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

Diagnosis: High blood sugar. 
Treatment: Inpatient admission. 

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

This is a male patient. 

The patient has a history of type I diabetes complicated by multiple prior ICU admissions for diabetic ketoacidosis, ADHD and asthma. The patient was brought by medics for worsening nausea, vomiting, abdominal pain, lightheadedness, with a glucose at home in the 500s. The patient admitted to nonadherence with outpatient medications due to running out of insulin. Pulse was 138. Respiratory rate was 21. Blood pressure was 98 /63 Mucous membranes were dry. His abdomen was tender. PH was 7.51. Potassium was 2.7. Phosphate was 1.6. Magnesium was 1.1. All were low. Glucose was 251. Beta hydroxybutyrate was 1.99. 

In the emergency department, the patient was treated with intravenous fluids, magnesium, phosphorus, potassium. The patient's mother reported that she was unable to pay for his medications because his insurance was not active. 

A note reports that the patient was on fluids. Glucoses overnight were reported to be in the 500s. The morning potassium was still low at 2.9 as were the magnesium and phosphorus. He continued on Lantus and Humalog. The Lantus dose was increased. IV fluids were continued for hypokalemia, low magnesium and phosphorus. Magnesium, potassium, phosphorus were also supplemented separately. 

A reports that the blood sugars have been trending down in that his appetite is good. His potassium was still low at 2.9. Phosphorus was normal. Magnesium was still low at 1.3. IV fluids with potassium were continued. Potassium phosphorus and magnesium were supplemented. His Lantus was increased to 30 units. Given the continued electrolyte abnormalities the patient was supplemented, and labs were to be drawn.
The potassium normalized to 3.7. Magnesium remained low at 1.3. 

The patient was deemed safe for discharge. 

Yes. Acute inpatient admission for patients with symptomatic diabetes is necessary when the patient has evidence of ketoacidosis or a hyperosmolar state [1], [2], [3], [4], [5], [6] or ketosis with other findings requiring inpatient admission [7], [8], [9]. The patient presented with severe hyperglycemia, vomiting, ketosis and severe electrolyte abnormalities with hypokalemia hypo-magazine and hypophosphatemia. Discharge from the emergency room would have been unsafe. 

Inpatient treatment to clearly ketones and to replete the electrolyte abnormalities was necessary. The patient continued to have severe hypokalemia until the day of discharge. The patient hypokalemia was appropriately treated. The patient was unsafe for discharge. The requested acute inpatient admission was medically necessary in its entirety with discharge.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Appendicitis.  
Treatment:  Inpatient hospital admission.

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

This is a patient who presented to the Emergency Department with complaints of abdominal pain.  The patient reported that he had constant and moderate abdominal pain with loose bowel movements in the morning.  The physical examination revealed right lower quadrant abdominal tenderness and suprapubic region tenderness to palpation with no rebound or guarding.  The white blood cell count was 15.5.  CT scan of the abdomen and pelvis revealed acute appendicitis.  The patient decided to undergo non-surgical management and was treated with intravenous (IV) fluids, IV antibiotics, and pain medications.  The patient was discharged with follow-up for appendectomy planning with the general surgeon.

The length of hospital stay for this patient is consistent with what is seen in most studies on patients with uncomplicated appendicitis treated non-operatively.  Intravenous (IV) antibiotics is generally recommended for 3 days, typically on an inpatient basis, then followed by 7 days of oral antibiotics on an outpatient basis if patient responds to IV antibiotics.  Discharge criteria for patients with uncomplicated appendicitis treated non-operatively is antibiotics, control of pain with oral analgesics, and resolution of fever.  This patient had fever up to 102.  Another criteria that has been looked at for discharge is that the patient tolerates their diet (3).   He was started on clear diet in the morning, and his diet was advanced that evening.  Discharge the following day is reasonable, as it allowed for 24 hours of being afebrile, insured that he tolerated diet, and also that his WBC was improving.

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 is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Migraines.

Treatment: Botox.

The insurer denied coverage for Botox.

The denial is overturned.

This is a female patient with chronic migraines. At an office visit, the patient reported that her migraines had worsened since her last visit. The patient had tried a myriad of medications, including non-steroidal anti-inflammatory drugs (NSAIDs), Fioricet, Imitrex, and Maxalt with minimal control. The patient reported having migraines almost on a daily basis. Her physicians requested a pre-authorization of Botox for her migraines.  

A Cochrane review of 28 trials found that Botox reduced the frequency of migraines in patients with chronic migraines. They concluded that "In chronic migraine, botulinum toxin reduces migraine frequency by 2 days/month and has a favorable safety profile."

Botox is FDA approved for migraines and is appropriate and medically necessary for this patient. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The medical necessity for Botox is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Withdrawal, Alcohol Intoxication Delirium.

Treatment: inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is overturned.

This is a male patient who was admitted for inpatient treatment of alcohol detoxification. The patient had alcohol withdrawal symptoms, including tremors, nausea and vomiting, and elevated blood pressures. He was given intravenous (IV) Ativan and was put on a Librium protocol for detoxification from alcohol. He was treated and discharged after 3 days of inpatient stay.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that patients who fail to achieve abstinence, relapse frequently, fail to cooperate with or benefit from outpatient detoxification, have current abuse of other substances with very heavy use or tolerance that places them at high risk for complicated withdrawal, are candidates for inpatient detoxification treatment. In this case, this patient had active alcohol withdrawal symptoms and elevated blood pressures. 

The patient's comorbid medical condition of hypertension put him at risk medically as he continued to have elevated blood pressures in the setting of alcohol withdrawal, and required stabilization. According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient was at high-risk for complicated and life-threatening withdrawal symptoms and therefore required 24-hour treatment as he could not safely and effectively be treated in a less restrictive detoxification setting.

The patient presented with active withdrawal symptoms that required two detoxification medications to stabilize his withdrawal symptoms. He was at risk for worsened withdrawal symptoms. The patient's risk of life complicated withdrawal such as delirium tremens can occur 4 days after alcohol use. The patient used large amounts of alcohol and required the entire time of inpatient stay in this hospital detoxification setting.

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 inpatient admission is substantiated.  The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, macular degeneration with legal blindness, schizoaffective disorder and congestive heart failure
Treatment: Increase in PCW service to seven days/week, 12 hours/day - 84 hours/week 
The insurer denied the Increase in PCW service to seven days/week, 12 hours/day - 84 hours/week.
The denial is overturned.

The patient is a female with a history of dementia, macular degeneration with legal blindness, schizoaffective disorder and congestive heart failure. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Appeal review requested for potential approval of 84 hours/week personal assistance (PCW) services to offer increased ADL support.

Yes, the proposed treatment of 84 hours/week personal assistance services is deemed medically necessary. 

This is a female with a history of dementia, macular degeneration with legal blindness, schizoaffective disorder and congestive heart failure. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Recent documentation from the patient's physician indicates that due to the patient's progressive functional decline, she has limited judgement and poor executive functioning making her fully dependent on the support of a caregiver for completion of all ADLs. Due to her poor vision, poor balance, increased fall risk and urge incontinence, she requires assistance with diaper changes and clothing changes. Lastly, due to the patient's poor vision and executive functioning, she is unable to warm up precooked meals on her own without significant safety concerns. For these reasons, the currently approved plan of 42 hours/week personal assistance services is no longer sufficient to meet the patient's current needs. Hence, the proposed treatment 84 hours/week personal assistance services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: PCW services 12 hours x 2 (split shift), 7 days per week
The insurer denied the PCW services 12 hours x 2 (split shift), 7 days per week. 
The denial is overturned. 

The patient is a male with a history of advanced dementia, stroke with cognitive deficits, left sided hemiplegia and gait ataxia. Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs). An appeal review was requested for potential approval of 12 hours x 2 (split shift), 7 days per week Personal Assistance Services to offer increased ADL support.

Yes, the PCW services 12 hours x 2 (split shift), 7 days per week is deemed medically necessary. 

The patient is a male with a history of advanced dementia, stroke with cognitive deficits, left sided hemiplegia and gait ataxia. 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 patient's Primary Care Provider indicates that due to worsening cognitive impairment, gait ataxia and muscle weakness, the patient's overall functionality and ability to perform ADLs has dramatically worsened. Specifically, he requires multiple daytime and nighttime diaper changes and assistance with toileting/bed mobility to prevent pressure ulcer development. For these reasons, the currently approved plan of 24 hours per day (Live in) 7 days per week Personal Assistance Services is not sufficient to meet the patient's current needs due to the requirement to allow for designated sleep hours for the live-in home health aide.  During those designated sleep hours, the patient is at high risk for falls, aspiration and being left in soiled diapers for prolonged periods of time which would dramatically increase the risk of skin breakdown/ulcer development. Hence, the proposed treatment of 12 hours x 2 (split shift), 7 days per week Personal Assistance Services is deemed medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

This is a female patient with a history of cluster headaches.  It was reported that she had been headache free for four years, but then started experiencing them again.  She has tried multiple treatments including verapamil up to 960mg, Bosweillia, Magnesium, Imitrex, triple dose Ajovy.  Her treating neurologist recommended intravenous ketamine. It was reported that she had improved with ketamine treatments.
There are several studies and case reports documenting cluster headache response to IV ketamine (1-5).  Because cluster headaches are so rare, larger clinical trials would be difficult. 
  
This patient is a good candidate for intravenous ketamine for cluster headaches.   No other treatment was effective.

Intravenous guanethidine, ketamine for cluster headaches is the best available treatment for this patient at this time.  There were no other treatment options.

IV ketamine is likely to be more beneficial than any of the standard treatments/procedures for this patient.  It was, in fact, effective when no other treatments were.  

The carrier's denial of coverage for intravenous ketamine for cluster headaches should be reversed.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Cluster Headaches
 
Treatment:  Intravenous Ketamine

The insurer denied the Intravenous Ketamine.  The denial was reversed. 

This is a female patient with a history of cluster headaches.  It was reported that the patient had 4 headache attacks in one week.  The patient reported not being certain of the current medication had helped because she had simultaneously increased her Verapamil at the same time.  Her current medication regimen included included verapamil, sumatriptan succinate, amlodipine besylate, Imitrex and cyanocobalamin.  She received Emgality injection and ketamine injections to treat her cluster headaches.

Ketamine has not been evaluated in a double-blinded, placebo-controlled study for the treatment of cluster-migraine headaches.  There are small, case studies/observational studies of Ketamine for cluster headaches.  Therefore, the scientific and peer-reviewed literature does not support an improvement of health outcomes for cluster headaches.  Ketamine does not have final approval from the appropriate regulatory bodies for the diagnosis of cluster headaches.  The patient is not a good candidate for intravenous ketamine for cluster headaches.  Ketamine has not been evaluated in a double-blinded, placebo-controlled study for the treatment of cluster-migraine headaches.  Intravenous Ketamine is not the best available treatment for this patient at this time.  There are a wide variety of abortive and prophylactic approaches with better clinical validation against cluster migraine headaches.  Ketamine has not been evaluated in a double-blinded, placebo-controlled study for the treatment of cluster-migraine headaches.  

The requested service is not more likely to be more beneficial than any standard treatment/procedure for the patent.  There are a wide variety of agents and therapies to help with the abortive and prophylactic therapy of cluster headaches with much stronger validated clinical support than Ketamine.

The carrier's denial of coverage for intravenous guanethidine, ketamine for cluster headaches should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Digestive System/Gastrointestinal
Inpatient Hospital

Diagnosis: Abdominal Pain
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a man who presented to the hospital. He had a history of chronic liver disease and deep vein thrombosis (DVT) on anticoagulation, and he presented with abdominal distention. He was diagnosed with liver cirrhosis two months prior to presentation and had been prescribed Lasix and Spironolactone. He denied fevers and chills and he also denied nausea and vomiting. Other past medical history included chronic alcohol abuse. He stated that his last alcoholic drink was two months ago. 

The inpatient hospital stay was not medically necessary. The patient did need medical care for his decompensated chronic liver disease with ascites but could have been safely and effectively cared for in the hospital at a lower level of care. This is because he was not acutely unstable, did not have evidence of infection or spontaneous bacterial peritonitis (SBP) or sepsis, did not have acute bleeding, and did not have other significant acute complications of chronic liver disease such as encephalopathy and hepatorenal syndrome.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Uterine fibroids and abnormal bleeding 
Treatment: Inpatient admission 

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

The patient is a female with a diagnosis of uterine fibroids and abnormal bleeding. The patient underwent a robotically assisted laparoscopic total hysterectomy with bilateral salpingo-oophorectomy and cystoscopy. Because of pelvic adhesions, lysis of adhesions was performed. Estimated blood loss was 150 cubic centimeters (cc). 

The post-operative progress note stated that the patient was stable. Progress note showed that the patient was resting comfortably. Her pain was well controlled. She was tolerating oral intake. She was discharged later that day. 

No, the proposed inpatient admission was not medically necessary. 

There are many ways of doing a hysterectomy. The trend has been towards less invasive procedures. Conventional and robotic laparoscopy share similar advantages over laparotomy, including decreased morbidity, rapid recovery, and improved aesthetics of incisions. Robotic assisted laparoscopic hysterectomies are outpatient procedures unless a complication arises. Admission becomes necessary if the patient is febrile, hypotensive, bleeding, has difficulty breathing or the severity of the pain is such that admission is necessary. 

According to the standard of care, inpatient stay may be needed for: 1) Surgical complications (bladder ureter or bowel injury or hemorrhage) 2) Conversion to abdominal surgery 3) Wound complications 4) Comorbidities. 

This patient did not have any of these criteria. Her procedure was uncomplicated. There was no evidence of any injury to other organs. Postoperatively, the patient was stable. Nothing in the operative report or the progress notes suggested any serious problem that warranted admission. Please note that a robotic hysterectomy is an outpatient procedure and includes appropriate postoperative monitoring and an overnight stay if required. 

Based on the above, inpatient hospital stay was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overbite 
Treatment: Braces 

The insurer denied the braces. The denial is overturned. 

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

Yes, the proposed braces are medically necessary. 

The patient has a deep, impinging overbite causing severe soft tissue damage to his palatal tissue. This is an automatic qualifier according to the handicapping index scale. Orthodontic treatment is medically necessary to correct this problem.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Skeletal Class I, Class II canines, maxillary and mandibular crowding, excessive overjet and anterior crossbite with gingival attachment loss (mandibular lateral incisor).
Treatment:  D8080 braces and D8670 monthly visits.

The insurer is denied coverage for D8080 braces and D8670 monthly visits.  The denial is overturned. 

This is a patient presented for evaluation for orthodontic care.  A diagnostic evaluation was 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, Class II canines, maxillary and mandibular crowding, excessive overjet and anterior crossbite with gingival attachment loss (mandibular lateral incisor).  The orthodontist has completed the handicapping labio-lingual deviation (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 Labio-Lingual Deviation Index is utilized.  This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are considered 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 claimed 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 review of the clinical documentation, this automatically qualifying condition criterion is met for this patient and does support for comprehensive orthodontic care for this patient.

The requested D8080 braces and D8670 monthly visits are considered medically necessary for this patient.

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 D8080 braces and D8670 monthly visit should be overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis. 
Treatment: Inpatient admission. 

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

This is a female patient with a history of asthma and low back surgeries. She presented to the emergency department with complaints of abdominal pain. She was referred from urgent care to evaluate for appendicitis. The physical examination revealed she was in no apparent distress. The patient had diffuse tenderness to the abdomen. She refused a pelvic examination and it was recommended she undergo laboratory and diagnostic studies. The laboratory studies revealed she was hemodynamically stable. A computed tomography scan of the abdomen was performed that revealed a 7 mm tip of appendix.  The patient was admitted for further observation. The patient was treated with intravenous medications and she was maintained nothing by mouth. The patient was discharged the following day with instruction to follow up. 

The patient presented with acute abdominal pain and imaging showed a possibility of early acute appendicitis. No perforation or complications were noted. No clinical instability was documented. The patient did not have any significant co-morbidities placing her at a high-risk needing care at a higher level. In this setting, the appropriate course of action would be to admit under observation and decide on the course of action based on her clinical condition over the 24 hours of observation. Inpatient admission was not necessary based on the information documented. 

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 admission for acute level of care was not substantiated. The insurer's denial is upheld.