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

Diagnosis: Schizophrenia.
Treatment: Inpatient admission from inpatient behavioral health admission.
The insurer is denied coverage for inpatient behavioral health admission.
The denial is overturned.

This is a male patient who was admitted to the hospital for mental health treatment in this hospital due to psychotic symptoms. His symptoms included auditory and visual hallucinations threatening to kill him, paranoid delusions including thinking that parasites were in his brain and that he had to drink distilled water as a result to clean them up, internal preoccupation, thought blocking, irritable mood, circumstantial thinking, poor sleep, poor activities of daily living (ADL), loud speech, poor impulse control, and past aggression. He had a history of Schizophrenia with multiple past psychiatric hospitalizations. He reported smoking cannabis daily. He reportedly took Seroquel, Trazodone, and Neurontin. After a period of medically he was discharged.

The APA Practice Guidelines for the Treatment of Patients with Schizophrenia reports that patients with hallucinations, delusional thinking, disorganized thinking or behavior, severe agitation, aggression, or inability to care for basic needs are in need of hospital treatment. In this case she still had reports of psychotic symptoms including paranoid delusional thinking during the denial period as notes reported paranoid delusions including still thinking the parasite was in his body. He reportedly also had auditory hallucinations, was responding to internal stimuli, and he had Seroquel and Gabapentin increased that day to better target these symptoms. He was discharged the next day. He had active psychotic symptoms still interfering with his functioning which required acute hospital treatment as he was not considered safe outside of this setting then. He also was considered a high risk for decompensation and worsening of his psychotic symptoms if discharged prematurely. As a result, the recommendation is to reverse the previous decision and approve coverage for continued inpatient mental health treatment in this hospital as he was discharged. It did not appear that the health care plan acted reasonably, with sound clinical judgment, or in the best interests of the patient then.

Based on the above, the medical necessity for the inpatient admission from inpatient behavioral health stay is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

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

This is a female patient with a history of congestive heart failure (CHF), nonischemic cardiomyopathy, hypertension, asthma, eczema, chronic back pain with sciatica, homelessness, and tobacco abuse. She presented to the Emergency Department with a complaint of intermittent, dull, persistent severe chest pressure after an altercation at the homeless shelter. Vital signs were stable. Initial troponin was 0.11, and brain natriuretic peptide was 152. Electrocardiogram (ECG) was performed that revealed sinus rhythm with left anterior fascicular block, septal infarct, T wave abnormality, consider lateral ischemia. The patient was admitted for further management of chest pain. The patient underwent cardiac catheterization, which demonstrated non-occlusive coronary artery disease. She was ruled out for myocardial infarction with negative cardiac biomarkers. After treatment and once medically stable, the patient was cleared for discharged to the shelter with follow-up.

The patient presented with chest pain. The initial evaluation in the Emergency Room (ER) was unremarkable, including non-diagnostic EKG and cardiac biomarkers. Inpatient admission was not medically necessary for this patient. The patient's care could have been provided in the observational setting, allowing for additional diagnostic testing. Further evaluation was warranted, however inpatient admission criteria was not met. There was no hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions warranting acute inpatient level of care. The observational level of care would have been appropriate.

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

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

Diagnosis: Fibroid Uterus

Treatment: Continued inpatient admission
 
The insurer denied the continued inpatient admission.

The denial was upheld.

This is a female patient with a history of symptomatic fibroid uterus. She was admitted to the hospital for an elective robotic-assisted laparoscopic total hysterectomy with bilateral salpingectomy.  She underwent the procedure with no complications. The patient reported dizziness after ambulating with a noted blood pressure of 86/57.  A bolus of intravenous (IV) fluids was given. A repeat blood pressure was 101/69.  Per a Gynecology note the patient was tolerating a clear diet.  Bloodwork revealed hemoglobin 10.5 and hematocrit 32.7.  The patient was medically stable and was discharged.

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.

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 Milliman Care Guidelines, Inpatient and Surgical Care, Laparoscopic Hysterectomy, a laparoscopic hysterectomy is an ambulatory procedure. Inpatient stay may be needed for:

1)	Surgical complications (bladder ureter or bowel injury or hemorrhage)
2)	Conversion to abdominal hysterectomy
3)	Complex surgery (staging of endometrial cancer)
4)	Wound complications
5)	Comorbidities.

This patient did not have any of these criteria. Her procedure was uncomplicated. There was no evidence of any injury to other organs. Post operatively, the patient was stable except for one episode of dizziness and hypotension that subsided following hydration. While she lost 600 cc of blood, there was no significant drop in her hematocrit.

Based on the above, the patient could have been dischBased on above, the inpatient hospital admission was medically necessary. However continuous admission was not.

The health care plan acted reasonably and with sound medical judgment and 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: Upheld

Diagnosis: Transient ischemic attack
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female with diabetes and stroke who presented to the emergency ward with lethargy, confusion and blurred vision. At presentation, the patient's neurological examination and computed tomography (CT) of the brain were normal and she was admitted for possible transient ischemic attack (TIA). 

No. The patient was admitted with possible TIA.  At presentation, the patient's neurological examination and computed tomography (CT) of the brain were normal. Current risk stratification guidelines do not support acute inpatient admission. The diagnostic studies, neurology consult, monitoring and treatment could have been safely and effectively treated at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Respiratory system/asthma.  
Treatment:  Inpatient hospital stay.

The insurer denied the inpatient hospital stay.  The denial is overturned in whole. 

The patient with a past medical history of intermittent asthma was brought in by his parent with the complaint of chest tightness for 2 days not relieved with albuterol at home.  The patient also had an associated runny nose and cough.  The patient had no vomiting or diarrhea and, no fever at home   The patient had normal by mouth (PO) intake and a normal urine output. 

Yes, the requested health service/treatment of the inpatient hospital admission was medically necessary for this patient.  This patient presented with complaints of shortness of breath and chest pain, which were not resolved after reasonable ER management. The patient was given multiple nebulizer treatments but persisted with symptoms and became hypoxic on room air requiring supplemental O2 to maintain saturations.  The patient's condition was such that the admitting physician placed him on frequent albuterol nebulization every 2 hours.  Such frequent nebulization requires close monitoring and frequent respiratory assessments.  Given persistence of the symptoms despite adequate and acceptable ER management, as well as his hypoxia that required supplemental O2, the inpatient stay was medically necessary for this patient, due to a past medical history of asthma in conjunction with hypoxia and pneumonia evident on chest X-ray, clinical progression of the disease process and/or worsening was a concern.  Surveillance as an inpatient is reasonable and medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Migraine headaches.

Treatment: Nurtec.

The insurer denied coverage for the medication Nurtec.

The denial is overturned.

This female patient has refractory chronic migraines.  The patient has tried many prophylactic and abortive medications.  Aimovig reduced headache frequency but the patient still needed abortive medication.  The patient has tried several triptan medications.  Axert was initially effective, but then became ineffective and caused worsened headache the next day.  The patient's headache specialist prescribed Nurtec for this patient. 

This medication was denied by the patient's insurance because alternative, preferred drug(s) were not tried. However, most of the suggested alternative drugs are triptans, and the patient has already tried three triptan medications in the past with little success. There is no evidence support and reason for this patient to try and fail every one of the insurer's preferred list of medication before transitioning to another medication with a different mechanism of action. (American Headache Society) Most of the other suggested alternative drugs are ergot-based.  Ergot-based drugs are associated with many side-effects and drug interactions, and according to a review by Antonaci et al (2016), "ergotamine can no longer be considered a drug of choice." Nurtec is an FDA-approved medication for the treatment of acute migraine with or without aura in adults shown to be effective in randomized trials.  Based on the review of the medical record and literature, Nurtec is 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 Nurtec should be overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Central Nervous System
Ambulance (including Air Ambulance)

Diagnosis: CVA
Treatment: Ambulance transport
The insurer denied the ambulance transport. The health plan's determination is upheld.

This is a female patient. Records provided indicate the patient sustained a stroke and was hospitalized for treatment of the stroke as well as weakness. The patient was then transferred via non-emergency ambulance from the hospital to a rehabilitation center. Coverage for the non-emergency ambulance transfer was denied as there was no documentation of the patient's clinical or functional status and no documentation that the patient was completely bed confined or had an unstable cardiac or pulmonary issue. There was no documentation of confusion or indication that special infection precautions were required during transport.

Under review is the non-emergency ambulance transportation from the hospital to a rehabilitation center.

The Non-Emergency Ambulance Transportation from the Hospital to a Rehabilitation Center was not medically necessary for this patient. Records provided indicate the patient sustained a stroke and had been treated in the hospital for approximately seven days. She was then transferred via non-emergency ambulance from the hospital to a rehabilitation center. There were no notes from the hospital showing the patient's condition at the time of transfer, only notes from the ambulance facility which note that the patient was able to ambulate with assistance and walked to the stretcher. The patient was not bedbound or any condition that suggests she would require ambulance transportation based on any other condition that suggests that other forms of transportation would not have sufficed. The patient was medically stable. There is no indication this patient could not have been safely transported by car or wheelchair van. The Non-Emergency Ambulance Transportation from the Hospital to a Rehabilitation Center was not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite.
Treatment: Braces.
The insurer denied the braces.
The denial is overturned.

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

Yes, the braces are medically necessary. 

The patient has an anterior crossbite (reverse bite) between teeth 7 and 27. There is clinical attachment (gum) loss on tooth #27. This is an automatic qualifying condition according to the handicapping index scale.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Migraines
Treatment: 200 units of Botox Injections every 10 weeks
The insurer denied the 200 units of Botox Injections every 10 weeks.
The denial is upheld. 

The patient is a female with chronic migraine headache disorders. She has tried and failed nadolol, topiramate, divalproex sodium and amitriptyline. She has experienced a reduction in headache frequency from seven days per week to three days per week. 

No, the requested Botox 200 units every 10 weeks are not medically necessary. 

Although the use of Botox for the treatment of chronic migraine headache would be considered appropriate in this clinical context, the dose and frequency are not consistent with standard of care, FDA labeling guidelines or clinical trials published in the peer reviewed medical literature. There are no high quality clinical trials supporting that increasing the dose of Botox beyond 155 units every 12 weeks improves outcomes for persons with migraine headache disorder.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Impacted tooth and overjet
Treatment: Comprehensive orthodontic treatment of the adolescent dentition (D8080) and periodontic orthodontic treatment visits (D8670)
The insurer denied the Comprehensive orthodontic treatment of the adolescent dentition (D8080) and periodontic orthodontic treatment visits (D8670).
The denial is overturned. 

The patient is a male.  The request is for orthodontic benefits as well as periodic treatment visits.

Yes, the proposed comprehensive orthodontic treatment of the adolescent dentition (D8080) and periodontic orthodontic treatment visits (D8670) are medically necessary. 

The patient has an impacted upper right permanent canine which is not indicated for extraction. The patient also has an overjet of more than nine millimeters. Both of these conditions are automatic qualifiers according to the handicapping index scale. Orthodontic treatment with periodic follow up visits are medically necessary to correct these problems.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin disorders/other  
Treatment: Pharmacy prescription drugs 
The insurer denied Xeljanz.
The denial is upheld in whole.

The patient is a male with axial psoriatic arthritis, and has had increasing spinal pains that are most severe in the mornings. The patient also has alopecia areata totalis. The patient has also been treated with Cyclosporine, Prednisone, and Celebrex, as well as intralesional Kenalog.
No, Xeljanz is not medically necessary for this patient.
Xeljanz is not proven to be safe for long-term use in the treatment of alopecia areata. Xeljanz is not proven to be reliably effective in the treatment of psoriatic arthritis without concurrent use of Disease-Modifying Anti-Rheumatic Drugs (such as Methotrexate, Sulfasalazine, or Leflunomide).
Furthermore, Xeljanz is only FDA-approved for use in psoriatic arthritis when concurrently used with Disease-Modifying Anti-Rheumatic Drugs such as Methotrexate, Sulfasalazine, and Leflunomide, and this calls into question the reliable efficacy of Xeljanz when used alone for the indication of psoriatic arthritis.
The same FDA approval did not occur for Xeljanz in the treatment of alopecia areata, where physical/functional impairment and overall health impacts are minimal to nonexistent despite the social/psychological impacts that can occur in some patients. The proper dosing, anticipated side effects and long-term outcomes are not known at this time for Xeljanz in the treatment of alopecia areata, as well as short-term and long-term safety risks of relevance to this patient's overall health. There are no large, randomized, controlled, prospective trials demonstrating and proving the safe and effective treatment of alopecia areata with a specific dosing of Xeljanz.
Therefore, as per the evidence-based literature, Xeljanz is acceptable only within the investigational setting and not medically necessary for less-monitored outpatient clinical use.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma
Treatment: Inpatient admission
The insurer denied Inpatient admission.
The denial is upheld.

The patient is an adult female with history of asthma. She presented to emergency room with wheezing and shortness of breath. 

The patient was found to be in mild asthma exacerbation. The patient received frequent nebulization treatment, as well as IV steroids in the emergency room, with improvement in her symptoms. The patient was admitted to acute in hospital level of care for frequent nebulizations, IV steroids, and peak flow monitoring.

The patient was in mild asthma exacerbation that improved with emergency room care. Since the patient had mild asthma exacerbation and she responded to the emergency room care, she could have been safely and effectively treated as an observation level of care. The acute in hospital level of admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pulmonary/Asthma
Treatment: Inpatient stay
The insurer denied the inpatient stay
The Denial is overturned

The health plan's determination of medical necessity is overturned in whole. The requested inpatient admission is considered medically necessary for this patient. This is a patient with known asthma and prior ICU admission (no intubation) who presented with acute asthma exacerbation The patient was given appropriate treatment in the ED, including steroids and 3 DuoNebs, was re-evaluated multiple times. The decision for admission was made 3 hours after treatment began, and after a 4th nebulized treatment (albuterol) was given. Per national evidence-based guidelines, this pediatric patient should be considered for admission due to the presence of residual symptoms after ED care. Estimates of lung function may not be feasible in children, and clinical signs and symptoms may be just as accurate predictors in the acute setting (see citation below, based on EPR3 evidence-based guidelines). Therefore, the continued degree of wheezing after 3 hours of appropriate ED intervention and reassessment supports the need for inpatient hospitalization due to asthma exacerbation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Choking.
Issue under review:  Inpatient admission.

The health plan denied Inpatient admission.  The health plan's denial is upheld.

The patient is a female toddler.  She presented after reported choking on a piece of bread.  There was a history of runny nose for two days.  EMT performed finger sweep and removed a piece of bread.  

The patient's vital signs were stable, and there was no respiratory distress after the child was calmed.  Oxygen saturation was at upper 80s to 99% on room air after the child stopped breath holding.  WBC (white blood count) was 29.9.  CXR (chest x-ray) reported no opaque foreign body. 

The patient was taken to the OR (operating room) and underwent a flexible bronchoscopy.  There was no pathology noted on bronchoscopy.  The patient was discharged home.  

Post bronchoscopy, the patient had no complications, and there was no degradation of the patient's condition.  There was no problem with PO (oral) intake post op, and no FBs (foreign bodies) were found.  Vital signs were stable.  Therefore, based on the information provided, the medical necessity of the inpatient admission cannot be confirmed as the patient's care could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Crossbite.
Treatment:  Braces and monthly visits.
The insurer denied Braces and monthly visits.  The denial is overturned.

The patient is a teen-aged female.  Tooth #7 is in crossbite with tooth #26 on the bottom.  This will cause trauma to both of them over time, with resulting fracturing and/or loosening of either tooth.  Orthodontic treatment and monthly follow up appointments are needed to correct the severe crowding this patient has and allow these teeth to be in proper alignment.  This will correct the crossbite and help prevent broken and loose teeth in the future.