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

Diagnosis: Schizophrenia
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial was upheld. 

This is a female patient with a history of schizophrenia. It was reported that the patient had multiple past hospitalization for psychiatric treatment. The patient presented to the emergency department (ED) by her mother for erratic and disorganized behavior. She was admitted for inpatient mental health treatment due to psychotic symptoms including persecutory delusions, disorganized thinking and behavior, erratic behavior, noncompliance with medication and psychiatric outpatient follow up, poor sleep and appetite. The patient was admitted and was restarted on Haldol and was also given Haldol Decanoate. She attended group therapy and it was noted that the patient was calm and cooperative, mood-congruent and full range of effect. At the time period of discharge, it was documented that the patient refused to go to her husband's home and was not welcomed into her mother's house. Thus, the patient was discharged to a shelter.
    
The American Psychiatric Association  (APA) Practice Guidelines for the Treatment of Patients with Schizophrenia reports that patients with hallucinations, delusional thinking, disorganized behavior, suicidal or homicidal plan or intent, agitation, or aggressive behavior are candidates for inpatient treatment.  In this case there were no reports of further serious psychotic symptoms such as delusions, hallucinations, or disorganized behavior, suicidal or homicidal ideation, intent, or plan, manic symptoms, aggressive, threatening, self-injurious, or agitated behavior, withdrawal symptoms or acute medical instability.  

Documentation reported that the patient was calm and cooperative, had congruent mood, denied hallucinations or delusions, had goal directed thought process, fair judgment and insight, denied suicidal or homicidal ideation, was sleeping well and had better ADL's. The patient was calm and cooperative with normal range mood, and was compliant with medications though withdrawn. The patient was discharged to shelter as it was reported that she refused to go to her husband's home and was not welcomed to return to her mother's house.  

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 the continued inpatient hospital admission is not substantiated.  The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Class I Malocclusion, Deep Impinging Overbite, Maxillary and Mandibular Crowding.
Treatment:  D8080 braces.

The insurer denied the D8080 braces.  The denial was upheld.

This is a patient, who consulted an orthodontist to be evaluated for orthodontic care.  The orthodontist recommended comprehensive orthodontics due to Class I malocclusion, deep impinging overbite and maxillary and mandibular crowding.  The orthodontist has completed the HLD index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage. 

It is evident that the patient exhibits a malocclusion.  However, to assess for severity of the malocclusion and, therefore, medical/dental necessity for orthodontic care, a Handicapping Labiolingual Deviation Index is utilized.  This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.  In this case, the treating orthodontist claims an automatic qualifying condition of deep, impinging overbite with severe soft tissue damage.  This reviewer finds that this automatically qualifying condition criterion is not met and does not support comprehensive orthodontic care.  In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care.  This reviewer concurs with the insurer attaining a score of 15 points on the HLD index (4 overjet, 3 overbite, 5 anterior crowding, 3 Iabiolingual spread), which is below the threshold of 26 points to justify orthodontic care. 

Based on this review, D8080 braces are not considered medically necessary for this patient.

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 D8080 braces is not substantiated.  The insurer's denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Digestive system/Gastrointestinal/Inflammatory bowel disease  
Treatment: Pharmacy Prescription drugs
The insurer denied Stelara  syringe every 6 weeks 
The denial is overturned in whole 

The patient is with past medical history significant for Lynch Syndrome, colon cancer, subtotal colectomy, and primary sclerosing cholangitis.the patient  had a diagnosis of ulcerative colitis; however, he was subsequently diagnosed with chronic ileitis, and  symptoms were thought to have been more suggestive of Crohn's disease. The patient has chronic pouchitis and ileitis. The patient  had an anal stricture and abscess adjacent to the pouch.
Yes, the dosage escalation of Stelara to 90 mg every 6 weeks is likely to be more beneficial than any standard treatments. The patient has Crohn's disease with chronic pouchitis, chronic ileitis, and a history of a peri-pouch abscess. the patient  has chronic abdominal pain, hematochezia, and diarrhea. The  serum trough level of Ustekinumab was found to have been low, and a dose escalation of Ustekinumab to 90 mg every 6 weeks resulted in clinical remission for the patient.The patient has already demonstrated clinical remission with the dosage of 90 mg every 6 weeks. the patient  has previously failed therapy with Entyvio. This dosage escalation is considered clinically indicated and medically necessary and is supported by current peer-reviewed medical literature.
"Shortening the ustekinumab 90 mg dose interval to 4 weeks for patients withCrohn's disease (CD) who did not respond to doses every 8 weeks improved clinical and biological indices of disease activity. Patients who lose response to the standard dose of ustekinumab might benefit from dose interval shortening, which was effective and safe." [Jacob E. Ollech et al. Effectiveness of Ustekinumab Dose Escalation in Patients with Crohn's Disease. Clinical Gastroenterology and Hepatology. 2020].
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Digestive system/Gastrointestinal/Inflammatory bowel disease  
Treatment: Pharmacy Prescription drugs
The insurer denied Stelara  syringe every 6 weeks 
The denial is upheld.

This is  patient with a history of Crohn's disease, Lynch syndrome and colon cancer status post subtotal colectomy now with J pouch complicated by chronic pouchitis/ileitis who has had symptoms that have been refractory to various therapies including Vedolizumab, Flagyl and most recently,  Stelara (ustekinumab) with dosing every 6 weeks 
No, the proposed health service of treatment Stelara 90 mg/ml syringe at a dose of 90 milligrams (mg) every 6 weeks 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 requested dosing of Stelara has not been proven to be safe and effective for treatment of Crohn's disease as evidenced by well-designed randomized controlled trials. Retrospective cohort studies have shown some beneficial effects of more frequent dosing of Stelara compared to Food and Drug Administration (FDA) labeled dosing and frequency; however, there are no well-designed randomized controlled trials in review of the medical literature that have shown that more frequent dosing of Stelara is more beneficial than the FDA approved dosing and frequency of 90 mg every 8 weeks[1].
In addition, there are no studies in review of medical literature that have shown superiority of the requested dosing and frequency of Stelara compared to alternative medical therapies including anti-TNF biologic agents such as Remicade and Humira and other biologic agents such as Tysabri in FDA labeled dosing and frequencies [2].
Therefore, the benefits of the requested Stelara therapy does not necessarily outweigh the potential risks of the increased frequency of dosing.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Digestive system/Gastrointestinal/Inflammatory bowel disease  
Treatment: Pharmacy Prescription drugs
The insurer denied Stelara  syringe every 6 weeks 
The denial is overturned in whole 

The patient with Crohn's disease, and Lynch syndrome complicated by colorectal cancer status post subtotal colectomy with a J-pouch complicated by ileitis and pouchitis.
Yes, the proposed Stelara is more beneficial than standard treatment for the insured condition. Current medical literature supports continuation of Stelara 90 mg every 6 weeks in this case. The patient has severe Crohn's disease with diagnosis , and recent surgery. The patient  has had active Crohn's disease despite Stelara 90 mg every 8 weeks; the patient  has previously failed high-dose Entyvio.
American Gastroenterological Association guidelines state that when the drug level is low, as in this case, the drug dose should be increased (Battat, et al; American Gastroenterological Association, et al; Feuerstein, et al). Stelara dosing every 8 weeks or a change to another medication may result in loss of disease control, with complications such as fistula, stricture, bowel obstruction, flare, hospitalization, need for surgery, or other complications.
For these reasons, Stelara 90 mg every 6 weeks is supported as more beneficial than any standard treatment or treatments for this patient's Crohn's disease.
Appeal type: Medical necessity
Decision: Overturned

Orthopedic/Musculoskeletal
Durable Medical Equipment

Diagnosis: Foot pain
Treatment: Custom Shoe Inserts 
The insurer denied the Custom Shoe Inserts. The health plan's determination is overturned. 

This case describes a male patient with a history of bilateral foot pain. The records document that this began a few years ago at which time the patient was prescribed custom orthotics for both feet for acquired pes planovalgus deformity. The records document that the patient had these custom orthotics stolen at his gym. The patient had subsequent bilateral foot pain with activity due to the loss of the orthotics. The provider in this case prescribed bilateral foot orthotics for this patient.

The Durable Medical Equipment: Custom Shoe Inserts are medically necessary for this patient. This is established based on the provided medical records in this case and the current, peer-reviewed orthopedic literature on the topic of pes planovalgus deformity. The records document that this patient had used custom foot orthotics in the past with good functional results. The orthotics were successful in relieving his pain from pes plano valgus, plantar fasciitis and bilateral foot pronation according to the provided records.
The use of custom orthotics for painful pes planovalgus is established in the current, peer-reviewed literature as documented by Sheikh and colleagues in Foot and Ankle Clinics in 2015 and by Chevalier and associates in the Journal of the American Podiatric Medical Association.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Emgality. The denial is upheld in whole.

The patient is a male who according to an appeal letter has episodic migraines. He had a contraindication to use to Topamax a history of renal stones, could not use beta blockers because of bradycardia, and did not want to use tricyclic antidepressants due to an anticipated adverse effect of weight gain. His treating provider noted "most of these treatments are indicated for chronic migraines and not episodic migraines and he does not want to be subject to taking pills on a daily basis." The patient received Emgality two months previously with an 80% reduction in headaches. His typical migraine is pain in the left eye radiating to the left temple and then to the left side of his forehead with immense discomfort with the blurred vision in the left eye, with each episode lasting 30 to 45 minutes. Within 6 days after starting Emgality his migraine frequency dropped from 12 episodes per month to 2 episodes, and he had an excellent response. 
Office notes  indicated treatment with sumatriptan as the only migraine medication. The patient had been treated with a sample of Emgality in the office.  The reported a significant reduction in eye pain and headaches and required sumatriptan twice in the previous 6 weeks.

The reason for denial indicated that the patient had a history of episodic cluster headaches. There is no documentation of any diagnosis of episodic cluster headaches. The provider diagnosed episodic migraine without aura. The appeal request did not make any mention of episodic cluster headaches. The subject under review is the medical necessity of treatment with Emgality.

The health plan's determination is upheld in whole.

The reason for denial was based on a diagnosis of episodic cluster headaches, which this patient does not have. The patient's provider documented a diagnosis of episodic migraine in both notes.  The plan alternative Verapamil 360 milligrams (mg) daily is not an appropriate alternative for migraine prophylaxis. (It is for cluster headaches). The use of Emgality, however, would not be considered medically necessary as there is evidence-based migraine prophylactic medication available for the patient (tricyclic antidepressants or venlafaxine). The only the reason why neither of these medications were used was because of the patient's concerns about weight gain. However, anticipation of an adverse effect does not predict its occurrence and is no reason why the patient cannot use amitriptyline or venlafaxine. There is no evidence in the peer-reviewed medical literature that either medication is less effective than Emgality. Therefore, based on the treating provider's diagnosis of episodic migraine and the history of prior treatment, the use of Emgality not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic musculoskeletal/Osteoarthritis 
Treatment: Home Health Care 

The insurer denied Home Care/Personal Care HHC- Increase to 24 Hour(s) per Day(Split Shift). Live in per diem. The denial is overturned in whole. 

The patient with past medical history of atrial fibrillation on anticoagulation, coronary artery disease, congestive heart failure, tobacco abuse, dementia, chronic pain, hyperlipidemia, gastroesophageal reflux disease, chronic obstructive pulmonary disease (COPD), depression, hypothyroidism, bladder and bowel incontinence, and gait /mobility disorder. 

Yes, the requested Home Care/ Personal Care HHC Increase to 24 hours per day (Split shift) live in per diem is medically necessary for this patient. 

The patient had worsening of chronic medical problems including chronic pain, gait and mobility impairment and dementia. Following the  hospitalization  the patient had increased ADL needs. The patient required frequent help with ADLs of bed mobility, toilet use, incontinence cares, transfer toilet, walking and locomotion in the overnight hours. PCA services would not be for safety and supervision alone. A personal care aid would not be able to sleep for 5 hours uninterrupted due to the patient's PCA care needs in the overnight hours. The patient's PCP noted on 2 occasions that the patient requires turning and positioning every 2 hours due to incontinence and fragile skin. PCA services are medically necessary 24 hours/day, split shift, 7 days/week.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiovascular.
Treatment: Inpatient stay.
Issue: Medical necessity of the inpatient stay.

The health plan's determination is upheld in whole.

Patient has  a history of coronary artery disease and previous bypass surgery, chronic congestive heart failure with left ventricular ejection fraction  of 30% on guideline-directed medical therapy for greater than 6 weeks, hypertension and diabetes who presented to the hospital on for elective implantation of an implantable cardioverter defibrillator  which was performed without complication. The patient was observed and monitored uneventfully overnight and discharged the next day.

The patient needed an ICD implantation for primary sudden death prevention. He has a history of hypertension, diabetes, coronary artery disease and previous bypass surgery, chronic congestive heart failure with left ventricular ejection fraction of 30%. He has been on guideline-directed medical therapy for greater than 6 weeks. This was an elective, planned procedure. A full inpatient admission was not necessary for this procedure as it would be expected that in the absence of complications, the discharge would be within 24 hours with a very low risk of serious complications. The patient could have had the implantation procedure with overnight observation and monitoring on a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Norovirus.

Treatment: Inpatient admission.

The insurer denied the inpatient admission.

The denial was upheld.

This is a female patient with past medical history significant for immune disorder, status post liver transplant, seizure disorder, CNS toxoplasmosis, and recent liver abscess who returned to the Emergency Department with complaints of abdominal pain and right upper quadrant (RUQ) drainage. Her presentation vital signs included: Temperature 98.6 F, Blood Pressure-147/65, Pulse-96, Respiratory Rate-19, and Oxygen (O2) saturation-100% on room air.  Laboratory results included the following: White blood cell (WBC) count-6.3, hemoglobin (HGB)-9.6, hematocrit (HCT)-29.2, creatinine-0.92, and glucose-127. She was admitted to the hospital for abdominal discomfort at site of previous drainage procedure.  She was treated with intravenous fluids.  Gastroenterology PCR panel was positive for norovirus. Infectious Diseases consulted and recommended adjustments in antibiotics.  The patient had been on oral ciprofloxacin and linezolid since recent discharge from the hospital.  The patient remained afebrile, hemodynamically stable.  All other cultures were negative.  She was discharged to continue outpatient management. 

According to documentation, patient presented with some gastrointestinal symptoms following discharge from hospital for management of liver abscess.  Otherwise, patient was afebrile, hemodynamically stable with unremarkable laboratory results including normal WBC.  In fact, Infectious Diseases noted "overall improvement in liver abscess." GI panel was positive for norovirus PCR which required symptomatic management.    Intravenous (IV) hydration and anti-emetics could have been given in the Emergency Room (ER) as an outpatient. Based on the above findings, the patient met criteria for observation level of management.  She did not meet fulfill criteria for acute inpatient re-hospitalization.  

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

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

Diagnosis: Mental Health/Depression 
Treatment: Mental Health Inpatient 
The insurer denied part of the inpatient mental health hospital stay
The denial is upheld in whole

The patient who presented for acute inpatient level care transferred from general medical services to address respiratory problems and urinary retention following a suicide attempt and overdose. 

No, the requested health service/treatment of Inpatient Hospital Stay is not medically necessary for this patient.
The continued acute inpatient mental health stay and treatment from is not medically necessary for this patient. The patient no longer required the structure or the 24-hour monitoring of an acute inpatient level of care in order to administer continued treatment for the psychiatric disturbance and comorbid conditions including continued treatment for the substance use disorders and support of daily activities and general medical conditions.
The patient's presentation and clinical features included an exacerbation of the patient's psychotic and mood disorder in the context of severe symptoms of depression and deterioration in functioning in the context of severe psychosocial stressors and suicidal behavior/attempt. The patient exhibited cognitive impairment (disorder thought processing and executive function) had acted on his depressive thought content with an overdose. The patient responded to treatment such that by 02/14/2020, he was clinically improved and had no persistent symptoms that posed an imminent risk for harm to self (or others) or interfered with the patient's ability to cooperate with care. There was no evidence of other symptoms or behaviors that would have required continued acute inpatient level of care from  going forward. The patient's mental health issues and co-occurring substance use disorders and general medical conditions could have been managed at a lower level of care during the time frame under review. The primary reason for the continued inpatient stay was related to the patient's need for placement with safe and appropriate housing and other social services. 
This answer is consistent with the practice guidelines and scientific literature referenced below, as well as the application of NY State OASAS LOCADTR 3.0 Criteria/Guidelines.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nausea and vomiting, left sided weakness and facial droop
Treatment: Inpatient admission
The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is an male with diabetes, hypertension, and previous cerebrovascular accident (with residual left-sided deficits) who was admitted to the hospital with left-sided weakness and facial droop.  Computed tomography of the brain demonstrated no acute process.  Labs were notable for a potassium 5.0, blood urea nitrogen (BUN) 28, creatinine 1.7, and glucose 151.  On admission the patient was afebrile with a blood pressure 137/84 and pulse 101.  Intravenous fluids and a heparin infusion (for atrial fibrillation) were provided.  Nephrology, cardiology, and neurology were consulted.  The creatinine dropped to 1.2-1.4.  Magnetic resonance imaging of the brain demonstrated no acute cerebrovascular accident.  An echocardiogram demonstrated a normal ejection fraction with no cardiac thrombus or valvular abnormality.  Anticoagulation was transitioned to the oral route and oral metoprolol was given.  Physical therapy was provided.  Gastroenterology consulted for vomiting.  Upper endoscopy demonstrated duodenal hives.  Oncology consulted for mediastinal lymphadenopathy noted on computed tomography of the abdomen/pelvis.

No, the proposed treatment, inpatient admission, was not medically necessary.

The patient's left-sided weakness and increased facial droop were evaluated with computed tomography and magnetic resonance imaging of the brain which demonstrated no evidence of acute cerebrovascular accident.  There was no evidence of bleeding on heparin infusion.  The patient's atrial fibrillation was easily rate controlled and the patient did not have hemodynamic instability or need for cardioversion or antiarrhythmic therapy.  The patient had only a mild degree of acute kidney injury, with prompt improvement in renal function with intravenous fluid administration.  The patient did not require dialysis and did not have hyperkalemia, uremia, acidosis, or volume overload.  There was no evidence of persistent vomiting, and upper endoscopy demonstrated only duodenitis.  Computed tomography of the abdomen/pelvis demonstrated no acute process.  

In summary, acute inpatient admission was not medically necessary.