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

Diagnosis: Avoidant/Restrictive Food Intake Disorder (ARFID)
 
Treatment: Intensive Outpatient Mental Health Treatment

The insurer denied the Intensive Outpatient Mental Health Treatment. The denial was reversed.  

This is a young male patient who was admitted to this mental health intensive outpatient program (IOP) treatment in early 2018 due to eating disorder symptoms. He had a history of avoidant/restrictive food intake disorder. He was eating at a starvation level and lost weight when not in this structured program. He was only able to complete 40% of meals when outside of this IOP treatment. He only ate certain foods when at home including peanut butter, bread, crackers, and Nutella. He was unable to eat certain food due to the texture and smell causing his avoidance of foods to interfere with his functioning. He also had reports of sad mood, feelings of helplessness, lack of energy, difficulty sleeping, and dizziness. 
The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Eating Disorders reports that the least restrictive level of care for safe and effective treatment is appropriate. It also states that in considering changing levels of care for treatment, one should consider step down to the next least restrictive level of care. In this case, this patient still had significant eating disorder symptoms interfering with his functioning. It was reported that when he did not attend the IOP treatment he had lost 3.8 lbs. He had difficulty utilizing skills when not in this IOP setting and was struggling to complete meals. He was completing up to 70% of meal plans when in IOP versus 40% when out of IOP. He had individual, group, and family therapy. He had comorbid depressive symptoms as well. He needed to gain more coping skills in order to try certain foods, learn improved and more effective communication regarding thoughts and feelings during meals. As part of his treatment plan, he needed to be monitored regularly to improve his food variety and consumption based on his progress. 

Based on the above, the medical necessity for a continued intensive outpatient mental health treatment is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Myasthenia gravis 
Treatment: Soliris

Summary:
The patient is a female with serum antibody positive myasthenia gravis (MG).  Clinic note from mid-2018 reported she was stable on IVIG (intravenous immunoglobulin) and had tapered off steroids. Clinic notes prior to the initiation of Soliris (in 2018) noted that she was doing well, had no significant impairment from MG, was walking independently and performing ADLs (activities of daily living). She has weaned off prednisone due to the effectiveness of IVIG. There was no rationale provided for starting her on Soliris.
Notes after Soliris initiation suggested she failed first line therapy but this is not consistent with the clinic note from mid-2018 or the examination documented on that date. 
Taken together, the use of Soliris is not consistent with standard of care practice in this clinical context.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with a diagnosis of chronic paranoid schizophrenia.  Case notes document that the patient had been discharged from a psychiatric hospital about a month prior to the admission under review. Soon after the previous discharge, the patient began to experience command auditory hallucinations (CAH), paranoid delusions (PD), depressed mood, and suicidal ideation (SI) with a plan to kill himself.  He did not tell his community psychiatrist of his auditory hallucinations because of fear that he would be jailed.  As the hallucinations intensified, he also experienced paranoid delusions of persons coming after him.  He was brought to the hospital emergency department from where he was admitted involuntarily to an inpatient psychiatric unit.  The health plan's determination is overturned.  Admission for treatment for an exacerbation of schizophrenia with CAH , delusions, and a plan to kill himself by two specific means, mandates inpatient psychiatric admission and treatment, using good medical judgment, and in accordance with current standards of best treatment and in accordance with the medical literature.  This patient has a history of chronic paranoid schizophrenia, and had been recently discharged from a prior admission.  He presented to hospital again (involuntarily) with a plan to kill himself because of the content of his CAH.  Second, the derogatory content of his auditory hallucinations is not uncommon in patients with paranoid schizophrenia.  Thirdly, the resulting suicidal ideation with a plan to kill himself is credible and mandates admission to psychiatric hospital.  Fourth, he showed evasive intent to conceal his plan by not telling his community psychiatrist about his CAH.  There is no reasonable or safe possibility that he could be treated acutely at a lower level of care than inpatient.
Appeal type: Medical necessity
Decision: Overturned

The patient presented to the hospital with the diagnosis of symptomatic cholelithiasis.  Comorbid health conditions included hypertension and hyperlipidemia.  The patient underwent a laparoscopic cholecystectomy that was converted to open cholecystectomy.  The operative dictation describes that due to inability to adequately determine critical anatomic structures, the surgeon converted to open surgery via a right subcostal incision.  A drain was placed, and the patient was treated with post-surgical parenteral analgesia.  Inpatient care was medically necessary, as this patient required conversion of laparoscopic surgery to open cholecystectomy.  This procedural event necessitated provision of IV analgesia and antiemetics for a period of greater than 48-hours and was most appropriately rendered with an inpatient designation.
Appeal type: Medical necessity
Decision: Overturned

This patient has a history of perinatal/postnatal stroke, seizure disorder, nonverbal, non-mobile, tracheostomy and GJ (gastrojejunal) tube dependent who presented for a dislodged GJ tube. The tube was dislodged on the day of presentation. Reportedly, the patient usually has 6-7 wet diapers/day. The patient only had 1 very light wet diaper since the tube was dislodged. The patient gets the medications and feeds via J tube and nothing via G-tube due to concerns for reflux. The patient is tracheostomy dependent and has a home ventilator. The patient is tracheostomy to ventilator when she is agitated and every day while sleeping. The feeds are run over 14 hours with breaks. In the emergency room, the patient was afebrile and tachycardic up to 111 beats per minute. Blood pressure was 99/65 and she was satting 98% on room air. Labs revealed CO2 18. Interventional radiology was consulted with pending scheduling for GJ tube placement the following day.

The health plan's determination is overturned. The inpatient stay was medically necessary. This patient with history of perinatal/postnatal stroke, seizure disorder, nonverbal, non-mobile, tracheostomy and GJ tube dependent presented with dislodged GJ tube. This patient receives all of her medications as well as feeds via the J tube port and G tube port was not used due to risk of aspiration. The patient presented with decreased urine output as well as low CO2 which is a marker for developing metabolic acidosis due to dehydration. Given the past medical history and complexity of her medical care, admission to an inpatient level of care for close monitoring and intravenous fluids (IVF) resuscitation would be prudent as the patient is at risk for breakthrough seizures leading to possible status epilepticus or circulatory collapse due to dehydration. Ventilator dependent patients need higher level of care to monitor their cardiorespiratory status during hospitalization. Given the patient's dependence on the GT for the medications and feeds, expedient replacement of the tube is medically necessary and the level of care needed as she waits for it to be replaced must be provided as an inpatient. Therefore, the inpatient level of care was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This patient has a history of hypertension (HTN), Diabetes, hypothyroidism, morbid obesity, status/post (s/p) gastric sleeve, s/p panniculectomy, right inguinal hernia repair and multiple admissions for chronic abdominal pain who presented to the emergency department (ED) on 3/31/19 with complaint for abdominal pain that began 3 weeks prior and was increasing for 3 days. The patient also reported nausea, vomiting and inability to hold food down. The patient was treated with intravenous fluids and Morphine and antiemetic. The patient was seen by surgery and recommended no surgical intervention. The patient also seen by GI (gastroenterology) and recommended esophagogastroduodenoscopy (EGD) and colonoscopy, however, the patient could not tolerate the prep and was discharged home with outpatient follow-up.

The health plan's determination is upheld. The inpatient stay was not medically necessary. None of the severity of illness criteria were present to support inpatient admission. This patient had chronic symptoms and there was no evidence of any acute findings that would necessitate inpatient management. The patient did not appear to be dehydrated and did not require intravenous fluids as she was able to tolerate oral hydration. She could have been cared for at a lower level of care. This patient had no clinical indications that required an inpatient admission. There were no acute findings or evidence of significant pathology. The patient was not dehydrated and did not require surgery or any other inpatient need.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory Syncytial Virus (RSV)
 
Treatment: Inpatient admission, monitoring

The insurer denied the inpatient admission. The denial was upheld.

This is an infant who presented with fever of 102.0 F, worsening cough for three days, nasal congestion, and difficulty breathing. The documentation of the Emergency Department (ED) examination was contradictory. The chest was said to be clear to auscultation, but congestion was heard. There was no tachypnea, no wheezing, no retractions, nor increased work of breathing. A test was positive for Respiratory Syncytial Virus (RSV). A chest-x-ray was unremarkable. Following admission, the History & Physical (H&P) stated: "Chest: Clear, equal breath sound bilaterally without rhonchi, crackles, or wheezes. Normal work of breathing. No retractions. Good air entry bilaterally." 

Subsequent physician notes stated the patient's chest was clear with equal breath sounds and no retractions. The patient was documented as having good oral intake and urinary output, no respiratory distress, with intermittent fevers. A blood culture result was pending.  The disposition plan stated: "Discharge today if remains non-toxic appearing, good p.o. and urine output, stable respiratory rate and maternal concerns about intermittent fevers are completely addressed".  The patient remained hospitalized until the next day. The blood culture remained with no growth. The infant was in no distress and was discharged to home. 

This infant presented with an RSV infection that mainly affected the upper airway. There was no need for oxygen or intravenous (IV) fluid. PO intake and urine output were adequate. Inpatient criteria were not met. Observation criteria (e.g., MCG: Bronchiolitis Observation Care: Observation) is appropriate for patients whose situation includes 1 or more of the following: Clinical response to outpatient therapy uncertain.

The denial of the inpatient admission was appropriate. The patient met the MCG: Bronchiolitis Observation Care: (Observation) criteria.  The carrier's denial of coverage for inpatient services is upheld. The medical necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Atrial fibrillation
Issue under review: Transcatheter closure of the left atrial appendage and hospital admission

Determination:
The health plan should cover the Transcatheter closure of the left atrial appendage and hospital admission

Left atrial appendage closure devices have limited indications, which are satisfied in this patient. There must be a high CHADSVASC score making anticoagulation necessary, and the patient must also have a contraindication to anticoagulation.

In this case, the patient's hemorrhagic stroke on anticoagulation, Eliquis, makes future anticoagulation contraindicated. His elevated risk of stroke was determined with his elevated CHADSVASC score.

Left atrial closure is indicated. The percutaneous placement of a LAA closure device (Watchman) has been shown to be safe and effective. This has become the standard of care in this setting.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Atrial fibrillation
Issue under review: Transcatheter closure of the left atrial appendage and hospital admission

Determination:
The health plan should cover the Transcatheter closure of the left atrial appendage and hospital admission

The patient has a documented history of atrial fibrillation, and an elevated CHADS-VASC (congestive heart failure, hypertension, age, diabetes mellitus, prior stroke or TIA or thromboembolism, vascular disease, age 65-74, sex category ) score, and it would be consistent with the current guidelines that chronic anticoagulation be used for reduction of his risk of thromboembolic complications, such as CVA. The patient also has a history of hemorrhagic CVA, and is therefore not a candidate for continued anticoagulation. 

The Watchman Left Appendage closure device is FDA approved, and is currently considered to be an appropriate therapy for patients in whom the use of long-term anticoagulation is not an option, which would be consistent with the medical history in this case. Therefore the use of the requested device would be likely to be more beneficial than any standard treatment or treatments for the insured's condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Atrial fibrillation
Issue under review: Transcatheter closure of the left atrial appendage and hospital admission

Determination:
The health plan should cover the Transcatheter closure of the left atrial appendage and hospital admission

This patient has a history of atrial fibrillation and an elevated stroke risk.  Despite being treated appropriately with non-vitamin K anticoagulant therapy (apixaban), the patient had a hemorrhagic stroke.

Left atrial appendage occlusion has been shown to be non-inferior to warfarin therapy in preventing stroke in patients with atrial fibrillation (References 2-5).  Current guidelines recommend considering transcatheter left atrial appendage occlusion in patients that suffer from atrial fibrillation, have an elevated risk of stroke, and a contraindication to oral anticoagulant therapy due to an elevated risk of bleeding (Reference 6).  Current FDA guidelines approve the use of the Watchman device in patients that have an elevated risk of stroke based on the CHADSVASC score and have appropriate rationale to seek an alternative to long term anticoagulant therapy.  

The patient has a CHADSVASC score of 5 and clearly had a contraindication to long term anticoagulant therapy, given his intracerebral hemorrhage.  In conclusion, transcatheter left atrial appendage occlusion was more beneficial than any other treatment and is in line with the standard of care for such patients.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion 

Treatment: D8080 Braces

The insurer denied the D8080 Braces. The denial was reversed.   

This is a young male patient who consulted an orthodontist for orthodontic care. An evaluation was completed which included lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images. A  Handicapping Labio-Lingual Deviation (HLD) index was performed. It was determined that the patient was a candidate for orthodontic treatment.
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.  

Each of the consulted peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care.  As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.  

Reverse denial and approve coverage for braces as the clinical circumstance as presented does substantiate medical/dental necessity of orthodontic care.

The carrier's denial of coverage for D8080 Braces is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Depression with psychotic features
 
Treatment: Continued inpatient mental health treatment services 

The insurer denied continued inpatient mental health treatment services. The denial was upheld.

This is a middle-age male who was admitted to inpatient mental health treatment due to depressive and psychotic symptoms. It was reported that he had command auditory hallucinations that were suicidal in nature, paranoid thinking, suicidal ideation and plan to jump off a bridge, homicidal threats towards his ex-girlfriend and her children, depressed mood, anhedonia, feelings of guilt, worthlessness, hopelessness, and helplessness, sleeping and appetite problems, racing thoughts, and poor insight and judgment.  He reportedly was using cocaine. He had a diagnosis of Major Depressive Disorder with psychotic features. He had a recent past psychiatric hospitalization, and a past substance inpatient rehabilitation treatment.  

The chart notes provided did not have enough specific evidence to support that he only required acute psychiatric hospital treatment or that he could not have been treated in a less restrictive level of care for the final days of his hospital stay. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Major Depressive Disorder indicates that the least restrictive level of care for safe and effective treatment is appropriate. It also states those patients with suicidal intent or plan, or behaviors, or who present as an imminent danger to self or others are in need of hospital treatment. As of hospital day #16, this patient did not have further reports of suicidal or homicidal ideation, plan, or intent, hallucinations, paranoid thinking, and had no reports of out of control behavior, or other psychotic symptoms. There were no reports of specific identifiable or quantifiable treatment goals or objectives that could only be achieved in a 24 hour acute psychiatric hospital setting or that could not be achieved in a less restrictive setting.

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

Diagnosis: Bilateral breast gynecomastia 
Treatment: Removal of breast tissue (bilateral)

Summary:
This male has bilateral breast gynecomastia thought to be due to over the counter supplements. Ultrasound confirms the diagnosis of gynecomastia.  

The mastectomies are cosmetic. There is no documentation of a concern for a breast malignancy and ultrasound confirms the diagnosis of gynecomastia. He is reported to have pain but the records do not document a need for treatment with analgesics, and the surgeon's consultation note does not document disabling pain.  Gynecomastia is a benign condition that does not cause health or functional problems.  According to a 2009 review article from the Mayo Clinic, "Overall, gynecomastia is a benign condition and is usually self-limited. Over time, fibrotic tissue replaces symptomatic proliferation of glandular tissue and tenderness resolves. If the appropriate work-up does not reveal considerable underlying pathology, reassurance and periodic follow-up are recommended...Patients with gynecomastia have a favorable prognosis. These patients present with 2 main concerns: ruling out breast cancer and cosmetic correction. The first concern is adequately addressed by following the appropriate diagnostic evaluation. Breast cancer is rare in males, representing less than 1% of all cases of breast cancer; only 1% of mammograms in men reveal breast cancer.  Therefore, the decision to treat and the choice of treatment should be based on the degree to which this condition has affected the quality of life and mental health of patients and on their desire for cosmetic correction."  The records do not provide any evidence of a concern regarding breast cancer. The procedure will primarily improve appearance and self-esteem and therefore is cosmetic and not medically necessary. Observation, reassurance and use of analgesics as needed are reasonable management approaches for this condition. The patient is likely to derive emotional benefit from the surgery, but his physiologic health will not be improved.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Deep impinging overbite
Treatment: Braces and Follow-up Visits
The proposed braces and follow-up visits are medically necessary. 

The patient has a "deep impinging overbite with severe soft tissue damage", which is an "automatic qualifying" condition. He also has severely protruding upper front teeth. These teeth will constantly be prone to trauma as they are sticking way too far out. Both the severe overbite and the protrusion of his upper front teeth need to be corrected with orthodontic treatment, so he does not continually traumatize his teeth and oral tissues. This case has a medical necessity for orthodontic treatment.
Appeal type: Experimental/Investigational
Decision: Overturned

The patient has a melanoma of the right upper extremity. She was treated with wide local excision with final surgical pathology demonstrating a T4AN0 melanoma. A Decision Dx Melanoma gene assay was performed. This was denied by the health plan and this determination is being appealed.

The health plan's determination is overturned. The Decision Dx Melanoma Test is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. The Decision Dx melanoma gene assay is beneficial in allowing for the physician to be able to make decision regarding adjuvant treatment and more importantly surveillance for recurrence. The gene assay gives insight into the tumor biology that is utilized in addition to the histopathology to formulate the best course of action. A gene assay test identifies high-risk patients who are likely to experience recurrence or die of melanoma within low-risk groups of subpopulations of patients with melanoma who have early stage node negative disease.
It is very difficult to treat metastatic melanoma. The concept of using all available tumor biology data to help formulate a treatment plan to minimize distant disease or recurrence is of utmost importance and is being utilized in the clinical setting.