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

Diagnosis: Degenerative arthritis of the hip. 
Treatment: Inpatient Hospital Stay. 

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

The patient attempted and failed conservative treatment for left hip degenerative arthritis. The patient underwent a primary left total hip replacement surgery. The surgery was successful with no documented complications. He had physical therapy after the surgery and his vital signs and lab values were within normal limits. The patient recovered well after the operation and was deemed stable for discharge. The inpatient hospital admission was denied by the patient's health plan as not medically necessary and at issue, in this case, is the medical necessity of the inpatient hospital admission. 

The requested health service/treatment of inpatient stay was not medically necessary for this patient. The provided medical records in this case do not document any complications of the operation. The records also document that the patient progressed well with supervised physical therapy following the surgery and that his vital signs and lab values were within normal limits. Therefore, based upon the documentation in the medical records, the inpatient hospital admission in this case was not medically necessary. The current, peer-reviewed orthopedic literature supports the performance of total hip replacement surgery with either a short hospital stay or outpatient status. A recent article published by Leroux and colleagues in the Journal of Bone and Joint Surgery in 2020 concluded that "When comparing matched cohorts of patients who underwent short-stay and longer-stay total hip arthroplasty (THA) or total knee arthroplasty (TKA), we observed no difference in outcomes, suggesting that a short stay with a discharge home in the appropriately selected patient is safe following THA or TKA." An inpatient stay was not medically necessary based on the provided medical records and the recommendations of the current, peer-reviewed orthopedic literature.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems. 

Treatment: D2751- white glass with metal crown, Tooth 8. 

The insurer denied coverage for D2751- white glass with metal crown, Tooth 8. 

The denial is upheld. 

This is a female patient who presented to the dentist for comprehensive care. The treating dentist recommended full coverage crown for #8. The insurer has denied these services stating the there is no clinical/ radiographic evidence, such as traumatic injury or decay, provided to support the necessity of this service. 

The objective documentation provided for review is a copy of poor quality and illegible dental records and periapical radiographs. It appears that there is no evidence of fracture or other pathology specifically affecting #8 based on the images provided for review. There does not appear to be any radiographic evidence of caries. The radiographs do not substantiate the requested dental services as enumerated above and therefore the crown is deemed not medically necessary. 

Uphold denial of coverage for D2751- white glass with metal crown tooth 8 as not medically necessary as the documentation is insufficient to justify or substantiate the treatment. 

The healthcare plan did act reasonably and with sound medical judgement and in the best interest of the patient. 

The insurer's denial of coverage for D2751- white glass with metal crown, Tooth 8 is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bradycardia.
Treatment: External Mobile Cardiovascular Telemetry (MCOT) (procedure code: 93229), Pre-service.
The insurer denied the External Mobile Cardiovascular Telemetry (MCOT) (procedure code: 93229), Pre-service.

The denial is upheld.

The patient is a male with a past medical history of hypertension (HTN), coronary artery disease (CAD) status post percutaneous coronary intervention (PCI), dyslipidemia, congestive heart failure (CHF), and hypothyroidism, who was found to have bradycardia with a pulse rate in 40 beats per minute (bpm) range. The patient was prescribed an Mobile Cardiac Outpatient Telemetry (MCOT) device to evaluate for bradyarrhythmia. The use of the Mobile Cardiac Outpatient Telemetry device as an alternative to event monitor was denied. The medical necessity of the Mobile Cardiac Outpatient Telemetry is being reviewed.

No, the proposed Mobile Cardiac Outpatient Telemetry was not medically necessary.
The medical necessity of this treatment could not be established.

Currently there are no prospective trials that demonstrate improvement in outcomes with this technology. The available evidence suggests that Mobile Cardiac Outpatient Telemetry is likely at least as good at detecting arrhythmias as ambulatory event monitoring. Compared with ambulatory event monitoring, Mobile Cardiac Outpatient Telemetry is associated with the theoretical advantage of real-time monitoring, however, no studies were identified that addressed whether the use of Mobile Cardiac Outpatient Telemetry is associated with differences in the management of or outcomes. Therefore, there is insufficient evidence to demonstrate a clinically significant incremental benefit of Mobile Cardiac Outpatient Telemetry.  Event monitors or loop recorders can be used for detection of arrhythmias that are less frequent and cannot be detected with 24 hour Holter. In this patient with palpitations and bradycardia, use of ambulatory event recorder would have been the standard modality. Thus the medical necessity of Mobile Cardiac Outpatient Telemetry cannot be established.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Trauma/Injuries.
Treatment: Inpatient Hospital .
The insurer denied the inpatient hospital admission. 
The denial is upheld.

The patient is a female with a past medical history significant for hyperlipidemia and depression, who was brought to the emergency department after she took multiple doses of Tylenol countless times throughout the day. Apparently, the patient stated that she took Tylenol to ease her chronic hip pain, which was unbearable. The statement was contrary to the initial impression that the patient took Tylenol to commit suicide. The patient stated to the admitting physician that she did not try to kill herself.

At the time of admission, the patient had an elevated acetaminophen level of 24.8. This was treated with N-Acetylcysteine, which brought down the serum acetaminophen level to low.

In the hospital, the patient was seen by a psychiatrist who recommended initiation of treatment with Lexapro for depression and anxiety.

During the hospital stay, the patient's clinical condition stabilized and the patient was discharged from the hospital with recommendations to follow up with her primary care physician, orthopedic surgeon, and psychiatrist.

The subject under review is the medical necessity for the inpatient hospital admission.

The health plan's determination is upheld.

The inpatient hospital admission was not medically necessary.

The patient presented to the hospital after ingestion of a large dose of Tylenol. Since the time of admission, it was not completely clear if the overdose was intentional or unintentional, therefore the admission was definitely warranted to rule out suicidal ideations as well as determine if the patient needed inpatient psychiatric treatment. Since it was determined that the patient was not suicidal, she did not require admission to a psychiatric facility.

Even though the patient initially had elevated serum Tylenol level, this was treated very effectively with N-Acetylcysteine. The Acetaminophen overdose was not associated with liver failure. In fact, the patient's liver enzymes were unremarkable.

Overall, the patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. The acetaminophen overdose was effectively treated in the emergency department. The patient did not demonstrate active suicidal ideations.

Taking into consideration these facts, the admission at a lower level of care was definitely warranted. However, neither the severity of the patient's condition nor the complexity of the services provided rose to the acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Blindness.
Treatment: Personal Care Services: 24 Hours a Day, 7 Days a Week (Split-Shift). 

The insurer denied Personal Care Services: 24 Hours a Day, 7 Days a Week (Split-Shift). The health plan's determination is upheld. 

The patient is a female with past medical history of vascular dementia, depression, macular degeneration with legal blindness, congestive heart failure, coronary artery disease, asthma, osteoarthritis, and urinary incontinence who had been assigned shared PCA (personal care assistant) services with her spouse 24 hours/day, split-shift, 7 days/week. The patient had a telephonic assessment tool performed assessing her at maximum assistance with tasks of meal preparation, ordinary housework, and shopping while extensive assistance with tasks of managing finance, managing medication, stairs, transportation, bathing, and dressing lower body. The patient was assessed at limited assistance with phone use, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, and toilet use while independent with tasks of bed mobility and eating. The patient was hospitalized recently with Covid-19 infection and pneumonia. Her husband was also hospitalized but recently expired.

Personal Care Services: 24 Hours a Day, 7 Days a Week (Split-Shift) is not medically necessary for this patient. 

The patient had previous 24 hour, split-shift, PCA (personal care assistant) services 7 days/week shared with her spouse. Unfortunately, he passed related to complications of Covid-19 infection and the patient/patient's family requested continued PCA services. The patient underwent assessment tool, and although the patient requires assistance with all activities of daily living (ADL) tasks, she did not require frequent repositioning and turning, and there was no documentation of frequent overnight toileting needs. Based on the information provided, the personal care aide would be able to obtain 5 hours of uninterrupted sleep. 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, the requested PCA services 24 hours/day, split-shift, 7days/week, are not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer/Anal and Rectal Cancer
Treatment: Radiation Therapy
The health plan denied the requested radiotherapy. 
The health plan's determination is upheld.

This is a male with history of stage pT1cN0M0 adenocarcinoma of his low rectum status post robot-assisted transanal resection. He has been recommended to proceed with a course of postoperative chemoradiotherapy with curative intent. The request is for approval of proton beam radiotherapy.
At issue is the medical necessity of the requested procedure.


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

No, the requested proton beam radiotherapy is not medically necessary in this patient's situation. There are currently insufficient high quality clinical outcomes published in the peer reviewed medical literature to allow one to make definitive conclusions regarding the relative safety/efficacy of proton beam radiotherapy in the patient's setting, as compared to standard of care photon-based radiotherapy. While proton radiotherapy can decrease the volume of normal tissue exposed to low radiation dose levels, it cannot reduce the volume exposed to high dose. Since it is high dose that is correlated with treatment induced toxicity, it remains to be seen whether the use of proton beam radiotherapy in the patient's setting will translate into clinically meaningful improvements in outcomes. The ASTRO Model Policy for proton radiation does not support its use in the patient's setting outside the context of a prospective clinical trial. There are not any extenuating circumstances present in the patient's setting that would necessitate the use of proton beam radiotherapy (e.g., prior receipt of therapeutic radiation to an abutting/overlapping area or presence of a comorbid/genetic condition which increases his risk for normal tissue radiosensitivity).
The health plan's determination is concordant with the current industry standard and recommendations issued forth by expert-consensus national guidelines.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Severe anemia and menorrhagia.

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld. 

This is a female patient with a history of fibroids who presented to the Emergency Room (ER) from the Primary Care Physician's (PCP) office with complaints of a hemoglobin (hgb) level of 4.9. The patient was noted to have menorrhagia with severe anemia despite oral contraceptives (OCP) and iron supplementation. A Gynecology consultation was done. A pelvic sonogram revealed uterine fibroids. A blood transfusion was initiated in the ER. The patient was hemodynamically stable. She was admitted with severe anemia and menorrhagia. During the admission, 3 units of packed red blood cells were transfused. The hospital course was uneventful, and the patient was discharged home in good condition. 

This patient was asymptomatic. However, she fulfills the transfusion guidelines for use of blood components: her hemoglobin was less than 8 grams per deciliter (g/dl), so transfusion was necessary. Transfusions are done routinely in outpatient settings (oncology clinics, infusion centers, even at home); so, the need for transfusion is not a reason for admission.

The transfusion was started in the Emergency Department (ED). The transfusion could have been completed in the ED without the need for admission. Following transfusion, the patient could have been monitored for a few hours in the ED, her complete blood count (CBC) repeated and then discharged home with a follow-up within 24 hours with her primary physician or gynecologist. Nothing was done in the hospital that could not be done as an outpatient.

Milliman Care Guidelines list the clinical indication for inpatient care for patients with anemia. These include: active massive hemorrhage, active hemolysis, cognitive impairment, tachycardia, orthostatic changes, heart failure, chest pain, syncope. 

The patient was stable and did not have any of the above indications for admission. 

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

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vomiting and dehydration. 
Treatment: Inpatient hospital admission.

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

This patient is a female child with no significant past medical history. The patient was brought to the Emergency Department (ED) for evaluation of projectile vomiting. Upon presentation she was assessed as dehydrated, with sunken fontanelles. She was also toxic appearing and had tachycardia. She failed oral fluid challenge in the ED, described as losing the entire oral intake, resulting in a decision to admit her to the hospital for continued monitoring and rehydration. 

The patient was in the age group for risk for hypertrophic pyloric stenosis, for which evaluation was done by sonogram in the ED. This was excluded sonographically. However, she also had evidence of:  1)	A chronic inflammatory process, as evidenced by erythrocyte sedimentation rate (ESR) 97 and a platelet count of over 1.7 million; 2) An acute inflammatory process, with the leukocytosis of 20,500 with 17% bandemia. In this patient's age group (1, 2), an acute inflammatory reaction has to be considered to be a serious bacterial infection (SBI) until proven otherwise. Children at this patient's age may not manifest any focal signs or abnormal vital signs or hemodynamic instability, but still can have SBI, such as late onset group B strep or Escherichia coli (E. coli). An SBI can include meningitis without any sign of a stiff neck, and sometimes the child does not even exhibit significant irritability. Importantly, they may not mount a robust fever response, or the fever may not have been recorded accurately at home. Children at this patient's age with this presentation need to be treated in hospital on intravenous (IV) antibiotics for at least 48 hours until the results of the blood and spinal fluid cultures come back negative, and the child has not shown any signs of clinical deterioration; 3) Pernicious vomiting, value of oral challenge and need for ongoing IV fluids. Sunken fontanelles signify a moderate degree of dehydration, up to 10% of fluid loss; and 4) Extreme thrombocytosis, which entails a risk thrombosis including cerebral thrombosis. She was at risk for hypernatremic dehydration, which has been reported to result in cerebral sinus venous thrombosis in neonates. (3)

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 hospital admission is overturned. Medical necessity is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Asthma.
Treatment: Formulary Exception for Asmanex to treat asthma.

The insurer denied coverage for the Formulary Exception for Asmanex to treat asthma.  The denial is upheld. 

This is a female patient with history of asthma.  The patient was prescribed Asmanex (mometasone) 220 micrograms (mcg) per day and Albuterol as needed.  The patient is seeking a formulary exception for Asmanex.

As per rules of the insurance company, the patient must be tried on all of the medications on the formulary of the insurance company (with a minimum of 3) before a formulary exception can be approved.

The formulary has the following Inhaled Corticosteroids (ICS):  1) Arnuity Ellipta - fluticasone - corticosteroid inhalant, 2) 	Flovent Diskus, Flovent hydrofluoroalkane (HFA) - fluticasone, 3) Pulmicort Flexhaler - budesonide, and 4) Qvar RediHaler - beclomethasone.

As per documentation in the chart, the patient reportedly had tried two other ICS - Arnuity and Flovent, which in fact are the same form of corticosteroid, and did not obtain relief with increased use of rescue inhaler.  No further details are provided.

There are two other ICS drugs on the formulary, Pulmicort and Qvar, which are different corticosteroids and have not been tried.  It is thus reasonable to try one of these two prior to consideration for Non-Formulary medication approval. They are both recommended for use in such patients along with Asmanex.  (see Table 4 in Up to Date)

It cannot be confirmed that the requested drug would be likely to produce a more clinically beneficial outcome than the formulary options, as there are formulary options that have not been trialed.

The insurer's denial of coverage for Request for Formulary Exception for Asmanex to treat asthma is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Myocardial Infarction
Treatment: Inpatient stay
The insurer denied the inpatient stay. 

The health plan's determination is upheld.

The patient is a male with a history of former tobacco use who presented to an emergency department (ED) with chest pain and shortness of breath. The electrocardiogram (ECG) demonstrated inferior ST segment elevation. Cardiac catheterization demonstrated an occluded mid right coronary artery, 95% occlusion of a diagonal, 80% mid left anterior descending (LAD) stenosis, and 50% mid circumflex stenosis. The left ventricular ejection fraction (LVEF) was 50%, and there was inferior wall hypokinesis. There was successful percutaneous intervention of the culprit right coronary artery (RCA). He remained stable and was discharged.

The requested inpatient hospital admission was not medically necessary for this patient.
This patient presented with an acute myocardial infarction, underwent successful treatment, and was an early responder to administered therapy. He 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, need for urgent repeat invasive procedure, need for prolonged 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)], or a recurrent unstable coronary syndrome. In the setting of this case an acute inpatient level hospitalization, compared to lower level observation has not been established as standard of care towards improved cardiac outcomes. A lower level of care would have been appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder-Paralysis
Treatment: Durable Medical Equipment(DME)-wheelchair accessory, power standing system, power seat elevation system
The health plan denied the wheelchair accessory as not medically necessary. The reviewer has overturned in whole the health plan's determination.

The patient has a Cervical(C)4 spinal cord injury and resulting quadriplegia and neurogenic bladder with secondary autonomic nervous system instability. Additional past medical history is significant for infarcts of the right lentiform nucleus, right thalamic area, and parietal region, as well as obesity.

The service of wheelchair accessory, power standing system, any type, and wheelchair accessory, power seat elevation system, any type, is medically necessary for this patient.
The patient has a medical history significant for C4 spinal cord injury with residual spastic quadriplegia, neurogenic bladder, and autonomic nervous system instability. E2300 (power seat elevation feature) is considered standard of care in a patient with quadriplegia or one in paraplegia who has shoulder injury preventing adequate range of motion/function of shoulders. A power seat elevation feature is necessary to allow a person to adapt to any environment and not rely on the environment to be adapted. This seat elevation feature is necessary for a caregiver to provide a safe slide board transfer from an even height at any location. It is also necessary for the patient to remain independent in the community as numerous things (with something as simple as a mailbox) are not always at a wheelchair accessible height. E2301 (power standing feature) is also medically necessary for this specific patient. As documented by the provider, the patient does not have any open wounds. This is likely related to the fact that he has had the power standing feature on his wheelchair for over 10 years. He has been able to reposition often and prevent skin breakdown. It is medically appropriate and within standards of medical care to continue an accessory for a patient's wheelchair if it has shown benefit. It would not make medical sense to take this feature away after 10 years of utilizing it on a daily basis as the patient has learned how to live in the home and community and complete activities of daily living with the assistance of a power standing system. Documentation noted numerous times that he has had the power standing feature on his wheelchair for over 10 years. Power standing feature allows for complete pressure relief and, therefore, wound prevention. It also assists with circulation and prevention of osteoporosis as it can improve bone density. It is not appropriate or within the standards of medical care to take away a wheelchair feature that has been successfully used for the past 10 years. This patient has learned how to live his daily life with this feature and to take it away would likely lead to regression in independence.