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

Diagnosis: Tooth decay. 
Treatment: Nerve Treatment on Tooth 21. 

The insurer denied the Nerve Treatment on Tooth 21. 
The denial is upheld. 

The patient is a female.  Per the patient report, her dentist said that the tooth is very decayed and needs to be replaced and a root canal done.  She also stated she cannot eat well and is experiencing pain and swelling. She reportedly is in constant pain and she cannot eat on the left side of her mouth. 

No, the Nerve Treatment on Tooth 21 is not medically necessary. 

While the patient reported her dentist told her that tooth #21 is very decayed, there was no apparent assessment of her gum tissue, periodontal health of the tooth, or the surrounding bone level.  This information is crucial to determine if the tooth is restorable.  If it is not restorable due to severe bone loss, then nerve treatment would not be necessary for the tooth. Medical necessity cannot be established in this case. 

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

Without x-ray or clinical note, medical necessity for nerve treatment for tooth #21 cannot be established.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis.
Treatment: Otezla 30 mg (milligrams) tablets.

The insurer denied coverage for Otezla 30 mg tablets.  The denial is overturned.

The patient is a male with a diagnosis of mild-moderate psoriasis with a past medical history significant for hypothyroidism and hypercholesterolemia. The patient has failed therapy with topical steroids, light therapy, and prednisone. The requested medication is Otezla 30 mg (milligrams) tablets.  

Based on the submitted documentation, the use of Otezla is medically necessary. The patient has mild-moderate psoriasis and has failed light therapy, as well as topical steroids. Otezla is the most appropriate systemic therapy for mild psoriasis. The patient has failed reasonable alternatives, including numerous topical steroids, light therapy, and prednisone. The use of alternative systemic agents, such as methotrexate, cyclosporin, or biologics, are generally reserved for more moderate to severe diseases. The use of Otezla is approved for use in the management of the patient's psoriasis based on the standard of care.

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

The insurer's denial of coverage for Otezla 30 mg oral tablet is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes
Treatment:  Durable Medical Equipment (custom shoe inserts)
The insurer denied the  Durable Medical Equipment (custom shoe inserts)
The denial is upheld

The patient is a female with a history of diabetes and foot ulcers who is status post a transmetatarsal amputation of the right foot. She has a persistent right foot ulcer. A custom orthotic was requested. It was initially denied and is being reviewed upon appeal.

No, the requested custom shoe inserts are not medically necessary.
The patient underwent a transmetatarsal foot amputation with a persistent ulcer. Custom shoe inserts are not indicated for the management of a transmetatarsal amputation. The patient does not have foot pain along with a muscular disorder, joint disorder, pes cavus, or plantar fasciitis. The requested custom shoe inserts are not medically necessary.

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

Diagnosis: Type 2 diabetes mellitus

Treatment: Inpatient admission 

The insurer denied coverage for an inpatient admission

The denial is upheld

According to the medical records, the patient is a female with diagnoses of Type 2 diabetes mellitus, Obesity, Hypertension, Bipolar disorder, and Hyperlipidemia who presented in the Emergency Room with complaints of dizziness, abdominal pain, and vomiting. She was in the Emergency Room previously with similar complaints and was found to have a urinary tract infection (UTI). She was started on antibiotics. Her symptoms persisted and glucose level was 291 mg (milligrams)/dl (deciliter) and Anion gap of 20 mEq (millequivalents)/L (liter). The patient had a pH (potential of hydrogen) of 7.46 and a bicarbonate of 24. Vitals were within normal limits. The patient was started on an insulin drip and intravenous (IV) Ceftriaxone. A 2-liter intravenous (IV) fluid bolus was given. She was admitted on a diabetic ketoacidosis (DKA) protocol. Ceftriaxone and an insulin drip were continued. The patient left against medical advice (AMA).

The patient had a glucose level of 291 mg/dl. However, her admission blood gas pH was 7.46 and her bicarbonate was normal at 24 and there were no documented urine ketones or ketonemia. Therefore, the inpatient emergency admission is not considered medically necessary for this patient. This patient had no evidence to support admission for DKA. (Up to Date)

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

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

Diagnosis: Status Post Surgery - Right Below Knee Amputation.
Treatment: Alternate Level Of Care.
The insurer denied the Alternate Level Of Care.
The denial is overturned.

The patient is a male. He has PMH (past medical history) of HTN (hypertension), HL
(hyperlipidemia), anemia, Respiratory failure, DM (diabetes mellitus), ESRD (end stage renal disease) on HD (hemodialysis). He reportedly has respiratory failure and has tracheostomy in place.
He needs ongoing tracheostomy care and monitoring. The patient had surgery for his right leg and is status post right below knee amputation. He still needs ongoing surgical site care.

The review is for Alternate Level of Care.

Yes, the Alternate Level Of Care is medically necessary.

The patient has respiratory failure and has tracheostomy in place. He needs ongoing tracheostomy care on daily basis. His trach cuff needs to be changed. The plan is to change to cuff-less tracheostomy for better airflow and speaking. This needs to be done by an ENT (otolaryngology) specialist on inpatient basis. The patient also needs PEG (percutaneous endoscopic gastrostomy) tube feeds and free water flushes. He needs ongoing oral care to prevent any infections. The patient still needs surgical care of his right BKA (below knee amputation) site.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Upper gastrointestinal bleeding
Treatment: Sequential or periodic EGD (esophagogastroduodenoscopy), procedure code 43239.
The insurer denied coverage for sequential or periodic EGD, procedure code 43239.
The denial is overturned.

The patient had a history of gastroesophageal reflux disease (GERD) with erosions and gastritis with Helicobacter Pylori. She was taking Omeprazole and Carafate. She was having black tarry stool. An endoscopy revealed gastritis and duodenitis.  

Milliman Care Guideline (MCG) guideline ACG: A-0203 lists indications for upper gastrointestinal (GI) endoscopy. These indications include having gastrointestinal bleeding such as blood in the stool with a history of dyspepsia, gastrointestinal reflux disease associated with GI bleeding, and dyspepsia with a poor response to medical therapy. 

The submitted medical record states that the patient had abdominal pain and black tarry stools. A previous endoscopy showed erosive esophagitis. The black stools suggest that she was having upper GI bleeding. The patient had dyspepsia with a history of GI bleeding, a poor response to medical therapy, and a history of esophagitis with erosions. These criteria met MCG guidelines for Upper GI endoscopy.

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

The insurer's denial of coverage for sequential or periodic EGD (esophagogastroduodenoscopy), procedure code 43239 is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Barrett's esophagus.
Treatment: Esophagogastroduodenoscopy (EGD).
The insurer denied coverage for EGD.
The denial is upheld.

The patient has Barrett's esophagus. She had an endoscopy and it showed Barrett's esophagus without dysplasia. A repeat endoscopy was performed. Biopsies at that time showed reflux esophagitis. There was no intestinal metaplasia or dysplasia. 

Milliman Care Guidelines (MCG) guideline ACG: A-0203 lists indications for Upper GI (gastrointestinal) Endoscopy. Barrett's esophagus is an indication. However, if there was no previous dysplasia found, then follow-up endoscopy is recommended every 3-5 years. 

Up To Date has an article titled "Barrett's esophagus: Surveillance and management." The article states that if no dysplasia was found on the initial biopsies, then ongoing surveillance should be done every 3-5 years. 

This patient has Barrett's esophagus without dysplasia. The recommended follow-up for a repeat endoscopy and biopsies by both the MCG guideline and Up To Date is 3-5 years. The patient was not due for a repeat surveillance yet. 

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

The insurer's denial of coverage for esophagogastroduodenoscopy (EGD) is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: COPD Exacerbation. 
Treatment: Inpatient Hospital Stay. 

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

The patient presented to the emergency department with a cough and dyspnea. He has a history of bronchitis and is a current smoker with a 6 pack-year history. His vital signs showed a pulse of 97, respiratory rate 20, and blood pressure 118/76. His room air oxygen saturation was noted to be 90%. An arterial blood gas showed a partial pressure of oxygen (pO2) of 82 and partial pressure of carbon dioxide (pCO2) 36 while on 28% fraction of inspired oxygen (FiO2). Expiratory wheezes were heard bilaterally. The white blood cell count was 7.2, Coronavirus (COVID) and influenza testing were negative, and a computed tomography (CT) scan of the chest was unremarkable. He was diagnosed with a chronic obstructive pulmonary disease (COPD) exacerbation and given albuterol/ipratropium nebulizers and intravenous (IV) steroids. Despite this therapy, he was described as still being dyspneic in the emergency department to the extent that he became short of breath while changing clothes, and he was admitted to the inpatient service. 

At issue is the medical necessity of an inpatient stay. 

Yes, the inpatient stay was medically necessary. 

The patient had marked dyspnea after appropriate therapies in the emergency department (supplemental oxygen, intravenous (IV) steroids, nebulized albuterol-ipratropium). Discharge from the emergency department (ED) or a lower level care would not have been appropriate given the severity and persistence of the patients symptoms. The patient's symptoms were severe enough that further decompensation would have needed rapid action to avert death or serious injury. 

Based on guidelines from the Global Initiative for Chronic Obstructive Lung Disease, severe symptoms beyond baseline would be an indication for admission. The Milliman Care Guidelines (MCG) also support inpatient admission despite optimal emergency department care for severe dyspnea which this patient had. For continued treatment of his dyspnea and careful monitoring for decompensation, the inpatient stay was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia.
Treatment: Home health care.
The insurer denied CDPAS (Consumer Directed Personal Assistance Services) - 24 Hours per Day [Split-Shift]. 
The health plan's determination is upheld. 

The patient is a male with past medical history of Alzheimer's dementia, osteoarthritis, anemia, constipation, prostate cancer, and urinary incontinence who had been assigned CDPAS (Consumer Directed Personal Assistance Services) 25 hours/week based on telephonic assessment assessing the patient at total assistance with managing finances while maximum assistance with tasks of meal preparation, ordinary housework, and shopping. With tasks of managing medication, phone use, and transportation, the patient was assessed at extensive assistance while limited assistance with tasks of bathing and dressing lower body. The patient was assessed at supervision with tasks of stairs, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, toilet use, and eating while independent with task of bed mobility. The patient's neurologist provided a letter stating the patient's cognitive status was declining and now required 24 hours of care Monday-Friday and required and increase in home care hours to ensure a safe home environment.

CDPAS (Consumer Directed Personal Assistance Services) - 24 Hours per Day [Split-Shift] are not medically necessary for this patient.

Although there is documentation of deterioration of the patient's cognitive and functional status as well as lack of informal care there is no documentation supporting overnight care needs requiring split shift services. There are no overnight logs documenting assistance needs that would not allow a PCA (personal care assistant) 5 hours of uninterrupted sleep. There is no documentation from the patient's provider that he requires turning and repositioning at least every 2 hours. The requested split shift services would be for safety and supervision without documentation of medical necessity of assistance with activities of daily living (ADL) and Instrumental activities of daily living (IADL) overnight or the need for turning and repositioning every 2 hours. Services for safety and supervision or when the patient doesn't require assistance with ADLs/IADLs are not indicated.
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, CDPAS services 24 hours/day, split-shift, are not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive system/gastrointestinal. 
Treatment: Inpatient hospital. 
The insurer denied inpatient stay. 
The denial is upheld. 

The patient is a male with medical history of alcohol abuse, diabetes mellitus type 2, asthma, seizures, and alcohol-related pancreatitis. He presented to the emergency department with abdominal pain radiating to his back for 3 days, nausea, and vomiting. He had consumed a liter of vodka the prior day. He had not been taking his insulin for three days and presented with initial glucose of 450 milligrams per deciliter (mg/dL). He was treated with intravenous fluids, morphine, ondansetron, and famotidine, and subcutaneous insulin. He was made nothing by mouth (NPO) and started on Clinical Institute Withdrawal Assessment (CIWA) protocol, thiamine, folate, and Librium. He had stable symptoms, and no dyspnea or chest pain. He felt better and tolerated a diet. Labs showed low white blood cell count of 3.9K millimoles per liter (mmol/L), low hemoglobin of 10.4 grams per deciliter (g/dL) and hematocrit of 31.7%, and low sodium of 133 milliequivalents per liter (mEq/L). He was discharged, with a plan for Primary Care follow-up. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld.

The inpatient level of care is not supported as medically necessary by the provided information. The patient presented with symptoms and labs consistent with acute pancreatitis [1]. He was appropriately treated, with intravenous fluid administration, and subsequent improvement in pain [1-5]. However, there was no hemodynamic instability or other complications such as pseudocyst, pancreatic necrosis, thrombosis, ascending cholangitis, abscess, active gastrointestinal bleeding, peritonitis, or sepsis, which would require a higher level of care [4-8]. He did not have persistent signs or symptoms of acute alcohol withdrawal and was appropriately maintained on a CIWA protocol [9,10]. The interventions performed, including labs, intravenous fluids, monitoring, and gradual advancement of diet, could have been performed without the inpatient level of care, at a lower level of care status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pre-term labor
Treatment: Inpatient admission
The insurer denied coverage for an inpatient admission
The denial is overturned

The patient is a female at 26.2 weeks of gestation with a history of previable delivery at 19 weeks of gestation and was maintained on vaginal progesterone. She presented to the emergency room (ER) with complaints of cramping. Evaluation showed evidence of cervical changes: 3.8 cm (centimeters) to 2.15 cm. The patient was hydrated and started on magnesium sulfate. Betamethasone was given. The patient was discharged after a period of hemodynamic stability. 

Preterm labor is an indication for admission and tocolysis. Preterm labor is defined as uterine contractions with cervical changes. Upon evaluation, there was documentation of cervical changes. So, the patient was in preterm labor and admission was needed for tocolysis. According to MCG (Milliman Care Guidelines) admission is indicated for one or more of the following: 

Condition requiring premature delivery
Fetal distress or demise
Preterm prelabor rupture of membranes
Significant maternal disease
Vaginal bleeding
Complications of tocolytic treatment
Continued fetal monitoring that require inpatient care
Tocolytic therapy needed that requires inpatient care
Inability to stop preterm labor.

In this patient's case, tocolytic therapy that requires inpatient care (magnesium sulfate) was needed with close monitoring. The admission was medically necessary.
 
The inpatient admission is considered medically necessary for this patient.

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

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

Diagnosis: Hernia

Treatment: Inpatient admission

The insurer denied coverage for an inpatient admission

The denial is overturned

The patient is a female who underwent an open incisional/ventral hernia repair with implantation of mesh and bilateral component separation. The patient has a history of a prior cystectomy with neobladder. The patient also has a history of chronic obstructive pulmonary disease and a history of a pulmonary embolism. The patient underwent lysis of adhesions prior to the hernia repair by the plastic surgery team. A 20 x 25 cm (centimeter) mesh was required for this patient's hernia repair. Two Relivac drains were placed. Patient controlled analgesia was initiated post-operatively. The patient noted nausea after her diet was started on postoperative day one. Per MCG (Milliman Care Guidelines), inpatient admission may be needed for open repair of large, recurrent, incarcerated ventral or incisional hernias. An extension in hospital stay may also be necessary for active comorbidities or peritoneal adhesions during surgery. [3] Per clinical documentation, the patient had a large incisional hernia, as well as peritoneal adhesions. The patient also developed hypoxia on postoperative day 2, which also supports an inpatient admission. Per provided clinical documentation and guidelines, the requested inpatient hospital admission was medically necessary. 

Complex hernias have been defined as hernias with signs of incarceration, strangulation, infection, chronic pain, irreducible scrotal hernias, multiple recurrence(s), or a relevant history of lower abdominal surgery or radiation. Although some complex hernias are suitable for ambulatory repair, there is insufficient data to support repair of complex hernias in the ambulatory setting. [1,2] Strangulated hernias should not be repaired in the ambulatory setting. [1]

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

The insurer's denial of coverage for an inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Migraine Headaches
Treatment: Qulipta 60MG Tablets
The insurer denied the Qulipta 60MG Tablets.
The denial is upheld.

The patient is a woman with migraines. Her provider wishes to start Qulipta for prevention of migraines. The request was previously denied as patient had not tried a second oral preventative medication and she has not tried any CGRPs (calcitonin gene-related peptides).

No, the requested Qulipta is not medically necessary.

The patient has not tried at least two oral preventative medications for at least 8 weeks, per American Headache Society CGRP guidelines. Furthermore, there are no head to head clinical trials showing that Quilipta is more effective than any of the other CGRPs that the plan has offered.

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

The health plan is following the American Headache Society CGRP guidelines, which is evidence-based medicine.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Leg Infection. 
Treatment: Inpatient admission. 

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

The patient is a male whose inpatient hospital admission is under review. The patient has a history of diabetes mellitus (DM), obesity, and congestive heart failure (CHF) and presented to emergency room (ER) with two months of right lower extremity (RLE) erythema, and three days of fever and chills. 

In the emergency room, the patient's vital signs were: temperature (T) - 97.8, pulse (P) -133 beats per minute, respiratory rate (RR) - 24, and blood pressure (BP) - 151/106.  General assessment revealed no abnormality detected.  The patient's chest assessment was normal, the patient had tachycardia, abdomen was normal, and the extremities had skin redness, weeping skin to the lower extremity and open ulcerations.  The patient's laboratory values were as follows: white blood cell (WBC) - 13.07 (high), hemoglobin (Hg) - 14.7, hematocrit (Hct) - 45.9, platelets (Plt) - 212, sodium (NA) - 140, potassium (K) - 4.1, chloride (Cl) - 104, bicarbonate (HCO3) - 20, blood urea nitrogen (BUN) - 25, and creatinine (Cr) - 1.0. 

In the emergency room, the patient was thought to have sepsis secondary to cellulitis and he was started on intravenous (IV) clindamycin (later switched to cefazolin and Zosyn). In addition, the patient was noted to be in acute heart failure (and rule out myocardial infarct [MI]) for which he was treated. His course was complicated by lactic acidosis and elevated troponin. He refused a cardiac catheterization but improved after several days and was discharged home on oral (PO) antibiotics. 

Yes, the proposed inpatient hospital admission was medically necessary. 

The patient meets the criteria for inpatient treatment according to the Infectious Diseases Society of America, as the patient had systemic signs of infection (elevated white blood cell count, tachycardia, and tachypnea). In addition, standard of care would require admitting such a patient because of concurrent acute congestive heart failure, lactic acidosis, and elevated troponin. 

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient. 

Failure to admit and treat with intravenous (IV) in this patient could lead to loss of function, septic shock, or death.