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

Diagnosis:  Recurrent pregnancy loss (RPL).
Treatment: Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic screening).

The health plan denied the Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic screening).  The determination was upheld.

The patient is an adult female with history of two prior miscarriages.  The product of conception on the second miscarriage was tested and showed trisomy 15.  The patient underwent IVF (in vitro fertilization) with PGT (Preimplantation Genetic Testing) and is requesting coverage for PGT.

There is no indication for PGS in this patient.  This patient does not have any genetic anomaly and is not a carrier of a genetic condition or chromosomal anomaly known to cause the birth of a child with a genetic condition. 

Please note that PGS will not improve the outcome.  It will just help the patient find earlier if the fetus is normal or not.  PGS is not indicated for recurrent pregnancy loss or for recurrent implantation failures. 

ACOG (American College of Obstetricians and Gynecologists) stated the following:
"At this time there are no data to support preimplantation genetic screening for recurrent unexplained miscarriage and recurrent implantation failures; its use for these indications should be restricted to research studies with appropriate informed consent."

ASRM (American Society for Reproductive Medicine) also stated the following: "A study of women with recurrent miscarriages found no evidence of benefit of preimplantation genetic screening in women of any age."

The patient, when pregnant, can undergo CVS (chorionic villus sampling) or amniocentesis to rule out any genetic anomaly of the fetus.  According to the standard of care and even after PGS is performed, the patient is counseled about undergoing genetic testing during the pregnancy.

Based on the above, Biopsy oocyte polar body were not medically appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Major depressive disorder
Treatment: Trintellix 10MG OR TABS
The insurer denied the Trintellix 10MG OR TABS.
The denial is overturned. 

The patient is a female with major depressive disorder. She writes, "I was on Zoloft for a while which I discontinued for headaches. Lexapro was a disaster. It made me so sick I could barely get out of bed, headaches, dizziness, nausea. I took Wellbutrin after that... also Valium and Xanax. I've never had such a dramatic difference before... my mood swings have stopped being so severe... (On Trintellix) I have been doing a lot of art which is something I haven't done in over a year... I was able to avoid two panic attacks this weekend and I've stopped obsessively checking my vitals."

The patient's physician writes, "Patient has been on sertraline-gave her headaches that persisted. Escitalopram-dizzy-nausea, headaches-Buspirone-not effective for the anxiety. Trintellix made a dramatic improvement in her mood, has no sexual dysfunction, and feels in balance. By prescribing Trintellix, I have kept her out of the hospital." 

The denial letter states that the insurer's selective serotonin reuptake inhibitor (SSRI) Step-Therapy Criteria have not been met.

The health plan denied approval of this medication stating that their SSRI criteria had not been met because the patient had not taken or had a poor response to medications of the preferred drug list. This is contrary to fact. The patient had taken and did have a poor response to sertraline and escitalopram. Given the poor response to these two traditional SSRIs, it is unlikely that the patient would have had a positive response to fluoxetine or citalopram, also recommended by the health plan. Therefore, the treatment with Trintellix 10MG OR TABS is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

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

The patient is a female with a past medical history of seizures who presented with multiple seizure episodes.  She was well until the day of presentation when she had multiple episodes of seizures at school.  Each episode consisted of a few seconds of unresponsiveness, eye blinking, and staring.  She denied any fall or trauma prior to the event.  She did report that she had 2 examinations in school on the day of presentation and didn't get much sleep the night before. 

The inpatient hospital stay was medically necessary for this patient.

This is a young girl with a history of epilepsy who presented with multiple episodes of seizures at school.  In fact, she was reported to have up to 30 episodes during that day.  She required a prompt evaluation including laboratory values, imaging studies, and an EEG.  It was appropriate for her to be admitted to the hospital for ongoing care, close monitoring, additional treatment as needed and adjustment of her medications to ensure that her seizures were under control.

The decision-making at the time of admission for this patient was consistent with her young age, the occurrence of an extreme cluster of 30 seizure events of unknown etiology, and the need for prompt initiation of an evaluation with adjustments of medications and monitoring for further seizure events.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: ADHD.
Treatment: Focalin 5 mg.
The insurer denied the Focalin 5 mg.
The determination is upheld.

The patient has a diagnoses of attention deficit hyperactivity disorder, excessive daytime sleepiness, and circadian rhythm disorder, shift work type.
On the request for brand medication the treating provider documented that the patient was prescribed generic dexmethylphenidate 5 milligrams (mg) and tried it for 15 days. The medication was discontinued due to the patient experiencing nausea, heartburn, and upset stomach. The treating provider documented in the office visit that the patient was prescribed 15 tablets of dexmethylphenidate 5 mg but it was discontinued due to nausea, stomach upset, and heartburn. Then the treating provider documented an order for brand-name Focalin 5 mg twice a day.
Three days later the treating provider filled out the same request for brand medication stating that the patient had been on the dexmethylphenidate 5 mg for trial of 30 days but it was discontinued due to nausea, heartburn, and upset stomach. At issue is the medical necessity of brand Focalin 5 mg tablet.
The requested health service/treatment of Focalin 5 mg tablet is not medically necessary for this patient. Treatment with stimulants, such as Focalin, for attention deficit hyperactivity disorder (ADHD) is standard of care and commonly used for adult ADHD.  However, there are no studies proving that the brand-name Focalin is more efficacious than the generic.
There are no  adequate or well-conducted randomized controlled or cohort trials in the prevailing peer-reviewed published medical literature that established higher efficacy with brand name Focalin over generic. The treating provider documented twice that the patient had tried and failed the generic however the documentation was conflicting as to the length of the trial.
All the conditions necessary for the brand Focalin to meet medical necessity we are not met. The patient did have a trial with the generic dexmethylphenidate 5 mg (15 pills) but only for 15 days. The 2/12/2020 office visit note stated the patient was prescribed 15 tablets of the generic but was discontinued on 2/12/2020 based on adverse events which included nausea, heartburn, and upset stomach.
There were inconsistencies between the treating provider's request for the medication on the form that documented a 15 day trial of the medication while the other form document had a 30 day trial.
Therefore, Focalin is not medically necessary based on the information provided.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chondrodysplasia punctata
Treatment: CDPAS 12 hours/day, 7 days/week, a total of 84 hours/week (Health plan is reducing hours to 46 hours/week)
The insurer denied the CDPAS 12 hours/day, 7 days/week, a total of 84 hours/week (Health plan is reducing hours to 46 hours/week). 
The denial is overturned. 

Yes, the CDPAS 12 hours/day, 7 days/week, a total of 84 hours/week is medically necessary.

The patient is a male child with medical history significant for chondrodysplasia punctata, central midfacial hypoplasia, chronic respiratory failure status post tracheostomy placement, obstructive and possible central sleep apnea necessitating mechanical ventilation at night, spinal stenosis, gastrostomy tube placement, and global developmental delay. He had been living in a pediatric skilled nursing facility. Per the mother's letter of appeal, the child tries to pull out his tracheostomy tube and his jejunostomy or gastrostomy tube becomes clogged and pops out periodically. 

The patient lives with his family, and prior to the pandemic, he was attending school where he received therapies. There is limited clinical information, but based on the documentation provided, his personal assistance needs include the following: bathing, dressing, personal hygiene, positioning, transfers, gastrostomy tube feeding, mobility, and maintenance of safety during all activities of daily living. 

This young child has a number of medical problems as a result of his chondrodysplasia punctata and midface hypoplasia, including tracheostomy dependence, dependence on mechanical ventilation when sleeping, gastrostomy dependence for all nutrition and fluids, and global developmental delay. He requires assistance and performance of all activities of daily living above and beyond what would be required by a typical child his age. While his exact home situation is not known (e.g., parents work schedules, number of siblings), it is clear that he requires constant supervision and frequent intervention to meet his needs, maintain his health and well-being, and prevent morbidity. During this time of pandemic, he is not able to go to school where he receives his therapies and must rely on family members to maintain some level of therapeutic intervention so that he does not regress. It is neither safe nor appropriate to expect trained family members to provide the level of medical care that this child requires (including but not limited to gastrostomy care and feedings, tracheostomy care and management of mechanical ventilation, application of supplemental oxygen as needed, medication administration) while also maintaining all of his activities of daily living (including but not limited to bathing, dressing, diapering, mobility, transfers, positioning, feeding, range of motion and other therapy interventions). The requested CDPAS services 12 hours daily 7 days a week are medically necessary and appropriate. The health plan's approved plan of 46 hours per week is not adequate to meet this patient's needs.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary Artery Disease, Dementia, Hypertension and Diabetes Mellitus
Treatment: Increase in Personal Care Aide Hours
The insurer denied Increase in Personal Care Aide Hours. The denial is overturned.

This is an elderly female with a history of Coronary Artery Disease, Dementia, Hypertension and Diabetes Mellitus. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Recent documentation from her provider indicates that the patient has sustained significant functional decline with worsening cognitive impairment, insomnia, urinary incontinence and mobility. She is currently bed bound, unable to reposition herself in bed, requires total assistance for bathing, incontinence care, medications and feeding. Hence, she requires assistance throughout the night, which is not possible with the plan's currently approved hours. For these reasons, the currently approved plan is insufficient to meet the patient's current needs, and the proposed treatment of an increase in Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial fibrillation 
Issue under review: Inpatient admission 

Determination: The Inpatient admission was not medically necessary. 

The patient is an adult woman with a history of symptomatic atrial fibrillation. She presented to the hospital for elective left atrial catheter ablation. Her past medical history was significant for morbid obesity and anxiety disorder.  She underwent successful uncomplicated pulmonary vein electrical isolation and was discharged the following day. 

This patient presented to the hospital for an elective electrophysiologic study and ablation. According to hospital records, the ablation was successfully performed without complication. Observation following ablation was unremarkable, and no post-operative issues were noted. The patient was discharged home the following day. In this case, there were no clinical reasons for hospital admission, and the patient could safely be managed at a lower level of care. 

In two multicenter registry studies looking at healthcare utilization after EP study catheter ablation, more than 80% of patients undergoing ablation were hospitalized for a single day, regardless of age or co-morbidity (Reference 1). Another study demonstrated that patients undergoing atrial fibrillation ablation procedures could be safely discharged on the same day (Reference 2). The current standard of care in an uncomplicated atrial fibrillation ablation is to manage patients at a lower level of care. 

Inpatient admission to the hospital was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal 
Treatment: Inpatient Hospital 

The patient is a female admitted to the hospital for multiple episodes of non-bloody emesis. She did have 4 alcoholic drinks before admission. She tried Zofran at home which was not beneficial. In the recent past, had an upper endoscopy which demonstrated only gastritis. In the emergency room (ER), the patient's vitals demonstrated tachycardia to 110-120's. Other vitals were stable. Abdomen was described as non-tender. Labs were notable for a markedly elevated lipase at 466. Liver function test (LFT) was normal and an ultrasound was negative for gallstones. In the ER, she was given intravenous (IV) antiemetics, lactated ringers and proton pump inhibitor (PPI). During course in the ER, she did achieve significant improvement per the nursing notes. A computed tomography (CT) of abdomen was felt to be unnecessary. She was discharged uneventfully the following day. 

The health plan's determination is upheld. The patient did not meet criteria for acute inpatient care. Her symptoms were manageable with IV hydration and IV anti-emetics. Her vitals were stable except for mild tachycardia which responded to fluids and treatment of vomiting. Her abdominal exam was not impressive. She had normal LFT's, a normal white blood cell (WBC), and a negative ultrasound. She responded significantly to anti-emetic therapy. Although the patient showed significant improvement in the ER (rated 4/10 by ER nurse after treatment) she required observation and ongoing IV fluids and anti-emetics for several hours after time in the ER. However, she could have been cared for at a lower level of care. The inpatient level of care was not indicated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal 
Treatment: Physical Therapy 

The patient is a male noted to be status post left knee patellofemoral ligament reconstruction surgery. Records provided indicate the patient has completed 22 physical therapy treatments. It is noted that additional physical therapy was denied as they showed strength was 5-/5 and the patient can now function on day-to-day tasks. Movement of the knee was now full, and this allows the patient to function in daily tasks and pain was rated at 0-2/10. While some pain remains, the patient is able to function and there is no documentation showing the patient requires skills of a physical therapist to manage, carryout or set up a maintenance program. 

The health plan's determination is upheld. 

The requested health service/treatment of physical therapy is not medically necessary for this patient. Per the Official Disability Guidelines (ODG) Online Version, Knee and Leg, Physical Therapy, "Recommended as indicated below. As with any treatment, if there is no improvement after 2-3 weeks, the protocol may be modified or re-evaluated. Allow for fading of treatment frequency (from up to 3 visits per week to 1 or less), plus active self-directed home physical therapy (PT)." The patient is noted to be status post left knee patellofemoral ligament reconstruction surgery. Records provided indicate the patient has completed 22 physical therapy treatments. At completion of therapy, the patient had minimal pain rated at 0-/10, full range of motion, motor strength 5-/5. It was noted the patient was able to function. The letter of appeal states that the patient had difficulty engaging in any kind of sports or strenuous activities like running, jumping, hopping and maintaining a prolonged squatting position. However, these are not essential activities of daily living (ADLs). The patient is able to function appropriately and can continue progressing independently in the home setting within a home exercise program as instructed and prior therapy sessions. This does not require ongoing supervised/skilled physical therapy services. Additional physical therapy is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute congestive heart failure 
Treatment: Inpatient admission 

The inpatient admission was medically necessary.

The patient is a male. He has a past medical history significant for coronary artery disease (CAD), systolic CHF (congestive heart failure), s/p (status post) AICD (automatic implantable cardioverter defibrillator), diabetes mellitus, HTN (hypertension), dyslipidemia, hidradenitis suppurativa, and anemia. He presented to the ER with CHF (congestive heart failure) exacerbation, dyspnea, and leg edema. 

The patient was hemodynamically stable. The respiratory rate was elevated to 26/minute. The physical exam was significant for bilateral edema, pulmonary rales, fibronodular skin thickening with pus oozing on skin pressure. ECG (electrocardiogram) revealed normal sinus rhythm with non-specific ST changes. The chest X-ray revealed cardiomegaly and pulmonary congestion. Labs were significant for severely elevated pBNP (brain natriuretic peptide) of 15,000, negative troponin, anemia. 

The patient was admitted to telemetry for acute CHF exacerbation. He was started in IV diuretic regimen. Antibiotic therapy was initiated for the purulent discharge for his skin lesions. Medical therapy for CAD/CHF was continued. An echocardiogram was obtained, revealing severely reduced LV (left ventricle) function. Consultations with dermatology and surgery were obtained. LE (lower extremity) Doppler to rule out DVT (deep venous thrombosis) was performed. The skin lesions were treated conservatively. The patient improved with diuresis and was discharged with a plan for outpatient follow-up. 

The patient presented with symptoms of acute CHF exacerbation, with known severe systolic dysfunction and CAD. Although, usual course of hospitalized patients with CHF exacerbation is brief, with expected discharge in 24 hours with adequate diuresis, there are certain subsets of patients that require extended periods of hospitalization for control of their symptoms. This patient with multiple co-morbidities, who presented with CHF exacerbation was appropriately treated with IV diuresis. He required close monitoring of his CHF, given advanced systolic dysfunction. Given this presentation, acute CHF, as well as multiple risk factors, co-morbid conditions and known CAD, it would be consistent with the current standard of care that this patient be managed in an inpatient setting. Therefore the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain 
Treatment: inpatient admission 

The insurer denied coverage for inpatient admission. The denial is upheld. 

This patient is a female who presented to the Emergency Room (ER) with reports she fainted a few hours prior; she was caught by a friend before hitting the ground.  An hour later she developed right lower quadrant (RLQ) abdominal pain and cramping.  She was in her first trimester of gestation.  She denied nausea, vomiting, diarrhea, fever, and vaginal bleeding.  Bloodwork revealed white blood cell (WBC) count 11.55, creatine kinase (CK) 32, troponin <0.015.  Electrolytes and liver function tests were normal. Urinalysis was positive for small leukocytes, trace ketones, WBC 11, and few bacteria.  Abdominal examination showed some mild tenderness.  Ultrasound showed a normal intrauterine pregnancy.  Magnetic resonance imaging (MRI) of the abdomen showed a 6.5 mm appendix with no surrounding inflammatory changes.  The patient was treated with intravenous (IV) fluids and Tylenol and was admitted with a diagnosis of abdominal pain. IV fluids and antibiotics were given.  She was seen by Surgery and Obstetrics.  Surgery determined appendicitis was unlikely.  The plan was to admit her for observation for a day or 2.  The patient had an episode of chest pain with deep inhalation.  A chest X-ray was normal; her symptoms resolved.  The patient's abdominal pain improved, her diet was advanced, and cultures were negative.  Evaluation showed the patient was stable and the plan was to discharge her that day.  A repeat MRI showed no appreciable change compared to before.  She was discharged. 

This patient presented with abdominal pain.  However her examination showed a benign abdomen.  She was afebrile and her vital signs were stable.  Abdominal ultrasound did not reveal any pathology necessitating surgical intervention.  Acute appendicitis should be strongly suspected in pregnant women with classic findings: abdominal pain that migrates to the right lower quadrant, right lower quadrant tenderness, nausea/vomiting, fever, and leukocytosis with left shift.  This patient had none of these symptoms.  With a non-classical presentation, which often happens in pregnancy, imaging is indicated.  This patient's imaging both ultrasound and MRI were not suggestive of appendicitis. Ideally, this patient would have been observed for up to 24 hours.  If no worsening of symptoms were observed, then the patient could have been sent home to be followed up as an outpatient.

Based on the above, and based on physical examination and results of laboratory and imaging tests, inpatient admission was not medically necessary.  The observation level of care would have been adequate to manage this patient.  The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.  The inpatient admission is not considered medically necessary for this patient. 

Based on the above, the medical necessity for the inpatient admission is not substantiated.  The insurer's denial is upheld.