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

Diagnosis: Muscle tenderness
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

This case involves a male who presented to the emergency department with complaints of muscle pain for 3 days. He had a history of chloride channel (CICn1) myotonia congenita and upon presentation, his heart rate was elevated, he had muscle tenderness, and had recently received the Coronavirus (COVID) vaccine. Pain was well controlled with oral Motrin and work-up was negative. He was given intravenous fluids, and he was subsequently admitted for care. Services were denied given that records did not support evidence of unstable vital signs that did not improve after treatment nor were there other findings justify an inpatient admission. The adverse determination letter stated the patient could have been treated at an observational level. An appeal was submitted claiming that the patient had a 3-day history of muscle pain and soreness, high heart rate, and muscle tenderness. He was admitted to telemetry and neurology reportedly recommended the continuation of Diamox and intravenous fluids. A barium swallow study was recommended with the notation that the patient's condition improved after treatment. He was subsequently discharged. 

Literature notes that vaccination is a well-established part of a preventative and public health medicine but is not without risk. COVID-19 vaccination frequently leads to minor side effects, for example pain, swelling, and redness at the site of injection, and systemic symptoms of fatigue, headache, muscle pain, chills, and fever. Records noted the patient had a history of CICn1 myotonia congenita who presented to the emergency department with complaints of muscle pain for 3 days. He confirmed that he recently received the COVID-vaccine and was admitted with muscle tenderness. However, the information provided for the review did not endorse that the patient had fever or shortness of breath, and labs were normal, electrocardiogram (EKG) was normal, and after receiving fluids and Toradol, his pain resolved. His initial presenting symptoms were mild, with gradual onset over 2 days, and did not result in any dehydration, significant reduction in activity, nor did he endorse chest pain, diarrhea, dysuria, fever, nausea, or shortness of breath and had no vomiting. Based upon the provided information, the work-up and care rendered to the patient could have been conducted on an observational basis and did not require inpatient care. 

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

The insurer's denial of coverage for inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 
The insurer denied full braces, monthly brace adjustment visits. 
The denial is overturned.

The patient is a female with an anterior crossbite on tooth 7. She presents with a skeletal Class I malocclusion with moderate crowding in the maxilla and mandible. She is treatment planned for orthodontics to address the crowding and crossbite, but the treatment was denied due to lack of medical necessity. The subject under review is the medical necessity for the treatment of full braces, monthly brace adjustment visits.

The requested treatment is necessary.
This patient presents with an anterior crossbite on tooth 7. 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.1,2,3
If left untreated the damage that will likely occur to the patients teeth will be much more complicated to correct than the patient's existing orthodontic problem. For this reason, treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis, glaucoma, gout, and hypertension
Treatment: Increase in Personal Care Aide (PCA) services for a total of 63 hours/week
The insurer denied the increase in PCA services for a total of 63 hours/week.
The denial is overturned.

This female has medical conditions including osteoarthritis, glaucoma, gout, and hypertension.  She is appealing denial of an increase in personal care aide (PCA) services for a total of 63 hours/week.  The plan approved 49 hours/week.  Uniform Assessment System (UAS) evaluation completed shows minimally impaired cognition and functional status: total dependence with housework, managing finances and medications, and phone use; maximal assistance with meal preparation, shopping, bathing, personal hygiene, dressing, walking, locomotion, toileting, bed mobility, and eating.  She has frequent bladder incontinence.  No falls in past 90 days.  Comparison of UAS evaluations previously completed shows a functional decline with eating and bed mobility.

A letter from the provider notes the member is legally blind and cannot be left alone.  She needs full time assistance.  

A discharge report notes she was admitted for evaluation of fall, physical deconditioning, and weakness.

Yes, the proposed treatment is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.

Personal Care Services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs), health maintenance activities, and routine support services.  The member has several chronic conditions including osteoarthritis and blindness causing limited mobility.  She was recently discharged after admission for a fall.  She is appealing denial of an increase in PCA services for a total of 63 hours/week.  The plan approved 49 hours/week.  UAS evaluation completed shows the member requires assistance with all ADLs.  She has bowel incontinence.  Comparison of UAS evaluations previously completed shows a functional decline with eating and bed mobility.  The appeal letter from her doctor notes she needs full time assistance due to vision loss.  This member has significant physical impairments that have progressed between UAS evaluations.  The approved personal care aide 49 hours/week is inadequate to meet the member's needs for assistance with ADLs/instrumental activities of daily living (IADLs).  The proposed increase in PCA to a total of 63 hours/week is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain.
Treatment: Inpatient admission.

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

This patient is a male who presented to the emergency department with the complaint of right sided abdominal pain, loss of appetite, and diarrhea. The patient's vital signs at the time of presentation were normal.  His examination revealed a tender right lower quadrant. The white blood cell (WBC) count was normal at 5.0 thousand.  Hemoglobin was normal at 14.7.  Bilirubin was elevated at 2.7.  The patient's ultrasound showed a normal gallbladder and normal caliber common duct.  Abdominal computed tomography (CT) showed a nonspecific mural hyperenhancement of the appendix without surrounding inflammation or definite stigmata of appendicitis.  Surgical consultation was obtained.  The patient was admitted to the hospital.

The patient was initially treated with nothing by mouth (NPO) status, intravenous (IV) fluid, antibiotics, and follow up lab data.  The next day, the records indicate that the patient had normal vital signs and was considered to be stable for discharge home.  

The health plan rationale for denial of inpatient care was based on Milliman Care Guidelines Criteria 25th ed-General Admission Criteria.

No, the proposed inpatient hospital admission was not medically necessary.
In this case, inpatient care was not medically necessary.  The care and treatment provided during this time could have been rendered with an observation level of care and did not require an inpatient designation.  This lower level of care would have provided for surgical assessment, intravenous fluid, follow up, labs, and overnight monitoring.

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

The health plan acted reasonably and with sound medical judgment.  Acute inpatient hospitalization was not medically necessary for this patient.  The medical records support that this patient could have been reasonably and safely monitored with an observational status.  

This patient presented with abdominal pain.  His evaluation with examination, lab data, ultrasound, and computed tomography scan identified abdominal tenderness but no obvious indication for acute surgical intervention.  The patient was monitored overnight, and remained clinically stable during the period of monitoring.

This patient's clinical needs could have been satisfied with an observational level of care.  This level of care would have provided for clinical assessment and monitoring including overnight observation as was performed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis

Treatment: Consentyx Sensoready (300 milligrams [mg]) 150 mg/milliliter (ml) subcutaneous (SC) solution autoinjector (SOAJ) in combination with Otezla

The insurer denied coverage for Consentyx Sensoready (300 mg) 150 mg/ml SC SOAJ in combination with Otezla.

The denial is upheld.

The patient is a female with severe psoriasis involving the plantar feet and nails. The patient has failed multiple topical treatments, as well as treatment with Enbrel and Otezla. The requested medication is Cosentyx in combination with Otezla.

The requested service is not medically necessary based on the provided medical records and the medical literature. The patient has failed topical therapy and has failed the combination of Enbrel and Otezla. Cosentyx injections are a reasonable alternative which can be administered within the psoriasis care guidelines. However, the combination of Otezla with Cosentyx has at best anecdotal support and is thus not supported. (Glyndenlove, et al and Arora, et al)

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

The insurer's denial of coverage for Consentyx Sensoready (300 milligrams [mg]) 150 mg/milliliter (ml) subcutaneous (SC) solution autoinjector (SOAJ) in combination with Otezla is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Acute ST segment elevation myocardial infarction.
Treatment:  Air ambulance.
The insurer denied air ambulance. 
The health plan's determination is upheld.

Emergency Medical Services (EMS) was called to a home to attend to a man with acute chest pain and diaphoresis. His blood pressure was 143/86 with a heart rate of 60. His room air oxygen saturation was 100%. An electrocardiogram showed marked ST segment elevation in the inferolateral leads. The patient was diagnosed with an acute ST segment elevation myocardial infarction (STEMI). A helicopter was called for medical transport. 

Air Ambulance Services were not medically necessary for this patient.

Based on the information provided, specifically the information that the distance from the scene to the hospital was 26 miles, and the estimated time for ground transportation would have been 42 minutes, air transportation was not medically necessary.

For patients with acute ST segment elevation myocardial infarction, the time from symptom onset to revascularization with percutaneous coronary intervention has a substantial impact on outcomes. Longer times, particularly times longer than four hours, are strongly correlated with infarct size and increased one-year mortality. Thus, current guidelines endorse minimizing this time interval as much as possible. In this case, however, based on the information provided, the time saved by air transportation was negligible (4 minutes) and, therefore, unlikely to have had a salutary effect on this patient's outcome and, therefore, was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis.
treatment: Euflexxa injections.
The insurer denied Euflexxa injections. 
The health plan's determination is overturned. 

This is a female who has been diagnosed with bilateral knee osteoarthritis and recommended for Euflexxa.

Based on the provided documentation, the Euflexxa 10mg/mL Injections is medically necessary for this patient.

The documentation indicates the patient has chronic bilateral knee pain in the setting of osteoarthritis. The pain has been refractory to bracing, non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy, home exercises, corticosteroid injections, and weight loss. The patient was previously treated with Euflexxa with benefit. Euflexxa is Food and Drug Administration (FDA) indicated for the treatment of pain and osteoarthritis of the knee in patients who have failed to respond adequately to conservative nonpharmacologic therapy and simple analgesics. Given the patient did not respond adequately to nonpharmacologic therapy and simple analgesics, the patient meets the FDA indication for Euflexxa.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Cholecystitis 
Treatment: Inpatient Hospital Admission 
The insurer denied coverage for an inpatient hospital admission. 
 The denial is upheld. 

Acute cholecystitis is a common inpatient diagnosis. Acute cholecystitis is also estimated to attribute to millions of ambulatory visits each year, and is a leading cause of hospital admissions. [1] Studies have shown that ambulatory laparoscopic cholecystectomy is safe and avoids an overnight hospital stay. [2, 4, 5] Factors that contribute to admission after laparoscopic cholecystectomy include drain placement, conversion to open surgery, persistent abdominal pain, nausea, and vomiting. [3] In patients without abnormalities of the bile duct or abnormal liver function tests, ambulatory laparoscopic cholecystectomy is safe and feasible. [5] Ambulatory and/or outpatient laparoscopic cholecystectomies reduce hospital costs without compromising patient outcomes. [6] 

Per clinical documentation, this patient presented to the ED (emergency department) with a three-day history of acute right upper quadrant abdominal pain. There was associated nausea and vomiting. Vital signs in the ED were within normal limits. The patient had a CT (computed tomography) scan that demonstrated a gallstone within the gallbladder body without evidence of acute cholecystitis. The white blood cell count was normal at 6.66. Liver function tests were within normal limits. The patient was diagnosed with biliary colic and taken to the operating room for a laparoscopic cholecystectomy with intraoperative cholangiogram. There were no reported complications. Per MCG (Milliman Care Guidelines) criteria, an admission is indicated for calculus or obstruction of the gallbladder or bile duct and either hemodynamic instability, common bile duct obstruction, severe or persistent vomiting or dehydration, severe pain, or bacteremia. According to clinical documentation, the patient did not meet criteria for an inpatient hospital admission. Peer-reviewed literature indicates that a laparoscopic cholecystectomy can successfully be performed as an outpatient procedure. Therefore, the requested hospital stay should be billed as observation status. An inpatient hospital admission is not medically necessary. 

The insurer's denial of coverage for an inpatient hospital admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic low back pain
Treatment: Pain Management (spine cord stimulator trial, 01 unit)
The insurer denied the pain management (spine cord stimulator trial, 01 unit),
The denial is overturned.

The patient is a female with chronic low back pain (7-10/10) with right lower extremity radicular pain secondary to a lumbar radiculopathy. Her symptoms have not responded to conservative management, including four months of physical therapy, chiropractic care, home exercise program, and medication management with an NSAID (non-steroidal anti-inflammatory drug).

Yes, the requested pain management (spine cord stimulator trial, 01 unit) is medically necessary.

The patient meets the criteria for a spinal cord stimulator according to the North American Neuromodulation Society (see reference 4).

Information is provided concerning the patient. The attending physician has made a recommendation. The patient meets applicable and generally accepted practice guidelines developed by the federal government, national or professional medical societies, boards and associations.

No, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Breast Cancer
Treatment:  Out-of-Network (OON) - Lab Blood Test (Liquid Biopsy)

The insurer denied the  Out-of-Network (OON) - Lab Blood Test (Liquid Biopsy).  The denial is upheld.

The patient in this case is a female diagnosed with breast cancer.  Guardant 360 testing was performed.

No, the proposed treatment was not medically necessary.

Guardant 360 is a next generation sequencing assay that is done to look for genomic alterations in circulating cell free deoxyribonucleic acid (DNA). This test includes many different genes.  It is done to try to find potentially effective treatment options.  There is currently no evidence based on the results of any prospective clinical trial that has shown use of broad molecular profiling can improve overall health outcomes.  This test is not recommended as a standard test known to improve overall health outcomes by National Comprehensive Network (NCCN) guidelines.  Therefore, this test has not been shown to improve overall health outcomes and it should not be considered medically necessary.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Closed fracture of the right ankle.
Treatment: Inpatient admission.
The insurer denied coverage for an inpatient admission.
The denial is overturned.

This is the case of an adult male with a history of diabetes mellitus and a closed fracture of the right ankle with malunion, status post open reduction internal fixation (ORIF). The patient was admitted to the hospital for planned right pilon open reduction internal fixation and external fixator removal. 

The medical record demonstrates the injury is complex and extensive. The operation was of extremely long duration. (i.e., surgery was over 7 hours not including total anesthesia time). This type of procedure has an extremely high risk of complications. There are problems with circulation and soft tissue healing. The physician placed a VAC (vacuum-assisted closure) with a drain system to avoid fluid collection and to assist with wound care. This type of operation is extremely painful and several dosages of IV (intravenous) narcotics were provided. Monitoring the wound, drainage, and the patient's pain level would be extremely important. This type of procedure is not performed in an ASU (ambulatory surgical unit) or an ambulatory setting. 

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

The insurer's denial of coverage for inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems- Hypertension/High Blood Pressure
Treatment: Inpatient Hospital Stay
The health plan denied the inpatient stay as not medically necessary. 
The health plan's determination is overturned.

This is a female with a history of anemia, chronic kidney disease, and diabetes, who presented to the emergency department (ED) due to elevated blood pressure. The patient was scheduled for outpatient left wrist surgery; however, she was found to have elevated blood pressures in the 200s millimeters of mercury (mmHg) and was sent to the ED. The patient reported taking her dose of lisinopril 10 milligrams (mg) that morning. She denied any headache, dizziness, or chest pain.
The ED physician documented giving amlodipine to treat the high blood pressure. She was then given 0.5 mg of Xanax in the hopes that the blood pressure may be anxiety related. The intervention was not as successful as anticipated, and she was subsequently treated with 10 mg of intravenous (IV) labetalol. This caused a rapid drop in the blood pressure to 149/98 mmHg.
Medical admission was requested. The medical team planned for a slow blood pressure correction and postponed the surgery. The electrocardiogram (EKG) and cardiac troponins were unremarkable.
Of note, the patient had a head computed tomography (CT) scan in the middle of the night, given the acute mental status change, which was normal. The medical team decided to continue to watch the patient for another 24 hours to ensure the stability of the blood pressure.
The patient's blood pressure improved. Repeat labs showed the creatinine increased. The medical team treated the patient with another 1 liter (L) of saline. A repeat chemistry panel showed an improvement. The patient was instructed to follow up with her primary care physician and surgery.
At issue is the medical necessity of the inpatient admission.

I overturn, in whole, the health plan's determination of medical necessity.

The patient presented to the hospital with accelerated hypertension and no evidence of end-organ damage. However, after admission, a combination of vasovagal response and aggressive antihypertensive treatment caused the patient to develop encephalopathy and profound hypotension requiring IV fluids, which later led to acute tubular necrosis causing acute kidney injury. The patient's blood pressures fluctuated wildly within the first 24 hours, and therefore are deemed uncontrolled during this timeframe. Rapid fluctuations in the blood pressure can cause serious side effects, including cerebral hypoperfusion and stroke, acute kidney injury, and coronary hypoperfusion with severe end-organ dysfunction. The patient did not achieve stability of blood pressure within the first 24 hours. The blood pressure stabilized during the next 24 hours, when the patient was already showing signs of acute kidney injury. It was reasonable to admit this patient under the inpatient level of care.