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

Diagnosis: Cerebral Palsy.

Treatment: Private Duty Nursing 8 hours per day; 7 days a week.

The insurer denied the Private Duty Nursing 8 hours per day; 7 days a week.

The denial was overturned.

This is a female patient with history of cerebral palsy with developmental delay and intellectual disability, medically refractory seizures and is an aspiration risk. The patient has urinary incontinence and a percutaneous endoscopic gastrostomy (PEG). She requires aspiration precautions and receives feedings multiple times a day. The PEG requires flushing after each administration. It was reported that she has been receiving private duty nursing services. 

Recommendation was made for continued private duty nursing services including seizures/safety precautions, administering and monitoring feeding and maintaining aspiration precautions administer ordered medication. The request is for private duty nursing 8 hours a day, 7 days a week. 
 
Documentation shows that patient requires full assistance for all activities of daily activity and PRN seizure medication.  Rectal diazepam is typically reserved for patients with high risk of breakthrough seizures and cluster of seizures. In light of the history of refractory seizures, significant developmental delay, cerebral palsy, aspiration risk, the request for private duty nursing 8 hours a day, 7 days a week are medically necessary. 

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

Based on the above, the medical necessity for Private Duty Nursing 8 hours per day; 7 days a week is substantiated.  The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Digestive System/Gastrointestinal - Abdominal/Stomach Pain
Inpatient Hospital

The patient is a male with a history of hyperlipidemia. He presented to the emergency room with a three-day history of abdominal pain and a one day history of diarrhea. He was afebrile and his vital signs were normal. Epigastric tenderness was elicited, but there was no rebound or guarding. The exam was otherwise unremarkable. Labs were notable for a mild leukocytosis of 14,300. An abdominal computed tomography (CT) scan was non-contributory. The patient was admitted for further treatment and evaluation. Upon admission, the patient was treated with intravenous fluids and antibiotics. His symptoms resolved and he was discharged.
The subject under review is the medical necessity for the inpatient stay. 

The health plan's determination is upheld.

Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no significant objective evidence on physical exam, labs, or imaging of an imminently life-threatening cause of the patient's complaints. There is no evidence that the patient failed treatment in the emergency room with outpatient follow up. In addition, there was not good evidence that he required antibiotics. There was no fever, chills, change in mental status, or evidence of metabolic disarray. Based on the standard of care and peer reviewed literature, the acute inpatient level of care was not medically necessary, and the patient could have been managed at a lower level of care.
Appeal type: Experimental/Investigational
Decision: Upheld

Cardiac
Pharmacy/prescription drugs

Diagnosis: Hypertension/Hyperlipidemia
Treatment: Repatha
The insurer denied Repatha. The health plan's determination is overturned. 

The patient is a woman with a history of obesity, hypertension and hyperlipidemia. She has been intolerant to multiple statins and to ezetimibe. Her coronary artery calcium score is 185, placing her in the 95th percentile for her age, race and gender. Her low density lipoprotein (LDL) cholesterol level was 157 mg/dl.

The Repatha Sureclick 140 mg/mL Pen Injector is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. This woman's coronary calcium score places her in the 95th percentile for her age and gender, which is consistent with significant coronary atherosclerosis. Her National Lipid Association recommended LDL cholesterol goal level is 70 mg/dl; her current level is more than twice that. A PCSK9 inhibitor, such as Repatha, is the only currently available option that would be expected to allow this woman to reach her goal level. No other currently available lipid-lowering agent would be expected to decrease her level to the degree that a PCSK9 inhibitor would.
Appeal type: Experimental/Investigational
Decision: Upheld

Cardiac
Pharmacy/prescription drugs

Diagnosis: Hypertension/Hyperlipidemia
Treatment: Repatha
The insurer denied Repatha. The health plan's determination is upheld. 

The patient is a woman with hyperlipidemia and hypertension. Statins including Crestor, Lipitor, simvastatin and pravastatin have in the past produced liver function abnormalities as had Zetia. The patient has evidence of anatomic coronary artery disease (CAD) by computed tomography (CT) calcium scoring, but has had no evidence of no clinical atherosclerotic cardiovascular disease (ASCVD). LDL-C ((low-density lipoprotein)) was 154 mg/dL.

The Repatha Sureclick 140 mg/mL Pen Injector is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The patient has elevated LDL-C and cannot tolerate statins and Zetia. A PCSK9 inhibitor is required to bring the LDL-C to target of 100 mg/dL. However, in this patient subset, i.e. no clinical ASCVD and baseline LDLC < 190 mg/dL, the American College of Cardiology (ACC) 2016 and 2017 lipid lower guidelines specifically do not recommend a PCSK9 inhibitor in view of absence of trials in this subgroup. As such, Repatha cannot be recommended for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Cardiac
Pharmacy/prescription drugs

Diagnosis: Hypertension/Hyperlipidemia
Treatment: Repatha
The insurer denied Repatha. The health plan's determination is upheld. 

The patent is a woman with hypertension and hyperlipidemia. The low-density lipoprotein (LDL) was 151. She has had an elevated coronary calcium score of 185, in the 90-95th percentile, indicating moderate atherosclerotic plaque. However, she had a low risk treadmill test. She is reportedly unable to tolerate statins and Zetia.

Repatha is not likely to be more beneficial than any standard treatment. The standard treatment for LDL lowering are statins. While the office note indicates that the patient is unable to tolerate any statins, no specific statin trials, including doses, dates, and side effects were recorded. Also, the patient has an elevated coronary calcium score, but no clinical symptoms of atherosclerotic cardiovascular disease. The use of evolocumab in the study by Sabatine, et al (1) included patients with myocardial infarction, stroke or symptomatic peripheral arterial disease, but not asymptomatic patients with elevated coronary calcium score.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia, Acute Coronary Syndrome.

Treatment: Acute Inpatient Stay.

The insurer denied the acute inpatient stay.

The denial was upheld.

This is a male patient with history of congestive heart failure (CHF), hypertension (HTN), dyslipidemia (DLD), and paroxysmal nocturnal dyspnea (PND).  He presented to the Emergency Department (ED) with complaints of shortness of breath (SOB) and chest tightness. The patient also reported orthopnea and that had not been taking her blood pressure medications for the past two months. His presenting vital signs were:  temperature (T) 98.3 F, heart rate (HR) 89, respiratory rate (RR) 20, blood pressure (BP) 171/112 mm Hg and oxygen (O2) saturations 96 % on room air (RA).  Lung exam revealed bilateral basal rales.  Cardiovascular system (CVS) S1 S2 was normal (N) and pedal edema 1+ was noted. Laboratory work up was performed that revealed a white blood cell (WBC) count was 6.7 K, hemoglobin (Hb) 13.9 and BUN/ Creatinine 19.5/1.26, D Dimer was elevated. Chest x-ray showed possible right lower lobe (RLL) pneumonia.  There were no signs of deep vein thrombosis (DVT).  BNP was normal.  EKG showed normal sinus rhythm with some T wave changes but no change consistent with prior EKG. The patient was admitted for treatment of congenital heart disease (CHD), rule out acute coronary syndrome (ACS) and possible pneumonia. He was re-started on his cardiac and blood pressure medication. He received antibiotics to treat his community acquired pneumonia. He was medically stable and discharged.

As per History & Physical the patient was in no acute distress (NAD).  He was afebrile, O2 saturations were 98 % on room air.  There was no jugular venous distention (JVD).  There were minimal rales at bases. Cardiology was consulted. Cardiac catheterization was planned but scheduled to be done as an outpatient.  The patient did not need acute hospitalization.  He could have been placed on Observation status while diagnostic testing and treatment are initiated.  The patient remained afebrile and hemodynamically stable; myocardial infarction (MI) had been ruled out.  Also CT Chest determined that the patient did not have pneumonia.  The patient was afebrile; BC was normal and had no clinical signs of infection.  CURB 65 score was Zero.  CHF if present was mild.  BNP was Normal.  There were minimal rales on exam.  The patient was not hypoxic, was ambulatory and tolerating orally (PO).

This patient's symptoms were triggered by non-compliance with his medications.  Once acute issue had been resolved and MI ruled out the patient could have been re-started on oral medications and oral antibiotics if clinically indicated and discharged home with close follow-up in an outpatient setting.  The prior denial is upheld.

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

Diagnosis: Anterior crossbite (reverse bite) with attachment (gum) loss. 
Treatment: Braces.
The insurer denied the braces. 
The denial is overturned. 

The patient is a female.  The request is for orthodontic benefits.

Yes, the proposed orthodontic braces are medically necessary. 

The patient's lower right canine (tooth #27) is in anterior crossbite (reverse bite) with attachment (gum) loss. This is an automatic qualifier according to the handicapping index scale. Orthodontic treatment is needed to correct this problem.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skeletal Class I, maxillary and mandibular crowding, Class II canines, and deep impinging overbite
Treatment: Braces 
The insurer is denied coverage for braces.
The denial is upheld. 
This is a patient who consulted an orthodontist for orthodontic care. Diagnostic studies were performed that included lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images. The orthodontist recommended comprehensive orthodontics due to skeletal Class I, maxillary and mandibular crowding, Class II canines, and deep impinging overbite. The orthodontist has completed the HLD index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage to support orthodontic necessity. 

It is evident that the patient exhibits a significant malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, 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 deep
impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of soft tissue damage, and does not support comprehensive orthodontic care. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care. This reviewer concurs with the HLD index of the insurer attaining 21 points (3 points overjet, 5 points overbite, 10 points anterior crowding and 3 points Labiolingual spread).

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. This is confirmed by several studies. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.

The healthcare plan acted reasonably and with sound medical judgment in the best interest of the patient. Braces are not considered medically necessary for this patient.

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

Diagnosis: Crohn's disease 
Treatment: Non-emergency Ambulance Services 
The insurer denied the ambulance services. 
The determination is overturned. 

This patient with Crohn's disease diagnosed 20 years prior, asthma, vulvar cancer, colostomy, and neuropathy. She presented to the emergency department with severe generalized abdominal pain, dry mouth, and fever. She had been there hours prior with an episode of abdominal pain. Vital signs were notable for a low blood pressure of 96/53 millimeters of mercury (mmHg), pulse rate of 101/minute, and temperature of 99.8 degrees Fahrenheit (reported to be 102.6 degrees Fahrenheit). The physical examination was notable for a distressed appearance, decreased bowel sounds, mild to moderate abdominal tenderness, functioning ostomy, and lack of abdominal rigidity, rebound tenderness, and guarding. Lab results showed a normal white blood cell count with elevated band neutrophil predominance of 16%. Urinalysis showed trace blood and trace leukocyte esterase. A computed tomography scan of the abdomen and pelvis reportedly showed increase in fluid collection which was pending drainage. The assessment was fever and abdominal pain in the setting of increased fluid collection size, and elevated band neutrophil fraction; this was concerning for serious infection. She was treated with intravenous hydromorphone, cefazolin, and metronidazole. Due to a concern for rapid decompensation, she was transferred via ambulance. At issue is the medical necessity for ambulance transfer. 

The patient had Crohn's disease, with an intra-abdominal fluid collection; Crohn's disease can be complicated by perforation, abscess, and phlegmon, with attendant infectious complications and sepsis which require management [1-4]. The patient's presentation with low blood pressure, elevated neutrophil fraction, and fever was concerning for developing sepsis, which can have rapid onset [5].  Intensive care was potentially imminently necessary, and the assessment was that the patient was at "high risk for rapid decompensation" with the need to be transferred as soon as possible for emergent intervention, with high risk for decompensation en route; based on presenting history, vital signs, and labs, this is supported by current medical literature. For these reasons, transfer is supported, and private automobile would not have been appropriate for a patient with the possibility of rapid decompensation en route. Therefore, the medical necessity of ambulance transfer is supported as medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Left acetabular fracture
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is approved, in part. 

This is a female patient admitted to hospital. She had placement of a vena cava filter prior to reconstruction of left acetabular fracture (pathological). Her past medical history was significant for metastatic uterine carcinoma, urethral obstruction, sepsis and deep vein thrombosis (DVT) to lower left leg. 

The patient's filter was placed and hip reconstruction was completed. She required several days to obtain satisfactory pain relief. She also required a psychiatric consult due to depression.  She was discharged to home. She had a preoperative foot drop. 

Yes, in part; the inpatient admission was medically necessary, in part.

Placement of IVC filters is a semi-elective procedure which does not require an overnight stay. The procedure was not emergent. There was the report of DVT weeks prior. The placement of the filter was to decrease the risk of thromboembolic events. It was non-complicated with no evidence of bleeding, infection or fever. Heparinization was initiated but required discontinuation prior to surgery. The IVC filter could have been placed the same day of elective surgery.

However, admission was required for the hip reconstruction. The patient's procedure was complex and extensive with blood loss. The patient had underlying chronic pain which required multimodal analgesia titration. In view of her unique medical condition, the days for the hip reconstruction were warranted. Milliman Care Guidelines (MCG) report a length of stay to be surgery plus two post-operative days. Extended is considered moderate of four to seven days (i.e., the patient's underlying morbidities). 

The patient did not require inpatient admission for IVC filters.  The medical records demonstrate no acute level services were provided. The patient was able to tolerate medications by mouth. Her vital signs were stable. She did not require treatment for other underlying medical conditions. Her hematocrit was stable. She was sufficiently anti-coagulated. No additional testing nor procedures were required. There were no extenuating circumstances to substantiate ongoing length of stay.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain 
Treatment: Acute inpatient admission
The insurer is denied coverage for acute inpatient admission. 
The denial is upheld. 

This is a male patient with a history of hypertension. He presented to the emergency room with mid-sternal chest pain. Vital signs were stable. He described the pain as non-radiating and non-exertional. Bloodwork revealed d-dimer less than 150, BNP 88, and troponin less than 0.010. A chest X-ray showed no evidence of acute disease. An electrocardiogram (EKG) showed sinus tachycardia. The patient's HEART score was 4. Cardiology was consulted.  The patient rated his pain 10 out of 10 in severity. An echocardiogram showed normal left ventricular size and function, traces aortic regurgitation, and mildly dilated proximal ascending aorta; no wall motion abnormality was noted. The patient was admitted to telemetry with a diagnosis of chest pain. Computed tomography angiography (CTA) of the chest was negative for pulmonary embolus. Repeat troponin levels were normal. He underwent a cardiac catheterization which showed normal left ventricular contractile function and elevated left heart filling pressure. His coronary arteries were normal. The patient's symptoms resolved and he was discharged.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. The acute inpatient admission was not medically necessary.

The patient presented with a history of chest pain which was concerning for cardiac etiology. He underwent appropriate initial evaluation in the Emergency Department, which was unremarkable. This included normal hemodynamics, physical exam, a non-diagnostic EKG and negative cardiac biomarkers. There were no other high-risk symptoms present to suggest acute coronary syndrome. As medically essential as it was to evaluate the patient's symptoms, inpatient admission was not medically necessary in this instance. The patient's care could have been provided under the observational setting, allowing for additional diagnostic testing, as was performed. During the patient's initial evaluation and subsequent hospitalization, there was no objective evidence of hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions warranting acute inpatient level of care. The observational level of care would have been appropriate.

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:  Chest Pain, Abdominal Pain.
Treatment: Inpatient hospital admission.
The insurer is denied coverage for inpatient hospital admission. 
 The denial is upheld.

This is a male patient with a history of Roux-en-Y gastric bypass, hypertension, morbid obesity, and diabetes mellitus.  He presented to the emergency room with complaints of lower left chest pain and epigastric pain for several days.  The pain radiated to his back and was constant, waxing and waning in intensity, worse with exertion and better upon rest.  The patient additionally reported nausea, diaphoresis, and chills.  Vital signs noted hypertension.  Bloodwork revealed a normal troponin. An electrocardiogram (EKG) showed sinus tachycardia with no ischemia.  A chest X-ray was negative.  A computed tomography (CT) scan of the chest, abdomen and pelvis showed no evidence of pulmonary embolism or bowel obstruction.  The patient was admitted with diagnoses of abdominal pain and chest pain with concern for acute coronary syndrome.  His pain was managed with Percocet and Morphine.  Repeat troponin levels were negative.  The patient underwent an esophagogastroduodenoscopy (EGD), which showed no obvious erosions, ulcers or evidence of bleeding; the Z-line was irregular.  No etiology for abdominal pain was identified.  His diet was advanced, his symptoms improved, and he was discharged.

The patient presented with a history of chest pain.  The initial evaluation in the ER was unremarkable, including a non-diagnostic EKG and negative cardiac biomarkers.  There were no other high-risk symptoms suggestive of acute coronary syndrome.  As medically essential as it was to evaluate the patient's symptoms, inpatient admission was not medically necessary in this instance.  The patient's care could have been provided under the observational setting, allowing for additional diagnostic testing.  There were no high-risk or concerning findings on diagnostic testing to necessitate further inpatient evaluation.  During the patient's initial evaluation and subsequent hospitalization, there was no objective evidence of hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, or myocardial ischemia.  There were no abdominal findings consistent with an acute process needing inpatient management.  There were no other medical conditions warranting acute inpatient level of care.

The health plan acted reasonably with sound medical judgment 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 is upheld.