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

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

The patient is a male who had the complaints of watery diarrhea while on immunotherapy. The patient had a history bladder cancer with a cystectomy.  There was a concern for immunotherapy-induced colitis. The patient was noted to be status post drainage of an anterior abdominal wall fluid collection consistent with ulcerative colitis with plasmacytoid features. 

The patient's white count was 8.4, hemoglobin/hematocrit (H/H) was 14.1/41, sodium (Na) was 132, potassium (K) was 3.6, blood urea nitrogen (BUN) was 16 and the creatinine was 1.5.  The vital signs were: temperature of 37.5, pulse 78, respirations 20, and blood pressure 105/68.  A computed tomography (CT) scan of the abdomen and pelvis was consistent with pancolitis and reactive mesenteric nodes. The patient received intravenous (IV) fluid and a tap water enema at the recommendation of the Gastroenterology (GI) consultant.

No, the inpatient admission was not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient as there was no notation of hemodynamic instability, severe pain or bloody diarrhea, toxic megacolon, perforation, severe vomiting or severe electrolyte abnormalities. The patient was afebrile, and vitals were stable. The labs were significant for an elevated C-reactive protein (CRP) of 10.21, and also a creatinine of 1.6 which trended down with intravenous (IV) fluid hydration. A computed tomography (CT) scan of the abdomen and pelvis showed a new pan-colonic wall thickening and hyperemia which was consistent with colitis and new mesenteric nodes, possibly reactive. A gastroenterology (GI) polymerase chain reaction (PCR) and Clostridium (C) difficile were negative. Gastroenterology was consulted and the patient underwent a flexible sigmoidoscopy that showed erythematous mucosa in the recto-sigmoid colon as well as several rectal ulcers.  The diarrhea improved with treatment with methylprednisolone. The patient remained afebrile and hemodynamically stable. The care could have been provided in its entirety at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status Asthmaticus

Treatment: Inpatient admission

The insurer denied the inpatient admission.

The denial was overturned.    

This is a male patient with a history of asthma.  It was reported that the patient had been sick for several days with a cough and rhinorrhea. The patient presented to the Emergency room (ER) with complaints of shortness of breath. It was reported that the patient had run out of his albuterol rescue inhaler. In the ER, the patient was noted to be in respiratory distress with intercostal retractions.  On physical examination, there was marked reduction in air entry bilaterally and wheezing.  The patient was treated with 3 doses of duoneb treatments, steroids, magnesium and IV normal saline bolus.  There was improvement with this treatment. However after a short period of time the patient was again noted to have a recurrence of respiratory distress with intercostal retractions.  The patient was then treated with subcutaneous terbutaline and three additional treatments with albuterol.  When his diminished air entry did not improve following this additional treatment, the decision was made to admit the patient to the hospital for albuterol every 2 hours with a diagnosis of status asthmaticus. After a period of medical stability the patient was discharged home.

Based on the review of the medical record and literature, the patient was treated appropriately in the Emergency Room for persistent wheezing and decreased breath sounds from status asthmaticus.  As per UpToDate review on asthma for pediatric patients, intravenous magnesium sulfate is reserved to patients with severe asthma exacerbations while in the Emergency Department. This was the case with this patient, and despite given IV magnesium sulfate, the patient's respiratory symptoms persisted. The patient was noted to have persistent wheezing and evidence of airway obstruction with diminished breath sounds and increased work of breathing. UpToDate states that "Patients who were moderately to severely ill on arrival and who have little improvement after initial therapy with beta agonists and systemic glucocorticoids require hospitalization. This includes patients who continue to have significant wheezing and retracting, poor aeration, or altered mental status, such as drowsiness or agitation." This was the case for this patient. 

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

The carrier's denial of coverage for the inpatient hospital admission should be overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Intracerebral hemorrhage (ICH) secondary to arteriovenous malformation (AVM)
Treatment: Inpatient rehabilitation admission
The insurer denied coverage for the hospital admission.
The denial is upheld.

This is a female patient was multiple medical problems including intracerebral hemorrhage (ICH) due to arteriovenous malformation (AVM), spasticity, as well as status left hip girdle-stone procedure. The patient underwent a right elbow capsule contracture release, heterotopic ossification removal and ulnar neurolysis.  She was admitted for acute inpatient rehabilitation.  

The clinical records do not demonstrate a level of functional improvement to support the medical necessity of continued acute inpatient rehabilitation services for the time period under review.  The patient was admitted to the acute inpatient rehabilitation unit status post right elbow ulnar neurolysis with heterotrophic ossification and contracture release.  Upon admission, the patient was total to maximal assistance for activities of daily living and functional mobility.  The patient remained at the total to maximal assistance level when she was discharged home.  The patient's treatment which included use of the continuous passive motion (CPM) machine, baclofen pump management and percutaneous endoscopic gastrostomy (PEG) tube feeds did not require acute inpatient rehabilitation.  In addition, there were no specific medical or nursing needs that warranted acute inpatient rehabilitation.

From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, continued inpatient rehabilitation was not medically necessary.

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.  

Based on the above, the medical necessity for continued inpatient rehabilitation is not substantiated.  The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness Of Breath And Leg Swelling
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld. 

The patient is a male. He presented with dyspnea on exertion, abdominal distension, and 12 pound weight gain. His co-morbidities include hypertension and BPH (benign prostatic hyperplasia). 

The patient was hypertensive with 100% Oxygen saturation. He had elevated WBC (white blood count) and BNP (brain natriuretic peptide).

The patient was prescribed diuretics and antibiotics. The BP (blood pressure) normalized, and he diuresed. Echocardiogram showed EF (ejection fraction) of 20% and valvular heart disease. Catheterization showed non-obstructive CAD (coronary artery disease). After 20 pounds of fluid loss, he was discharged on medical therapy.

No, the Inpatient admission was not medically necessary.

Determination of level of care is primarily dependent on the actual care a patient receives, and whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results. It is highlighted in the orders for care. 

In this case, the patient's symptoms were typical Acute on Chronic CHF (congestive heart failure). The patient's initial hypertension resolved to normal in seven hours. His saturations were always 96% or higher. He had no hemodynamic instability. He responded to conservative therapy of diuresis promptly and successfully. While echocardiogram was abnormal, it was not a new finding. Cardiac catheterization was without complications, and it showed no CAD (coronary artery disease).  No care that was actually provided required an acute level of care. 

All of the testing and therapy that were provided would have been appropriate, safe and guidelines-consistent in a lower level of care. Thus, inpatient level of care was not medically necessary.

The denial explanation was consistent with guidelines and usual community care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia

Treatment: Inpatient hospital admission

The insurer denied the inpatient hospital admission.

The denial was upheld.  

This is a male patient with a history of treatment-refractory FSGS (Focal segmental glomerulosclerosis) status post bilateral native nephrectomies and kidney transplant over a year ago. He presented to the Emergency Department (ED) with a fever. The patient's vital signs in the ED showed blood pressure of 115/60 with a pulse of 94 beats per minute.  The patient's temperature was 100.6 and respirations were 20 with oxygen saturation at 98%.  The patient's exam revealed a right chest wall catheter with dressing present. The patient was alert, oriented and not in distress. The patient had normal breath sounds with no wheezing as well as a normal cardiovascular and abdominal exam.  The physician indicated that the patient was febrile in the setting of immunosuppressed status.  Laboratory worked up revealed a white blood cell count (WBC) count 4.4 and creatinine 2.13. It was recommended that the patient undergo an infectious work-up. The patient's chest x-ray showed infiltrate/pneumonia and he was treated with intravenous (IV) antibiotics (i.e. cefepime and Vancomycin). The patient was admitted to the hospital and treated with continued IV fluids and IV antibiotics.  The patient's blood culture showed no growth at day #1.  After a period of stability, the patient was discharged home.

As in the general adult population, common infections that occur in transplant patients include respiratory tract infections such as pneumonia and the treatment of these patients is the same as for the general population. In this case, the patient presented with a fever and a chest X-ray that revealed an infiltrate suggestive of pneumonia. Considering this patient's immunosuppressed status, the patient received IV antibiotics as well as IV fluids. However, the patient was hemodynamically stable and was not in distress. As per MCG clinical guidelines for pneumonia, admission is indicated for hypoxemia, hemodynamic instability, altered mental status that is severe or persistent, dehydration that is severe or persistent, complicated pleural effusions, and/or patient failed outpatient treatment. At the time of inpatient admission, the patient's clinical presentation was stable to warrant observational level of care. Inpatient admission could have been considered after failing observational level of care. 

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient stay should be upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Plaque Psoriasis.
Treatment: Otezla.
The insurer denied the Otezla.
The denial is upheld. 

This is a female with psoriasis of the scalp, which has failed topical therapy with clobetasol. She reports severe itch and great psychological distress. Her dermatologist put her on Otezla samples, and she was much improved. A continuation of therapy was requested.

No, the proposed Otezla is not medically necessary.

The current treatment guidelines that are in accordance with nationally accepted standards of medical practice for moderate to severe plaque psoriasis recommend typical first-line treatments such as topical corticosteroids and calcipotriene followed by typical second-line treatments such as ultraviolet phototherapy, oral systemic treatments (methotrexate, acitretin, cyclosporine) or biologics. There is no documentation that the patient has tried and failed topical treatments other than clobetasol or that she is not a candidate for them.  Therefore, Otezla is not medically necessary. Also, there is not a body surface area (BSA) or severity documented in the medical record.

Otezla, an inhibitor of phosphodiesterase four (PDE4), is indicated for the treatment of adult patients with active psoriatic arthritis and patients with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy.  (Celgene, 2015)  Otezla is an oral small-molecule inhibitor of PDE4 specific for cyclic adenosine monophosphate (cAMP) and is indicated for the treatment of adult patients with active psoriatic arthritis (PsA) as well as the treatment of patients with moderate to severe plaque psoriasis. (Celgene, 2016)  

There is no documentation that the patient has moderate to severe plaque psoriasis and is a candidate for phototherapy or systemic therapy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Atopic Dermatitis.
Treatment:  Pharmacy/Prescription Drugs (Dupixent).

The insurer denied Dupixent.  The denial is upheld in whole.

The patient is a male with moderate to severe atopic dermatitis (86% body surface area involvement) located on the body throughout.  The patient has tried and failed topical triamcinolone, betamethasone, clobetasol, Elidel, Eucrisa, mupirocin, and tacrolimus, as well as oral doxycycline.

The subject under review is the medical necessity for the treatment with Dupixent.

No, treatment with dupilumab (Dupixent) is not medically necessary for this patient.  It should be emphasized that atopic dermatitis is an ongoing inflammatory disease affecting the skin, with the need to control any immune/inflammatory hypersensitivity being for some patients intermittent, and for some patients to be controlled on a chronic and ongoing basis.

The usual treatment is with topical steroids and topical immunomodulators (1-4), emollients, mild soap, avoidance of irritants, and similar conservative treatments.  Weather changes, physical illness, and even emotional stress can trigger atopic dermatitis.  If topical therapies cannot control this patient's atopic dermatitis, then systemic therapies become standard of care in order to achieve proper disease control, physical functioning and quality of life.  Systemic therapies are often needed for more severe and/or treatment-resistant cases of atopic dermatitis (5-8), and such appears to be the case with this patient.

Dupixent is only truly medically necessary when other similar, reasonable, and standard treatments have been tried and failed, but such is not the case at this time.  The patient has no documented treatment failure with, or true medical contraindication to, either of the standard, first-line oral medications such as Methotrexate, Azathioprine, or Cyclosporine.  Dupixent is not proven to be superior to plan preferred alternatives as per comparative, controlled studies.

Modern dermatology literature reviews (1-4, 6-8) and American Academy of Dermatology Clinical Guidelines in the treatment of atopic dermatitis (5) support use of phototherapy, Cyclosporine, Methotrexate, Azathioprine and/or brief courses of systemic corticosteroids as potential and appropriate systemic therapies for more severe cases of atopic dermatitis.  These treatments are both time-tested, standard of care, and supported by modern dermatology literature and larger studies/comparative trials.  While Dupixent is a promising new agent in the systemic treatment of atopic dermatitis, it is not confirmed to be significantly superior to these alternative, and time-tested therapies described above.  To date, this patient has had no past history of systemic therapies.

The request for Dupixent is, therefore, not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia
Treatment: Home Health Care
The health plan denied an increase in PCA hours. 
The health plan's determination is upheld.

The patient is a female with past medical history of dementia, pseudophakia of both eyes, chronic kidney disease stage 3, diabetes mellitus type 2, hyperlipidemia, hypertension and gastroesophageal reflux disease (GERD) who had been assigned Personal Care Assistant/Consumer Directed Personal Assistant Services Program (PCA/CDPAS) service hours of 4 hours/day, 7 days/week to total 28 hours/week based on an assessment tool. The patient was assessed at maximum assistance with tasks of meal preparation and ordinary housework and extensive assistance with tasks of managing finances, managing medication, stairs, shopping and transportation. The patient was assessed at limited assistance with tasks of bathing and dressing lower body while supervision level of assistance for tasks of personal hygiene, dressing upper body, toilet use and eating. The patient was assessed as independent for tasks of walking, locomotion and toilet transfer . The assessor noted this was an initial assessment for patient, cognitive skills were minimally impaired, lives with her granddaughter, uses a cane to ambulate, is not allowed to cook, lives on the third floor of her house with three flights of stairs and has infrequent incontinence. The patient was referred to a neurologist. The patient's primary care physician provided a letter requesting more home care hours for the patient. The letter stated " this request is medically necessary for the following reasons: the patient needs more assistance maintaining self-care due to dementia. She needs assistance with eating, bathing, cooking, cleaning, taking medication and transporting to appointments. Patient would benefit from 6-8 hours a day of home care". There was a formal request to increase PCA/CDPAS service hours. There was a final adverse determination denial notice sent stating the assessments and the New York Department of Health (NYDOH) guidelines for CDPAS do not support the medical necessity of 6-8 hours/day, 7 days/week of CDPAS to assist your activities and maintain your health in the home. This notice stated the daughter spoke to a nurse who stated there was no significant change in the patient's clinical status.

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

No. Based on the information provided for review which included the assessment tool, a letter from the PCP and the denial letter from insurer the request to increase in CDPAS services is not medically necessary. The patient did not have another assessment tool performed at the time of the request for increased CDPAS hours which is typical, as this was not provided for review. The patient's PCP letter indicated the patient needed an increase in CDPAS service hours to 6-8 hours per week. There is insufficient evidence that it is medically necessary for the patient to have an increase in PCA/CDPAS service hours.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary Incontinence/Pelvic Organ Prolapse.
Treatment: Inpatient Stay.
The health plan denied the inpatient stay. 
The health plan's determination is upheld.

The patient is a female with stress urinary incontinence and pelvic organ prolapse. She had a history of mitral valve prolapse without complication. She had a robotic supracervical hysterectomy, bilateral salpingectomy, sacrocolpopexy, suburethral sling and cystoscopy. There were no complications. She was admitted as an inpatient that day. She was given oral pain medications. She was discharged the following day. There is a question of the medical necessity of the inpatient hospital admission.

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

The requested health service/treatment of an inpatient stay was not medically necessary for this patient.
The patient was a healthy woman with only mild mitral valve prolapse. She had an outpatient procedure without any complications. Blood loss was minimal and vital signs were normal. She was monitored in recovery and then admitted as an inpatient however she could have been treated at a lower level of care under extended monitoring without the need for inpatient hospital admission. She had no cardiovascular or hemodynamic complications after surgery. She had no hepatic, renal or pulmonary complications. She had no excessive bleeding, infection nor poor pain control. She had no anesthesia complications. She was in the hospital for less than 24 hours, which does not support the severity of any condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems/malpositioned teeth.
Treatment: Orthodontic procedure.
The health plan denied the treatment plan of Braces as not medically necessary. 
The reviewer has upheld the determination in whole.

The patient has mild maxillary and mandibular crowding. #6 and #11 have erupted lingually within the arch and baby teeth C and H remain. The patient has a class II occlusion with overjet and 10% overbite. The patient is treatment planned for 24-30 months of orthodontics to align the teeth and correct the bite, but the plan was denied due to lack of medical necessity.

While the patient has crowded teeth, there is not anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. [2] This patient presents with none of those conditions. If the teeth were aligned it would provide an aesthetic improvement, but it would not create a medically significant improvement to the patient's health. For these reasons' treatment is not medically necessary.
#6 and #11 are lingual but they have erupted successfully. There are no indications of gingival recession or pathology from the tooth position of #6 or #11. It is not as if the tooth was so crowded it was prevented from erupting, which left untreated it could damage the roots of other permanent teeth [1] leading to more invasive and expensive procedures than orthodontic treatment.