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

Diagnosis: Alopecia Areata and Vitiligo 

Treatment: Xeljanz

The insurer denied the Xeljanz. The denial was reversed. 


This is a middle aged male who presented to the visit in mid-2019 for alopecia areata and vitiligo. The patient reported that it had been present for years. He also had loss of his eyebrows and eyelashes, and had 30% hair loss to the scalp. Additionally, he had severe eye irritation, scattered patches on the scalp and body. His face and neck had demonstrated vitiligo depigmented patches as well. The recommendation was to start Xeljanz 5 mg oral tablet, one tablet twice per day.
The patient has alopecia areata and vitiligo.  There is no Food and Drug Administration (FDA) approved or plan approved therapies for alopecia areata or vitiligo. Xeljanz has been found to be effective and safe for the treatment of alopecia areata and vitiligo. The patient's condition has had a severe negative impact on his personal life. It has caused embarrassment, isolation, and depression, in addition to having a negative impact on his livelihood and overall well-being. The patient has tried and failed conservative therapies.

"Agents which are commonly used to treat rheumatologic diseases and psoriasis are also being studied in the treatment of autoimmune diseases including vitiligo. Janus kinase (JAK) inhibitors have been evaluated in several case reports, with potential therapeutic promise thought to be related to their interference with interferon (IFN)- signaling 48, 49, 74, 75. Research has shown that IFN-induced expression of CXCL10 is critical for the progression and maintenance of depigmentation in vitiligo 76. In a recent case report, a patient with vitiligo was treated with tofacitinib, an oral JAK 1/3 inhibitor, for 5 months, and had significant repigmentation with no significant adverse effects 74." (Manga, P., Elbuluk, N., & Orlow, S. J., 2016).

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

Diagnosis: Bilateral Lower Lobe Pulmonary Emboli and Pneumonia.
 
Treatment: Genetic testing (F5 coagulation Factor V gene analysis, Leiden variant) and (F2 gene analysis 20210G>A variant)

The insurer denied the Genetic testing (F5 coagulation Factor V gene analysis, Leiden variant) and (F2 gene analysis 20210G>A variant). The denial was upheld.   

This case involves male who was seen in early 2019 for a consultation.  The patient was being seen for a bilateral provoked pulmonary emboli, as well as community-acquired pneumonia. He had a history of a fractured his fibula and tibia back in early 2019 and underwent an internal fixation. He experienced increasing pain to the left lower extremity after surgery and was found to be negative for a deep venous thrombosis. He began to complain of back and chest pain; a CT scan of the chest was performed showing filling defects in both lower lobe pulmonary arteries compatible with pulmonary emboli.  The patient began utilizing Xarelto and continues on the medication.  The patient stated he had a family history of thrombosis. It was recommended he undergo a hypercoagulable work-up due to his recent diagnosis and family history. The patient completed a three months regimen of anticoagulation; and additional laboratory studies were recommended.
The F2 gene is known as the coagulation factor which is associated with impaired clotting ability. The F5 gene is also known as coagulation factor V, and is associated with coagulation factors essential for proper blood clot formation. According to current peer-reviewed literature, the testing for hypercoagulable disorders in a patient with a diagnosis of venous thromboembolism is not warranted. This is because the identification of an inheritable defect does not alter therapeutic or prophylactic anticoagulation management, and consequently it has not been associated with improved outcomes. 

Based on the above, the medical necessity for genetic testing for CPT code 81241 (F5 coagulation Factor V gene analysis, Leiden variant) and 81240 (F2 gene analysis 20210G>A variant) is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

The patient presented to the emergency department with suicidal ideation. The patient reported being noncompliant with the psychiatry medications for approximately 3 weeks. In the emergency department, the patient verbalized wishes to harm himself. The patient was found to have uncontrolled diabetes with a glucose in the 400s. The initial work up showed a chest x-ray that was unremarkable. On examination, the patient had reduced ability to focus attention, thought content paranoid, poor judgment, depressed mood, poor insight with auditory hallucinations. The patient was evaluated by psychiatry for suicidal ideation and medication management. A one-to-one sitter for patient safety was recommended. The patient was started on citalopram, quetiapine and hydroxyzine. The patient was admitted to medicine unit for treatment of uncontrolled diabetes and was started on basal insulin with Lantus, regular insulin before meals and a sliding scale.

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient was evaluated by psychiatry and one-to-one sitter for safety was ordered; he was restarted on his psychiatric medications. He was also followed by endocrinology and insulin regimen was adjusted for better diabetes management. He remained clinically stable during his hospitalization, pending possible transfer to inpatient psych facility, however, after further evaluation by psychiatry, he was considered stable from psychiatry standpoint to be discharged home. Based on the available clinical information, and patient's presentation and plan of care, the patient required hospitalization for further monitoring and evaluation of his clinical condition, however, the services could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Angioedema 

Treatment: Inpatient Admission

The insurer denied Inpatient Admission. The denial was upheld.

This is a middle aged male who presented to the Emergency Department (ED) in early 2019 with complaints of an allergic reaction after taking Aleve. His presenting complaints were an acute onset of flushing, hives, facial swelling; difficulty speaking that started 15 minutes after taking Aleve. He was given Benadryl in the ambulance and symptoms improved. On examination in the ED it was noted that there was tongue swelling with mallimpati 3. He has a history of hypertension, hyperlipidemia, anxiety and obstructive sleep apnea.
The documentation indicates that the patient was seen due to an allergic reaction after taking Aleve. He got hives and had tongue swelling.  Airway was non-obstructive. The patient was given medications with improvement in the emergency department. There was no indication that the patient had an allergic reaction with severe symptoms not responsive to emergency or observational care treatment such as airway edema, stridor, respiratory distress, bronchospasm or hemodynamic instability.

Based on the above, the medical necessity for inpatient hospital services at the inpatient level of care is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

The patient with a past medical history significant for a generalized anxiety disorder who presented to the emergency department with sudden onset of progressive right arm and hand weakness and tingling.The patient, complained of paresthesia, which was described as a "pins and needles", sensation in the right medial aspect of the arm. During the hospital stay the patient's symptoms, which included weakness and tingling in the right arm, improved but did not resolve completely. The patient was discharged from the hospital the health plans determination is upheld in whole. The admission for a lower level of care and with a workup was appropriate, since the admitting diagnosis in the emergency department was transient ischemic attack (TIA). The workup of the TIA does not usually require admission at the acute inpatient level of care, since the patient was hemodynamically stable, had no progression of the neurological deficits during the hospital stay, did not require administration of parenteral anticoagulants or antiplatelet agents, and had no additional medical conditions that would justify medical necessity for the admission at acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

The patient presented to the emergency department (ED) with complaints of dyspnea. According to the documentation provided, the patient was admitted as an observation but developed hypoxemia on the planned day of discharge and was converted to an inpatient level of care. The patient presented with dyspnea that had started the night prior to admission. It was not improved with nebulized albuterol and was associated with increase in the sputum production as well as a change in the character of the produced sputum. The patient was started on intravenous (IV) steroids and given multiple nebulized treatments but continued to have wheezing and dyspnea. The patient was admitted at that time. 

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient appeared to be improving and the listed reason for requiring an inpatient level of care was episodic hypoxemia. However, this documented hypoxemia into the 80's was short lasting and appears to have been precipitated from a decrease in her oxygen to 2 lpm (liters per minute) from her baseline requirement of 3 lpm. This appears to have resolved by later the same day on the documents that were provided. This patient could have been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

The patient is a female who presents with a large filling and root canal treated on tooth #8. A crown on tooth #8 is being requested at this time. This has been denied by the health plan.
The subject under review is the medical necessity of the requested treatment, white glass with high gold content crown, tooth # 8.
The health plan's determination is overturned.

The requested white glass with high gold content crown, tooth # 8, is medically necessary for this patient. Tooth #8 has a root canal with a large restorative filling on the mesial lingual surface. A tooth that is root canal treated has a high chance of fracturing due to loss of tooth structure from the root canal procedure. When a tooth with a root canal fractures, the tooth cannot be saved, and extraction is then needed. Therefore, a crown on tooth #8 is medically necessary to prevent fracturing of the tooth. Accordingly, the request for a crown on tooth #8 is approved.
Appeal type: Medical necessity
Decision: Upheld

The patient presents with a skeletal class II molar malocclusion, moderate overjet and overbite and moderate maxillary and mandibular crowding. Excessive incisors proclination. The proposed treatment is braces 24-30 months. The malocclusion in question does not meet the criteria used in most programs to be classified as handicapping and therefore, treatment would not be considered medically necessary. Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 20 with no auto qualifier present. Most programs using these evaluation methods require a score of 26 or more for treatment to be considered medically necessary. The proposed treatment of braces is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This  patient underwent bilateral breast reduction for symptomatic macromastia.  The  central pedicles are ptotic, and the patient has too much tissue laterally.  The  nipples measure 55 millimeter (mm) in diameter and are too large.  The surgeon recommends breast reduction revision.  The patient continues to complain of back pain and poor fitting bras.  The health plans determination of medical necessity is upheld in whole.  The requested health service is not medically necessary.
The records do not document a workup for other possible causes of the symptoms.  The requested revision of the patient's breast reduction will primarily change appearance and, therefore, is a cosmetic treatment and not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness
Treatment: Inpatient admission
The inpatient admission was not medically necessary. 

This is a male who presented to the ER for further evaluation/management of dizziness. Intake vitals were afebrile, hemodynamically stable with no evidence of profound tachycardia, hypotension or hypoxemia. Physical examination and labs were unremarkable for any significant abnormalities including no cardiopulmonary, neurologic changes and no findings consistent with end organ damage. Medical records indicate that the patient was admitted solely for observation/monitoring and treated with IV fluids and continued cardiac monitoring with significant improvement in symptoms. He was subsequently discharged from the hospital in stable condition. 

There is no evidence of intensification of services throughout the course of this patient's hospital stay. Hence, the patient's care could have been safely furnished in a less intensive setting without adversely affecting patient's safety or outcome. For these reasons, the proposed treatment inpatient admission is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

This is a patient  with a past medical history of hypothyroidism who presented to the emergency department  with the complaint of severe abdominal pain and inability to have a bowel movement for nearly 2 weeks. She denied any history of similar. She had been taking over the counter laxatives for a week without relief and was having increasing epigastric abdominal pain and distention. She had consulted with her primary care physician the day prior to her emergency department (ED) visit, who had recommended trying magnesium citrate. She followed this advice with resultant passage of a small liquid stool and flatus, but noted an in increase in abdominal pain, described as severe and crampy. The triage note mentioned her concern at not having more significant results with the magnesium citrate. She denied any nausea, vomiting, fever, and the rest of her review of systems was recorded as negative. She was examined by the ED physician and her abdominal exam was significant for increased bowel sounds, mild distention, and mild tenderness in the epigastric region. A kidney ureter bladder (KUB) was performed. The emergency department (ED) physician interpreted the KUB as positive for mild constipation and gas in the descending colon. The patient's pain had improved without intervention and she was counselled to repeat the magnesium citrate the next day if she did not have a large bowel movement during the night. The health plan's determination is overturned.
The patient was complaining of progressively worsening pain, ultimately described as severe, abdominal distention, and inability to have a bowel movement for almost 2 weeks, despite first trying over the counter laxatives, and then the advice of her primary care physician to try magnesium citrate. When she failed to have a significant bowel movement and experienced increased abdominal pain, she became sufficiently concerned that she presented to the Emergency Department for evaluation. According to a letter written by the patient's mother, she and the patient were concerned that she was experiencing an intestinal obstruction because the magnesium citrate had not provided "quick, if not immediate, results" as counseled by her primary care physician. This  meets the Prudent Layperson Standard and definition of an emergency condition defined as "a medicalcondition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in (A) placing the health of such person or others in serious jeopardy." Additionally, this occurred on a Saturday evening, when the Emergency Department was the only healthcare option available to her.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cracked Tooth Syndrome.

Treatment:  Core Buildup including Pins for Tooth 18 and Gold Crown; Full Cast for Tooth 18

The insurer denied Core Buildup including Pins for Tooth 18 and Gold Crown; Full Cast for Tooth 18.  The denial was upheld. 

This patient is a female who consulted her dentist for comprehensive treatment for her cracked distal-buccal (DB), distal lingual (DL), and mesial lingual, (ML) cusps. It was recommended that she have a core buildup and full coverage crown for tooth #18 

The objective documentation provided for review is solely a periapical radiograph. On review of the radiograph, there is no evidence of fracture or other pathology specifically affecting tooth #18. There is no radiographic evidence of caries.  There is no periapical pathology. The radiograph does not substantiate the recommended dental services as enumerated above.

Based on the above, the medical necessity for core buildup including pins for tooth 18 and gold crown; full cast for tooth 18 is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who was admitted for treatment of a fever and urinary tract infection. According to the available medical records, she was reported to have a fever for 5 days prior to admission. She was seen in an urgent care center 3 days prior to admission and diagnosed with a viral syndrome. Due to a continued fever, she was seen again and had an evaluation in the Emergency Department (ED). In the ED, she had laboratory testing including a white blood cell count of 19.7 and an elevated C-reactive protein (CRP) of 24.8. Urine testing revealed increased white blood cells (WBC), positive (+) leukocyte esterase, + blood, and was cloudy in appearance suggestive of a urinary tract infection.
The health plan's determination is upheld.
There is a large amount of data for treatment of UTI in infants that are accepted as standard of care especially in infant 2 months and older.
Admission for UTI is reserved for infants under 2 months if seriously ill. Infants 1-2 months and older who are not in distress or ill-appearing do not necessarily require admission when there is an indication via urine testing that there is a likely UTI. This was the case here.

This child was non-toxic, feeding normally, and well appearing. The child received ceftriaxone and would not need another dose of the medication for another 24 hours. This infant could have been followed up the next day to review the urine culture results and then begin oral antibiotics.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest pain
 
Treatment: Inpatient admission, diagnostic testing, and monitoring

The insurer denied the continued inpatient admission. The denial was upheld.

This patient had a history of hypertension, hyperlipidemia, obesity and obstructive sleep apnea.  Home medications included atorvastatin, aspirin, vitamin D, and metoprolol.  She presented to the Emergency Department (ED) late in the evening with intermittent chest pain for one week, described as burning, radiating to the right shoulder blade, worse with movement, and with relief after sublingual nitroglycerin.  She also related a similar event two years prior, with normal coronary angiography at that time.  Vital signs included blood pressure 160/82, heart rate 77, and oxygen saturation on room air 97%.  Electrocardiogram (EKG) is described as normal sinus rhythm, low voltage QRS, cannot rule out anterior infarct age undetermined.  Laboratory test results the next morning include white blood count (WBC) 7.87, hemoglobin 12.5, creatinine 0.8, troponin 0.00. Follow-up troponin was 0.00.  Chest x-ray was normal.  She was discharged on her home medications.

There is no evidence that this patient required an acute inpatient level of care to determine that her chest discomfort was not related to acute coronary syndrome.  

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

Diagnosis: Metastatic nerve sheath tumor
Treatment: Inpatient admission 

Summary:
The health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
For patients with febrile neutropenia in the setting of wound infection with purulent draining, hypotension, tachycardia and fevers, hospital admission for administration of IV antibiotics, and surgical wound debridement is medically appropriate.
Appeal type: Medical necessity
Decision: Upheld


The patient has a past medical history significant for hypertension, hyperlipidemia, tobacco abuse, ulcerative colitis, nephrolithiasis, benign prostatic hyperplasia (BPH), and abnormal liver function tests (LFTs) who presented to the emergency department after  noticing streaks of blood in the sputum following a bout of cough. Apparently, the patient reported cold symptoms that included a sore throat, rhinorrhea, and cough with sputum production. At the time of admission, the patient denied fever, chills, chest pain, shortness of breath, or palpitations. Patient also denied any sick contacts, night sweats, or weight-loss. The rest of the review of systems was negative. A chest x-ray demonstrated no active pulmonary disease. The patient also underwent a computed tomography (CT) of the chest that demonstrated a 5 millimeter (mm) nodule in the right upper lobe. The patient was seen by a pulmonologist, who suggested that the patient's symptoms were consistent with   (COPD) exacerbation associated with hemoptysis due to bronchitis. The pulmonologist stated that the patient had no constitutional symptoms to suggest pulmonary tuberculosis and no need for isolation. The patient was recommended an empiric five-day course of antibiotics for the COPD exacerbation, treatment with bronchodilators, and Prednisone. The health plan determination is upheld in whole. The inpatient hospitalization is not medically necessary. The patient presented to the hospital with complaints of coughing up blood following a bout of coughing. The patient was afebrile, hemodynamically stable, did not require supplemental oxygen, and was able to tolerate food and oral medications. Neither the severity of the patient's condition nor the complexity of services provided justified an acute inpatient level of care.