Persius/hicric huggingface dataset:
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 abdominal pain of two-days duration. Of note, he had undergone laparoscopic cholecystectomy for the condition of gallstone pancreatitis.  

The patient's vital signs at the time of presentation were notable for mild tachycardia (heart rate 102 beats per minute).  Examination revealed a tender abdomen. The white blood cell (WBC) count was elevated at 12.6 thousand (K).  Alanine aminotransferase (ALT) and alkaline phosphatase (Alk Phos) were elevated with normal bilirubin.  An abdominal computed tomography (CT) was obtained.  A gastroenterology consultation was obtained.  

The patient was initially treated with nothing by mouth (NPO) status, intravenous fluids and follow up lab data.  Day two, the records indicate that the patient was clinically stable with normal vital signs.  The patient was deemed stable for discharge from the hospital on day three.

The health plan rationale for denial of inpatient care was based on the Milliman Care Guidelines (MCG) Criteria 25th edition - Abdominal Pain, Undiagnosed.

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.  He was status post cholecystectomy for gallstone pancreatitis performed four days earlier.  His evaluation with examination, lab data, and computed tomography (CT) scan identified no obvious indication for acute surgical intervention.  There was pancreatic inflammation that was improved compared to a prior study.  The patient was monitored 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 as was performed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity, chronic lymphedema, HTN (hypertension), and aortic dissection, wound of buttocks with muscles necrosis.
Treatment: Continued Skilled Nursing Facility.
The insurer denied the Continued Skilled Nursing Facility.
The denial is overturned.

The patient is a female. She has a PMH (past medical history) of obesity, chronic lymphedema, HTN (hypertension), and aortic dissection. She reportedly has wound of buttocks with muscles necrosis and needs skilled nursing care at a facility. The patient has deconditioning.

The review is for Continued Skilled Nursing Facility. The health plan's reason for prior denial of coverage was that continued skilled services are not medically necessary.

Yes, the Continued Skilled Nursing Facility is medically necessary. The patient has morbid obesity with buttocks wound and significant deconditioning. The patient has decreased strength and coordination, and decreased activity tolerance. She cannot do her ADLs (activities of daily living). She has been progressing with PT (physical therapy) and showing improvement. She requires skilled PT (physical therapy) and OT (occupational therapy) services.

The patient also has wound size of 10x10x5 and needs wound care regularly.

The request for continued skilled services is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
The patient has significant weakness and deconditioning. She required ongoing wound care. Continued skilled care is appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital admission. 
The denial is overturned.

This patient is a female (body mass index [BMI] 48 kilograms per square meter [kg/m2]) who presented to the hospital emergency department (ED) with the complaint of abdominal pain of 7-days duration. Lab data showed an elevated white blood cell (WBC) count of 13.9 thousand (K). Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were elevated. She was tender in the right upper abdomen. Computed tomography (CT) scan identified findings consistent with acute cholecystitis.

She underwent laparoscopic cholecystectomy. The operative dictation describes an acutely inflamed and gangrenous gallbladder. The surgical dissection was difficult due to the severity of the inflammation and phlegmonous reaction of the pericholecystic tissues. A surgical drain was placed. The patient was started on a diet. The WBC count was normalized, and liver enzymes had decreased. The pathology report confirmed the diagnosis of acute cholecystitis. The patient was discharged from the hospital. The records indicate that the surgical drain was kept in place to be removed in the outpatient setting. The subject under review is the medical necessity for the inpatient stay.

The inpatient hospital admission was medically necessary for this patient.
The records support that this patient had acute cholecystitis. Her presenting condition, lab and imaging data, likelihood of need for hospitalization for at least 2 nights all support that inpatient admission was medically necessary.
This patient had upper abdominal pain and tenderness at the time of presentation to the ED and had an elevated WBC count of 13.9 K in addition to elevated liver enzymes (AST and ALT). Her clinical condition was consistent with acute cholecystitis. Imaging data also identified findings consistent with acute cholecystitis. At the time of surgery this diagnosis was confirmed with direct inspection of the gallbladder and the pathology report corroborated this condition. During this period of inpatient admission, the patient required provision of IV fluid, antibiotics, and pain medications. She also had a surgical drain in place. The WBC count was still elevated. The records indicate that the patient was appropriately cared for over a period of time that spanned greater than (>) 2-nights.
Inpatient care was medically necessary because this patient had documentation of acute cholecystitis. This condition required provision of intravenous (IV) fluid, antibiotics, antiemetics, and prompt surgical intervention This care and treatment was most appropriately carried out in the inpatient setting as there was need for regular clinical assessment by the treating surgical service, follow up lab assessment, and provision of parenteral medications that spanned >2-nights for the diagnosis of acute cholecystitis. Milliman Care Guidelines (MCG) also support that inpatient care was appropriate as this patient had acute cholecystitis with upper abdominal pain and tenderness and a WBC count of 13/9 K.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Humira. 
The denial is upheld.

The patient is a male with psoriatic arthritis, psoriasis and diabetes mellitus (DM). The issue in this case is Humira is being denied by the health plan as its not considered to be medically necessary at this time. Plan alternatives are methotrexate (MTX), sulfasalazine (SSz), imuran, Arava and cyclosporine. Records were reviewed. The patient has tried and failed nonsteroidal anti-inflammatory drugs (NSAIDs). A letter from the patient's provider states that the patient has not tried any plan preferred drugs.

No, Humira is not medically necessary at this time for this patient. There is no reason the patient cannot try MTX, which is indicated for psoriatic arthritis and is not contraindicated in patients with diabetes. According to UpToDate, 'MTX is the most commonly used first-line disease modifying anti-rheumatic drug (DMARD) in psoriatic arthritis (PsA), although only limited data are available supporting its efficacy in PsA. Despite the lack of randomized trial evidence of efficacy, observational studies and our clinical experience indicate that MTX may be effective for some patients in clinical practice. Expert opinion also supports use of MTX as a first-line DMARD, including treatment guidelines of the European League Against Rheumatism (EULAR) and the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA); we prefer it as well based upon ease of use, tolerability, and proven efficacy in psoriasis.
There is no medical reason/contraindication to this patient trying a DMARD, such as MTX, which is indicated for the treatment of psoriatic arthritis.
Appeal type: Experimental/Investigational
Decision: Upheld

Reviewer #1 

Diagnosis: Crohn's disease

Treatment: Adalimumab/Humira [citrate-free (cf)] 80 milligrams (mg)

The insurer denied coverage for Adalimumab/Humira (cf) 80 mg

The denial is upheld

The patient has Crohn's disease. He was started on adalimumab 40 mg every 14 days. He was having active bowel symptoms and the adalimumab level was 1.6. The adalimumab dose was then increased to 40 mg weekly. He subsequently was having at least 10 bowel movements a day. An adalimumab level was read as not detected. There is no submitted antibody level to review. 

The American Journal of Gastroenterology article titled "Clinical utility of measuring infliximab and human anti-chimeric concentrations in patients with inflammatory bowel disease" concludes measuring infliximab concentrations and antibody levels is clinically useful. Increasing the drug dose may be a good strategy if infliximab levels are subtherapeutic.

Digestive and Liver Diseases article titled "Adalimumab dose escalation is effective and well tolerated in Crohn's disease patients with secondary loss of response to adalimumab" concludes that adalimumab dose escalation is an effective and well tolerated therapeutic option in patients with secondary loss of response. A 40 mg every week optimized regimen was predictive of a good response by patients receiving the adalimumab dose escalation. 

This patient has already had dose escalations with adalimumab. The usual recommended dose escalation is to 40 mg weekly. At the already escalated dose of 40 mg a week, he was still having non-detectable levels. The physician's letter does not include the results of antibody testing. The scientific literature supports dose escalation to 40 mg weekly but there is limited experience in giving higher doses. Giving 80 mg weekly is not listed as a Food and Drug Administration (FDA) approved dosage. The patient is not a good candidate for further dose escalation as there are other biologics that are recommended for Crohn's disease. It is not clear if there may be more adverse reactions with this dose as compared to switching to another biologic therapy. Since the requested dose of 80 mg weekly is above the usual escalated dose, with the lack of submitted antibody testing, and the availability of multiple other biologics available for Crohn's disease, giving adalimumab 80 mg weekly is not likely to be more beneficial than any other standard therapies.

The carrier's denial of Adalimumab/Humira (cf) 80 mg should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Home Health Care. 
The insurer denied: increase in Personal Care Worker (PCW) service to 7 days per week, 24 hours per day, continuous care by more than one person - 168 hours. 
The denial is overturned.

The patient is a female with past medical history Parkinson's disease, generalized osteoporosis, dementia. This review is for the medical necessity of Increase in Personal Care worker (PCW) to 7 days a week, 24 hours a day continuous care by more than 1 person - for a total of 168 hours per week. The current approved hours of 10 hours daily, 7 days a week, 70 hours. The request was made to increase hours as patient gets confused at night and has falls.

The requested health service/treatment of increase in Personal Care Worker (PCW) service to 7 days per week, 24 hours per day, continuous care by more than one person - 168 hours is medically necessary for this patient
The patient has severe Parkinson's disease, severe dyskinesia with confusion, visual hallucinations and sleep disruption. She requires assistance with all ADLs as she cannot perform any of her daily tasks due to her progressive neurologic disorder. She requires assistance with toileting and toilet transfers and unable to do this independently and requires cuing and reminders to do so, and per review of overnight logs, she requires a caregiver overnight to assist with ADLs and toileting. She also does not have informal caregiver availability for overnight hours.
The requested increase in assistance was not solely for safety and supervision but to assist the patient with safe completion of ADLs and Instrumental activities of daily living (IADLs). Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, the requested hours are medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skin Disorders/Other/Chronic idiopathic Urticaria
Treatment: Pharmacy/Prescription Drugs
The health plan denied the requested medication, Xolair, as not medically necessary. 
The health plan's determination is overturned.

This is a female patient with a request for Xolair for chronic idiopathic urticaria (CIU), and angioedema. She has tried Allegra 4 times a day. The patient has required Prednisone.

At issue is the medical necessity for the requested medication, Xolair.

The health plan's determination is overturned, in whole.

Yes. The guidelines for the treatment of chronic spontaneous urticaria were updated with the publication of the 2018 international expert document on the definition, classification, diagnosis, and management of urticaria [2]. These 2018 guidelines recommend that after the failure of high-dose (up to 4 times) non-sedating 2nd generation antihistamines, the third step of therapy is Omalizumab.
In this case, the patient has failed 4 times the normal dose of a second-generation antihistamine for CIU. This would be the standard of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dyspepsia, history of esophageal and gastric ulcers.
Treatment: Esophagogastroduodenoscopy
The insurer denied the Esophagogastroduodenoscopy.
The determination is upheld.

The patient has a history of esophageal and gastric ulcers. He presented with dyspepsia, and had failed omeprazole; an esophagogastroduodenoscopy was planned. He presented for follow-up of esophageal and gastric ulcers found on endoscopy; he was on omeprazole twice daily with resolution of abdominal pain and acid reflux. Esophagogastroduodenoscopy showed Los Angeles Grade A esophagitis, Hill grade 2 valve, hiatal hernia, mild patchy antral gastritis, and normal duodenum; the recommendation was omeprazole 40 milligrams (mg) daily; biopsies showed mild reflux esophagitis, focally increased intraepithelial eosinophils, and mild chronic active gastritis. At issue is the medical necessity for the esophagogastroduodenoscopy.

The request for esophagogastroduodenoscopy is not medically necessary based on the submitted documentation. The patient had a prior finding of esophageal and gastric ulcer disease, without note of a malignant appearance, bleeding, concerning findings on biopsies, or persistent symptoms; according to the most recent American Society for Gastrointestinal Endoscopy (ASGE) guidelines for ulcer disease, "no United States (US) or Canadian gastroenterologic society has recommended routine surveillance for gastric ulcers" [1,2]. The most recent American College of Gastroenterology guidelines for the evaluation of gastroesophageal reflux disease (GERD) and esophagitis in effect at the time of the procedure did not recommend repeat endoscopy to assess esophageal ulceration, stating "Repeat endoscopy is not indicated in patients without Barrett's esophagus in the absence of new symptoms" [3,4].
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer. 
Treatment: Advanced Imaging. 
The insurer denied Emission Tomography (PET) and Computed Tomography (CT) scan. 
The denial is upheld.

The patient is a female with history of tumor (T)1node (N)1 papillary thyroid carcinoma status/post (s/p) surgical resection and radio iodine ablation. The subject under review is the medical necessity for positron emission tomography (PET) and computed tomography (CT) scan for this patient.

No, the requested PET/CT was not medically necessary for this patient. The patient did not have any clinical, biochemical, nor radiographic suspicion for recurrent disease. The thyroglobulin level was not abnormally elevated. PET/CT is not routinely utilized for surveillance of an asymptomatic thyroid cancer patient, and its use is not supported by the National Comprehensive Cancer Network (NCCN) guideline nor the peer reviewed medical literature.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain. 
Treatment: Inpatient admission. 

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

This female was hospitalized for chest pain. She was sent to the ED (emergency department) by her cardiologist for further evaluation of intermittent CP (chest pain) x3 weeks associated with DOE (dyspnea on exertion) and palpitation. Her PMH (past medical history) includes MVP (mitral valve prolapse) with MR (mitral regurgitation). 

The patient's vitals were stable. TEE (transesophageal echocardiogram) done showed bileaflet MVP (mitral valve prolapse) and moderate MR (mitral regurgitation) only LHC (left heart catheterization) done on the same day showed normal coronaries. She was observed overnight and deemed stable for discharge home. This is an appeal of the denied claim the requested Acute Inpatient Hospital Stay was medically necessary for this patient approved at the Observation level of care. 

No, the Inpatient admission was not medically necessary. 

Based on the peer reviewed medical literature, there was not a medical need for the acute inpatient hospital stay. The documentation submitted shows the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. Criteria per MCG (Milliman Care Guidelines) guidelines for Chest Pain, #M-89 for inpatient admission is not met, including hemodynamic instability, respiratory distress, pulmonary edema, angina with acute coronary syndrome, chest pain that is indicative of a serious cardiac condition like pulmonary embolism or aortic dissection, acute myocardial infarction, pneumonia, hypertension requiring inpatient hospitalization or any other medical condition, symptom or finding for which emergency and observation care have failed or are not considered appropriate. The patient's vitals were stable, and there is no documentation of elevated troponin or procedural complications. The care the patient received, including routine TEE (transesophageal echocardiogram) and urgent and uncomplicated cardiac catheterization, like in this case, is routinely provided safely and effectively at a lower level of care, such as, at the Observation LOC (level of care). Therefore, based on the submitted information and the current published medical literature, the inpatient admission was not medically necessary. 

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

Diagnosis: Diabetes
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

This is a male with asthma, reflux, fatty liver, hypertriglyceridemia, hypertension, obesity, sleep apnea, thyroid nodule, and hypothyroidism who presented with blurry vision, polyuria, polydipsia, dry mouth, lethargy, and weight loss. He was tachycardic to 111 in the emergency room. His blood pressure (BP) was 140/92, heart rate was 80, temperature was 98.8, respiratory rate was 15, and oxygen saturation (O2) was 95%. The patient's glucose was greater than 800, potential hydrogen (pH) was 7.34, lactate was 10.4, beta-hydroxybutyrate was 5.42, carbon dioixde (CO2) was 12.4, creatinine was 1.35, and potassium was 3.3. The patient was treated with intravenous fluids and insulin drip and transitioned to subcutaneous insulin. 

No, the proposed inpatient hospital stay was not medically necessary.
The proposed inpatient stay was not medically necessary. This patient presented with symptoms of new onset diabetes mellitus. He was hyperglycemic and dehydrated. He had a potential hydrogen (pH) of 7.34 indicating no significant acidosis. He responded to intravenous fluids and insulin therapy. His hyperglycemia improved and he was transitioned to subcutaneous insulin injections. He was hemodynamically stable. Therefore, no, the proposed inpatient stay was not medically necessary.

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

The requested inpatient stay was appropriately denied.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class II malocclusion
Treatment: D8080 Comprehensive Orthodontic Treatment of the Adolescent Dentition and D8670 Periodic Orthodontic Treatment Visit x (times) 12
The insurer denied the D8080 Comprehensive Orthodontic Treatment of the Adolescent Dentition and D8670 Periodic Orthodontic Treatment Visit x12.
The denial is overturned.

The patient is female with a Class II malocclusion. She has mild upper and lower crowding and a severe excessive overjet. The reason for denial was due to a handicapping score of 17.

Yes, the proposed D8080 Comprehensive Orthodontic Treatment of the Adolescent Dentition and D8670 Periodic Orthodontic Treatment Visit x (times) 12 is medically necessary.

The patient has a deep, impinging overbite with soft tissue damage on her palate. This is an automatic qualifier according to the handicapping index scale. There is medical necessity and orthodontic benefits are needed to correct this problem.

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