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

Diagnosis: Chronic obstructive pulmonary disease (COPD)

Treatment: Inpatient admission

The insurer denied coverage for an inpatient admission
The denial is upheld

Patient is a male with history of (H/O) chronic obstructive pulmonary disease (COPD)/Asthma on home oxygen (O2) 3L (liters) by nasal cannula (NC). The patient presented to the emergency department (ED) with complaint of (C/O) some dizziness accompanied by nausea, vomiting and diarrhea. The patient also has past medical history (PMH) of hypertension (HTN), hyperlipidemia (HLD), diabetes mellitus (DM), status post (S/P) pacemaker, gastroesophageal reflux disease (GERD) and Covid.

Vital signs (V/S) at presentation to the ED (emergency department) were as follows: Temperature (T) 97.7F (Fahrenheit) Heart Rate (HR) 76 Respiratory Rate (RR) 24 Blood Pressure (BP) 111/62 mmHg (millimeters of mercury) O2 (oxygen) saturations 96 % on 5L NC. The patient was noted to have some wheezing.

He was placed in Observation. He was treated with IV (intravenous) steroids, BD (bronchodilator) Via nebs (nebulizers), fluids, Antivert and Zofran.

Initial Labs: white blood cell count (WBC) 7.7K (thousand) electrolytes within normal limits (WNL), BUN (blood urea nitrogen)/ Creatinine WNL, and Troponin was negative.

The chest x-rays revealed (CXR) no acute infiltrates. The Head computed tomography (CT) showed no active pathology. Some paranasal sinusitis was noted.

The patient was subsequently admitted to the hospital for COPD exacerbation.

This patient's V/S as per H&P (history and physical) T 98.5 HR 78 BP 120/75 RR 20
O2 saturation 97 %. Lungs were clear. The patient was speaking in full sentences.

As per medical notes there was also a possibility of Vocal Cord Dysfunction and some supra tentorial element.

This patient C/O some dizziness while he was doing pulmonary function test (PFT's). No H/O syncope.

 
This patient did not need acute inpatient hospitalization. He could have been placed in Observation status. The patient remained stable after admission. Had some minimal increase in O2 requirement from 3 L to 4/5 L. The patient was awake, alert, and had improved after treatment in ED. He was afebrile and hemodynamically (HD) stable. No pneumonia (PNA), congestive heart failure (CHF), Pleural Effusion or pneumothorax (PTX) on CXR (chest x-ray). His WBC and other labs were WNL. The patient was tolerating oral (PO). He was stable for DC (discharge) on PO (oral) meds after a period in observation status. The patient's symptoms were mild and observation, which could have been for up to 48 hours, was a sufficient period for this patient. He was stable for DC with close follow up (FU) in an outpatient setting. There was no syncope, no evidence of MI (myocardial infarction) or Ischemia. COPD/Asthma was mild.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for an inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma

Treatment: Inpatient admission

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

This is a male with a history of asthma with a previous hospitalization for status asthmaticus. He was noted to be wheezing at home and having difficulty breathing. He described shortness of breath with exercise. His father administered albuterol in the home on two occasions and when he did not improve, he was brought to the emergency room (ER) by his father for further treatment.

In the ER he was noted to be in respiratory distress with suprasternal retractions and wheezing. He was started on supplemental oxygen at 2 liters. On physical exam the child was afebrile and had diffuse wheezing upon auscultation of the chest. He was treated with albuterol on three occasions. In addition, he was treated with dexamethasone and magnesium sulfate. Following his albuterol treatments, he was noted to have low pulse oximeter readings of 92 and 93% and on physical examination he was noted to continue to have suprasternal retractions. A venous blood gas was abnormal with a pCO2 (carbon dioxide) of 42. Following treatment in the ER, the decision was made to admit the child to the hospital with a diagnosis of asthmaticus for continued treatment with albuterol every 3 hours.

The patient was treated appropriately in the ER for an acute episode of wheezing, hypoxemia and difficulty breathing. The child has a history of a previous hospitalization for asthma. When he did not respond to treatment in the ER and he was noted to have an elevated pCO2 on a blood gas, low oxygen saturation despite oxygen supplementation and suprasternal retractions, it was appropriate and consistent with the standard of care to admit the child to the hospital with a diagnosis of status asthmaticus for ongoing oxygen supplementation and albuterol every three hours. He was not stable enough to be safely discharged. 

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

Diagnosis: Chest pain

Treatment: Inpatient admission

The insurer denied coverage for an inpatient admission
The denial is upheld

The patient is a male who presented to the ED (emergency department) with a 3-day H/O (history of) chest pain and dry cough. The pt (patient) denied fever, chills, or SOB (shortness of breath). The patient had been seen in the hospital for the same symptoms recently but had signed out AMA (against medical advice). Imaging studies were reported as a R (right) hilar mass with B/L (bilateral) infiltrates. R/O (rule out) malignancy and R/O PNA (pneumonia). The patient returned back to the ED. At presentation to ED: T (temperature) was 97.2 F (farenheit), HR (heart rate) was 96, BP (blood pressure) was 159/91, O2 (oxygen) sats (saturation) was 96% on RA (room air). The pt was in NAD (no apparent distress) and was ambulatory. Lungs were clear. He was awake and alert and the neurologic exam was noted as non-focal. Labs: WBC (white blood cell count) 3.8K (thousand), BUN (blood urea nitrogen) / Cr (creatinine) 15/0.8. Electrolytes were WNL (within normal limits) and mildly elevated LFT's (liver function tests) were noted.

This patient did not need acute inpatient hospitalization. He could have been placed in observation while diagnostic testing and treatment were continued. Observation can be up to 48 hrs (hours). The pt's pneumonia, if present, was mild. CURB (confusion, urea, respiratory rate, blood pressure) 65 score of zero.

The patient remained stable. He was cleared for DC (discharge) by pulmonary and the ID (interdisciplinary) team with FU (follow up) in an outpatient setting.
The pt was not hypoxic and was tolerating PO (oral). He remained afebrile after admission. FOB (fibreoptic bronchoscopy) and TBBX (transbronchial lung biopsy) are ambulatory surgery procedures and the pt did not need an acute inpatient hospitalization to R/O malignancy or sarcoidosis.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

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

Diagnosis:  Back pain.
Treatment:  Epidural steroid injection.

The insurer denied the epidural steroid injection.  The health plan's determination is overturned.

The patient is a female with low back pain. A letter from the provider stated that the patient had low back pain radiating into the right leg with positive neuro-tension signs. It was noted that a magnetic resonance imaging (MRI) revealed disc displacement and stenosis. The patient has been treated with Tylenol and Ibuprofen for 2 months. It was also noted that the patient was treated with physical therapy. 

The requested Epidural Steroid Injection is medically necessary for this patient.

Injections of steroids directly into the epidural space are used for treatment of radicular back or neck pain after failure with conservative management. The steroids are given with or without anesthetic agents for relief of pain. Epidural steroid injections have been considered a generally accepted standard of medical practice for many years. The results of clinical trials have been mixed. Although short-term relief of radicular pain may occur, long-term outcomes vary. No more than three-four injections should be given in a six month period.

Repeat injections after the initial therapeutic phase should be done at intervals of at least 2 months, provided that previous injections resulted in at least 50% pain relief or functional improvement for at least 2 months.

There is a risk of bleeding, infection or spinal cord injury with this invasive procedure. Some practitioners may give epidural steroid injections blindly however the use of fluoroscopy for visualization of needle placement has been shown to reduce the risk and complications of the procedure.

In this case, the patient had persisting complaints despite conservative treatment with positive findings on imaging and exam therefore the epidural injection would be indicated.
Appeal type: Medical necessity
Decision: Upheld

Dental Problems. 
Dental/Orthodontic Procedure. 

Diagnosis: Skeletal Class II malocclusion. 
Treatment: Braces and monthly visits. 

The insurer denied braces and monthly visits. The health plan's determination is upheld. 

The patient is a female with Skeletal Class II malocclusion, severe maxillary crowding and severe mandibular crowding, severe anterior and posterior open bites with severe overjet. The case has prognathic maxillary and retrognathic mandible. 

Braces with Monthly Visits are not medically necessary for this patient. 
To qualify there must be evidence of planned TMJ (temporomandibular joint) or orthognathic surgery along with cleft palate, maxillary prognathism and mandibular retrognathism, severe asymmetry, and ankylosis of temporomandibular joint. It is the standard of care to have a fully developed treatment plan including multi-disciplinary treatment objectives along with an orthodontic treatment plan. It is not the standard of care to proceed with orthodontic treatment without addressing the TMJ and skeletal problems. The HLD Index score can then be scored after receiving that information so a complete multi-disciplinary treatment plan can be created. This information was not provided and therefore, the braces and monthly visits are not medically necessary.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis:  Abdominal and pelvic pain.
Treatment:  Inpatient admission.

The insurer denied the inpatient admission.  The denial is overturned in part. 

This woman presented to an outside hospital with abdominal and pelvic pain. Her recent history was notable for admission with bacteremia (S.agalactiae) that required treatment with Levaquin.

Workup showed occlusion of the inferior mesenteric artery, raising concern for bowel ischemia. Moreover, both echocardiogram and computed tomography (CT) showed possible dissection of the aortic root, raising concern for endocarditis. Additional imaging was recommended.

The patient was transferred to another facility.  On arrival, she was stable but had suprapubic pain and nausea, symptoms that she attributed to being hungry. She was admitted for monitoring because of need to rule out endocarditis and/or aortic dissection. A repeat echocardiogram was suboptimal but showed no dissection at the aortic root. Ejection fraction and cardiac motion were normal. The patient was now asymptomatic with stable vital signs.

Yes, in part; the inpatient admission was medically necessary for admission day one.  However, no, in part; the inpatient admission was not medically necessary for admission day two.

The patient presented with a clinical picture concerning for endocarditis complicated by embolization to the inferior mesenteric artery (IMA). She had a history of recent bacteremia and presented on this occasion with abdominal pain.  Computed tomography (CT) showed inferior mesenteric artery (IMA) occlusion. Both computed tomography and echocardiogram raised concern for aortic root dissection. This picture can be explained by endocarditis and embolization to the inferior mesenteric artery (IMA). Even though the patient was stable when she presented to Montefiore, inpatient admission was warranted because of the legitimate concern for endocarditis complicated by embolization. This medical condition demands inpatient hospital stay because patients can rapidly deteriorate.

In contrast to the conclusion reached by the health plan, the admission day one was medically necessary. It is true that the patient was hemodynamically stable. However, she had history, symptoms and outside imaging concerning for endocarditis with embolization to the inferior mesenteric artery (IMA). 

By admission day two, there was no longer concern for endocarditis with embolization to the inferior mesenteric artery (IMA). The health plan's conclusion that the patient did not need inpatient stay was reasonable for admission day two.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma
Treatment: Pharmacy/Prescription Drugs (Spiriva Respimat)
The health plan denied the requested prescription drug. 
The health plan's determination is overturned.

This patient is a female with difficult to treat asthma and severe persistent asthma. She was on multiple long acting inhaled corticosteroids and beta agonist. Still she was noted to have frequent exacerbations and lower airway obstruction. Her body mass index (BMI) was 19. She was on Spiriva Respimat for last 6 months and her FEV (forced expiratory volume) and symptoms have improved.

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

Yes. As alluded in the clinical summary, this is a patient who have severe persistent asthma and difficult to treat asthma. She also has very high igE (immunoglobulin). there was mention of frequent exacerbation and lower airway obstruction as indicated by the low FEV. Due to the poor asthma control the treatment team is considering bronchoscopy and computed tomography (CT) scan to evaluate for bronchiectasis. Patient also developed restrictive lung disease over the time. Patient is improving in terms of her lung function and number of exacerbations. Moreover, the Spiriva was approved for pediatrics in 2017. The team tried high dose ICS (inhaled corticosteroids), ICS-LABA (inhaled corticosteroids-beta agonist) and still asthma was not controlled. Hence the next step in asthma management is muscarinic receptor antagonism via Spiriva.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pelvic inflammatory disease (PID)

Treatment: Inpatient admission 

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

The patient is a female who presented to the emergency room (ER) with complaints of a one-week history of suprapubic pain. Her white blood cell (WBC) count was elevated. Her temperature was 99.8. She was given an intravenous (IV) fluid bolus, IV morphine, IV Ondansetron, IV Famotidine, IV Cefoxotin, IV Ceftriaxone, IV Doxycycline, and IV Metronidazole. The patient was admitted with pelvic inflammatory disease (PID). She was continued on Ceftriaxone, Metronidazole, and Doxycycline. The patient was transitioned to oral (PO) antibiotics, and she was discharged. 

Most females with PID can be safely treated in outpatient settings. Indications for hospitalization and parenteral antibiotics include:

Severe clinical illness (eg, fever >=38.5C (celcius) [101 F (farenheit) ], nausea and vomiting) 
Complicated PID with pelvic abscess (including tubo-ovarian abscess) 
Possible need for invasive diagnostic evaluation for alternate etiology (eg, appendicitis or ovarian torsion) or surgical intervention for suspected ruptured tubo-ovarian abscess
Inability to take oral medications
Pregnancy
Lack of response or tolerance to oral medications
Concern for nonadherence to therapy

This patient had severe nausea and vomiting with inability to take oral medications. An admission was medically necessary for treatment. Once the patient was able to tolerate oral medications, she was transitioned to PO antibiotics and discharged home.

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

The inpatient admission is considered medically necessary for this patient.

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

Diagnosis: Central Nervous System/Neuromuscular Disorder. Treatment: Skilled Nursing Facility. 
The insurer denied skilled nursing services. 
The denial is upheld.

The patient is a male status/post (s/p) cardiac arrest with cardiopulmonary resuscitation (CPR) x 2 resulting in anoxic brain injury. The patient was treated at a Brain Injury program and discharged to skilled nursing facility (SNF). He was discharged from the SNF. The subject under review is the medical necessity for skilled nursing facility services. This was denied by the plan as the patient is not receiving any skilled care services, and it is felt that the care the patient is receiving is considered custodial. 

The request for skilled nursing services is not medically necessary for this patient. The criteria for SNF level of care is not met. The patient is dependent and total care for all transfers, mobility, and activities of daily living (ADLs). He is making some very minimal gains/progress which can be pursued at a lower level of care status and do not require a skilled nursing facility level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriatic Arthritis
Treatment: Stelara 90MG/ML (milligrams per milliliter)  SC (subcutaneous) SOSY (Solution Prefilled Syringe)
The insurer denied the Stelara 90MG/ML SC (subcutaneous) SOSY (Solution Prefilled Syringe)
The denial is overturned.

This patient is a male with history of psoriatic arthritis and psoriasis.  The patient is currently receiving biologic disease modifying antirheumatic drug (DMARD) Cosentyx. The patient has previously tried and failed biologic disease modifying antirheumatic drugs (DMARD) Humira and Enbrel.  

The request for Stelara was initially denied due to the policy not allowing coverage of the requested medication unless the patient has previously tried and failed formulary alternatives Avsola, Infectra or Renflexis.  The reason the provider is appealing the determination is because the provider states there is some documentation for a demyelinating condition which could be made worse with formulary alternatives.

Yes, the proposed treatment is medically necessary.
The patient has a history of psoriatic arthritis and psoriasis and has previously tried and failed Humira, Enbrel and Cosentyx.  While clinical documentation does not support specifically that the patient does have a diagnosis of demyelinating conditions such as multiple sclerosis, the documentation does support that the patient has already tried and failed two tumor necrosis factor (TNF) inhibitors.  Clinical research does not support having to then try and fail a third tumor necrosis factor (TNF) inhibitor.  Formulary alternatives of Avsola, Renflexis and Inflectra are all TNF inhibitors.  Clinical research would further support switching to an alternative method of action after a patient has previously tried and failed two tumor necrosis factor (TNF) inhibitors.  The requested drug Stelara is an interleukin (IL)-12/23 inhibitor which is a different method of action than the patient has previously tried.  Therefore this would be a better alternative treatment option than one of the formulary alternatives.  Therefore, the proposed treatment is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment in in the best interest of the patient.
Documentation submitted did show that the patient had already tried and failed two tumor necrosis factor (TNF) inhibitors and the patient was only offered by the medical plan further tumor necrosis factor inhibitors which is not in the patient's best interest.  The patient would be best served to try an alternative method of action at this time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Growth deceleration; delayed onset of menarche
Treatment: Genetic testing
The insurer denied the genetic testing 
The denial is overturned

The patient is a female who is diagnosed with growth deceleration as well as delayed onset of menarche. There was a concern for possible Turner syndrome. After evaluation by the patient's regular physician, due to the delayed onset of menarche as well as the growth deceleration, and the common cause of Turner syndrome as a genetic reason for these pathologies, as well as the significant co-morbidities associated with this diagnosis, genetic testing was ordered as well as x-rays to assess bone age.

Yes, this test was medically necessary.

This patient is a female with delayed menarche and growth deceleration. These are two very common symptoms of Turner syndrome. Upon exam by her physician, Turner syndrome was suspected. With the prevalence of this disorder, as well as the known comorbidities associated with it, the delayed diagnosis of Turner syndrome would lead to significant health risk for the patient long-term. Therefore this test is medically necessary to create an appropriate medical and healthcare plan for this child and their family in a timely fashion to appropriately care for the child. The test is medically necessary and the denial is overturned.

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

Genetic testing for common genetic disorders with significant pathology such as Turner syndrome, is medically necessary for planning of future comorbidities associated with the diagnosis. This test is medically appropriate to create an appropriate diagnosis in medical management planning for this patient. This would also make other testing unnecessary for the growth deceleration as well as the late onset menarche. It would also help in the education of the patient of what their body will be and how they can prepare to live a healthy physical, mental and emotional life. The denial is overturned.