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

Diagnosis: Status asthmaticus.

Treatment: Inpatient admission.

The insurer denied coverage for the inpatient admission.

The denial is overturned. 

This patient is a male child with a history of mild persistent asthma and previous hospital admission for status asthmaticus in the pediatric intensive care unit (PICU).  He was sick for 2 days with a sore throat and a runny nose.  When he developed a cough, chest tightness and shortness of breath his mother administered albuterol at home every 4 hours.  When his wheezing was noted to be getting worse, his mother brought him to the Emergency Room (ER) for further treatment.

In the ER, the patient was noted to have respiratory distress with retractions and evidence of increased work of breathing. There was tachypnea, prolonged expiration and audible wheezing.  The ER physician also mentioned decreased breath sounds on the left side of the lung.  He was treated with 3 doses of Duoneb, dexamethasone, intravenous (IV) magnesium and a bolus of IV normal saline.  When the patient continued to have evidence of respiratory distress with tachypnea, and he indicated that his breathing had not improved with treatment in the ER, the decision was made to admit him with a diagnosis of status asthmaticus for ongoing treatment with albuterol every 3 hours.  

The patient was treated appropriately in the ER for a cough, wheezing and respiratory distress. He has had a previous admission for asthma and additional ER visits in the past but had not been treated with inhaled steroids.  He failed outpatient treatment with albuterol at home.  When there was ongoing respiratory distress with persistent wheezing and increased work of breathing, it was appropriate and consistent with the standard of care to admit him to the hospital for ongoing treatment with albuterol every 3 hours.  He was not stable enough to be sent home.  As noted by Scarfone in Up to Date "Hospitalization - Patients who were moderately to severely ill on arrival and who have little improvement after initial therapy with beta agonists and systemic glucocorticoids require hospitalization. This includes patients who continue to have significant wheezing and retracting, poor aeration, or altered mental status, such as drowsiness or agitation."

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

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

Skin
Surgical services

Diagnosis: excess skin.
Treatment: Panniculectomy.
The insurer denied a panniculectomy. 
The health plan's determination is upheld. 

This is a female history of massive weight loss status/post (s/p) sleeve gastrectomy. She complains of excess skin in abdomen and flattened ptotic breasts resulting in uncomfortable skin hanging and multiple intertriginous folds causing irritation and infections. The massive weight loss has made her skin extremely lax and overhanging, creating an area for moist rash under the pannus. She notes that often the skin gets raw and breaks down from the moisture. The patient also reports recurrent irritation, pruritus and rashes within skin folds in which have been refractory to topical treatments (i.e. powders, deodorants, creams). A panniculectomy is planned.

The Surgical Procedure to Remove Excess Skin (Panniculectomy) is not medically necessary. The medical records do not provide any documentation in the form of primary care physician (or provider) (PCP) or dermatology progress notes that describe ongoing clinically significant dermatologic problems that have either 1) never responded to physician directed topical therapy or 2) despite initial response, have recurred and caused significant functional impairment. Supervised medical management for rashes is not documented in any of the progress notes. The patient is not sick from her excess skin, and has not had ulcerations, panniculitis or sepsis from her infections. A dermatologist has not evaluated the rashes. The patient has not required hospitalization or treatment with intravenous (IV) or oral antifungal or antibiotic medications. The excess skin has not jeopardized her health. Summary treatment letters and member appeal testimonies in the absence of physician office note documentation of specific dates of treatments and medications prescribed do not provide sufficient documentation to confirm the failure of medically supervised care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back pain. 

Treatment: Lumbar spinal fusion. 

The insurer denied coverage for the lumbar spinal fusion. 

The denial is overturned. 

This is a female patient with a history of arthritis, a heart murmur, and hypertension. She presented to the Orthopedic Surgeon's office with complaints of a one year history of lower back pain and bilateral lower extremity pain. The pain could go up to a level of 8 out of 10. The patient tried chiropractic care, non-steroidal anti-inflammatory drugs (NSAIDs), neuromodulators, hydrocodone, and epidural injections with limited relief. She had lumbar disc disease with radiculopathy, lumbar stenosis with neurogenic claudication, and degenerative lumbar scoliosis. The physician recommended lumbar vertebra (L)2-L5 decompression and instrumented fusion to treat back pain. 

The insurer denied coverage for the lumbar spinal fusion performed, as not medically necessary. 

In an appeal letter, the patient's Orthopedic Surgeon stated that the patient has undergone conservative care with home exercises, chiropractic care, NSAIDs, neuromodulators, other pain medications, and epidural injections. Symptoms persisted despite treatment. The patient failed conservative management and there was clear radiographic evidence of a spinal deformity. A lumbar spinal fusion was medically necessary. 

The medical records were consistent in substantiating medical necessity. The subjective complaint, objective findings, and imaging studies support the diagnosis of degenerative scoliosis with associated neurogenic claudication. 

A pain generator was defined. The degenerative scoliosis curve measured 35 degrees. This is consistent with lateral instability. The physician has also reported the need to remove facets. A course of conservative treatment had been provided which did not help. 

These findings of "lateral listhesis" and removal of posterior elements denote instability. The abnormal motion after decompression requires a spinal fusion. The physician performed a multilevel decompression and stabilization as required. There are no alternatives to this clinical scenario (that is, lateral instability pattern plus (+) removal of posterior elements). The scientific literature supports treatment provided. 

The physician had documented the instability. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The insurer did not take into consideration the pattern of lateral instability, that is, scoliosis.

The lumbar spinal fusion is considered medically necessary for this patient.

The insurer's denial of coverage for the lumbar spinal fusion is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back Pain and Chest Pain (Sickle Cell Pain Crisis)
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient in this case is a male with hemoglobin sickle cell (SC) disease.  On the morning of admission, he woke up with lower back and chest pain.  He tried ibuprofen at home but that was not effective.  He had no other symptoms except for occasional dizziness when turning his head.  

The patient presented to the emergency department and while there he was given intravenous (IV) morphine, ketorolac and acetaminophen.  He was also given intravenous fluids. He was hemodynamically stable and physical exam was unremarkable.  Chest x-ray was unremarkable.  Laboratory studies were unremarkable, with only mild anemia noted.  His pain was treated with MS (morphine sulfate) Contin and hydromorphone.  He improved following hospitalization and was discharged to home without oral narcotics, which he did not take on a routine basis when out of the hospital.

No, the proposed inpatient admission was not medically necessary.  This patient presented with pain crisis, but he had no active acute infection, organ dysfunction or hemodynamic instability.  He also did not have severe anemia causing symptoms or requiring transfusion, and had no acute neurologic impairment.  He did have pain and was treated with narcotic pain medication.  However, records do not document severe ongoing pain requiring frequent doses of intravenous pain medication other than the initial three doses of morphine given in the emergency department.  While the patient needed treatment for his pain, there is no documentation indicating that he could not have been suitably treated with oral pain medication.  Oral pain medication can be provided at a lower level of care.  This patient did not fail a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Undiagnosed genetic disorder. 
Treatment: Electric Bed. 

The insurer denied the Electric Bed. The health plan's determination is overturned. 

The patient is a female. According to the medical records provided, she has multiple medical problems stemming from an undiagnosed genetic disorder. She has facial dysmorphism and a submucous cleft palate. She developed refractory epileptic spasms when she was a baby. She subsequently transitioned to having generalized tonic clonic seizures which have been refractory but are under better control in recent months. She has cerebral palsy, hypotonia, severe global developmental delay, and cortical visual impairment. She has a gastrojejunostomy tube. She has gastroesophageal reflux and has had Nissen fundoplication. She is on the ketogenic diet, 2:1 ratio. She has central obstructive sleep apnea and is on bi-level positive airway pressure (BiPAP). She has aspiration, and poor control of secretions. She uses a cough assist device and percussive vest for chest clearance. 

The Rent to Purchase of an Electric Bed [E1399-NU for 10 Units] is medically necessary for this patient. This patient is at risk of aspiration and has poor control of secretions. Head of bed needs to be elevated above 30 degrees. She has BiPAP and gastrostomy tube feeds, and the tubing could become trapped in regular wedges or pillows. The patient is working with an electronic switch device as part of a learning process to use a remote bed control. The patient has a lack of safety awareness and needs an appropriate side rail and transfer height to prevent injury.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/circulatory problems. 
Treatment: Inpatient Hospital. 

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

The patient is a male with coronary artery disease, status/post (s/p) right coronary artery stent, human immunodeficiency virus (HIV) positive, diabetes mellitus (DM), chronic obstructive pulmonary disease (COPD), hypertension (HTN), previous tobacco and cocaine use who presented to the emergency room (ER) with chest pain. The pain was 7/10 in severity. Blood pressure was 143/72 millimeters of mercury (mmHg) and pulse 74. Respiratory rate was 18. Troponin was reported at less than (<) 3.5 x 2. Electrocardiogram (EKG) showed normal sinus rhythm, moderate voltage criteria for left ventricular hypertrophy (LVH) and no ST elevation. 

He was admitted and seen in cardiology consultation. He was given aspirin, Lipitor, Lopressor and nitrates. Treadmill testing was planned but could not be done due to mechanical issues with the treadmill. He preferred to do the test as an outpatient and left the hospital against medical advice. 

The subject under review is the medical necessity for the inpatient hospital admission. 

The health plan's determination is upheld. 

The patient has a history of coronary artery disease (CAD), with previous coronary stenting, and presented with chest pain. However, he was hemodynamically stable, without ongoing pain, congestive heart failure (CHF) or serious arrhythmias. His cardiac biomarkers and electrocardiograms (EKGs) were not diagnostic for ischemia or infarction.
While there are no American College of Cardiology (ACC)/American Heart Association (AHA) consensus guidelines for management of patients presenting to the emergency room (ER) with low risk (negative cardiac biomarkers, no ischemic EKG changes) chest pain, there are large population studies supporting that these patients can be safely managed on an at a lower level of care status without full inpatient admission. [2,3] That is the situation for this patient: he was hemodynamically stable, with no positive cardiac biomarkers or EKG changes supporting acute ischemia/infarction. The patient could have been managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tooth decay. 
Treatment: D2750 Crown porcelain fused to high noble metal to tooth #14. 

The insurer denied the D2750 Crown porcelain fused to high noble metal to tooth #14. 
The denial is upheld. 

The patient is a male requesting benefits for a crown on tooth #14. 

No, the requested health service is not medically necessary. 

The x-ray shows decay in the tooth on the occlusal and distal surfaces. A crown should not be needed to restore the tooth with the amount of decay seen on the x-ray provided.  A two surface restoration would be standard of care for this amount of decay.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: atopic dermatitis

Treatment: Dupixent Syn 300

The insurer is denied coverage for Dupixent Syn 300.

The denial is upheld. 

This female patient has a history of atopic dermatitis and asthma.

The requested medication Dupixent is not medically necessary based on the standard of care, and there are no unique clinical circumstances to this particular individual in the documentation provided that would make it medically necessary.  It is noted that the patient has a diagnosis of atopic dermatitis, and that the patient has failed topical steroid therapy, tacrolimus ointment, as well as multiple anti-histamines.  However, the patient has no true contraindications to the conventional medications commonly used for atopic dermatitis.  
According to the American Academy of Dermatology Atopic Dermatitis Clinical Guidelines and dermatology literature, the conventional medications such as topical steroids, protopic, elidel, and methotrexate are effective treatments for the management of atopic dermatitis (1, 2). 
Within the peer-reviewed literature, in 2018, Gerbens et al writes "MTX and AZA seem to be effective and safe as maintenance treatments in moderate to severe AD up to 5 years" (3).  Shah et al 2018 writes "Methotrexate is an effective treatment for moderate to severe atopic dermatitis with an acceptable safety profile. A low dose can be used to control the disease for prolonged periods without significant risk" (4). There are several published studies that show that methotrexate is effective and safe for moderate-severe atopic dermatitis (5-8).  
The conventional medications, such as methotrexate, should be tried and failed prior to initiating Dupixent.  

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

The carrier's denial of coverage for the Dupixent Syn 300  is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left lateral oral tongue squamous cell carcinoma

Treatment proton beam radiation therapy

The insurer denied coverage for proton beam radiation therapy

The denial is overturned

This case involves a female patient who has been diagnosed with left lateral oral tongue squamous cell carcinoma status post left partial glossectomy and left neck level 2-4 dissection with close medial tongue margins of 7.5 mm (millimeter) who is being seen regarding adjuvant radiotherapy. The documentation indicated the presence of multiple intermediate risk factors on surgical pathology warrants of the requested adjuvant radiation therapy to reduce the risk of local primary or neck recurrence. The request has been received for coverage for proton beam radiation therapy. 
Additional submitted documentation does include radiation oncology consult note where she was seen for consultation. The documentation indicated her history began when she first noticed an area of irritation to the left posterior lateral portion of the tongue. There are no other associated symptoms present. She underwent biopsy with pathology consistent with squamous cell carcinoma. She then underwent a left partial glossectomy and neck dissection.  The documentation indicated the patient did feel well, overall. She denied any pain and does not utilize any medication. Her speech was overall understandable, and the physician indicated once again, given the presence of multiple intermediate risk factors on surgical pathology it was recommended; she receive adjuvant radiation therapy.
The medical records include a comparison plan for this specific patient between intensity-modulated radiation therapy (IMRT) photons and proton therapy. The dose to several critical structures are significantly lower for the proton plan. In particular, the radiation dose to both left and parotid gland are remarkably lower with the proton plan. The parotid gland doses for the IMRT photon plan are unusually high, but even if the mean dose of 26 Gy [(Gray) unit to measure radiation a patient is exposed to] is met for both glands, the proton plan is clinically significantly superior. For this reason, proton therapy is medically necessary in this case to spare these critical adjacent structures and because the treatment is part of a protocol.
The health plan did not act reasonably with sound medical judgment and in the best interest of the patient.
The insurer's denial of coverage for proton beam radiation therapy is reversed. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Non-ruptured cerebral aneurysm

Treatment hospital admission

The insurer denied coverage for hospital admission

The denial is upheld

This case involves an adult female with a history of a subarachnoid hemorrhage. The documentation indicated that she presented for a scheduled cerebral angiogram with embolization of basilar aneurysm pipeline embolization of a right posterior inferior cerebellar artery aneurysm. She had undergone prior diagnostic angiograms and which demonstrated stability. The patient was taken for a cerebral angiogram with embolization and tolerated the procedure well without any complication. She was extubated at the completion of the case and standard postoperative care was given. A head computed tomography (CT) scan was done with no acute pathology immediately post procedure. A heparin drip was started, and on postoperative day 1 the drip was discontinued. The patient was given her normal daily dose of Plavix and aspirin. The documentation indicated that at the time of discharge she was neurologically stable, and it was recommended she be seen for a follow-up in 6 months.

This patient underwent an elective procedure with no complications. Her vital signs were stable. Her physical examination and laboratory results did not show any new anomaly; she could have been treated with a status of observation without admission. Based on the medical records, an inpatient admission was not considered medically necessary treatment for the patient's condition.

The health care plan did act reasonably, with sound clinical judgment, and in the best interest of the patient.

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

Diagnosis: Acute cholecystitis. 
Treatment: Hospital admission. 

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

This female patient has a history of hypertension. 

This patient did not have signs and symptoms for acute cholecystitis as she did not have an elevated white blood count (WBC), she did not have a fever, and she did not have elevated liver function test (LFT) or confirmation test for acute cholecystitis. The only test that was done was an ultrasound and computed tomography (CT) which showed gallbladder sludge with some mild wall thickening but no pericholecystic fluid. She also did not have acute cholangitis or common bile duct stone. She did have right upper quadrant tenderness but did not have other signs of acute cholecystitis and the pain was improved as noted in the chart. Milliman Care Guideline (MCG) Inpatient and Surgical Care 25th Edition cholecystectomy by laparoscopy also notes that the operative status criteria is ambulatory. Thus, this patient did not require an inpatient admission for this procedure and could have been cared for in an observation/ambulatory setting based upon the MCG guidelines. 

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

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

Diagnosis: Left renal colic.
Treatment: Inpatient admission.

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

The patient is a male. He was admitted with left renal colic.

The patient's vitals were Temperature 98.6, blood pressure 101/84, pulse 55, respiration rate 17.  The WBC (white blood cell) count was 10,600.  The creatinine was 2.36.  CT (computed tomography) imaging demonstrated a 5 mm (millimeter) right proximal ureteral calculus with hydronephrosis.

IV (intravenous) pain medications, nausea medications, IV (intravenous) antibiotics and IVF (intravenous fluid) were administered.

Day 1, the patient had a cystoscopy with right ureteral stent placement.  IV (intravenous) pain medications, IV (intravenous) antibiotics and IVF (intravenous fluid) were administered.

Day 2, the patient was discharged home.  The WBC (white blood cell) count was 13,500.  The creatinine was 1.3. He was afebrile and hemodynamically stable throughout the stay.

No, the Inpatient admission was not medically necessary.

An acute inpatient level of care was not medically necessary. Care could have been provided at a lower level of care. The patient was afebrile and hemodynamically stable throughout the hospitalization. There was no significant evidence for sepsis. Following admission, there were no unstable vital signs reported. He did not have a documented infection or kidney failure, solitary kidney or a kidney transplant, or need for an open surgery. He did not have bilateral obstruction, severe vomiting. The creatinine improved after stent placement. Pain control, IV (intravenous) antibiotics and IVF (intravenous fluid) followed by stent placement in a non-toxic patient can be provided at a lower level of care.