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

Diagnosis: Nausea and High Blood Sugar
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

The patient is an adult male with a past medical history of type 2 diabetes. He presented to the hospital with nausea, vomiting, tachycardia, and severe hyperglycemia. He was found to have hyperosmolar hyperglycemic state and acute kidney injury. He was taking metformin at home prior to admission. The patient was treated with intravenous fluids and was started on insulin. Acute kidney injury, nausea and vomiting, and hyperosmolar hyperglycemia state resolved, and the patient was discharged home on an insulin regimen, metformin, and Januvia. Coverage of provided medical services at the inpatient level of care was denied due to lack of documentation showing unstable heart rate or blood pressure after treatment, severe electrolyte problems, worsening kidney problems, or pulmonary edema with low oxygen. An appeal was requested, and the requested information was provided.

The requested heath service was medically necessary.

The patient had tachycardia, acute kidney injury, nausea and vomiting, and hyperosmolar hyperglycemic state that resolved with intravenous fluids and insulin treatment. In addition, the patient had never been on insulin before and required education on how to use insulin. Inpatient treatment was needed to correct electrolyte abnormalities with intravenous fluids, educate the 
patient on insulin use and make sure that the severe hyperglycemia was resolved before the discharge. The requested inpatient hospital admission was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pain and swelling of the right medial ankle ulcer
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

The patient is an adult male with past medical history significant for morbid obesity, venous stasis ulcers, Deep Vein Thrombosis (DVT) who presented to the emergency room with complaints of pain and swelling of the right medial ankle ulcer.

Vitals on presentation included: Temperature 98.3 degrees Fahrenheit, Blood Pressure 139/73, Pulse 100 beats per minute, Respiratory Rate 18 breaths per minute, oxygen (O2) saturation 96% (percent) on Room Air. Laboratory results included the following: White blood cells (WBC) 6.6, hemoglobin (HGB) 13.9, Hematocrit 42.6, Creatinine 0.98, Glucose 100, C-reactive Protein (CRP) 3.3.

The patient was started empirically on intravenous antibiotics (Unasyn) for a right ankle chronic venous stasis ulcer. X-ray of the foot showed soft tissue infiltration, likely edema, no ankle joint effusion. Podiatry recommended wound care and Unna boot. Patient remained afebrile, hemodynamically stable. The patient was discharged to continue oral antibiotics (Augmentin) as an outpatient.    

According to documentation, patient presented with a chronic right ankle venous stasis ulcer. Otherwise, patient was afebrile, hemodynamically stable with unremarkable laboratory results including a normal WBC. Patient denied any fever. There was no evidence for a disseminated infection and no surgical intervention was required. Based on above findings, the patient met criteria for observation level of management.  

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient. The medical necessity for an inpatient hospital admission to is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastrointestinal bleeding. 
Treatment: Inpatient admission. 
The insurer denied coverage for inpatient admission. 
The denial is upheld. 

The patient reported black stools with some red blood. The patient was taking Ibuprofen after a dental extraction. The patient was hemodynamically stable. The abdominal exam was benign. The hemoglobin was 5.8 but after receiving 2 units of packed red blood cells (PRBC's) went up to 7.5 on the same day. Proton pump inhibitor (PPI) therapy was started. An endoscopy revealed a non-bleeding duodenal ulcer with a clean base. The patient tolerated the procedure well and their diet was resumed. 

Medical necessity was determined based on Milliman Care Guidelines (MCG) guideline M-180 for Upper Gastrointestinal Bleeding. Clinical indications for admission include hemodynamic instability, ongoing active bleeding, and peptic ulcer disease with high risk endoscopic features such as a visible vessel, active bleeding, or an adherent clot. The patient did not have these conditions. The duodenal ulcer was clean based and was not bleeding. Other indications include having a severe coagulopathy, gastric outlet obstruction, peritoneal signs, or anemia with signs of cardiac ischemia that persists after observation care with transfusions. The patient had anemia but it improved rapidly with the transfusions and his clinical status improved after the transfusions. 

This patient had a bleed from a duodenal ulcer. The patient required Proton pump inhibitor (PPI) therapy, transfusions, and then an endoscopy. This could have been done with observation status. The endoscopy was negative for active bleeding or a visible vessel. The ulcer was clean based and the patient could then have been discharged on the Proton pump inhibitor (PPI) medication. An inpatient admission was not medically necessary. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld



Diagnosis: knee pain.
treatment: inpatient stay.
The insurer denied the inpatient stay.
The health plan's determination is upheld. 

The patient is a female with a past medical history of human immunodeficiency virus (HIV), Hepatitis C, cirrhosis, chronic complicated medical seizures, asthma, rheumatoid arthritis, tobacco abuse, history of right shoulder osteomyelitis, recent diagnosis of adrenal cortical insufficiency and history of multiple knee replacements who presented to the Emergency Department (ED)with complaints of bilateral knee pain and difficulty ambulating. 

The inpatient hospital stay was not medically necessary. 
Although the patient has a complex past medical history, there was no documentation of the medical necessity of an inpatient level of care. Furthermore, the patient had no documented fever, normal inflammatory markers, and normal WBC (white blood cell) making the diagnosis of infection unlikely. The patient had no specific signs or symptoms of sepsis. The patient had normal vital signs. The patient had intractable pain with no need for an IV or frequent pain medication. The patient did not require urgent consultation. The patient did not require an urgent procedure. The patient did not show decompensation during the observation period. The severity of illness and intensity of care at the time of admission were not medically necessary at the inpatient level of care. At the time of admission, there was not a reasonable expectation of a greater than two-midnight stay. Therefore, the inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Breast cancer.
Treatment: Proton beam radiation therapy (PBT); procedure codes 77432, S8030, 77301, 77520, 77295, 77370, 77470, 77435, 61796, 77387, 77338, 63620, 61800.

The insurer denied coverage for proton beam radiation therapy (PBT); procedure codes 77432, S8030, 77301, 77520, 77295, 77370, 77470, 77435, 61796, 77387, 77338, 63620, 61800.  The denial is upheld.

This is the case of an adult female who had a mammogram which was positive. Patient underwent biopsy followed by right partial mastectomy and had pT1bN0 (cancer stage) breast cancer. Patient is being evaluated for adjuvant radiation therapy using Proton beam. The health plan does not cover Proton beam for breast cancer.

This treatment is being evaluated under National Cancer Institute (NCI) sponsored trials.

National Comprehensive Cancer Network (NCCN) does not recommend Proton beam therapy routinely for breast cancer.

Although physician has provided the dose volume histogram (DVH) comparison of intensity-modulated radiation therapy (IMRT) and Proton beam, mean dose to heart from IMRT is still acceptable. This patient has right sided breast cancer and can be treated safely with IMRT.

Proton beam therapy is an emerging technology which has been used in past few years to treat several clinical conditions. However, there are no clinical published data to support its superior clinical outcome compared to other routine three dimensional conformal radiation therapy (3D CRT) or IMRT techniques. Most published studies are small studies from single institutions which do not provide long term outcome of proton compared to conventional established photon radiation therapy(RT). These studies suggest improved dosimetry coverage with less side effects. However, there is no clinical published study comparing proton vs photon to conclude any advantage of proton over established RT techniques. Thus, it is not possible to draw any conclusion of any advantage of proton over photon beam RT in breast cancer.

The report of American Society for Radiation Oncology (ASTRO's) emerging technology committee also does not include proton therapy for breast cancer.  

Proton beam radiation therapy, therefore, is not an appropriate treatment due to insufficient clinical data in the medical literature supporting its routine use.

Medically necessary treatments are defined as those which are generally accepted practice in USA. Generally accepted practice for breast cancer in USA is IMRT.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for proton beam radiation therapy (PBT);  procedure codes 77432, S8030, 77301, 77520, 77295, 77370, 77470, 77435, 61796, 77387, 77338, 63620, 61800 is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Central nervous system
Home health care

Diagnosis: cerebral vascular accident.
Treatment: home health care/Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 84 Hours per Week.
The insurer denied Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 84 Hours per Week. The health plan's determination is overturned. 

This is a case review for a female with medical history notable for prior cerebrovascular accident, speech and language deficit, coronary artery disease, atrial fibrillation, and retinopathy. 

The requested Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 84 Hours per Week is medically necessary for this patient.
The patient requires hands-on assistance with transfers, ambulating, toileting, and management of incontinence care products. Her personal care needs are expected to be continuous and unscheduled throughout the day and occasionally at night as well. The patient's physician and care team have attested that she requires additional assistance with these needs. It is therefore reasonable and medically necessary to increase her personal care hours to allow her to have sufficient coverage throughout the daytime when her needs arise. Failure to address these personal care needs could result in falls, skin breakdown, and/or infections.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Morbid Obesity

Treatment: Biliopancreatic diversion with duodenal switch and inpatient admission

The insurer denied coverage for biliopancreatic diversion with duodenal switch and inpatient admission.

The denial is overturned.

The National Institutes of Health has indicated that bariatric surgery is appropriate for all patients with a body mass index (BMI) greater than 40, or for patients with a BMI of 35 to 40 with associated comorbid conditions. Obesity-related comorbidities are conditions that are directly caused by obesity or contribute to the severity of the condition. Obesity-related conditions include cardiovascular problems, diabetes mellitus, obstructive sleep apnea, asthma, musculoskeletal conditions, and various reproductive conditions. [1,2] Roux-en-Y gastric bypass, biliopancreatic diversion with or without duodenal switch, adjustable gastric banding, and sleeve gastrectomy, are available bariatric surgery procedures. Duodenal switch is a very effective procedure with optimal outcomes in super-obese patients. [3] Scientific evidence in peer-reviewed literature supports a result in improvement in health outcome with the duodenal switch procedure. This procedure has final approval from the appropriate regulatory bodies along with inpatient admission.

There is no bariatric surgery that is best. They all have their pros and cons. The single-anastomosis duodenal switch, also known as the loop duodenal switch, stomach intestinal pylorus-sparing surgery, or the single-anastomosis duodenoileal bypass with sleeve gastrectomy has been reviewed by the American Society for Metabolic and Bariatric Surgery (ASMBS) and has been endorsed as an appropriate metabolic bariatric surgery. It has been shown to meet appropriate standards for safety and benefit. Therefore, its adverse risks are not increased over other bariatric procedures [4].

Per clinical documentation, the patient has a history of morbid obesity. BMI (body mass index) is 47. The patient also has a history of severe obstructive sleep apnea. Previous attempts at weight loss has failed. The patient is an ideal candidate for bariatric surgery. Duodenal switch is considered a standard bariatric procedure.

In summary, the denial of biliopancreatic diversion with duodenal switch and inpatient admission and coverage for the requested treatment should be reversed. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Withdrawal
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a male patient who presented with concerns for alcohol withdrawal. The pertinent history included excessive alcohol consumption for two weeks duration and self-discontinuation of prescribed medications. Intravenous lorazepam and ondansetron were administered. The patient was admitted to the hospital with an impression of alcohol withdrawal with paranoia. The treatment plan included scheduled Librium and Clinical Institute Withdrawal Assessment (CIWA) with lorazepam as needed. Bilateral tremor and anxiety were noted. The CIWA was continued. Lorazepam was administered throughout the day per withdrawal assessment. The patient was noted as very agitated with a CIWA of 15. A "code grey" was activated that as the patient was attempting to leave against medical advice and was deemed not safe to discharge. Additional lorazepam was provided. At issue is the medical necessity of inpatient hospital admission.

Based on the clinical documentation provided, evidence-based literature and standard of care, acute inpatient level of care was medically necessary for the entire admission.

The patient had a history of alcohol abuse, anxiety, and mood disorder and presented with concerns of alcohol withdrawal. The initial examination documented the patient as anxious, tremulous, and with a heart rate of 100 beats per minute (bpm). Additionally, vomiting was noted after water intake. The treatment plan included doses of intravenous lorazepam followed by scheduled Librium. Multiple doses of lorazepam, almost every 2 hours, were administered for the next 24 hours. Despite this aggressive regimen, the patient was noted to be severely agitated with a CIWA (Clinical Institute Withdrawal Assessment) of 15. The patient requested to leave against medical advice but was initially deemed unsafe to do so. Additional lorazepam was provided, and the patient was cleared to leave against medical advice.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Major Depressive Disorder
Treatment: Transcranial Magnetic Stimulation (TMS)
The insurer denied the request for TMS.
The health plan's determination is overturned. 

The patient is a male with a diagnosis of depression whose provider is requesting treatment with transcranial magnetic stimulation (TMS). The progress note indicates the patient has experienced symptoms of generalized anxiety disorder and trauma for many years, including intrusive thoughts and rumination. He did report some symptoms of depression, including decreased interest in doing things, feeling down, trouble with sleep, and psychomotor agitation. His Patient Health Questionnaire (PHQ-9) score was reported as 9, and his General Anxiety Disorder (GAD-7) score was reported as 15. He was currently prescribed Wellbutrin 150 milligrams (mg) and Lorazepam 1 mg, both of which are ineffective. He reported previous trials of Zoloft 10 mg, Lexapro  and Cymbalta 30-60 mg. The plan was to start treatment with TMS. The patient's PHQ-9 score was recorded as an 18.
At issue is transcranial magnetic stimulation (TMS). Coverage was denied by the health plan because TMS for the treatment of generalized anxiety disorder is considered experimental/investigational. It also states that a diagnosis of treatment-resistant depression for the current episode is not supported by the documentation, including no documentation that the patient failed a six to eight week trial of maximum tolerated pharmacological dosage to include at least three antidepressant medications from at least two drug classes or at least two different antidepressants from two classes plus an augmenting agent during the current episode. The decision was appealed by the treating provider who states the patient's diagnosis is major depressive disorder and not generalized anxiety disorder. The decision was upheld by the health plan using the same rationale as the one previously used. The decision is being appealed by the treating provider, who indicates that standard health services or procedures have been ineffective or would be medically inappropriate and that TMS is likely to be more beneficial to the patient than any standard covered health service.
 
The proposed treatment with TMS is not likely to be more beneficial than any standard treatment(s) for the insured's life-threatening or disabling condition or disease. The information in the submitted clinical documentation indicates the patient's primary symptoms were consistent with his reported diagnosis of generalized anxiety disorder. Review of the medical literature concludes that the effectiveness and safety of TMS has not been established for the treatment of generalized anxiety disorder. With regards to the patient's symptoms of his depression, his PHQ-9 scores of 9 and 18 are not indicative of severe depression.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Major Depressive Disorder
Treatment: Transcranial Magnetic Stimulation (TMS)
The insurer denied the request for TMS.
The health plan's determination is overturned. 

The patient is a male with a history of treatment resistant depression and generalized anxiety disorder. He has had trials of at least 5 antidepressants (Wellbutrin, Cymbalta, Zoloft Lexapro, and Lorazepam. The following review is evaluating the medical necessity of transcranial magnetic stimulation (TMS) treatments for his mental health condition.

The proposed health service or treatment Transcranial Magnetic Stimulation (TMS) likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. TMS is a Food and Drug Administration (FDA) approved treatment for the patient's depression. The patient has failed multiple treatments for depression and there is evidence to support use of TMS in patients with multiple medication failures (Touloumis 2018 and Alexopoulos et al., 2021).

The health plan's determination regarding the proposed TMS treatment is overturned in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Autism, Developmental coordination disorder

Treatment: Occupational therapy

The insurer denied coverage for occupational therapy.

The denial is upheld. 

This is a child with a diagnosis of autism with associated developmental coordination disorder and monocular diplopia.  The patient receives weekly 30-minute individual school-based occupational therapy sessions.  Under review is the request for weekly outpatient occupational therapy visits.  

The occupational therapy (OT) treatment notes made available for review are inadequate and do not provide sufficient objective clinical information to support the medical necessity of the requested weekly outpatient occupational therapy visits.  The clinical records do not establish the medical necessity of continuing a structured out-patient (once/week) OT treatment program.  There are no specific functional assessment ratings, quantitative assessments or documented measurable response to prior treatment.  The patient has had extensive prior occupational therapy of more than 100 visits over the past 2 years in addition to the school based occupational therapy sessions.  However, there is no specific assessment or quantitative evaluation by the treating occupational therapists demonstrating specific quantitative improvement of the prior occupational therapy provided.  There is a lack of credible documented quantitative functional improvement to support the medical necessity of the requested and indefinite continuation of weekly outpatient occupational therapy sessions. 

From a physical medicine & rehabilitation perspective the requested occupational therapy (OT) treatment visits are not  medically necessary.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for occupational therapy treatment is not substantiated.