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

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

The patient is a male with a history of asthma who presented with fever dyspnea, and cough for the prior 2 weeks with an emergency department (ED) visit 1 week prior at which time he was given steroids and nebulizers, but had persistent symptoms. He was given azithromycin 6days prior by his PCP (primary care provider).
In the ED, temperature was 100.2, blood pressure (BP) 96/75, heart rate (HR) 121, respiratory rate (RR) 18, and oxygen saturation 99% on room air (RA). He was not in distress, heart was tachycardic but regular, and he was breathing comfortably with diffuse wheeze. White blood cell count (WBC) was 17, Na (sodium)137, and creatinine (Cr) 0.81.

An inpatient hospital admission was medically necessary. This patient presented with persistent dyspnea, cough, and wheeze despite appropriate outpatient treatment including oral steroids, antibiotics, nebulizer bronchodilators, and asthma maintenance therapy. While otherwise not severely ill, the lack of response to outpatient therapy suggests either more severe disease that could worsen and require Intensive Care Unit (ICU) care, more severe disease that will prolong symptoms, or an additional or alternative diagnosis that will require frequent testing, repeated and frequent re-assessments. Given these concerns and risks, an inpatient admission was needed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of Breath, Chest Pain.
Treatment: Inpatient Hospital Stay.

The insurer denied Inpatient Hospital Stay.  The determination is upheld.

The patient is a female admitted with shortness of breath and chest pain. There was a history of a pulmonary embolism (PE), anticoagulation, and obesity. A computed tomography (CT) angiogram four days prior was negative for a PE and a lower extremity duplex scan negative for a deep vein thrombosis (DVT). The blood pressure (BP) was mildly elevated. Other vital signs and the oxygen saturation were normal. She was in no distress. The electrocardiogram (ECG) was reported as nonacute. It was reported that the cardiac enzymes were mildly elevated. The troponin was 0.039 and essentially flat. The patient remained stable. She underwent a cardiac catheterization, which was negative for obstructive coronary artery disease (CAD). The left ventricular ejection fraction (LVEF) was normal. She remained stable and was discharged. An inpatient hospitalization is under review for medical necessity.

This patient presented with chest pain and remained stable. There was no congestive heart failure (CHF), respiratory distress, ongoing symptoms suggestive of treatment refractory angina or angina equivalent, severe arrhythmia, hemodynamic instability, another serious cause for chest pain, such as a PE or aortic dissection, need for prolonged intravenous (IV) medications or oxygen support, introduction of high risk medications requiring ongoing in-hospital monitoring, severe catheterization related complication (i.e., severe bleeding, cerebrovascular accident [CVA]), need for invasive hemodynamic monitoring, need for vasopressor or mechanical cardiac support, or supporting evidence for an acute coronary syndrome such as increasing cardiac biomarkers or an abnormal ECG. In the setting of this patient, an inpatient hospitalization compared to observation has not been established instead of care toward improved cardiac outcomes. The inpatient stay is therefore considered not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Pre-term labor.
Treatment:  Inpatient admission.

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

The patient is an adult female multigravida who presented to the hospital with complaints of contractions at 36.4 weeks of gestation. Contractions were every 5 minutes. Fetal heart was reassuring. Examination showed that the cervix was 5 centimeters (cm) dilated. 
The patient was admitted with preterm labor. The care plan consisted of continuous external fetal monitoring and toco meter, intravenous (IV) fluids, intramuscular (IM) Celestone. Re- examination showed no change in cervical dilation. The patient was discharged. 

Preterm labor is an indication for admission and tocolysis. Preterm labor is defined as uterine contractions with cervical changes. During this admission, there was no documentation of cervical changes. So, the patient was not in preterm labor.

According to Milliman Care Guidelines (MCG) admission is indicated for one or more of the following:  1) Condition requiring premature delivery, 2) Fetal distress or demise, 3) Preterm prelabor rupture of membranes, 4) Significant maternal disease, 5) Vaginal bleeding, 6) Complications of tocolytic treatment, 7) Continued fetal monitoring that requires inpatient care, 8) Tocolytic therapy needed that requires inpatient care, or 9) Inability to stop preterm labor.

Observation care is appropriate for patients with one or more of the following:  1) Condition requiring premature delivery suspected, 2) Preterm premature rupture of membranes suspected, 3) Suspected maternal infection, 4) Ongoing uterine contractions (tocolytic therapy needed, monitoring of cervical changes needed), 5) Fetal distress suspected, or 6) Suspected placenta previa, vasa previa or placenta accreta.

Both patient and fetus were stable. There was no evidence of preterm labor. The patient could have been observed for a few hours. Once the provider ascertained that there was no evidence of preterm labor, the patient could have been sent home. This is in accordance with the standard of care and Milliman guidelines.

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 the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Foot Pain.
Treatment:  Durable Medical Equipment (walking boot-L4361RTx1).

The insurer denied: Durable Medical Equipment (walking boot-L4361RTx1).  The denial is overturned.

The patient is a teenage female. She suffered a right ankle injury when she jumped off of something on the playground. Documentation notes that the patient was diagnosed with a severe sprain of her ankle. The physician recommended immobilization in a Cam walking boot. The patient's physical examination showed tenderness to palpation at the anterior lateral ankle. Ankle x-rays were normal. The request is for a Cam walking boot. The health plan denied coverage of the request due to the patient not having a severe ankle sprain, severe ankle or foot fracture, or recent foot or ankle surgery. The denial is being appealed.

The requested health service is medically necessary.

The requested Cam walking boot is medically necessary. The previous documentation notes the reason for denial being that the patient does not have a severe ankle sprain, severe ankle or foot fracture, or recent foot or ankle surgery. However, documentation provided notes that the patient was diagnosed with severe ankle sprain. The physical exam documented is consistent with a severe ankle sprain. Cam boot immobilization is the appropriate treatment in this case and is medically necessary.
Beck et al. performed a prospective randomized study on low energy to pediatric lateral ankle injuries and showed Cam boot treatment of low-energy lateral ankle injuries in pediatric patients results in improved results and lower complications. Melanson et al. state that early weight-bearing with support of a walking boot has been found to improve return to sports, return to work, persistent swelling, the range of motion, and patient satisfaction. Cam boot immobilization and physical therapy are considered standard of care in this condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes Type I.
Treatment: Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

This is a male patient with a medical history significant for asthma and type 1 diabetes managed with an insulin pump who presented to the emergency department (ED) with multiple episodes of vomiting, hyperglycemia (blood glucose 400), and ketones in his urine. His mother contacted endocrinology with recommendations to go to the emergency department (ED) for evaluation and concerns for diabetic ketoacidosis (DKA) in the setting of pump malfunction. He was given additional insulin via pump prior to arrival.
He was started on an insulin infusion and two-bag method.  Ongoing endocrinology consultation included recommendations to repeat venous blood gases every two hours and metabolic panels every four hours. The blood sugar continued to decrease, with adjustments made in his intravenous (IV) fluid hydration as per the DKA protocol. He was considered stable enough for admission to the general pediatric floor, with notation that even though his DKA was corrected while in the ED, he required admission for insulin optimization and possible insulin pump recalibration.
Admission orders included blood glucose monitoring before meals and at 22:00 hours (hrs) and 02:00 hrs, Lantus 12 Units (U) nightly, maintenance normal saline IV fluids, diabetic diet, morning labs, albuterol as needed, and carbohydrate correction regimen. The family received further diabetes education. His blood sugar stabilized with long-acting and short-acting subcutaneous insulin, and he was cleared for discharged to follow-up closely with pediatric endocrinology. The insulin regimen with carbohydrate counting parameters were reviewed at the time of discharge. At issue is the medical necessity of inpatient hospital admission.

Inpatient hospital admission was not medically necessary for this patient.
This male child with type 1 diabetes presented with hyperglycemia and vomiting after playing outside all day in the heat. He had no other signs of illness. His laboratory evaluation was consistent with DKA, corrected with insulin infusion and IV fluids while in the ED. Because of concerns for pump malfunction and need for insulin adjustment, he was admitted for further care. While it was reasonable to monitor him in the hospital while adjusting his regimen and providing further education, he was overall hemodynamically stable with no further evidence of dehydration or sequelae from DKA. He did not require acute inpatient admission and could have been safely managed at lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Asthma Exacerbation.
Treatment:  Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is overturned.

This is a female patient with a past medical history (PMH) of asthma (no intubations or intensive care unit (ICU) admissions), diabetes mellitus type 2 (DM2), and osteoarthritis (OA) who was admitted with complaints of (c/o) an asthma attack with positive sick contact. The physical exam was notable for right-sided wheezing and decreased air entry. Lab work was notable for partial pressure of carbon dioxide (pCO2) 57. Imaging studies, a chest x-ray (CXR) showed no focal consolidation. The patient was diagnosed with severe asthma exacerbation and treated with bronchodilators, magnesium, and steroids, with minimal improvement in the emergency department (ED). The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

The hospital stay was medically necessary at an acute inpatient level of care. This patient presented with worsening shortness of breath (SOB) associated with a cough and wheezing. The patient was evaluated and found to have wheezing with minimal air movement on initial examination. The patient was treated aggressively in the ED with treatments of duonebs, magnesium and intravenous (IV) steroids, but was still found to have wheezing after these treatments with minimal overall improvement. In addition, the patient's partial pressure of carbon dioxide (pCO2) was significantly elevated to 57 with new onset hypoxia and sustained tachycardia, consistent with a severe asthma exacerbation. This is compounded by the patient's tachycardia, hypoxia, hypercarbia, and lack of significant response in the ED. Overall, this patient suffered a severe exacerbation of asthma and could not have been safely treated at a lower level of care, as she required aggressive management and close clinical monitoring, which is consistent with the ED physician's impression of status asthmaticus.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Class I/Molar, Class II Occlusion.
Treatment:  Braces, Monthly Visits, and Retainer .

The insurer denied braces, monthly visit, and retainer. The health plan's determination is upheld. 

The patient is a male with a canine Class I/molar and Class II occlusion. He has a 2-millimeter (mm) overjet and a 2 mm overbite. He has severe maxillary and minor mandibular crowding. Teeth 4 and 13 are erupted but blocked from the arch to the lingual. He has treatment planned for braces, monthly visits, and a retainer to correct his malocclusion. 

Braces, monthly visits, and a retainer are not medically necessary for this patient. The patient has crowding, but it is really limited to the blocked-out teeth 4 and 13. His overbite is appropriate, and there is no indication of damage to the incisors in the photographs. His cephalometric radiograph shows the lower incisors are contacting the maxillary teeth in occlusion, not the palate. There is no indication from the photographs that this patient has severe soft tissue damage (or any soft tissue damage).

There is no medical reason to correct his malocclusion with braces. The original treatment plan includes extraction of teeth 4 and 13. Removing these teeth without orthodontics (ortho) would resolve all of the maxillary crowding without further intervention. There is no evidence of wear or periodontal recession. Functional problems may occur in the dentition that becomes more difficult, if not impossible, to correct if not addressed in adolescence. The patient's overjet is ideal - excessive overjet would only affect oral health-related quality of life if it is greater than 6 mm. The patient's teeth becoming aligned may provide an esthetic improvement, but it would not significantly improve his health.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: type I diabetes, heart failure, legal blindness.

Treatment: Consumer-directed personal assistance services (CDPAS), a total of unspecified hours per week

The insurer denied coverage for consumer-directed personal assistance services (CDPAS), a total of unspecified hours per week.

The denial is modified.
 

This case pertains to an adult male who lives alone. He has a diagnosis of anxiety, depression, type I diabetes, heart failure, legal blindness, hypertension, gastroesophageal reflux disease, hypercholesterolemia, insomnia, and constipation. Medications include Amlodipine, Aspirin, Atorvastatin, Atropine, Bupropion, Carvedilol, Docusate, Hydrochlorothiazide, Lantus, Losartan, Melatonin, Omeprazole, Trazadone and Vitamin D2. 

The patient requested help with meal preparation, cleaning, medications, and doctor's visits due to legal blindness in both eyes. He had an overnight hospitalization when he underwent bariatric surgery. He is cognitively intact. He requires maximal assistance with meal preparation, housework, managing finances, and shopping. He requires extensive assistance with transportation. He requires supervision with managing medications, stairs, and ambulation. He utilizes a walking cane. His aide provides set-up assistance for bathing, and clothing set up. 

The tasking tool noted the need for 7.48 hours per week of personal assistance. The review of the assessment found that the patient requires set-up help with bathing, toileting, eating, and dressing. The tool notes those tasks as independent and does not assign any time to them. He noted in the assessment that due to his blindness; his aid sets out clothes, sets up his bath items and toileting items, and sets his food out. She also sets up his medications. These small tasks were allotted 5 minutes each. The meal preparation was only allotted 5 minutes per meal. This was increased to 30 minutes per meal. The new total hour for the week is 16.25 hours per week. The decision is overturned, and he is approved for 16 hours per week. Considering the assessment and allotted times for tasks in the tool, this patient should receive 16 hours per week of consumer-directed personal assistance service.

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

The medical necessity for consumer-directed personal assistance services (CDPAS), a total of 16 hours per week is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Orthopedic
Home health care

Diagnosis: decreased mobility
Treatment: Personal Care Assistance Services/Housekeeping: Total of 16 Hours per Week
The insurer denied Personal Care Assistance Services/Housekeeping: A total of 16 Hours per Week
The health plan's determination is overturned. 

The patient is a male with a past medical history of chronic low back pain, chronic thoracic back pain, bilateral knee pain with bipartite patella, gastroesophageal reflux disease (GERD), asthma, and autonomic neuropathy who had been assigned 8 hours of housekeeping per week. 

Personal Care Assistance (PCA) Services/Housekeeping: A total of 16 Hours per Week is medically necessary for this patient.
The patient's medical provider documented the patient's assistance needs with activities of daily living (ADL) and Instrumental activities of daily living (IADL). The tasking tool underestimated the patient's ability to perform tasks of meal preparation, ordinary housework, transportation, stairs, shopping, and locomotion. In addition, the tasking tool did not assign hours for medication reminders and assistance, cleaning the kitchen, and laundry, and only assigned 30 minutes/week for errands. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with ADLs and IADLs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 16 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support functions is essential to the maintenance of the patient's health and safety in his own home.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Insomnia
Treatment: Belsomra
The insurer denied: Belsomra
The denial is overturned.

This case involves an adult male diagnosed with a sleep disorder, primary insomnia. The patient has been prescribed Belsomra 5 mg (milligram) tablets with up to two tabs daily to address his sleep disturbance. The patient has failed to benefit from the formulary agent, zolpidem (Ambien). The patient has comorbid conditions including major depressive disorder and anticipatory anxiety treated with Prozac and Wellbutrin. There is no substance use disorder or significant general medical conditions in this case. The denial is based on prior authorization criteria indicating that the patient must have tried and failed treatment with formulary alternatives, ramelteon (Rozerem) and zolpidem (Ambien) immediate or extended-release formulations.
The prescribing physician is requesting coverage for treatment with Belsomra at the dosage of 5 to 10 mg (milligrams) daily targeting symptoms of sleep disturbance/insomnia in keeping with FDA (Food Drug Administration) indications. The patient was previously treated with the formulary alternative, zolpidem.

The health plan should cover the proposed treatment.

In this case scenario, the formulary drug zolpidem has been ineffective for this patient, and the remaining formulary alternative, ramelteon, would not be as effective as the requested non-formulary drug. The non-formulary drug and formulary alternatives pose risk for adverse effects for this patient with no particular advantages with either. Moreover, the use of Belsomra in this case is reasonable and in the best interest of the patient and is provided with sound medical judgment in keeping with an FDA approved indication. The requested service is in keeping with prevailing standards of medical practice for the condition under treatment in this case with an approved and evidence-base treatment; and the requested services/treatment with Belsomra
being provided in this case is clinically appropriate and is backed by credible scientific evidence known to benefit patients with the insomnia diagnosed in this case. Belsomra that has a disparate
mechanism of action and is known to benefit patients with insomnia. Additionally, clinical practice guidelines strongly support the administration of the requested medication for this patient's condition, and the use of Belsomra 20 mg (milligrams) is as an accepted standard of practice in the United States. This answer is in keeping with the New York State Instruction for this review pertaining to a formulary exception and is consistent with the scientific literature and published guidelines, referenced below.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Right epididymo-orchitis. 
Treatment: Full hospital admission. 
The insurer denied the full hospital admission. 
The health plan's determination is overturned in part. 

This male patient was admitted through the emergency room (ER) to urology with a worsening right epididymo-orchitis after 3 days of oral doxycycline therapy. Vitals were Temperature 99 degrees Fahrenheit, pulse 102, and blood pressure (BP) 110/56. Computed tomography (CT) imaging and Ultrasonography demonstrated marked scrotal edema with potential gas in the anterior penis. The white blood cell count (WBC) count was 15,600. The urinalysis had leukocyte esterase. Triple intravenous (IV) antibiotic therapy was administered. Infectious disease (ID) was consulted. 

An acute inpatient level of care was medically necessary for 2 days. 
Scrotal edema or infection is not manageable in observation care. Orchitis not manageable in observation care. The presence of gas in the affected tissue after 3 days of outpatient antibiotic therapy is very concerning for Fournier's gangrene. This clinical condition requires close inpatient follow-up as clinical deterioration can be rapid. By day 3, the patient was stable and no longer required an inpatient level of care.