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

Diagnosis: Cystitis
Treatment: Inpatient Stay
The insurer denied the Inpatient Stay.
The determination is upheld.


The patient has a past medical history (PMH) of diabetes mellitus type 2 (DM2), hypertension (HTN), hyperlipidemia, chronic kidney disease (CKD), and recurrent cystitis and was admitted with complaints of (c/o) a two-week history of abdominal pain associated nausea. Vital signs were notable for a blood pressure (BP) of 202/100. The physical exam was significant for suprapubic tenderness to palpation (TTP), non-toxic appearing. Lab work was notable for a urinalysis (UA) with pyuria and hematuria, creatinine 2.8 (baseline 2.2), and a negative urine culture. Imaging studies, an ultrasound (US) of the bladder showed an enlarged prostate and mild post void residual (PVR). The patient was diagnosed with cystitis and HTN and treated with observation and anti-hypertensives. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with complaints of (c/o) suprapubic/abdominal pain without systemic toxicity. The patient was hemodynamically stable, did not meet systemic inflammatory response syndrome (SIRS) criteria, did not have acute severe acute kidney injury, pyelonephritis, ascending infection, toxic appearance, unstable vital signs, immunosuppression, urinary obstruction, coexisting urolithiasis, failure of outpatient treatment, abnormal anatomy, abscess formation, single kidney, or kidney transplant. The patient was suspected of urinary tract infection (UTI) on admission, but due to the patient's stability, antibiotics were held and the urine culture was ultimately negative. For the HTN, there was no alteration of consciousness, neurologic deficits, encephalopathy, cerebrovascular accident (CVA), intracerebral hemorrhage (ICH), retinal hemorrhage/papilledema, acute coronary syndrome (ACS), aortic dissection, or acute heart failure. Overall, this patient was found to have a UTI and was treated with IV antibiotics, with resolution of the patient's symptoms, and these interventions could have been safely and appropriately provided at a lower level of care.
The patient did not have hemodynamic instability, severe dehydration, failure of outpatient treatment, urinary obstruction, immunocompromised state, recent urologic manipulation, acute kidney injury (AKI) with 3-fold increase in creatinine from baseline, creatinine greater than (>) 4, glomerular filtration rate (GFR) reduction 75%, or cessation of urine output.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol withdrawal.
Treatment: Inpatient admission.
The insurer denied coverage for an inpatient admission. 
 The denial is overturned.

This patient was admitted to this inpatient medical hospital due to active alcohol withdrawal symptoms including active vomiting, tongue fasciculations, hand tremors, elevated blood pressure of 153/101, critical lactate level of 5.58, hyperkalemia of 6, low Na (sodium) of 128, low Cl (chloride) of 83, low CO2 (carbon dioxide) of 16, elevated AG (albumin/globulin) and AP (alkaline phosphatase). He reportedly was given multiple IV (intravenous) Diazepam doses including 5 mg (milligram), 10 mg, and 20 mg for detoxification and was on a Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol, had continuous cardiac monitoring, was given IV medications including Zofran, insulin, IV Mg (magnesium) and vitamin B1. His ultrasound revealed hepatosteatosis. He was discharged and refused the recommendation for outpatient substance treatment.
    
The medical records provided enough specific evidence to support that the patient required this level of care and that he was considered a high risk medically for worsened alcohol withdrawal and that he required hospital treatment. The APA (American Psychiatric Association) 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 conditions that complicate the management of withdrawal are also candidates for inpatient detoxification.  

In this case this patient had several comorbid medical conditions including a pulmonary embolism complicating the management of withdrawal, which required 24-hour hospital treatment. The risk of delirium tremens can occur 3-4 days after alcohol use so he was considered at risk for complicated and life-threatening withdrawal as he had active alcohol withdrawal symptoms including active vomiting, tongue fasciculations, hand tremors, elevated blood pressure of 153/101 requiring IV detoxification medication and also had multiple medical issues putting him at risk medically. 

The insurer's denial of coverage for the inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Cancer-Tongue cancer
Treatment: Radiation Therapy-Proton bean radiation therapy (PBT)
The health plan denied the proposed health service or treatment of proton beam radiation therapy (PBT) as Experimental/Investigational. The health plan's determination is upheld in whole. 
This is an adult male with history of Tumor(T)2Node(N)2Metastasis(M)0 invasive squamous cell carcinoma of his right tongue base. Request is for proton beam radiotherapy.

The proposed proton radiation is likely to be more beneficial than any standard treatment for the patient's locally advanced oropharyngeal carcinoma. The treating provider has supplied a proton/photon plan comparison which reveals that the photon-based intensity modulated radiation therapy (IMRT) plan would be associated with a significantly higher risk for xerostomia, feeding tube dependence, and swallowing dysfunction including aspiration risk. The exposure to the patient's oral cavity and salivary tissues (bilateral parotid and left submandibular gland) was above nationally accepted normal tissue dose constraints. The proton radiation plan was able to significantly reduce the exposure to these critical radiosensitive tissues, thereby limiting the patient's risk for high grade toxicity. Proton radiation for management of oropharyngeal carcinoma is supported by numerous prospective clinical outcomes reported in the peer reviewed medical literature. The American Society for Radiation Oncology (ASTRO) Model policy for proton radiation supports its use in the setting where it is shown that photon radiation cannot provide adequate safety/precision. The health plan's determination if overturned in whole.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Cancer-Tongue cancer
Treatment: Radiation Therapy-Proton bean radiation therapy (PBT)
The health plan denied the proposed health service or treatment of proton beam radiation therapy (PBT) as Experimental/Investigational. The health plan's determination is upheld in whole. 
This is the case of an adult male patient who presented with Tumor(T)2Node(N)2metastasis(M)0 cancer of the right (R) base of tongue. Patient is being evaluated for curative Radiation Therapy (RT) using Proton beam. This is the subject of review.

The proposed health service or treatment of proton beam radiation therapy (PBT) is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Currently, there is no clinical data in the medical literature to suggest that treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques for head and neck cancer. In this setting, there is no published literature that compares clinical outcomes of proton beam radiotherapy compared to standard photon techniques. In the majority of cases the standard approach to treat this malignancy is with standard photon techniques.
Also, the American Society for Radiation Oncology (ASTRO) emerging technology committee report on proton therapy specifically states that there is insufficient data to recommend proton beam therapy for routine head and neck radiation therapy outside of clinical trials
Although with intensity modulated radiation therapy (IMRT), dose to certain critical structures may be higher, it is still considered an acceptable to use IMRT in this setting and the difference between the two plans may not be considered clinically significant.
Currently, there is insufficient clinical data to discern whether treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques in this setting. The provider has not provided a significant justification for why proton therapy should be utilized over standard photon radiation in the records provided for review. Consensus group guidelines do not support the use of proton therapy in this setting. The health plan's determination is upheld in whole.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Cancer-Tongue cancer
Treatment: Radiation Therapy-Proton bean radiation therapy (PBT)
The health plan denied the proposed health service or treatment of proton beam radiation therapy (PBT) as Experimental/Investigational. The health plan's determination is upheld in whole. 
This patient is an adult male with a right base of tongue squamous cell carcinoma, staged Tumor(T)2Node(N)2Metastasis(M)0. Radiation therapy is recommended as definitive treatment for this patient and proton beam approach is requested.
The proposed treatment of proton beam radiation therapy is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The recommended proton beam radiation therapy for this patient with oropharynx squamous cell carcinoma is not considered likely to be more beneficial as there is lack of any significant clinical trials published in peer reviewed journals supporting the benefits and safety of proton beam radiation therapy as compared to standard conventional photon beam radiation therapy. There are multiple ongoing clinical trials accruing patients that need to mature and be evaluated and published in peer reviewed journals to assist in determining the benefits and safety of proton beam radiation therapy as compared to photon beam radiation for this clinical scenario. The health plan's determination is upheld in whole.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ulcerative Rectosigmoiditis with Rectal Bleeding. 
Treatment: Entyvio (300 mg [milligrams] every 4 weeks). 

The insurer denied Entyvio (300 mg every 4 weeks). 
The denial is overturned. 

The patient is an adult male with moderate to severe ulcerative colitis. He has failed mesalamine, canasa, 6-MP (mercaptopurine) and Humira. Two years ago he was started on Entyvio 300 mg (milligrams) every 8 weeks, and did well until this year when he had increased diarrhea, bleeding and mucus. His provider is requesting to increase Entyvio to 300 mg every 4 weeks. 

The requested Entyvio every 4 weeks is medically necessary. 

Medical literature supports dose intensification of biologic agents in patients who lose response to FDA (United States Food and Drug Administration)-approved dosing. Entyvio has been found to be safe and effective at doses as high as 600 mg IV (intravenous) every 4 weeks. 

Per Singh, et al, "Shortening infusion interval from 8 to 4 weeks led to improved effect in 3/7 (43% [percent]). This is supported by recent pharmacokinetic data demonstrating significant correlation between higher vedolizumab drug levels and clinical response in inflammatory bowel disease (IBD) patients.'' 

During the trial completed by Williet, et al, 30 out of 47 IBD patients undergoing induction with vedolizumab who had not achieved remission by week 6 of treatment had their dose frequency increased to every 4 weeks. All of those with vedolizumab trough levels less than 10 mcg/mL (micrograms per milliliter) at week six achieved clinical remission 4 weeks after initiation of the higher dosing frequency. 

The patient did not have a complete response to Entyvio 300 mg every 8 weeks, and has done well on Entyvio 300 mg every 4 weeks. Serum Entyvio levels were therapeutic, but are not as reliable as anti-TNF (tumor necrosis factor) drug levels. Medical literature supports dose intensification of Entyvio to 300 mg every 4 weeks prior to changing to another biologic. This patient has tried and failed Entyvio 300 mg every 8 weeks, with increased symptoms. Therefore, the requested Entyvio 300 mg every 4 weeks is clinically appropriate, accepted standard of care and medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gestational hypertension

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient is a pregnant female at 34.3 weeks of gestation who presented to the hospital as a transfer from another facility with suspected preeclampsia because of a low platelet count. She had a 24-hour urine collection a week before presentation that was normal. The thrombocytopenia predated the mild elevation of blood pressure. 24hour urine protein was negative. She was admitted with a diagnosis of gestational hypertension rather than preeclampsia for monitoring.

Her blood pressure was within normal limits to mildly elevated. Laboratory evaluation was normal except for decreased platelets count. Urine protein was negative. Fetal heart rate was reassuring, and the patient was discharged home.

According to the medical records, the patient was admitted for the following reasons:
Gestational hypertension for monitoring.

Preeclampsia refers to the new onset of hypertension and proteinuria or hypertension and significant end-organ dysfunction with or without proteinuria after 20 weeks of gestation in a previously normotensive woman. Women with gestational hypertension with severe range blood pressures (a systolic blood pressure of 160 or higher, or diastolic blood pressure of 110 or higher) should be diagnosed with preeclampsia with severe features. These severe ranges of blood pressure increase the risk of morbidity and mortality.

According to American College of Obstetricians and Gynecologists (ACOG), hospitalization is appropriate for women with severe features. This patient did not have preeclampsia. She had a mild elevation in blood pressure that stabilized without any medication. In addition, there was no protein in the urine and her laboratory evaluation was normal except for low platelet count that predated any increase in blood pressure.

This patient could have been observed. Once her laboratory evaluation returned normal and no significant elevation of her blood pressure was noted, she could have sent home without the need for admission. Neither the patient nor the fetus was in any jeopardy. Fetal heart rate was reassuring. There was no evidence of ruptured membranes.

Milliman Care Guideline (MCG) lists clinical indication for admission to include:
Condition requiring premature delivery; Delivery; Fetal distress or demise; Preterm labor and positive fetal fibronectin (fFN); Significant maternal disease, infection, or comorbidity as cause; Significant vaginal bleeding or any vaginal bleeding with known placenta previa, vasa previa or placenta accrete; Continued fetal monitoring; Tocolytic therapy that requires inpatient care; Complications of tocolytic treatment

This patient did not have any of the above. Based on the above, the acute inpatient hospital admission was not medically necessary.

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

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

Diagnosis: Acute Cholecystitis. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is overturned. 

The patient presented with upper abdominal pain. She had a history of gastroesophageal reflux disease (GERD) and a sleeve gastrectomy. She was afebrile but had hypertension. Abdominal tenderness was present but there was no rebound or guarding. The white blood cell (WBC) count was 11.8. The abdominal ultrasound showed a large stone in the neck of the gallbladder along with gallbladder wall thickening and the impression was that she had acute cholecystitis. She was given antibiotics and improved. There was a plan for an outpatient cholecystectomy. 

Clinical indications for admission for Gallbladder or Bile Duct inflammation or Stone (MCG [Milliman Care Guidelines]) include having acute cholecystitis as manifested by right upper quadrant (RUQ) abdominal pain and a systemic sign of inflammation. The systemic sign of inflammation can be fever or a WBC count over 10,000. In this case, the patient had both RUQ pain as well as a WBC count over 10,000. This met the criteria for admission for acute cholecystitis under MCG guidelines for Gallbladder or Bile Duct Inflammation or Stone. An inpatient admission was medically necessary. 

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

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

Diagnosis: Bipolar disorder
Treatment is PCA (personal care aide) services 10 hours/week, consumer direct, 1 client.
The insurer denied coverage for PCA services 10 hours/week, consumer direct, 1 client.
The denial is upheld.

This patient is an adult with diagnosed bipolar disorder and depression. She lives with her parents and 2 sisters. The insurer approved PCA services 1.25 hours/week. Under review is the requested increase PCA services 10 hours/week, consumer direct, 1 client.

The Uniform Assessment System (UAS) report was reviewed. There were no specific cognitive deficits, she was described as independent and is able to perform shopping, cooking and housekeeping independently. The patient is also independent for activities of daily living and mobility including bathing, personal hygiene, dressing, toilet transfer/use and bed mobility. She is continent of bowel and bladder. She ambulates independently without the use of a device. The patient's documented independent cognitive and functional ability do not support the requested personal care aide (PCA) services 10 hours per week, consumer direct, 1 client.
  
The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the personal care aide (PCA) services 10 hours per week, consumer direct, 1 client is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

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

The patient is a girl who presented with right breast pain and redness. She was well until two days prior to presentation when she developed some pain around her right breast. She then developed redness which seemed to be increasing. She also noted some discharge from her areola. She then developed pain on the side of her breast and right upper arm. In addition, she noted that she was feeling some nausea and dizziness. Her symptoms were progressively worsening, so she was brought to the emergency department for evaluation.

Inpatient Hospital Admission was medically necessary for this patient.
Hospitalization for parenteral antimicrobial therapy is indicated for patients with cellulitis who have a rapid progression of erythema and for children with systemic signs, including fever, tachycardia, or an inflammatory response. Specifically for adolescents with mastitis who have rapid progression of erythema, treatment should be given parenterally. Patients may be transitioned from parenteral to oral therapy when systemic symptoms have resolved and localized findings have improved, as was done for this patient.
 
This is a young girl who presented with mastitis. Her symptoms were progressing, and she was having additional symptoms of dizziness and nausea. At the time of presentation, she had a large area of erythema as well as induration around the nipple. This was accompanied by significant discomfort. Her temperature was elevated at 99.6, and she had tachycardia. Therefore she required hospital admission for prompt administration of parenteral antibiotics, along with appropriate monitoring with escalation of therapy as needed. She had specialist consultation from the surgical team, who recommended this treatment plan.
The decision-making at the time of admission for this patient was consistent with her young age, the presence of mastitis that was progressing and associated with systemic symptoms, and the need for prompt initiation of therapy along with close monitoring for potential worsening of her clinical status.