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

Diagnosis: Chronic obstructive pulmonary disease (COPD)
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient has suspected chronic obstructive pulmonary disease (COPD). She is otherwise very active and is a hiker. Her presenting complaints were shortness of breath, a cough, wheeze, and chest tightness for about 2 weeks. She had seen her primary care doctor and pulmonologist who prescribed inhalers and steroids but she continued to feel worse. On arrival to the emergency department, the patient's vital signs were a blood pressure of 187/110, heart rate 102, respiratory rate 22, with oxygen saturation 82% on room air. The physical exam was notable for expiratory wheezing. Lab results were unremarkable. She underwent computed tomography angiography (CTA) of the chest showing increased interstitial markings. She was admitted to an inpatient level of care and received intravenous (IV) steroids, bronchodilators, supplemental oxygen, and rehabilitation services. Her hypoxia and symptoms improved and she was discharged home two days later. At issue is the medical necessity of an inpatient stay.

The inpatient stay was medically necessary. The patient presented with symptoms and signs consistent with a severe COPD exacerbation, which included hypoxia, dyspnea far beyond her baseline (she is very active), wheezing, and chest tightness. She failed outpatient management of her condition, evidenced by documentation of a pulmonology outpatient visit one week prior in which steroids and inhalers were prescribed. Admission to an inpatient level of care was necessary both to carefully monitor the patient for signs of worsening and to treat her COPD aggressively. The condition she presented with was life-threatening and a lower level of care would have been inappropriate based on the severity of her illness and prior failure of outpatient management. The inpatient level of stay was medically necessary to safely and successfully care for the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Surgical Services. 
The insurer denied back surgery. 
The denial is upheld.

The patient is a male who underwent bilateral decompressive laminectomy of the lumbar spine at thoracic (T)8-T9 with decompression of spinal cord and nerve roots bilaterally with bilateral posterior instrumentation of the thoracic spine at T7, T8, T9 and T10 and bilateral posterior transverse fusion T7-T10 using allograft, autograft and Trinity bone graft with computer assisted navigation and neurophysiological monitoring. His diagnoses listed herniated disc, degenerative disc disease thoracic spine, thoracic spondylosis, and thoracic radiculopathy. The subject under review is the medical necessity for back surgery.

The health plan's determination is upheld in whole. 

The requested back surgery is not medically necessary. Medical records fail to show the patient's subjective complaints, exams, conservative treatments prior to surgery and imaging reports. There is no indication for surgery in the operative report. The requested current procedural terminology (CPT) codes do not meet general guidelines and standard of care and are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems-Teeth spacing problems
Treatment: Dental/Orthodontic Procedure- Comprehensive orthodontic treatment of transitional dentition and periodic visits
The health plan denied the comprehensive orthodontic treatment of transitional dentition and periodic visits as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

This patient has a Class II malocclusion. He has severe maxillary crowding and mild mandibular crowding. There is moderate overjet and severe overbite. 

Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 12 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 9 millimeters(mm) 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. The submitted HLD document has checked that the patient has an auto qualifier of impacted permanent anteriors where extraction is not indicated. Although tooth # (number) 9 is impacted, tooth #F could be extracted in this case. The main reason why tooth #9 is impacted is due to it being blocked by tooth #F. Since its contralateral tooth #E has exfoliated and noting that tooth #F is delayed in exfoliation, it is appropriate and the standard of care to extract tooth #F to allow tooth #9 to self-erupt. Thus, according to the standard of care, Comprehensive orthodontic treatment of the transitional dentition, periodic orthodontic treatment visit[s] are not medically necessary for this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low Levels of Oxygen In The Blood
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient is a female with a history of sickle cell anemia. She was seen in her school with low oxygen saturation with a room air saturation of 89% and moderate leg pain. She was seen in the outpatient sickle cell clinic. She had a hemoglobin of 7.9. A chest x-ray was normal. The patient was admitted to the hospital and received a blood transfusion and was discharged without complication.

No, the Inpatient admission was not medically necessary.
The medical records indicate that the patient had anemia and hypoxia that was improved after a blood transfusion. There was no evidence of acute chest syndrome, stroke or other complication that required inpatient hospitalization. The patient could have been safely managed at a lower level of care.

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

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

The patient is a male with medical history of hypertension, peptic ulcer disease, diverticulitis, intussusception status post repair, and Clostridioides difficile colitis. He presented to the emergency department with abdominal pain, nausea, and bloody diarrhea. He had been to an emergency department two days before and was diagnosed with Clostridioides difficile (without colitis on imaging). He had been on metronidazole for two days. Vital signs were notable for tachycardia with pulse rate of 108/minute. Physical examination was notable for mild distress and generalized abdominal tenderness. Labs showed low white blood cell count of 4.2, low hemoglobin of 11.2 (but normal hematocrit), and elevated lactate of 2.06. An abdominal x-ray showed a nonspecific bowel gas pattern. He was treated with intravenous fluids, morphine, and oral vancomycin. He was made nil per os (NPO). 

The inpatient hospitalization was not medically necessary. The patient had a finding of recurrent and persistent Clostridioides difficile infection; however, there was no sustained hypotension, persistent severe volume depletion or sepsis, toxic megacolon, or other reasons for the inpatient level of care such as perforation, abscess, or gastrointestinal obstruction. Although uncomplicated Clostridioides difficile infection was present, the patient did not have persistent gastrointestinal bleeding, peritonitis, or other complications warranting inpatient level of care. He was appropriately started on treatment for Clostridioides difficile infection with oral vancomycin. He was found to have coronavirus-19 infection, but did not have markers of progressive or severe disease, was not treated for it, and left the hospital against medical advice. The measures which were undertaken, such as observation, labs, antibiotic administration, and Gastroenterology consultation, could have been performed at a lower level of care.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Chronic pain syndrome
Treatment: OxyContin
The insurer denied the request for OxyContin. 
The denial is upheld.

The patient has a diagnosis of chronic pain syndrome. The patient has failed Nucynta, Lyrica, gabapentin, morphine sulfate, oxycodone, and Xtampza. The patient is allergic to codeine, Dilaudid and tramadol. OxyContin has been requested and is at issue for this review.

Although the patient has failed some medications (Nucynta, Lyrica, gabapentin, morphine sulfate, oxycodone, and Xtampza), it is unclear why all of the formulary drug alternatives have not been trialed and failed. The formulary drug alternatives include fentanyl transdermal, hydrocodone extended release, methadone, and morphine and will likely be just as effective. Additionally, there are insufficient large-scale, randomized, controlled studies showing the superiority of OxyContin over the formulary alternatives in this patient's clinical situation.

The health plan's determination is upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Ulcerative Colitis
Treatment: Stelara (every 4 weeks), Pre-service
The insurer denied the Stelara (every 4 weeks), pre-service.
The denial is upheld.

The patient is a male who has the diagnosis of inflammatory bowel disease. Specifically, the patient had been diagnosed with ulcerative colitis (UC). The patient received Stelara as treatment for this condition. As the patient evidenced increasing symptoms attributable to their condition, the provider has requested the provision of Stelara at a decreased dosing interval of every 4 weeks. This is the subject of this review.

No, the health plan should not cover the Stelara every 4 weeks.

The use of Stelara (ustekinumab) subcutaneously (SQ) 90 mg (milligrams) every 4 weeks is not medically appropriate for this patient with UC.

The patient has a medical diagnosis of UC. The patient has the diagnosis of inflammatory bowel disease (IBD). Specifically, the patient has the diagnosis of UC. The patient has received Stelara as treatment for this condition. The patient evidenced increasing symptoms attributable to their condition between dosing. The treating provider has requested the provision of Stelara at a decreased dosing interval of every 4 weeks. The provider has requested Stelara at a dosing not approved by the FDA (United States Food and Drug Administration). A review of the literature indicates that there have been no significant studies to date demonstrating the safety and efficacy of Stelara dose escalation to every 4 weeks in UC. Therefore, the request for Stelara SQ 90 mg every 4 weeks is denied and not medically appropriate for this patient.

"The efficacy of antibody-based therapeutics depends on their pharmacokinetics. The pharmacokinetic and exposure response profiles of ustekinumab, a monoclonal antibody against interleukin 12/interleukin 23, are known in patients with Crohn's disease, yet there are few data from patients with ulcerative colitis." (Adedokun, et al)

"The efficacy of ustekinumab, an antagonist of the p40 subunit of interleukin-12 and interleukin-23, as induction and maintenance therapy in patients with ulcerative colitis is unknown." (Sands, et al)

"A subset of patients with Crohn's disease (CD) do not respond to ustekinumab at the standard dose of 90 mg every 8 weeks. Little is known about the efficacy of shortening the interval between doses." (Ollech, et al)

No, Stelara every 4 weeks is not more beneficial.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lower extremity wounds
Treatment: Skilled nursing visits
The insurer denied skilled nursing visits. 
The health plan's determination is overturned. 

The patient is a female with past medical history of idiopathic chronic venous hypertension right lower extremity ulceration according to records who also had a history of lymphedema with lymphedema pumps at home and obesity. The patient was receiving daily visiting nurse services to treat right lower extremity ulcers/wounds. The patient is home bound due to difficulty and taxing effort to leave home requiring a cane and 1-2 person assist. 

Skilled Nursing Visits x 14 are medically necessary for this patient.
There is documentation of diagnoses of lymphedema and chronic venous hypertension with leg ulcers. The wound care nurse from visiting nurse services recommended treatment with iodoform packing. It was recommended to continue this regimen daily. The insurer denied coverage on the basis that patient's wounds were small; however, there is documentation of one of the ulcers 0.8 cm of depth by 6 cm of the length and the other 0.5 cm of depth by 5 cm in length. In fact, the notes indicate the #1 wound actually increased in size. The insurance denial also stated the patient's wounds were not complex and did not require the specialized skill set of a nurse, but in fact these wounds were large and complex requiring packing with iodoform which is a skill set of a nurse. The insurer also stated the patient could learn to treat her wounds or a caregiver could be taught how to take care of her wounds. This was not feasible for the patient herself due to her morbid obesity and mobility issues and the patient's caregiver was not willing to perform wound care. It is not appropriate for denial of services based on a caregivers inability to provide complex wound care. In addition, the insurer stated the wound care could be performed by a different provider such as LPN (licensed practical nurse) or HHA (home health aide) but in New York state, this is out of their scope of practice. Literature from Up-to-Date states" wound packing is considered basic standard care Packing wounds associated with significant dead space or undermining is important to reduce physiological dead space, absorb exudate/seroma collection, and reduce the potential for infection. Packing can also be an effective temporary dressing technique between planned serial debridements".
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Spinal stenosis. 
Treatment: Laminectomy and fusion of L (lumbar) 4-L5. 

The insurer denied coverage for laminectomy and fusion of L (lumbar) 4-L5. 

The denial is overturned. 

The patient is a male. 

Clinical records note that the patient called and reported falling twice due to numbness in his leg as well as burning. His surgery was denied twice. He was seen in the office for progressive low back and bilateral leg pain to the feet with dysesthesias and radiculopathy with weakness in the left leg. He denied falls at this time. An epidural steroid was denied by insurance. His exam at this time noted left TA (tibialis anterior) weakness 4/5 and evertor weakness 3/5. He is taking oxycodone for pain. A lumbar MRI (magnetic resonance imaging) noted instability L (lumbar) 4-5 with flexion and extension. A lumbar MRI notes moderate to severe spinal stenosis with narrowing of the lateral recesses and impingement on the exiting L4 nerve roots. L5-S (sacral)1 mild impingement upon the right S1 nerve root due to herniation. Physical therapy noted that he has 10/10 pain in the low back and bilateral legs more on the left. He notes his legs go dead and he falls. His exam notes motor weakness, most significant of the left ankle evertor 3+/5, otherwise 4+/5 to 4/5 L4 dermatomes bilaterally with positive bilateral straight leg raise. Gait is severely antalgic. Disability score 52%. He treated and was unable to participate in any therapy due to pain without benefit and continued weakness with increased disability score of 58%. He was discharged. The plan was for a TLIF (transforaminal lumbar interbody fusion) L4-5 due to instability with moderate to severe stenosis. 

The surgery was denied for no physical therapy within six months of surgery date. 

The patient did not have physical therapy at the time of request. 

The patient has failed conservative treatment and is severely disabled due to instability and nerve root compression. Surgery is indicated based on guidelines and standard of care. 

The patient met NIA (national imaging associates) guidelines for Single Level Fusion with or without Decompression. 

Operative treatment is indicated for patients with severe pain and constant neurologic symptoms, and in patients where conservative treatment has failed. (2) 

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 spine surgery and hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain

Treatment: Inpatient admission

The insurer denied coverage for an inpatient admission
The denial is upheld

The patient presented with RUQ (right upper quadrant) abdominal pain. She was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. An abdominal ultrasound revealed a contracted gallbladder with a mildly thickened wall but no pericholecystic fluid. A CAT (computed tomography) scan showed multiple small gallstones. There was no leukocytosis. There were elevated liver enzymes, but this was felt to be related to a fatty liver. A laparoscopic cholecystectomy was performed. No complications were reported. 

Clinical indications for an admission for Gallbladder or Bile Duct Inflammation or Stone {MCG (Milliman Care Guidelines) M-555) include having acute cholecystitis with upper abdominal pain along with systemic signs of inflammation. In this case, the patient had upper abdominal pain but did not have systemic signs of inflammation. Other indications for admission for gallstones include hemodynamic instability, common bile duct obstruction, severe vomiting, severe dehydration, severe pain, and bacteremia. The patient did not have these conditions.

This patient had gallbladder disease but did not have systemic signs of inflammation. She was stable to have had the laparoscopic cholecystectomy performed as ambulatory surgery. She did not meet MCG criteria for admission for Gallbladder or Bile Duct Inflammation or Stone. The health care plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary. 

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 hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive system/Gastrointestinal
Treatment: Inpatient Hospital
The health plan denied the requested inpatient stay as not medically necessary. 
The health plan's determination is upheld.

The patient is a woman who presented to the hospital emergency department (ED) with abdominal pain and jaundice. The records indicate that she has a known history of elevated liver enzymes and gallstones and is evaluated with ultrasound every 6-months. At the time of presentation, the patient was without fever and vital signs showed a normal heart rate of 71 beats per minute (bpm) and a blood pressure of 115/74 millimeters of mercury (mmHg). The ED records state that she was not tender in the upper abdomen. The white blood cell count (WBC) was normal at 8.3 K (thousand). The complete metabolic panel identified elevated serum transaminases. Bilirubin was elevated at 10.4. An ultrasound performed in the outpatient setting showed gallstones, peripancreatic fat stranding and biliary ductal dilatation. She was admitted to the hospital with obstructive jaundice.
She was initially treated with an endoscopic retrograde cholangiopancreatography (ERCP)with removal of two common duct stones. Surgical consultation was obtained. A laparoscopic cholecystectomy was planned. The submitted records do not indicate that this operation was performed. The patient did undergo imaging with a magnetic resonance imaging (MRI) of the abdomen.
The immediate post-procedure recovery was uncomplicated, though liver enzymes did remain elevated. The next day, the patient had stable vital signs. The diet was advanced. She was discharged from the inpatient setting.
At issue is the medical necessity of the inpatient stay.

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

No, the inpatient care was not required for this patient. This patient is a woman who presented to the hospital emergency department (ED) with obstructive jaundice. She was known to have gallstones. The patient was hemodynamically stable at the time of presentation. The white blood cell count (WBC) was normal at 8.3 K and liver enzymes and bilirubin were elevated. She was treated with an ERCP with stone extraction. The patient remained hemodynamically stable during the period of pre-procedure care, during the endoscopic procedure, and during the period of post-procedure monitoring. The records do not indicate that a cholecystectomy was performed, as was initially planned.
An inpatient level of care was not appropriate or medically necessary for this patient with choledocholithiasis. The care provided on these dates could have been rendered with an alternate level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: prostate cancer
Treatment: OncotypeDx testing 
The insurer denied OncotypeDx testing. 
The health plan's determination is upheld.

The patient is a man with newly diagnosed Gleason grade Group 1 prostate cancer. Prostate-specific antigen (PSA) was 4.7. His clinical sage is T1c. Oncotype Dx testing was performed as part of his diagnostic workup. This is the subject under review.

The OncotypeDx test is not medically necessary as it has not been established by the literature to improve net health outcomes. The current medical evidence is insufficient to establish efficacy of the test.
The guidelines of the National Comprehensive Cancer Network (NCCN) do not endorse biomarker testing for low-risk prostate cancer, nor do current guidelines of the American Urological Association (AUA). The AUA notes, "Clinicians should not routinely use tissue-based genomic biomarkers for risk stratification or clinical decision-making." The American Society of Clinical Oncology (ASCO) concurs. Therefore, the requested testing is not medically necessary at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Crohn's disease
Treatment: Injection of Infliximab in a Hospital Setting
The insurer denied the injection of infliximab in a hospital setting.
The health plan's determination is upheld.

This patient is a female with a history of Crohn's disease. She is on treatment with infliximab infusions. Under review is the medical necessity infliximab infusions at the hospital-based outpatient infusion center.

The injection of infliximab in a hospital setting is not medically necessary for this patient.

Continuation of infliximab is appropriate. However, there is no medical necessity for the infusions to be at the hospital outpatient setting. The patient has no documented reactions to prior infusions of infliximab. There is no change of treatment or dose adjustment that might be associated with adverse events or intolerance. There is no evidence that the hospital infusion center is safer than an independent office-based infusion center. This patient can safely continue her treatment at an independent infusion center. Hospital based infusions are not proven to be safer or more effective.

It was noted in recent publications that home based infusions are associated with suboptimal outcomes in inflammatory bowel disease patients. However, these observations do not apply to independent infusion sites or office based office-based infusions.

Therefore, medical necessity for the hospital-based infusion cannot be established.