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

Diagnosis: Mucocutaneous Candidiasis
Treatment: Jakafi 20MG TAB
The insurer denied the Jakafi 20MG TAB.
The denial is upheld. 

The patient is a female with a history of signal transducer and activator of transcription one (STAT1) gene mutation associated chronic mucocutaneous candidiasis and failure to thrive.  The request is for approval for janus-activated kinase (JAK) inhibitor ruxolitinib, which is non-formulary for the health plan.  The patient has tried multiple antifungal therapies including griseofulvin and Diflucan, as well as topical therapies such as nystatin and ketoconazole.

No, the proposed treatment with Jakafi 20MG TAB is not medically necessary.

According to the Food and Drug Administration (FDA), ruxolitinib has an orphan drug designation for the treatment of polycythemia vera in patients with an inadequate response or intolerance to hydroxyurea, myelofibrosis, essential thrombocythemia and acute graft versus host disease, steroid-refractory.  In addition, the non-Food and Drug Administration (FDA) uses include chronic and steroid-refractory graft versus host disease following allogeneic stem cell transplantation.  Based on both the Food and Drug Administration (FDA) approved and non-Food and Drug Administration (FDA) approved indications available, the medical necessity for the treatment of chronic mucocutaneous candidiasis is not supported.

The requested indication, chronic mucocutaneous candidias associated with janus-activated kinase one (JAK1) gene mutation, is not listed as a Food and Drug Administration (FDA) approved indication or an orphan drug indication for rare disease.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic wound. 
Treatment: Inpatient admission. 

The insurer denied coverage for the inpatient admission. 

The denial is upheld. 

This is a male patient with past medical history significant for hepatitis C virus (HCV) and intravenous (IV) drug abuse who presented to the Emergency Department (ED) with complaints of right arm and shoulder pain and erythema. The patient's vital signs on ED presentation included: temperature 98.7, blood pressure 145/75, pulse 120, respiratory rate 20, and oxygen saturations 99% on room air. The patient's laboratory results included the following: white blood cell (WBC) count 12.5, hemoglobin 7.3, hematocrit 27.7, creatinine 0.87, glucose 116, and C-reactive protein (CRP) 10.2. The patient was empirically treated with intravenous (IV) antibiotics (i.e., vancomycin and Zosyn) for right arm wound/cellulitis. According to documents, the patient had a "chronic wound on dorsal surface with no surrounding erythema or streaking or tenderness." Surgery service consulted and recommended referral to Plastic Surgery. The patient's imaging studies were negative for any collection or abscess. The patient remained afebrile, hemodynamically stable. The patient signed out of the hospital against medical advice (AMA). 

According to documentation, the patient presented with a chronic right upper extremity wound- "right forearm wound has been there for years from skin popping heroin." Otherwise, the patient was afebrile, and remained hemodynamically stable. As per medical records, there was "no surrounding erythema or streaking or tenderness" found on this patient's physical exam. The patient had a chronic, poorly healing wound that required non-emergent intervention. The patient had no clinical evidence for a disseminated infection. Based on above findings, the patient met criteria for observation level of management. This case did not meet criteria for acute inpatient admission. 

As per review of the medical record and literature, the hospital admission was not 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 the inpatient admission is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Endocrine
Inpatient hospital

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

The patient is a female with a history of insulin-dependent diabetes mellitus and cardiomyopathy who presented with hypokalemia.

She was well until the day prior to presentation when she was seen in the endocrinology clinic and had blood work obtained. She was informed of the results the following day and was noted to have a potassium of 2.8. She was subsequently referred to the emergency department for care. She denied having any symptoms at that time.

Her past history was significant for multiple episodes of diabetic ketoacidosis and a high degree of insulin resistance. She had a persistently elevated hemoglobin A1c of > (greater than) 14%. She also had a history of depression. In the emergency department, she was noted to have a blood pressure of 125/87 and a pulse of 115 beats per minute (bpm). Her exam was only notable for tachycardia. An electrocardiogram (EKG) was obtained which also showed sinus tachycardia. A venous blood gas was obtained which revealed a potassium of 3.6. She also had an elevated glucose of 465. A normal saline bolus was given as well as 6 units of insulin and potassium chloride. 

The inpatient hospitalization was medically necessary for this patient.

This patient presented with both hypokalemia and uncontrolled diabetes. Her potassium was initially at a critically low value of 2.8. She required prompt intervention with potassium, which was initially given orally. However, due to a lack of substantial response, she required intravenous potassium chloride. Hospitalization was indicated for continued careful monitoring of electrolytes as well as potential symptoms of hypokalemia, with additional treatment as needed. She also had a history of significantly uncontrolled insulin-dependent diabetes, which warranted careful management and ongoing education.

Symptoms of hypokalemia can include severe muscle weakness, cardiac arrhythmias, renal abnormalities, and further glucose intolerance. Treatment must be administered promptly and carefully with close monitoring of electrolyte status as well as heart rhythm. The decision-making at the time of admission for this patient was consistent with her young age, the presence of severe hypokalemia requiring prompt initiation of treatment and close monitoring, and the need for ongoing management of uncontrolled diabetes to prevent future complications.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 

The denial is upheld. 

This patient is a male with a history of acquired immunodeficiency syndrome (AIDS), hepatitis B, pancreatitis and substance abuse who presented to the emergency department (ED) with five days of chest pain associated with shortness of breath (SOB) and diaphoresis.  The patient had an episode of vomiting on the day of presentation.  He last used cocaine the day prior. 

The patient's vital signs (VS) were as follows: temperature 98.2, pulse 71, respiratory rate 18. blood pressure 114/69 and oxygen saturation 100%. His exam was unremarkable.  Labs were as follows: sodium (Na) 138, potassium (K) 4.7, blood urea nitrogen (BUN) / creatinine (Cr) 34/1.92, white blood cell (WBC) 5.8, hemoglobin (H) / hematocrit (H) 13.5/40.4, platelets (Pl) 196, troponin .03, .01, lipase 223, and venous blood gas (VBG) 7.26/64.7/16/28.  The patient was COVID (coronavirus disease) negative.  Chest x-ray (CXR) revealed no abnormality detected (NAD). An anteroposterior (AP) computed tomography (CT) showed possible pancreatitis and left hydronephrosis.  His electrocardiogram (EKG) was normal. 

The patient was admitted with likely cocaine induced vasospasm.  The plan of care included serial cardiac enzymes, monitor blood urea nitrogen (BUN) / creatinine (Cr), and Urology consult.  The patient was uncooperative with management.  The patient was discharged the following day. 

No, the proposed inpatient admission was not medically necessary. 

This patient with a history of cocaine use was admitted with chest pain secondary to probable cocaine induced vasospasm.  The patient was hemodynamically stable.  He had normal oxygenation.  Electrocardiogram (EKG) was normal and troponins were negative.  Admission for serial cardiac enzymes and electrocardiogram (EKG) to rule out acute coronary syndrome (ACS) did not require an acute inpatient level of care. 

Medically necessary services are those which are: safe, effective, generally accepted national standard of medical practice, not provided primarily for convenience of the patient or the practitioner and the least intensive and/or most appropriate alternatives among diagnostic and treatment option. 

The requested inpatient admission was not medically necessary because the patient did not have findings consistent with acute coronary syndrome (ACS), had not failed a lesser level of care and did not receive intervention that required an acute inpatient level of care.  The requested inpatient admission from was not in accordance with generally accepted national standard of medical practice for this patient's scenario.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Root canal
Treatment: D2740 Porcelain Crown, Tooth 8
The insurer denied the D2740 Porcelain Crown, Tooth 8.
The denial is upheld. 

The patient is a male requesting a crown on tooth #8 after having root canal therapy.

No, the proposed treatment is not medically necessary.

The patient had a root canal procedure done on tooth #8 which was a virgin tooth that had no decay, fractures or existing fillings as evidenced by the new set of x-rays provided.  The root canal procedure only made a small access hole on the lingual (back) side of the tooth. The left and right sides of the tooth as well as the front and biting edge of the tooth are all solid. There is no clinical need for a crown on this tooth as it is still strong enough to just have a conservative filling placed in the access hole. Medical necessity for a crown on this tooth has not been shown.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia, Coronary Artery Disease and Depression.
Treatment: Increase of Personal Care Services hours to 8 hours x 7 days (56 hours) per week.
The insurer denied the Increase of Personal Care Services hours to 8 hours x 7 days (56 hours) per week.
The denial is upheld. 

The patient is a female with a history of Dementia, Coronary Artery Disease and Depression. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). An appeal review was requested for potential approval of 56 hours/week Personal Assistance Services to offer increased ADL (activities of daily living) support.

No, the 56 hours/week Personal Assistance Services is not deemed medically necessary.

The patient is a female with a history of Dementia, Coronary Artery Disease and Depression. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). However, an in home assessment of the patient's functionality and ability to perform ADLs (activities of daily living) was completed and does not indicated that the currently approved plan of 35 hours/week Personal Assistance Services is insufficient to meet the patient's current needs.

The patient's daughter/POA (power of attorney) provided logbooks of the patient's activities which indicates that she is ambulating with a walker and routinely skips breakfast and dinner due to inability to prepare her meals. However, the UAS (uniform assessment system) documents that the patient ambulates with a cane with no weight bearing support needed. As per the daughter, the patient is able to perform toileting without any support provided. She wears pads for occasional bladder incontinence. There were no falls reported in prior 90 days. The patient was on a soft food diet. Her skin was reported intact. The daughter comes over and prepares breakfast. The PCA (personal care assistant) prepares lunch, and the roommate prepares dinner. Lastly, the patient currently has a Personal Emergency Response System (PERS), which allows her safety monitoring in an effective manner.

There is a final note from the patient's daughter/POA (power of attorney) which states that her mother has been in the ICU (intensive care unit) and as such will require an updated assessment due to worsening functionality. However, until a new assessment can be completed, the proposed treatment 56 hours/week Personal Assistance Services is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left discoid meniscus and chronic knee degeneration.

Treatment: Procedure code 29881 [arthroscopy, knee, surgical; with meniscectomy (medial or lateral, including any meniscal shaving)] and the inpatient hospital admission.

The insurer denied coverage for procedure code 29881 and the inpatient hospital admission.

The denial is overturned. 

This patient is a female child with a medical history of left discoid meniscus and chronic knee degeneration who was scheduled for surgical procedure of the knee.  The patient was taken to the operating room and underwent bilateral medial distal femur hemiepiphysiodesis, implant-mediated guided growth and left knee arthroscopy partial lateral meniscectomy for the pre-operative diagnosis of bilateral genu valgum and left lateral discoid meniscus, torn, chronic degeneration.  The patient tolerated the procedure well without complications and was taken to the recovery room in stable condition.  The patient was noted post-operatively doing well with oral intake and pain controlled with oral medications.  Per physical therapy (PT), the patient was noted able to ambulate with PT initially limited by dizziness and noted anxiety but was able to walk several feet with assistance of rolling walker.  The patient was medically cleared for discharge home with instructions to follow up with surgery outpatient.

The medical record denoted multiple conditions to warrant treatment.  The patient was found to have abnormalities to her meniscus.  She was found to have limb malalignment. 

The physical examination was significant for her knees touching while extended (i.e. valgus deformity). This would be expected to cause her medial knee pains.  Correction will allow straightening and resolution of symptoms.  Surgical management is standard of care after failure of non-operative treatment. 

Her physician operated on both knees.  He also performed arthroscopy to the left knee.  The surgeries consisted of open placement of hardware to both knees. I.e. Epiphysiodesis type procedures.  The operation duration was over 2 hours.
 
The records show significant delay in mobilization and PT progress.  The records show the patient was unable to arise without dizziness.  She was fearful that she could not walk.
 
These findings of open bilateral procedures with arthroscopic surgery are complex and warrant the need for hospitalization.  A person would not be able to receive the same care as outpatient/ ambulatory surgical unit (ASU). 

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

The inpatient hospital admission is considered medically necessary for this patient.

The procedure performed was medically necessary for this patient. 

The carrier's denial of coverage for procedure code 29881 [arthroscopy, knee, surgical; with meniscectomy (medial or lateral, including any meniscal shaving)] and the inpatient hospital admission is overturned.  The medical necessity is substantiated
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Retainer
Treatment: Retainer
The insurer denied the retainer.
The denial is overturned. 

The patient is a female. The request is for orthodontic retention code D8680. She is already in braces.

Yes, the retainer is medically necessary.

The request is for orthodontic retention (i.e. a retainer) to hold the patient's teeth in the position her braces have put them in. She is in braces now. She is not requesting new braces, she is requesting the retainer to keep her teeth from shifting after her existing braces come off. So "new braces" as some correspondences erroneously indicate, is not what this patient needs. Withholding new braces will not affect the patient's health as she already has braces on. Withholding her retainer will adversely affect her health, because without it, her teeth will shift.

The request for code D8680 for a retainer to wear after the patient's existing braces are removed is medical necessity.
Appeal type: Medical necessity
Decision: Upheld

Digestive System
Inpatient hospital

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

The patient is a woman with a history of gastritis, depression, marijuana use and anxiety who presented to the emergency department with abdominal pain, nausea and vomiting for the past two hours. She reported using marijuana earlier that day. She denied other drug use. She had reportedly experienced cyclical vomiting due to marijuana use. This resulted in multiple emergency department visits over the past few months. Vital signs showed blood pressure 140/85, heart rate 54, temperature 97.4 Fahrenheit, and respiratory rate 20. On physical exam, the abdomen was tender in the epigastric region. Labs showed white blood cell (WBC) 11.6,. Hemoglobin 12.0, platelets 255, sodium 142, potassium 4.3, creatinine 0.73, and calcium 10.3. Imaging of the abdomen was negative for obstruction and free air. The patient was admitted for suspected marijuana hyperemesis. 

The inpatient stay was not medically necessary. The patient did require further management for marijuana hyperemesis, and received several agents including Zofran, Reglan, and Haldol. However, she was hemodynamically stable, had no severe electrolyte abnormalities, and had no other suspected cause of her abdominal pain such as bowel obstruction or inflammatory bowel disease. Her care did not need to be provided at the acute inpatient level of care. A lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: TMJ
Treatment: Fat grafting into the jaw space at the time of TMJ arthroplasty
The insurer denied  fat grafting into the jaw space at the time of TMJ arthroplasty.
The determination is overturned.

The patient underwent bilateral temporomandibular joint replacements. Autologous fat grafting was performed at the time of surgery. This treatment was denied based on the fact that it would not improve the clinical outcome. At issue is the medical necessity of the fat grafting into the jaw space at the time of temporomandibular joint (TMJ) arthroplasty.
The autologous fat grafts are medically necessary. The formation of extensive fibrosis and heterotopic bone has been problematic after total joint reconstruction of the TMJ. The rationale for placing autologous fat grafts is to obliterate the dead space present around the joint prosthesis, thus preventing the formation and subsequent organization of a hematoma. Creating this physical barrier serves to minimize the presence of pluripotent cells and prevents the formation of extensive fibrosis and heterotopic calcifications. Autologous fat grafting is a useful adjunct to prosthetic reconstruction of the TMJ. Graft procurement is quick and easy, with minimal morbidity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain, nausea
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female. Her medical history included obesity; her surgical history included Cesarean (C)-section. The patient presented to an emergency room with acute-on-chronic abdominal pain, nausea, vomiting, and diarrhea. Her vitals were: temperature 97.6, pulse 82, blood pressure 135/85, respirations 18, oxygenation 100% on room air. Physical examination demonstrated tenderness-to-palpation of the right-upper-quadrant of abdomen. Serum laboratories demonstrated leukocytosis to 11.2. Abdominal ultrasound demonstrated gallstones. 

The patient was admitted at an acute inpatient level-of-care with a diagnosis of gallstones, possible acute cholecystitis. She was made nil per os (nothing by mouth [NPO]); and provided with intravenous fluids, antibiotics, and analgesics. She was offered laparoscopic cholecystectomy; however, she declined. Her pain resolved, and the patient opted for non-operative management with antibiotics. 

The patient was discharged home in good and stable condition with prescriptions for oral antibiotics and outpatient surgical follow-up.

No, the proposed inpatient admission was not medically necessary.

The Tokyo Guidelines are gold-standard/international consensus statements regarding the diagnosis and management of biliary diseases, including acute cholecystitis [Tokyo Guidlines]. According to the Tokyo Guidelines, patients with mild cholecystitis, including this patient, may be managed surgically (i.e.: with cholecystectomy) or non-surgically (i.e.: with antibiotics). In the absence of significant co-morbidities or physiologic derangements, neither approach requires admission at an acute inpatient level-of-care; patients may be managed at a lower level-of-care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental/Skeletal Class I Occlusion
Treatment: Braces and Monthly Visits x12
The health plan denied the requested dental plan. 
The health plan's determination is upheld.

The patient is a female with a Skeletal Class I occlusion. There is mild maxillary crowding and moderate mandibular crowding with a supernumerary tooth at the lower left quadrant adjacent to the cuspid, a mild overjet and overbite. The subject to be determined is the medical necessity for braces and monthly visits.

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

Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 23 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-millimeter (mm) or greater and underbite 3.5 mm 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. Thus, braces and monthly visits are not medically necessary for this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fibromyalgia.
Treatment: Lyrica (Brand) 100 mg CAP.
The insurer denied the Lyrica (Brand) 100 mg CAP.
The determination is upheld.

The patient has a diagnosis of fibromyalgia. On appeal, it was noted that the patient has been on Lyrica brand for fibromyalgia and was switched to generic with adverse outcomes/reactions (not further described), needs brand Lyrica. At issue is the medical necessity of Lyrica (Brand) 100 mg capsule (CAP).

The requested health service/treatment of Lyrica (Brand) 100 mg CAP is not medically necessary for this patient. The patient has a diagnosis of fibromyalgia. The provider has submitted an appeal statement stating that the patient has been on Lyrica brand for fibromyalgia and was switched to generic with adverse outcomes/reactions, however, there is no further information indicating what specific adverse reaction the patient had and this is not actually documented in the progress notes provided for review. There was no mention of any adverse reaction and the patient's allergy list does not show any medications. Medical necessity is not established as the actual medical notes do not reflect any type of adverse reaction to the inactive ingredients in the generic version.