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

Diagnosis: Elevated blood pressure 

Treatment: Inpatient hospital admission 

The insurer denied coverage for inpatient hospital admission. The denial is reversed. 

This patient is a male with a past medical history of hypertension, diabetes mellitus, hyperlipidemia, alcohol abuse, cigarette smoking, marijuana abuse, cocaine abuse, left ulnar/radial fracture and repair and cerebrovascular accident (CVA) with left-sided weakness who was brought to the Emergency Department (ED) by Emergency Medical Services (EMS) for elevated blood pressure.  The patient stated he had not taken his medications for three months since he had his CVA.  The patient stated he did not know what medications he was supposed to be on.  The presenting blood pressure was 215/78.  The patient had decreased sensation in the left lower extremity and left upper extremities.  The patient's heart rate was 99.  The EKG revealed marked sinus bradycardia at 48 bpm and moderate left ventricular hypertrophy (LVH).  The patient had an anion gap of 14, RDW percent of 14.6, calcium of 9.1 and carbon dioxide of 22.  The urine toxicology was positive for THC.  The patient was hospitalized.  During hospitalization, the patient was bradycardic with a heart rate of 48 bpm.  The patient was diagnosed and treated with a Holter monitor, echocardiogram, physical therapy and medications.  Once medically stable, the patient was discharged home.

The admission was denied by the insurer utilizing Neurology guidelines.  The Milliman Care Guidelines note that inpatient admission is appropriate for patients with cardiac arrhythmias of immediate concern or with severe hypertension with a systolic blood pressure greater than 180 mmHg.  The patient had a blood pressure of 215/78.  The patient had a cardiac arrhythmia of immediate concern including bradycardia.  The patient had a significant medical history of hypertension, diabetes mellitus, hyperlipidemia, alcohol abuse, cigarette smoking, marijuana abuse, cocaine abuse, and a previous CVA.  The patient was noncompliant with medications.  Observation status or outpatient evaluation would not be appropriate given the significant history and potential for readmission.

Upon review of the case, the patient was likely experiencing a transient ischemic attack (TIA), possibly related to elevated blood pressure and possibly cardiac abnormalities.  The patient did complain of hemisensory loss, thus suggesting a TIA.  All TIA's should be immediately evaluated and treated to prevent subsequent development of a true acute stroke.  Many patients who are not properly admitted and evaluated for TIA end up being re-admitted with recurrent or worse symptoms.  Thus, it is prudent to properly evaluate all patients with TIA symptoms.  Therefore, the health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The inpatient hospital admission for an acute level of care was medically necessary for this patient.

The carrier's denial of coverage for the inpatient admission for acute level of care is reversed.  The medical necessity is substantiated
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Immunologic disorders/Arthritis.
Treatment: Radiology Services.   
The insurer denied the Radiology Services.  The denial was overturned.

The patient  with a past medical history (PMH) of obesity and psoriatic arthritis (on Cosentyx and Arava).  From a note the recent laboratory evaluation was notable for an erythrocyte sedimentation rate (ESR) of 94, despite well controlled psoriatic arthritis (PsA).  The subject under review is the medical necessity of the CT scan of the chest. The health plan's determination is overturned in whole.

The requested health service/treatment of CT scan of the chest is medically necessary for this patient.  As stated, the patient has an ESR in the 90's without any explanation.  As part of the work-up for a persistently elevated ESR, occult malignancy needs to be ruled out.  Other causes for a high ESR include, but are not limited to, rheumatologic disease, such as PsA; however per chart review, her PsA is well controlled at this time on Cosentyx and Arava.

Infection is another cause of an elevated ESR; however, this seems very unlikely given the 2 years history of an elevated ESR, lack of fevers and normal white blood cell count (WBC) (recent labs revealed a WBC of 8.3 and an ESR of 94).  It is reasonable and consistent with the standards of care to check a CT of the chest without contrast to rule out an occult malignancy.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Suicide attempt.
Treatment:  Continued behavioral health hospital admission. 
The insurer denied the continued behavioral health hospital admission.  The denial is overturned.

The continued behavioral health hospital admission was medically necessary.

The patient represented an elevated risk of dangerous behaviors including self-injury and suicide, and there was no less-restrictive treatment environment appropriate.  Therefore, the treatment was medically necessary.  While the patient was not endorsing active suicidality, the patient remained at an elevated risk of dangerous behaviors.  The patient had multiple static risk factors for potentially dangerous behaviors, including prior suicide attempts, substance abuse, and diagnosis with a severe mental illness.  Therefore, the patient represented a chronic risk of potentially dangerous behaviors.  The fact that the patient had ongoing medication changes was an acute risk factor for dangerous behaviors.  Furthermore, the fact that there was no less-restrictive environment of care appropriate suggests that ongoing inpatient psychiatric hospitalization was medically necessary and should be covered by the patient's health plan.

The patient represented an acutely elevated risk of dangerous behaviors, and there was no less-restrictive treatment environment appropriate.  The acute risk factors of depression and medication changes with the chronic risk factors of potentially dangerous behaviors suggest that the patient would have been at an acute risk of self-injurious behaviors (including but not limited to suicide) were she to have been discharged from the inpatient hospital setting.  The patient was discharged from the inpatient psychiatric hospital setting as soon as a less-restrictive treatment setting was appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Acute cholecystitis.
Treatment:  Inpatient admission.

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

This patient is a female with a past medical history of deep vein thrombosis x3, peptic ulcer disease, gallstones, protein C blood deficiency, PCOS, alcohol abuse, and was a current smoker.  The patient presented to the emergency department with subjective complaints of chest pain/back pain/vomiting.  The pain was rated 7/10.  The patient had chest pain several days prior to presentation after an argument.  The patient had associated symptoms with 3 episodes of non bloody, non bilious (NBNB) emesis.  The patient's blood pressure was 119/50.  The physical examination revealed right upper quadrant tenderness to palpation and a positive Murphy sign.  There was mild epigastric tenderness to palpation a small blister to the right lower quadrant.  The patient had lower extremity swelling rated +1.  The patient underwent an ultrasound revealing a non-mobile gallstone in the gallbladder neck.  There was clinical evidence of acute cholecystitis.  The physician noted that the patient had a medical necessity beyond the capabilities of the emergency department for possible acute cholecystitis.  The patient could not safely be discharged home, and she required further management.  The patient was to be admitted to surgery and was to be treated with intravenous antibiotics; however, the patient was discharged the next day.

The patient presented with right upper quadrant pain with no fever or hemodynamic instability.  The patient has a history of deep vein thrombosis (DVT) but is not on anticoagulation.  The liver profile was essentially normal.  The patient was reportedly admitted for a laparoscopic cholecystectomy, which ultimately could not be performed due to her thrombophilia state.

The patient was appropriate for management under observation, and the cholecystectomy could be performed electively.  There seems to be no indication for inpatient management.  The inpatient admission was not medically necessary.

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

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

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Pharmacy/Prescription Drugs. 

The insurer denied: Stelara. 
The denial is overturned in whole. 

The patient is a male with ileocolonic stricturing Crohn's disease. Stricture was seen on magnetic resonance enterography (MRE). He has a symptomatic anal fissure. The patient underwent colonoscopy which confirmed the anal fissure and ulceration on the ileocecal (IC) valve. The patient was previously on Stelara and responded very well with respect to inflammatory markers but stopped on his own as he wanted to try management with diet. The patient is currently with significant anal pain and tenesmus. 
The patient's provider has recommended treatment with Stelara. This request was denied by the plan based on lack of medical necessity. Plan alternatives including Renflexis, Inflectra, Humira or Entyvio were offered. 

The subject under review is the medical necessity for Stelara. 

The plan's determination of medical necessity is overturned in whole. Yes, treatment with Stelara is medically necessary for this patient. 

The patient previously was on ustekinumab (Stelara) and demonstrated a significant response with respect to inflammatory markers. He is now doing very poorly and needs to be on efficacious therapy to prevent significant complications. There is concern that tumor necrosis factor (TNF) and integrin inhibitors may not be as effective in this patient. He will be highly symptomatic during these trials and could wind up needing bowel surgery due to complications. This is clearly not in the best interest of the patient. If the patient had not used Stelara in the past the situation would be different. However, it is extremely likely that Stelara will work when re-introduced as it worked well before. Neutralizing antibodies to this biologic are rare.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Ears/Nose/throat/hearing problem/loss.
Treatment:  Oxygen/oxygen treatments.

The insurer denied hyperbaric oxygen therapy.  The denial is overturned in whole.

The patient is a female with a history of sudden sensorineural hearing loss in the left ear.  The patient was noted to have an audiogram, which confirmed the hearing loss, and she underwent a subsequent steroid injection.

Yes, the requested service hyperbaric oxygen therapy (HBO), is medically necessary for the patient.  The patient received two steroid injections in the middle ear space without improvement in the hearing.  There is evidence within the literature and recommendation from the American Academy of Otolaryngology/Head and Neck Surgery that HBO therapy can benefit a patient's hearing if administered within 3 months of the initial insult.

There is some evidence that HBO therapy can have an effect on reversing idiopathic Sensorineural hearing loss (SNHL).  While patients can have an increased opportunity for treatment sudden hearing if the HBO is administered within 2 weeks, current guidelines published by the American Academy of Otolaryngology state that patients can have a hearing benefit if administered within 3 months.  Hearing loss is a life impacting change for patients, and all reasonable treatment should be utilized to improve a patient's outcome, in the case of this patient, who sustained sudden hearing loss in the left ear.

Therefore, the hyperbaric oxygen therapy is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis.
Treatment: Skyrizi.
The insurer denied the Skyrizi.
The denial is overturned. 

The patient is a man with severe psoriasis affecting trunk and extremities, for whom Skyrizi is requested. He has tried and failed topical steroids, calcineurin inhibitors, vitamin D derivatives, acitretin and Dupixent. He has an extensive family history of cancer. 

Yes, the treatment with Skyrizi is medically necessary.

Skyrizi is indicated for the treatment of moderate to severe plaque psoriasis in adults who are candidates for systemic therapy or phototherapy. As such, it is a medically appropriate choice for this patient's severe psoriasis. It does not carry an increased risk of malignancy and has excellent efficacy data.

Risankizumab (Skyrizi; risankizumab-rzaa) is a humanized immunoglobulin (Ig) G1 monoclonal antibody that specifically targets the p19 subunit of interleukin (IL)-23, thereby inhibiting IL-23-dependent cell signaling. Subcutaneous risankizumab is approved for the treatment of adults with moderate to severe plaque psoriasis who are candidates for systemic therapy (in the EU), those who are candidates for systemic therapy or phototherapy (in the USA) and those who have an inadequate response to conventional therapies (in Japan). 

In pivotal phase III trials (UltIMMa-1, UltIMMa-2, IMMvent and IMMhance), risankizumab was more effective than placebo, ustekinumab and adalimumab with regard to the proportion of patients achieving >= 90% improvement from baseline in Psoriasis Area and Severity Index score (PASI 90) and a static Physician's Global Assessment score of 0 or 1 at week 16, with these benefits maintained over the longer term. In supportive head-to-head trials, risankizumab was also superior to secukinumab and fumaric acid esters in terms of PASI 90 response rate. 

In an ongoing open-label extension study (LIMMitless), risankizumab was associated with durable and improved efficacy after switching from ustekinumab or adalimumab, as well as durable maintenance of efficacy through > 2.5 years of continuous exposure. Treatment with risankizumab improved health-related quality of life and was generally well tolerated, both in the short- and longer-term. 

Methotrexate has a black box warranty for increased malignancy risk, is much less effective and has a long time to onset of improvement, all significant shortcomings compared to newer biologics, such as Skyrizi.

Therefore, given the above, the treatment with Skyrizi is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease, coronary artery disease
Treatment: Increase PCA Level II: 12 hours per day - seven days per week; 12 hours per day - seven days per week (Split Shift) 
The insurer denied the Increase PCA Level II: 12 hours per day - seven days per week; 12 hours per day - seven days per week (Split Shift) .  
The denial is overturned.

The proposed treatment of an increase in personal care assistant services to 12 hours per day - seven days per week; 12 hours per day - seven days per week (Split Shift) is deemed medically necessary. 

This is a male with a history of Parkinson's disease and coronary artery disease. Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs). Recent documentation from the patient's medical provider indicates that the currently approved plan of 52.5 hours per week personal care services is insufficient to meet the patient's current needs. Specifically, the provider notes that the patient's functionality and clinical status continues to progressively worsen including worsening cognitive impairment, gait ataxia, dizziness and falls. Furthermore, the patient has required numerous evaluations in the emergency room (ER) over the recent months due to his worsening clinical status. For these reasons, the proposed treatment of an increase in personal care assistant services to 12 hours per day - seven days per week; 12 hours per day - seven days per week (Split Shift) is deemed medically necessary to offer increased assistance with completion of the patient's ADLs.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial fibrillation

Treatment: hospital admission

The insurer denied coverage for full hospital admission. The denial is upheld. 

This patient is a male with no significant past medical history. The patient presented to the Emergency Department (ED) with complaints of palpitations, dizziness, and substernal chest pain. The patient's heart rate was 135 beats per minute. The patient's labs were unremarkable. The patient's electrocardiogram (EKG) revealed atrial fibrillation with rapid ventricular rate, and the patient was started on intravenous Diltiazem. The patient was admitted to the Coronary Care unit and was started on aspirin, Lipitor 40 milligrams a day, metoprolol 12.5 milligrams twice a day, and amiodarone 200 mg twice a day. The patient's trending troponins were all negative. The patient's echocardiogram was done and showed that the patient's ejection fraction was 60%. The patient's stress echocardiogram was negative for stress induced angina. The care plan was implemented and the patient's symptoms improved. The patient was discharged home in good condition with instructions to follow up with the primary care physician.  
Based on the review of the medical record, the patient presented to the Emergency Department with atrial fibrillation. However, otherwise, the patient's cardiac workup in the ED was unremarkable, including negative cardiac troponin levels. The patient remained clinically and hemodynamically stable throughout the hospitalization. Based on the review of the literature, inpatient admission was not medically necessary for this patient. In the absence of evidence of myocardial ischemia, hypoxemia, hemodynamic instability, or other end-organ dysfunction, the patient's care could have been provided in the observational setting, allowing for additional cardiac testing. Although the patient had new onset symptoms, a criterion was not met for inpatient stay since the patient did not have any other additional extenuating circumstances. Thus, 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.

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

Diagnosis: Acute pyelonephritis

Treatment: Inpatient admission 

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

The patient is a female child with a history of obesity who presented to the Emergency Department (ED) with complaints of severe headache both sides of her head, photophobia, fever, nausea, vomiting, dysuria, abdominal pain and other constitutional symptoms.  The patient was febrile at 102.8, had a heart rate of 109 bpm, and pain score of 10 out of 10 in severity.  The patient was initially ill-appearing although not toxic, and her neck was supple although it was tender to palpation. The patient's differential diagnoses included pyelonephritis, migraine, meningitis and idiopathic intracranial hypertension. The patient's lab results were markedly abnormal for leukocytosis and pronounced left shift (bandemia of 18%). The patient's urinalysis was abnormal indicating urinary tract infection (UTI) and was with ketones indicating dehydration.

Although this patient's ultimate diagnosis was acute pyelonephritis due to E. coli infection, the ED's medical decision making was appropriate in considering this patient's possible diagnosis of meningitis. The patient's lumbar puncture (LP) attempt was unsuccessful and needed to be done under interventional radiology (IR) guidance.  Pending the LP, the patient required and received intravenous (IV) ceftriaxone.  Besides ruling out meningitis, an LP was important to perform for the opening pressure, as this patient was at risk for idiopathic intracranial hypertension given her body habitus and age. Literature supports that intracranial hypertension if not managed urgently could lead to blindness. This, based on this patient's clinical presentation at the time of admission, inpatient admission was medically necessary to safely treat and monitor this patient's medical condition.

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

Diagnosis: Hypersensitivity reaction

Treatment: Inpatient hospital stay

The insurer denied coverage for inpatient hospital stay. The denial is upheld. 

This patient is a male with a history of bipolar disorder, peptic ulcer disease, methicillin-resistant staphylococcus aureus (MRSA) cellulitis, substance abuse, history of spine surgery, and status post recent right total knee arthroplasty. The patient presented to the Emergency Room (ER) with complaints of knee pain, swelling, redness and blisters since his knee replacement surgery several days prior. On exam, the patient was found to have swelling, erythema and warmth to the right knee. The patient had blistering at the edges of the dressing. The patient was found to have a large joint effusion. The patient's bloodwork showed ESR of 38 and CRP of 14.05. The patient was admitted with a diagnosis of postoperative infection. The patient was evaluated by orthopedics who reported no evidence of dehiscence, drainage or blisters around the incision. The patient's dressing was changed and knee immobilizer was placed by orthopedics. The patient was then diagnosed to have a hypersensitivity reaction to the dressing; no surgery was recommended. The patient left the hospital against medical advice later that day.

Based on the review of the medical record, the patient's workup in the ER was not suspicious for infection. The patient's complaints, physical findings, laboratory results, and diagnosis were most consistent with hypersensitivity reaction to the tape. The patient's vitals were stable and his bloodwork was unremarkable for clinical signs of infection. The patient's physical findings and x-rays that showed no evidence of an acute process indicated that the patient's clinical symptoms were most consistent with post-surgical total knee replacement (TKR). The patient's management required orthopedic evaluation with replacement of dressing and knee mobilizer. However, the level of service would not be considered extensive or complex that would require inpatient level of care. The patient could have received this care in the Emergency Room (ER) with safe discharge home with continuation of care as outpatient. Based on the review of the medical records provided and the literature, this patient did not have extenuating circumstances to substantiate the acute level of care provided at the inpatient status. Thus, inpatient admission was not medically necessary to treat this patient's medical condition.

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

The carrier's denial of coverage for the inpatient hospital stay is upheld. The medical necessity is not substantiated.