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

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient stay. 
The denial is upheld in whole. 

The patient is a male who presented with gasping during sleep and apneas. No sleep study was provided. He is said to have presented with supraglottic edema, with interarytenoid edema and polypoid change in the pyriform sinuses. There is no documentation of respiratory distress. A gastrointestinal evaluation was performed, and esophagogastroduodenoscopy was recommended with a Bravo capsule. Due to the edema, this procedure was to be done under general anesthesia. At the same time the patient had a laryngoscopy with biopsies performed intraoperatively. The procedure was uneventful as was his postoperative course. He was discharged with stable vital signs. 

The health plan's determination is upheld in whole. 

The requested health service/treatment of inpatient stay was not medically necessary for this patient. Preoperatively there is no documentation of hoarseness or respiratory distress. Laryngoscopy with biopsies were uneventful, with no respiratory distress or shortness of breath documented postoperatively. There was no documented bleeding, the patient was able to tolerate liquids orally, and diet was advanced. Pain was controlled, and his vital signs were stable. He was afebrile. Based upon Milliman Care Guidelines (MCG) guidelines and the standard of care inpatient stay was not medically necessary for this patient. 

The patient could have been managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic procedure. 

The insurer denied braces and monthly visits. 
The denial is overturned. 

The patient is a male. He has a Class II malocclusion with spacing and protrusive maxillary incisors. He has a 9 millimeter (mm) overjet. He is treatment planned for orthodontics to correct the spacing and protrusion. The subject under review is the medical necessity for the requested treatment. 

The health plan's determination is overturned in whole. 

The treatment of braces and monthly visits are medically necessary for this patient. 
Teeth #8 and #9 are protruding forward within the dental arch. This makes them more prone to trauma. There is strong medical evidence that the correction of patients with prominent maxillary front teeth can reduce the risk of incisor trauma. According to the provided documentation a letter from the patient's mother indicates that the patient has already chipped his front teeth multiple times. Closing the space present will make the teeth significantly less protrusive. Evidence shows orthodontic treatment will reduce the chances of damage to the maxillary incisors and the associated costs and morbidity of repairing these teeth. Furthermore, there is scientific evidence that oral health quality of life is reduced in patients with 6+mm overjets, which this patient has. For these reasons orthodontic treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis. 
Treatment: Inpatient Hospital Stay. 

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

The patient had a 1 day history of abdominal pain who presented to an outside hospital (OSH) and was transferred to rule out appendicitis. The OSH ultrasound (US) did not visualize the appendix and a transfer for a pediatric surgery consult was done. She received a magnetic resonance imaging (MRI) scan for evaluation which demonstrated a 9 millimeter (mm) appendix with mild edema. She was started on antibiotics and taken to the operating room (OR). The appendix was reportedly edematous without perforation or appendicolith. 

On presentation, her BP was slightly elevated-125/52and her heart rate (HR) was elevated at 143. At the receiving facility, she had a blood pressure (BP) of 129/54 and she had 2 episodes of BP 90/54. 

She was given Tylenol and intravenous fluids (IVF). She had a leukocytosis to 16.9. The pediatric early warning score (PEWS) was 0-1. She had an uneventful laparoscopic appendectomy and the findings were acute appendicitis without perforation. 
The inpatient stay was not medically necessary. The patient underwent an uneventful surgery. The findings were acute appendicitis without perforation. She did not demonstrate significant findings warranting inpatient admission She would have been appropriate for treatment at a lower level of care. The literature supports same day discharge (SDD) in safety as well as parental satisfaction for pediatric patients (1). In addition, SDD after laparoscopic appendectomy in pediatric patients was not associated with an increased risk of 30-day hospital admission or complication rate. Protocols to expedite perioperative care, including standardization of intraoperative care, may facilitate same-day hospital discharge, resulting in a decrease in health care costs. (2) Implementation of an ERAS protocol to reduce postoperative nausea was found in a study of 691 children to decrease the need for inpatient beds by 45% (3).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class I Occlusion.
Treatment: Braces and monthly visits.
 
The insurer denied Braces and monthly visits.  The health plan's determination is upheld.

The patient in question is a female with a Class I occlusion with 4 millimeter (mm) overbite and 3 mm overjet. She has maxillary and mandibular crowing. She is treatment planned for 18-24 months of orthodontics to correct her malocclusion.

Under review is the medical necessity of Braces and monthly visits.

Braces and monthly visits are not medically necessary. There is no medical reason to correct her malocclusion with braces. While the patient has crowding, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. This patient presents with none of those conditions. Aligning her teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion. The patient's overjet is slightly more than ideal but her overjet would not affect oral health related quality of life unless it was greater than 6 mm (millimeters).

If her teeth were aligned it would provide a minor esthetic improvement, but it would not create a medically significant improvement to the patient's health. Orthodontic treatment is not medically necessary. The doctor and the patient's teacher have supplied a narrative that the patient has tooth pain, and according to her teacher she requires dental surgery. There is no indication of an orthodontic reason that the patient would be having this pain from the records provided. Perhaps it is due to the wisdom teeth, and extraction of these teeth should be considered to help resolve her dental pain.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Genetic Diseases/Sickle Cell Disease.
Treatment: Inpatient Hospital.
The health plan denied the requested inpatient hospital stay. The health plan's. determination is overturned.

The patient is a female who was admitted to the hospital for a sickle cell crisis. She has a history of sickle cell anemia. On presentation she had severe diffuse pain. Her hemoglobin was 9.3; lactate dehydrogenase (LDH) and bilirubin were elevated. She was given intravenous (IV) fluids as well as IV Morphine for the pain crisis. She was continually managed with IV fluids and IV pain management for the duration of the admission. Her condition improved and she was discharged in stable condition.
The question at hand is whether the patient met medical necessity for the acute inpatient level of care.

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

The patient in question does meet medical necessity for the acute inpatient level of care per current literature and standard of care. According to Rees et al., (2010), Smith et al., (2008), and Alexander et al., (2004), the patient's clinical presentation was consistent with a sickle cell crisis and required inpatient management with IV fluids and pain control until the crisis resolved. Lab-work was consistent with a sickle cell crisis. The patient would not have been appropriate for the observation level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Grandparent of Ashkenazi Jewish descent
Treatment: Genetic Testing (Codes: 81212 and 81162), Pre-service
The insurer denied the Genetic Testing (Codes: 81212 and 81162), Pre-service.
The denial is upheld.

The patient is a female without a personal history of cancer. She has a grandparent of Ashkenazi Jewish descent and was recommended to undergo BRCA (Breast Cancer Assessment) testing.

No, the proposed genetic testing was not medically necessary.

The proposed testing is not medically necessary since the patient does not have any personal history of cancer and her relative of Ashkenazi Jewish descent does not have a known cancer history either. There are no data from peer reviewed literature to support that testing for BRCA genes in this case would improve health care outcomes, it is not standard of care and it is not supported by professional organizations.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Varicose Vein
Treatment: Vein Treatment (Endoluminal Ablation) - Code: 36475, Pre-service
The insurer denied the  Vein Treatment (Endoluminal Ablation) - Code: 36475, Pre-service.
The denial is overturned.

This patient presents with recurrent right leg venous insufficiency symptoms several years after a "vein stripping" procedure. His current duplex demonstrates reflux in the right greater saphenous vein (GSV) from the groin to the knee. The provider has recommended ablation of the right greater saphenous vein.

Yes, the proposed vein treatment (endoluminal ablation) is medically necessary.

In order to determine the medical necessity of the procedure (CPT 36475, endovenous ablation), widely accepted published criteria have been utilized.

Under widely accepted criteria [1-7], endovenous ablation of an axial saphenous vein is medically necessary when:
1) The patient has venous insufficiency symptoms severe enough to affect normal function. 2) The patient has failed a trial of prescription compression stockings. 3) The patient has duplex-proven reflux affecting the vein in question and the reflux can be reasonably construed as a cause of the patient's symptoms.

Requirement number (#) 1 has been met. The office notes and appeal letter state that the patient has swelling, itching and burning. The appeal letter describes in detail the adverse impact of these symptoms on the patient's job (he is an attorney).

Requirement #2 has been met. The office note states that compression stockings "have not deviated his symptoms". The submitted documents include a receipt showing that the patient ordered stockings online. The appeal letter reiterates that the stockings have not been helpful and that the patient has used them for several years. 

Requirement #3 has been met. The venous reflux study showed severe enlargement (7.4 millimeters) and severe reflux (2.6 to 5.0 seconds) in the right greater saphenous vein.

Therefore, the patient meets published, well-accepted criteria for the proposed ablation therapy.

The denial letter overlooks information showing that the patient has tried and failed a long trial of compression stockings.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain and dyspnea. 
Treatment: Inpatient admission.
The insurer denied coverage for the inpatient admission.
The denial is upheld. 

This is a female patient with a history of chronic obstructive pulmonary disease (COPD) on home oxygen, obstructive sleep apnea (OSA) on continuous positive airway pressure (CPAP), obesity, diabetes mellitus, hyperlipidemia, current tobacco use, heart failure, and bipolar disorder. Her home medications included atorvastatin, carvedilol, lisinopril, metformin, and oxygen 2 liters via nasal cannula. She was brought to the Emergency Department (ED) by a family member with complaints of dyspnea for several hours and transient left sided chest pain which spontaneously resolved, as she was not certain whether her oxygen tank was depleted. She described lying in bed and suddenly feeling unwell with chest tightness and dyspnea, as though she was having an anxiety attack, and then checked her oxygen saturation which was "in the 80s". She also related that she had several prior hospitalizations at other facilities for similar symptoms. The patient was admitted as an inpatient for hypoxia and sepsis. Consultations included Cardiology and Psychiatry. Sepsis and pneumonia were ruled-out. The patient's condition was stabilized, and she was discharged home with short steroid taper, short course antibiotics, and Lasix. At discharge, her symptoms were felt to be related to a combination of acute on chronic diastolic heart failure and exacerbation of COPD.

There is no evidence that this patient was at increased risk for short term adverse cardiovascular events requiring inpatient monitoring and management, based on her clinical presentation, results of initial testing, and response to treatment provided shortly after presentation. There is no evidence that this patient required an acute inpatient level of care to determine that her chest discomfort and dyspnea were not related to acute coronary syndrome or to hemodynamically unstable acute heart failure. Evaluation and treatment should have been completed in the ED or at an observation 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 admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Genitourinary/Kidney Disorder/Urinary Tract Infection/UTI.
Treatment: Inpatient Hospital stay.

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

The patient is a male with a history of stroke, atrial fibrillation on Eliquis, non-ischemic cardiomyopathy, chronic kidney disease stage III, and hypertension, who presented to hospital after being found unresponsive at home by his family. His family witnessed the patient experiencing sudden loss of consciousness. He was unresponsive to sternal rub. In the emergency department (ED) he was noted to have altered mental status, but denied chest pain, fever, or dyspnea. He was afebrile and normotensive. On physical examination he was confused, but oriented to person. He had equal strength in all four extremities. His creatinine was elevated to 1.34 (baseline 1.5). His white blood cell count (WBC) was elevated at 11.2. Troponin was mildly elevated at 0.367. An electrocardiogram (EKG) showed non-specific  changes. His urinalysis was cloudy and positive for 3+ leukocyte esterase and elevated leukocytes. A computed tomography (CT) of the head was negative for acute pathology. His chest x-ray was negative for acute pathology. He was admitted to the hospital for altered mental status, query syncope, and a urinary tract infection (UTI). He was thought to have probable demand ischemia. The plan was to admit on telemetry and trend his troponins. He was started on Ceftriaxone for the UTI, and urine cultures were sent. Following admission the patient was noted to be agitated and still confused, being still unable to provide a history. His encephalopathy was thought to be secondary to his UTI and Ceftriaxone was continued. The patient's mental status returned to baseline. He was discharged home on oral antibiotics and with home care services at that time.

At issue is the medical necessity of the inpatient stay.

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

Yes, the inpatient stay was medically necessary for this patient.  He met Milliman Care Guidelines (MCG) inpatient criteria for admission owing to persistent altered mental status (AMS).  The AMS was likely secondary to his urinary tract infection (UTI).  UTIs can present in elderly patients as confusion or behavioral disturbances.  This patient's urinalysis was consistent with a UTI and intravenous (IV) antibiotics were appropriate while he was confused.  This state of confusion continued the following day, being associated with agitation at that time.  This indicates persistence of his AMS.  Fortunately, his mental status improved to baseline, and he was discharged.  However, it could not be assumed earlier that he would improve within 48 hours of admission.  In addition, this patient's extensive medical history made it prudent to monitor him closely at an inpatient level. The safest course of action was to monitor this patient on telemetry in an inpatient setting where staffing would be adequate to handle any such complication.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders. 
Treatment: Pharmacy/Prescription Drugs. 

The insurer denied Ilumya.  The denial is upheld.

The patient is a female with moderate to severe psoriasis (15% body surface area involvement) of the elbows, upper/lower extremities, hands, feet, back, and torso. The patient has tried and failed topical Enstilar, Taclonex, Topicort, Tazorac, Dovonex, and Ultravate.

The subject under review is the medical necessity for Ilumya is under review for medical necessity.

The health plan's determination is upheld.

The requested Ilumya is not medically necessary for this patient.

The patient has no documented treatment failure with, or true medical contraindication to, standard, first-line systemic therapies such as either Methotrexate, Acitretin, and/or Phototherapy. The patient also has no documented treatment failure with, or true medical contraindication to, second-line systemic therapies such as Cosentyx or Otezla. Therefore, the requested Ilumya is not medically necessary.

Modern dermatology literature [1-4] supports use of the health plan preferred medications as similarly efficacious to the requested Ilumya, particularly for a patient with a limited history of systemic psoriasis therapy previously utilized and recommend use of these preferred agents as appropriate for this patient's clinical scenario. Therefore, as per current medical standards of care, Ilumya is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal.
Treatment: Pharmacy/Prescription Drugs.
The insurer denied: Stelara 90 mg every 4 weeks.
The denial is overturned.

The patient is a male. He has a history of refractory and severe Crohn's disease (CD). He has tried and failed numerous treatments, including Remicade, Humira, Entyvio and steroids. He was started Stelara at the standard dose, however, he continued to have active symptoms.
The requested service is Stelara dose escalation to 90 milligrams (mg) every 4 weeks. This is now under review for medical necessity.

The health plan's determination is overturned.

Dose escalation is often required in biologics in order to achieve therapeutic levels and maintain clinical remission. There are many peer reviewed literature reports showing that low Stelara levels were associated with poor clinical response. The requested dose of 90 mg every 4 weeks is proven to be effective in patients who fail the standard dose.
Per Ollech, Jacob E., et al. "Shortening the ustekinumab 90 mg dose interval to 4 weeks for patients with CD who did not respond to doses every 8 weeks improved clinical and biological indices of disease activity. Patients who lose response to the standard dose of ustekinumab might benefit from dose interval shortening, which was effective and safe."
Per Cohen, Erica et al. "A majority of patients with moderate to severe CD benefited from ustekinumab (UST) dose escalation suggesting the clinical utility of optimizing dosing in the treatment course. "
This patient has a history of refractory Crohn's disease which failed anti-tumor necrosis factor alpha (Remicade and Humira), Entyvio and steroids. He also failed to respond to Stelara standard dose (90 mg every 8 weeks) and continued to have an active disease. He is at risk of disease complications if not treated adequately.
Therefore, dose escalation is the only appropriate option for this patient and is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cogan's syndrome.
Treatment: Kineret.
The insurer denied Kineret. 
The health plan's determination is overturned. 

The patient is a female with a history of Cogan's syndrome followed by rheumatology and an ear, nose, and throat (ENT) specialist with presentation of recurrent autoimmune sensorineural hearing loss and history of recurrent autoimmune eye disease including keratitis and uveitis. She had responded to high doses of steroids in the past. Previous trials of methotrexate, leflunomide, Humira, and Cellcept. Intratympanic steroid injections have been ineffective as steroid sparing agents. The patient was given a trial of Kineret (IL-1 inhibitor). She showed clinical improvement in her hearing and was able to taper down the high of steroids. The patient's rheumatologist and ENT specialists are requesting approval of Kineret as she had responded to this treatment. This is the subject under review.

Kineret 100mg/0.37ml Syringe is medically necessary for this patient.
This is a unique case of a rare autoimmune disease/ Cogan's Syndrome that has failed to respond to traditional immunosuppressive therapy with Methotrexate, leflunomide, Humira, CellCept, intratympanic steroid injection. Kineret has been considered as a potential treatment option for these patients. In this case according to the notes, the patient did respond to Kineret Therapy and was able to taper down the high dose of prednisone. Due to the fact that the patient did respond to IL-1 blockade better than other modes of immunosuppression, Kineret is medically necessary. Since this is a rare disease there are not many society guidelines available for its treatment.