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

Diagnosis: Crohn's Disease
Treatment: Stelara (90 mg every 4 weeks)
The insurer denied Stelara (90 mg every 4 weeks). 
The health plan's determination is overturned.

The patient has Crohn's disease status post total colectomy with ileoanal pouch anastomosis. The patient has failed prednisone, antibiotics, cyclosporine, and Remicade. The patient was started on Stelara. Due to only partial improvement, the dose was escalated to every 4 weeks with good control of disease. The coverage is requested to continue Stelara 90 milligrams (mg) every 4 weeks for the treatment of Crohn's disease.

The request for Stelara to 90 mg every 4 weeks is supported as medically necessary by current medical literature. Stelara is Food and Drug Administration (FDA)-approved for the treatment of Crohn's disease, and a large randomized controlled trial demonstrated safety and efficacy of Stelara for induction and maintenance of remission in patients with moderate-severe Crohn's disease and pouchitis [1-3]. Guidelines for the treatment of Crohn's disease recommend the use of Stelara [4]. In this case, the patient has severe disease based on need for surgery. A study showed dosing intensification (90 mg every 4 weeks) was used frequently to address loss of response, and a large proportion of patients were able to maintain response [5-7]. One study showed that dose escalation was required in approximately half of patients, and successful in 61.1% (percent) of dose escalation attempts [5]. Another study showed efficacy of dose escalation to recover lost response in 73% of patients in whom it was attempted [7]. Additionally, American College of Gastroenterology guidelines for the treatment of Crohn's disease state that "Those with continued symptoms should be treated with an alternative therapy for mild to moderate disease, have their medication dose adjusted in order to attempt to optimize therapy" [4]. In this case, the patient has failed Stelara every 8 weeks, and has had disease control on Stelara 90 mg every 4 weeks; discontinuation of dosing every 4 weeks (even if an alternative therapy is attempted immediately) may result in complications such as fistula, stricture, bowel obstruction, flare, hospitalization, need for surgery, or other complications in this patient with moderate to severe disease. For all of these reasons, continuation of Stelara 90 mg every 4 weeks is supported to be more beneficial than any standard treatment or treatments in this case and is medically necessary by current medical literature.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Appendicitis.

Treatment: Inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

The patient presented to the emergency department (ED) with right-sided abdominal pain. The white blood cell count was normal at 8.70. Lactate was elevated to 2.70. The vital signs were unremarkable. The patient had a computed tomography (CT) scan that demonstrated "findings consistent with acute, non-complicated retrocecal appendicitis." The patient underwent an uneventful laparoscopic appendectomy and was discharged within 24 hours after the procedure on the same day. 

Admission may be necessary for patients with severe systemic illness (eg, sepsis), poorly controlled comorbidities (eg, chronic obstructive pulmonary disease [COPD], chronic heart failure), or complications from the procedure (eg, infection, bleeding) that require more than 24 hours of postoperative care. This patient did not require more than 24 hours of postoperative care and he was discharged within this time frame. There were no immediate complications documented after the surgery. According to clinical documentation, the patient was treated under observation standards. Peer-reviewed literature also indicates that laparoscopic appendectomy can successfully be performed as an outpatient procedure in those with uncomplicated appendicitis. Therefore, the requested hospital stay should be upheld.

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

Diagnosis: Asthma
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is male with a history of intermittent asthma who was admitted for acute asthma exacerbation.  The inpatient admission was denied by the plan for lack of inpatient medical necessity.

No, the proposed inpatient admission was not medically necessary.
According to the emergency room triage records, the patient was hemodynamically stable.  His blood pressure was 104/55, temperature was 36.4, and oxygen saturation was 97% on room air.  He was noted to have wheezing, coughing, chest tightness and shortness on admission. His pulmonary examination was noted to show decreased breath sound bilaterally.  The patient received Duoneb, Albuterol nebulized treatment, oral prednisone and intravenous magnesium for management.  He was not improving with the above treatment and inpatient admission was recommended. 

According to the admission records, the patient received nebulized albuterol every three hours, which changed to every four hours with oral prednisolone.  He was not intubated and no concerns for airway compromise were raised.  Additionally, the patient remained afebrile, with oxygen saturation maintaining above 95% on room air.   Based on the lack of criteria for inpatient admission service such as airway edema, stridor or hemodynamical instability, the level of inpatient admission does not meet medical necessity.  Based on the treatment received, such as nebulized treatment and oral medication, an observational level of care is appropriate.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
The level of medical management including diagnostic tests, medication administered and complexity of medical decision making can be managed at an observational level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Inpatient Hospital. 

The insurer denied the inpatient stay. 
The health plan's determination is upheld in whole. 

The patient is a female with right hip pain and known advanced right hip osteoarthritis. She failed conservative treatment of this condition and elected to undergo right total hip replacement surgery. The surgery was successful with no documented complications. The patient recovered well after the operation and was deemed stable for discharge. The patient's health plan denied the inpatient hospital stay as not medically necessary.
At issue in this case is the medical necessity of the inpatient hospital admission. 

The health plan's determination is upheld in whole. 

The requested inpatient hospital stay was not medically necessary for this patient. This determination is based upon the provided medical records and the recommendations of the current, peer-reviewed orthopedic literature. First, the records document that this patient underwent an elective right total hip replacement. There were no documented complications of the operation. She had an uneventful post-operative recovery. There were no post-operative bleeding complications and no signs of infection. The post-operative progress note stated that the patient had adequate pain control. The plan was for discharge home that day according to the provided progress note. Thus, the inpatient hospital stay is not justified and not medically necessary based on the documentation in the patient's chart. 

Second, the current, peer-reviewed literature has documented the advantages of short stay and outpatient total hip replacement with documentation of high patient satisfaction and low complication rates. A recent article published by Xu and colleagues in the Journal of Orthopedics concluded that "Outpatient total joint arthroplasty had comparable total complication rates to inpatient total joint arthroplasty (TJA). Along with that, outpatient TJA can significantly reduce costs to healthcare systems, but careful pre-operative patient selection is required to optimize outcomes." A second article published by Leroux and associates in the Journal of Bone and Joint Surgery in 2020 found that "When comparing matched cohorts of patients who underwent short-stay and longer-stay total hip arthroplasty (THA) or total knee arthroplasty (TKA), we observed no difference in outcomes, suggesting that a short stay with a discharge home in the appropriately selected patient is safe following THA or TKA." Thus, based upon the provided records and the recommendations of the peer-reviewed literature, the inpatient hospital stay in this case, was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right Knee Osteoarthritis. 
Treatment: Hospital Admission. 

The insurer denied coverage for hospital admission. 

The denial is upheld. 

This is the case of a female with a history of hypertension, autoimmune hepatitis, vasovagal syndrome, vitamin D (calciferol) deficiency, stress urinary incontinence, cholecystectomy, spinal compression fracture, hip bursitis, bilateral foot fracture, morbid obesity and severe end stage right knee osteoarthritis who presented for a scheduled right total knee arthroplasty. She was admitted for further post-operative monitoring. While up and ambulating with Physical Therapy (PT), she felt light-headed, weak, and vomited. She was medicated for nausea and her pain medication was changed from oxycodone to dilaudid. The patient was able to increase her distance walking with a rolling walker. During a dressing change, her surgical wound was noted to be clean and dry. Her pain was well controlled and experienced no further vomiting. She was deemed medically stable for discharge and instructed to follow up with her orthopedist as an outpatient. 

The medical records show a non-complicated total knee arthroplasty was performed. The patient's blood loss was 300cc (cubic centimeters) with stable hematocrit. She did not require a drain. There was no evidence of infection nor fever. Her vital signs were stable. Her wound was clean. PT services noted ability to walk 200 feet with walker on post operative day #1. Her episode of emesis was on one occasion and treated. 

Anesthesia records showed the duration of surgery was approximately 90 minutes with associated nerve block. She was able to tolerate oral pain medication. The records considered her American Society of Anesthesiology (ASA) score of 2 with reported morbid obesity of 38. 

She did not require treatment nor testing for an underlying medical condition. 
Based upon her uneventful course and clinical status, there was no indication for the acute inpatient admission. The level of service could have been provided at a lower level. 

There were no extenuating circumstances to substantiate the admission. 

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

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

Diagnosis: Psoriatic Arthritis.
Treatment: Otezla.
The insurer denied the Otezla.
The denial is upheld.

The patient is a male. He has a medical history of plaque psoriasis and psoriatic arthritis. The request for Otezla was denied by the health plan on the basis of medical necessity. The provider is appealing the denial, stating that the patient has been well controlled on a combination of Humira weekly and Otezla since being initiated on this regimen earlier this year.

No, the use of Otezla is not medically necessary.
The requested Otezla 30 mg (milligrams) one tablet by mouth twice daily is unproven in this patient's case. After reviewing the submitted medical documentation, it is clear that the patient's provider intends on using Otezla in combination with Humira weekly. Concurrent use of these drugs is neither FDA (United States Food and Drug Administration)-approved nor a clinically acceptable practice. The request, therefore, is not medically necessary.

Yes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Oligodontia in the maxilla and mandible

Treatment: D5213 partial upper denture

The insurer denied coverage for D5213 partial upper denture

The denial is overturned.

Based on review of the submitted documentation which includes copies of bitewing and periapical radiographs, and insurer correspondence, it appears that this patient presented for evaluation and comprehensive dental care. Recommended treatment was for a maxillary removable partial denture to restore function. The insurer has denied these services stating that there is inadequate periodontal bone support for a metal base partial denture and a partial denture of resin may be approved.

Upon review of the documentation, in particular the radiographs the patient exhibits oligodontia in the maxilla and mandible. Review of the remaining dentition 01 radiograph indicates a level of moderate periodontal alveolar bone loss corresponding to periodontal disease. However, the teeth that would be supports for the removable partial denture are stable and would be adequate abutment teeth. This treatment of a removable partial denture is a standard of care in dental practice for this clinical circumstance. As this is a covered service and indicated for restoration of function and occlusal stability, the partial denture is considered medically/dentally necessary, and meets the insurers criteria for approval.

Partial dentures are designed for use in this clinical circumstance, are a covered service for this patient, are a standard of care in general dental practice and would be an appropriate treatment to restore function and occlusal stability.

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

D5213 partial upper denture is considered medically necessary for this patient.

The insurer's denial of coverage for D5213 partial upper denture is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

The patient is a male for which an inpatient level hospitalization is under review. The patient has a history of hypertension and asthma. He presented with worsening shortness of breath for three days. There was no chest pain.

The patient's BP (blood pressure) was elevated. The patient's heart rate was mildly elevated. His oxygen saturation was normal. He was in no acute distress. His chest x-ray demonstrated mild bilateral interstitial opacities. The BNP (brain natriuretic peptide) was 5130. Electrolytes and the creatinine were normal. He was thought to have CHF (congestive heart failure) due to the elevated BP (blood pressure).

The patient was administered intravenous Lasix and started on BP (blood pressure) medications. Echocardiography demonstrated an LVEF (left ventricle ejection fraction) 35-40% (percent). An exercise test was normal. Cardiac catheterization was recommended. However, the patient signed out against medical advice. At that time, he was considered clinically and hemodynamically stable for discharge.

No, the Inpatient admission was not medically necessary.
This patient presented with CHF (congestive heart failure) and a cardiomyopathy, which improved with medical therapy, including diuretics. He remained stable. He was an early responder to medical therapy. There was no hemodynamic instability, worsening cardiac symptoms, severe electrolyte abnormality, renal failure, need for ongoing oxygen support, severe arrhythmia, acute coronary syndrome (minimally elevated troponins likely secondary to CHF [congestive heart failure], and cardiomyopathy), myocardial infarction, need for ongoing in-hospital intravenous medications, need for mechanical or pharmacologic cardiac support, or administration of high risk medications requiring in-hospital monitoring. In the setting of this case an inpatient level hospitalization, compared to for example observation then outpatient, has not been established standard of care towards improved cardiac outcomes. It is therefore considered not medically necessary in this case.

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

Diagnosis: Acute Appendicitis

Treatment inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is overturned

The patient is a child who presented to the emergency department due to complaining of abdominal pain.  The documentation indicated the patient had associated symptoms that included fever as well as nausea and vomiting.  The patient has been tolerating fluids and his last bowel movement was the day prior to presentation.  The documentation indicated on physical examination he was noted to have a temperature of 102.3.  He had a blood pressure of 99/67.  His pulse was 106 beats per minute and oxygen saturation was 99% (percent).  The abdominal examination revealed diffuse tenderness with right lower quadrant pain as well as guarding and rebound tenderness.  The recommendation was made for laboratory diagnostic studies.  The physician indicated he did have a positive strep test however given the lack of exudates or palatal petechiae it is likely he is a carrier.  The documentation indicated he had an elevated white blood cell count of 17.1 and a computed tomography (CT) scan of the abdomen did show a dilated appendix with periappendiceal inflammatory stranding.  He was recommended to undergo surgical intervention.  The documentation detailed he did undergo an uncomplicated laparoscopic appendectomy and tolerated the procedure well.  He had control of pain with medication and his diet was advanced as tolerated.  The documentation indicated he did not have any further adverse events and therefore the following day he was discharged with instructions to follow-up.

This admission should be covered. The patient was taken appropriately to the emergency department for concerning abdominal pain and was diagnosed with and underwent surgery for appendicitis. The appendix was necrotic and phlegmous at the time of surgery, supporting the need for the intervention. He had an appendicolith, which typically indicates a high failure rate with medical management. The surgery occurred and he was admitted late the night prior for fluid and electrolyte replacement and was discharged home the following day.  The mean post-operative stay for children undergoing this type of surgery is 1.9-5 days after surgery, so it would be expected that he remain in the hospital for more than 48 hours. This is a completely indicated admission that should be covered.

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 hospital admission is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal-Joint Fracture/Break
Treatment: Inpatient Hospital Stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

This case describes a patient who was struck by a car while riding a motorcycle. This resulted in a complex left mid foot fracture. The injury occurred and the patient was admitted to the hospital for further work up and care. The patient underwent closed reduction and pinning of the foot fracture and a laceration repair  on the same day. The patient was deemed stable for discharge home the following day. 

The requested health service/treatment of an inpatient hospital stay was not medically necessary for this patient. This determination is based upon the provided medical records and the recommendations of the current, peer-reviewed literature. The provided records document that this patient underwent closed reduction and pinning of a left foot Lisfranc fracture dislocation. The surgery was successful with no documented complications. This patient had normal vital signs and lab values after surgery and was deemed stable for discharge on the day after surgery. The plan was for definitive open reduction and internal fixation of this foot injury one week after discharge. Based upon the documentation in the provided records, the medical necessity of the inpatient stay is not established. This care was appropriate and consistent with the recommendations of the peer-reviewed literature as documented by Philpott and colleagues in the Journal of Foot and Ankle Surgery in 2021.
Appeal type: Medical necessity
Decision: Upheld

Dental problems
Dental/Orthodontic procedure

Diagnosis: Class II Occlusion
Treatment: Braces (Comprehensive Orthodontic Treatment). The insurer denied Braces (Comprehensive Orthodontic Treatment). The health plan's determination is upheld.

The patient in question is a female with a Class II occlusion with 4-millimeter (mm) overjet and 5 mm overbite. The maxillary and mandibular arches have moderate crowding. She is treatment planned for 24-30 months of orthodontics with extraction of teeth 5 and 12 to correct her malocclusion. Under review is the medical necessity of Braces (Comprehensive Orthodontic Treatment).

Braces (Comprehensive Orthodontic Treatment) are not medically necessary for this patient. The patient does have a deep bite, however, that alone is not a medical necessity to treat. There are functional problems that can occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. This patient presents with none of those conditions. Although the dental evaluation indicates a bilateral posterior crossbite, the supplied photos do not show any crossbites. The photographs do not illustrate any damage to the teeth or soft tissue damage from their current position. The patient has a 4mm overjet, but this amount of overjet does not affect oral health related quality of life. If her teeth were aligned, it would provide an aesthetic improvement but it would not create a medically significant improvement to the patient's health. Therefore, Orthodontic treatment is not medically necessary.