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

Diagnosis: alcohol withdrawal symptoms.
Treatment: inpatient admission.
The insurer is denied coverage for inpatient admission.
The denial is overturned. 

This male patient has a history of daily alcohol use (vodka), marijuana, and tobacco use.

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 reportedly had active alcohol withdrawal symptoms including tremors, agitation, nausea and vomiting, anxiety, irritable mood, sweats, headache, numbness, and had a CIWA(Clinical Institute Withdrawal Assessment for Alcohol)of 15 putting him at high risk for more severe, complicated, and life threatening withdrawal including delirium tremens. He reportedly was put on a Librium taper. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) he did require 24 hour treatment as he could not safely and effectively be treated in a less restrictive treatment setting as he continued to use large amounts of alcohol daily including 1 pint of vodka per day and two 40 ounce beers despite multiple past inpatient substance/alcohol detoxification/rehabilitation treatments including a recent one in which he reportedly relapsed after 2 days of leaving the hospital. Also, he required and needed detoxification medication, Librium, to modify withdrawal including a Librium taper and needed 24 hour treatment then as he was at risk for worsened withdrawal symptoms if not in this 24 hour setting then including severe and life threatening withdrawal symptoms. The risk of life complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use so he required inpatient detoxification protocol treatment. He also was unemployed and had comorbid psychiatric issues including a diagnosis of bipolar disorder and post-traumayic stress disorder (PTSD). He was considered at risk medically and required 24 hour inpatient detoxification hospital treatment then.

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

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

Diagnosis: cocaine dependency

Treatment: inpatient chemical dependency admission

The insurer is denied coverage for inpatient chemical dependency admission

The denial is overturned. 

This male patient has a history of anxiety, post-traumatic stress disorder (PTSD), bipolar disorder, hypertension, obesity and diabetes.

American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that inpatient treatment is indicated primarily for individuals whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. In this case this patient was considered in need of 24 hour substance rehabilitation treatment as he lacked the necessary coping skills, sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. It was reported that he needed to identify relapse triggers and could not maintain abstinence. He reportedly had a 30-40 year history of multiple serious substances of use including crack, cocaine, and THC[Tetrahydrocannabinol]. He reportedly was at risk for serious medical issues due to his large amount of daily crack and cocaine use. He reportedly lacked the support system to maintain abstinence outside of a 24 hour inpatient therapeutic rehabilitation treatment setting that was structured and supervised.  According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) he met criteria for inpatient substance rehabilitation treatment as he continued to use multiple serious substances of use for a long duration of time putting himself at risk medically.  He also reportedly had comorbid psychiatric diagnoses including bipolar disorder and PTSD and had comorbid medical issues including hypertension and diabetes.  He reportedly lacked supports and motivation, insight, and judgment as well as coping skills to be treated outside of this 24 hour therapeutic inpatient substance rehabilitation treatment.  He reportedly lacked coping skills, needed to better identify relapse triggers, and needed to learn relapse prevention skills. Without this structured and supervised therapeutic residential treatment he likely would have relapsed and not been able to try to work on recovery skills.  

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

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

Diagnosis: facial feminization

Treatment: inpatient hospital stay

The insurer is denied coverage for inpatient hospital stay.

The denial is upheld. 

This female patient has a history of Bipolar 1 disorder, benign prostatic hyperplasia, and gender dysphoria

According to the Milliman Care Guidelines (MCG), 25th Edition, "General Admission Criteria." She had pain following the surgery but was hemodynamically stable. Her pain was controlled with analgesics. She did not have any significant physiologic or surgical complications following the procedure. She did not require inpatient monitoring for her urinary catheter and JP drain. She could have been managed at an observation level of care.  According to MCG General Admission Criteria: "General Criteria: Observation Care. Observation is not a location within the hospital, but rather a short period when the same active diagnostic and therapeutic services used during an inpatient hospitalization are provided to gather more information and assess the response of the patient. Typically it is 48-hours or less, but can be up to 72-hours in certain situations."  This patient was medically stable and needed only additional analgesic medication. She could have been safely managed at an observation 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 the inpatient hospital stay is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atypical 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 tobacco abuse.

This patient presented with atypical chest pain His pretest probability of coronary artery disease is low. (Reference 1) Utilizing the HEART score he was considered low risk. (Reference 2) Utilizing the thrombolysis in myocardial infarction (TIMI) risk score he also had a low risk of developing major adverse cardiac events in the subsequent 30 days (TIMI score=1). (Reference 3) Risk assessment of patients presenting with chest pain and no significant ST 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, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation. Even though this patient had a positive stress test performed prior to presentation, there was no evidence of acute coronary syndrome.

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

Diagnosis: Other specified polyneuropathies

Treatment Healthcare Common Procedure Coding System (HCPCS) J1561 Gamunex-C 1 gram/10 milliliter vial, 25 grams by intravenous infusion daily for 5 days every 4 weeks = 50 HCPCS units per dose for a total of 3250 HCPCS units

The insurer denied coverage for Healthcare Common Procedure Coding System (HCPCS) J1561 Gamunex-C 1 gram/10 milliliter vial, 25 grams by intravenous infusion daily for 5 days every 4 weeks = 50 HCPCS units per dose for a total of 3250 HCPCS units

The denial is overturned

This case involves a female who has diagnoses including hypercholesterolemia, other specified polyneuropathies, gastroesophageal reflux disease and radiculopathy. The submitted documentation indicated the patient has complaints of worsening fatigue as well as burning in her legs with severe diffuse weakness. Extensive prior evaluation which included blood work as well as electrodiagnostic studies and cerebrospinal fluid (CSF) analysis showed elevated protein indicating an inflammatory neuropathy. The documentation also includes electrodiagnostic study revealing mild chronic, mainly S1 (sacral nerve root) possibly L5 (fifth lumbar) radiculopathy on the right and left with possible myopathic motor units seen. She has had treatment with high-dose corticosteroids causing severe adverse effects. She meets the criteria for CIDP (chronic inflammatory demyelinating polyneuropathy) according to the physician. She has been recommended to utilize IVIG (intravenous immune globulin) due to ongoing symptoms.

The submitted documentation indicated the patient met the criteria for a diagnosis of CIDP and had failed other treatment options. It is a Food and Drug Administration (FDA)-approved medication for CIDP. There are no contraindications for IVIG in this patient. There was sufficient evidence to support that Healthcare Common Procedure Coding System (HCPCS) J1561 Gamunex-C 1 gram/10 milliliter vial, 25 grams by intravenous infusion daily for 5 days every 4 weeks = 50 HCPCS units per dose for a total of 3250 HCPCS units was medically necessary treatment for the patient's condition.

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 Healthcare Common Procedure Coding System (HCPCS) J1561 Gamunex-C 1 gram/10 milliliter vial, 25 grams by intravenous infusion daily for 5 days every 4 weeks units = 50 HCPCS units per dose for a total of 3250 HCPCS units is reversed. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: chronic microvascular ischemic changes.
Treatment: inpatient hospital admission.
The insurer is denied coverage for inpatient hospital admission.
The denial is overturned. 

This female patient has a history of atrial fibrillation, hypertension, hyperlipidemia, asthma, diabetes, and a cerebrovascular accident (CVA).

This patient with multiple vascular risk factors and previous right thalamic cerebrovascular accident (CVA) with residual left arm weakness presented to the emergency department (ED) after waking up severely dizzy with room spinning.  She reported nausea and vomiting as well as difficulty walking.  She also reported left leg and left facial tingling followed by weakness.  The dizziness was made worse by moving her head.  On exam, she was noted to have a mild left arm drift and inability to ambulate  persistent falling to the right. Stroke code was called.  She was unable to walk.  Blood pressure (BP) was high at 182/100. Head computed tomography (CT) and computed tomography angiography (CTA) were unremarkable.  Due to concern for acute posterior circulation stroke, she was admitted to inpatient level of care. 

Given that this patient had persistent ataxia on exam in the ED as well as focal neurological symptoms with very high BP and multiple vascular risk factors, inpatient admission was medically necessary given high clinical suspicion for acute stroke.

The health plan did not 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 overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Autism spectrum disorder, epilepsy.
Treatment: Personal care aide (PCA) services for a total of 40 hours per week.

The insurer denied coverage for PCA services for a total of 40 hours per week.  The denial is upheld.

This case involves a male infant who is nonverbal and has a diagnosis of autism spectrum disorder as well as epilepsy. The documentation indicated that due to increasing seizures it was recommended that he have home health care service to provide constant supervision and safety. A request for 40 hours of personal care aide (PCA) services was made. 

It was noted the patient continued to present with more than 10 seizure episodes a day leaving him very disoriented. Disorientation leads him to frequent accidents. He does need assistance with daily living activities (ADLs) such as ambulating as well as eating and utilizing the restroom. He also required supervision with medication administration. He has seasonal allergies and dermatitis, and his mother is his primary and sole caregiver; however, she has full-time work as well as takes care of 3 other children. 

The insurer has denied 40 hours per week and approved 15 hours per week. There is no medical indication for a personal care assistant for 40 hours as requested. While the parent expresses some hardship with caring for her children, the documentation submitted did not support necessity for 40 hours. The documentation does not indicate the need for a PCA, as noted above, and may seek respite services versus the requested PCA on a daily basis.

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

The insurer's denial of coverage for the requested Personal Care Aide (PCA) Services for a total of 40 hours per week is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cross-bite, shallow overbite, and overjet
Treatment: D8080 Braces (Pre-service)
The insurer denied the D8080 Braces (Pre-service)
The denial is overturned. 

The patient is a male requesting dental benefits for Orthodontic treatment (Braces). The patient presents with a Class I molar relationship, anterior cross-bite (UR3 [upper right 3]/LR3 [lower right 3]), shallow overbite and overjet.

The patient had clinical consultation. Orthodontic records were made, photos were taken, and a treatment plan was created.

Yes, the Braces are medically necessary.

As evident in the photos and as stated in the clinical findings on the HLD (Handicapping Labio-Lingual Deviation) index, the patient presents with an anterior crossbite in (UR3 [upper right 3]/LR3 [lower right 3]) area. This is an automatic qualifier for orthodontic treatment as per the HLD (Handicapping Labio-Lingual Deviation) index.

Furthermore, anterior crossbites can lead to difficulty with speech, proper chewing and the inability to maintain proper hygiene.

Therefore, given the above, the Braces are medically necessary.

Non-treatment of this condition, can lead to difficulty with speech, proper chewing and the inability to maintain proper hygiene, therefore; this will only contribute to long term problems with the patient's overall dentition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder
Treatment: Home Health Care. 
The insurer denied an increase in home health care services for medical necessity. 
The denial was upheld. 

The patient is a female with a past medical history significant for Alzheimer's disease with dementia, insomnia, hyperlipidemia, anxiety, anemia, osteoporosis, osteoarthritis, diabetes mellitus, gait dysfunction and behavioral problems consistent with dementia. The patient's provider is requesting personal care level 2 aide hours, 12 hours a day times () 2 shifts a day  7 days a week for a total of 168 hours a week (split shift).
The tasking tool noted that the patient required an average of 6.4 hours a day of services. Tasking tool noted the patient averages 6.57 hours a day of services. The patient has been approved for 112 hours a week, 16 hours a day  7 days a week personal care level 2. Additional services were denied for medical necessity.

At issue is the medical necessity of 168 hours (HRS)/week (WK), 12 HRS x 2 x 7 days (split shift), personal care aide 2. 

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

No, the requested health service/treatment of 168 HRS/WK, 12 HRS x 2 x 7 days (split shift), personal care aide 2, is not medically necessary for this patient.

Additional services, split shift is not medically necessary. Specifically, there is no documented nocturnal need for activities of daily living (ADLs) or instrumental activities of daily living (IADLs) that could not be performed during the allotted time. Additional services requested at night would be for supervision. 

The patient has been approved for 16 hours a day  7 days a week of services for a total of 112 hours a week, Personal Care Level 2. The services which were provided at night were mainly for supervision, monitoring and redirecting. Specifically, there are no medically necessary services that are required at night such as frequent turning for an active bedsore or change in the diaper every 2 hours for an active bedsore. The patient is significantly confused from her cognitive disability, however the services provided during nocturnal hours are mainly for supervision and no medically necessary services were noted.

Therefore, the requested service of 168 HRS/WK, 12 HRS x 2 x 7 days (split shift), personal care aide 2 is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal/Other/Pancolitis
Treatment: Inpatient Hospital
The health plan denied the requested inpatient stay as not medically necessary. 
The health plan's determination is overturned.

This is a review for the medical necessity for acute inpatient level of care. This female patient with a past medical history of inflammatory bowel disease (unclear if Crohn's disease or ulcerative colitis), hypertension (HTN) and diabetes mellitus (DM) presented to the emergency room with diarrhea and rectal bleeding. Her most recent colonoscopy showed pancolitis and she was started on Mesalamine. She was hemodynamically stable on presentation and was afebrile. Her abdominal examination revealed tenderness to palpation in the epigastrium without guarding or rigidity. She did have mild anemia, leukocytosis, hypokalemia and hypoalbuminemia.
A computed tomography (CT) scan showed moderate to marked pancolitis. She was admitted as inpatient and started on intravenous (IV) fluids and broad-spectrum antibiotics. Stool studies for infectious pathogens and Clostridium Difficile (C diff) were sent. Her hypokalemia was corrected. Gastroenterology was consulted and recommended sending inflammatory markers and continued supportive care with consideration for starting the patient on biological therapy as an outpatient. During her hospitalization she did not have evidence of hemodynamic instability, nor did she continue to have evidence of ongoing gastrointestinal (GI) blood loss. Her white blood cell count (WBC)  gradually trended down; her antibiotics were discontinued. She was discharged to home with outpatient follow up.
At issue is the medical necessity of the inpatient stay.

I overturn, in whole, the health plan's determination of medical necessity.

Yes, the requested health service/treatment of an inpatient stay is medically necessary for this patient.
Although this patient was hemodynamically stable, she had severe colitis and it was prudent to rule out fulminant UC vs Toxic megacolon from C difficile given her marked leukocytosis. Additionally, she had severe hypokalemia that needed correction.
Ulcerative colitis is a chronic inflammatory disease of the colon; as many as 25% of patients with this disease may require hospitalization. The goals of hospitalization are to assess disease severity, exclude infection, administer rapidly acting and highly effective medication regimens, and determine response. During hospitalization, patients should be given venous thromboembolism prophylaxis and monitored for the development of toxic megacolon. Patients who do not respond to intravenous corticosteroids should be considered for rescue therapy with infliximab or cyclosporine. Patients who are refractory to medical therapies or who develop toxic megacolon should be evaluated promptly for colectomy. Patients who do respond to medical therapies should be discharged on an appropriate maintenance regimen when they meet discharge criteria.
Based on the severity of colitis, the inpatient admission was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Respiratory System
Inpatient hospital

Diagnosis: shortness of breath.
Treatment: Inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is overturned. 

The patient is a man with a history of heart failure who presented with worsening shortness of breath on exertion, bilateral leg swelling, and left greater than right lower extremity edema. He denied chest pain, palpitations, fevers, chills, nausea and vomiting. He also reported gaining 20 pounds over the past week. In addition, the patient had a history of recent lower extremity stenting and bypass and was complaining of paresthesias/burning sensation in his feet. Vital signs showed blood pressure 129/68, heart rate 77, and respiratory rate 20. On physical exam, breath sounds had crackles, heart was regular, abdomen was soft and nondistended. Labs showed sodium 140, creatinine 1.06, potassium 4.8, calcium 8.5, white blood cell count (WBC) 10.1, hemoglobin 9.1, and platelets 368. Chest x-ray showed no evidence of acute one disease. Brain (or B-type) natriuretic peptide (BNP) was elevated at 2128. Troponin was 0.646. The patient was admitted for acute congestive heart failure (CHF) exacerbation. 

The inpatient stay was medically necessary. The patient presented with a significant heart failure exacerbation, required supplemental oxygen, had some evidence of hemodynamic instability with a systolic blood pressure as low as 102 in the emergency department, and had a complex overall cardiovascular profile with peripheral vascular disease and a recent lower extremity bypass with stenting. In addition, he reported a 20 pound weight gain which indicated a relatively severe presentation of acute heart failure. Because of his overall complexity and need for prolonged diuresis, the inpatient hospital admission was appropriate.