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

Diagnosis: Hyperglycemia

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is overturned.

This is the case of a male child who presented to the Emergency Room (ER) via ambulance after his mother noted a finger stick blood sugar of 500. His mother reported the patient had increased tiredness, sleepiness, thirst, and urinary frequency. The patient did not follow a specific diet and his mother noted that he had been eating sugary food. In the ER, he was found to have a high blood glucose level (428) and a positive novel corona virus disease-19 (COVID-19) test, even though he did not display symptoms of infection. Intravenous fluids were initiated and insulin was administered. Endocrinology admitted the patient for evaluation and treatment of hyperglycemia and COVID-19 infection. The patient was started on long- and short-acting subcutaneous insulin. Infectious disease service prescribed a 2-day course of intravenous Remdesivir as the patient was in a high-risk group (asthma and diabetes). The patient and his mother received diabetic teaching. He was discharged home two days later and instructed to quarantine for an additional 11 days.

Diabetes education consists of several components, including nutritional counseling, self-monitoring of blood glucose, and treatment of hyper and hypoglycemia. The standard of care is that all patients with diabetes should receive all these components. [1, 2]

Practice patterns differ depending on the availability of educators, and so on. Whether a patient gets hospitalized for intensive insulin therapy initiation depends on the available program where the patient is seen.

The patient presented with severe hyperglycemia and ketosis needing initiation of insulin and diabetes education for insulin administration, using an insulin to carbohydrate ratio, using an insulin sensitivity factor, nutrition education to count carbohydrates, and adjusting the diabetes regimen, clearing the ketones and hydrating the patient. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.

The health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient as the request is medically necessary as described below.

The insurer's denial of coverage for the inpatient is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Injury of Face

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld. 

This is the case of an adult male with a medical history of hypertension, sigmoid volvulus, left colectomy, chronic back pain, right knee replacement, and substance and alcohol abuse. He presented to the emergency room (ER) after being punched in the face and right shoulder during an attempted mugging. The patient was transferred to a hospital floor under the care of the Oral Surgery service in anticipation of surgery. The patient was cleared for the operating room (OR), where both old and new mandibular fractures were repaired. He was discharged home. The appeal letter has multiple Milliman Care Guidelines (MCGs) for admission, but does not document any of the criteria that are met. 

A study of patients who underwent orthognathic surgery at Massachusetts General Hospital found that individual variables associated with duration of length of stay (LOS) are complexity of the orthognathic procedure and type of fixation used. In the multiple logistic regression model, LOS decreases significantly when rigid fixation, hypotensive anesthesia, and perioperative steroids are used in combination. Almost all patients receive this protocol today and as a result, an ambulatory setting is used.

The patient was admitted, but not treated until days later. There is no reason given for the extended delay in treatment other than convenience. The patient was suitable for discharge on the day after surgery. The surgery can be compared to orthognathic surgery which is as or more invasive. These procedures are performed on an observation basis and the patient is not admitted unless discharge criteria are not met within 23 hours.

As the patient's surgery was delayed for no documented reason and he was suitable for discharge within 23 hours after surgery, an observation status would be appropriate.

The health care plan did act reasonably, with sound medical judgement, and 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: Upheld

Diagnosis: Chronic Obstructive Pulmonary Disease (COPD)

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

The patient is a female with history of chronic obstructive pulmonary disease (COPD) and asthma who presented to the Emergency Department (ED) with complaint of shortness of breath (SOB). The patient was placed on continuous positive airway pressure support (CPAP) by Emergency Medical Services (EMS) on the way to the hospital. The patient was also given Decadron, Nebs.  Initial vital signs included temperature 97.6 (F) Fahrenheit, blood pressure (BP) 169/90, heart rate (HR) 101, respiratory rate (RR) 36, and oxygen (O2) saturations 100% (percent) on bilevel positive airway pressure support (BiPAP).  The patient was given epinephrine and intramuscular (IM) Decadron. She was continued on bronchodilator (BD) nebulizers and given 1 dose of Azithromycin. The patient was continued on CPAP/BiPAP. She was noted using accessory muscles and was tachycardic. There was no jugular vein distention (JVD). Lung exam revealed some wheezes. The patient was alert and oriented.  White blood cell count (WBC) was 6.2, hemoglobin (Hgb) 11.7, blood urea nitrogen (BUN)/ creatinine 25/1.3, brain natriuretic peptide (BNP) was normal, and lactate was 1.7. Chest x-rays (CXR) revealed no acute infiltrate. There was an incidental cyst.

The patient was admitted to the hospital for COPD exacerbation. She was continued on the same treatment with steroids, BD (bronchodilators), and intravenous (IV) fluids. The patient improved with treatment in ED. She was weaned off of BiPAP to non-rebreather mask (NRB) to nasal cannula (NC). By the next day, (after only a few hours of being in the hospital) (patient was actually admitted close to midnight) vital signs were temperature 98.4 F, BP 120/80 mm Hg (millimeters of mercury), HR 80, RR 18, O2 sats 100% on NC (nasal cannula). The patient was in no acute distress (NAD). Peak expiratory flow (PEF) was 150 liters per minute. Her WBC was stable. Acute kidney injury (AKI) had resolved with creatinine at 1.1. The patient remained stable and was discharged the next day.

This patient did not need acute inpatient hospitalization. She could have been placed in observation status while diagnostic testing and treatment were initiated. This patient had improved after treatment in ED and was able to be weaned from CPAP to NC after a few hours. This patient was stable to be discharged home on oral meds after a period in observation with close follow up in outpatient setting.

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 is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Upper Limb Spasticity
Treatment: Botox Injections
The insurer denied the Botox Injections.
The denial is overturned.

The patient is a female with history of Cerebro-Vascular Accident (CVA) affecting the Left Middle Cerebral Artery, complicated by Right spatic hemiparesis. She has increased tone with spasticity mostly in the right shoulder adductors and elbow flexors affecting her functionality. She has relevant past medical history of Scleroderma, Hypertension, Hyperlipidemia, DVT (deep venous thrombosis), etc.

The request by the patient's treating physician is for Botox injections into the right shoulder adductor and elbow flexor muscles. The patient is Right-side dominant and requiring more regular use of her right upper extremity.

The patient has tried and failed acute inpatient rehab, Physical therapy, occupational therapy and speech therapy.

Yes, the requested Botox injections are medically necessary.
The requested Botox injections for upper limb spasticity are medically necessary. According to the Randomized Controlled Trial by Lindsay et al, Botox reduced spasticity and contractures after stroke and effects lasted for approximately 12-weeks. Botox reduced the need for concomitant contracture treatment and did not interfere with recovery of arm function.

It is also the accepted general medical standard of care for spasticity post-CVA (cerebrovascular accident), and the purpose of the Botox for spasticity.

Based on the above, the patient will benefit from the Botox injections.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.

The patient has history of Cerebro-Vascular Accident (CVA) affecting the Left Middle Cerebral Artery, complicated by Right spatic hemiparesis. She has increased tone with spasticity mostly in the right shoulder adductors and elbow flexors affecting her functionality. She has failed conservative measures. She is more likely to benefit from a Botox injection for the spasticity than any other available option outside major surgery for tendon release which will further affect her functionality.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anxiety, Depression, Self-harming behaviors
Treatment: Residential Treatment
The insurer denied Residential Treatment.
The determination is overturned.

The patient has diagnoses of Asperger's disorder, anxiety and depression. She has had severe self-harming behaviors and has had multiple suicide attempts. Prior to residential treatment she failed outpatient treatment on a weekly basis as well as therapeutic boarding schools. Her providers recommended a higher level of care and she was rejected from programs at an intensive outpatient level of care due to her self-harming behaviors and prior history of suicide attempts. The patient was unable to function in multiple school setting due to the severity of her mental illness. At issue is the medical necessity for residential treatment.
The requested residential treatment is medically necessary.
The patient has struggled with incessant suicidal thoughts. She has shown that with a less restrictive environment she is unable to cope with activities of daily living such as returning to school. Her mental illness is severe and impedes her judgement and activities of daily living. She meets criteria for residential treatment per Milliman Care Guidelines (MCG) and InterQual guidelines as she is a danger to herself, has a pattern of self-destructive behaviors and would not be able to safely be treated at a lower level of care.
The patient arrived to residential treatment with hopelessness, dysphoria, low self-esteem and suicidal ideation. She also endorsed mood lability, racing thought and crying spells. She was reluctant to engage in some groups regarding coping skills  and required prompting. She was noted to struggle with emotional dysregulation and particularly with expression of her emotions to her family. While in treatment she continued to demonstrate mood lability, hopelessness and uncontrolled impulsive behaviors (ripping a stuffed animal in half). Her providers in residential treatment felt that she needed 1:1 supervision in the restroom out of fears that the patent would self-harm. Given the above, the residential treatment is warranted and medically necessary.

The health plan's determination of medical necessity is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: TIA (transient ischemic attack).
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has diagnoses of Hodgkin's lymphoma and hyperlipidemia who developed an inability to concentrate and pre-syncope while shopping. He was taken to the emergency room for further evaluation. In the emergency room, the patient underwent a computed tomography (CT) scan of the head, a computed tomography angiography (CTA) of the head and neck, and a CT perfusion of the head. These studies were unremarkable. In the emergency room, a normal neurologic examination is recorded by the emergency room physician. The patient had a National Institute of Health (NIH) stroke scale of zero. He was admitted to the hospital. An MRI of the brain was deferred to the outpatient setting. An electroencephalogram (EEG) was performed but did not show seizure activity. The patient was anxious to leave the hospital and he was discharged.
At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient stay is not medically necessary for this patient. The patient presented to the hospital with confusion and pre-syncope. On evaluation in the emergency room, a normal neurologic examination is documented with an NIH stroke scale of zero. Initial imaging in the emergency room did not show an acute process. The patient had no significant vital sign abnormalities or laboratory abnormalities that would qualify for an acute inpatient admission. The patient was admitted to the hospital as an acute inpatient. He underwent an EEG that did not show seizure activity. An MRI of the brain was deferred to the outpatient setting. The patient was diagnosed with a transient ischemic attack.
Transient ischemic attack is rarely treated as an acute inpatient in the United States. This is a diagnosis that is treated at a lower level of care. This patient did not have any significant neurologic deficits or imaging, laboratory, or vital sign abnormalities. The patient was not treated with thrombolytic therapy. Advanced imaging of the brain was not performed. The patient did not require an intervention or surgery on any of the cerebral blood vessels. The patient did not require complex nursing or rehabilitation therapy. None of the services performed were consistent with an acute inpatient admission. As such, the stay was not medically necessary at the acute inpatient level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Crohn's Disease
Treatment: Stelara SQ 90mg Every 4 Weeks
The insurer denied the Stelara SQ 90mg Every 4 Weeks.
The denial is upheld.

This is a female with Crohn's disease involving the terminal ileum.  The patient has failed Humira.  Stelara every 4 weeks was started several years ago.

No, the Stelara every 4 weeks is not medically necessary.
Dose escalation of therapy by increasing the frequency of administration or by increasing the dose is conducted in clinical practice if a patient exhibits signs of increased disease activity. However, the documentation does not support trial failure of standard dosing of Stelara. Given this absence of trial of standard dosing of Stelara, the medical necessity of Stelara every 4 weeks cannot be confirmed.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Osteoporosis.
Treatment: Reclast.
The insurer denied Reclast. 
The health plan's determination is upheld. 

The patient is a female with history of osteoporosis. Under review is the use of Reclast. The coverage was previously denied because the medication was not preferred, and records do not show why the patient cannot use generic zoledronic acid.

A formulary exception is not indicated in this case. Zoledronic acid would not be ineffective, would not be as effective as non-formulary drug (Recast), or would have more adverse effects.
Although there are many efficacious agents in the treatment of osteoporosis - in most mild to moderate cases of osteoporosis and high-risk osteopenia patients, the guidelines by American Association of Clinical Endocrinologists, National Osteoporosis Foundation and Endocrine Society favor bisphosphonates as the first line agents due to their high efficacy and lower cost.
Zoledronic acid in the HORIZON trial (Black et. al. 2007) had a 25% reduction in nonvertebral fractures, a 33% reduction in clinical fractures, and 77% reduction in clinical vertebral fractures as compared with placebo.
Thus, zoledronic acid is a suitable option for treatment of this patient's osteoporosis. There is no supporting evidence that the brand name Reclast is more effective than generic zoledronic acid or has less side effects.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Interstitial Cystitis (IC). 
Treatment: Uribel. 

The insurer denied coverage for Uribel. 
The denial is upheld. 

This is a patient with past medical history of interstitial cystitis, vesicoureteral reflux, renal calculi. The patient is status post cystoscopy and hydrodistenson. The patient continued to note nocturia, lower abdominal pain, pressure. The patient is currently on amitriptyline, oxybutynin, uribel, allopurinol, HCTZ (hydrochlorothiazide), Urocrit-K (potassium citrate) tabs. She has tried/failed Elmiron previously. She has also taken aloe vera tablets which help with her interstitial cystitis (IC). The Urologist's office requested coverage of uribel - the insurer has denied coverage for this prescription. The insurer noted the physician must demonstrate that the patient has either serious side effects or drug failure with all of the formulary alternatives within the drug class- these include pyridium, methanamine in various forms, hyoscyamine, Elmiron. 

Uribel is an agent which is prescribed for "symptoms of irritative voiding" it is taken 5 times a day and contains Methenamine, sodium biphosphate, phenyl salicylate, methylene blue, and hyoscyamine. This patient has tried and failed Elmiron. There is no documentation that she has tried/failed pyridium or other medications specifically prescribed for dysuria or symptoms of irritative voiding. 

Uribel is not likely to have any more risk of side effects than pyridium, uribel has 4 compounds in it, it may be more likely than the formulary drug (pyridium) to cause an adverse reaction. Pyridium and the other formulary drugs are not likely to cause the patient an adverse reaction. 

No evidence is presented that all of the formulary drugs have been ineffective based on the patient's clinical history. It appears that the patient only tried/failed Elmiron for 2 doses. 

The requested drug (uribel) is not likely to be more effective that the formulary drug pyridium. 

The insurer's denial of coverage for Formulary Exception for Uribel is upheld.
Appeal type: Medical necessity
Decision: Upheld

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

This case involves a male with multiple medical problems, including diabetes, asthma, a history of stroke with left-sided weakness, bipolar disorder, chronic alcohol, and marijuana dependence; he resides at a  rehabilitation center and was sent over to the hospital secondary to diarrhea. The symptoms started approximately six days before this presentation. On arrival, the patient denied any diarrhea, nausea, or vomiting on the presentation day. The principal admitting diagnosis is diarrhea, which the medical team presumes is noninfectious and could be related to withdrawal symptoms. The patient was started on loperamide 2 milligrams (mg) every 6 hours and half-normal saline at 100 milliliters per hour (mL/h.) The medical team documents non-compliance with diabetic therapy and initiated the patient on Lantus plus lispro sliding scale. Subsequent blood glucose values compared to the initial chemistry panel improved at 183. The Clinical Institute Withdrawal Assessment (CIWA) score was 0 on admission. The diarrhea improved. All the stool cultures remain negative. The patient was discharged on the hospital regimen of short and long-acting insulin. The rest of the patient's chronic medications were also continued. The patient was released back to the substance abuse rehab for ongoing care.

The requested health service of inpatient stay is not medically necessary for this patient. The admission documentation describes a benign abdominal exam, no leukocytosis, no fevers, or hemodynamic instability. The testing for infectious diarrhea results was available within 24 hours of hospitalization, showing no evidence of infectious causes. The imaging studies were unremarkable for major intra-abdominal pathology.
The patient's magnesium levels were low, but there is no evidence that these could not be corrected under a lower level of care. The hyperglycemia rapidly improved after the initiation of an insulin regimen. There is no evidence of diabetic ketoacidosis. The insulin regimen did not include the continuous insulin infusion but long-acting plus sliding scale insulin.
All major metabolic derangements improved within the first 24 hours of hospitalization. Therefore, clinical indications for admission to inpatient care are not satisfied. The patient's condition can be managed under a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Avoidant Restrictive Food Intake Disorder (ARFID). 
Treatment: Procedure code 92507 x (times) 10, speech therapy sessions to treat impaired oral motor skills. 

The insurer denied coverage for procedure code 92507 x 10, speech therapy sessions to treat impaired oral motor skills. 

The denial is overturned. 

This patient has a history of oral stage dysphagia, avoidant restrictive food intake disorder (ARFID), attention deficit hyperactivity disorder (ADHD), and obsessive-compulsive disorder (OCD). He presented to the Speech Therapist's office for a feeding therapy session. The patient lost 24 pounds in a 6-month period. 

Avoidant/restrictive food intake disorder (ARFID) is a heterogeneous psychiatric disorder in which individuals present with avoidance of certain foods or categories of food resulting in a diet that is limited in variety, and/or restriction of overall intake resulting in a diet that is limited in volume. One of the most common rationales for avoidance and restriction in ARFID is a heightened sensitivity to the sensory properties of food (e.g., taste, texture, appearance, smell). Individuals with sensory sensitivity may experience vegetables or fruits as intensely bitter, for example, and therefore avoid these foods and be fearful of or disgusted by the prospect of trying novel foods. In turn, these individuals frequently rely on highly processed energy-dense foods and may have significant deficiencies in vitamins and minerals. For individuals with sensory sensitivity, food avoidance is often longstanding, having developed in early childhood. 

While ARFID has a psychological basis, there is currently no pharmacological/psychotropic treatment for this disorder. 

The patient has demonstrated severe deficits by evidence of failure to thrive in context of significant ARFID, with loss of 24 lbs in a 6-month period due to significantly restricted food choices and disinterest in PO [oral] intake. He also has demonstrated decreased oral motor skills for deglutition, including lack of rotary mastication skills.  The treating therapist has documented progress in addition of a number of acceptable foods, food combinations and ability to consume foods on a regular basis at mealtimes, which is important not just for physical but social/emotional growth.  Documentation also shows improvement in mastication skills and decreased amount of gag reflexes triggered in context of eating. 

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

The insurer's denial of coverage for procedure code 92507 x 10, speech therapy sessions to treat impaired oral motor skills is overturned. Medical Necessity is substantiated.