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

Diagnosis: Hyperglycemic

Treatment: inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is overturned. 

According to the documentation submitted, this is a female child with a history of autism, attention deficit hyperactivity disorder (ADHD), asthma, and type 1 diabetes. She presented to the emergency room (ER) from an Endocrinology clinic with elevated glucose and skin infections. In the ER, she was hyperglycemic and there was glucosuria. There was no ketonuria or acidosis. The patient was admitted for care. Skin infections were initially treated with intravenous (IV) Clindamycin and then topical mupirocin. Blood sugar levels were monitored. Glycated hemoglobin (HbA1c) was 12.3. Metformin and insulin were started. The patient remained hemodynamically stable. She was discharged. 

Acute inpatient admission for patients with symptomatic diabetes is necessary when the patient has evidence of ketoacidosis or a hyperosmolar state [1-6] for other comorbidities such as infection [7-9]. The patient had nonhealing wounds consistent with a bacterial superinfection in the setting of uncontrolled diabetes. The patient was admitted for diabetes control as well as intravenous antibiotics. It would have been unsafe to discharge the patient home from the emergency department. The requested inpatient admission was consistent with generally accepted standards of medical practice. The request is therefore medically necessary.

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

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

Diagnosis: Impacted tooth #6
Treatment: - Medicine to help patient relax for procedure (intravenous moderate (conscious) sedation/analgesia, each subsequent 15 minute increment)
The insurer denied the - Medicine to help patient relax for procedure (intravenous moderate (conscious) sedation/analgesia, each subsequent 15 minute increment)
The denial is overturned

This patient, a female, is under the care of a dentist, orthodontist, and oral maxillofacial surgeon (OMS) for the treatment of impacted tooth #6. The tooth is palatally impacted and treatment is planned for exposure along with placement of a bracket to allow for forced eruption.

Yes, the medicine to help the patient relax for procedure (intravenous moderate (conscious) sedation/analgesia, each subsequent 15 minute increment), mobilization of erupted/malpositioned tooth #6, and x-ray(s) (cone beam computed tomography [CT] capture and interpretation, view of one full arch, mandible) are medically necessary.
Tooth #6 is impacted and needs to be orthodontically erupted. The degree of difficulty makes the anesthesia also medically necessary.  The use of the cone beam computed tomography (CBCT) is being requested to localize an impacted canine #6 and the roots of the adjacent teeth. It will also dictate the surgical approach to the tooth in question.

The tooth is palatally impacted and treatment is planned for exposure along with placement of a bracket to allow for forced eruption. The anesthesia, exposure and bonding of #6 (mobilization of erupted/malpositioned tooth #6), and the cone beam computed tomography are medically necessary.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient as the requested procedures are medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Xolair. 
The denial is upheld. 

This is a female patient with a request for Xolair for a history of chronic idiopathic urticaria (CIU). In addition, she has complaints of dry scalp and itching all over her body. She has a history of Raynaud's. Allergy panel all came back within normal limits. She has tried levocetirizine for 10 days, and hydroxyzine for 10 days.
At issue is the medical necessity of Xolair 150 milligrams (MG)/milliliters (ML) SC SOSY.

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

The requested health service/treatment of Xolair 150MG/ML SC SOSY is not medically necessary for this patient.
Per Hon and Bernstein et al, current guidelines states that for initial therapy, is to administer a second-generation antihistamine at standard therapeutic dose. If step 1 does not control symptoms adequately within one to two weeks, therapy may be increased by advancing the dose of the second-generation antihistamine, adding a different second-generation antihistamine, adding a histamine (H)2 antihistamine, or adding a leukotriene-receptor antagonist or adding a first-generation H1 antihistamine at bedtime. If the measures in step 2 do not result in adequate control of symptoms, the dose of the first-generation H1 antihistamine may be advanced gradually in step 3. Patients whose symptoms are not controlled by step 3 therapies or who are intolerant of dose advancement of first-generation H1 antihistamines are considered to have refractory chronic urticaria (CU) and can be considered for Xolair.
In this case, the patient has not had an adequate trial of 1st line therapies for CIU. The patient had not tried cetirizine, levocetirizine, loratadine or fexofenadine for up to at least 4 weeks.
The requested health service/treatment of Xolair is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorder. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.

The patient is a female who was directed to the emergency department by her primary care physician for positive breast wound fungal culture. Pertinent history included chronic anemia and breast implant surgery with non-healing wound treated with topical and systemic antibiotics.
Initial vital signs noted a temperature of 99.2 Fahrenheit (F), heart rate (HR) 94, blood pressure (BP) 115/79, respiratory rate (RR) 19, peripheral capillary oxygen saturation (SpO2) 99% [percent] on room air. Initial laboratory testing revealed a white blood cell (WBC) count of 7.3, hemoglobin (Hgb) 9.6, platelets (Plt) 367, blood urea nitrogen (BUN) 7, creatinine (Cr) 0.7, glucose (Glu) 86. Micafungin was infused and the patient was admitted thereafter. The attending physician had an impression of bilateral breast ulceration status/post (s/p) breast implant with a wound culture growing Candida parapsilosis. Treatment plan included continued intravenous Micafungin. Infectious disease consultation was obtained who recommended placement of a peripherally inserted central catheter (PICC) for three weeks of intravenous Micafungin. The next day there was no significant change.  A PICC line was placed by interventional radiology and the patient was discharged thereafter. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld in whole. 

The inpatient stay was not medically necessary based on the clinical documentation provided, evidence-based literature and standards of care. Evaluation and management could have been performed at a lower level of care.
Ramakrishnan et al. note inpatient treatment is necessary for patients who have uncontrolled infection despite adequate outpatient antimicrobial therapy or who cannot tolerate oral antibiotics. Hospitalization is also indicated for patients who initially present with severe or complicated infections, unstable comorbid illnesses, or signs of systemic sepsis. Broad-spectrum antibiotics with proven effectiveness against gram-positive and gram-negative organisms and anaerobes should be used until pathogen-specific sensitivities are available; coverage can then be narrowed. Intravenous antibiotics should be continued until the clinical picture improves, the patient can tolerate oral intake, and drainage or debridement is completed.[1]
In this particular situation, none of aforementioned criteria for hospitalization, or continued hospitalization, were present. The patient had non-healing wounds for several months following breast implant placement. A wound culture had been obtained three weeks prior which eventually grew a yeast. Due to this positive result, and not because of any acute clinical findings, the patient was directed to the emergency department for intravenous antifungal therapy. Infectious disease consultation was obtained and noted significant improvement in wound healing from the last outpatient assessment. A PICC line was placed, and outpatient parenteral therapy was arranged.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Pain.
Treatment:  Formulary exception for Oxycontin.
The insurer denied the  Formulary exception for Oxycontin.
The denial is upheld.

The patient is a female with chronic pain secondary to fibromyalgia. She has been prescribed OxyContin. Coverage for this was denied by the health plan, as the patient has not failed 3 formulary alternatives. These include fentanyl transdermal QL/PA (quantity limits/prior authorization), hydrocodone extended release, hydromorphone extended release, methadone, morphine extended release, oxycodone extended release, Nucynta extended release, and Xtampza ER (extended release). This has been appealed. The patient has been on this medication for multiple years, and has been stable. This is a continuation of treatment.

No, the health plan should not cover the Formulary exception for Oxycontin.
The patient is a female with chronic pain secondary to fibromyalgia. She has been prescribed OxyContin. Coverage for this was denied by the health plan as the patient has not failed 3 formulary alternatives. These include fentanyl transdermal QL/PA (quantity limits/prior authorization), hydrocodone extended release, hydromorphone extended release, methadone, morphine extended release, oxycodone extended release, Nucynta extended release, and Xtampza ER (extended release). This has been appealed.

The patient has been on this medication for multiple years, and has been stable. While this is a continuation of treatment, there is no documentation that the patient has failed alternative opiate medications. The documentation states that patient has been on this medication for several years, but there is no documentation that the patient has failed formulary alternatives. There is no literature to support that OxyContin is superior to formulary alternatives in chronic pain. Furthermore, evidence does exist that, opiates should be avoided in the treatment of fibromyalgia due to dose escalation, opiate induced hyperalgesia, and risk of abuse and overdose. Given the above, the requested medication is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.

The patient is a male with medical history significant for environmental allergies and attention deficit hyperactivity disorder (ADHD) that presented to his physician with swelling of the right side of his face, associated redness, and a pimple near his nose. He had been squeezing it the night before, and when he awoke his face was swollen and painful. He had no constitutional symptoms. On examination, there was a pimple between his nose and lip on the right side with redness and swelling to the upper cheek below the eye, tenderness of the nasal bridge without swelling, and no sinus tenderness. Culture was sent from some of drained material, with improvement in the pain. He was given a diagnosis of cellulitis and treated with Bactrim and cephalexin to cover methicillin-resistant staphylococcus aureus (MRSA) and Strep. Additional recommendations included warm compresses and topical antibiotic to the pustule site. 

Follow-up phone call the next day revealed that the redness was spreading to underneath the eye. He remained afebrile. At this point, he was referred to the emergency department (ED) for blood work and parenteral antibiotics. Due to the location in proximity to the eye and the worsening presentation despite treatment with Bactrim and cephalexin, he was admitted for further care. Admission orders included ongoing treatment with Unasyn and vancomycin, Toradol as needed for pain, Tylenol round-the-clock, regular diet, and melatonin for sleep. The following day, the swelling and pain were significantly improved. He was transitioned to Bactrim and Augmentin. Blood cultures remained negative. Wound culture was negative pending. He was deemed stable for discharge home to complete a total of ten days of antibiotic.
The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld.

The inpatient stay was not medically necessary. Although he failed outpatient therapy and required a period of monitoring and observation in the hospital, he was overall hemodynamically stable, with no evidence of impending sepsis or orbital cellulitis. He did not require acute inpatient admission and could have been safely managed at a lower level of care. While it was not unreasonable to monitor in the hospital for progression of disease while treating with parenteral antibiotics, he was overall stable with no evidence of sepsis or eye involvement. He did not require acute inpatient admission and could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder.
Treatment:  Braces and Office visits.
The insurer denied Braces and office visits.
The determination is overturned.

The patient has a diagnosis of Class I crowding. Tooth number (#) 20 is underdeveloped, impacted, and blocked out of the arch. Tooth #6 is blocked out to the labial. The patient was treatment planned for 30-36 months of orthodontics to create space to bring tooth 6 and tooth 20 into the arch. At issue is the medical necessity of braces and monthly visits.

The requested orthodontic treatment is medically necessary.
Impacted teeth can lead to bone defects of the adjacent erupted teeth. (1) It is a generally accepted practice guideline to address the impacted tooth by attempting to surgically remove it or to gain space to allow the impacted tooth to erupt. Impacted teeth can cause damage to the roots of adjacent teeth (2), which could lead to restorative treatments. Orthodontic treatment to address 20 is one of the most conservative treatment option available.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alzheimer's, coronary heart disease, diabetes, heart failure, osteoarthritis, and peripheral vascular disease (PVD).

Treatment: 84 hours/week consumer direct, 1 client.

The insurer denied coverage for 84 hours/week consumer direct, 1 client.

The denial is upheld.

This patient is an adult with Alzheimer's dementia, diabetes mellitus, congestive heart failure and peripheral vascular disease. She lives with her daughter in a private home. The insurer approved an increased from 42 hours/week to 56 hours/week consumer direct, 1 client services. However, the patient, through her representative requested an increase to 84 hours/week consumer direct, 1 client services, which is currently under review.

According to the Uniform Assessment System (UAS) report, the patient requires maximal assistance for ordinary housework, meal preparation and shopping. She requires extensive assistance for bathing, lower body dressing and toilet transfer/use. She is bladder and bowel incontinent. She requires limited assistance for upper body dressing and personal hygiene. She has cognitively deficits described as "moderately impaired." The patient uses a cane for ambulation in the home and unable to walk long distances. The combination of her limited functional ability and dementia supports the increase from 42 hours/week to 56 hours/week, in order for her to continue living safely at home.

From a physical medicine and rehabilitation perspective, the combination of the patient's limited functional ability and dementia does support the increase from 42 hours/week to 56 hours/week, in order for her to continue living safely at home, however not the 84 hours/week that are requested.

Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. All decisions are evidence-based.

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

The insurer's partial denial of coverage for 84 hours/week consumer direct, 1 client is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: Braces
The insurer denied Braces.
The determination is overturned.


The patient has an anterior crossbite on teeth 7 and 10. He presented with a Class II malocclusion with severe crowding in the maxilla and mandible. Teeth 12 and 19 have significant decay. The narrative states that tooth 29 is missing but it appears present in the photographs. He is treatment planned for 24-30 months of orthodontics with extraction of teeth 5, 12, and 19 to address the crowding but the treatment was denied due to lack of medical necessity. At issue is the medical necessity of braces.

The orthodontic treatment is medically necessary. This patient presented with an anterior crossbite on teeth 7 and 10, as well as significant crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. (1,2,3) The patient has severe crowding, an anterior crossbite, and severe decay on teeth 12 and 19. Orthodontics is a very appropriate treatment plan to remedy his dental problems. If left untreated the damage that will occur to the patient's teeth will be much more time consuming to correct than the patient's existing orthodontic problem. Orthodontic treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Infectious Disease-HIV/AIDS.
Treatment: Pharmacy/Prescription Drugs/Serostim.
The health plan denied Pharmacy/Prescription Drugs/Serostim.
The reviewer has upheld in whole the health plan's determination.

The patient has a history of human immunodeficiency virus (HIV) (well-controlled on Biktarvy), neurosyphilis status-post treatment with doxycycline, cervical osteomyelitis, and hypogonadism. Available records indicate that he was previously receiving depo-testosterone injections and Serostim (somatropin injections) to manage his hypogonadism. The continued use of Serostim was denied as not medically necessary because he had not met body mass index (BMI) requirements or demonstrated a suboptimal response to alternative therapies. 

Based on pertinent peer-reviewed literature, Serostim is not medically necessary for this patient. Serostim has been approved to treat HIV-associated wasting and cachexia. (1). There is no indication that this patient was being treated for these conditions, and his BMI was in the normal/healthy range at 18.97 kilograms per meters squared (kg/m2). Additionally, records indicate that Serostim was being used to treat hypogonadism, which is not an approved indication for this medication and not well-supported in peer-reviewed literature. (2) Hypogonadism is not an approved indication for this medication and its use in this context is not well-supported in peer-reviewed literature. There is no documentation provided to show that this patient has or has previously had evidence of HIV-associated wasting and cachexia, and his BMI was normal just prior to the request for Serostim. Additionally, even if the patient had clearer evidence of HIV-associated wasting and cachexia, there is no indication that he has demonstrated suboptimal response to any of the alternative therapies (asdronabinol, megestrol acetate, cyproheptadine, testosterone monotherapy for hypogonadism).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Preseptal Cellulitis. 
Treatment: Inpatient Hospital Stay. 

The insurer denied coverage for inpatient hospital stay. 

The denial is upheld. 

The patient was brought in after a two-day history of eye redness and swelling because eye was completely shut after a nap. Only 1 dose Augmentin had been taken which was prescribed at an urgent care center. History documents visit to a park and insect bites to left face, same side as the preseptal cellulitis. 

In emergency department (ED), vital signs were normal, patient was active and alert, well hydrated, in no distress, extraocular muscles intact, no proptosis or conjunctival redness or other evidence of post-septal (i.e., orbital) involvement. 

The ED medical decision-making statement states likely preseptal cellulitis not improved on oral antibiotics so being admitted for intravenous (IV) antibiotics. 

Admission indications for a child with preseptal cellulitis include age under 1 year, underlying sinusitis or if the etiology is unclear (no obvious eyelid or facial skin focus), in which case a ophthalmology consult is needed before determining disposition.  Vital sign abnormalities, systemic symptoms (e.g. SIRS (systemic inflammatory response syndrome), rapidly expanding cellulitis, inability to visualize the globe, concern for eyelid abscess, and inability to tolerate oral medication are red flags. None of these were present. Also, an indication could be if the patient failed appropriate outpatient medications, but in this case, there was not adequate time (only 1 dose taken). 

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

Diagnosis: s/p (status post) Fall (seizures). 
Treatment: Inpatient Admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a male with a history of seizures and Bipolar II and schizoaffective
disorder, bipolar type. The patient had previously been prescribed Keppra and
Depakote but was reportedly non-compliant with his medications. He was found
unresponsive at a subway station and was taken by EMS (emergency medical
services) to the hospital. 

In the ED (emergency department), the patient had a contusion above his left
eyebrow and a contusion on his left elbow. In the ED he underwent a CTH
(computed tomography of head), which returned negative for any acute process. He
was loaded with Keppra. 

Requests for consults with oral surgery, trauma surgery and neurology were made. 
However, the patient elected to leave the ED (emergency department) AMA
(against medical advice) and refused examinations. 

No, the Inpatient admission was not medically necessary. 
The inpatient level of care was not medically necessary for this episode. 

The patient presented to the ED after a suspected seizure. However, he was noted
to have had a history of medication non-compliance, which was likely a cause for
the episode. His initial neuroimaging was negative for any acute process. There
was no evidence of any acute neurological problem or event that would have
necessitated the inpatient level of care. The patient also had no further seizures
following admission. There was no evidence of hemodynamic or metabolic
instability. There was no evidence of an infectious process. The patient ultimately
opted to leave the facility AMA (against medical advice). In such a setting, it cannot
be determined that the patient would have required the inpatient level of care. 

Yes, the health plan did act reasonably, with sounds medical judgment, and in the
best interest of the patient. 

The patient's condition could have been managed adequately in the observation
setting.