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

Diagnosis: Substance use. 
Treatment: Inpatient admission.

The insurer denied coverage for the inpatient admission.
The denial is overturned.

This is a female patient who was admitted to inpatient hospital treatment for detoxification. The patient presented with withdrawal symptoms including tremors, sweats, abdominal pain, irritable mood, and anxiety. The patient had a Clinical Opiate Withdrawal Scale (COWS) score of 9 and Clinical Institute Withdrawal Alcohol (CIWA) score of 9. The patient reportedly was using 10-15 bags of intravenous (IV) heroin daily and drinking six 12-ounce beers daily. The patient had past inpatient substance detoxification. The patient reportedly was put on detoxification protocols of methadone and Librium, and took these detoxification medications.
  
The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. In this case, this patient had use of multiple substances including heroin and cannabis, and was at risk for death from overdose. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient required 24-hour treatment as she could not safely and effectively be treated for detoxification in a less restrictive setting as she continued to use serious substances including IV heroin with alcohol despite past inpatient substance treatment. The patient also required and received 2 detoxification medications, i.e. Librium and Methadone to modify her withdrawal symptoms from alcohol and heroin. The patient needed this 24-hour inpatient treatment because she was at risk for worsened withdrawal symptoms, and likely would have relapsed again as evidenced by her history of relapsing after past inpatient treatment. 

Based on the review of the medical record and literature, inpatient admission was medically necessary for this patient. The patient was at risk for overdose and also severe, complicated, and life-threatening withdrawal that required this 24-hour inpatient detoxification treatment.

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

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

Diagnosis: Parkinson's disease
Treatment: Personal Care Services 24 hours a day, 7 days a week (split-shift)
The insurer denied the Personal Care Services 24 hours a day, 7 days a week (split-shift).
The denial is upheld.

The patient is a male with a diagnosis of Parkinson's disease who is requesting Personal Care Services at 24 hours a day, 7 days a week (split-shift).  The plan has approved 56 hours per week.

The patient's assessment performed shows minimally impaired cognition and needs: max assistance with meal prep, and shopping; total dependence with housework; extensive assistance with managing finances and medications, bathing, personal hygiene, and dressing; limited assistance with phone use and bed mobility; and independent with walking, locomotion, and toileting.

A letter from the provider notes the patient has tremors, decreased strength and slowed movements.  It states that the patient needs assistance with ADLs (activities of daily living) and contact guarding with ambulation.  The patient is unable to bathe and get to the bathroom in a timely manner. It states that the patient requires assistance with nighttime diaper changes.

The Plan provides equipment including diapers, shower chair, grab bars, and bedside commode.  Therapy has been offered to help with strength and balance.

No, the Personal Care Services 24 hours a day, 7 days a week (split-shift) are not medically necessary.

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 
- the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

The proposed treatment is not medically necessary, because it is not consistent with generally accepted national standard of medical practice for this patient's scenario.

Continuous, or split-shift, personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning or positioning.

The assessment does not support the medical necessity for split shift personal care services.  The patient require assistance with meal prep, housework, bathing, personal hygiene, dressing, shopping, and medications.  He wears diapers due to incontinence and is requesting additional services to assist with nighttime incontinence.  Nighttime diaper changes do not support the need for 24 hour split-shift personal care services.  This patient's level of functioning does not require 24 hour split-shift personal care services.  The approved 56 hours per week is sufficient to provide assistance with ADLs (activities of daily living) and personal care for this patient's scenario.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Missing tooth
Treatment: Partial Lower Denture (D5226)
The insurer denied the Partial Lower Denture (D5226).
The denial is overturned. 

The patient is a female requesting lower partial denture to replace tooth #25.

The Partial Lower Denture (D5226) is medically necessary.

The patient is having a hard time speaking due to spitting from the missing tooth area. Also, the teeth on either side of missing tooth could move out of position, causing trauma to them. The partial denture will help keep everything in position.

The missing tooth was creating speech problem, which needed to be addressed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right-sided profound sensorineural hearing loss with essentially normal hearing to the left ear.

Treatment: Cochlear implants.

The insurer denied coverage for cochlear implants.

The denial is overturned. 

This patient is a male child who was seen for evaluation of right-sided profound sensorineural hearing loss with essentially normal hearing to the left ear. The documentation detailed this patient has previously undergone Magnetic Resonance Imaging (MRI) of the brain and a Computed Tomography (CT) scan which does not reveal a cause. The physician noted that without an identifiable cause they cannot exclude the very possibility that hearing in his good ear may also decline. The documentation indicated that based on audiologic test results the patient was a candidate for a cochlear implant to the right ear. Other rehabilitation options for single-sided deafness do include Contralateral Routing of the Signal (CROS) hearing aids and bone anchored hearing aids. The documentation does include hearing evaluations detailing his hearing was normal in the left ear and the right ear had profound mixed hearing loss from 250-6000 hertz (Hz). 

Single-sided deafness and asymmetric hearing loss have been proposed as an indication for cochlear implantation. Most options considered rely on the transfer of sound from the poor ear to the better ear, using CROS hearing aids or bone anchored hearing aids. In contrast, cochlear implantation allows the poor ear to be stimulated and binaural hearing abilities to be at least partially restored. There are level IV published studies have reported an improvement in the spatial localization of an incoming sound and better speech recognition in noisy environments after cochlear implantation in patients with unilateral deafness. It also provides consistent relief of tinnitus in many patients. The Food and Drug Administration (FDA) has now approved cochlear implantation as a treatment for single-sided deafness.

In the present case, the patient has been evaluated for standard hearing aids, CROS hearing aids, and bone anchored hearing aid evaluation, which will not re-establish hearing perception to the right ear. At this point, cochlear implantation would be the only viable treatment to reestablish this patient's hearing for speech perception in the right ear. In this case it is especially important since the "good" ear may also decline, which would also effect the patient's social development and education. 

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

Based on the above, the medical necessity for the Pre-Service request for cochlear implants is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal distension; Abdominal pain. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a male. 

A brief summary of the hospital stay is as follows: 

(Admission History and Physical) Two-to-three-week history of worsening abdominal distension and abdominal pain. He was seen in in the ED (Emergency Department). CT (computed tomography) scan showed abdominal distention and ileus. Surgery consulted with no acute issues. GI (gastroenterology) consulted and recommended admission for inpatient care. The plans included IV (intravenous) fluids; routine monitoring. 

(Progress note) Clinically stable and discharged home. 

No, the Inpatient Admission was not medically necessary. 

As documented in the clinical notes, this patient had worsening abdominal distention and was admitted for inpatient care. During the hospital stay, the patient received IV (intravenous) fluids, but not any other acute intervention. The patient was clinically stable on the second day and then discharged home. There was no documentation for suspected acute intra-abdominal process, ascites requiring acute treatment, severe diarrhea, severe dysphagia, gastroparesis, encopresis or severe fecal impaction or any other acute issues. Thus, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Paraganglioma.
Treatment: Proton beam radiation therapy.

The insurer denied coverage for proton beam radiation therapy.
The denial is overturned. 

This is a female patient with recurrent paraganglioma of her bilateral carotid sheath and mediastinum. The patient previously has been treated in the past with resection, radiotherapy, and systemic chemotherapy. The patient has been recommended to proceed with a course of re-irradiation to minimize the risk for further tumor progression. The request is for approval of proton beam radiation therapy.

As per Cao, et al (2018), "Proton beam therapy is an effective and well-tolerated treatment modality of skull base paragangliomas, with documented functional benefit. A longer follow-up is planned in order to assess local control and long-term toxicities." 

As per Kang, et al (2020), "Patients with [head and neck paragangliomas (HNPGs)] can be effectively and safely treated with proton therapy with excellent tumor control, successful volumetric tumor reduction, and symptomatic improvement." 

As per Lesueur, et al (2019), "Proton-therapy for treatment of adult benign intracranial and cervical tumors is safe. Randomized or prospective cohorts with long term cognitive evaluations are needed to assess the real place of proton-therapy in the treatment of adults [with] benign head and neck tumors."                                                      

Based on the review of the medical record and literature, proton beam radiation therapy is considered medically necessary for this patient. The American Society for Radiation Oncology (ASTRO) Model Policy supports the use of proton beam radiation therapy for re-irradiation cases as proton beam radiation allows for maximal sparing of surrounding normal tissues. The use of photon beam radiation therapy in this patient's setting would be associated with an excessive risk for high grade toxicity, while the use of proton beam radiation therapy will significantly minimize these risks. There are high quality prospective clinical outcomes published in the peer reviewed medical literature which support the use of proton beam radiotherapy for management of paraganglioma.

The health plan did not act reasonably with sound medical judgment and in the best interest of the patient. As discussed above, proton beam radiotherapy is medically necessary and standard of care in this patient's setting as this is a case of re-irradiation and the patient has an excellent prognosis with long life expectancy.      

Based on the above, the medical necessity for proton beam radiation therapy is substantiated. The insurer's denial should be overturned.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Ulcerative Colitis
Treatment: Formulary exception for Xeljanz 10MG Tablet
The insurer denied the Treatment: Formulary exception for Xeljanz 10MG Tablet.
The denial is upheld. 

The patient is a female with ulcerative colitis. She has failed treatment with Apriso and Budesonide. She was started on Xeljanz and has been doing well. Her provider is requesting continuation of Xeljanz.

The patient has moderate to severe ulcerative colitis. The plan-preferred agent in Humira. Xeljanz is FDA (Food and Drug Administration)-approved and supported by medical literature for the treatment of moderate to severe ulcerative colitis, when patients have failed anti-TNF (tumor necrosis factor) agents such as Humira. As the patient has not failed Humira, or any anti-TNF (tumor necrosis factor), the health plan should therefore not cover the formulary exception for Xeljanz.

While the provider states in appeal letter that, "Xeljanz inhibits JAK (janus kinase)-1 and JAK (janus kinase)-3, which in turn block several types of interleukins that are responsible for activating T cells and B cells. It's thought that by suppressing JAKs and thereby inhibiting the chain of events that activates T cells and B cells, it may stop the inflammatory process that fuels some immune-mediated conditions, such as arthritis and inflammatory bowel disease," Humira, an anti-TNF (tumor necrosis factor), blocks activation of other cells (macrophages, T-cells, B-cells), proinflammatory cytokine production (IL [interleukin]-1, IL [interleukin]-6), chemokine production (IL [interleukin]-8, RANTES [regulated upon activation, normal T cell expressed and presumably secreted]), expression of adhesion molecule (ICAM-1 [intercellular adhesion molecule 1], E-selectin), inhibition of regulatory T-cells, RANK (receptor activator of nuclear factor kappa-B)-ligand expression upregulation, matrix metalloproteinase production and induction of apoptosis, and thereby decreases inflammation in ulcerative colitis and arthritis.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism; Feeding Difficulties

Treatment: Speech and Swallow Therapy

The insurer denied coverage for continued speech and swallow therapy.

The denial is overturned. 

This is a female child patient with a history of autism, psychogenic food refusal, and poor growth bordering on FTT (failure to thrive). She had demonstrated significantly restricted food choices which have proven inadequate for growth and development. She had moderate success with an outpatient feeding program and her pediatrician feels participation is medically necessary for this patient in order to achieve adequate growth and development. Her growth curves continue to drop. The insurer has denied coverage for continued feeding therapy services as not medically necessary.

Pediatric feeding disorders are one of the most frequent concerns in pediatric medicine. Avoidant/restrictive intake disorder (ARFID) can contribute to impaired cognitive or emotional development, comprised immune functioning, and may contribute to hospitalization. Adequate nutrition and growth curve maintenance may also be impacted. (1) Behavioral and sensory-based food avoidance can be a common issue in children with Autism Spectrum Disorder (ASD). Expert consensus is increasingly recognizing intensive multidisciplinary intervention at a day hospital program as the standard of care for children with complex feeding disorders. (2, 3)

Additionally, the patient has already been medically affected by her ARFID by loss of weight, decreasing body mass index (BMI) and occasional constipation. She has excellent family carryover and support with the guidance of the interdisciplinary team in the outpatient feeding program she attends.

In a systematic review of such feeding programs, findings corroborated positive outcomes associated with intensive day feeding programs. Treatment was also shown to promote oral intake, improved mealtime behavior and reduced parental stress. (4)

Treatment at the program the patient attends is multi-disciplinary and highly regarded. The patient has made gains in acceptance of a great variety of healthy foods and some decreases in refusal behaviors, to the point that her clinicians are recommending continued therapy to maximize on her progress to date.

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

The medical necessity for continued speech and swallow therapy is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Mental Health
Inpatient hospital

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

The patient is a male with a history of anxiety and hypertension who was referred to the psychiatric emergency department. He presented with a chief complaint of anxiety. He was evaluated by psychiatry and found to be dizzy, shaking, and sweating, at which time he was referred to the medical emergency department. Vital signs showed blood pressure 121/75, heart rate 75, temperature 98.8 Fahrenheit, and respiratory rate 20. On physical exam, heart was regular, breath sounds were normal, and cranial nerves were intact. Labs showed white blood cell (WBC) 9.5, hemoglobin 12.8, platelets 320, sodium 135, creatinine 0.94, and potassium 4.2. Chest x-ray was negative for pneumonia. The patient was admitted for suspected benzodiazepine and methadone withdrawal and suspected alcohol withdrawal. 

The inpatient stay was not medically necessary. The patient primarily received an outpatient evaluation and treatment for both benzodiazepine withdrawal and methadone withdrawal, which are routinely provided at the outpatient level of care. The patient was hemodynamically stable and had no complicating medical illnesses that required inpatient level of care during the hospital stay.

The patient presented primarily with methadone withdrawal and benzodiazepine withdrawal, which do not necessarily need to be managed at the inpatient level of care. The patient did need psychiatric evaluation, which was provided during the hospital stay, but there was no evidence of withdrawal seizures, no evidence of acute psychosis, or other complications such as suicidal or homicidal intentions.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain and Vomiting
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

This patient is a female with a history of cyclic vomiting syndrome and cannabis abuse who presented to the emergency department (ED) with abdominal pain and requesting Dilaudid and Zofran.  The patient had multiple admissions but leaves against medical advice (AMA) after getting Dilaudid.  Extensive gastrointestinal (GI) work up was negative.  

The patient's vital signs (VS) were as follows: temperature 97.9, pulse 103, respiratory rate 17, blood pressure 127/100, and oxygen saturation 100%.  The patient's exam was remarkable for abdominal tenderness.  Labs revealed the following: complete blood count (CBC) normal, sodium (Na) 140, potassium (K) 3.3, and blood urea nitrogen (BUN) / creatinine (Cr) 10/1.  The patient's liver function tests (LFTs) were normal.  Chest x-ray (CXR) showed nothing abnormal detected (NAD).  

In the emergency room, the patient refused all meds except Dilaudid.  The patient was admitted.  Plan of care included intravenous fluids (IVF), Tigan, personal protective equipment (PPE), Dilaudid, and clear liquid diet.  Vital signs were stable (VSS).  The medication was helping.  The patient was tolerating oral (PO) intake.  Current management was continued.  Gastroenterology (GI) and psych follow up was recommended as outpatient.  Intravenous (IV) access was discontinued due to right upper extremity (UE) thrombus.  Nausea and vomiting (N/V) had resolved.  Abdominal pain had resolved.  She as tolerating the diet.  No anticoagulation was needed.  The patient was cleared for discharge.

No, the proposed inpatient admission was not medically necessary.

Medically necessary services are those which are:

1)	safe 
2)	effective
3)	generally accepted national standard of medical practice 
4)	not provided primarily for convenience of the patient or the practitioner 
5)	the least intensive and/or most appropriate alternatives among diagnostic and treatment option.

The requested inpatient admission was not medically necessary because it was not in accordance with generally accepted national standard of medical practice.

Cycling vomiting syndrome is characterized by recurrent vomiting between periods of normal health.  Cannabis abuse is associated with hyperemesis.  Treatment is supportive care during acute episodes.  This patient has recurrent admissions for cyclic vomiting.  At time of presentation, the patient was hemodynamically stable.  Labs were unremarkable.  She did not have findings of dehydration or inability to tolerate oral intake.  The patient remained clinically stable during admission with resolving symptoms.  She had not failed symptomatic treatment at a lesser level of care.  The patient could have been safely and effectively treated at a lesser level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Double Vision and Weakness on the Left Side. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 

The denial is upheld. 

The patient is a female who presented to the emergency ward with the complaint of double vision, left eye deviation and left sided weakness. At presentation, the patient was noted to have left sided weakness. Computed tomography (CT) of the brain was interpreted as normal at presentation. She was subsequently admitted to the acute inpatient service for possible transient ischemic attack (TIA)/stroke. Magnetic resonance image (MRI) showed likely mid brain stroke. 

No, the acute inpatient admission was not medically necessary. 

The patient presented with a National Institutes of Health Stroke Scale (NIHSS) score of one and was found to have a possible, small, midbrain stroke on magnetic resonance image (MRI) following cardiac catherization. She did not have any significant deficit to warrant acute inpatient level of care. The diagnostic test results were not concerning for recurrent infarction, critical large vessel stenosis or diffuse intracranial atherosclerosis. The patient's vitals and neurological condition remained stable. The clinical evaluation, diagnostic studies, monitoring and treatment could have been safely and effectively provided at a lower level of care.