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

Diagnosis: Knee Chondral Lesion

Treatment: Consumer Directed Personal Assistance Services, 26.25 hours per week; Consumer Direct, 1 Client.

The insurer denied the Consumer Directed Personal Assistance Services, 26.25 hours per week; Consumer Direct, 1 Client. The denial was upheld. 

This is a male patient with a history of benign prostatic hyperplasia, cervicalgia, insomnia, asthma, muscle spasm, unspecified pain and a right knee chondral lesion; surgical intervention was recommended. It was reported that the patient ambulates with a cane and is able self-hygiene and self-toilet.  He participates in physical therapy and is able to go out of his home as well as drive a car without restrictions. A request was made for Consumer Directed Personal Assistance Services; Consumer Direct, 1 Client 
26.5 hours per week.

The documents submitted report he was to be scheduled for an MRI to his knee. There was no diagnosis nor surgical procedure contemplated at this time. These facts have nothing to do with general assistance at home. 

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. There were no extenuating circumstances to substantiate increased personal care hours. There was no medical condition to warrant increased support. 

Based on the above, the medical necessity for the requested 26.25 hours per week of Consumer Directed Personal Assistance Services; Consumer Direct, 1 Client is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic dermatitis
Treatment: Dupixent 300mg/2ml sc sosy 
The insurer denial Dupixent 300mg/2ml sc sosy.
The denial is upheld.

The treatment with Dupixent is not medically necessary.

The patient is a male with atopic dermatitis, treated with multiple topical steroids and Protopic.  His provider (PA) is requesting Dupixent. 

This patient has not demonstrated an adequate trial and failure to all other standard of care measures for atopic dermatitis. The documentation does not support aggressive topical measures with emollients and wet-to-dry wraps, bleach baths, and phototherapy, which are considered first and second line therapies for eczema.  Systemics such as cyclosporine can also be used in atopic dermatitis.  The appropriate treatments would include phototherapy and oral immunosuppressive medications. 

While oral immunosuppressive medications may not be specifically FDA approved for the treatment of atopic dermatitis, their use is considered standard and well supported in the medical literature. 

Dupixent is not appropriate or medically necessary for this patient at this time.
Appeal type: Medical necessity
Decision: Upheld

Seizures
Inpatient hospital

This is a female with a history of (h/o) seizures (not on medication) who presented to the emergency department (ED) with a syncopal event. She was found by a coworker on the floor with blood-tinged sputum on her blouse. She had a similar episode 1 month prior. In the ED, her blood pressure was 142/55, pulse 90, respiratory rate 20, O2 sat 100% on room air, and she was afebrile. On exam, she was alert and oriented, lung and heart exams were normal, and she was neurologically intact. Her labs were normal and computed tomography (CT) brain negative for acute abnormalities. While in the ED, she had a seizure and was briefly post-ictal.
The patient was admitted to the hospital for seizures. 

The health plan's determination is upheld. The inpatient stay was not medically necessary. According to Emedicinehealth.com, a seizure is considered an emergency when it does not stop within minutes or prolonged confusion remains after the seizure, greater than 10-15 minutes.   These are considered reasons to come to the ER. This patient, while I agree a brief hospitalization for further workup, did not require a prolonged hospitalization. Her care could have been provided at a lower level of care.
This patient did not meet Milliman Care Guidelines as an inpatient for seizures as she was hemodynamically stable, she did not have recurring seizures that could not be controlled in the ED or in an observation period of time, she did not have any cardiac arrhythmias, she did not have a brain disorder such as a mass or bleed, she did not have a focal neurologic deficit, and did not have a significant metabolic derangement.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Uterine fibroids
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

Summary:
The patient is a female with a diagnosis of uterine fibroids and post-menopausal bleeding.  She underwent a robotically assisted laparoscopic total hysterectomy with bilateral salpingo-oophorectomy and cystoscopy. Because of pelvic adhesions, ureterolysis and lysis of adhesions was performed. Estimated blood loss was 1000 cc.

There are many ways of doing a hysterectomy. The trend has been towards less invasive procedures. Conventional and robotic laparoscopy share similar advantages over laparotomy, including decreased morbidity, rapid recovery, and improved aesthetics of incisions. Robotic assisted laparoscopic hysterectomies are outpatient procedures unless a complication arises. Admission becomes necessary if the patient is febrile, hypotensive, bleeding, has difficulty breathing or the severity of the pain is such that admission is necessary.

According to the standard of care, inpatient stay may be needed for:
Surgical complications (bladder ureter or bowel injury or hemorrhage)
Conversion to abdominal surgery
Wound complications
Comorbidities.

This patient did not meet any of these criteria. Her procedure was uncomplicated. There was no evidence of any injury to other organs. Post operative, the patient was stable. Nothing in the operative report or the progress notes suggested any serious problem that warranted admission. A robotic hysterectomy is an outpatient procedure and includes appropriate postoperative monitoring and an overnight stay, if required.

Based on the above, inpatient hospital stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Active osteomyelitis
Treatment: Topical Oxygen Wound Therapy - 96 units
The insurer denied the Topical Oxygen Wound Therapy - 96 units.  The denial is upheld.
The Topical Oxygen Wound Therapy - 96 units is not medically necessary.

The patient is a female patient has had a sacral wound for over a year and a half. She was previously undergone surgical debridement. She has been treated for osteomyelitis as well. Negative pressure therapy has been applied to the wounds. She has also been admitted to the hospital for infections and treated with IV Vancomycin. 

A progress note indicated that the patient had a right knee stage I pressure ulcer, left heel stage I pressure ulcer, right heel stage III pressure ulcer, right hip stage four pressure ulcer, sacral stage four pressure ulcer (1.2x1.5x.8 cm) with 100% granulation, and a left hip stage four pressure ulcer (.2x.2x.5cm with 100% granulation). Offloading, nutrition, dressing changes, negative pressure therapy, home health, and family support were all addressed.  Topical oxygen therapy was additionally ordered to expedite mean healing and reduce the risk of infection as well as pain.    

Progress note indicated the patient has had wound care for over 12 weeks including debridement, collagen, antibiotics, offloading and wet to dry dressings. The wounds were noted to improve (dimensions and quality were not provided) while using topical oxygen therapy. The recommendation was to continue to use oxygen therapy for wound healing and closure for 96 units. 

The patient was prescribed 12 weeks of topical oxygen treatment for (2) stage IV pressure ulcers on the sacrum and left hip.

The NY State DME Guidelines recommend topical oxygen for stage IV pressure ulcers, provided the patient has had an attempt to adequate offload, debridement of necrotic tissue and received appropriate dressings to maintain a moist wound environment. A maximum of 12 days in a 28 day period is recommended. Extension of treatment requires documentation of wound healing, dimensions, and wound quality.  The patient had received at least a month of topical oxygen therapy. Documentation of wound dimensions and quality were not provided. 

The amount of oxygen therapy recommended exceeded the guidelines recommendations. In addition, there is insufficient evidence for the use of topical oxygen and pressure ulcers (non-diabetic related) (Ref 1). The request for topical oxygen from 96 units was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse/addictions
Treatment: Mental health Inpatient
The insurer denied the Inpatient rehabilitation as not medically necessary. The health plan's determination is upheld in whole, the patient did not require inpatient rehabilitation and could have been treated at a lower level of care. 

Based on your responses, the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Level of Care is:
Stabilization Services in a Residential Setting
The patient did not require immediate hospitalization for a life-threatening medical condition or severe psychiatric crisis. Alcohol was the substance with the greatest potential to cause harm to self or others. Patient clearly had a history of alcohol use disorder, meeting criteria for this diagnosis. The patient was not in full remission from a substance use disorder. The patient did not have serious medical symptoms that needed management in an inpatient rehabilitation setting. The patient did not have serious psychiatric symptoms that needed to be managed in an inpatient rehabilitation setting for treatment to be effective. The patient was not noted to be using substances and hazardous situations or in amounts or frequencies likely to imminently cause severe physical or emotional harm to self or others. Patient was reported to have difficulty maintaining stable relationships and employment. There was no evidence of predatory behavior. Patient was not noted to have strong cravings, but did have some past history of behavioral or emotional instability. Inpatient rehabilitation was not medically necessary for this patient. Services could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental issue/orthodontics
Treatment: Orthodontics/braces
Health plan denied: Orthodontics/braces
The denial is upheld in whole.

There is no medical reason to correct the malocclusion with braces. The patient does have a deep bite, however, that alone is not a medical necessity to treat. The photographs do not illustrate any damage to the teeth or soft tissue damage from their current position. There are many ways to correct patients with a deep bite, and there is strong evidence that one treatment is not better than another. Furthermore, deep bites may be corrected in adulthood. The patient has crowding. The bite is slightly deep but there is no indication of damage to the incisors in the photographs, and the cephalometric radiograph shows the lower incisors are contacting the maxillary teeth in occlusion, not the palate. There is no indication from the photographs there is severe soft tissue damage (or any soft tissue damage) on this patient. The patient is an identical twin.
Studies have shown there is the possibility of significant variation between monozygotic (identical) twins in both the timing of their tooth eruption and their dental presentation given the complex interplay of environmental and genetic factors involved in human development. This could easily explain why one monozygotic twin would have more severe orthodontic needs than the other.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gastrointestinal/Ulcerative colitis
Treatment: Pharmacy/Prescription drugs
Insurer denied oral Vancomycin for the patient's IBD based on not medically necessary.
The health plan's denial is overturned in whole. 

The management of pediatric inflammatory bowel disease is very complex and challenging. Patients with very early onset disease, like this patient, have more refractory disease then later onset disease.
The use of oral antibiotics as an adjunct therapy is well established and supported by peer reviewed literature.
Per Breton, Jessica, et al: "Oral combination antibiotics appears to be an effective rescue and steroid-sparing therapy to induce remission in the short term in patients failing a biologic."
Oral vancomycin (OV) is among many oral antibiotics that have been used in inflammatory bowel disease. Oral vancomycin is not absorbed systemically and has no systemic side effects.
The evidence supporting the long term use of oral vancomycin in inflammatory bowel disease is not very solid, however, the available evidence should allow the physicians to use it in refractory and difficult cases.
Lev-Tzion, Raffi, et al; reported a case series of 5 children with early onset inflammatory bowel disease (IBD), who were previously refractory to standard treatments. These patients received oral vancomycin with or without gentamicin. The study results showed that four out of the 5 children demonstrated substantial therapeutic effect, and the effect was sustained in 3 children over a follow-up period of 12-33 months.
Per Ayers, Travis D., et al "POV may be an effective adjuvant treatment for pediatric IBD. Its effectiveness is likely due to a combination of its anti-tumor necrosis factor alpha activity and its influence on the gut microbiome."
Finally, per Ayers, Travis D., et al "Pediatric Ulcerative Colitis Activity Index (PUCAI) scores improved from a pre-OV mean of 26 (range 0-60) to 1.8 (range 0-20) on OV. Twelve of 17 had PUCAI scores improve to 0. Paired fecal calprotectin (FC) were available in 15. Mean FC improved from 1055 pre-OV to 51, all 15/15 normalized to < 200. Fifteen of 17 children had paired colonoscopies pre-OV and on OV. All 15 colonoscopies showed macroscopic normalization on OV to Mayo endoscopic score 0. Overall, there was normalization of histological inflammation in nine patients."
Despite the lack of strong and well-structured prospective evidence, the use of oral vancomycin in refractory cases of inflammatory bowel disease is appropriate. This child has failed many other therapies and was finally controlled on oral vancomycin as an adjunct therapy with Remicade. The patient  failed to wean off the vancomycin on many occasions. Therefore, denying this service is likely to cause harm and disease flares.
The requested service is medically necessary and appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's disease

Treatment: Remicade Injections

The insurer denied coverage for Remicade Injections. The denial is reversed. 

This patient is a male who has Crohn's disease and failed mesalamine.  He was previously treated with Remicade in several years ago but stopped it after losing his insurance.  He was treated with methotrexate but got significant side effects.  He has a rectal fistula.

The American College of Gastroenterology (ACG) has published a Clinical Guideline: "Management of Crohn's Disease in Adults."  For moderate to severe disease, anti-TNF agents are recommended if there is an inadequate response to Methotrexate.  The article also discusses biosimilar anti-TNF agents.  The article states that Biosimilar infliximab is an effective treatment for patients with moderate to severe Crohn's disease and can be used for de novo induction and maintenance therapy. 

This patient has active Crohn's disease with perianal complications.  He has not been controlled with mesalamine or methotrexate and now needs a biologic agent.  Therefore, Remicade is a medically necessary treatment. 

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

The carrier's denial of coverage for Remicade Injections is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Myasthenia gravis. 
Treatment:  Inpatient hospital stay. 
The insurer denied the inpatient stay.  The health plan's determination is upheld. 

The patient is a woman who presented to the hospital for evaluation of juvenile myasthenia gravis.  On presentation to the emergency room, the patient had fatigue, mild generalized weakness, and mild ptosis.  The patient was admitted to the hospital for infusion of intravenous immunoglobulin.  Despite these complaints, the patient was noted to have no respiratory weakness during the admission as noted by a negative inspiratory force of -80 and her gait was recorded as normal/unassisted.

The inpatient hospital admission is under review.

The acute inpatient hospitalization was not medically necessary.  On presentation to the emergency room, the patient was noted to have mild weakness in the legs.  However, she was able to walk independently and without assistance.  Additionally, the patient complained of dyspnea or shortness of breath.  Nonetheless, assessment of her pulmonary function indicated that she had a negative inspiratory force of -80.  This does not suggest any respiratory muscle weakness.

On examination, she was also noted to have mild neck weakness and mild ptosis.  The patient did not require acute inpatient admission for evaluation or treatment of the symptoms.  She did not have any significant laboratory or imaging findings.  She did not have disabling weakness that required transition to an acute rehabilitation facility.  She did not have any other complex nursing needs such as wound changes or lines.  The intravenous immunoglobulin could have been safely administered on an outpatient basis or on an observation basis.  Typically, the total amount of intravenous immunoglobulin required for a myasthenia gravis exacerbation can safely be administered over 2 days.  Nonetheless, the documentation submitted does not clearly support a myasthenia gravis crisis, which is defined as respiratory collapse, severe bulbar weakness, or disabling weakness in the arms and legs.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder
Treatment: Braces.  The insurer denied the Braces.
The determination is upheld.

This is a patient with a Class II occlusion, slightly high overjet and deep overbite. She has moderate maxillary and mandibular crowding. She is treatment planned for 18-24 months of orthodontics to correct her malocclusion. The health plan denied braces as not medically necessary. The provider appealed stating the patient has a traumatic deep bite with severe soft tissue damage. At issue is the medical necessity of braces.

The requested braces are not medically necessary.

The patient has crowding. Her bite is slightly deep but there is no indication of damage to the incisors in the photographs, and her cephalometric radiograph shows the lower incisors are contacting the maxillary teeth in occlusion, not the palate. There is no indication from the photographs there is severe soft tissue damage (or any soft tissue damage) on this patient. There is no medical reason to correct the patient's malocclusion with braces. The patient does have a deep bite, however, that alone is not a medical necessity to treat. The photographs do not illustrate any damage to the teeth or soft tissue damage from their current position. There are many ways to correct patients with a deep bite, and there is strong evidence that one treatment is not better than another (1).
Appeal type: Medical necessity
Decision: Upheld

Dx: Genitourinary /Kidney Disorder
Tx: Home Health Care
Denied: Home Health Care 12 hours per day nursing services
Denial: UPHELD in whole

The patient is a male with end-stage kidney disease (ESKD) secondary to posterior urethral valves (PUV) and is maintained on nightly home peritoneal dialysis (PD). He also has a vesicostomy and receives chronic Gastrostomy (G)-tube feeds. He has the expected complications of ESKD including anemia, acidosis, and secondary hyperparathyroidism / hyperphosphatemia, which are all being managed and treated. He is listed for a kidney transplant.The subject under review is the medical necessity for nursing services - 12 hours per day.

The health plan's determination is upheld in whole.

No, 12 hours per day of nursing services is not necessary for this patient. Families/caregivers routinely provide nightly PD and G-tube feeds for their children with ESKD, once the appropriate training has been provided. Monitoring of weights and blood pressures are done by the families before and after the overnight PD session, but vital sign monitoring during the night is not routinely prescribed or required. In this case, there is no mention of separate cardiac or pulmonary issues (e.g. oxygen need) that would change this recommendation.
There is a high burden of care for families that elect in-home dialysis for their children, but this care can be successfully provided, and these patients usually do not qualify for home nursing care. (1)
Appeal type: Medical necessity
Decision: Upheld

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

The Inpatient admission was not medically necessary for the management of this patient's condition. 

The patient is a female with h/o (history of) diabetes mellitus. She presented to the ED for EGD (esophagogastroduodenoscopy) and Colonoscopy. She has a history of weight loss and anemia and passing streaks of blood in the stool. She had undergone CT chest, abdomen and pelvis as an outpatient that showed lung nodules and renal cyst.

In the ED, the patient was hemodynamically stable and afebrile. Her CBC (complete blood count) revealed Hb (hemoglobin) 10.4 and HCT (hematocrit) 32.4. Her electrolytes and BUN/Cr (blood urea nitrogen/creatinine) were normal. She was admitted and was given IV iron infusion.

The patient underwent colonoscopy that showed rectal mass, and the biopsies were positive for adenocarcinoma. The EGD was normal. She was discharged home and was advised to follow up with PCP (primary care provider) and Hematology/Oncology in one week for port placement for chemotherapy.

The patient presented to the ED with weight loss and was scheduled for EGD/colonoscopy. She was hemodynamically stable in the ED. She was c/o (complaining of) having streaks of blood in the stool for some time, but she did not have severe hematochezia and marked anemia that required any blood transfusion. She was given iron infusion during her hospital stay for mild anemia. She underwent EGD, which was normal. Colonoscopy revealed friable rectal mass, which, on biopsy, was revealed to be adenocarcinoma. She remained clinically and hemodynamically stable and was discharged home on iron and folic acid supplements and advised to follow up with her PCP and Heme/ONC consultant as an outpatient. Given this clinical scenario, the acute level inpatient was not medically necessary, and she could have been safely managed under lower level of care.