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

Diagnosis: Genitourinary/Kidney disorder-Kidney stones
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has overturned in whole the health plan's determination.

The patient initially presented to the emergency department with concerns of left flank pain. Pertinent history included recent diagnosis of a left 6 millimeter (mm) ureteropelvic junction stone with mild hydronephrosis. Initial vital signs revealed a temperature of 98.7 Fahrenheit, heart rate 77, blood pressure 117/64, respiratory rate 17, peripheral capillary oxygen saturation 100% on room air. Initial serology revealed a white blood cell count (WBC) 16.6, hemoglobin 13.6, platelets 185, sodium 139, potassium 4.0, blood urea nitrogen 26, Creatinine 2.18, Lactate 1.08. Urinalysis revealed WBC 7 and bacteria. A computed tomography scan of the abdomen/pelvis revealed a left perinephric stranding and mild left hydronephrosis due to a 4 to 5 mm proximal left ureteral calculus. The patient was placed in the hospital with an impression of sepsis secondary to complicated urinary tract infection/cystitis with acute unilateral left obstructive uropathy. Treatment plan included empiric ceftriaxone, intravenous fluids, and urology consultation. Urology consultation had an impression of acute kidney injury and leukocytosis in the setting of nephrolithiasis. Recommendations were nothing by mouth (NPO) status in case urgent decompression was needed. Serum creatinine remained elevated at 2.16. Urology placed a ureteral stent without issue or complication.

Acute inpatient level of care was indicated as medically necessary for the entire admission. Fontenelle et al. note pain relief is the priority in the acute management of renal colic. Nonsteroidal anti-inflammatory drugs (e.g., ketorolac, 30 to 60 milligrams (mg) intramuscularly) are more effective and have fewer adverse effects than opioids. If an opioid is used, meperidine should be avoided because of the significant risk of nausea and vomiting. Neither scopolamine nor increased fluid intake alleviates renal colic. Immediate referral to a urologist or emergency department is warranted when medical analgesia is insufficient; when sepsis is suspected; when anuria, bilateral obstruction, urinary tract infection with renal obstruction, or obstruction of the sole functioning kidney are present; in women who are pregnant or have delayed menstruation (because of the risk of ectopic pregnancy); and in patients who have potential comorbidities or are older than 60 years, especially those with arteriopathy (because of the risk of leaking abdominal aortic aneurysm). In this particular situation, the patient presented with renal colic with suspected sepsis as well as a urinary tract infection with renal obstruction. This warranted immediate referral to a urologist. The patient did have acute renal failure as well as concerns for sepsis secondary to a urinary tract infection.[2]
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain.
Treatment: Inpatient Stay.

The insurer denied coverage for inpatient stay.  The denial is upheld

The patient is a female with past medical history of lupus, chronic obstructive pulmonary disease (COPD), fibromyalgia, hypertension, hyperlipidemia, diverticulitis, hiatal hernia, and known coronary occlusion who presented to the Emergency Department (ED) with left sided neck pain and chest pain since waking up that morning.  The patient also endorsed 50 pounds of weight loss in the prior months. In the ED, vital signs (VS) were stable.  Physical examination revealed subconjunctival hemorrhage to the medial aspect of the right sclera.  EKG revealed normal sinus rhythm.  The patient was initially placed on observation status for evaluation of left sided chest pain and neck pain.  The patient was placed on continuous pulse oximetry and cardiac monitoring.  Chest X-ray and computed tomography of the chest showed no acute findings.  Troponin level was negative.  The patient's platelet count was noted to be 12 thousand (k).  Cardiology was consulted and there was a suspicion for musculoskeletal chest pain.  She has a cardiac catheterization pending for an abnormal stress test as an outpatient.  Hematology recommended a platelet transfusion.  The patient was admitted as an inpatient. Rheumatology was consulted and stated that the patient's signs and symptoms were not consistent with lupus flare.  Outpatient Rheumatology follow-up was recommended.  Platelet count is 217 k (thousand) after one unit, and a lab error was suspected on the initial value.  The patient was discharged home. 

The patient had chest pain that was ascribed to non-cardiac causes in the ED.  Rheumatology did not feel the patient was having a flare, and no treatment for lupus was changed.  She had a platelet count of 12k with a subconjunctival hemorrhage, a non-threatening source of bleeding.  The need to monitor the chest pain and the low platelets (regardless of whether it was eventually ascribed to lab error or not) supported an Observation level of care.  This would allow prompt response if any acute problems should arise.  An acute level of care was not supported, given the absence of good evidence for acute coronary syndrome (ACS) or lupus flare and the lack of any significant bleeding.  Severity of illness was not met. The health plan acted reasonably with sound medical judgment.

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

Diagnosis: Dental Disorder. 
Treatment: Braces. 

The insurer denied Braces. 
The determination is upheld. 

The patient has a diagnosis of Class I malocclusion, appropriate overjet and overbite. The upper arch has mild spacing and the lower arch has mild crowding. The narrative states tooth number (#) 22 is in crossbite. He is treatment planned for 24-30 months of orthodontics to correct his malocclusion. At issue is the medical necessity of braces. 

The braces are not medically necessary for this patient. 

The patient has an appropriate overbite and overjet. There is mild crowding but that alone does not rise to the threshold of medically necessary. The photos do not support a diagnosis of a crossbite of tooth 22 with tooth 10, and the gingival margin of 22 appears to be the similar to the gingival margin of tooth 27. There does not appear to be attachment loss. There is no indication of functional problems on the diagnostic records or the orthodontic treatment plan. The diagnosis states the patient is has a skeletal Class I relationship which is the most efficient jaw relationship for mastication. (2) If his teeth were aligned it would provide an esthetic improvement but it would not create a medically significant improvement to the patient's health. 

For these reasons, the requested treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System/Other/Hemoptysis
Treatment: Inpatient Hospital
The health plan denied the inpatient stay as not medically necessary. 
The health plan's determination is upheld.

This is a case of a female admitted for a diagnosis of hemoptysis. The patient presented with chief complaint of hemoptysis for three days prior to admission. Vital signs demonstrated a temperature 98.6F, a pulse of 70 beats per minute (bpm), a respiratory rate of 13/minute, a blood pressure of 109/77 millimeters of mercury (mmHg) and an oxygen saturation of 97%. Physical exam showed no altered mental status or acute distress. A pulmonary exam showed normal respiratory effort. The white blood cell count was 5.5 with a hemoglobin of 12.7. Chloride was 108 with electrolytes otherwise normal. A chest x-ray showed patchy bilateral midlung zone predominant opacities compatible with infectious/inflammatory etiology. A computed tomography (CT) of the chest showed active/acute infectious/inflammatory airway and parenchymal disease involving all five lobes. An infectious disease consult was requested for management of tuberculosis versus non-tuberculosis mycobacterial infection. She was found to have previous treatment for Mycobacterium avium intracellular infection and at the time of discharge she was placed on optimal treatment for mycobacterium avium-intracellulare (MAI). She was then recommended to follow up with infectious disease in 1 to 2 weeks and was discharged.
At issue is the medical necessity of the inpatient stay.

The health plans determination of medical necessity is upheld, in whole.

The patient in this case did not have life-threatening hemoptysis causing airway obstruction, gas exchange abnormality or hemodynamic instability. The patient did not have a large amount of blood loss or rapid rate of bleeding. The patient did not have bronchogenic cancer, tuberculosis, fungal infection or bronchiectasis.
Although the patient had needs best addressed in the hospital setting the monitoring, diagnostic workup and therapeutic interventions prescribed could have been safely administered at the observation level of care. Therefore, the medical necessity of admission has not been established.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia

Treatment: Inpatient Admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient presented to the Emergency Department (ED) with a past medical history of iron deficiency anemia and a chief complaint of chest tightness, weakness, and shortness of breath (SOB) of 1 week duration.  The patient reported that she was seen at an outside hospital the day prior for the same symptoms and was found to have a hemoglobin level below 6; she received 1 unit of packed red blood cells (pRBC) but left before receiving more.  The patient's hemoglobin was 7.1 and she was symptomatic for anemia.

The patient was admitted as an inpatient for anemia requiring transfusions.  She was given 1 unit of pRBC with improvement in her hemoglobin to 7.3.  The patient asked to leave and was discharged home in a stable condition with instructions for Primary Care Provider follow-up preferably within 3 days, and Gynecology follow-up for evaluation of menorrhagia.

This patient was symptomatic.  In addition, she fulfills the transfusion guidelines for use of blood components: her hemoglobin was less than 8 g/dl (grams per deciliter), 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 could have been completed in the Emergency Department (ED) without the need for admission.  Following transfusion, the patient could have been monitored for a few hours in the ED, her complete blood cell (CBC) count 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.
Based on all of the above, admission was not medically necessary.

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 admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Crohn's Disease
Treatment: Stelara, Pre-service
The insurer denied the Stelara, Pre-service
The denial is upheld. 

The patient is a male with severe small bowel Crohn's. He was a primary non-responder to Humira. The physician is requesting treatment with Stelara.

No, the proposed Stelara is not medically necessary.
The patient has moderate to severe Crohn's and was a primary non-responder to Humira, an anti-tumor necrosis facot (TNF). In patients who are primary non-responders to anti-tumor necrosis facots, medical literature supports using a drug with a different mechanism of action. Therefore the use of Renflexis, Avsola or Cimzia would not be medically appropriate. 

While Dulai et al. looked at patients with Crohn's most likely to respond to 26 weeks of Entyvio therapy, they concluded that further studies are needed to optimize its accuracy in select populations. That being said, Entyvio has been found to be a safe and effective treatment option in patients with Crohn's who do not respond to anti-tumor necrosis factors.  Therefore, as the patient has not tried and failed the planned preferred Entyvio, the proposed Stelara is not medically necessary.

As the patient has not tried and failed the preferred formulary alternative Entyvio, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient by denying it.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal - Helicobacter (H.) Pylori infection
Treatment: Pharmacy/Prescription drugs - Talicia DR (delayed-release)
The health plan denied Talicia DR as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

The patient has a diagnosis of H pylori infection. The patient tried a regimen of (proton pump inhibitor) PPI/Biaxin/Amoxicillin/Probiotic which was not successful in eradicating H pylori. The patient's provider has recommended Talicia DR (delayed-release) as therapy for H pylori. This request was denied. At issue is the medical necessity of the prescribed Talicia DR.

No, the treatment of Talicia DR is not medically necessary for this patient.

The documentation provided is very limited in this case. The patient had one treatment regimen, which was Biaxin(Clarithromycin)/Amoxicillin/PPI. The probiotic does not affect H pylori. The regimen the provider used has a high likelihood of failure as clarithromycin resistance is very high. The treatment regimen used is not recommended anymore. A salvage regimen (meaning a second line treatment if the first therapy fails) would be metronidazole based quadruple therapy. A standard salvage regimen would be metronidazole/tetracycline/bismuth/PPI for 2 weeks. 2 of the drugs are twice daily (BID), 2 of the drugs are four times a day (QID). Generally, a rifabutin based regimen is 3rd line. (The term "salvage regimen" is used interchangeably with 2nd and 3rd line therapy.) [4]
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rheumatoid Arthritis
Treatment: Humira Pen 40mg/0.4ml SC PNKT, Pre-service
The insurer denied the Humira Pen 40mg/0.4ml SC PNKT, Pre-service
The denial is overturned.

The patient is a female with seropositive rheumatoid arthritis (RA).  She has failed treatment with methotrexate, leflunomide, Plaquenil, prednisone, and various NSAIDs (nonsteroidal anti-inflammatory drugs), including Celebrex, Mobic, and Ketorolac.  Specifically, Plaquenil was prescribed for six months and was ineffective.  Leflunomide was prescribed for one year and led to nausea.  Chart notes documenting the dates of these medications have been provided. She has taken methotrexate, which is ineffective and causes dyspepsia.  Current methotrexate dose is 20 mg (milligrams) weekly.

The patient has active polyarticular arthritis and morning stiffness for up to six hours. The provider now wishes to treat with Humira 40 mg (milligrams) every other week, and add prednisone 5 mg (milligrams) daily as bridge therapy.  The appeal is for Humira Pen 40mg (milligrams)/0.4ml (milliliters) for the treatment of RA (rheumatoid arthritis).

Yes, the treatment with Humira is medically necessary.

Humira is FDA (United States Food and Drug Administration)-approved for the treatment of moderate-to-severe RA (rheumatoid arthritis), as seen in this specific patient.  Per published American College of Rheumatology guidelines for the treatment of RA (rheumatoid arthritis), for patients who have failed DMARD (disease-modifying antirheumatic drug) therapy, biology therapy is an appropriate option. This patient with seropositive RA (rheumatoid arthritis) has failed several DMARDs (disease-modifying antirheumatic drugs), including leflunomide, Plaquenil, and methotrexate, and prednisone. The provider now wishes to treat with Humira.

Although this patient has not tried or failed the plan-preferred DMARD (disease-modifying antirheumatic drug) sulfasalazine, it would be clinically appropriate and in accordance with standard of care at this juncture to escalate treatment to a TNF (tumor necrosis factor) inhibitor such as Humira, and not trial a fourth DMARD (disease-modifying antirheumatic drug).  Therefore, the proposed Humira for the treatment of active RA (rheumatoid arthritis) in this patient is clinically appropriate and in accordance with standard of care in the rheumatology community, and is thus medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 
The insurer denied braces for medical necessity. 
The denial was upheld. 

The patient is a male with a Skeletal Class I occlusion, mild mandibular crowding, moderate overjet, and moderate overbite. The patient has a treatment plan for comprehensive orthodontics.
At issue is the medical necessity of braces.

The health plan's determination is upheld in whole.

The requested health service/treatment of braces is not medically necessary for this patient.
Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 16 with no auto qualifiers. Auto qualifiers include cleft palate deformity or cranio-facial anomaly, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9-millimeter (mm) or greater and underbite 3.5 mm or greater. The case requires a score of 26 or more for treatment to be considered medically necessary according to standards of care. The malocclusion in question does not meet these criteria to be classified as handicapping and treatment would not be considered medically necessary. According to the standards of care, braces and monthly visits are not medically necessary for this case.
Therefore, the treatment of braces is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 
The insurer denied braces and monthly visits. 
The denial is overturned.

The patient is a male presenting with a skeletal Class I malocclusion and significant spacing. He has a 50% deep bite. He is missing teeth 4, 5, 12, 13, 20, 21, 28, and 29. Primary teeth A, I, J, K, L and T are retained. He is treatment planned for orthodontics to address the spacing and missing teeth. The treatment was denied due to lack of medical necessity.

This treatment is medically necessary.
This patient has oligodontia, which is a more significant form of hypodontia involving agenesis of 6 or more teeth. This patient is missing 8 out of 28 of his permanent teeth (not counting 3rd molars). Several primary teeth are retained but they will not last. Chewing efficiency will be severely compromised if at least some of these teeth aren't planned for replacement - but a multidisciplinary approach involving orthodontics is necessary to ensure proper space creation for the replacement teeth. It is classified as a craniofacial developmental anomaly.
Hypodontia, or tooth agenesis, is the most prevalent craniofacial malformation in humans. Excluding third molars, the reported prevalence of hypodontia ranges from 1.6 to 6.9%, depending on the population studied. Hypodontia individuals often present a significant clinical challenge for orthodontists because, in a number of cases, the treatment time is prolonged, and the treatment outcome may be compromised. Due to the functional problems of the many missing teeth and inevitable loss of the retained primary teeth a combined ortho-prosthetic treatment plan is necessary to restore function. In order for future treatment to be successful this requires orthodontic intervention to create proper space for the replacement teeth.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Mental Health/Attention Deficit Hyperactivity Disorder/ADHD
Treatment: Mental Health/Residential
The health plan denied the requested residential mental health admission as experimental/investigational. 
The health plan's determination is upheld.

The patient is a male with a request for an outdoor wilderness therapy program for children and adolescents. The patient was admitted. The patient was diagnosed with attention deficit hyperactivity disorder (ADHD), combined type. In review of the documentation, the patient was camping in tents and there was not 24/7-day access to nursing or medical care. Letters of appeal were reviewed. There are no clinician individual or group therapy notes. There are no weekly psychiatric notes.

The health plan's determination regarding the proposed health service or treatment should be upheld, in whole.

No, the proposed health service or treatment at the wilderness therapy facility is not likely to be more beneficial than other standard treatment such as a RTC (residential treatment center) given there is no 24/7 day a week nursing or medical monitoring. In addition, there is no documentation of a psychiatric evaluation within 48 hours of admission, weekly medication management visits, multiple hours of group, individual or family therapy daily. Though there is literature that Wilderness therapy is effective (Bettman et al 2016, Tucker et al 2016 and Roberts et al, 2015), there are no head-to-head trials of Wilderness therapy vs standard RTC or randomized controlled studies of wilderness therapy for ADHD and/or substance use issues. Therefore, there is no clinical literature to support that wilderness therapy is more beneficial than any standard treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Mental Health/Attention Deficit Hyperactivity Disorder/ADHD
Treatment: Mental Health/Residential
The health plan denied the requested residential mental health admission as experimental/investigational. 
The health plan's determination is upheld.

The patient is a male with a history of attention deficit hyperactivity disorder(ADHD) and persistent depressive disorder. He was admitted  for wilderness therapy. His treatment  has been denied by his insurance plan as being experimental investigational. The following review is evaluating the medical necessity for wilderness therapy.

I uphold, in whole, the health plan's determination regarding the proposed health service/treatment.

Treatment for ADHD and depressive disorder/dysthymia are well established in the child and adolescent psychiatric literature. Wilderness Therapy is not the standard of care when treating the above conditions and is not likely to be more beneficial than other standard treatments. Given the above wilderness therapy is considered to be an investigational/alternative therapy and is not a covered benefit under the plan.
The patient has a diagnosis of attention deficit disorder and dysthymia. The conditions  have established treatments both pharmacological and psychological in nature. Wilderness therapy is not an established treatment nor a standard of care treatment for the client's diagnoses.
More specifically, the standard of care when treating attention deficit disorder is use of stimulant medication which is supported by a recent review article. Use of stimulant medications in youth, reduces presence of mood disorders and leads to improved academic outcomes (Boland et al., 2020).
Dysthymia and depressive disorders in adolescents are best treated with a combination of medications and cognitive behavioral therapy which has been well published in the psychiatric literature (Kober et al, 2017). The patient was not an imminent danger to self or others and there was no evidence to support the patient requiring a higher level of care.