Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Hives, Irritable Bowel Syndrome.
Treatment: Gastrointestinal pathogen panel.
The insurer denied the gastrointestinal pathogen panel.
The determination is upheld.

The patient presented for evaluation of urticaria. She has a history of psoriatic arthritis. The patient notes in a letter that in the week or two prior to her appointment, she experienced consistent diarrhea which she brought up with her physician. The patient's hives were potentially thought to be due to an infectious pathogen within her gastrointestinal (GI) tract and in some way related to irritable bowel syndrome (IBS) and she underwent a urea breath test for Helicobacter (H) pylori. This was despite a record on the history and physical (H&P) that the patient had no GI symptoms including no diarrhea; the physician office note specifically states the patient is not experiencing diarrhea in the review of symptoms (ROS). The history of present illness (HPI) summary and assessment/plan do not mention it either.
The patient also underwent testing for infectious diarrhea with a proprietary polymerase chain reaction (PCR) multiplex panel. No pathogens were identified. At issue is whether the gastrointestinal pathogen panel is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

No. The gastrointestinal pathogen panel is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The patient apparently has spontaneous unexplained urticaria. Rarely, urticaria can be associated with a gut pathogen such as H. pylori or an intestinal parasitic infection usually in the setting of systemic eosinophilia. It is not necessary, nor the standard of care, to test for a wide array of stool pathogens in a patient lacking GI symptoms. If she did have diarrhea, there is no data in this setting to support a multiplex polymerase chain reaction (PCR) platform over targeted culture and microscopic examination for common pathogens associated with urticaria (e.g., strongyloides).
Therefore, the gastrointestinal pathogen panel is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a previously healthy woman who presented to the hospital emergency department (ED) with a history of progressively worsening abdominal pain of 1-day duration. Her evaluation included a physical exam, a computed tomography (CT) scan, and labs. She was afebrile at the time of presentation. The heart rate was normal at 77/minute at presentation. The abdomen was tender in the right lower quadrant. Lab data identified an elevated white blood cell (WBC) count of 12.5K (thousand). A CT scan showed a dilated appendix consistent with acute appendicitis. Her evaluation yielded the diagnosis of appendicitis. Treatment was initiated with intravenous (IV) fluid and antibiotics. Surgical consultation was requested. She was admitted to the hospital.
The patient was provided IV fluid and antibiotics. She underwent a laparoscopic appendectomy with findings of appendicitis. Surgery was performed without complication. Following surgery, the diet was advanced and pain management was converted to oral medications. She was discharged home.
At issue is the medical necessity of the inpatient stay.

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

No, inpatient care was not medically necessary. An alternate level of care would have satisfied the clinical needs of this patient. This patient is a previously healthy young woman who presented to the ED and underwent an uncomplicated appendectomy procedure. The post-surgical course was without adverse incident. The patient responded favorably to this treatment and the hospitalization was uncomplicated. The patient was previously healthy, and the vital signs were consistently normal during the period of monitoring. The clinical notes document clinical stability without complication during this period of monitoring.
The submitted clinical documentation does not support the need for inpatient admission for this patient. An alternate level of care would have satisfactorily provided for the care provided and would have been consistent with the accepted standard of medical care.
Generally accepted medical standards indicate that in the absence of hemodynamic instability, sepsis or toxicity, significant electrolyte imbalance, bleeding, gastrointestinal (GI) obstruction or surgical complications, the treatment of appendicitis can be provided without an inpatient level of care. In this case the patient tolerated oral hydration, diet/medication, and surgical treatment. An alternate level of care would have appropriately provided for surgical treatment and perioperative monitoring. Inpatient care was not required or medically necessary in this case, per generally accepted medical standards.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholecystitis
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is upheld.

The patient presented to the emergency department with complaints of 2 weeks of abdominal pain that was progressively worsening. The patient also reported associated nausea and chills. The pain was 10/10 in severity. The patient had a previous ultrasound positive for gallstones. Her vital signs were documented as stable by the surgical team, but there was one reading that demonstrated tachycardia to 108. The examination demonstrated the patient was tender to palpation with guarding. Her white blood cell (WBC) count was 10.93. Liver function tests (LFTs) were unremarkable. A repeat ultrasound was performed, which demonstrated cholelithiasis with a positive sonographic Murphy's sign. The patient was hospitalized on the general surgery service. She underwent a laparoscopic cholecystectomy without complications. The patient recovered well and met discharge criteria and was discharged home.

At issue is the medical necessity of an inpatient hospital stay.

The patient's hospital admission was not medically necessary at the inpatient level of care.

The patient did not demonstrate signs of a systemic infection in association with the cholecystitis. The patient also did not demonstrate significant concern for cholangitis. The patient did not demonstrate hemodynamic instability. She did not demonstrate severe or persistent pain that would require high dose medication administration and monitoring. The patient did not demonstrate significant vomiting. The patient did not have signs of sepsis or bacteremia. The documentation does not suggest that the patient's care could not have been performed at a lower level care. There is no evidence that additional complex testing or therapy other than the surgery was performed. There is no evidence that a complicating event occurred before, during, or after the procedure that required a higher level of care. There is no documentation that the treating team identified conditions or problems specific to the patient that would have required inpatient care. The provided documentation does not support the medical necessity of an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastritis.

Treatment inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

The patient presented with hiccups and vomiting. The symptoms had been present for months. A previous endoscopy revealed gastritis. He was afebrile and the vital signs were stable. The abdominal exam was benign. An abdominal computed axial tomography (CAT) scan was negative for acute disease. The gastroenterologist advised adding Baclofen and Pantoprazole to his medication regimen. H (helicobacter) Pylori testing was also recommended.

Milliman Care Guidelines (MCG) clinical indications for admission for Gastritis and Duodenitis (MCG M-560) include hemodynamic instability, gastric outlet obstruction, perforation, peritoneal signs, severe vomiting that is not responsive to antiemetics, severe dehydration, severe electrolyte abnormalities, and an inability to maintain oral hydration after observation care. The patient did not have these conditions.

MCG clinical indications for admission for Vomiting (MCG M-370) include having a severe metabolic derangement, hemodynamic instability, severe electrolyte abnormalities, bacteremia, acute renal failure, or an inability to maintain oral hydration after observation care. The patient did not have these conditions.

This patient had gastritis and required adjustments to his medications and treatment for the hiccups. This could have been done as an outpatient with observation status. He did not meet MCG criteria for admission for either Gastritis or Vomiting. He could have been treated with a proton pump inhibitor (PPI) and Baclofen as an outpatient. 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 admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems/ anterior crossbite.
Treatment: Orthodontic treatment/visits.

The insurer denied Comprehensive orthodontic treatment of the adolescent dentition and periodic orthodontic treatment visit x 12. 
The health plan's determination is overturned. 

The patient in question is a female with an anterior crossbite on teeth 7 and 10. She presents with a skeletal Class I malocclusion with moderate crowding in the maxilla and mandible. She is treatment planned for 24-30 months of orthodontics to address the crowding and crossbite.

Comprehensive orthodontic treatment of the adolescent dentition and periodic orthodontic treatment visit x 12 are medically necessary for this patient.
This patient presents with an anterior crossbite on teeth 7 and 10, as well as significant crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. If left untreated the damage that will likely occur to the patient's teeth will be much more time consuming and difficult to correct than the patient's existing orthodontic problem. For this reason, treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Depression. 
Treatment: Spravato Nasal Spray. 

The insurer denied Spravato. The health plan's determination is overturned. 

The patient is a male who is diagnosed with major depressive disorder (MDD), and attention deficit hyperactivity disorder (ADHD). He is currently prescribed Adderall, Vyvanse and Prozac. The request is for Spravato Nasal Spray for treatment of Major Depressive Disorder. This was denied by the health plan. 

Spravato Nasal Spray is medically necessary for this patient. Spravato is Food and Drug Administration (FDA) approved for patients with treatment refractory Major Depressive Disorder or patients with Major Depressive Disorder and active suicidal ideation.  Based on medical records submitted, the patient has treatment resistant depression and has tried other psychotropic medications in the past.  Additionally, he is noted to have been diagnosed with suicidal ideation as well.  He is prescribed Prozac 20 mg (milligram) thus fulfilling the criteria that Spravato be prescribed concurrently with an antidepressant medication. As such, he meets criteria for this medication based on standard of care in the community.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma, Shortness of Breath. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the Inpatient Hospital Stay. 
The determination is upheld. 

The patient has a medical history significant for allergies and asthma who presented to the emergency department (ED) with a one-day history of cough, shortness of breath, and fever to 101 degrees Fahrenheit. His mother was treating with albuterol every two hours at home. Vital signs included a temperature of 37.2 degrees Celsius, heart rate 128, respiratory rate 30, and 92% (percent) oxygen saturation on room air. 
The examination was significant for moderate respiratory distress, diffuse wheezing with intercostal retractions. He was aggressively treated for status asthmaticus with three CombiVents, prednisone, magnesium, and a normal saline bolus. He required supplemental oxygen after this and was admitted to the pediatric floor for ongoing care and treatments every two hours. Admission orders included ongoing bronchodilator therapy every two hours, transition from nebulizer to metered dose inhaler (MDI) with spacer, five-day course of steroids, continuous pulse oximetry while on supplemental oxygen, a regular diet, consideration for magnesium infusion, and asthma education. He was able to space rather quickly to every four hours. At that point, he was deemed stable for discharge home. 

No. The requested inpatient admission was not medically necessary. The patient could have been safely managed at a lower level of care. 
Asthma is an inflammatory process characterized by airway obstruction due to airway hyper-responsiveness, bronchospasm, airway inflammation, and mucus production. Gas exchange abnormalities are due to ventilation/perfusion mismatch, as a result of atelectasis and airway over-distention. Asthma can still be a fatal illness if treatment is not initiated quickly or aggressively enough. 
In the ED, primary management strategies include correction of hypoxia, rapid improvement of airflow obstruction, and prevention of progression. This is achieved with supplemental oxygen, bronchodilators, and steroids. Fluid hydration may also be necessary. For patients with moderate to severe exacerbations that do not respond to such intensive therapy in the ED, admission is necessary. 

This patient with a history of mild intermittent asthma and upper respiratory infection (URI) symptoms known to be a trigger, presented to the ED with signs and symptoms of an acute exacerbation and status asthmaticus. He was treated aggressively in the ED with some improvements noted. Because he remained partially symptomatic, he was admitted for ongoing treatment which included intermittent supplemental oxygen. While it was not appropriate to discharge him home at this point, he was overall hemodynamically stable with no indication of impending respiratory failure. He did not require acute inpatient admission and could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hyperlipidemia
Treatment: Duplex scan of the extracranial arteries
The insurer denied the duplex scan of the extracranial arteries.
The determination is overturned.

The patient has a past medical history of hyperlipidemia. The patient had a previous dental computed tomography (CT) scan showing carotid artery plaque. The patient had a family history of carotid artery disease and stroke. The patient's primary care physician (or provider) (PCP) ordered a duplex scan of the extracranial arteries. The patient underwent the recommended test. The insurer denied coverage of duplex scan of extracranial arteries stating the test should be used when there are symptoms of a narrowing or blockage of a blood vessel in the neck such as vision problems, difficulty speaking, or numbness and the patient's doctor did not tell the insurer that the patient had such symptoms. The patient's primary care physician (or provider) (PCP) provided a letter to the insurer stating when the patient was seen for a physical exam  the patient mentioned she had a dental CT showing carotid artery plaque about three years prior and the patient also reported a family history of carotid artery disease and plaque. The provider noted the test was ordered as a preventative measure as the patient was not experiencing any stroke symptoms and was ordered to determine the patient's risk for stroke or ministroke in the future and/or to assess for severity of carotid artery disease.
At issue is the medical necessity of a duplex scan of the extracranial arteries.
This is medically necessary.
There was clinical concern for carotid artery disease based on CT imaging done at the dentist and the patient's family history of carotid artery disease and stroke increased the likelihood of carotid artery disease. The recommended imaging would assess if there was carotid artery stenosis and to what degree if it were present. A cerebrovascular accident (CVA) can be a life threatening or debilitating medical condition and given the likelihood of disease, a duplex scan of the extracranial arteries was medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Orthopedic 
Surgical services

Diagnosis: foot pain
Treatment: bunion surgery
The insurer denied bunion surgery. The health plan's determination is upheld. 

The patient is a female with right foot pain at the first IPJ (interphalangeal joint) and 2nd toe. The patient has prior history of Right bunion surgery. The patient continued to experience pain in the Right 1st MTPJ (metatarsophalangeal joint). She had conservative care which consisted of over-the-counter (OTC) pain relievers and modifications of shoes. X-rays of the Right foot showed significant arthritis to the 1st metatarsophalangeal joint. X-rays also showed evidence of avascular necrosis in the first metatarsal head. The patient also has limited range of motion of the 1st MTPJ. She also had mild pain at the distal tip of the Right 2nd digit. The patient was given an injection of the IPJ with cortisone. The provider recommended Bunion Surgery. 

The requested bunion surgery is not medically necessary for this patient. The patient has documentation of a previous bunion surgery. The patient has documented pain in the IPJ of the right hallux. The patient has undergone an injection of the IPJ of the right hallux. It is uncertain how the request for another type of bunion surgery (Keller bunionectomy) will improve the pain in the patients IPJ of the right hallux. The patient also has documented mild pain in the distal tip of the right 2nd digit. The patient has not had a documented course of conservative treatment to warrant surgical correction.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Unspecified coordination, vison, and motor deficits

Treatment therapeutic activities (97530), neuromuscular reeducation (97112), and therapeutic exercises (97110)

The insurer denied coverage for therapeutic activities (97530), neuromuscular reeducation (97112), and therapeutic exercises (97110)	

The denial is overturned

This is a male with reported history of unspecified coordination, vison, and motor deficits. Treatment included but not limited to occupational therapy. Currently under review is the medical necessity for therapeutic activities (97530), neuromuscular reeducation (97112), and therapeutic exercises (97110).

The occupational therapy (OT) evaluation notes from OT provides sufficient objective clinical information to support the medical necessity for direct OT services. The initial evaluation note is comprehensive, provides specific clinical information regarding functional deficits and identifies short- and long-term goals. The recommended clinical intervention of "1 x per week" is also reasonable. Unfortunately, the subsequent treatment notes are handwritten and poorly legible; albeit, reporting ongoing functional progress. However, further approval for continued occupational therapy services (after the dates of service currently under reviewed) should be accompanied by specific evidence of measurable (quantitative) progress that is documented at a similar detailed level as the comprehensive initial evaluation and not via the non-specific, hand-written and poorly legible treatment notes.   	

The health plan did not act reasonably, with sound medical judgment or in the best interest of the patient. Including but not limited to, the clinical standards of the plan, the information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, nation or professional medical societies boards and associated were taken into consideration. All decisions are evidenced based.  

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, based on the treatment records, the therapeutic activities (97530), neuromuscular reeducation (97112), and therapeutic exercises (97110) were medically necessary.

The insurer's denial of coverage for the therapeutic activities (97530), neuromuscular reeducation (97112) is overturned. Medical Necessity is substantiated
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder
Treatment: Pharmacy/Prescription Drugs - Neupro patch
The health plan denied the requested prescription medication, Neupro. 
The health plan's determination is upheld.

The patient is a man with Parkinson's disease. Treatment with the Neupro patch is the subject of this review.

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

The patient is diagnosed with idiopathic Parkinson's disease. The formulary offers drugs such as Levodopa/Carbidopa, Ropinirole, and Pramipexole. These drugs are all Food and Drug Administration (FDA) approved and literature supported treatments for Parkinson's disease. Similar to the requested drug Neupro (Rotigotine), Ropinirole and Pramipexole are Dopamine agonists. The physician indicates that the patient is unable to use these particular oral agents because he is diagnosed with "gastric slowing" and "gastric swelling".

The neurologic consultation note indicates that the patient has been treated with other oral medications including Propranolol (when he was thought to have essential tremor) and Bupropion for depression. The physician argues that all of the formulary alternatives will not be effective due to this history of gastric swelling; however, there is no medical reason why at least one of the drugs cannot be trialed and the patient can be re-evaluated for signs and symptoms of Parkinson's disease while the patient is on the medication.

As such, while the Neupro patch is a reasonable treatment option, it cannot be said that it is medically necessary over the formulary alternatives because, despite the history of gastric swelling, the patient has been prescribed oral medications before. Furthermore, the neurologic consultation note indicates that one of these medications was even somewhat helpful for this tremor.