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

Diagnosis: Kidney stone. 
Treatment: Inpatient stay. 

The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a woman who was admitted to the hospital. She was previously seen for evaluation of nephrolithiasis. She had a history of a large left-sided lower pole stone that was approximately 2 centimeter (cm) in size. Abdominal computed tomography (CT) showed 2 centimeter left lower pole stone and a renal ultrasound from showed the same findings. She reported occasional left flank pain. She denied fevers and chills. Vital signs showed blood pressure 121/82, temperature 98.4 Fahrenheit, and respiratory rate 16. On physical exam, she was in no acute distress, respirations were normal, abdomen was soft and nontender, and there was no flank tenderness to palpation. Labs showed white blood cell count (WBC) 8.5, hemoglobin 12.4, platelets 314, sodium 142, potassium 3.6, and creatinine 0.73. The patient was admitted for nephrolithiasis, the plan of care included percutaneous nephrostomy placement, urology consult, pain control, and intravenous (IV) fluids. 

The inpatient hospital stay was not medically necessary, based on the available documentation. The reason is that the patient did not have sepsis, acute kidney injury (AKI), uremia, rapidly progressive renal disease, anemia from hematuria, hemodynamic instability, or other acute complications associated with nephrolithiasis. The patient did have a large left lower pole stone, which is more complex than other renal stones, but she was hemodynamically stable and underwent percutaneous nephrostomy placement without complications. A lower level of care would have still permitted continued evaluation and management of her presenting symptoms.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension.
Treatment: Inpatient admission.

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

This male patient has a history of essential hypertension (on amlodipine) and obstructive sleep apnea.

This case involves a child who presented to the emergency department with hypertension.  The documentation indicated he presented with elevated blood pressure noted by his grandmother.  He had complaints of abdominal pain with nausea and vomiting.  The documentation indicated on examination his blood pressure was 140/101 mmHg.  The documentation indicated they attempted a blood pressure check 3 times in both arms, and it was consistent with the home reading.  The pulse was 90 bpm (beats per minute), and the temperature was 97.6.  Respiration was 22, and oxygen saturation was 100%.  The patient was in no acute distress.  The recommendation was made to undergo laboratory studies and a consultation.  The documentation indicated the patient was given isradipine for hypertension.  Upon reevaluation his blood pressure was 111/81.  It was recommended the patient be admitted for further evaluation.  The documentation indicated laboratory studies did not reveal any significant abnormalities.  The notes do indicate upon admission he was stable.  He did not have any further complaints of abdominal pain or nausea and remained asymptomatic during the brief stay.  His blood pressure remained under 120/80 mmHg.  Given the lack of further complication the recommendation was made to discharge the patient with instruction to follow-up.

This patient's hypertension could have been managed on an outpatient basis. He did not exhibit any clinical or laboratory evidence of end organ injury from his hypertension that warranted inpatient admission and emergent treatment of his blood pressure.

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

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

Diagnosis: Skin Disorders-psoriasis.
Treatment: Pharmacy/Prescription Drugs (Humira) 
The insurer denied Humira for medical necessity. 

The denial has been upheld. 

The patient is a female with psoriasis that has been worsening on her face for six months. The patient has tried and failed topical steroids, topical calcipotriene, and topical tacrolimus, as well as Dupixent and oral steroids which were used prior to biopsy-confirmation of psoriasis.
At issue is the medical necessity of Humira.

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

The requested health service/treatment of Humira is not medically necessary for this patient.
The patient has no documented treatment failure with, or true medical contraindication to, Methotrexate. Methotrexate is a standard, first-line, and effective treatment for moderate to severe psoriasis, and has been used for decades in patients of both genders and of mostly all ages. This patient is a medically appropriate candidate for first-line therapy.
Modern dermatology literature [1-4] supports use of the preferred medications as similarly efficacious to the requested Humira, particularly for a patient with a limited history of systemic psoriasis therapy previously utilized and recommends use of the preferred agents as appropriate for this patient's clinical scenario. As per current medical standards of care, Humira is not medically necessary.
Therefore, the requested health treatment of Humira is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastrointestinal bleed.
Treatment; Inpatient stay.

The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a male who presented to the emergency room with a report of a large black bowel movement. He has a history of aortic aneurysm surgical repair. He is a nursing home resident. The initial blood pressure was 134/91, pulse 69, temperature was normal, and oxygenation 97%. The abdomen was benign, and mental status was normal. He was admitted to evaluate for possible dissection of the aneurysm. The hemoglobin was 12.4, metabolic panel was stable, and he was comfortable. A computed tomography (CT) angiogram of the chest abdomen and pelvis was performed and showed a type a aortic dissection of the ascending, descending, and super renal abdominal aorta to just below the renal arteries. There was no infiltrate, no kidney stones, status post aortic valve replacement by prosthesis. A stent was patent in the true lumen of the aortic dissection. The results were compared to prior imaging with a concern that the new CT findings represent "possible progression of dissection". He was placed on a beta blocker drip to keep the pulse below 60 and the systolic blood pressure below 110. The original cardiothoracic physician from the hospital where the repair had been performed reviewed the images and stated that there was no concern for any change. On the same day, the beta-blocker drip was discontinued. He was admitted to acute care for management of a gastrointestinal bleed. 

The inpatient admission was not medically necessary for this patient.

Once the physician that performed the original dissection repair from the original hospital where the dissection repair had occurred reviewed the images and felt there was no progression of dissection, the patient was hemodynamically stable, the hemoglobin was stable, there was no observed bleeding, the patient did not require acute care and was medically stable for a lower level of care. The patient remained in the hospital for the convenience of performing an EGD (Esophagogastroduodenoscopy) that did not require acute care and could have been performed at a lower level of care. Throughout the entire hospitalization, there was no evidence of worsening of a known aortic dissection, no melena, no active bleeding, no hemodynamic instability, no vomiting, and no requirement for acute hospital level of care. Although there was a report of black stool in the nursing home, there was no evidence of melena throughout the entire hospitalization that would require acute care. There was no bowel compromise. There was no need for a blood transfusion, no need for colonoscopy, no need for EGD, and no need for surgery. The renal function was normal, the metabolic panel stable, and the hemoglobin remained 12 or above throughout the entire admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Epigastric pain and vomiting.
Treatment: Inpatient admission.

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

The patient is a female. Her medical history included obesity, gastritis, and polycystic ovarian syndrome. She presented to an emergency room with a 12-hour history of epigastric pain and vomiting.

The patient's vitals were temperature 97.3, pulse 84, blood pressure 152/107, respirations 18, and oxygenation 100%. Physical examination demonstrated tenderness-to-palpation of the epigastrium and right-upper-quadrant of the abdomen. Serum laboratories demonstrated leukocytosis to 21.6. Abdominal ultrasound demonstrated cholelithiasis and the presence of a sonographic Murphy's Sign. Surgical consultation recommended observation with nil per os [NPO] and intravenous fluids.

The patient was admitted at an acute inpatient level of care. Because her abdominal pain continued, the patient underwent computed tomography of the abdomen, which demonstrated acute cholecystitis. The patient received intravenous antibiotics, analgesics, and anti-emetics.

Day 2, the patient underwent laparoscopic cholecystectomy. Surgery and recovery were uncomplicated.

Day 3, having returned to her baseline health and function, the patient was discharged home in good and stable condition with prescriptions for oral antibiotics and analgesics, and outpatient surgical follow-up.

No, the Inpatient admission was not medically necessary.

The patient's treatment entailed: 1) observation prior to a diagnosis of acute cholecystitis, and 2) laparoscopic cholecystectomy following a diagnosis of acute cholecystitis. Both of these could have been completed at a lower level of care; neither required admission at an acute inpatient level of care.

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 patient could have been treated at a lower level of care, precluding the need for admission at an acute inpatient level of care.

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 at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status post traumatic C7-spinal cord injury.
Treatment: Locomotor Training x382 visits.
The insurer denied the Locomotor Training x382 visits.
The denial is overturned.

This is a female child with history of traumatic spinal cord injury at C7 (cervical
spine) level. The patient received comprehensive inpatient rehabilitation at Shriner's
Children Hospital. The patient has been recommended to undergo outpatient
locomotor training at the local facility. Sixty sessions have been requested.

Initial review by the Health Plan led to denial of additional visits. Only six visits have
been approved. 

This review based on limited data on functional progress of the child. The child
sustained devastating life changing event requiring prolong rehabilitation and
habilitation services.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Keratitis and dry eye syndrome.
Treatment: Lotemax SM 0.38% Gel, Pre-service.
The insurer denied the Lotemax SM 0.38% Gel, Pre-service.
The denial is overturned.

The patient is a female with the diagnosis of keratitis and dry eye syndrome, for whom request is made for coverage of Lotemax SM 0.38% Gel. 

Per the provider letter, the patient has severe keratitis, dry eye and meibomian gland dysfunction.  She has a hypersensitivity to most ocular preservatives.  For this reason, Lotemax SM 0.38% is the only steroid preparation that has worked to date for her given it has a very small amount of benzalkonium chloride (BAK) (0.003%).  She has tried prednisolone acetate, pred forte, Lotemax 0.5% and fluorometholone (FML) 0.1% previously without success. 

The Plan previously denied coverage as patient had not tried alternatives such as prednisolone, fluorometholone (FML), or dexamethasone.

Yes, the health plan should cover the proposed Lotemax SM 0.38% Gel.
Lotemax gel is a corticosteroid indicated for the treatment of post-operative inflammation and pain following ocular surgery.  Per the American Academy of Ophthalmology, topical corticosteroids have been reported to decrease ocular irritation symptoms, decrease corneal fluorescein staining, and improve filamentary keratitis.  The guidelines further state that  "Low-dose topical corticosteroid therapy can be used at infrequent intervals for short periods of time (i.e., several weeks) to suppress ocular surface inflammation."  

In this case, the patient is noted to have dry eye syndrome / keratitis, and has required topical steroids.  She has already tried the plan's formulary alternatives of prednisolone acetate, pred forte, lotemax 0.5% and fluorometholone (FML) 0.1% previously without success.  Therefore, the requested Lotemax Gel is considered medically necessary, as the patient has tried/failed other acceptable alternatives.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anaplastic Astrocytoma.
Treatment: Tibsovo 250mg TABLET, Pre-service.
The insurer denied the Tibsovo 250mg TABLET, Pre-service.
The denial is upheld. 

The patient in this case is a man who has been diagnosed with anaplastic astrocytoma.  He has an allergy to temozolomide, which causes hives.  His cancer has a mutation in IDH1 (isocitrate dehydrogenase 1).  Based on this history, his physician has prescribed Tibsovo.

No, the treatment with Tibsovo is not medically necessary.
Tibsovo is not a standard treatment option for anaplastic astrocytoma. There is not sufficient supporting evidence in the published peer-reviewed medical literature substantiating the safety and efficacy of this agent for treatment of IDH (isocitrate dehydrogenase) mutation-positive anaplastic astrocytoma.  Furthermore, this treatment is not currently endorsed as a standard treatment option by NCCN (National Comprehensive Cancer Network) guidelines under any circumstances.  Based on these considerations, Tibsovo is not medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: dementia	

Treatment: personal care services of 10 hours per day, 7 days per week for a total of 70 hours per week.

The insurer is denied coverage for personal care services of 10 hours per day, 7 days per week for a total of 70 hours per week.

The denial is overturned. 

This female patient has a history of colon cancer, dementia, osteoarthritis, coronary artery disease, hypertension, gastroesophageal reflux disease, dizziness, incontinence, as well as a history of falling.

Per the telephonic New York State Department of Health's Uniform Assessment System (UAS-NY) dated 10/15/20, the patient and daughter were present on the call. The patient lives alone in a private home. Her daughter assists with her activities of daily living (ADLs) and instrumental activities of daily living (IADLs) when the personal care aide is not present. The patient needs maximum assistance with meal preparation, ordinary housework, managing stairs, shopping, and transportation. She needs extensive assistance with managing finances, managing medications, equipment management, bathing, dressing her lower body, walking, locomotion, toilet transfer, and toilet use. The patient is occasionally bladder incontinent but has complete bowel control. She uses pads for urinary incontinence. The patient uses an assistive device for locomotion. The patient's daughter reported she ambulates with a cane due to an unsteady gait and weakness in her legs. The patient needs limited assistance with phone use, personal hygiene and dressing her upper body. She is independent and needs setup help only with bed mobility and eating. 

The patient currently has 38 hours/week. The provider requested 70 hours/week - 10 hours/day. The provider noted it was imperative to increase the hours of home assistance in order to ensure the safety of the patient.  

This patient with advanced age and dementia is unable to care for herself and is at risk for selfharm due to dementia. The increased hours (10 hours a day) are certainly required for her safety and decrease her risk for hospitalization.

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

The carrier's denial of coverage for the personal care services of 10 hours per day, 7 days per week for a total of 70 hours per week is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Open bite
Treatment: D8080 Braces, D8670 Monthly Visit x12, Pre-service
The insurer denied the D8080 Braces, D8670 Monthly Visit x12, Pre-service
The denial is overturned.

The patient is a female with Class I skeletal and Class II canine dentition. She has severe open bite, tongue thrust and finger sucking habit. The request is for braces and monthly visits.

Yes, the braces and monthly visits are medically necessary.
The patient has a severe anterior open bite. This means her upper front teeth to not close over her lower front teeth, and there is a big opening between them. Without the front teeth touching, there can be no "anterior guidance," which is when the lower front teeth glide along the back of the upper front teeth during the chewing cycle. This will ultimately cause trauma and/or fracturing of her posterior teeth due to these teeth grinding together in an un-coordinated fashion. Potential TMJ (temporomandibular joint) problems are also a possibility over time. The only way the correct this is with orthodontic treatment, which is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obstructive sleep apnea (OSA)
Treatment: Continued Rental of Continuous Positive Airway Pressure (CPAP) Device (Pre-service)
The insurer denied the Continued Rental of Continuous Positive Airway Pressure (CPAP) Device (Pre-service)
The denial is overturned. 

The patient is a male with a history of moderate obstructive sleep apnea (OSA).  The patient has been treated with continuous positive airway pressure (CPAP).  The provider is requesting continued rental of continuous positive airway pressure (CPAP) equipment.  The request was previously denied as there has not been good compliance with the continuous positive airway pressure (CPAP). 

Yes, the proposed continued rental of the continuous positive airway pressure (CPAP) device is medically necessary.
All records were reviewed.  It is reported that the patient has a deviated septum on exam and was having initial problems with the continuous positive airway pressure (CPAP) mask.  It is also now reported that with saline and nasal strip therapy, the patient is having markedly improved continuous positive airway pressure (CPAP) compliance.  Continuous positive airway pressure (CPAP) is often not tolerated and there is a significant adaption period, especially with nasal obstruction.  Continuation of therapy with continuous positive airway pressure (CPAP), the gold standard conservative treatment for obstructive sleep apnea (OSA), can enable the patient to avoid surgery.  Obstructive sleep apnea (OSA) is a serious health condition with serious morbidity that requires treatment.  Therefore, based on the information provided, the medical necessity of the continued continuous positive airway pressure (CPAP) rental is confirmed.

While the health plan's initial denial was reasonable based on information provided at the time, the health plan's final adverse determination is not appropriate as there is now reported improvement in compliance with continuous positive airway pressure (CPAP) so the previous determination would be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bilateral anterior crossbite
Treatment: Orthodontic Treatment (braces) and periodic treatment
The insurer denied the Orthodontic Treatment (braces) and periodic treatment
The denial is overturned. 

The patient is a male. The request is for dental benefits for orthodontic treatment (Braces) and periodic treatment.

The patient presents with bilateral anterior crossbite on the upper lateral incisors. He has moderate crowding on both arches.

The health plan denied the claim because the patient did not score greater than 26 required on HLD (Handicapping Labio-Lingual Deviation) index for orthodontic treatment.

The provider appealed based on the overall diagnoses, particularly the anterior crossbite as noted on HLD (Handicapping Labio-Lingual Deviation) index, which is an automatic qualifier for orthodontic treatment.

Yes, the requested orthodontic therapy (Braces) and periodic treatment are medically necessary.
As demonstrated in the x-rays and the photos, the patient presents with moderate crowding in both the Maxilla and Mandible. The patient also exhibits bilateral anterior crossbite in the maxillary lateral incisors.

The crowding and crossbite (mal alignment) can affect the patient's ability to chew properly, speak properly and the inability to maintain proper hygiene. This can lead to gingivitis/inflammation and gum disease. Therefore, the braces and treatment are medically necessary.

If these conditions are left untreated, the complications of decreased proper function as it relates to chewing, speech and compromised oral hygiene can only lead to more dental problems in the future.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: acute appendicitis

Treatment: inpatient hospital admission

The insurer is denied coverage for inpatient hospital admission.

The denial is upheld. 

This male patient has a history of iron deficiency anemia, atrial septal defect (ASD), and hypothyroidism.

Alkhoury et al in a study of acute appendicitis found that "Routine same-day discharge after pediatric laparoscopic appendectomy (LapAppy) for acute appendicitis is safe, with good parent satisfaction." Similar results were reported by Benedict et al and Cheng et al. Same day discharge or an overnight period of observation is now the accepted approach for post-operative management of laparoscopic appendectomy.

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.
	
The carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.