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

Diagnosis: Nasal obstruction.
Treatment: Ambulatory surgery - 30802 - Cautery ablate Turbinate Mucosa Intramur.
The insurer denied the Ambulatory surgery - 30802 - Cautery ablate Turbinate Mucosa Intramur. 
The denial is upheld. 

The patient is a male with sleep disordered breathing and nasal obstruction. The provider suspects OSA (obstructive sleep apnea). There is a history of a tonsillectomy. Physical exam reported a deviated nasal septum with inferior turbinate hypertrophy. The provider is requesting multiple procedures, including CPT 30802, inferior turbinate surgery.   

All records were reviewed. The patient is a male with sleep disordered breathing and nasal obstruction. The provider suspects OSA. There is a history of a tonsillectomy at age four. Physical exam reported a deviated nasal septum with inferior turbinate hypertrophy. The provider is requesting multiple procedures including CPT 30802, inferior turbinate surgery. 

Inferior turbinate hypertrophy is one of the major causes of nasal obstruction. First-line treatment for this condition would be medical therapy. The provider started the patient on a nasal steroid, Flonase, which reportedly caused bleeding, so treatment was stopped. There was no attempt at changing the patient to a different nasal steroid or other prescription nasal spray, however. As Flonase is known to be associated with higher rates of bleeding, a medication change attempt would have been medically appropriate. Therefore, with the lack of documentation of the failure of maximal medical therapy, the medical necessity of the inferior turbinate surgery CPT 30802 cannot be confirmed at this time, and the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Cardiac/Circulatory
Nursing Services (including Private Duty Nursing)

Diagnosis: coronary artery disease  
Treatment: Personal Care Services, Level 2: 24 Hours per Day, 7 Days per Week (Split Shift) - Total of 168 Hours per Week 
The insurer denied Personal Care Services, Level 2: 24 Hours per Day, 7 Days per Week (Split Shift) - Total of 168 Hours per Week 
The health plan's determination is upheld. 

The patient is a female with past medical history significant for dementia, coronary artery disease, proximal atrial fibrillation, carotid stenosis, hypertension, fecal urgency, overactive bladder with nocturia, incontinence, gait abnormality, dizziness, insomnia, joint pain, neuropathy, ataxia with history of falls and osteoarthritis.

The Personal Care Services, Level 2: 24 Hours per Day, 7 Days per Week (Split Shift) - Total of 168 Hours per Week is not medically necessary for this patient. 
The patient currently has a wheelchair, walker, shower chair, grab bars, oxygen tank and bedside commode at the home. She had a UAS completed on 4/27/2020 that indicated that she needs extensive assistance with personal hygiene, dressing, locomotion, toilet transfer, toilet use, eating and bed mobility. She needs maximal assistance while bathing. Home evaluation recommended that the patient receive 45.3 hours per week to safely meet her needs. The patient needs to be changed due to incontinence about twice overnight. It was noted that the live-in aide can accommodate his schedule and still have 5 hours of uninterrupted sleep. The letter from the provider states that the patient needs overnight split shift for safety and incontinence status.
The documentation provided did not demonstrate that the live-in aide could not get adequate sleep and also care for the patient. According to documentation, the live-in aide is present 168 hours out of the week. Health care services required total time of 45 hours a week. This leaves an additional 123 hours out of the week for the aid to sleep. This means that the aid getting 35 hours a week of sleep, 7 days a week 5 hours at night or day in a 24-hour period of sleep is adequate to meet state guidelines. There is an additional 88 hours a week that the aid has hours unaccounted for. Is not unreasonable to expect that in the additional 88 hours a week that are unaccounted for that the aid can get enough sleep. With live-in services, this means that the aid should be present for 91 hours a week of services.
It was noted that the aid needs to be present at night to change a diaper on 2 separate occasions throughout the night, however, there is no mention that the aid cannot sleep some other time in those 123 hours out of the week. It was also noted that the patient sleeps for long periods of times during the day. Assuming the aid is up the entire night every night it still leaves adequate amount of time for restful sleep as per guidelines. . Therefore, the services fall under live-in services and not split shift services.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder. Treatment: Pharmacy/Prescription Drugs. 
The insurer denied: Wellbutrin SR. 
The denial is overturned in whole.

The patient is a female who is requesting the use of Brand Wellbutrin SR for treatment of anxiety and depression.
An office note from the patient's neurologist indicates complaints of memory difficulty and headaches. She complained of memory loss, such as forgetting a code on a security system, forgetting or misstating words. She was had was previously treated prescribed Vyvanse with improvement. She also complained of headaches that had been present for many years with headaches occurring 15 days per month with six severe headache days requiring Relpax. Headaches have improved on Topamax 100 milligrams (mg) at bedtime. She continued to take Wellbutrin XL 300 mg for anxiety. It was also noted "she wants to switch from Trintellix to Wellbutrin." Other medications used were Fioricet-codeine, butalbital-acetaminophen, Lexapro, Fioricet, Relpax, Trintellix, Trokendi XR, violet and Vyvanse. No examination was documented (telehealth visit). Neurotrax had showed below average concentration and processing. The treating provider continued Topamax, stopped Trintellix, and content continued Wellbutrin XL 150 mg daily and continued Trokendi XR.
A letter of medical necessity indicated that the patient has failed Trintellix, escitalopram, Wellbutrin, bupropion extended-release and Wellbutrin extended-release. It was noted when she was receiving bupropion 150 mg extended-release and was experiencing unwanted mood changes. She also had side effects on generic escitalopram. She did not have the side effects with Wellbutrin XL for 5 years. She felt depressed and anxious on Trintellix. She improved when she was back on Wellbutrin XL.
The reason for denial on prior review is that documentation of a failure of bupropion 150 mg extended release is needed in order to consider the use of Wellbutrin SR 150 mg.

The health plan's determination is overturned in whole.

According to the provided documentation, bupropion extended-release was ineffective due to unwanted mood changes that did not occur on brand name Wellbutrin XL at the same dose. Bupropion extended-release has not been as effective as Wellbutrin extended-release in the past. The patient meets the criteria for use of brand-name Wellbutrin SR as there has been a prior trial and failure of an eight month trial and failure of bupropion 150 mg extended release.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous system / Neuromuscular disorder/other  
Treatment: Home Health Care 
The insurer denied the  Increase in Personal Care Aide (PCA) Level 2 Services: Total Amount of 168 Hours per Week,12 hours per day 7 days per week (split shift )
The denial is overturned in whole

The patient is  with past medical history of congestive heart failure, Alzheimer's dementia, transient ischemic attack (TIA), malignant neoplasm of the liver, atrial fibrillation, osteoarthritis, pulmonary hypertension and recent covid-19 infection. The patient who had been hospitalized with pneumonia and cognitive decline, subsequently transferred to Skilled Nursing Facility (SNF).
Yes, the requested health service of the increase in personal care aid services level 2 to 168 hours per week 12 hours per day 7 days per week split shift is medically necessary.
The patient has history of liver cancer and dementia which are both progressive medical conditions. Medical records clearly document progression of both of these conditions with additional decline in functional status related to recent Covid -19 infection.
The patient has 3 medical providers/physicians stating the medical necessity of 24-hour PCA services. It is medically necessary for split shift services as there is no physical space for PCA aide to sleep. The patient's increased need for PCA services is not solely for supervision and safety but to assist the patient with her activities of daily living (ADL's). Given the patient's medical diagnoses and current condition there is anticipation of ongoing decline in functional status. Therefore, the services are medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive system / Gastointestinal / Crohn's disease 
Treatment: Pharmacy/Prescription drugs 

The insurer denied the medication Stelara. The denial is over turned in whole. 

The patient with a diagnosis of Crohn's Disease. The patient has ileocolitis. He has a long segment of ileal involvement with more proximal small bowel ulcerations. 
Yes, the requested medication Stelara is medically necessary for this patient. 
In the 2018 American College of Gastroenterology(ACG) guidelines under recommendation #30 it is strongly recommended, with high quality evidence of support, that patients with moderate-severe Crohn's Disease who have failed an anti-TNF drug such as adalimumab should be treated with ustekinumab.[1] The basis of that recommendation is the known high failure rate of vedolizumab in anti-TNF non-responders. This is best demonstrated in GEMINI 2, a Phase 3 trial which was the basis of Food and Drug Administration (FDA) approval for vedolizumab for Crohn's disease. In the supplemental figures (S2) it is clear that vedolizumab is not better than placebo for the subgroup of 175 patients with prior anti-TNF exposure (P=0.88). [2] Prior anti-TNF exposure did not appear to influence the efficacy of ustekinumab as much in the UNITI trial (Figure S3C). [3] Usual clinical practice in 2020 is to follow anti-TNF failure with ustekinumab for moderate-severe Crohn's disease as the study data and real-world experience with vedolizumab has been disappointing. Although the patient has not previously taken and had a poor response to Entyvio, he has failed Thiopurine and Humira and required steroids in the form of Budesonide and Prednisone. Medical necessity is established for the recommended Stelara, according to the ACG guideline recommendations, and the current peer reviewed literature.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Enteropathic arthritis and Crohn's disease
Treatment: Rinvoq
The insurer denied the Rinvoq.
The denial is upheld. 

No, the proposed Rinvoq is not medically necessary.

The patient is a female with Crohn's disease.  She is status post partial ileectomy.  She failed treatment with prednisone and mercaptopurine (6-MP), and was then treated with methotrexate and infliximab.  On infliximab, she developed scalp psoriasis and increasing joint pains treated with Celebrex.  She was treated with Stelara and methotrexate, but continued to have pain in her bilateral hips, knees and low back.  X-rays documented sclerosis of her sacroiliac joints.  Appeal is for Rinvoq for the treatment of enteropathic arthritis in the setting of Crohn's disease.

This patient with Crohn's disease and enteropathic arthritis failed treatment with various disease modifying anti-rheumatic drugs (DMARDs) and biologic therapies, as discussed above.  The AP now wishes to prescribe Rinvoq for the treatment of both enteropathic arthritis and underlying Crohn's disease.  Rinvoq is FDA-approved for the treatment of rheumatoid arthritis.  It is not FDA-approved for the treatment of Crohn's disease or enteropathic arthritis.  Although there are published phase II data supporting the use of Rinvoq (upadacitinib) for the treatment of Crohn's disease, phase III trials are still in process, and there have been mixed data for other Janus kinase (JAK) inhibitors for the treatment of Crohn's disease.  Furthermore, per www.clinicaltrials.gov, Rinvoq is still undergoing Phase II/III trials for the treatment of psoriatic arthritis and spondyloarthropathy, which are similar to enteropathic arthropathy.  Therefore, Rinvoq would be considered to be unproven at this juncture for the treatment of enteropathic arthritis and underlying Crohn's disease.  There are various other FDA-approved medications that would be considered to be standard of care in the rheumatology community for the treatment of this patient.  As such, Rinvoq is not clinically appropriate, or standard of care in the rheumatology community for the treatment of either Crohn's disease or enteropathic arthritis.  Therefore, the proposed Rinvoq for the treatment of enteropathic arthritis in the setting of underlying Crohn's disease is not medically necessary for this specific patient.
Appeal type: Medical necessity
Decision: Upheld

Dental Problems 
Dental/Orthodontic Procedure 

Diagnosis: Class I occlusion 
Treatment: Orthodontic treatment (braces) and periodic treatment visits 

The insurer denied the orthodontic treatment (braces) and periodic treatment visits. The health plan's determination is upheld. 

The patient in question is a male with a Class I occlusion with appropriate overbite and overjet. He has minor maxillary and mandibular crowding. He is treatment planned for orthodontics to correct his malocclusion. 

The Orthodontic Treatment (Braces) and Periodic Treatment Visits are not medically necessary for this patient. There is no medical reason to correct his malocclusion with braces. While the patient has crowded teeth, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. This patient presents with none of those conditions. The patient's parent commented that he has trouble chewing his food. This may be true but it is doubtful this is caused by the position of his teeth since masticatory efficiency is highest in patients with a Class I occlusion. If his teeth were aligned it would provide a minor aesthetic improvement but it would not create a medically significant improvement to the patient's health. For these reasons, treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

No, the proposed treatment, admission at an acute inpatient level of care, was not medically necessary. 

The patient is a female. Her medical history was negative; her surgical history included tubal ligation. The patient presented to an emergency room with a one-day history of right-upper-quadrant abdominal pain, nausea, vomiting, and anorexia. Her vitals were temperature 98.0, pulse 76, blood pressure 137/89, respirations 18, and oxygenation 100%. On physical examination, she was found to have tenderness to palpation in the right-upper-quadrant of the abdomen. Serum laboratories demonstrated a normal white-blood-cell count of 6.84. Ultrasound demonstrated cholelithiasis. HIDA scan demonstrated "No radionuclide evidence of acute cholecystitis."
 
The patient was admitted at an acute inpatient level of care with a diagnosis of right-upper-quadrant abdominal pain -- in the setting of cholelithiasis and with the possibility of acute cholecystitis. She was made nil per os [NPO - nothing by mouth]; and provided with intravenous fluids, analgesics, and anti-emetics. The patient underwent laparoscopic cholecystectomy. Surgery and recovery were uncomplicated. Having returned to her baseline health and function, she was discharged home in good and stable condition with outpatient surgical follow-up. 

According to the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), "patients undergoing uncomplicated laparoscopic cholecystectomy for symptomatic cholelithiasis may be discharged home on the day of surgery" [SAGES]. Indeed, insofar as the patient did not demonstrate significant co-morbidities or physiologic derangements, and insofar as surgery and recovery were uncomplicated, the patent could have been treated at a lower level of care, precluding the need for admission.

Based on the provided medical documentation and in accordance with national guidelines, for this patient, admission at an acute inpatient level of care was not necessary. The patient could have been treated a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with hypertension and asthma, who presented to the hospital with a complaint of a hand-wound. The patient was cutting an onion with a knife and sustained a wound to the right hand. He experienced progressive swelling and drainage of clear liquid, with pain that was worse with palpation. He initially went to an urgent care center and was referred to the emergency department for further evaluation: no associated fevers or chills, vomiting, or diarrhea were noted.
The patient's vital signs on admission included a temperature of 98.1 degrees Fahrenheit, a pulse of 97, a respiratory rate of 14, and a blood pressure of 146/93. The patient was sitting in bed and was nontoxic-appearing upon evaluation. The examination of the hand showed a laceration in the webspace of the right side, with mild surrounding erythema and no purulence. His capillary refill pressure was less than 1 second.
The laboratory studies revealed a normal prothrombin time, normal electrolytes and renal function, and normal liver function tests. The C-reactive protein (CRP) was 3.3 and the patient's sedimentation rate was 33. The white blood cell count was normal at 9.5. An x-ray of the hand was completed which showed no foreign body, no fracture or dislocation, and soft tissue swelling was present dorsally.
The health plan's determination is upheld.  This type of presentation can be managed at a lower level of care with similar outcomes.
The patient was diagnosed with cellulitis of the right hand. He was started on Vancomycin and Unasyn and given a Tdap vaccination. Orthopedic surgery was asked to evaluate the patient, and they saw him and described the wound as a 2 centimeter (cm) superficial laceration of the first webspace, with erythema, and swelling in the dorsal hand extending proximately to the wrist, with no fluctuance. The compartments were soft and compressible. The orthopedic team recommended pain control, nonweightbearing to the right upper extremity, and he was placed in a splint. The patient's blood cultures remained negative by this date. A repeat white blood cell count was decreased down to 6.3; the rest of the laboratory studies were unremarkable.
The swelling, as well as the erythema, had resolved. There was no evidence of an abscess. The patient had full strength, ability, and mobility and his vital signs remained stable. The white blood cell count was 5.8, and the blood cultures were negative. The patient was converted to an oral antibiotic regimen and discharged to home.
This patient had no evidence of a bone or tendon injury. There was no radiographic evidence of an abscess. This patient did not fail outpatient treatment with oral antibiotics. There was no indication for surgery. He was observed on broad-spectrum antibiotic therapy, monitoring for a response.  There is no indication for inpatient hospitalization.
Appeal type: Medical necessity
Decision: Upheld

Chest pain
Inpatient hospital

The patient is a woman who was admitted to the hospital. She had a history of iron deficiency anemia and pericarditis. She presented with chest pain. She reported that she had left-sided chest pain radiating to her left arm while she was at work. She took nitroglycerin and the pain resolved completely. She also reported left-sided paresthesia. She denied fever, chills, palpitations, headache, Nausea and vomiting. Vital signs showed temperature 36.9 Celsius, heart rate 53, and blood pressure 116/61. On physical examination, cranial nerves were intact, motor function and strength were intact, heart was regular, breath sounds were normal. Labs showed Sodium 141, potassium 5.1, creatinine 0.75, white blood cell (WBC) 3.83, hemoglobin 12.7, and troponin negative. Head computed tomography (CT) was negative for acute stroke. The patient was admitted for left sided paresthesia and chest pain/suspected acute coronary syndrome (ACS). 

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient was hemodynamically stable and had no significant evidence of acute stroke or acute cardiac ischemia. In addition, there was no evidence of acute seizures, syncope, toxic ingestion, or encephalopathy. She was primarily undergoing a diagnostic evaluation and the pericardial effusion was not considered to be hemodynamically significant. The inpatient hospital admission was not medically necessary at the acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia
Treatment: Inpatient hospital stay
The insurer denied the medical necessity of the inpatient stay. 
The determination was upheld in whole.

The patient has a past medical history of schizophrenia, hypertension , asthma and recent chest tube from hemothorax who was admitted  with complaints of auditory hallucinations after running out of psychiatric medications. Of note, the patient was recently undergoing detoxification, but left against medical advice  and it is documented that the patient was not experiencing hallucinations while in the emergency department  and was determined not to have any emergent psychiatric condition. Vital signs were unremarkable. Physical exam notable for no apparent distress , awake, alert, oriented (AAOx3). Lab work was unremarkable. Imaging studies, chest x-ray showed a right middle lobe infiltrate. The patient was diagnosed with pneumonia and treated with broad-spectrum antibiotics. The patient absconded the same day without staff awareness.

The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the ED with c/o of a non-productive cough. The patient was found to have pneumonia and treated with intravenous (IV) antibiotics. The patient was hemodynamically stable, did not require intubation, non-invasive positive pressure intubation, did not have any severe respiratory distress, tachypnea, use of accessory muscles in neck, severe intercostal retractions, cyanosis, new altered mental status (AMS), hypoxia, and the CURB-65 score was 0, indicating a low-risk patient. The pneumonia severity index was risk class II, indicating that outpatient therapy was reasonable and low risk for mortality. The patient was diagnosed with non-severe community acquired pneumonia and treated with IV fluids and antibiotics all of which could have been safely provided at a lower level of care and would have been within standard of care.