to an inpatient medical intensive care with intravenous (IV) hydration, IV insulin drip and pain control with IV opioid medications. Endocrinology was consulted, who agreed with ongoing treatment with insulin drip and IV hydration. The patient decided to leave against medical advice and was discharged with endocrinology and primary care physician (PCP) follow up.

At issue is the inpatient hospital admission for medical necessity.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of inpatient hospital admission was medically necessary for this patient.

The patient had severe hypertriglyceridemia with acute pancreatitis noted on imaging. The standard of care for such situations is IV insulin drip and hydration with close monitoring of electrolytes, triglyceride levels and blood glucose levels. The treatment for this patient with an insulin drip is generally recommended for an average of 2.5-4 days to bring triglyceride levels lower than 500. Based on review of the patient's medical records, this inpatient level of care was medically necessary.

Therefore, the inpatient hospital admission was medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Viral upper respiratory infection (URI)/Asthma.

Treatment: Inpatient emergency admission.

The insurer denied coverage for the inpatient emergency admission.

The denial is upheld. 

This is a male patient with a history of (H/O) asthma who was brought to the emergency department (ED) with complaints of (C/O) wheezing. The patient also complained of some productive cough with clear discharge, some congestion, and loss of smell. The patient had run out of his medications.

Vital signs at presentation were: Temperature (T) 98.1, Heart rate (HR) 112, respiratory rate (RR) 20, Blood pressure (BP) 135/82, and Oxygen (O2) saturation (sats) 98% on room air (RA). The patient was noted to be wheezing. There was no respiratory distress noted, and no retractions noted. The patient was speaking full sentences. The patient was treated with intravenous (IV) steroids, bronchodilators (BD) via nebulizer (Nebs), and Magnesium. Presentation Labs were: white blood count (WBC) 12,200, hemoglobin (Hb) 15.7, electrolytes were within normal limits (WNL), Lactate 1.1, and venous blood gas (VBG) 7.36/49/34/27. Chest x-ray (CXR) showed no acute infiltrates, pneumothorax (PTX) or pleural effusion. Influenza screen was negative. The patient improved with treatment, was in no acute distress (NAD), denied shortness of breath (SOB), but was still wheezing so was admitted to the hospital. As per the history and physical (H&P): T 98.1, HR 121, RR 20, BP 113/63, and O2 sats 96%. The patient was awake, alert, and oriented x3. The lung exam revealed scattered wheezing. Cardiovascular system was normal, abdomen was soft and the admitting diagnosis was: Viral upper respiratory infection (URI)/Asthma.

This patient did not need acute inpatient hospitalization. He could have been placed in observation status (which could be up to 48 hours). He was afebrile and hemodynamically (HD) stable, and not hypoxic. There was no pneumonia, pleural effusion, or pneumothorax. WBC was normal and potential of hydrogen (pH) on VBG was 7.36. The patient had improved with treatment in ED. The patient was tolerating oral intake (PO). This patient could have been discharged after a period in observation on oral steroids, BD and other inhalers as indicated with close follow up in outpatient status.

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

The medical necessity for the inpatient emergency admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rectal bleeding.
Treatment: Inpatient admission. 
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female. She had presented to the emergency department of the facility filing the appeal. She had complaints of rectal bleeding. The patient had a medical history of asthma, hypertension, elevated cholesterol, kidney stones, diverticulosis and second degree hemorrhoids noted on a recent colonoscopy. The patient also had a rectal polypectomy, which was a week prior to this presentation. She had been seen the day prior at the emergency department with the same complaints and diagnosed with hemorrhoids and discharged. She re-presented due to the persistence of the condition, but now black stools mixed with the bright red blood. Lower abdominal cramping, weakness and nausea were also reported.

The patient's hemoglobin had dropped from 11.2 to 10.8. A CT (computed tomography) scan showed a hiatal hernia but no acute findings. The patient received IV (intravenous) PPI (proton pump inhibitor) treatment and supportive care. The patient was admitted due to a concern for a diverticular bleed.

The patient was admitted to an acute medical bed. She was monitored, and she was allowed a clear liquid diet. As the patient evidenced clinical stability without a significant drop in the blood count, the patient was discharged.

No, the Inpatient admission was not medically necessary.

The treatment was medically appropriate but not medically necessary at the level at which the care was provided.

Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had rectal bleeding, yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for NPO (nothing by mouth) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission. As such, the care could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Transient Ischemic Attack (TIA)
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a female with hypertension, diabetes and obesity who presented with the complaint of acute onset right hemibody weakness and aphasia. The patient had resolution of her symptoms in the emergency ward and tissue plasminogen activator (TPA) was not administered. The patient was admitted for possible stroke. After admission, magnetic resonance image (MRI) of the brain was negative.

Yes, the acute inpatient admission was medically necessary.

The patient had a transient ischemic attack (TIA) with resolution of her symptoms prior to admission. However, risk stratification score for this patient who is diabetic, had uncontrolled hypertension at presentation, prolonged unilateral weakness and chronic infarcts on neuro-imaging support that her risk for stroke, particularly within 48 after presentation, is high. Therefore, acute inpatient admission here is consistent with current standard of care (Arsava et al.; Lo et al.).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Covid-19.
Treatment: Non-Emergent Ambulance transport.

The insurer denied Non-Emergent Ambulance transport. The health plan's determination is upheld. 

The patient was female with a past medical history significant for hypertension, obesity, hypothyroidism, prediabetes, and gastroesophageal reflux disease (GERD) who presented to the emergency department with a 1-1/2-week history of worsening fatigue, and shortness of breath. It was mentioned that the patient was diagnosed with a COVID-19 infection. Since that time, her condition became progressively worse. Her symptoms included lack of appetite, fatigue, generalized weakness, headaches. At the same time, the patient denied nausea, vomiting, diarrhea, or syncopal episodes.

The transportation by Non-Emergency Ambulance was not medically necessary for this patient, because she was in stable clinical condition and did not require services en-route that are usually provided in a non-emergency ambulance.
Centers for Medicare and Medicaid Services (CMS) defines Medical Necessity for Ambulance Transportation as: "Ambulance transportation is indicated when the patient's condition requires the vehicle itself and/or the specialized services of the trained ambulance personnel. A requirement of coverage is that the needed services of the ambulance personnel were provided and clear clinical documentation in the patient's medical record validates their medical need and their provision. The patient's condition, as well as changes in that condition and the treatment provided, must be in the record of the ambulance service."

The review of the medical record clearly demonstrated that in this clinical case the patient had none of the circumstances in which she would endanger her individual health if she was transported home by other means of transportation.

According to the medical records, during the hospital stay the patient was diagnosed with acute respiratory failure due to COVID-19 pneumonia. In the hospital, she received appropriate for her medical condition care, and by the time of discharge, she was in stable condition. There was no evidence that the patient was severely debilitated to the point that she was unable to be transported to her residence by a private vehicle. There was no evidence that the patient required close monitoring or administration of any medications while en-route.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Incontinence, headache, and vertigo
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female with diabetes, hypertension, HIV (human immunodeficiency virus) and pituitary adenoma. She presented to the emergency ward with the complaint of incontinence, headache, and vertigo for two days.

At presentation, the patient had a non-focal neurological examination and negative CT (computed tomography) brain.

No, the inpatient admission was not medically necessary.

The patient presented with a two-day history of headache. She had a normal examination, and CT (computed tomography) brain did not demonstrate any acute or concerning findings.  Based on the documented presentation, there were no concerning features (e.g. thunderclap headache, focal deficits) to support intracranial pathology requiring inpatient evaluation, monitoring or treatment. The diagnostic studies, monitoring, treatment and clinical evaluation could have been safely and effectively completed at a lower level of care.