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

Diagnosis: Abscess
Treatment: Inpatient admission
The insurer denied Inpatient admission.
The denial is upheld.

The patient is an adult woman. Her medical history included pilonidal cyst and arrhythmia. Her surgical history included automatic cardioverter/defibrillator implantation. The patient presented to an emergency department with a one-week history of pilonidal abscess despite treatment with oral antibiotics. 

The patient's vitals were temperature 98.0, blood pressure 109/73, respirations 18, oxygenation 98%. Physical examination demonstrated a pilonidal abscess with surrounding erythema and draining puncta. Laboratories demonstrated a white-blood-cell count of 3.9. 

The patient underwent incision-and-drainage of her pilonidal abscess. Surgery and recovery were uncomplicated. 

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

Guidelines from the Infectious Diseases Society of America are clear -- for patients with abscesses, treatment includes the following: incision and drainage with associated wound care, abscess culture, and a short-course of antibiotics [Stevens et al.]. All of these interventions may be provided at a lower level of care. In fact, according to the Infectious Diseases Society of America, "Outpatient therapy is recommended for patients who do not have SIRS, altered mental status, or hemodynamic instability." As this patient did not have SIRS (Systemic Inflammatory Response Syndrome), altered mental status, or hemodynamic instability, she did not require inpatient admission.

Admission at an acute inpatient level-of-care is not consistent with guidelines from the Infectious Diseases Society of America.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite 
Treatment: Orthodontic braces 

The insurer denied coverage for orthodontic braces. The denial is reversed. 

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to skeletal Class I, Class II canines, maxillary and mandibular crowding, and anterior crossbite with gingival attachment loss. The orthodontist has completed the HLD index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. 

It is evident that the patient exhibited a significant malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, a Handicapping Labiolingual Deviation Index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care, a total score of 26 points is necessary. 

In this case, the treating orthodontist claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. Based on the literature review, this patient meets the criteria for automatically qualifying condition for comprehensive orthodontic care. Thus, orthodontic braces are considered medically necessary to treat this patient's dental condition. 

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

Based on the above, the medical necessity for the orthodontic braces is substantiated. The insurer's denial should be reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left zygomaticomaxillary complex fracture
Treatment: Inpatient admission
The insurer denied Inpatient admission.
The denial is upheld.

The patient is an adult female who was assaulted and suffered a left zygomaticomaxillary complex fracture. This was treated with an open reduction. The patient was observed overnight and discharged the following day.

This procedure is no more traumatic than orthognathic surgery. A study of patients who underwent orthognathic surgery at Massachusetts General Hospital between January 1994 and July 2006 found that individual variables associated with duration of length of stay (LOS) are complexity of the orthognathic procedure and type of fixation used. In the multiple logistic regression model, LOS decreases significantly when rigid fixation, hypotensive anesthesia, and perioperative steroids are used in combination. In the United States, it has been reported that between 46% and 84% of patients go home the same day of surgery after an orthognathic procedure. It is rare for an orthognathic surgery patient stay to extend beyond the first postoperative day following a 3.5-hour bimaxillary surgery. The short duration of LOS found in Andersen's study supports the possibility of increasing outpatient pathways for selected patients. 

Posnick's study showed that 137 patients (83%) undergoing upper and lower jaw and intranasal surgery along with a genioplasty were discharged after a 1- or 2-night in-hospital stay. The increased length of stay was based on the need for blood transfusion, operating time, success of nasotracheal intubation, time and place of extubation. 

This patient underwent surgery and was observed overnight. She had no postoperative problems and had recovered sufficiently to be discharged the following day. The appropriate classification is outpatient status with an overnight stay on an observational status. An admission would only be appropriate with documented failure to meet discharge criteria.

Based on the literature, an inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abnormal electrocardiogram
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission. 
The denial is upheld.

The patient was a female with a history of hypertrophic cardiomyopathy, anxiety and asthma.  The patient was sent to the Emergency Room (ER) by her Cardiologist because of an abnormal electrocardiogram (EKG).  The patient reported having shortness of breath for the last 1 year with intermittent chest pain.  The patient was then over 20 weeks pregnant. In the ER, the patient's vital signs were stable.  The patient denied chest pain, palpitations and shortness of breath, and reported positive fetal movement.  The patient's bloodwork revealed white blood cell (WBC) count 10.9, sodium 132, potassium 6.2, troponin 0.00, b-type natriuretic peptide 352, and alcohol level less than 10.  The patient's urine drug screen was negative.  The patient's EKG showed sinus rhythm with left atrial enlargement and probable left ventricular hypertrophy.  The patient was admitted to Telemetry for further cardiac workup and management.  The patient's prior EKG showed repolarization abnormalities consistent with left ventricular hypertrophy (LVH).  The patient's prior echocardiogram on showed hypertrophic obstructive cardiomyopathy (HOCM) with left ventricular outflow tract (LVOT) gradient of 60 mmHg.  The patient was continued on metoprolol in the hospital.  The patient's repeat troponin levels were negative.   The patient was seen by Maternal Fetal Medicine.  The patient denied vaginal bleeding, leaking of fluids, contractions, or decreased fetal movements.  The patient eloped from the hospital.

Based on the review of the medical record, the patient presented with a history of shortness of breath and chest pain.  The initial evaluation in the ER was unremarkable, including non-diagnostic EKG and cardiac biomarkers.  Inpatient admission was not medically necessary for this patient.  The patient's care could have been provided in the observational setting, allowing for additional diagnostic testing.  Further evaluation was warranted, however inpatient admission criteria was not met.  There was no hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions warranting acute inpatient level of care.  Clinical guidelines support that this patient's inpatient admission was not medically necessary to treat this patient's medical condition.

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

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated.  The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute Coronary Syndrome 
Treatment: Inpatient Admission 

The insurer denied the inpatient admission. The denial was overturned. 

This is a male patient who was admitted to inpatient hospital with complaints of chest pain that lasted an hour and very high blood pressure of 168/130 and then 194/130. It was reported that the patient had a history hypertension, erectile dysfunction, and substance abuse. The patient had withdrawal symptoms that included nausea, over 10 episodes of vomiting, diaphoresis, tremors, agitation, and anxiety; the patient's Clinical Institute Withdrawal Assessment of Alcohol (CIWA) score was 13. The patient had a diagnosis of alcohol withdrawal and rule out unstable angina with acute coronary artery syndrome. The patient reported taking Suboxone and had a past hospitalization a few months prior to admission due to passing out. He was started on a Librium and Ativan protocol but signed out against medical advice (AMA). 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. In this case, this patient had active alcohol withdrawal symptoms with serious comorbid medical conditions including very high blood pressure with chest pain complicating the management of his alcohol withdrawal. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient required 24-hour treatment as he could not have been safely and effectively treated in a less restrictive detoxification setting as he required and received detoxification medications to modify his withdrawal symptoms. The patient was treated with Librium and Ativan, and the patient needed 24-hour treatment then as he was at risk for worsened withdrawal symptoms. The patient was at risk for worsened withdrawals and serious medical consequences as his blood pressure was very high and he had chest pain. The risk of life complicated withdrawal symptoms such as delirium tremens can occur 3-4 days after alcohol use so this patient required the entire time in this hospital even though he left against medical advice (AMA). 

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 inpatient hospital admission should be reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory problems/Chest pain  
Treatment: Inpatient hospital 
The insurer denied the inpatient hospital stay 
The denial is upheld in whole

The patient presented to the emergency department with chest pain. The chest pain was graded as 9/10. The patient  described it as left sided, non-radiating, pressure type. Prior to arrival, the patient took two tablets of Aspirin.
No, the requested health service/treatment of the inpatient stay was not medically necessary for this patient.
In this case, his troponin was normal, and ECG did not have any changes suggestive of acute ischemia. The  vital signs were normal,  physical examination was unremarkable. Cardiology did not recommend any additional tests be done. Based on above, the patient did not have medical necessity indications for inpatient admission. A lower level level of care would be more appropriate in this particular case.
According to the 2014 American Heart Association (AHA)/American College of Cardiology (ACC) guideline for the management of patients with non-ST-elevation acute coronary syndromes: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, Discharge from the ED or Chest Pain Unit: Class IIa 
1) It is reasonable to observe patients with symptoms consistent with ACS without objective evidence of myocardial ischemia (nonischemic initial ECG and normal cardiac troponin) in a chest pain unit or telemetry unit with serial ECGs and cardiac troponin at 3- to 6-hour intervals. (Level of Evidence: B) 2) It is reasonable for patients with possible ACS who have normal serial ECGs and cardiac troponins to have a treadmill ECG (Level of Evidence: A), stress myocardial perfusion imaging, or stress echocardiography before discharge or within 72 hours after discharge. (Level of Evidence: B) (4)
The above guidelines recommend to observe the patient until serial ECG and cardiac troponin are negative and complete ischemia work up as an outpatient. 
This part of the guideline is applicable in this case. The patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Leukemia, chronic low back and bilateral
knee pain.
Treatment: Consumer Directed Personal Care Assistance Services 25 hours/week .
The insurer denied the Consumer Directed Personal Care Assistance Services 25 hours/week.
The denial is upheld. 

No, the proposed treatment of an increase in Consumer Directed Personal Care Assistance Services to 25 hours/week is not deemed medically necessary. 

The patient is a female with a history of leukemia, chronic low back and bilateral knee pain. Due to impairments related to these conditions, she requires assistance for completion of many of her activities of daily living (ADLs), bed mobility, transfers and ambulation. 

Appeal review requested for potential approval of an increase in Consumer Directed Personal Care Assistance Services to 25 hours/week to offer increased ADL assistance. 

Due to impairments related to these conditions, she requires assistance for completion of many of her ADLs, bed mobility, transfers and ambulation. However, an in home assessment of the patient's functionality and clinical status was completed and revealed that the currently approved plan of 23 hours/week Consumer Directed Personal Care Assistance Services is sufficient to meet the patient's current needs. There is no additional documentation which indicates that the patient has sustained additional functional decline since the date of this last assessment. For these reasons, the proposed treatment of an increase in Consumer Directed Personal Care Assistance Services to 25 hours/week is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Infectious disease/Fever
Treatment: Inpatient stay
Insurer denied the inpatient stay based on medical necessity. The health plan's determination of medical necessity is upheld in whole, inpatient stay was not medically necessary. 
  
This patient presented with one day history of symptoms that included fever, decreased PO intake and decreased urine output. In the ER patient did have dry mucous membranes on exam and urine with SG of >1030 with ketones. After receiving 2 NS boluses in the ER  admission physical exam showed no distress, white patches to tonsils, otherwise unremarkable. Decision was made to admit due to fever and dehydration requiring IV hydration. This patient did not meet criteria for inpatient level of care. Fever does not constitute the need for inpatient level of care. As far as dehydration, there was no mention of a failed by mouth (PO) trial in the ER after patient received  IVF bolus as oral rehydration is the recommended first line for mild to moderate dehydration. At the time of admission  exam was normal. There were no physical signs of dehydration on exam. Patient responded well to ER resuscitation of 2 normal saline boluses followed by IVF. Patient  did not have any suspected severe infection as  inflammatory markers were not significantly elevated. Patient did not have any severe abdominal tenderness, hemodynamic instability, vomiting that was severe or persistent nor did patient demonstrate inability to maintain oral hydration.  Patient did not require any highly skilled or intensive care while admitted. Inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Duchenne muscular dystrophy 
Issue under review: Exondys 51
The insurer denied the Exondys 51.
The denial is overturned. 

Yes, the treatment with Exondys 51 is medically necessary.

The patient is a male child with medical history significant for Duchenne muscular dystrophy (with deletion of exons 49 and 50 in the dystrophin gene). A letter stated he was attending school, walking the hallways with a paraprofessional for safety. He was not wearing ankle-foot orthoses. He was wearing night splints to maintain heel cord range of motion. He was receiving physical therapy five times a week. 

During a six-minute walk test, the patient was able to walk 790 feet (approximately 240 meters). According to a progress note from the multidisciplinary clinic he had previously been in the Wave exon skipping trial after previously receiving eteplirsen, including two muscle biopsies for the Wave trial and two muscle biopsies for the eteplirsen trial. Additional medications included deflazacort, lisinopril, and metformin. The current request is for continued treatment with eteplirsen. It has been denied because the patient has not demonstrated that he can walk 300 meters during the six-minute walk test.

Eteplirsen (Exondys 51) was granted accelerated approval by the FDA in 09/2016 for patients with a confirmed mutation of the dystrophin gene amenable to exon 51 skipping (a situation affecting about ten to 15% of those with DMD [Duchenne muscular dystrophy]). In a double-blind placebo-controlled protocol to the ability of eteplirsen to induce dystrophin production and improve walking distance on the six-minute walk test, children were included that had confirmed deletions correctable with exon 51 skipping and possessed the ability to walk 200-400 meters on a six-minute walk test. Dystophin was restored in the patients randomized to receive eteplirsen with duration of therapy accounting for dystrophin production, with the resultant improvement in the six-minute walk test (1). 

In a very comprehensive review of eteplirsen, the authors discussed use of the six-meter walk test (6MWT) as a measure of efficacy or clinical endpoint, not as criterion for treatment. Further, "while the 6MWT is a standard end point for assessing the clinical utility of DMD therapeutics, it is limited, as it applies only to ambulant patients and has been shown to be motivation-dependent." (2) 

This patient meets criteria for eteplirsen treatment. It is medically and necessary for treatment of his Duchenne muscular dystrophy.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Advanced dementia, low back pain, bilateral knee osteoarthritis and urinary/fecal incontinence. 
Treatment: Increase to 12 hours per day, seven days per week, total 84 hours per week of Personal Care Service, Level II.
The insurer denied the Increase to 12 hours per day, seven days per week, total 84 hours per week of Personal Care Service, Level II.  The denial is overturned. 

Yes, the proposed treatment of an increase in personal care service hours to 12 hours per day, seven days per week; total 84 hours per week is deemed medically necessary. 

The patient is a female with a history of advanced dementia, low back pain, bilateral knee osteoarthritis and urinary/fecal incontinence.  Due to impairments related to these conditions, she requires assistance with the majority of her activities of daily living (ADL).  An appeal review was requested for potential approval of an increase in personal care service hours to 12 hours per day, seven days per week, total 84 hours per week to offer increased ADL assistance. 

This is a female with a history of advanced dementia, low back pain, bilateral knee osteoarthritis and urinary/fecal incontinence. Due to impairments related to these conditions, she requires assistance with the majority of her activities of daily living.  Recent documentation from the patient's Attending Physician indicates that the patient is no longer able to engage in any self-care due to her severe cognitive impairment and musculoskeletal conditions.  Due to her chronic urinary and fecal incontinence, she requires assistance with bathing after these episodes, which can occur during the day or overnight hours.  She has been observed engaging in dangerous activities, such as accidentally turning on the stove and climbing on furniture.  She has also been observed opening the front door for strangers.  For these reasons, the currently approved plan of ten hours per day, seven days a week, total of 70 hours per week personal care services, level II is not deemed sufficient to meet the patient's current needs.  Hence, the proposed treatment of an increase in personal care service hours to 12 hours per day, seven days per week; total 84 hours per week is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: cancer/Lung cancer 
Treatment: Home health care . 
The insurer denied for increased PCA service hours . 
The denial is overturned in whole . 

The patient  with past medical history of small cell lung er, tobacco abuse, hypertension, urinary incontinence, bowel incontinence and repeated falls, who had been assigned 6 hours/day, 7 days/week to total 42 hour/week of Personal Care Aid ( PCA) services. There was a request for increased PCA service hours due to the patient's worsening functional status due to worsening small cell lung cancer. 
Yes, the requested health service of increased consumer directed personal care assistance to 10 hours per day, 7 days a week, for a total of 70 hours a week, is medically necessary for the patient.
The increase in PCA service hours is medically necessary.  Medical Necessity is defined as medical care and services that are necessary to prevent, diagnose, correct or cure conditions in the person that cause acute suffering, endanger life, result in illness or infirmity, interfere with such persons capacity for normal activity or threaten some significant handicap.  The patient has a diagnosis of small cell lung cancer with worsening functional capacity due this disease process.  The patient's PCP appealed the decision not to increase her PCA hours.  Per report of her family, the patient needed total care for toilet transfer, toilet use and incontinence cares.  The patient had 4 falls in a one-day period of time.  These falls all occurred when the patient was attempting toileting.  At the time of the assessment the patient was not able to ambulate on  own or with assistance of device and is not able to self-propel in a wheelchair.  For bed mobility the patient's family communicated that the patient  required assistance greater than this.  An increase in PCA hours is medically necessary in this patient with small cell lung cancer and uncontrolled diarrhea and is a service that is necessary to prevent and correct conditions in this patient who would be at risk for falls with injury without assistance with bed mobility, toilet transfer, toileting, incontinence cares, walking and locomotion.