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

Diagnosis: Parotid mass
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a history of periauricular pain and a mass that was present for 1.5 years. The biopsy of the mass was suggestive of a parotid malignancy (adenoid cystic carcinoma). A computed tomography (CT) scan of the neck showed fullness and enhancement with a mass effect of the left parotid gland. The patient underwent a left total parotidectomy (deep lobe removal) with facial nerve dissection, along with left neck adjacent tissue transfer. The patient was admitted (as an inpatient) postoperatively for monitoring of hematoma, nerve injury, and swelling. Post operatively the patient was tolerating a regular diet, voiding and ambulating independently. Other significant co-morbidities include hypertension. The patient was discharged without complications.
At issue is the medical necessity of an inpatient stay.

The inpatient stay was not medically necessary. Post operative management could have been provided at a lower level of care.
The patient underwent a left deep lobe parotidectomy for a malignancy without complication. There was no respiratory distress or difficulty with taking anything by mouth following the surgery. There was no indication for an inpatient admission. Postoperative recovery of the patient could have been managed appropriately at a lower level of care. Postoperatively, the patient was tolerating a regular diet, voiding and ambulating independently.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse/Addiction.
Treatment: Inpatient stay.

The health plan denied the requested inpatient stay. 
The health plan's determination is overturned.

The patient is an adult male who presented to the emergency department and was evaluated and subsequently admitted to acute inpatient level services for detoxification and withdrawal management of severe opioid (heroin and non-prescribed Methadone) and alcohol use disorders. The patient was using large amounts of alcohol and opioid substances on a daily basis with up to 4 pints of vodka and 10 bags of heroin with inhalation, as well as 80 mg of Methadone twice weekly. He had longstanding substance use with heroin and alcohol beginning in adolescence. The patient had experienced severe drug and alcohol withdrawal symptoms in the past, and he had received detoxification and rehabilitation services in the past with up to two years of sobriety while participating in treatment with relapse. He reported an inadvertent overdose of Methadone and Benzodiazepine requiring emergency services and hospitalization.

Following his first day of treatment, the patient began to participate in counseling and educational sessions, as he was feeling better and able to eat with improving appetite. His mental status examination included persistent symptoms of anxiety and irritability with associated symptoms of insomnia. He demonstrated no severe symptoms such as mania, psychosis, perceptual disturbance, or severe cognitive impairment. His Clinical Institute Withdrawal Assessment (CIWA) and Clinical Opiate Withdrawal Scale (COWS) scale scores were light or mild at 9/9.
The patient did continue with detoxification treatment with completion of the medication tapers, and he was provided education and counseling during the inpatient stay including involvement with recovery groups and motivational enhancement therapy. The patient was discharged with referral for clinically appropriate aftercare including plans for inpatient residential rehabilitation treatment and consideration of medication assisted treatment and recommendation for involvement in recovery groups.

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

Yes, the requested health service/treatment of Medically Supervised Inpatient Detoxification, Withdrawal Management, and Stabilization Services is medically necessary for this patient.
The patient in this case presented with a diagnosis of severe alcohol and opioid use disorders with history of severe alcohol and drug withdrawal in the past and inadvertent overdose. The patient also has severe psychosocial stressors with limited support and functional impairments.
The presenting clinical features and history and risk for withdrawal seizures and other complications of severe alcohol and opioid use disorders did warrant the admission and continued inpatient level services with medical monitoring. The patient's admission and continued inpatient stay with detoxification, withdrawal management, and other medical services through discharge could not have been provided at a lower level of care in this case scenario.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Complete Loss of Teeth.
Treatment: Ensure LiQ Origin.
The insurer denied the Ensure LiQ Origin.
The denial is upheld.

This male patient has complete loss of teeth and a diagnosis of human immunodeficiency virus (HIV).  He is appealing denial of Ensure.  He has a body mass index (BMI) of 17.8.  He has been taking "this medication" for several years.

No, the proposed treatment is not medically necessary.
Nutritional supplements are typically used in patients who cannot maintain adequate oral intake of food or nutrition to meet their metabolic demands due to malabsorption or disorders of metabolism.  This patient has human immunodeficiency virus (HIV) and is edentulous.  There are no clinical notes supporting this patient's need for this nutritional supplement, i.e. concerning low body mass index (BMI), failure to thrive, and and participation in a nutrition program.  Based on all available information, the proposed treatment is not medically necessary.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Plaque Psoriasis

Treatment: Otezla

The insurer denied coverage for Otezla

The denial is overturned

The patient has a past medical history significant for diabetes and hypertension who has a diagnosis of psoriasis vulgaris.  The patient has been successfully treated with Otezla 30mg (milligrams) bid (twice per day) without complications.  Since the medication was denied, the patient has noted flaring of the psoriasis.  The requested medication is re-initiation of Otezla.  

The requested service is medically necessary based on the provided medical records and the medical literature.  The patient has medical conditions which may limit the use of standard systemic medications commonly used for the treatment of psoriasis.  The patient has successfully been treated with Otezla without any significant documented adverse reactions.  Although treatment with light therapy or other systemics may be alternative medical options, this patient has noted improvement of psoriasis with Otezla.  The request to re-initiate Otezla therapy is thus 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 30 milligrams (mg) of Otzela to treat plaque psoriasis is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma

Treatment Dupixent 300 milligrams/ 2 milliliters (300 mg/ 2 ml) subcutaneous (SC) solution pen injector (SOPN)

The insurer denied coverage for Dupixent 300 milligrams/ 2 milliliters (300 mg/ 2 ml) subcutaneous (SC) solution pen injector (SOPN)

The denial is overturned

This is the case of an adult female with a history of moderate persistent asthma and severe allergic rhinitis. As per information provided by the provider's office, the patient has been on multiple medications and has not had significant improvement. Presently, she is steroid dependent. Medications tried including Trelegy, Budenoside, Symbicort, Flonase, Duo Nebs, Montelukast and oral prednisone over past several months. The patient has had multiple exacerbations in the past year which required office visits and multiple courses of oral steroids. The patient has an IgE [immunoglobulin] of 410. The patient's provider recommended biologic agent Dupixent.

Based on failure to respond to multiple medications from the preferred list in this steroid dependent asthmatic, it is appropriate to try Dupixent in this patient.

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

The insurer's denial of coverage for Dupixent 300 milligrams/ 2 milliliters (300 mg/ 2 ml) subcutaneous (SC) solution pen injector (SOPN) is reversed. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder. Treatment: Inpatient Hospital. 
The insurer denied Inpatient Stay. 
The denial is upheld. 

The patient is a male with a past medical history remarkable for alcohol abuse, anxiety, and anemia, who was admitted for a fall and reports of a possible seizure. The review of systems was negative for additional clinical symptoms. The patient was afebrile with a temperature of 96.8. The patient was described as well-developed and well-nourished. His blood pressure was 155/98, pulse rate of 95, respiratory rate of 20, and oxygen saturation of 97% on room air. The physical examination was unremarkable for positive clinical findings.
Laboratory evaluation demonstrated a sodium of 135, potassium of 3.7, chloride of 105, carbon dioxide (CO2) of 24, blood urea nitrogen (BUN) of 9, creatinine of 1.20, glucose of 83, white blood cell (WBC) count of 10.2, hemoglobin (Hgb) of 13.0, hematocrit (Hct) of 37.8, and platelets of 161. The chest x-ray revealed no acute pulmonary disease. A computed tomography (CT) scan of the brain showed no acute infarct.
The patient was admitted for alcohol related seizure. The patient was treated with intravenous (IV) fluids and was monitored under Clinical Institute Withdrawal Assessment (CIWA) protocol. The patient was evaluated by a neurologist and psychiatrist. The patient was subsequently stable for discharge.
At issue is the medical necessity of Inpatient Stay.

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

The requested health service/treatment of Inpatient Stay is not medically necessary for this patient.
The patient was admitted for alcohol intoxication and withdrawal. The documentation does not support an inpatient level of care since the patient was hemodynamically stable and had no evidence of instability or focal neurologic deficits. There were no objective clinical findings that were consistent with alcohol withdrawal or delirium tremens. The Diagnostic and Statistical Manual of Mental Disorders defines alcohol withdrawal as 2 or more distinguishing symptoms which develop within several hours to days following a significant decrease in alcohol consumption after a prolonged period of heavy drinking. These symptoms include nausea or vomiting, autonomic hyperactivity, insomnia, increased anxiety and agitation, tremor, perceptual disturbances, and seizure. In this case, the patient had no objective signs of autonomic hyperactivity. In addition, his CIWA scores did not warrant treatment at the inpatient level.
Therefore, the requested health service/treatment of Inpatient Stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anaplastic astrocytoma
Issue under review: Optune device

Determination:
The Optune device is not medically necessary.

The patient had a craniotomy and biopsy of a left frontal abnormality. This was positive for a WHO grade III anaplastic astrocytoma. MGMT (O[6]-methylguanine-DNA methyltransferase) was unmethylated and was IDH1 mutation negative.

The patient has a grade III glioma (anaplastic astrocytoma). This is not glioblastoma multiforme. The letters of appeal and all the references provided by the provider are studies of Optune electrical field therapy to treat glioblastoma.

The study of the Optune device for adjuvant therapy were for treatment of glioblastoma and not anaplastic astrocytoma (Stupp R, Taillibert S, Kanner AA, Kesari S, Steinberg DM, Toms SA, Taylor LP, Lieberman F, Silvani A, Fink KL, Barnett GH, Zhu JJ, Henson JW, Engelhard HH, Chen TC, Tran DD, Sroubek J, Tran ND, Hottinger AF, Landolfi J, Desai R, Caroli M, Kew Y, Honnorat J, Idbaih A, Kirson ED, Weinberg U, Palti Y, Hegi ME, Ram Z. Maintenance Therapy With Tumor-Treating Fields Plus Temozolomide vs Temozolomide Alone for Glioblastoma: A Randomized Clinical Trial. JAMA. 2015 Dec 15;314(23):2535-43). Reviews only support the treatment of glioblastoma (Mehta M, Wen P, Nishikawa R, Reardon D, Peters K. Critical review of the addition of tumor treating fields (TTFields) to the existing standard of care for newly diagnosed glioblastoma patients. Crit Rev Oncol Hematol. 2017 Mar;111:60-65). 

The FDA-approval of the Optune device is only for treatment of newly diagnosed glioblastoma (https://www.healio.com/hematology-oncology/neuro-oncology/news/online/%7B66bdc933-f9f1-41ba-ad6e-d0d92a640aec%7D/fda-approves-optune-for-newly-diagnosed-glioblastoma-multiforme; accessed 11/20/2019).

The NCCN Guidelines only support use of the Optune device to treat glioblastoma and not anaplastic astrocytoma (NCCN Guidelines Version 2.2019, Central Nervous System
Cancers). 

The use is not supported for treatment of anaplastic astrocytoma and this use is considered unproven and not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumonia. 
Treatment: Inpatient Hospital Stay. 

The health plan denied the inpatient admission as not medically necessary.  The reviewer has overturned in whole the health plan's determination. 

This patient has a history of metastatic renal cell carcinoma (RCC) with pulmonary involvement who presents with dyspnea. On admission vitals were blood pressure 116/59, heart rate 112, respirations 18 and oxygen saturation 94% (percent) (lowest 89%) on room air. Labs were notable for a hemoglobin of 10, white blood cell count (WBC) 14.4, blood urea nitrogen (BUN) 15, and creatinine 0.87. Chest Xray showed near white out of the left lung, left sided patchy infiltrates and hilar fullness. He was started on intravenous (IV) antibiotics and supplemental oxygen and admitted for community acquired pneumonia. He was also seen by oncology for disease progression, with modification made to his outpatient oral chemotherapy regimen. He was discharged home to finish his course of antibiotics. 

Yes, inpatient admission was medically appropriate. This patient has metastatic cancer and presented with dyspnea, acute hypoxic respiratory failure, and radiographic findings consistent with pneumonia and disease progression. He presented with sepsis from pneumonia with elevated heart rate, white blood cell count, and suspected source of infection [1]. Patients who present with sepsis are best managed in the inpatient setting due to high acuity and nursing interventions. In addition, the Pneumonia Severity Index (PSI) / Pneumonia Patient Outcomes Research Team (PORT) Pneumonia Severity Index can be used to help risk stratify patients who present with pneumonia. He scored 91 points for age, sex and neoplastic disease which placed him in the high-risk category indicating that inpatient admission would be appropriate [2].
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Carrier for autosomal-recessive polycystic kidney disease (ARPKD). 
Treatment: Egg Retrieval. 

The health plan denied the egg retrieval as not medically necessary.  The health plan's determination is upheld. 

The patient is a woman who is seeking in vitro fertilization (IVF) with PGT-M (diagnostic procedure in which embryos are tested for genetic abnormalities), as she and her partner are both carriers for autosomal-recessive polycystic kidney disease (ARPKD).  At issue is the medical necessity of a second egg retrieval, as she has two embryos cryopreserved from her first egg retrieval. 

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

At this point in time, with two embryos available for testing, it is not medically necessary to create additional embryos. Each of these embryos has a 75% (percent) chance of not having two copies of ARPKD. 

The patient has two embryos available. With both parents being carriers of ARPKD, each embryo has a 25% chance of being affected and a 75% chance of not carrying the gene or only having one copy which does not result in disease. It is not medically necessary at this point to create additional embryos. 

As the patient's physician noted, one in four embryos (25% of embryos) will be homozygous for polycystic kidney disease (PKD-1). The provider recommends having at least four embryos to biopsy. However, there is a 25% chance that any one of the two embryos she has the disorder and a 75% chance that the embryos will either have no mutation or simply be carriers. So, it may be ideal to have four embryos, but it is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism Spectrum Disorder. 
Treatment: Autism Related Treatment (including ABA). 

The insurer denied Applied Behavioral Analysis (ABA) treatment. The denial is overturned. 

The patient is a male, who has a diagnosis of autism spectrum disorder and attention deficit hyperactivity disorder (ADHD). The patient has deficits in receptive and expressive language, delays in cognitive functioning, and global cognitive delays. 
At issue is the medical necessity of Applied Behavioral Analysis (ABA) treatment. 

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

The requested service/treatment of Applied Behavior Analysis (ABA) treatment is medically necessary for this patient. 

The reasons for the denial are specified in the letter from the health plan. According to this letter, "The information provided for this appeal did not clarify the reasons provided for the original denial; therefore, the denial is upheld on appeal as not medically necessary."  However, the updated treatment plan by the ABA provider, documents a conversation with the primary care physician (or provider) (PCP), phone messages left, and faxes sent to neurologist, physical therapy (PT), occupational therapy (OT), and Speech Language Pathologist (SLP). The updated treatment plan also documents that the Board-Certified Behavior Analyst (BCBA) went to the patient's school, observed him in class, reviewed school goals and the progress he's making with these goals. The patient already had an established diagnosis of autism at the time of these evaluations. The inclusion of a repeat of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) diagnosis criteria would not be clinically required in this case, as suggested by the denial, when a diagnosis of severe autism has already been firmly established. The psycho-social assessment documents that the medication Depakote is being used to manage the patient's symptoms of agitation. In an office note the provider documents that Depakote is part of the patient's treatment for ADHD. In addition, ABA is the generally accepted standard of care for this patient's diagnosis. 

Therefore, the requested service/treatment of Applied Behavior Analysis (ABA) treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Appendicitis

Treatment inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

This case involves a female teen who presented to the emergency department complaining of abdominal pain in addition to diarrhea and vomiting. The documentation indicated she did have physical examination findings of abdominal tenderness to the right lower quadrant. There was guarding. There was no rebound. The physical exam revealed a temperature of 98.4. The recommendation was made for laboratory diagnostic studies. The patient's white blood cell count was 18.4. The documentation indicated she was given Zofran however vomited. A computed tomography (CT) scan was recommended as an ultrasound was equivocal. The CT scan did reveal acute appendicitis. The recommendation was made to consult with surgery. She was admitted and underwent surgical intervention the following day. She was monitored postoperatively and was discharged given no significant adverse events postoperatively.

According to current literature, a pediatric appendectomy without abscess or peritonitis is typically an ambulatory procedure. An additional stay may be needed when there are complications noted during the procedure. Additionally, if there are postoperative complications, the patient may need to stay and be admitted. The documentation indicated she did initially present where it was noted she had an elevated white blood cell count and appendicitis by CT scan. She did undergo a laparoscopic procedure without complication the following day. She was discharged given the lack of significant adverse events postoperatively. The documentation does not indicate the need for the inpatient admission as she could have undergone surgical intervention on an ambulatory basis. 

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

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

Diagnosis: Bleeding from Esophagus or Stomach
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

The patient is a male who presented with two episodes of coffee ground emesis after breakfast. He reported black stool for four days.  He was hemodynamically stable. There was slight abdominal distension and no tenderness. The patient's hemoglobin (Hgb) was 14.5. His blood urea nitrogen (BUN) was 28. His stool was OB + [postive].  An x-ray was negative. 

The patient was seen by gastroenterology (GI). The patient was given a proton pump inhibitor (PPI) and plan was for esophagogastroduodenoscopy (EGD) the following day. The patient's hemoglobin (Hgb) was 12.6 with hydration. There was no further coffee ground emesis. Esophagogastroduodenoscopy (EGD) showed mild gastritis and esophagitis. There was no acute bleeding. The patient's hemoglobin (Hgb) was 12.6. The patient was discharged.

No, the proposed treatment was not medically necessary.
The patient presented with coffee grounds and melena. His hemoglobin (Hgb) was 14.5. He was hemodynamically stable. Esophagogastroduodenoscopy (EGD) the next day revealed gastritis and esophagitis without active bleeding. He was treated with proton pump inhibitors (PPIs) and discharged. As the patient was hemodynamically stable with a hemoglobin (Hgb) of 14.5, and did not have anemia, ongoing bleeding, a history of cirrhosis or anti-coagulation, observation status was medically appropriate. When EGD revealed a source of the coffee ground emesis, and when there was no active bleeding, the patient was medically stable for discharge.

In summary, observation status was medically appropriate and the patient was medically stable for discharge. Acute inpatient hospital stay was not medically necessary.

Yes, as acute inpatient hospital stay was not medically necessary, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient by denying it.