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

Diagnosis: Digestive System/Gastrointestinal/Abdominal pain, nausea, vomiting and hematemesis
Treatment: Inpatient Hospital

The insurer denied inpatient stay.
The denial is overturned. 

This patient is a male with a past medical history significant for lung cancer status post treatment, now in remission and admitted for acute gastrointestinal (GI) symptoms (abdominal pain, nausea, vomiting, and hematemesis) in the setting of an acute psychotic episode. His physical exam was noted for reproducible inguinal hernia, hyponatremia, and rhabdomyolysis. A diagnostic intravenous (IV) computed tomography (CT) scan revealed acute colitis. The patient was admitted to the inpatient floor and received IV fluids, antiemetic, serial monitoring labs, and IV broad-spectrum antibiotics. General surgery recommended conservative management for inguinal hernia. Gastroenterology recommended bidirectional diagnostic endoscopy to evaluate acute GI symptoms, but the patient refused. Psychiatry consultation recommended treatment for acute schizophrenia. He responded to antipsychotic treatment. Cardiology was consulted for new electrocardiogram (EKG) changes, hypotension, and acute kidney injury. Diagnostic echocardiogram revealed decreased left ventricular function and ejection fraction of less than 15 percent (%). He underwent acute coronary syndrome protocol with Intensive Care Unit (ICU) consultation and required IV fluids with bolus to correct his hypotension and acute kidney injury. He was discharged home after the resolution of his acute GI symptoms.
At issue is the medical necessity of the inpatient stay.

The health plan's determination of medical necessity is overturned in whole.

Yes, the requested health service/treatment of inpatient stay was medically necessary for this patient.
This is a patient with multiple comorbidities who presented with acute GI symptoms that required urgent inpatient medical care, IV antiemetics, IV fluid, IV antibiotics, serial labs, and multiple consultations ( cardiology, surgery, psychiatric and gastroenterology). His clinical presentation required inpatient care for and a delay in management of his colitis in the setting of acute psychotic episodes may have resulted in intraabdominal complication such as peritonitis, sepsis/shock, and death. His comorbidities included an acute psychotic episode that required urgent inpatient care to prevent further medical complications of his colitis. Delay of the medical management of his acute GI and acute psychiatric symptoms increase his mortality and morbidity.
Therefore, the requested health service/treatment of inpatient stay was medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope. 
Treatment: Inpatient Stay. 

The insurer denied the inpatient stay. The health plan's determination is upheld. 

This is the case of a male with autism who presented to the emergency department (ED) via Emergency Medical Services (EMS) transport after taking a fall in the shower at home. Loss of consciousness was reported with some possible seizure like activity. No prior history of seizure or syncope was noted. Review of symptoms (ROS) negative for fever, chills, chest pain, shortness of breath, abdominal pain, vomiting, or diarrhea. The patient did have a sore throat x 1 week. No home medications, no family history of cardiac or neurologic issues were noted. EMS noted confusion and agitation; and the patient had returned to baseline by arrival to the ED. He did not have memory of the event. 

The inpatient admission was not medically necessary in this case. This previously healthy male presented to the ED after syncopal episode with possible seizure activity. Work-up in the ED, including labs, and electrocardiogram (EKG) were normal except for sinus tachycardia and COVID positive. The patient's additional testing such as video electroencephalogram (EEG), monitoring, and consultation could have occurred at a lower level of care. The patient was hemodynamically stable in the ED with Glasgow Coma Scale (GCS)=15, there was no concern for further seizure activity, and heart rate (HR) was 98 on admission to the floor. Thus, a lower level of care is an appropriate disposition in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment is an inpatient admission 
The insurer denied coverage for an inpatient admission 
The denial is upheld

The patient had a history of anemia and gastric bypass surgery and presented with upper abdominal pain, vomiting, and diarrhea. She was recently on an antibiotic for a UTI (urinary tract infection). She was afebrile and the vital signs were stable. A stool hemoccult was negative. There was no abdominal rebound or guarding. There was no leukocytosis. An abdominal CAT (computed tomography) scan showed an adnexal cyst and fecal retention. She was started on PPI (proton pump inhibitor) therapy. No surgical interventions were advised. There was a plan to do an EGD (esophagogastroduodenoscopy), but it was rescheduled as an outpatient. 

Clinical indications for an admission for Undiagnosed abdominal pain {M-05) include having hemodynamic instability, peritoneal signs, inability to maintain oral hydration after observation care, bacteremia, and the need for a procedure that cannot be performed on an ambulatory basis. The patient did not have these conditions.

Clinical indications for admission for Anemia (MCG (Milliman Care Guidelines)M-35) include having hemodynamic instability, active hemolysis, active bleeding, altered mental status, syncope, severe cardiac arrhythmias, severe thrombocytopenia, and acute renal failure. The patient did not have these conditions. 

This patient had upper abdominal pain and there was a concern that she could have peptic ulcer disease. She required PPI therapy and then an endoscopy. This could have been done on an ambulatory basis. The anemia was a chronic problem, and she was not actively bleeding. She could have been managed with observation status. She did not meet MCG criteria for admission for either Undiagnosed Abdominal Pain or Anemia. The health care plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary. The denial is upheld.

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

Diagnosis: Osteoarthritis

Treatment is joint surgery

The insurer denied coverage for joint surgery
 
The denial is overturned

This is a patient with a history of osteoarthritis. He presented to the Orthopedist's office for a follow up visit for right knee pain. The patient was treated with rest, ibuprofen, Relafen, a compressive wrap, and activity modification. Pain affected his activities of daily living (ADL) and function at work. The patient had a right knee arthroscopy with partial medial meniscectomy and loose body removal. There was also an arthroscopic chondroplasty and tricompartmental synovectomy of the right knee.  

The indications for surgery are based upon definition of the pain generator and failure to improve with conservative treatment. There should be a consistency of the clinical condition with a likelihood operative intervention will provide benefit. 

The facts are the patient has a "locked knee". He has a mechanical block to normal motion. There was evidence of giving way and his knee "stuck" in position. The physical examination was dramatic where the motion was limited. He was unable to extend his knee (i.e., Lacking 10 degrees of extension and limited flexion.). Normal mechanics had been disrupted. His physician opined the differential diagnosis of loose body vs meniscal tear. 

Simply stated, he was unable to walk or function in a normal manner. This was acute in onset. The treatment options are limited. A course of conservative management (PT (physical therapy), brace, medication and/or injection) would not be indicated due to the level of pain and functional disability. 

An MRI (magnetic resonance imaging) is indicated to assist in obtaining additional information to diagnose and plan treatment options. The physician was clear in his reasoning about the diagnosis and need for surgery. (I.e., locked knee). An MRI is not absolutely indicated for this clinical scenario. "Clinical examination performed by an experienced knee surgeon provided equal or better results to diagnose meniscal injuries in comparison to an MRI. An MRI is not necessary to confirm these lesions and should not be used as the primary diagnostic tool." (Antinolfi et al)

There was pathology (either loose body or meniscal tear) which required arthroscopic surgery. There were no other treatment options. 

Based upon the clinical condition and documentation, surgery was appropriate and necessary. 
The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

Joint surgery is considered medically necessary for this patient.

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

Diagnosis: Obesity, lymphedema, osteoarthritis, and oxygen dependence. 

Treatment: Durable medical equipment, ramp. 

The insurer denied coverage for durable medical equipment, ramp. 

The denial is overturned. 
	
This is a morbidly obese female with chronic medical problems including lymphedema, osteoarthritis, and oxygen dependence. She is currently residing in a nursing facility and preparing for discharge home. Under review is the medical necessity of requested durable medical equipment (ramp). 

The requested ramp is clinically appropriate and medically necessary for this individual who is morbidly obese (more than 400 pounds) with medical problems that include lymphedema, osteoarthritis, and oxygen dependence. The insurer improperly cited the environmental modification criteria, "necessary to support the health, welfare and safety of the Member" and "necessary for and directly related to the Member's ability to remain safely in the home or community" as well as "there are no other options to safely and effectively meet the member's needs, as defined by the plan," to support the denial of the requested environmental modification. 

The patient's lack of proper home accessibility with photos of the multiple home stairs (back and front) demonstrates a significant safety issue. The patient is a significant falls risk. The requested environmental modification for the ramp installation provides a lifeline for adaptive home ingress and egress. Home ramp instillation is also medically necessary for access to clinical services and the community. 

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 durable medical equipment, ramp is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Periodontal disease.
Treatment: Adult Dental Cleaning; Surgical Bone Reshaping on More than Four Teeth, All Quadrants; Deep Gum and Root Cleaning, All Quadrants.
The insurer denied Adult Dental Cleaning; Surgical Bone Reshaping on More than Four Teeth, All Quadrants; Deep Gum and Root Cleaning, All Quadrants.  
The health plan's determination is overturned.

The patient is a male who presents for the treatment of the entire mouth for his periodontal disease. Previous denials have been on the basis that the service is either not covered or that there is no evidence of bone loss.

The requested Adult Dental Cleaning; Surgical Bone Reshaping on More than Four Teeth, All Quadrants; Deep Gum and Root Cleaning, All Quadrants medically necessary for this patient.

As the patient has evidence of angular bone defects, loss of lamina dura, clinical attachment loss, and bleeding on probing, the periodontal disease presentation is one that cannot be addressed with mechanical scaling and root planning alone. The initial scaling and root planning are necessary to reduce the level of inflammation from the root surfaces that have been affected, and the osseous surgery is necessary in order to address the angular bone defects that will not resolve otherwise. The osseous architecture has become a part of the cause of the current periodontal pockets and disease progression and can only be addressed through reshaping of the defects. The affected third molars are too far distal for proper oral hygiene as well as proper osseous surgery to reduce or eliminate the periodontal defects due to the presence of other anatomic factors such as the external oblique ridge. Hence, the Adult Dental Cleaning; Surgical Bone Reshaping on More than Four Teeth, All Quadrants; Deep Gum and Root Cleaning, All Quadrants is all medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Breast Cancer 
Treatment: Proton Beam Therapy 
The insurer denied proton beam therapy. 
The determination is overturned.

The patient is a female with history of (extent of cancer after therapy) - yp tumor (T)3node (N)1a left breast cancer status/post (s/p) neoadjuvant chemotherapy followed by surgical resection. The subject under review is the medical necessity for proton beam therapy for this patient.

The health plan's determination is overturned.

The requested proton beam radiotherapy is medically necessary in this patient's case. The treating provider has supplied a proton/photon plan comparison which reveals that the patient cannot be treated safely/effectively with the use of photon-based radiotherapy. Both the three dimensional (3D) and intensity modulated radiation therapy (IMRT) photon-based plans were not able to provide adequate safety/precision and protect the patient's heart. If delivered, the photon treatment plans would lead to an unacceptable risk for radiation induced cardiac morbidity/mortality. The proton radiation plan was able to significantly reduce the exposure to the patient's heart, thereby minimizing the patient's risk for high grade toxicity. Proton radiation in the patient's case is supported by numerous high quality clinical outcomes published in the medical literature, as well as the American Society for Radiation Oncology (ASTRO) Model Policy.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stroke
Treatment: Personal Care Aide Level II (24 hour split shift)
The insurer denied Personal Care Aide Level II (24 hour split shift). 
The denial is overturned.

The patient has a history of stroke with right-sided weakness, is wheelchair-bound and is dependent for activities of daily living (ADLs) and instrumental activities of daily living (IADLs).

The patient requires extensive assistance for bed mobility and is unable to turn in bed independently and had developed a pressure ulcer and will continue to be at risk for more pressure ulcers, thus it is important for patient to be turned every 2-3 hours throughout the day which requires assistance. The patient is also noted to be both bowel and urine incontinent and will need frequent diaper changes to avoid skin breakdown, given incontinence and being on a diuretic, toileting is unpredictable.

The requested increase in assistance was not solely for safety and supervision, but to assist the patient with safe completion of ADLs and IADLs during the day and night. 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, Personal Care Aide Level II (24 hour split shift), is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis; Ulcerative Colitis
Treatment: Rinvoq
The insurer denied Rinvoq.
The health plan's determination is overturned.

The patient is a male with Ulcerative Colitis. He has been having 10 bowel movements per day, some with bleeding. He has been on prednisone, and fecal calprotectin was elevated at 2000. A flexible sigmoidoscopy showed continuous disease activity (with edema, erosions, friability, and ulcerations) from the sigmoid colon to the anus; biopsies showed mildly active chronic colitis in the descending colon and at 20 centimeters (cm), and severely active proctitis with ulceration. Subsequent flexible sigmoidoscopy showed Mayo 3+ inflammation with ulceration. He has failed prednisone, Remicade, and Entyvio; he has required total parenteral nutrition in the past, and has been on hyperbaric oxygen. He has been on Rinvoq for approximately 4 weeks. A Colectomy is being considered. The coverage is requested to continue Rinvoq ER (extended release) 45 milligrams (mg) daily for the treatment of Ulcerative Colitis.

Rinvoq is medically necessary for this patient. 

Rinvoq is approved by the U.S. Food and Drug Administration (FDA) for the treatment of Ulcerative Colitis. The recommended dose is 45 mg daily during the 8-week induction phase. Furthermore, Rinvoq has demonstrated both safety and efficacy for the treatment of Ulcerative Colitis in a randomized clinical trial. Guidelines for the treatment of Ulcerative Colitis were written before the FDA approval of Rinvoq for the treatment of Ulcerative Colitis. Although the patient has not attempted Xeljanz or Xeljanz XR (extended release), he is currently on Rinvoq, and there is a risk of decompensation if Rinvoq is discontinued, even if an alternative such as Xeljanz is attempted. Furthermore, his disease is severe, and a colectomy is being imminently contemplated, so there is significant risk if he has decompensation after discontinuation of Rinvoq. For these reasons, the request to continue Rinvoq for the treatment of Ulcerative Colitis is supported by current medical literature and is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cytomegaloviral Disease. 
Treatment: Prevymis 480MG (milligrams) Tablet. 

The insurer denied the  Prevymis 480MG (milligrams) Tablet, preservice. 
The denial is overturned. 

The patient is a female with history of recent heart transplant. She is on CMV (cytomegalovirus) prophylaxis with valgancyclovir due to the donor having been CMV (cytomegalovirus) positive. 

The patient is now experiencing low WBC (white blood count) and bleeding due to the drug. The request is for a change to Prevymis (letermovir) for CMV (cytomegalovirus) prophylaxis. 

Yes, the requested Prevymis is medically necessary. 

Prevymis (Letermovir) is an alternative drug for CMV (cytomegalovirus) prophylaxis and treatment in patients after organ transplantation which has been shown to be safe and effective as other antivirals. 

In this case, due to the side effects that the patient is experiencing with valgancyclovir, Prevymis is an appropriate alternate for this patient whose donor heart was CMV (cytomegalovirus) positive. Use of the drug will be to prophylactically prevent CMV (cytomegalovirus) infection in the recipient while allowing the patient to recover from the side effects of valgancyclovir. 

The cited literature below describes the use of letermovir in the unusual circumstance of thoracic solid organ transplantation when valgancyclovir cannot be used to prevent CMV (cytomegalovirus). 

The available literature does support the use of this drug when the above circumstance does occur. In this patient, continuing valgancyclovir is likely to be fatal. Further no treatment for CMV (cytomegalovirus) prophylaxis will likely result in CMV (cytomegalovirus) infection, which will also be fatal.

Therefore, given the above, the requested Prevymis is medically necessary. 

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Cancer- Breast Cancer.
Treatment: Diagnostic Testing (other than Radiology)- BIS assessment. 
The insurer denied Diagnostic testing-bioimpedance spectroscopy (BIS) assessment using ImediMedL-Dex testing. The denial is overturned. 

The patient is a female with right breast cancer status post right mastectomy and right sentinel node biopsy and left breast prophylactic mastectomy. She has been recommended for Bioimpedance spectroscopy, which has been denied by the health plan.
At issue is whether the proposed health service or treatment Diagnostic testing- bioimpedance spectroscopy (BIS) assessment using ImediMedL-Dex testing is likely to be more beneficial than any standard treatment or treatments for the patient's condition.

The health plan's determination regarding the proposed health service or treatment is overturned in whole.

The proposed health service or treatment Diagnostic testing- bioimpedance spectroscopy (BIS) assessment using ImediMedL-Dex testing is likely to be more beneficial than any standard treatment or treatment's for the patient's condition.
Bioimpedance spectroscopy is more beneficial than traditional methods of measuring or identifying lymphedema. Traditional methods of measuring or identifying lymphedema such as arm circumference are outdated and tend to identify lymphedema at later stages. Whereas bioimpedance spectroscopy allows for the identification of the very start of lymphedema even before significant physical signs may develop. The key to managing lymphedema is to start treatment early in an effort to stabilize and decrease the severe morbidity of lymphedema.
Koelmeyer et al found that women who were in the early surveillance group and were able to have lymphedema care significantly earlier than those in the traditional referral group with the aid of bioimpedance studies had lower rates of stage and severity of lymphedema. Significantly more women in the traditional referral group were diagnosed with clinical lymphedema (stage 1-3 (I-III), 39 percent (%) versus (vs) 14%) and with greater severity (stage II-III, 24%) compared with those in the early surveillance group (4%).
Clinicians involved in multidisciplinary centers routinely monitor and utilize bioimpedance studies to help initiate early treatment for lymphedema in women who are at high risk for the development for lymphedema.
Therefore, the proposed health service or treatment Diagnostic testing- bioimpedance spectroscopy (BIS) assessment using ImediMedL-Dex testing is likely to be more beneficial than any standard treatment or treatment's for the patient's condition.