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

Digestive System
Inpatient hospital

Diagnosis: Abdominal pain
Treatment: Inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is overturned. 

The patient is a woman who presented to the hospital with worsening abdominal pain that was intermittent over the past two weeks. She denied seeing blood in her stool. She stated that the pain worsened with bowel movements. She rated it as a six out of 10 in severity. Past history included mitral valve repair, and she also drank alcoholic beverages each week. Vital signs showed blood pressure 109/62, heart rate 114, and temperature 99F Fahrenheit. On exam, heart was regular, breath sounds were normal, abdomen was tender in the right lower quadrant and suprapubic regions. Labs showed white blood cell (WBC) 12.7, hemoglobin 11.3, platelets 273, sodium 139, potassium 4.0, and creatinine 0.81. A computed tomography (CT) imaging demonstrated acute sigmoiditis with peri-diverticular phlegmonous collection. There was also concern for right sided pyelonephritis. The patient was admitted for acute sigmoiditis and phlegmon. The plan of care included surgery admission, intravenous (IV) fluids, IV antibiotics, serial abdominal exams, no food by mouth, and pain management. 

The inpatient hospital admission was medically necessary for this patient.
The patient presented with a complex case of diverticulitis. Imaging demonstrated evidence of a phlegmon along with possible pyelonephritis. She required IV antibiotics and was at increased risk of complications such as development of intra-abdominal abscess, particularly considering the initial imaging findings.
A patient with diverticulitis that is complicated by phlegmon and possible pyelonephritis should generally be managed at the inpatient level of care. The risk of development of abscess with need for either a surgical intervention or consultation with interventional radiology is increased in this setting. Hospital admission is usually appropriate for more complicated cases of diverticulitis/sigmoiditis, as in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe Ischemic Cardiomyopathy
Treatment: Inpatient Stay
The health plan denied coverage for the inpatient stay. 
The health plan's determination is overturned.

This case involves a male with a history of chronic systolic heart failure due to severe ischemic cardiomyopathy, mitral and tricuspid valve repairs, coronary artery bypass graft (CABG), ventricular tachycardia (VT) storm, atrial fibrillation, prior stroke, bipolar disorder, dual chamber implantable cardioverter defibrillator (ICD) implantation who underwent elective ICD extraction for displacement of an ICD lead with associated perforation through the right ventricle (RV) touching the sternum. It required laser assistance. Due to concerns for potential complications from the extraction procedure including vascular bleeding, cardiac tamponade, pulmonary embolism (PE), stroke, and death, the patient was admitted post procedure for close monitoring on telemetry, strict bedrest, supplemental oxygen and blood work in the coronary care unit (CCU). The vascular sheath was removed post procedure. Post procedure, the patient experienced hypoxia and tachypnea and bleeding in the left groin. The patient was fitted with a wearable cardiac defibrillator prior to discharge for protection of sudden cardiac death. The patient was discharged in stable condition.
At issue is the medical necessity of the inpatient stay.

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

The inpatient stay was medically necessary. Inpatient telemetry admission for close monitoring after an ICD extraction is medically necessary, appropriate, and in the best interest for the safety of the patient to assess for potential life-threatening complications such as bleeding, pericardial tamponade, stroke, and pulmonary embolism.
I would recommend that the health plan's determination be overturned because inpatient admission for monitoring after extraction of the ICD system is medically necessary, appropriate, and in the best interest for the safety of this patient. This approach is supported by peer-reviewed medical literature and the HRS (Heart Rhythm Society) expert consensus guideline statement on device extraction and management.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcohol withdrawal
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

This male with a history of alcohol abuse presented to the emergency room for evaluation of alcohol withdrawal.  He was reported to be confused.  

Vital signs were as follows: temperature 97, pulse 75, respiratory rate 20, blood pressure 154/97.
Exam at admission was unremarkable.  Laboratory results were as follows:  Sodium 142, potassium 3.8, blood urea nitrogen (BUN)/creatinine 8/.8, white blood cell (WBC) count 7.06, hemoglobin/hematocrit (H/H) 14.3/42.1, Platelets 246.  EtOH (ethyl alcohol) 76.  Ammonia 35.  Urine toxicology test positive for THC (Tetrahydrocannabinol). A chest x-ray had no abnormality detected (NAD).  Electrocardiogram (EKG) showed sinus tachycardia.  

The patient was admitted with alcohol withdrawal syndrome.  Plan of care included IVF (Intravascular Fluid) and CIWA (Clinical Institute Withdrawal Assessment for Alcohol) protocol.  The patient remained hemodynamically stable with no signs of acute withdrawal.  

No, the inpatient admission from was not medically necessary.

This patient was admitted for alcohol withdrawal.  He did not have active comorbid conditions and was hemodynamically stable and afebrile.  He had tachycardia, but no arrhythmia.  He did not have persistent vomiting, delirium, seizures, or gross tremor.  Electrolytes were stable. The patient was admitted with plan for IVF (Intravascular Fluid) and CIWA (Clinical Institute Withdrawal Assessment for Alcohol) protocol.  There were no signs of sever alcohol withdrawal during the hospital stay.  The patient was clinically stable and did not have findings of severe alcohol withdrawal.  He did not have symptoms that required an acute inpatient level of care.  He had not failed management in a lesser level of care.  The requested inpatient admission was not medically necessary.  Withholding the treatment would not reasonably be expected to affect the patient's health adversely.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's Disease. 
Treatment: Remicaide. 

The insurer denied the Remicaide. 
The denial is overturned. 

This is a male child. He had GI (gastrointestinal) symptoms and was recently
diagnosed with moderate to severe Crohn's disease involving large and small
intestine. His physician requested to start Remicade. He has not tried any other
medications. 

Yes, the Remicade treatment is medically necessary. 
NASPGHAN (North American Society For Pediatric Gastroenterology, Hepatology
& Nutrition) Clinical Report and Consensus Statement and treatment guidelines
recommended anti-TNF (tumor necrosis factor) as the choice of therapy for children with moderate to severe Crohn's disease. Infliximab is mostly considered as firstline biological (Bronsky; Bashir; van Rheenen). The recommended dose for moderate to severe Crohn's disease in children: for induction, 5 mg/kg (milligrams per kilogram IV [intravenous] at weeks 0, 2, and 6; for maintenance, 5 mg/kg (milligrams per kilogram [intravenous] IV every 8 weeks.) 

This specific patient was just diagnosed with moderate to severe Crohn's disease. Anti-TNF (tumor necrosis factor) drugs, such as Remicade, would be indicated and is medically necessary based on current treatment guidelines. In clinical practice, Remicade is first choice anti-TNF (tumor necrosis factor) agents in children and Humira is usually used if patient lost response or developed antibodies to Remicade. Thus, the proposed treatment is medically necessary. 

The enclosed clinical criteria may approve Remicade for children six years and older with moderate to severe Crohn's disease and inadequate response to conventional therapy. This patient has not tried and failed conventional therapy. However, recent treatment guidelines recommend top-down therapy with initial biological agents for children with moderate to severe Crohn's disease. Thus, use of Remicade in this patient is medically necessary and the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer. 
Treatment: Radiation Therapy. 
The insurer denied proton beam radiation. 
The denial is upheld in whole.

This patient is a male with a stage IIA nasopharynx mantle cell non-Hodgkin's lymphoma post systemic therapy and surgical debulking. Radiation therapy is now recommended as definitive treatment and proton beam approach is requested. The subject under review is the medical necessity for the therapy requested.

The health plan's determination is upheld in whole.

The requested treatment of proton radiation therapy is not medically necessary for this patient. The recommended proton beam radiation therapy for this patient with a non-Hodgkin's lymphoma of the nasopharynx is not medically appropriate nor necessary. The low doses of radiation needed for this diagnosis can be safely delivered with conventional photon beam radiation. There is a lack of any significant randomized trials published in peer reviewed journals supporting the benefits and safety over conventional photon beam radiation. There are small reports published in medical journals showing the potential benefit of proton radiation for this clinical scenario. However, until significant randomized trials are mature and published showing a benefit over photon radiation, this proton beam radiation recommended is not the standard of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems 
Treatment: Dental/Orthodontic Procedure. 
The insurer denied braces and monthly visit (x12). 
The denial was upheld in whole.

The patient is a male with Skeletal Class II malocclusion. Documentation reveals mild maxillary spacing, mild mandibular crowding, moderate overjet and moderate overbite. The subject to be determined is the medical necessity for braces and 12 monthly visits. The health plan's determination is upheld, in whole. The requested treatment, braces and 12 monthly visits are not medically necessary for this patient. Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 14 with no auto qualifiers. Auto qualifiers include cleft palate deformity or cranio-facial anomaly, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9mm or greater and underbite 3.5mm or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Infectious Disease
Inpatient Hospital

Diagnosis: Bacteremia/Anemia
Treatment: Inpatient Stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a male with a history of diabetes, diabetic nephropathy, neuropathy, and retinopathy, hypertension, and end stage kidney disease who was admitted to the hospital. He had recently been admitted for bacteremia in the setting of a right permacath infection that had since been removed. That afternoon, he was shopping with his son when he suddenly felt dizziness and lightheadedness. He denied palpitations and loss of consciousness. He also reported intermittent fevers and stated he was compliant with medications including his antibiotics. Vital signs showed blood pressure 135/92, respiratory rate 17, and oxygen saturation 98%. Labs showed hemoglobin 7.2, white blood cell (WBC) 10.8, lactate 0.9, sodium 135, and potassium 4.8. On physical exam, heart was regular, breath sounds were normal with no wheezes, abdomen was soft and nontender, cranial nerves were intact, and he had a rash in the right upper extremity. The patient was admitted for symptomatic anemia and concern for fever and infection. 

The inpatient hospital admission was not medically necessary. 
The patient presented with symptomatic anemia and a hemoglobin that was borderline low but responded normally to blood transfusion and had no evidence of active bleeding or G.I. (gastrointestinal) bleeding. He received diagnostic testing and also received dialysis but was hemodynamically stable throughout the hospital stay.
The patient had a hospital stay that primarily included routine dialysis and blood transfusion along with close monitoring of hemoglobin. He was hemodynamically stable and had no evidence of sepsis or new acute affection. The patient could have safely and effectively been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypogammaglobulinemia
Treatment: Hizentra
The insurer denied the Hizentra.
The denial is overturned. 

The patient is a female with a history of frequent infections in childhood and hypogammaglobulinemia.  The request is for approval of immunoglobulin infusion.

Yes, the proposed treatment with Hizentra is medically necessary.

The patient has met the criteria for diagnosis of common variable immunodeficiency disorder (CVID).  According to the lab results, the total immunoglobulin G (IgG) level is 340 milligrams per deciliter (mg/dL) and low immunoglobulin levels such as immunoglobulin A (IgA) and immunoglobulin M (IgM), as well as poor pneumovax vaccine response.  In addition, the patient has a history of childhood infections with pharyngitis and frequent sinusitis.  Given the low levels of immunoglobulins and poor antibody response, the use of immunoglobulin infusion is medically necessary for the treatment of primary immunodeficiency disorder.

Common variable immunodeficiency (CVID) is the most common form of severe antibody deficiency affecting both children and adults.  The diagnosis of CVID requires a history of recurrent persistent infections, a reduced total serum concentration of immunoglobulin G (IgG), and/or low Immunoglobin A (IgA) or immunoglobulin M (IgM), and poor responses to both protein and polysaccharide-based vaccines, and exclusion of other immunodeficiency disorders.  The service (intravenous immunoglobulin [IVIG]) has been shown to be safe and effective for treating primary immunodeficiency as shown by comparative controlled cohort trials in the prevailing peer reviewed medical literature.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems (skeletal Class I, non-vertical growth pattern, maxillary and mandibular spacing, Class III canines, and anterior crossbite).

Treatment: D8080 comprehensive orthodontic treatment of adolescent dentition and D8670 periodic orthodontic treatment visit.

The insurer denied coverage for D8080 comprehensive orthodontic treatment of adolescent dentition and D8670 periodic orthodontic treatment visit.

The denial is upheld. 

This patient is a female child who presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to skeletal Class I, non-vertical growth pattern, maxillary and mandibular spacing, Class III canines, and anterior crossbite. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present to support orthodontic necessity. 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 on the HLD index attaining only 4 points on review by their internal reviewers. 

Upon review of the submitted documentation, (study models were not provided for review), 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, an HLD index is utilized. This 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 crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of gingival attachment loss or gingival recession and therefore does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does not meet the insurer and plan criteria to justify orthodontic care. This reviewer concurs with the HLD index of the insurer attaining 4 points (i.e., 1 overjet, 3 labiolingual spread).

The coverage for D8080 comprehensive orthodontic treatment of the adolescent dentition and D8670 periodic orthodontic treatment visit is not considered medically necessary for this patient.

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

The medical necessity for D8080 comprehensive orthodontic treatment of adolescent dentition and D8670 periodic orthodontic treatment visit is not substantiated.  The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Inpatient Hospital. 

The insurer denied: Inpatient stay.  The denial is upheld in whole.

The patient is a male with a past medical history significant for dementia, chronic obstructive pulmonary disease (COPD), severe aortic stenosis, gastroesophageal reflux disease (GERD), peptic ulcer disease, benign prostatic hyperplasia (BPH), deep vein thrombosis (DVT), and chronic headache who presented from home with complaints of generalized weakness and left-sided tremor that had been going on for 10 days.

When the patient was seen by the admitting physician, he was afebrile, heart rate was 65 beats per minute (bpm), respiratory rate 19, blood pressure 112/73, and oxygen saturation was 98% on room air. The patient appeared to be an elderly male who was in no acute distress. He was lying in bed comfortably. The neck was supple without lymphadenopathy, masses, jugular vein distention (JVD), carotid bruits. Lungs were clear to auscultation bilaterally. The cardiac exam was within normal limits. The abdomen was soft, nontender to palpation, with normal bowel sounds, without guarding or rebound.

Laboratory evaluation revealed that white blood cell count was 6.3, hemoglobin was 11.1, hematocrit was 35.4, and platelets were 182. Sodium was 139, potassium was 4.1, chloride was 108, bicarbonate (HCO3) was 19, blood urea nitrogen (BUN) was 18, creatinine was 0.99, and glucose was 78. Troponin was normal. Liver function tests were within normal limits.
Computed tomography (CT) scan of the head showed no intracranial mass, acute territorial infarct, hemorrhage.

The subject under review is the medical necessity for the inpatient stay. 

The health plan's determination is upheld in whole.

Overall, this patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. The review of the medical records clearly demonstrated that neither the results of the physical exam nor the results of the laboratory studies and diagnostic tests were alarming. The review of the patient's records did not reveal any significant abnormalities that would justify admission at the acute inpatient level of care. Furthermore, the symptoms that brought the patient to the hospital such as tremors were not seen by the admitting physician at the time of the exam. Taking into consideration all these facts, neither the severity of the patient's condition nor the complexity of the services provided rose to the acute inpatient level of care. The patient could have been managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Spina bifida, post laminectomy syndrome.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a female with history of spina bifida and post-laminectomy syndrome who underwent a spinal cord stimulator. The patient presented with tachycardia, right flank tenderness, and computed tomography (CT) showed L2-L3 seroma. The patient was treated with fluids, antibiotics, and pain medications. Neurosurgery was consulted and did not recommended surgery. The patient was eventually found to have a urinary tract infection (UTI) and was discharged on adjusted antibiotics. 

Yes, the patient's inpatient admission was medically necessary. 

The patient had implanted hardware and a concern for infection postoperatively. The patient had adequate work up and treatments in the acute care setting which could not be provided at a lower level of care such as providing intravenous (IV) antibiotics/pain medications and neurosurgery consultation. At the time of initial evaluation, the computed tomography (CT) showed a fluid collection that had the possibility of infection which required further workup. 

The patient presented initially with concerning signs of hardware infection associated with the spinal cord stimulator, she had significant pain that required intravenous (IV) pain medications and the concern for infection necessitated intravenous (IV) antibiotics. The patient's clinical picture dictated that she should be admitted to the hospital and the acute inpatient length of stay was also appropriate for this patient to diagnosis and treat the underlying condition.