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

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

This is the case of a young male with autism and seasonal allergies who presented to the emergency department (ED) after a brief generalized tonic-clonic seizure. The patient was given rectal diazepam and transported to the ED by Emergency Medical Services (EMS); the seizure lasted < (less than) 5 minutes. The patient had 1 prior lifetime seizure approximately 1 month prior. There is a family history of epilepsy.

Based on the medical documentation provided, the inpatient hospital admission was not medically necessary for this patient. This young male presented with a second lifetime afebrile generalized seizure which self-resolved in less than 5 minutes. This child was otherwise healthy and medically stable. His care could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diverticulitis/colon surgery. 
Treatment: Personal Care Aide (PCA) Level 2: 4 hours per day - 5 day(s) per week  a total of 20 hours per week. 
The insurer denied Personal Care Aide (PCA) Level 2: 4 hours per day - 5 day(s) per week  a total of 20 hours per week. 
The health plan's determination is overturned. 

This is a case review for a male with medical history notable for diverticulitis, status/post (s/p) colon surgery with resultant colostomy, and mobility issues. The patient and his care team requested Personal Care Aide (PCA) Services: 20 Hours per Week. 

The patient's physician provided a letter of support for this appeal. The letter states that when he switched from short term to long term care, the frequency and duration of his visits declined. He now receives nursing visits two days per week (instead of three) and has a home attendant for 3 hours per day (instead of 4). He states that the patient "finds that that is insufficient to accompany him to his many appointments and still help with all activities of daily living (ADL) like shopping, cleaning, and cooking that he needs help with." 

Personal Care Aide (PCA) Services: 20 Hours per Week is medically necessary for this patient. 

The patient has documented unmet personal care needs. He has frequent medical visits and requires assistance with transportation, which has been utilizing the majority of his personal care hours and leaving other Instrumental activities of daily living (IADL) unattended. The task tool recommends 17.5 hours per day, and he is currently not even receiving that many hours. The requested increase is therefore medically necessary and reasonable for the patient. Failure to address his personal care needs could result in further adverse health outcomes.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Malocclusion.
Treatment:  Braces and monthly visits.

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

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, dental treatment noted, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified overjet, overbite, open bite, posterior unilateral crossbite, and anterior crowding among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index, attaining 31 total points. The insurer has denied coverage for orthodontic treatment as not medically necessary, as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements, attaining only 24 points on the HLD index by internal reviewers. 
 
Upon review of the submitted documentation (study models were not provided for review), 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, New York State requires, as of September 1, 2012, the use of an orthodontic index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after HLD index. 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 completes the second portion of the index arriving at 31 points to justify orthodontic care. This reviewer concurs with the index completed by the orthodontist, which remains above the threshold of 26 points to support orthodontic care.

Regarding the validity of the HLD index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. 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. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. 

The medical necessity for braces and monthly visits is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Biliary colic
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This patient is an adult male with biliary colic. The patient was unable to tolerate food over a two to three day period of time. The patient came to the emergency room and was found to have gall stones with no evidence of cholecystitis. His white cell count was normal. His allergies were normal. The patient was hemodynamically stable. He was admitted and underwent robotic assisted cholecystectomy. He was discharged.

The requested health service was not medically necessary.

The documentation indicates this patient had biliary colic, not acute cholecystitis. There was no evidence of sepsis or other life-threatening symptoms. The patient had a normal white cell count, 
normal vital signs, and an ultrasound that demonstrated gallstones. The patient underwent uneventful cholecystectomy and was discharged. Inpatient admission was not medically necessary given that there were no indications meeting criteria including electrolyte derangement, ongoing medical care issues, and/or complications from surgery. Therefore, the requested health service was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status Post (s/p) Fall and Seizure
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is overturned.

The patient is a teenage male. He presented to the emergency room after a witnessed seizure leading to a fall and temporomandibular joint (TMJ) fracture. He was noted to be altered and uncooperative. He was admitted for seizure workup and management, including electroencephalogram (EEG) and imaging. The inpatient admission was denied coverage by the health plan as not medically necessary. The denial is being appealed.

The inpatient admission was medically necessary.

Inpatient admission was medically necessary. At the time of admission, the patient was uncooperative and with altered mental status. Since he was not back to his neurologic baseline, inpatient admission was warranted for electroencephalogram (EEG) monitoring. Non-convulsive status epilepticus could not be ruled out without this. Non-convulsive status epilepticus can lead to significant morbidity and mortality and discharging someone with status epilepticus deviates from the standard of care. Therefore, the inpatient admission was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fever, Chest Discomfort (Pneumonia)
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

This patient is an adult female with right-sided chest pain for one day who presented to the emergency room for evaluation. The patient also had a fever, cough, and shortness of breath. In the emergency room, the patient was treated for asthma exacerbation as well as pneumonia with intravenous antibiotics, intravenous steroids, Duonebs, and intravenous fluids. The patient was admitted to acute hospitalization for the management of pneumonia after labs revealed leukocytosis and pneumonia. The patient was continued on intravenous fluids, intravenous antibiotics, and intravenous steroids. The patient left against medical advice on the next day. The acute hospitalization was denied due to lack of medical necessity. This denial is being appealed.

The requested health service was medically necessary.

The patient presented to the emergency room with chest pain and was found to have asthma exacerbation, and sepsis due to pneumonia with acute renal failure. The patient's CURB-65 (confusion, uremia, respiratory rate, blood pressure, age greater than or equal to 65 years) score was two, which has a 6.8% 30-day mortality. Given the patient also has a history of drug abuse and severe leukocytosis with fevers, the acute in-hospital level of care is medically necessary by the current standard of clinical practice. A lower level of care would not be safe and effective in treating this patient's multiple active issues.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Plaque Psoriasis

Treatment: Skyrizi 150 mg (milligrams) /ml (milliliter) pen injector

The insurer denied coverage for Skyrizi 150 mg (milligrams) /ml (milliliter) pen injector

The denial is upheld 

The patient is an adult male with a diagnosis of psoriasis.  The patient has failed therapy with topical tacrolimus, fluocinonide, clobetasol, and ketoconazole.  The request is for Skyrizi.

Based on the provided documentation, the use of Skyrizi is not medically necessary.  The patient has failed only topical therapies.  There is no documentation of absolute contraindications which would make the use of Skyrizi medically necessary over other first line alternatives.  There are no comparative, controlled head-to-head studies showing that Skyrizi has a superior efficacy or safety profile to all the alternatives such as methotrexate or Humira.  According to the American Academy of Dermatology Psoriasis Guidelines and dermatology literature alternative effective treatments for the management of psoriasis are available and appropriate for this patient (1,2,6).   West et al 2016 conducted a review of eleven comparative, controlled studies that passed a Cochrane risk of bias analysis (5).  They concluded that methotrexate achieved significant improvement in reducing psoriasis plaques.  Methotrexate is a preferred treatment, and based on data analysis, 45.2 percent (%) [95% confidence interval 34.160.0] of patients achieve Psoriasis Area and Severity Index (PASI75) at primary endpoint, Thus, methotrexate is an effective first-line treatment for the management of psoriasis (5).

Lanna et al (7) discuss the safety and efficacy of Humira in the treatment of psoriasis vulgaris.  As such, the health care plan acted reasonably in denying Skyrizi for this patient as numerous alternative options exist in the treatment of the patient's condition. The provided medical notes do not provide any evidence of an absolute contraindication for the use of available therapies or unique clinical situation which would specifically warrant Skyrizi.  

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Skyrizi 150 milligrams (mg)/milliliters (ml) pen injector is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Renal Failure
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

This patient is an adult male with a history of diabetes mellitus type 2 (two), gastritis, tobacco use, alcohol dependence, and hypertension who presented via ambulance to the Emergency Department (ED) for an emergency evaluation due to diarrhea, cough, and vomiting multiple times. The patient's initial vital signs were reported as a blood pressure of 182/82 mmHg (millimeters of mercury), a temperature of 99.1, a pulse of 98 beats per minute, a respiratory rate of 19 breaths per minute, and an oxygen saturation of 98% (percent) on room air. On examination, the patient was evidenced to have generalized abdominal tenderness. Initial laboratory studies were remarkable for a low venous pH (potential hydrogen) of 6.93, an elevated venous pCO2 (partial pressure of carbon dioxide) of 56.7, an elevated high-sensitivity Troponin level of 39.2 pg/mL (picograms per milliliter), an elevated white blood cell count of 11.7 10x3/uL, a hemoglobin of 11.7 g/dL (grams per deciliter), a blood urea nitrogen of 53 mg/dL (milligrams per deciliter), an elevated anion gap of 14 mEq/L (milliequivalents per liter), an elevated creatinine of 4.4 mg/dL, and an elevated potassium of 5.7 mEq/L. The patient required acute inpatient care for the management of acute kidney injury and metabolic acidosis. The patient was treated for renal failure due to poor oral intake, intractable vomiting, and pancreatitis. Per a progress note, the patient's creatinine continued to be elevated at a level of 5.2. The patient additionally presented with low calcium and high phosphorus. The patient was noted to be on a pureed diet. On day #4 and day #5, there were no acute events noted. The request for coverage of the inpatient hospital admission is under review. 

The requested health service of an Inpatient Hospital Admission is considered medically necessary. 

This patient had an acute kidney injury, secondary to dehydration due to nausea and vomiting. The patient's acute kidney injury required close monitoring of the patient's creatinine and 
electrolyte levels. The patient additionally required treatment with intravenous fluids. As such, the requested health service would be considered medically necessary for this patient, as he required additional treatment for his condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Benign prostatic hypertrophy. 
Treatment: Inpatient Hospital Admission. 
The insurer denied the inpatient hospital admission. 
The denial is upheld. 

The patient is an adult male with a history of hypertension, coronary artery disease (CAD), transient ischemic attack (TIA), and benign prostatic hypertrophy (BPH) who presented for a robotic assisted enucleation of the prostate. Postoperatively, the patient was monitored on an inpatient status. There were no intraoperative or postoperative complications. His bowel function returned on postoperative day 2 and his hematuria resolved by postoperative day 3. The patient was discharged home on day 4. Medical necessity for inpatient stay is under review. 

The requested health service was not medically necessary. 

The majority of patients who undergo robotic enucleation of prostate can be discharged within 24 hours of the procedure. This procedure was an elective scheduled procedure. The patient did not have any significant risk factors that increase risk of postoperative complications. His postoperative course was essentially normal without any significant complications or issues with pain control. Observation status for this patient's clinical presentation and postoperative course was the safe, effective, generally accepted standard and the most appropriate treatment option. Admission status may be changed any time during observation if the patient requires continuing services and monitoring, and if the patient's condition is severe enough to require inpatient treatment. Therefore, the requested health service was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope. 
Treatment: Inpatient services. 
The insurer denied the inpatient services. 
The denial is upheld. 

This is an adult female patient with syncope at work. She has a history of anxiety, hyperlipidemia, and gastroesophageal reflux disease (GERD). She also has a history of a normal echocardiogram. Symptoms included palpitations, dizziness, and shakiness. Exam showed presence of hypertension with blood pressure at 154/89 and pulse 84. No neurologic findings were noted. Computed tomography (CT) was negative. No arrhythmias were noted; she was admitted to telemetry to rule out arrhythmia. Labs were unremarkable. A repeat echocardiogram was normal. No further symptoms were documented. There were no arrhythmias. All tests were negative. The patient was discharged without change in medications. 

The requested health service was not medically necessary. 

Determination of level of care is primarily dependent on the actual care a patient receives and whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results; and highlighted in the orders for care. In this case, the symptoms were atypical and unlikely to be representative of acute coronary syndrome, valvular heart disease or central nervous system. Exam and cardiac findings were normal. Biomarkers and electrocardiogram showed no evidence of acute ischemia. Chest x-ray was normal. Computed tomography was negative. Echocardiogram showed no wall motion abnormality and was normal. The physicians' treatment did not reflect any serious concern about the patient's cardiac condition. Orders did not include medical therapy for an acute event or arrhythmia. The only care provided was telemetry and observation. These interventions did not require an inpatient level of care. The letter of appeal was carefully considered, but it offered no evidence to support inpatient level of care. The only cardiac care provided was telemetry, frequently performed in a lower level of care. The patient was admitted for monitoring and subsequent tests and therapy that did not require an inpatient level of care. There was no complex care that required inpatient care. While there is always a potential for an adverse event (and in this case a low probability), one did not happen, and no actual treatment was added. There are no examples of care requiring inpatient level of care. Milliman criteria requirements for inpatient admission for syncope were not fulfilled. Since all testing and therapy would be appropriate, safe and guidelines consistent in a lower level of care, inpatient level of care was not medically necessary. The denial explanation was consistent with guidelines and usual community care. The requested health service was not medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Skin Disorders Acne
Treatment: Pharmacy /Prescription Drugs-0.08% Retin-A Micro Gel 
The health plan denied the request for an exception for the non-formulary medication 0.08% Retin-A Micro Gel. The reviewer has upheld in whole the health plan's determination. 

The patient has acne vulgaris. The patient has tried topical clindamycin in the past and is currently being treated with oral spironolactone and 0.08% Retin-A Micro Gel.

The formulary drug(s) will not be ineffective for this patient.
The patient has no documented treatment failure with, or true medical contraindication to, alternative topical retinoids such as topical adapalene gel, generic tretinoin gel microsphere, or generic tazarotene cream, or Aklief (trifarotene) cream. Alternative formulary treatments include topical and oral antibiotics, or Winlevi cream.
Current medical literature and standards of care support use of these topical retinoids, and/or other formulary topical and oral acne medications as much as the requested topical Retin-A Micro Gel, 0.08%. Accordingly, the requested Retin-A Micro Gel, 0.08% is not considered more effective than the formulary alternative drugs.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting, diaphoresis, and generalized abdominal pain
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is an adult male. He presented to the emergency department with vomiting, diaphoresis, and generalized abdominal pain. The patient used marijuana on a daily basis. The patient underwent esophagogastroduodenoscopy (EGD) and colonoscopy without any significant findings. Computed tomography (CT) of the abdomen / pelvis showed generalized cecal and pan colonic wall thickening. White blood cell (WBC) count was 10.5 and lactate was 2.23. The patient was treated with intravenous fluids and Morphine intravenous. The patient was kept nothing by mouth (NPO). During the hospitalization, gastrointestinal was consulted and stated that pancolitis was doubtful given no diarrhea. The patient was able to tolerate oral intake. The patient had no further vomiting or pain. On hospital day #2, the patient was discharged.

The Inpatient admission was not medically necessary.

The patient did not have hemodynamic instability, severe pain requiring acute inpatient management, or peritoneal signs. The patient did not require identification of etiology or finding or evaluation requiring the patient to not eat or drink for extended period (e.g., more than 24 hours). The patient did not have inability to maintain oral hydration (e.g., needs intravenous fluid support) that persists after observation care and did not have suspected toxic megacolon. The patient did not have bacteremia. The patient did not require a procedure that could not have been performed on ambulatory basis. Therefore, the inpatient admission was not medically necessary.