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

Diagnosis: Respiratory System/Asthma/Exacerbation of Asthma
Treatment: Inpatient Hospital/inpatient hospital stay
The health plan denied the requested inpatient hospital stay as not medically necessary. The health plan's determination is upheld.

The patient is a male with a medical history of hypertension, gout arthritis, Vitamin D deficiency, chronic alcohol use, chronic obstructive pulmonary disease and asthma with a documented prior history of an intubation. He was admitted for an asthma exacerbation secondary to a COVID-19 infection with symptoms of shortness of breath, productive cough, wheezing, nasal congestion and a headache that began two days prior to admission. He was initially treated with a DuoNeb, intravenous Solumedrol 125 milligrams (mg) once, and Benadryl. He was subsequently treated for the asthma with Xopenex, Atrovent, Solumedrol and for the COVID-19 infection he was treated with Paxlovid.
At issue is the medical necessity for the inpatient hospital admission.

I uphold, in whole, the health plan's determination of medical necessity.

No, the requested health service/treatment of an inpatient hospital admission was not medically necessary for this patient.
Based upon the severity of illness and intensity of the required therapy, the inpatient level of care was not medically necessary. This patient with a medical history of hypertension, gout arthritis, Vitamin D deficiency, chronic alcohol use, chronic obstructive pulmonary disease and asthma with a documented prior history of an intubation was admitted for an asthma exacerbation secondary to a COVID-19 infection. He had symptoms of shortness of breath, productive cough, wheezing, nasal congestion and a headache that began two days prior to admission. In the emergency room, the patient was afebrile, hemodynamically stable, was in no acute distress, had an oxygen saturation of 100% on room air, but was in respiratory distress with generalized expiratory wheezing on chest auscultation. He was treated with DuoNebs, intravenous Solumedrol 125 mg once, and Benadryl. The patient was in no acute distress, he was alert and awake, hemodynamically stable, had a respiratory rate of 18 breaths per minute, had an oxygen saturation of 100% on room air and only had mild wheezing. He was treated for the asthma with Xopenex, Atrovent, Solumedrol and for the COVID-19 infection he was treated with Paxlovid. The patient did not have documented hypercapnia or documented hypoxemia (partial pressure of oxygen (PaO2)< 60 millimeters of mercury (mmHg)), he did not require any ventilatory support, he did not have a sustained respiratory rate >30 breaths per minute or sustained heart rate >140 beats per minute, he had no reported cyanosis or increased work of breathing and his chest x-ray did not demonstrate evidence for acute infiltrates, consolidations, pneumothorax, pleural effusions, or fractures. His asthma improved with the equivalent of an alternate level of care. Therefore, the requested health service/treatment of an inpatient hospital admission was not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hidradenitis Suppurative. 
Treatment: HCPCS Q5104 - Injection, infliximab-abda, biosimilar (Renflexis), 10MG (milligrams). 

The insurer denied: HCPCS Q5104 - Injection, infliximab-abda, biosimilar (Renflexis), 10MG (milligrams). 

The denial is overturned. 

The patient is an adult female with hidradenitis, Hurley stage III, treated with oral antibiotics, topicals, intralesional steroids and Humira. The provider is requesting infliximab. 

The proposed treatment with HCPCS Q5104 - Injection, infliximab-abda, biosimilar (Renflexis), ten milligrams (MG): is medically necessary. 

Infliximab is one of the best studied anti-tumor necrosis factor (TNF) agents in hidradenitis. Infliximab was first shown to be efficacious in hidradenitis suppurativa patients with Crohn's disease. A long-term study of ten patients looking at efficacy of a single course of three infliximab infusions at zero, two, and six weeks demonstrated improvement in all patients following therapy. The mean Dermatology Life Quality Index (DLQI) demonstrated improvement a year after initiating therapy.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse.
Treatment: Inpatient Admission.

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

This adult female was admitted to this hospital for alcohol withdrawal and medical issues including numbness. She had multiple episodes of vomiting and diarrhea, nausea, elevated heart rate, tremulousness, and had difficulty keeping food or fluids in. She reportedly relapsed with alcohol use including drinking 6 beers and multiple shots per day. She also was using cannabis daily, due to nausea, and had a positive tetrahydrocannabinol (THC) toxicology screen. She reportedly had hypokalemia with a potassium (K) of 2.8, carbon dioxide (CO2) of 31, blood urea nitrogen (BUN) under 3, chlorine (Cl) of 90, and a white blood cell count (WBC) of 11.2. She was given stat Librium 25 milligram (mg) orally (po) and stat Ativan 1 mg intramuscular (IM) for detoxification treatment. She reportedly had a nephrology consult and social work evaluation. She reportedly had a past inpatient substance/alcohol rehabilitation treatment prior to admission, which resulted in a few months sobriety period. She also reportedly received continuous intravenous (IV) fluids, IV potassium chloride (KCl) 3 times stat, sodium chloride (NaCl) one-time stat, folic acid, and thiamine, and had continuous cardiac monitoring. She reportedly left against medical advice (AMA).
  
The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. It also states that patients with past complicated or life-threatening withdrawal symptoms including withdrawal seizures or delirium tremens are in need of inpatient hospital treatment for the management of withdrawal and reports that patients with comorbid medical condition that complicate the management of withdrawal are also candidates for inpatient detoxification. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The insurer's denial of coverage for the inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism, lead poisoning
Treatment: Consumer Directed Personal Assistance
The insurer denied Consumer Directed Personal Assistance.
The denial is overturned.

The patient is a young female child with known autism, lead poisoning secondary to eating paint, poor impulse control, and self-injurious behavior with a need for constant supervision due to inability to appropriately communicate verbally and receive communication as well as maintain self-control and assess dangerous behaviors. The patient's mother is the only care provider and has two jobs as she cares for the patient. As per the physician, the patient has a medical team to follow the patient's multi-systemic medical needs.

Consumer directed personal assistance is medically necessary.

As noted by the physician caring for this child, the patient's lead poisoning is caused by continued eating of paint. The patient has multiple self-injurious tendencies, highlighted by her mouthing of dangerous and inedible objects. The patient is a known autistic child with poor impulse and communicative abilities resulting in the inability to safely and age appropriately assess her environment and what is best for her. As such, she has demonstrated a need for continuous home supervision for safety, not for custodial purposes. As such, the patient requires the requested home care, and the denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion 
Treatment: D8080 braces
The insurer denied coverage for D8080 braces.
The denial is upheld.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, orthodontist treatment records, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified several clinical findings including overjet, overbite, and anterior crowding and has recommended orthodontics. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 33 total points to support orthodontic care. 

Upon review of the submitted documentation (study models were not provided for review) it is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires, the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation 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 does not claim an automatic qualifying condition and completes the second portion of the index arriving at 33 points to justify orthodontic care. This reviewer concurs with the HLD index of the insurer attaining 18 total points (4 overjet, 3 overbite, 3 ectopic eruption, 5 anterior crowding and 3 labiolingual spread).

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. This is confirmed by several studies.

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

The insurer's denial of coverage for D8080 braces is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Recurrent uveitis; syphilis
Treatment: Inpatient hospital services
The insurer denied the inpatient hospital services.
The health plan's determination is upheld.

The patient is a male who was sent to the emergency department with a report of having neurosyphilis in his eye and needing intravenous (IV) treatment. The patient's vital signs appeared stable and he was in an afebrile state. His Glasgow Coma Scale was 15. The emergency department (ED) documentation notes a lumbar puncture was attempted for cerebrospinal fluid (CSF) sampling for suspected syphilis but was aborted after two unsuccessful attempts. The patient has a few-month history of a rash on his hands and recurrent uveitis. After being evaluated by ophthalmology, he was sent to the emergency department for the evaluation of neurosyphilis. He denied malaise or chills. The rash was additionally present on his feet and his penis. His rapid plasma reagin (RPR) was checked in the ED and it was 1:64.

The patient's laboratory studies were otherwise unremarkable, including his complete blood count (CBC), chemistry panel and liver function tests (LFT's). His coronavirus (COVID) polymerase chain reaction (PCR) testing was unremarkable. The medical team also ordered a midline for planned IV antibiotics. The infectious disease specialist continued to follow the patient and recommended human immunodeficiency virus (HIV) testing. The lumbar puncture was completed. Immediately after the procedure, the Penicillin G treatment was started. Outpatient IV antibiotic therapy with Penicillin G was set up, and the patient was released home with close outpatient follow-up.

In its determination of medical necessity, the health plan acted reasonably, with sound medical judgment, and in the patient's best interest. An inpatient hospitalization is not warranted in this case.

Based on the provided documentation, the inpatient hospital admission was not medically necessary. The patient was sent in for a lumbar puncture to evaluate for neurosyphilis. Upon examination, the patient is otherwise noted to have no throat exudate or erythema and no discharge from his ears. He had a normal cardiopulmonary exam, and no focal neurologic deficits. He was seen by infectious disease, who recommended IV Penicillin G 4,000,000 units every 4 hours after the lumbar puncture (LP) was done. Interventional radiology was consulted to perform the LP. 
The patient was hemodynamically stable, without central nervous system (CNS) deficits other than eye involvement. He was appropriately evaluated with a lumbar puncture, had a midline placed, was initiated on antibiotics, and was discharged safely home for continued home antibiotic therapy.

An alternate level of care satisfies the criteria for safe evaluation and treatment of this type of condition. There is no evidence that an inpatient admission was necessary, as there was no evidence of a severe systemic illness, severe sepsis with septic shock, acute neurologic deficits, brain herniation, elevated intracranial pressure, cognitive dysfunction, or behavioral issues.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: substance abuse
Treatment: Substance Abuse Inpatient Rehabilitation
The insurer denied Substance Abuse Inpatient Rehabilitation. The health plan's determination is upheld. 

The case involves an adult male who was self-referred with admission to inpatient rehabilitation and substance use disorder treatment to address substance use disorders with cocaine, as well as tobacco use (vaping) and occasional use of alcohol. The patient had no history of blackouts or withdrawal seizures or delirium tremens. He had been up to 6 grams of cocaine with intranasal administration after relapsing 3 weeks prior to admission and following a period of sobriety. He had past treatments and was familiar with substance-related rehabilitation services. He presented with no significant withdrawal symptoms but had 'unpleasant emotions' and symptoms of depression precipitated by past losses and induced by the cocaine use.

Inpatient Admission: Substance Abuse Inpatient Rehabilitation was not medically necessary for this patient.
The proposed inpatient substance disorder treatment and other inpatient medical services noted in the clinical summary could have been safely and effectively provided with lower level of care in a less restrictive treatment setting. The clinical features and indicated treatment dimensions of this patient's alcohol and cocaine use disorders did not require or warrant the structure or monitoring or intensity of treatment of an inpatient level service. The patient displayed no serious disturbance of mental status despite having a history of ongoing substance use disorder with cocaine following a relapse. Moreover, the patient had been evaluated and cleared with regard to safety concerns, and did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance, or general medical concerns that would have warranted an inpatient level admission and treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Headache
Treatment: Inpatient Admission
The insurer denied inpatient admission.
The health plan's determination is upheld.

The patient is a female with a history of hypertension, she is not compliant with her medication. She presented to the emergency room with a five-day history of right eye pain and right sided headache. In addition, the patient reported an episode of double vision several days previously, which had resolved. Her vital signs showed variable high blood pressures with the highest being the initial reading of 242/130. She was in no acute distress, and the physical examination showed limited right eye abduction. Her laboratory studies were remarkable for a glucose of 187. The computed tomography (CT) scan of her head was normal and the CT angiogram of her head and neck were non-contributory. The electrocardiogram (EKG) was negative for acute ischemia or significant arrhythmia. The patient was treated in the emergency room with antihypertensive medication with a good response. The patient was admitted for further treatment and evaluation.
Upon admission to a monitored bed, the patient was treated with oral medications and Lovenox for deep vein thrombosis (DVT) prophylaxis. On the following day, the patient's blood pressure was 187/92. A magnetic resonance imaging (MRI) of the patient's head was negative for an acute intracranial abnormality. The neurologist evaluated the patient and noted right 6th nerve palsy without any evidence of an acute stroke. The telemetry monitoring revealed nocturnal episodes of atrioventricular (AV) block with four second pauses. The cardiologist evaluated the patient and concluded that there was no indication for a pacemaker. The remainder of the stay was clinically uneventful and the patient was discharged. 

The requested health service and treatment of an inpatient admission was not medically necessary for this patient. Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical examination, laboratory studies, imaging, or EKG of an imminently life-threatening cause of the patient's complaints that required acute inpatient admission. Her blood pressure came under control within hours and there was no evidence of encephalopathy, cerebral infarction or hemorrhage, myocardial ischemia, or heart failure. The 6th nerve palsy did not require an acute inpatient admission and was not due to the hypertension. In addition, the AV block noted during nocturnal monitoring was not life-threatening. Therefore, based on the standard of care, as well as the peer reviewed literature and guidelines cited in the references, the acute inpatient level of care was not medically necessary and the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld

The patient is an adult female. She underwent a full acute hospitalization for the complaints of abdominal pain. The patient presented with a two-day history of right lower quadrant abdominal pain and anorexia. The CT (computed tomography) scan did not visualize an appendix, and there was free fluid noted. Surgery was consulted. The patient did well off antibiotics. General surgery and gynecology did not deem intervention necessary. GI (gastroenterology) was consulted for an endoscopy and colonoscopy.

The Inpatient Hospital Admission was not medically necessary. 

Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had abdominal pain; yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for NPO (nothing by mouth) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission. As such, the care could have been rendered at a lesser level in its entirety.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma
Treatment: Inpatient hospital admission
The insurer denied coverage for inpatient hospital admission.
The denial is upheld.

 
The patient is an adult who has a history of asthma, immunocompromise, and congestive heart failure. The patient presented to the Emergency Department (ED) with complaints of shortness of breath (SOB) and wheezing which was not relieved with taking Albuterol. The patient also had some cough with productive sputum.

Vital signs at presentation included a normal temperature, pulse 106, blood pressure (BP) 149/79 and a Peak Expiratory Flow (PEF) of 150. Wheezing was present. Initial Labs: White blood cell (WBC) count of 3.6, electrolytes were normal, Troponin < (less than) 0.012, D dimer negative. The EKG (electrocardiogram) showed no acute changes. The echocardiogram results were normal. The Chest x-ray (CXR) showed no acute infiltrates, effusion or pneumothorax. The patient was treated with intravenous (IV) Steroids and bronchodilators; following that he improved.

Upon re-examination in the ED the patient was in no acute distress. No use of accessory muscles was documented. No wheeze was described. The patient's PEF had improved to 300 after treatment in ED. The patient remained stable after admission. Within 24 hours the vital signs were normal and oxygen saturation was 99% (percent) on room air. The patient was ambulatory and was discharged the next day.

This patient did not need acute inpatient hospitalization. She could have been placed in Observation status while diagnostic testing and treatment were initiated. Observation could be for up to a period of 48 hours. She was stable to be discharged home after a period in Observation on oral steroids and bronchodilators with close follow-up in the outpatient setting.

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

The medical necessity for inpatient hospital admission is not substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Atrial Fibrillation.
Treatment: Formulary exception for Eliquis.
The insurer denied: Formulary exception for Eliquis.
The denial is overturned.

The patient is an adult male with paroxysmal atrial fibrillation. His comorbidities include HIV (human immunodeficiency virus). He is status post ablation, but still has breakthrough episodes on beta blockers. The patient is on anti-coagulation with Eliquis for the indication of PAF (paroxysmal atrial fibrillation).

The health plan denied coverage of Eliquis, as it is not the preferred formulary medication, and other medications, such as Xarelto and warfarin, are preferred by the health plan to be tried first. The denial is being appealed, as the preferred medications were deemed by treating physician to be inferior. The request is for formulary exception of Eliquis.

The health plan should cover the formulary exception for Eliquis.

The formulary drugs have been shown to be inferior, both in preventing strokes and bleeding occurrences. Several studies have now shown that Eliquis is more effective in preventing stroke and less bleeding compared to the formulary medications. Two of those studies were found within the medical records (5, 6). In addition, the use of Eliquis is preferred due to its superiority in outcomes.

Eliquis has been found to be more effective than warfarin in lowering the risk of stroke and systemic embolism. People who took Eliquis also had significantly fewer bleeding episodes than those who took warfarin. One study finds apixaban (Eliquis) is preferable to rivaroxaban (Xarelto) for stroke prevention, reduced bleeding complications.

Therefore, given the above, the health plan should cover the formulary exception for Eliquis.