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

Diagnosis: Transient Ischemic Attack
Treatment Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay
The determination is upheld.

The patient was sent to the emergency room from a rehabilitation facility after she developed slurred speech and right-sided weakness after taking oxycodone. Her medical history is significant for hypertension, sickle cell disease, and necrosis of the right hip. The patient had a total hip replacement and this was the indication for admission to a rehabilitation facility. On arrival to the hospital, the patient was mildly hypertensive and noted to have confusion, dysarthria, and now generalized weakness. A computed tomography (CT) scan of the head did not show any acute process. A computed tomography (CT) perfusion was unremarkable. An electrocardiogram (EKG) showed normal sinus rhythm. The patient was noted to have baseline anemia consistent with sickle cell disease. She was admitted to the hospital for further evaluation of a transient ischemic attack (TIA). Vessel imaging was significant for an unruptured saccular aneurysm of the distal left internal carotid artery that was unrelated to her present complaints. The patient was later evaluated by physical therapy and ambulated 75 feet with a rolling walker with an antalgic gait and a circumductive pattern on the right side consistent with recent hip replacement. The patient was subsequently discharged back to rehabilitation. At issue is the medical necessity of an inpatient stay.

The requested inpatient stay was not medically necessary for this patient. She was sent to the hospital after an episode of confusion and right-sided weakness after taking oxycodone. In the emergency room, the patient was noted to have generalized weakness rather than right-sided weakness. She had a persistent neurologic deficit in the right leg due to a recent hip surgery. A CT scan of the head and vessel imaging of the head did not show any acute process. The patient was noted to have a small incidental aneurysm of the left internal carotid artery. This was not treated on this admission. The patient was subsequently discharged back to rehabilitation. The patient did not have any new neurologic deficits and the neurologic deficits that were present were not likely due to a cerebrovascular origin but instead the affective a drug. TIA is customarily evaluated in the observation status while any diagnostic imaging is being performed. By definition, TIA does not have a permanent neurologic deficit.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Genitourinary. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient admission. 
The denial is upheld.

The patient is a female with a history of atrial fibrillation (A-fib) who presented with right flank pain and hematuria. She presented to an outside hospital a week prior with similar symptoms. She was found to have a right kidney stone but no intra-ureteral stone and no diagnosis of infection. She was supposed to follow up with urology for a ureteroscopy, but her cardiologist did not want to her to stop her anti-coagulation in the setting of a recent abnormal positive stress test. She denied fever, chills, dysuria, vomiting, chest pain, or shortness of breath. She noted her flank pain was moderate in severity and radiated to the groin. Her vitals showed that she was afebrile with a heart rate of 77, a blood pressure of 133/85, and a room air pulse oximetry of 97%. Labs showed a white blood cell (WBC) of 6.2, a hemoglobin of 11.9, and a creatinine of 0.61. She was admitted for further management. Her Xarelto was held, and she underwent a cardiac catheterization which showed normal coronary arteries, She was discharged in stable condition and her Xarelto was restarted. The subject under review is the medical necessity for the hospital admission.

The health plan's determination is upheld.

The hospital admission was not medically necessary based on the documentation provided. The patient presented with persistent hematuria in the setting of Xarelto therapy for A-fib and a known right kidney stone. The patient was hemodynamically stable, she did not have evidence of acute kidney injury, bilateral ureteral obstruction or obstruction of a unilateral kidney. There was no documented complicated urinary tract infection. The patient did not have any symptoms of acute cardiac ischemic, respiratory distress, or severe cardiac arrhythmias. The patient did not have severe or persistent pain, nausea, vomiting or changes in mental status. The patient did not have severe hematuria requiring inpatient management. The patient did not undergo an inpatient procedure or require inpatient monitoring after an outpatient procedure. The patient could have been safely and effectively managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Symptomatic Prolapse
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay
The determination is overturned.

The patient had a symptomatic prolapse who underwent robotic assisted supracervical hysterectomy, sacro-colpopexy and posterior repair. The patient had no significant past medical or surgical history. Her postoperative course was complicated by tachycardia and lactic acidosis. Critical care was consulted and the patient was admitted to hospital. The tachycardia and acidosis was diagnosed as related to hypovolemia. Volume replacement improved the patient's condition. At issue is the medical necessity of an inpatient stay.
An inpatient level of care was medically necessary in this patient.
This patient's surgery completed and she was noted to be tachycardic soon after. She was noted be acidodic. Critical care was consulted, she was evaluated and an echocardiogram (echo) was performed. A diagnosis of hypovolumia was made based on the echocardiogram. The patient received volume boluses. A further bolus was recommended after the echo. She was noted to be improved per the progress note. Under normal circumstances, a patient would be ready to be discharged from outpatient surgery at around the 4 hour mark while this patient was still under distress. She was still being evaluated by the critical care team which justified the admission based on the current standard of care.
She did not have a normal postoperative course. As outlined above, she was still under physical stress at 4 hour mark from her surgery when a normal outpatient case would usually be discharged. Her medical condition improved rapidly after simple treatment and correct diagnosis. There was no clear way for her medical team to predict this and therefore admitting her was the correct decision made by her care team.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic dermatitis.
Treatment: Dupilumab (Dupixent) SC (subcutaneous) Injection to treat Atopic Dermatitis.
The insurer denied coverage for Dupilumab (Dupixent) SC Injection to treat Atopic Dermatitis.
The denial is overturned. 

This patient is a female child with atopic dermatitis. She was noted to have atopic dermatitis which affected 40% of her body. She was prescribed 2.5% hydrocortisone valerate, oral cetirizine, and Keflex. She was advised to take bleach baths and to use moisturizers. In a follow-up visit, the child was noted to have worsened atopic dermatitis from head to toe. 

This child has severe atopic dermatitis (AD) involving most of the body, including the face, despite use of a medium potency corticosteroid cream. According to UpToDate, for children of a certain age "with refractory AD for whom phototherapy is not accessible or impractical, we suggest dupilumab therapy rather than other immunosuppressive therapy." This would be appropriate treatment for this child. It is also unlikely that adding tacrolimus ointment would give the type of favorable response that dupilumab would. Phototherapy would be problematic for atopic dermatitis involving the face and other ultraviolet (UV) sensitive skin areas. Use of cyclosporine, azathioprine and methotrexate would necessitate careful monitoring for adverse effects. This would not be the case for dupilumab. 

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

The medical necessity for Dupilumab (Dupixent) SC ( subcutaneous) Injection to treat Atopic Dermatitis is substantiated.  The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multiple knee injuries.
Treatment: Physical therapy services.

The insurer denied coverage for the physical therapy services.  The denial is overturned. 

This is a male patient with multiple knee injuries that required several knee surgeries.  The patient has a surgical history of left knee arthroscopic anterior cruciate ligament (ACL) reconstruction with bone patella tendon bone, medial meniscal repair and debridement of medical femoral condyle. He also has a surgical history of left knee arthroscopic partial medial meniscectomy. He sustained a left knee ACL rupture while playing soccer. He underwent surgical bone patella tendon bone autograft of the right knee taken as the autograft for the new left ACL. The patient received post-surgical physical therapy. 

The physical therapy services provided during the dates under review were clinically appropriate and medically necessary. The patient has a history of multiple knee surgeries and underwent extensive surgical procedures. The physical therapy notes adequately document the functional impairments, treatments provided and resultant functional improvements. The outlined therapeutic exercises and activities are sufficient to support the continuation of the current treatment plan as requiring the skills, performance or supervision of a qualified healthcare provider.  

From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, the physical therapy services were medically necessary.

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

The medical necessity for the physical therapy services is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Herpes simplex virus type 2 (HSV-2) encephalitis.
Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.  The denial is overturned. 

This is a female patient who presented to the Emergency Department (ED) with headaches of 1 week duration and fever. Computed Tomography (CT) of the head showed no acute infarct, Magnetic Resonance Imaging (MRI) of the brain showed chronic changes. She was admitted for concern of possible abscess. A lumbar puncture (LP) was positive for herpes simplex virus (HSV) encephalitis. Cerebral Spinal Fluid (CSF) showed total protein of more than 200. The patient was diagnosed with HSV type 2 (HSV-2) encephalitis. 

The patient presented with a complaint of headaches and history of fever. The LP showed an elevated white blood cell (WBC) count and elevated protein consistent with HSV encephalitis. She was treated with intravenous (IV) acyclovir. The course was complicated by seizure and respiratory arrest that required intubation and care in the Intensive Care Unit (ICU). She had a severe life threatening, neurologic condition that required hospitalization including treatment in the ICU.

"Prompt treatment of individuals with herpes simplex encephalitis is important as it improves the efficiency of treatment options. Treatment with the antiviral drug Zovirax (acyclovir) has resulted in a dramatic improvement of symptoms in most individuals with herpes simplex encephalitis. It is manufactured by GlaxoSmithKline. Another antiviral drug that has been used to treat herpes simplex encephalitis is vidarabine. However, antiviral therapy may not benefit affected individuals in advanced stages of the infection. Antiviral therapy should be started as soon as herpes simplex encephalitis is suspected. Seizures that are often associated with herpes simplex encephalitis may be treated with drugs that reduce, prevent, or suppress seizures (anticonvulsants)" (National Organization for Rare Disorders (NORD)).

"Autoimmune encephalitis is a clearly identified complication of HSV encephalitis. Inflammatory mechanisms are linked to the clinical presentation as well as severity and poor outcome. Initial corticosteroid therapy has to be evaluated in order to prevent complications" (Stahl & Mailles).

The health care plan did not act reasonably and 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: Overturned

Diagnosis:  Type One Diabetes mellitus (T1DM) with Diabetic Ketoacidosis (DKA). 
Treatment:  NovoLog.

The insurer denied NovoLog.  The denial is overturned in whole.

The patient is female diagnosed with type one diabetes mellitus (T1DM) with diabetic ketoacidosis (DKA). This request is for NovoLog. As reported; she cannot take the plan alternative Aspart, since she is using a pump that requires a NovoLog. She is using Tandem T-slim X2. She has been well managed on NovoLog in the past. She does have hypoglycemic awareness. She experiences hunger and jitteriness during episodes of hypoglycemia. She does have a continuous glucose monitor (CGM); Dexcom G6 and is using it consistently; she is currently using a Freestyle Libre meter and checks her blood glucose (BG) 4+ times per day. The subject under review is the medical necessity for NovoLog.

The health plan's determination is overturned.

The treatment with NovoLog is medically necessary for this patient.

There are no studies demonstrating superiority of one rapid acting insulin analog over another (1-4) for patients using injections. Insulin pumps are devices that deliver insulin automatically. They are studied with different kinds of insulin, and Food and Drug Administration (FDA) approved for use with different kinds of insulin. There are only certain insulins that have been studied in the patient's Tandem T-slim X2 insulin pump. These are brand-name Humalog and brand-name NovoLog. The generic formulations have not been studied and are off label. The denial was based on the fact that the patient has not tried generic Aspart. This pump is not FDA approved with this kind of insulin. There are no safety or efficacy studies. It cannot and should not be used in this pump. 

The requested insulin NovoLog is therefore medically necessary over the plan alternative.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Autoimmune encephalopathy.
Treatment: IVIG (Gammagard) and Rituxan.
The insurer denied IVIG (Gammagard) and Rituxan.
The determination is upheld.

The patient has a medical history of seizures on Vimpat who presented to the hospital for seizures/status epilepticus with a "lesion" in the right occipito-temporal region. Because of the patient's age and onset of seizure, she was diagnosed with autoimmune encephalitis. The cerebrospinal fluid work-up was "negative". Autoimmune testing such as antineutrophil cytoplasmic antibodies (ANCA), cerebrospinal fluid (CSF) immunoglobulin G (IgG), and oligoclonal bands were negative. At issue is the medical necessity of IVIG (Gammagard J1569) and Rituxan (J9312).
This is not medically necessary. Based on the documentation provided, there is insufficient documentation to conclude that the patient has an autoimmune encephalitis. Markers of systemic autoimmunity are negative. The results of an autoimmune epilepsy panel are pending or not available. The cerebrospinal fluid is negative. As such, it is unclear what criteria were used to establish a diagnosis of autoimmune encephalitis and thus propose a treatment plan. Based on the documentation, the member had a pre-existing diagnosis of seizure and then had worsening seizure cluster. As there is no causative auto-antibody identified or other marker identified, controlled studies are lacking to show that the drugs of IVIg or ritxuimab are safe or effective for treatment of the patient's condition. Therefore, it cannot be determined that the requested drugs are clinically appropriate or required for the direct care and treatment of the patient based on the information provided and therefore, the requested treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal-Appendicitis.
Treatment: Inpatient Hospital stay.
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld in whole the health plan determination.

The patient is a previously healthy male who presented to the hospital  with a history of progressively worsening abdominal pain of 1-day duration. His evaluation included physical examination, labs, and computed tomography (CT) scan. He was without fever at the time of presentation. Lab data identified an elevated white blood cell (WBC) count of 15.9 thousand. CT scan yielded the diagnosis of appendicitis. Treatment was initiated with intravenous (IV) fluid and antibiotics. Surgical consultation was obtained.
The patient underwent laparoscopic appendectomy. The clinical notes and the anesthetic record indicate an uncomplicated appendectomy. He was provided IV fluid and perioperative antibiotics. Vital signs remained normal throughout the hospitalization without fever. Diet was advanced and pain management was converted to oral medications. He was discharged home the next day.

The submitted clinical documentation does not support the need for inpatient admission for this patient. The patient presented with abdominal pain and underwent uncomplicated appendectomy. A lower level of care would have satisfactorily provided for the care provided and would have been consistent with the accepted standard of medical care. This lower level of care would also provide for overnight monitoring and care. The patient was clinically stable at the time of presentation and remained so during the course of care. A lower level of care would have provided for presurgical assessment, serial examination, operative treatment, and post-surgical monitoring. Generally accepted guidelines / criteria indicate that in the absence of hemodynamic instability, sepsis or toxicity, significant electrolyte imbalance, bleeding, gastrointestinal obstruction or surgical complications the procedure may be performed with a lower level of care. In this case the patient tolerated oral hydration, diet and medication and pain was well controlled. A lower level of care would have appropriately provided for presurgical assessment, laparoscopic appendectomy, and post-surgical monitoring. Inpatient care was not required or medically necessary in this case per generally accepted medical standards.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: back pain
Treatment: Consumer-Directed Personal Care Assistance Services
The insurer denied Increase in Consumer-Directed Personal Care Assistance Services (CDPAS) to 7 Days per Week, 8 Hours per Day (Total of 56 Hours per Week). The health plan's determination is overturned. 

The patient is a male with past medical history of chronic severe pain, hypertension, diabetes mellitus type 2, epilepsy, herniated spinal discs, spinal stenosis, spondylosis with radiculopathy, osteomyelitis of the right tibia, chronic regional pain syndrome, diabetic peripheral neuropathy, bilateral knee arthritis, history of intracranial hematoma post motor vehicle accident (MVA) with residual cognitive impairment and memory loss, chronic insomnia, chronic fatigue, diabetic retinopathy, macular edema, depression, anxiety and urinary incontinence with neurogenic bladder who had been assigned (CDPAS) Consumer-Directed Personal Care Assistance Services. The patient was assessed at maximum assistance with task of meal preparation and ordinary housework while extensive assistance with tasks of shopping, bathing and dressing lower body. The patient was assessed at limited assistance with tasks of transportation, equipment management, phone use, dressing upper body, toilet use, and eating while supervision with tasks of managing finances and managing medication. 

The Increase in Consumer-Directed Personal Care Assistance Services (CDPAS) to 7 Days per Week, 8 Hours per Day (Total of 56 Hours per Week) is medically necessary for this patient. 
The patient's PCP (Primary Care Provider) provided a letter outlining the patient's current functional deficits related to osteomyelitis of tibia and dominant arm limited mobility. The patient has documented worsening in his functional status and the telephonic assessment tool performed underestimated his assistance needs with multiple tasks, including walking, locomotion, transfer toilet, toilet use, and bed mobility. There were no specific notes in either assessment indicating the patient's assistance needs or his abilities to perform tasks independently. The patient's PCP recommended 8 hours/day, 7 days/week. The increase in hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs/ Instrumental activities of daily living (IADL). Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAS services 8 hours/day, 7days/week, to total 56 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in his own home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems (skeletal Class I, maxillary spacing, deep impinging overbite and overjet). 
Treatment: Dental braces (code D8080).
The insurer denied coverage for dental braces (code D8080).
The denial is overturned. 

This is a female patient who presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to skeletal Class I, maxillary spacing, deep impinging overbite and overjet. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage. 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 significant malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires the use of an orthodontic index. The HLD index provides 6 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 claims an automatic qualifying condition of deep, impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care.

Dental braces (code D8080) are considered medically necessary for this patient.

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

The medical necessity for dental braces (code D8080) is substantiated.  The insurer's denial should be overturned.