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

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

The patient is a female who was initially directed to the emergency department from home for concern of a low hemoglobin. Pertinent history included uterine fibroid, anemia (baseline 8.1), and hyperthyroidism. Review of symptoms negative for active bleeding. Initial vital signs revealed a temperature of 98.3oF, heart rate (HR) 95, blood pressure (BP) 139/78, respiratory rate (RR) 17, and peripheral capillary oxygen saturation (SpO2) 100% on room air. Initial examination documented the patient as alert and oriented with pale conjunctivae. Initial laboratory testing revealed a white blood cell count (WBC) 6.8, Hemoglobin (HGB) 3.6, platelets (Plt) 341, international normalized ratio (INR) 1.1, blood urea nitrogen (BUN) 11, Creatinine 0.79, Glucose 104, Na (sodium) 135, K (potassium) 4.2, and carbon dioxide (CO2) 22. Chest radiograph was unremarkable.

Based on the clinical documentation provided, evidence based literature and standards of care, the acute inpatient level of care was not medically necessary.
The patient had a history of uterine fibroids and chronic anemia (baseline 8.1) who was directed to the emergency department from home for an outpatient HGB of 3.6. Upon arrival, the patient was alert, oriented, hemodynamically stable, and without signs of active bleeding. Initial evaluation confirmed a Hgb of 3.6 without organ impairment. Treatment plan included transfusion of packed red blood cells. Following observation care with the initial transfusion, the patient was clinically improved. No active bleeding, nor other issues or complications, were documented throughout.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute appendicitis.
Treatment: Inpatient admission.
The insurer denied coverage for an inpatient admission.  
The denial is upheld.

The health plan acted reasonably. Based on clinical documentation, the patient had acute appendicitis. The patient presented to the emergency department and underwent an uneventful laparoscopic appendectomy. There were no reported complications, and the patient was cleared for discharge by the surgical team. An outpatient appendectomy is as safe and effective, with complication rates, readmission rates, and satisfaction equivocal to those patients kept in observation.  
 
The hospital stay was not medically necessary. Per clinical documentation, the patient presented to the emergency department with a two-day history of right-sided abdominal pain. There was one episode of vomiting. Vital signs were within normal limits. The white blood cell count was 7.9. The CRP (c-reactive protein) was elevated to 1.9. An ultrasound did not demonstrate the appendix. A computed tomography (CT) scan was positive for acute appendicitis. The patient underwent an uneventful laparoscopic appendectomy. 

The patient was cleared for discharge from a surgical standpoint on postoperative day 0. An admission may be necessary for patients with severe systemic illness (e.g., sepsis), poorly controlled comorbidities (e.g., COPD (chronic obstructive pulmonary disease), chronic heart failure), or complications from the procedure (e.g., infection, bleeding) that require more than 24 hours of postoperative care. There were no immediate complications documented after the surgery. Peer-reviewed literature also indicates that outpatient laparoscopic appendectomy can successfully be performed in those with uncomplicated appendicitis. Suitable criteria for same-day discharge include hemodynamic stability, tolerating liquids, and pain controlled on oral medications. Surgical documentation notes that the patient was uncomplicated. Therefore, the requested inpatient hospital stay was not medically necessary. Observation care would be more appropriate.  
 
The insurer's denial of coverage for inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity.
Treatment: Wegovy 0.25/0.5ML (milliliter) Pen-Injector.
The insurer denied the Wegovy 0.25/0.5ML (milliliter) Pen-Injector.
The denial is upheld.

The patient is a female with obesity with a body mass index of 40.1. The request for Wegovy is under review. The prior request was denied coverage by the health plan because there is a supply shortage of Wegovy. Requests for Wegovy will not be approved until all strengths of the drug become readily available again. The patient is appealing this determination.

The proposed Wegovy is not medically necessary.
This request is for Wegovy for the treatment of obesity. The prior request was denied because there is a supply shortage of Wegovy. The Wegovy website indicates, "we asked healthcare providers not to start new patients on Wegovy... and more recently we made the decision to temporarily stop shipments of the first two dose strengths." Given the ongoing supply issues, the proposed Wegovy is not medically necessary, as the patient may not be able to access the appropriate doses to safely titrate Wegovy. The patient indicated that her "pharmacy has all sizes of the drug in stock." No documentation from the pharmacy was provided, and the supply issues may be sporadic.

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

The requested Wegovy was appropriately denied due to supply issues, as the patient may not be able to access the appropriate doses to safely titrate Wegovy.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma.

Treatment is an inpatient admission.

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

This is a patient with a history of asthma. He had been non-compliant with his prescribed asthma controller therapy and taking albuterol 3 - 4 times per week for wheezing and chest tightness usually in the evening. He was sick with coughing and wheezing for 2 days. He developed diffuse wheezing and increased work of breathing despite taking 3 doses of 3 puffs of albuterol over the day and when his symptoms did not improve, he was taken by ambulance to the ER (emergency room) for additional treatment. He was administered another dose of albuterol in the ambulance in route to the ER.

In the ER he was noted to be in respiratory distress with wheezing, nasal flaring, retractions, and tachypnea noted on physical examination. His pulse ox (oximetry) reading was low at 94% and he was started on supplemental oxygen with a face mask. He was treated with 3 doses of Combivent, an IV (intravenous) normal saline fluid bolus, and oxygen. When he did not improve, he was also administered magnesium sulfate. A chest x-ray was found to have bilateral pulmonary infiltrates. Blood testing was significant for low serum potassium which required potassium supplementation. His oxygen supplementation was increased from 5 to 10 liters, and he was started on a continuous high-dose administration of albuterol. After treatment in the emergency room (ER) he was reevaluated, and he was noted to have persistent wheezing and subcostal retractions. The decision was made to admit him to the PICU (pediatric intensive care unit) with a diagnosis of status asthmaticus for ongoing treatment with continuous albuterol.  

The insurer has denied the admission as not medically necessary and indicated that there was no documentation in the medical record to support the need for inpatient treatment. 

The patient was treated appropriately in the ER for a cough, wheezing and respiratory distress. He had been taking albuterol for 2 days at home and following treatment in the ER, he continued to have ongoing respiratory distress with persistent wheezing and increased work of breathing. Based on my review of the medical record it was appropriate and consistent with the standard of care to admit him to the hospital for ongoing treatment with continuous albuterol and IV fluids with a diagnosis of status asthmaticus. He failed outpatient management of his asthma and had been non-compliant for over 6 months with asthma controller medication which had been prescribed by his pediatric Pulmonologist. Following treatment in the ER, he continued to be in respiratory distress with a diagnosis of status asthmaticus and was not stable enough to be sent home. The admission to the hospital should be covered by the insurer.

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 hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal/Ulcerative Colitis
Treatment: Pharmacy/Prescription Drugs/Stelara
The health plan denied the requested Stelara, as not medically necessary. 
The health plan's determination is overturned.

This patient is a female. She has a history of very early onset inflammatory bowel disease, ulcerative colitis phenotype. She previously tried and failed conventional therapy and Infliximab. The patient was then started on Stelara at the standard dose, 45 mg (milligrams) every 8 weeks. However, she continued to have active disease.
At issue is the medical necessity for the requested medication, Stelara dose of 45 mg every 4 weeks.

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

Yes. Stelara, as requested, is medically necessary.
Stelara is Food and Drug Administration (FDA) approved for the treatment of Crohn's disease and ulcerative colitis (UC) in adults. Despite the lack of FDA approval for pediatric patients, there are many peer reviewed publications supporting the efficacy and safety of Stelara in children with inflammatory bowel disease.
A report by Dayan JR et al, showed that Ustekinumab (Stelara) is efficacious and safe in pediatric patients with inflammatory bowel disease. According to Dhaliwal, Jasbir, et al: " Ustekinumab demonstrated efficacy in this paediatric cohort with otherwise treatment-refractory UC."
Therefore, the use of Stelara in refractory cases of pediatric ulcerative colitis is appropriate. However, some patients do not respond adequately to the standard dose. Dose escalation is often required in biologics in order to achieve therapeutic levels. There are many peer reviewed literature reports showing that low Stelara levels were associated with poor clinical response. The requested dose of 45 mg every 4 weeks is proven to be effective in patients who fail the standard dose.
According to Dalal, R., et al: "UST (Stelara) dose escalation resulted in clinical remission in >50% of UC patients and was more effective in those with loss of response compared to no/minimal response after induction."
This patient has a history of refractory ulcerative colitis which failed anti-tumor necrosis factor alpha (Infliximab) in addition to conventional therapy. The patient also failed to respond to Stelara standard dose (45 mg every 8 weeks) and continued to have an active disease. There are no other FDA approved alternatives for this child.
Therefore, dose escalation is the only appropriate option for this child and is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tooth fracture.
Treatment: Crown lengthening (D4249) for tooth #12.
The insurer denied coverage for crown lengthening (D4249) for tooth #12.
The denial is overturned.

Crown lengthening is a surgical procedure that involves the manipulation of either soft tissue or both soft and hard tissue around a tooth or teeth for esthetic or restorative purposes. Esthetic crown lengthening is indicated in patients with excessive gingival display (known as a gummy smile) or gingival overgrowth, whereas restorative (or functional) crown lengthening aims to gain retention and resistance form of a sound tooth structure above the alveolar crest level in cases of subgingival caries, subgingival restorative margins, or tooth fracture. Both aim to increase the amount of supragingival tooth structure for esthetic and/or restorative purposes. In selecting the type of procedure for esthetic or restorative (or functional) crown lengthening, the key considerations include assessment of the width of keratinized gingiva and distance of the cement enamel junction or finished restoration margin to the alveolar bone around the tooth/teeth involved. 

The documentation (photographs) shows that the tooth is fractured below the gingival level. Crown lengthening is needed to place a crown. 

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 crown lengthening (D4249) for tooth #12, is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female with a history of lung nodules who presented to the emergency room with abdominal pain. The patient also reported weight loss as well as palpitations. The patient was found to have pulmonary embolism and was admitted to an acute in-hospital level of care. The requested inpatient level of care was denied due to a lack of medical necessity. This denial is being appealed.

No, the proposed treatment was not medically necessary.
The patient was found to have a bilateral pulmonary embolism. The patient was started on Lovenox and subsequently switched to oral anticoagulation, Eliquis. The patient was hemodynamically stable. The patient was not in any distress. The requested inpatient level of care was not medically necessary. 

Since the patient was hemodynamically stable, and the treatment include subcutaneous Lovenox followed by oral Eliquis, it would have been reasonable to expect the patient's treatment course would have been expected to be safe and effective at a lower level of care.

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: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 
The insurer denied Inpatient Admission. 
The denial is overturned.

This patient is a female with a history of recurrent urinary tract infection (UTI)s, asthma, diabetes, and Acute lymphoblastic leukemia (ALL) in remission, who presented with acute gastrointestinal (GI) /genitourinary (GU) symptoms (intractable nausea/vomiting [N/V] with left [L] flank pain) and neurological symptoms (headaches, vertigo, and dizziness).
Labs on admission revealed abnormal urinalysis (UA) concerning urinary tract infection (UTI)s, metabolic derangement (hyperglycemia, hyperbilirubinemia, and elevated anion gap). She was admitted to the inpatient floor and received intravenous (IV) fluids, antiemetics, and analgesics, and multiple consultations from (gastrointestinal [GI], Endocrinology, and neurology) with further diagnostic workup.
At issue is the medical necessity of Inpatient Admission.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of Inpatient Admission is medically necessary for this patient.
This is a female with multiple comorbidities, who presented with multi-systemic symptoms (N/V and left flank pain, headache, and vertigo). Her clinical presentation required further diagnostic workup and urgent inpatient management with IV fluids, antiemetics, and analgesics for managing acute GI symptoms and correction of hyperglycemia and elevated anion gap metabolic acidosis. She required multiple consultations (gastroenterology, endocrinology, and neurology) for the workup of her multisystemic symptoms. She required further diagnostic workup and urgent management of acute symptoms to prevent further complications that could increase mortality and morbidity.

Therefore, the requested health service/treatment for Inpatient Admission is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis; Gynecomastia
Treatment: breast reduction surgery
The insurer denied breast reduction surgery. 
The health plan's determination is upheld.

This patient is a  male who had bilateral grade IV gynecomastia with both fat and firm breast tissue. He also had nipple hypertrophy. His surgeon performed bilateral mastectomies and chest liposuction and nipple reductions. He has a diagnosis of hypogonadism.

The breast reduction surgery is not medically necessary.
The surgery would be considered cosmetic. The patient had gynecomastia, but the records do not document any health or functional problems caused by the enlarged breasts. There is no documentation of a concern for a breast malignancy and there are no diagnostic studies provided. He is reported to have pain but the physician notes do not document a need for treatment with analgesics or problems with activities of daily living due to his enlarged breasts.
Gynecomastia is a benign condition that does not cause health or functional problems. The records submitted do not provide any evidence of a concern regarding breast cancer. The procedure will primarily improve appearance and self-esteem. Therefore, it would be considered cosmetic and not medically necessary. Observation, reassurance and use of analgesics as needed are reasonable management approaches for this condition. The patient is likely to derive emotional benefit from the surgery, but his physiologic health will not be improved.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal-Diverticulitis.
Treatment: Inpatient hospital stay.
The health plan denied the inpatient hospital admission as not medically necessary. 
The reviewer has overturned in whole the health plan's admission.

This is a patient with a history of diverticulitis who presented to the emergency room with fever, lethargy, weakness, and left lower quadrant pain. She reported prior similar abdominal pain now associated with nausea and decreased oral intake. Labs on admission revealed low-grade fever and tachycardia. The patient was positive for COVID-19 and low phosphorus at 1.5 with mild hyponatremia. A computed tomography (CT) scan of the abdomen showed uncomplicated diverticulitis of the splenic flexure. She was admitted to the inpatient floor and received intravenous (IV) fluids, antiemetics, and broad-spectrum antibiotics. Her symptoms improved, and she was discharged home.

Inpatient medical care is medically necessary. This is an elderly female with recurrent abdominal pain, fever and weakness secondary to sepsis induced diverticulitis. She is high risk for complication because of her advance age, and she presented with systemic inflammatory response syndrome (SIRS) criteria and CT finding was consistent with (c/w) diverticulitis in the setting of COVID 19 infection. She required inpatient admission for management of diverticulitis with pain control, IV fluids, and IV antibiotics (ABX) and serial monitoring to prevent further complication of diverticulitis.
The following detailed inpatient care, which includes IV fluids, IV analgesics, IV antiemetics, and broad-spectrum IV antibiotics with serial monitoring of labs, cannot be prudently provided under a lower level of care. Delay in providing prompt medical management of diverticulitis can result in intra-abdominal infection/peritonitis, leading to increased mortality and morbidity.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: Crohn's disease
Treatment; Stelara
The insurer denied Stelara 90 mg every 4 weeks. The health plan's determination is overturned. 

The patient is a male with Crohn's disease complicated by fistula and abscess requiring two surgeries. He reportedly required surgery and had a fistula and abscess, while taking Stelara 90 milligrams (mg) every 4 weeks. A colonoscopy showed normal ileum, and right and left colon with aphthous ulcers. He has failed methotrexate, Humira, and infliximab. He has been on Stelara 90 mg every 4 weeks.

Stelara 90 mg every 4 weeks is medically necessary. In this case, the patient has failed multiple other medications for the treatment of Crohn's disease, and had active disease complications (abscess and fistula) requiring surgery despite the use of Stelara 90 mg every 4 weeks. Decrease of Stelara dosing, or discontinuation of Stelara (even if an alternative therapy is attempted immediately) may result in complications such as fistula, stricture, bowel obstruction, flare, hospitalization, need for further surgery, or other complications of Crohn's disease. For all of these reasons, Stelara 90 mg every 4 weeks is supported as medically necessary for the treatment of Crohn's disease in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Home Health Care. 
The insurer denied Home Care/Personal Care HHC-Personal Care Aide-Live-In per diem 24 hours per day (Split Shift). 

The denial is upheld. 

The patient is a female with a past medical history significant for breast cancer, papillary cancer of thyroid and lateral myoma. She has advanced Alzheimer's disease and is bedbound. Services were denied by the patient's health plan stating the patient is currently approved for live in services. Uniform Assessment System (UAS) State of New York showed changes in the patient's abilities to perform bed mobility, bathing, personal hygiene, dressing upper and lower body, walking, eating, and the appropriate, and ordinary housework and medication management and that her memory is poor. Evaluation showed that there have been no significant changes in the patient's activities of daily living within the last 90 days. Her social circumstances have not changed. Her needs are predictable and can be scheduled. She has no compelling nighttime needs.
Services were denied based upon medical necessity and the patient is appealing the decision.
At issue is the medical necessity of Home Care/Personal Care HHC-Personal Care Aide-Live-In per diem 24 hours per day (Split Shift).

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Home Care/Personal Care HHC-Personal Care Aide-Live-In per diem 24 hours per day (Split Shift) is not medically necessary for this patient.
Personal care hours are currently authorized in the amount and duration and scope necessary to meet the members personal care needs. Hours beyond the currently authorized would be for safety monitoring. The question is whether the patient meets medical necessity for these services during the nocturnal hours and if the services can or cannot be provided by the aide who is already there. The patient has no active bedsores as noted. Prevention of bedsores can be provided through other means such as an alternating mattress. Medical necessity is currently not met for the services in the nocturnal hours. There is no documentation as to why a live-in aide could not provide the services during the overnight hours. There is no documentation that the aide could not get at least 5 hours of uninterrupted sleep. According to guidelines, this is the determining factor whether or not a patient would require split shift services versus 24-hour aide live-in services. Medical necessity has not been met for 24 hour a day continuous services as there is no documentation as to why a caregiver could not get 5 hours of interrupted sleep. The patient's needs are predictable and can be scheduled and she has no compelling nighttime needs.
Therefore, the requested health service/treatment of Home Care/Personal Care HHC-Personal Care Aide-Live-In per diem 24 hours per day (Split Shift) is not medically necessary.