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

Diagnosis: CHF, weakness, gait ataxia
Treatment: Increase in PCA services to 84 hours per week 

The proposed treatment of an increase in PCA services to 84 hours per week is deemed medically necessary. 

This is a female with a history of congestive heart failure, weakness, gait ataxia and associated frequent falls. For these reasons, she requires assistance with completion of the majority of her activities of daily living (ADLs). Recent progress note from her Cardiologist indicates that the patient has been hospitalized multiple times over the past year due to recurrent falls and various traumatic fractures sustained including recent pelvic and left arm fractures. Hence, the currently approved plan of 56 hours of PCA services is not sufficient to meet the patient's needs. For these reasons, the proposed treatment of an increase in PCA services to 84 hours per week is deemed medically necessary for increased assistance with completion of her ADLs.
Appeal type: Experimental/Investigational
Decision: Overturned

This is a male patient with chronic migraines. Single pulse transcranial magnetic stimulation (sTMS) eNeuro has been recommended. 

According to Bhola, et al. (2015), "Single pulse transcranial magnetic stimulation (sTMS) is a novel treatment for acute migraine.  Previous randomised controlled data demonstrated that sTMS is effective and well tolerated in the treatment of migraine with aura.  The aim of the programme reported here was to evaluate patient responses in the setting of routine clinical practice...sTMS may be a valuable addition to options for the treatment of both episodic and chronic migraine."

Per Lan, et al. (2017), "Five studies, consisting of 313 migraine patients, were identified.  Single-pulse transcranial magnetic stimulation is effective for the acute treatment of migraine with aura after the first attack (p =0.02).  And, the efficacy of TMS on chronic migraine was not significant (OR 2.93; 95% CI 0.71-12.15; p =0.14). TMS is effective for migraine based on the studies included in the article."

Lastly, Barker, et al. (2017) concludes, "Migraine is a debilitating condition characterized by headache, nausea, and sensory hypersensitivity.  It may affect up to 15% of the population, yet current drug treatments are often poorly tolerated.  Clinical studies have shown that TMS is an effective treatment for migraine.  In addition, it has the added advantages of being safe and well tolerated by patients.                                                    

The carrier's denial of coverage for TMS (eNeura device TMS mini) should be reversed.
Appeal type: Experimental/Investigational
Decision: Overturned

This is a male patient with a history of migraine headaches with aura. It was reported that the patient had headaches that last 4 hours per day, 15 day a month. The patient had failed preventive treatments.

TMS is currently undergoing clinical trials and it is not proven to result in greater benefits for the prophylaxis or treatment of headache compared with other forms of treatment. The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcomes.  TMS (eNuera device TMS mini) devices are FDA-cleared and not FDA-approved (and therefore have been shown to be safe without evidence of efficacy).  The TMS (eNuera device TMS mini) is not the best available patient treatment for this patient at this time as clinical trials are ongoing.  The requested TMS (eNuera device TMS mini) is not likely to be more beneficial than any of the other standard treatments/procedures for this patient. 

The carrier's denial of coverage for TMS (eNeura device TMS mini) should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic Migraines
 
Treatment: TMS (eNeura device TMS mini)

The insurer denied the TMS (eNeura device TMS mini). The denial was reversed.

This is a young male patient who presented to a neurologists office with complaints of chronic headaches that had occurred for more than 15 days per month for the past 3 months. The average untreated duration is about 4 hours. It was reported that the patient failed chronic migraine and prior preventive treatments. The eNeuro device was recommended.

This device has FDA approval for migraine and several high quality studies support its effectiveness. The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome - see citations below.

This patient is a good candidate for TMS (eNeura device TMS mini).  He has intractable migraines. His neurologist, a well-known headache expert thinks TMS (eNeura device TMS mini) is the best available treatment for this patient at this time. This device is likely to be more beneficial than other migraine therapies.

The carrier's denial of coverage for TMS (eNeura device TMS mini) should be reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath; leg ulcer
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient was admitted for a leg wound and shortness of breath. Despite the patient's complaints, there were no confirmed or witnessed withdrawal symptoms from opioid use (Ref 3). Although there were some bacteria noted in the wound cultures, there was no elevated WBC (white blood cell) count, elevate lactate, fevers or pus (ref 1). Cardiopulmonary testing was unremarkable. The patient did not receive Methadone and left against medical advice the next day. The clinicians were unable to provide further diagnostics or treatments. There were no acute abnormalities noted that could not have been managed as an outpatient.  The patient was admitted the prior month for one day for similar complaints and did not follow-up as recommended. The inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary Tract Infection
 
Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld.   

 This is a female patient who presented to the emergency department with complaints of a fever and right breast pain. Her blood pressure was noted to be elevated on arrival; it was stabilized in the emergency department. Gynecology consulted over the patient. The patient had an extensive work up for the fever of unknown origin. A computed tomography scan (CT) of her pelvic and abdomen was performed that revealed she had a right side pyelonephritis. The patient received intravenous (IV) hydration and antibiotics. She was safely discharged home on a course of oral antibiotics. 

Many patients can be managed in the outpatient setting.  As an example, in a study of 44 patients with pyelonephritis but no major co-morbidities, a 12-hour observation period with parenteral antimicrobial therapy in the Emergency Department followed by completion of outpatient oral antimicrobials was effective management for 97 percent of patients.
This patient presented with fever but no sign of sepsis.  Extensive evaluation was only suggestive of a urinary tract infection, possible pyelonephritis.  The mild elevation of her blood pressure and her laboratory evaluation was not suggestive of pre-eclampsia.

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

The patient presented to the hospital. She had no significant past medical history and she was transferred from an outside center for assessment of suspected diabetic ketoacidosis. She had blood drawn that was concerning for diabetes with a fingerstick of 589. She reported polyuria, polydipsia, and weight loss along with dehydration. She denied fevers, shortness of breath, nausea, and vomiting. She did report a family history of diabetes. Vital signs showed blood pressure 117/87, heart rate 93, temperature 98.6 Fahrenheit, and respiratory rate 16. On physical examination, heart was regular, breath sounds were normal, abdomen was soft and nontender. Labs showed white blood cell (WBC) 7.3, hemoglobin 13.6, platelets 238, sodium 136, Glucose 374, calcium 8.8, and Anion gap 16. The patient was admitted for suspected hyperglycemia. The plan of care included insulin, sliding scale, monitor glucose, intravenous (IV) fluids, monitor electrolytes, diabetes education, and endocrine consult. She improved with insulin and was discharged. The inpatient stay is under review.

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient had a largely benign physical examination, negative labs with no evidence of acidemia, no significant metabolic anion gap, no significant acute kidney injury (AKI), and she had no sepsis or hemodynamic instability as a trigger for diabetic ketoacidosis (DKA). The blood glucose in the medical record at the time of admission was elevated but was managed with insulin with rapid correction, and there was no evidence of concurrent complications from the hyperglycemia such as encephalopathy. She required further management but it could have been safely and effectively provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Supracondylar fracture to distal humerus

Treatment: inpatient hospital admission

The insurer denied coverage for inpatient hospital admission. The denial was upheld.

This patient is a female child who fell from monkey bars. She injured her left elbow. She was evaluated in the Emergency Department (ED).  She was found to have deformity and swelling. She was diagnosed with a supracondylar fracture to distal humerus. She underwent closed reduction with placement of percutaneous pins to the distal humerus. A splint was then applied. Her post-surgical course was noncomplicated with discharge.

There was no indication for inpatient admission. The medical records demonstrate an isolated elbow injury. It was of low energy. There were no open wounds. There was no evidence of neuromuscular compromise. There were no other medical conditions which required management. The post-surgical course would be expected to be noncomplicated based upon fracture pattern and treatment provided. There were no extenuating circumstances to substantiate inpatient hospital admission. The applicable level of service would be Observation.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. The inpatient hospital admission is not considered medically necessary for this patient.

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

Diagnosis: Gastroenteritis

Treatment: inpatient admission

The insurer denied coverage for inpatient admission. The denial was reversed.

This patient is a female who was seen in the hospital. The patient had a past medical history of recurrent Clostridium difficile colitis, obesity, tobacco use, kidney stones, glaucoma, gastric bypass and anxiety. The patient was seen in the hospital with complaints of nausea, vomiting and diarrhea with upper abdominal/epigastric pain x 2 days. The patient stated that she was unable to keep food down and complained of dry lips and posterior headache. The patient had a temperature 98.6 F., respirations 22, blood pressure 154/105. The patient had a white blood cell count of 11.17 K, platelets 245, the Computer Tomogram (CT) of the abdomen revealed thickening of the colon no suspicious for non-specific colitis. A renal ultrasound was normal. The patient was admitted with colitis. The patient was started on intravenous antibiotics Ciprofloxacin and Flagyl. The Clostridium difficile testing was negative.  Fluids were discontinued and patient was advanced on diet.  The patient was then discharged in stable condition.

The medical literature indicates that inpatient admission is indicated for patients with gastroenteritis if there is suspected severe infection, severe abdominal tenderness, toxic megacolon, hemodynamic instability, vomiting or dehydration that is severe, persistent, hemolytic uremic syndrome, inability to maintain oral hydration or parenteral nutrition required on an inpatient basis. The patient meets MCG guidelines for inpatient admission; Abdominal Pain (M-05). The documentation indicated that the patient did have complaints of epigastric pain. The patient's blood pressure decreased following the emergency department visit. The patient did have findings of colitis. The patient was given intravenous (IV) fluids. The patient did have a past medical history of recurrent colitis, Clostridium difficile colitis and leukocytosis. The patient had CT evidence of colitis. The patient's symptoms could be recurrent Clostridium difficile colitis with systemic, non-localized symptoms. 

Therefore, the requested inpatient hospital services were medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the inpatient hospital services
is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Bone fracture
Ambulance, Including Air ambulance

The patient at the time of the admission, who was the helmeted driver in a motorcycle crash. The patient  swerved to avoid an animal in the road, hit a concrete barrier), and was ejected 25 feet from the bike. A ground ambulance responded and found him on the side of the road, alert and in severe pain from left shoulder and bilateral leg injuries. At the trauma center, he was found to have a comminuted left clavicle fracture and puncture wounds of both lower legs without fracture. The health plans determination is overturned in whole. Yes, Emergency Air Ambulance was medically necessary for this patient based on the mechanism of injury and the potential for life-threatening injury. The paramedics saw the severity of the impact and understood this potential based on training that supports this as the highest classification of urgency. This response is supported by trauma systems held to standards written by the American College of Surgeons in the "Resources for Optimal Care of the Injured Patient" guideline manual.
Appeal type: Medical necessity
Decision: Upheld

Hip Problem/Pain
Home Health Care

The patient is a female with a past medical history for hip fracture, hip surgery, insomnia and anxiety. The patient had been receiving 40 hours of personal care assistance service per week which was reduced to 17 hours per week by the health plan. The patient is requesting an increase in personal care service to 40 hours per week. This was denied by the health plan based on lack of medical necessity.
The subject under review is the medical necessity for the increase in hours to 40 per week.

The health plan's determination is upheld.

No, the requested health service/treatment of Personal care assistance services (40 hours per week) is not medically necessary for this patient.  The services noted to be medically necessary for activities of daily living (ADLs) and Instrumental activities of daily living (IADLs) can be performed in the allotted time period. Additional service hours are not medically necessary. The record notes that the patient was independent with personal hygiene, dressing upper body, walking and toilet transfer. The patient needs assistance with dressing lower body and toilet use.

The Uniform Assessment System (UAS) Summary of Hours Recommended dated 6/21/2019 noted 16 hour per week which include mainly IADLs and certain ADLs including showering and toileting. The allowed time of 17 hours is sufficient to meet the patient's medical needs.

Personal care service hours are medically necessary for certain ADLS and IADLs, personal care service hours are not medically necessary for supervision or the prevention of falls unless they occur concurrent with specific ADLs of IADLs.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite
Treatment: D8080 - Braces and D8670 - Monthly visit

The proposed treatment with braces and monthly visits are medically necessary. 

Upper canines are very important teeth to have in their proper position. Without them being in the proper position, there can be no "canine guidance". This is when, during the chewing cycle, the canines guide the teeth and jaws so that all the teeth mesh together properly. Without the canine guidance (which this patient does not have now), the teeth will grind together traumatically. This will ultimately cause chipping and fracturing of many of the teeth. This can also lead to temporomandibular joint (TMJ) issues in the future. Also, the patient has crossbites of teeth #7 and #10. This will also increase the probability (not possibility) of trauma to these teeth since they will hit the lower teeth too hard and too much. This patient is in definite need of orthodontic treatment to correct these problems. Medical necessity is a definite for this patient. The monthly visits are to monitor the treatment and do adjustments as needed. They also have medical necessity.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's Disease
Treatment: Personal care assistance, level II, 56 hours per week

The proposed treatment of an increase in personal care assistance, level II to 56 hours per week is deemed medically necessary. 

This is a female with a history of advanced Alzheimer's disease. Due to this progressive neurodegenerative condition, she requires assistance with the majority of her activities of daily living (ADLs). Recent correspondence from the patient's Neurologist indicates that the patient's neurologic status is progressively worsening and she is currently demonstrating significant amnestic cognitive impairment, poor insight into her cognitive limitations, frequently loses important everyday items, forgets events and is prone to getting disoriented and lost. She is unable to navigate her community safely, including familiar blocks due to her persistent disorientation. She is unable to manage any of her ADLs, has difficulty preparing food and frequently leaves the stove on. For these reasons, the currently approved plan of 18 hours per week of personal care assistance is not sufficient to meet all of the patient's needs. Hence, the proposed treatment of an increase in personal care assistance, level II to 56 hours per week is deemed medically necessary for improved assistance with completion of the patient's ADLs.
Appeal type: Medical necessity
Decision: Upheld

The patient was admitted to inpatient mental health level of care in the context of substance use anxiety, and depression. The patient was experiencing depressed mood, feelings of hopelessness and helplessness, anxiety, and insomnia. The patient had reportedly stopped attending school and had sent text messages to a friend that included pictures of superficial cuts on the wrists. The inpatient mental health level of care is under review.

Clinical history was significant for three prior inpatient psychiatric hospitalizations with the last one after an attempted suicide by overdose on Prozac. The patient was noted to have a total of three past suicide attempts with the last one prior to this admission by cutting with a razor.

The health plan's determination is upheld. For dates of service in question, the patient did not meet criteria for continued inpatient hospitalization. The patient was not demonstrating either dangerousness to self or others. Dangerousness to self or others together are an essential element for hospitalization. The patient had not evidenced any suicidal ideation, command hallucinations to harm others, loss of impulse control, self-mutilation, or other evidence of risk to harm himself or others for at least several days prior to the dates in question. The patient could have been safely and effectively treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Depression
Issue under review: Latuda

Determination:
The Latuda is not medically necessary.

The patient notes a history of depression and anxiety symptoms and has reported poor response to multiple prior medications.  In spite of this, Latuda is not medically necessary.  There is no significant research to suggest that Latuda is more effective in the treatment of these symptoms than the other medications suggested.  There is no significant research suggesting that it is better tolerated than the other medications suggested by the patient's health plan.  There is no explicit medical documentation from a licensed prescriber suggesting that treatment with Latuda is medically necessary.

QTC prolongation and serotonin syndrome are possible with many medication combinations, including Latuda, and these are conditions that can be monitored for as standard of care.
Appeal type: Medical necessity
Decision: Overturned

Malpositioned teeth 
Dental /Orthodontic procedure

The patient with a Class III malocclusion, moderate crowding and anterior crossbite of #7-#10. The patient had treatment planned for 18-24 months of orthodontics to correct the malocclusion. The health plans determination of medical necessity is overturned in whole. The treatment of braces is medically necessary. This patient presents with an anterior crossbite, significant crowding, and a skeletal jaw imbalance. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects 1,2,3. 
The abnormal wear of the affected teeth and labial displacement of the teeth are current problems. These are occurring now and will continue to occur without the correction. If the root cause of this (the crossbite) is not corrected, the patient's teeth will continue to be compromised, and the problems will worsen in this case. The treatment of braces is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hernia
Treatment: Inpatient admission

The proposed treatment -- admission at an acute inpatient level of care -- was medically necessary. 

On the first day under review, the patient required admission at an acute inpatient level of care because his recovery was complicated by urinary retention (requiring voiding trials and bladder scans). On the second day, the patient required admission at an acute inpatient level of care because his recovery was complicated by urinary retention (requiring voiding trials and bladder scans) and medication-associated allergic rash (requiring Dermatologic consultation, and oral and topical treatments).   On the third day, having returned to his baseline health and function, the patient was discharged home in good and stable condition. 

Thus, in total, the patient required approximately 48 hours of admission at an acute inpatient level of care. This length of stay is consistent with the medical literature, particularly for patients with complications. For example, Kuriani et al cite a median length of stay of 1.54 days; Goodney et al cite a median length of stay of two days; and Beldi et al cite a median length of stay of six days. 

Due to post-operative complications, the patient required approximately 48 hours of admission at an acute inpatient level of care. This length of stay is consistent with the medical literature, particularly for patients.