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

Diagnosis: Sleep apnea
Treatment: Oral appliance

The insurer denied an oral appliance. 
The health plan's determination is overturned.

The patient is a male who is seeking approval for an oral appliance to treat obstructive sleep apnea. The provider noted that the patient has been previously controlled with oral appliance. A home sleep study noted an apnea hypopnea index (AHI) of 21.2 with an oxygen saturation nadir of 88%. Under review is the medical necessity of an oral appliance.

The oral appliance to treat the patient's obstructive sleep apnea is medically necessary. According to Pitsis et al., (2002), Vanderveken et al., (2008), and Quinnell et al., (2014), the patient does meet medical necessity for the oral appliance as this is an evidence based, noninvasive method to treat obstructive sleep apnea. These current data support using this as treatment and is indicated for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left Tibia and Fibula Fractures
Treatment: Inpatient hospital admission
The insurer denied coverage for inpatient hospital admission.
The denial is upheld.

The patient is a male with a history of congestive heart failure (CHF), coronary artery disease (CAD), status post coronary bypass graft x (times) 5, diabetes mellitus (DM), deep vein thrombosis (DVT), hypertension (HTN), myocardial infraction (MI), peripheral vascular disease (PVD), angina, asthma, hyperlipidemia, and avascular necrosis of bilateral hips. The patient presented to the emergency department (ED) by ambulance for evaluation and management of left leg pain after a fall. Imaging showed left tibia and fibula fractures. Orthopedic Surgery was consulted, and the patient was admitted. The patient underwent surgery and received physical therapy and medication management postoperatively. He was discharged with follow up with his Primary Care Physician.

A review of the clinical record demonstrates the patient had significant comorbidities. He was reported to have recent discharge for CHF, he required oxygen while in the hospital, he had uncontrolled diabetes (Hb1Ac [glycated hemoglobin] > [greater than] 9) and mild hyponatremia. The patient had a non-complicated post-surgical course. There was no overall change in his condition. The main issue was placement, as he did not want to be referred to a rehabilitation facility. His pain was controlled with oral medication. His wound was without problem. He did not have an infection, nor was he bleeding. His vital signs were stable. His use of Lasix and diuresis was a chronic condition which was already managed. There was no documentation of an acute medical condition to require treatment nor imaging. There were thus no extenuating circumstances to warrant the admission and length of stay. A lower level of service would be appropriate. 

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

The inpatient hospital admission is not considered medically necessary for this patient.

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

Diagnosis: Ischemic heart disease. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for the inpatient hospital admission. 

The denial is upheld. 

This patient has a history of ischemic heart disease, hypertension, and diabetes that presented to the hospital for elective cardiac catheterization as part of a staged revascularization.  Drug eluting stents were placed in both vessels.  No perioperative complications were noted, and the patient was discharged the following day. 

The health plan acted reasonably with sound medical judgment and in the best interest of the patient.  This patient presented for elective percutaneous revascularization via radial artery approach.  He underwent an uncomplicated procedure and drug eluting stents were placed in the mid LAD [left anterior descending] artery. The procedure was uncomplicated, and the patient was discharged later that same day. Several investigators have studied the safety and cost savings surrounding same day discharge following percutaneous intervention and demonstrated no difference between patients that are discharged on the same day as compared to patients admitted to the hospital (Reference 1-4).  Current expert consensus from the society of cardiovascular angiography and interventions support treatment at a lower level of care (Reference 4).  In conclusion, inpatient admission was not medically necessary.  The patient could have been managed at a lower level of care. 

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right hand osteoarthritis
Treatment: Durable Medical Equipment-Right hand splint (L3808)

The insurer denied Durable Medical Equipment-Right hand splint (L3808). 
The health plan's determination is upheld.

The patient is a female with right hand osteoarthritis status post carpometacarpal arthroplasty of the right thumb. An orthosis was fabricated for the left wrist/hand/fingers after a left carpometacarpal arthroplasty. An orthosis was fabricated for the right wrist/hand/fingers after a right carpometacarpal arthroplasty.
At issue is the medical necessity of Durable Medical Equipment-Right hand splint (L3808), which is a custom rigid wrist hand finger orthosis, without joints.

Durable Medical Equipment-Right hand splint (L3808), which is a custom rigid wrist hand finger orthosis, without joints is not medically necessary for this patient.
The Durable Medical Equipment-Right hand splint (L3808), which is a custom rigid wrist hand finger orthosis, without joints is not considered standard of care and there are no well-designed, well conducted studies published in peer-reviewed journals to support this device, demonstrate that this device affects health outcomes, or show that this device is equally or more effective than conventional therapies. There are many standard treatments for the diagnosis of right hand osteoarthritis status post carpometacarpal arthroplasty of the right thumb including standard prefabricated right wrist hand finger orthoses. The use of the Durable Medical Equipment-Right hand splint (L3808), which is a custom rigid wrist hand finger orthosis, without joints is not considered medically necessary, not supported by the peer-reviewed medical literature and is not considered the standard of care at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the Inpatient Hospital Stay. 
The determination is upheld. 

The patient has a past medical history (PMH) of hypertension (HTN), asthma, peripheral vascular disease (PVD), and chronic kidney disease (CKD) who was admitted with complaints of (c/o) left-sided chest pain, which resolved on its own within minutes, and intermittent over the prior week, and not exertional. The vital signs were unremarkable. The physical exam was unremarkable. Lab work was notable for a creatinine of 3.25 (baseline 1.8), hemoglobin (hgb) 8.6, and negative troponins. A chest x-ray (CXR) showed no acute pathology. An electrocardiogram (EKG) showed no acute ischemic changes. The patient was diagnosed with acute coronary syndrome (ACS) rule out (r/o) and treated with intravenous fluids (IVF), and a biochemical work-up. The patient was discharged in stable condition. At issue is whether the inpatient stay was medically necessary. 

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) chest pain that was not exertional. An EKG did not demonstrate any acute ischemic changes and troponins were negative. For the chest pain, the patient's HEART [history, EKG, age, risk factors, and troponin] score was 4, indicating that the patient had a moderate score, and not a high score. Given that the patient had stable vital signs, no unstable co-morbidities, a non-ischemic EKG and negative cardiac biomarkers, no new left bundle branch block (LBBB) or newly inverted T-waves believed to be ischemic in origin, and no classic anginal symptoms or other serious or life-threatening cardiopulmonary etiologies, this patient could have been safely and appropriately treated at a lower level of care. While the patient did have a new acute kidney injury, intravenous fluids (IVF) were administered and the patient's creatinine responded. This patient did not have hypertension (HTN) requiring continuous vasoactive medication, no concomitant febrile illness, and there was no urgent indication for dialysis, marked electrolyte abnormalities, volume overload, severe hyponatremia, hyperkalemia, metabolic acidosis, or acute respiratory distress. Overall, this patient without distress was admitted for chest pain and acute kidney injury, received IVF and work-up, and was discharged home in stable condition, and this could have been provided safely at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Immunologic Disorders. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Tofacitinib topical cream. 
The denial was upheld in whole. 

The patient is a male with alopecia areata, treated with minoxidil and intralesional Kenalog. His provider recommended Tofacitinib topical compounded cream for the areas on his scalp that had not improved. The patient is on oral Xeljanz as well.
At issue is the medical necessity of Tofacitinib topical compounded cream.

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

The requested health service/treatment of Tofacitinib topical compounded cream is not medically necessary for this patient.
A 2018 phase I, 28 week prospective, placebo-controlled, double-blind study (Bokhari, 2018) in patients with alopecia universalis investigated hair regrowth with two topical Janus kinase inhibitor (JAK) inhibitors, 2% tofacitinib and 1% ruxolitinib. Topical clobetasol dipropionate 0.005% was the active comparator while vehicle was used as the placebo control. Six patients demonstrated partial hair regrowth in areas treated with 2% tofacitinib ointment applied twice daily. Five patients demonstrated partial hair regrowth in the areas treated with 1% ruxolitinib ointment. Ten patients demonstrated partial hair regrowth in the areas treated with clobetasol dipropionate 0.05% ointment. No regrowth was observed in the placebo treated area. Topical JAK inhibitors are still under investigation, and while promising, this patient is already maintained on an oral JAK inhibitor.
Therefore, the health service/treatment of Tofacitinib topical compounded cream is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mental Health-Depression/Anxiety. 
Treatment: Mental Health: Residential. 

The health plan denied the continued Residential Mental Health Treatment as not medically necessary. The reviewer has upheld in whole the health plan's determination. 

The patient has a history of depression, generalized anxiety and substance use disorder who was admitted to the inpatient level of care for worsening depression and aggression. He was later transferred to Residential Mental Health treatment level of care. During his treatment he was started on Wellbutrin and participated in group, family, and individual therapy. He was not having suicidal ideation and was noted to not have vegetative symptoms such as disrupted sleep or appetite. The medical necessity of ongoing residential mental health treatment is currently under review. 

The requested Residential Mental Health Treatment is not medically necessary for this patient. The patient was participating well, was not a danger to self and was not agitated, manic or psychotic during his residential mental health treatment. He has good support from his family. He tolerated Wellbutrin and showed improvement on this medication. Guidelines have been established looking at medical necessity of residential level of care which were not met in this case (InterQual guidelines). The patient was not an imminent danger to himself and had family support and involvement. He was able to attend to activities of daily living and did participate in treatment. He was not agitated during his residential treatment.  He does not meet the established InterQual guidelines for continued residential treatment. 

Additionally, the least restrictive setting should be utilized, when possible, to achieve optimal generalized outcomes (Kober and Martin,2017). In this case, the patient was not a danger to himself and not acutely manic or psychotic. He was engaged in treatment and willing to attend treatment. He was tolerating medications.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Endocrine/Metabolic/Nutritional. 
Treatment: Pharmacy/Prescription Drugs. 

The insurer denied Nutropin. 
The denial is upheld in whole. 

The patient is a male who is seeking growth hormone (GH) treatment under the indication of idiopathic short stature (ISS). His mother and father were both late in pubertal development. He was initially evaluated in the pediatric endocrinology clinic for growth failure. He had been diagnosed with attention deficit hyperactivity disorder (ADHD), was on a stimulant and his appetite was poor. His growth chart showed that his height had dropped from 10th percentile to 5th percentile while his weight had dropped to less than (<) 5 percentile. 

His growth was followed and at a follow up visit. He was still on a stimulant and had a poor appetite. His evaluation was unremarkable including growth hormone (GH) stimulation testing. Clinical impression was constitutional delay in growth and undernutrition. 
At a most recent follow up visit, his height was 143.9 cm (-2.53 SD), and his weight was 34.7 kg (-2.5 SD). He was on a different stimulant and his appetite was still poor. His exam showed he was barely starting puberty. His adult height prediction based on bone age was calculated as 71'' and clinical impression was constitutional delay in growth and pubertal development plus nutritional factors. 

At issue is the medical necessity of Human Growth Hormone.

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

The requested health service/treatment of Human Growth Hormone is not medically necessary for this patient. 

Based on this patient's pubertal staging, he has not achieved peak growth velocity. His growth velocity has already improved with the onset of puberty, and he has grown at a rate of 6.4 cm per year in the last 7.93 months, and his growth velocity is expected to improve further with the progression of puberty. 

This patient is short for his age and not growing well. His height has dropped from -1.78 SD to -2.53 SD in the last 5 years; however, it is associated with poor appetite and drop in weight percentiles suggesting nutritional growth failure. He is on a stimulant and his growth chart shows that his height has dropped over years when he was diagnosed with ADHD and started on stimulant which is suggestive of stimulant induced growth failure. Stimulant induced growth failure is a well-known phenomenon.
Based on his bone age, his adult height prediction is within his mid parental height. This patient's short stature cannot be considered ISS from the documentation. The FDA approval limits ISS indication to pediatric patients for whom other causes of short stature have been excluded. Growth hormone is not an approved indication for constitutional short stature or growth failure due to stimulants or undernutrition.
Therefore, the requested health service/treatment of Human Growth Hormone is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems/Other/TIA
Treatment: Inpatient Hospital
The health plan denied the requested inpatient hospital stay as not medically necessary. 
The health plan's determination is upheld.

This patient is a male with no significant past medical history who presented to the hospital emergency department (ED) with a complaint of dizziness after eating a snack. He had a sensation that his head was expanding, and his balance was off. His wife noticed his speech was off and the left side of the face was drooping. Vital signs were a temperature of 98.0 F., a pulse of 100 beats per minute (bpm), respirations of 18/minute, and a blood pressure (BP) of 148/100 millimeters of mercury (mmHg). Physical examination showed the patient to be acutely ill appearing with a mildly distended abdomen. Abnormal laboratory values included a sodium of 133 and a prothrombin time (PT) of 15.3. A chest x-ray, computed tomography (CT) of the brain and carotids did not reveal any acute pathology. The patient was admitted to the stroke unit for a transient ischemic attack (TIA) and was seen by neurology. 
In question is the medical necessity of the inpatient stay.

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

This patient did not have clinical needs that required inpatient hospital stay. This patient could have been monitored and treated under observation level of care.
This patient presented to the hospital with dizziness, facial droop and being off-balanced. There was no evidence of hemodynamic instability. There was no evidence of recurrence of focal neurological signs. There were no acute findings on imaging studies. There was no evidence of altered mental status, or cardiac arrhythmias. The patient did not have severe hypertension. He was not started on parenteral anticoagulation. The patient was able to ambulate on his own. Based on review of the available medical records and Milliman Care Guidelines (MCG) guidelines for TIA, none of the severity of illness criteria were present to support inpatient admission. The inpatient hospital stay was not medically necessary.
According to current standard of care and guidelines for management of patients with transient ischemic attacks, the patient could have been monitored with further testing performed while under observation level of care.  Since the patient did not have any severe or acute findings, observation level of care would be most appropriate.
Appeal type: Medical necessity
Decision: Overturned

Central Nervous System
Home Health Care

Diagnosis: Parkinson's disease
Treatment: Home Health Care
The insurer denied Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes: 35 Hours per Week. The health plan's determination is overturned. 

The patient is a female with past medical history of Parkinson's disease, syncope, osteoporosis, hyperkalemia, coronary artery disease, recurrent urinary tract infection (UTI), depression, asthma, and bladder incontinence who had been assigned PCS (personal care services) based on telephonic assessment tool assessing the patient at total assistance with tasks of meal preparation, ordinary housework, and shopping while maximum assistance with tasks of managing finances, stairs, and transportation. With tasks of managing medication, bathing, dressing lower body, and transfer toilet, the patient was assessed at extensive assistance while limited assistance with tasks of phone use, personal hygiene, dressing upper body, walking, locomotion, toilet use, bed mobility, and eating. The patient saw her cardiologist who noted the patient's syncope was likely from orthostatic hypotension from her Parkinson's disease. 

Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes: 35 Hours per Week are medically necessary for this patient.
There is documentation that the patient requires assistance with all activities of daily living (ADL) and Instrumental activities of daily living (IADL) based on assessment performed telephonically while only needing assistance with tasks of meal preparation, ordinary housework, managing medication, stairs, shopping, transportation, and bathing, dressing upper/lower body on the assessment. The patient's family indicated that the patient underestimated her care needs when discussing with the nurse who performed the assessment. The patient does not have help from her husband as he is too frail and weak. There is documentation that the patient has had worsening of Parkinson's disease, recurrent syncope, and bladder incontinence. The requested increase in services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. The patient's care needs cannot be met with medical supplies and adaptive equipment alone. 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, Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes: 35 Hours per Week are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastrointestinal/Digestive System. 
Treatment: Inpatient Hospital (Custodial Care)

The insurer denied long term custodial care. 
The denial is upheld.

The patient is a male with past medical history significant for alcoholism, megacolon, status post colostomy, hyperlipidemia, and generalized muscle weakness. This review is for the medical necessity of long-term custodial care. The service was denied due to lack of medical necessity. This is the subject under review. The health plan's determination is upheld in whole.

The requested long term custodial care is not medically necessary for this patient for management of colostomy. The patient has a past medical history significant for colostomy. He has other medical and cognitive disorders. He was admitted to custodial care for management of his medical disorder along with colostomy issues. The patient had trouble managing his colostomy on his own.
Long-term custodial care was denied with the following statement: You do not meet the criteria for long-term placement. Long-term custodial care is designed for people with chronic illness or who have a disability that prevents them from caring for themselves and who require more assistance with activities of daily living such as personal hygiene, dressing, eating, walking, transfers to and out of the shower and toilet.
You do not need this care because of: You are able to walk on your own and to transfer in and out of bed and use a toilet independently. You are also able to direct your own care. You have physical abilities and mental capacity to function in the community.
The appeal letter states that the patient is unable to care for the ostomy site himself. Physician progress note indicates that the ostomy is pink and functioning well. Leakage noted. The patient is followed by an ostomy clinic, per physician note.
In general, long term custodial care is not medically necessary for patients that can manage independently in activities of daily living (ADLs) and instrumental activities of daily living (IADLs). There is not a specific description of his capacity for individual ADLs and IADLs however, it was noted that the patient is able to ambulate independently, transfer independently. He is able to dress and eat and perform personal hygiene independently. The main issue which has been complicating his discharge is management of his ostomy site. Physician progress note states that the ostomy is pink and functioning well, there is leakage noted. Long term custodial care is not medically necessary for this patient. He can manage his own ADLs and IADLs independently with exception of an ostomy site. Ongoing management of an ostomy site is typically non-skilled service unless certain complications are noted such as abscess or infection. In the absence of notation of either abscess or infection or continued bleeding, long term custodial care is not medically necessary. Services can be provided at a lower level of care status.