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

Diagnosis: Depression, Anxiety, Anger And Negative
Thinking
Treatment: Residential Mental Health Treatment
The insurer denied the Residential Mental Health Treatment.
The denial is upheld. 

This male from with diagnoses of oppositional defiant disorder, mild, attention deficit hyperactivity disorder (ADHD), predominantly inattentive type, generalized anxiety disorder, and parent child-relational problems was admitted to this residential facility in Utah.

The patient presented anger, depression, anxiety and aggressive behavior, uniquely directed toward his mother, but never to other individuals or to the six pets in the home. He at times called his mother names, was defiant, and reportedly threw things, such as a ruler, at her. On one occasion he damaged TV sets. As per the patient, his chief complaint was, "My mother and I don't get along." The patient denied suicidality or danger to others.

Other aspects of the patient's life were not problematical.  He had never been suspended or expelled from school. He worked as a scout camp counselor for six weeks and was told he was "a joy to be around," and never had any issues with other campers or staff. The Cub Scouts reportedly "love him," and one of the leaders told the mother that he wants the patient to be his assistant for every camp event.

The patient was born prematurely and had a concussion after striking his head on a wooden board. His mother noted that he had difficulties with aggression, sleep, and anger from his father's death when the patient was four years old.

In the facility the patient was treated with escitalopram, valproic acid, Rozerem, guanfacine, methylphenidate, and Vayarin, a "brain nutrition" supplement of no proven medical value. The patient's stay was uneventful. At no time was there evidence of danger to self or others or of significant behavioral dyscontrol. The patient participated in group therapy, tolerated his medication without noted difficulties, and was generally calm and cooperative.

No, the proposed treatment was not medically necessary.

The patient clearly had mother-child relational difficulties. Although the patient occasionally was threatening and destroyed property, these episodes were infrequent and did not present significant danger to anyone. The patient demonstrated model behavior in other aspects of his life. His difficulties with his mother should have been addressed at a less intensive level of care in his community. Nothing in the documentation reviewed indicates that this patient required or could benefit from 24-hour daily confinement in a residential setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fracture of the distal portion of the right ring finger
Inpatient hospital stay
The insurer denied the inpatient hospital stay.
The determination is upheld.

The patient fell and sustained an intra-articular fracture of the distal portion of the right ring finger proximal phalanx. About 2 days after the injury he presented to an emergency room on the advice of the hand surgeon. He was admitted to the hospital and underwent a closed reduction and percutaneous pinning of the fracture. At issue is whether an inpatient hospital admission was medically necessary for this patient.

No, an inpatient stay was not medically necessary. A displaced finger fracture in a child may in some cases require closed or open reduction, with open or percutaneous fixation. However, there is no reason this would need to be done on an acute, inpatient basis. There is no risk of compartment syndrome or nerve or vascular injury that would require close monitoring before or after surgery. Pain can be managed with oral analgesics. The procedure can be done at a lower level of care. The patient was admitted, underwent the procedure and was discharged the same day. There were no intraoperative or postoperative complications that would require an inpatient stay.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Traumatic Brain Injury.
Treatment:  Ankle Foot Orthotic (L1970 x 2, L2275 x 2, L2220 x 4).

The insurer denied the ankle foot orthotic (L1970 x 2, L2275 x 2, L2220 x 4).  The denial was reversed

This is a young male patient with a past medical history of subarachnoid hemorrhage following injury, subdural hematoma, traumatic brain injury, status post cranioplasty, status post ventriculoperitoneal shunt, seizure disorder, right spastic hemiparesis, elevated liver enzymes, cryptorchidism, chronic dysphagia, gastrostomy tube, right femur fracture, speech and language deficits, impaired mobility, and activities of daily living.  It was reported that the patient fell from a second-floor window a few years ago sustaining a traumatic brain injury.  Documentation indicated the patient could transfer from supine to sit and sit to stand with minimal to moderate assist.  The patient was currently ambulating with bilateral ankle foot orthoses (AFOs) with straps.  It further reported that the patient had a medical necessity for bilateral articulating AFOs with a posterior strap to provide proper biomechanical alignment for optimal gait pattern and capacity.

The healthcare plan did not act reasonably and with sound medical judgment and in the best interest of the patient.  It is customary to order an articulating AFO if the patient's function may improve by allowing added flexibility at the ankle joint of the brace.  In the case of this patient with traumatic brain injury and hemiplegia, transitions from the floor to stand and balance will likely be improved if there is room for dorsiflexion at the ankle joint while still offering the stability/alignment/support of a brace.

Ankle Foot Orthotic (L1970 x 2, L2275 x 2, L2220 x 4) is considered medically necessary for this patient.  A prefabricated pair of AFOs would not meet the patient's needs because in the setting of traumatic brain injury (TBI) with hemiplegia, the feet are not identical.  Usually the weaker side has more spasticity, is smaller, and may have a different positioning/configuration due to muscle imbalances.  Traumatic brain injury with hemiplegia often lead to weakness, difficulty with ambulation, and vestibular issues, which are normally treated with bracing and therapy.  The brain injuries with residual hemiplegia are usually permanent, as in the case of this patient, who was injured in late 2018 and continues to have deficits requiring therapy and bracing.  The requested equipment will improve safety and independence with ambulation by improving balance and reducing falls.  In the setting of traumatic brain injury with hemiplegia the brain does not function normally, and the muscles often display weakness and/or spasticity, so external control of movement of the knee, ankle, and/or foot is often required to optimize ambulation.

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

The carrier's denial of coverage for Ankle Foot Orthotic (L1970 x 2, L2275 x 2, L2220 x 4) is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Anterior Crowding, Overjet and Overbite.
Treatment:  D8080 braces and D8670 monthly visits x 14.

The insurer denied the D8080 braces and D8670 monthly visits x 14.  The denial was upheld.

This is a patient who consulted an orthodontist for orthodontic treatment.  A series of diagnostic tests were performed including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images.  Multiple orthodontists identified several clinical findings including anterior crowding, overjet and overbite and have recommended orthodontics.  Two separate orthodontists each completed the patient's HLD index attaining 33 total points and 26 and 30 points, respectively, to support orthodontic care. 

It is evident that the patient exhibits a malocclusion.  However, to assess for severity of the malocclusion and, therefore, medical/dental necessity for orthodontic care, Handicapping Labiolingual Deviation Index is utilized.  This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.

In this case, the treating orthodontists did not claim an automatic qualifying condition and did not complete the second portion of the index arriving at 26, 30 and 33 points to justify for orthodontic care.  This reviewer concurs with the index completed by the insurer attaining a total of 20 points on the HLD index (3 points overjet, 3 points overbite, 5 points mandibular protrusion, 5 points anterior crowding, 4 points labiolingual spread) which is below the threshold of 26 points to support for orthodontic care.

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

Based on the above, the medical necessity for D8080 braces and D8670 monthly visits x 14 is not substantiated.  The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastroenterology 
Treatment: Inpatient Hospital 

The insurer denied: Inpatient stay 
The denial is: Upheld in whole 

The patient is a male who presented to the emergency room (ER) on with right upper quadrant abdominal pain. The patient had associated nausea, no vomiting. The patient denied fevers. Labs demonstrated white blood cell (WBC) count of 10.7 with left shift aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were mildly elevated. Ultrasound demonstrated gallstone in the gallbladder neck, wall thickening up to 8.5, trace pericholecystic fluid, positive sonographic Murphy sign. Computed tomography (CT) scan showed gallstone in region of the gallbladder neck/cystic duct with mild gallbladder wall edema and adjacent pericholecystic inflammation. 

The patient was admitted. The patient was rounded on by the surgical team and setup for surgery later that day. The patient underwent laparoscopic cholecystectomy. The gallbladder was significantly inflamed. On postoperative day #1 patient was having abdominal pain and discomfort with pressure like sensation across the epigastrium. The patient had urinary retention. The patient was kept an additional day to ensure she could tolerate oral intake. Final pathology demonstrated acute cholecystitis. The subject under review is the medical necessity for the inpatient stay. 

The health plan's determination is upheld in whole. 

No, the inpatient stay is not medically necessary for this patient. 

The patient did have acute cholecystitis which was treated with laparoscopic cholecystectomy, however the indications for inpatient admission for acute cholecystitis are 1) Right upper quadrant pain, mass, or tenderness and 2) Systemic signs of inflammation as indicated by 1 or more of the following a) Fever b) C-reactive protein level greater than 10 mg/L, c) White Blood cell count greater than 10,000 (based on the hospital test a white blood cell count below 10,800 is considered normal). The patient did not meet these criteria. The also patient did not meet criteria for acute cholangitis or common duct obstruction. The patient did not have significant vomiting, dehydration, hemodynamic instability, severe pain, signs of intestinal obstruction or peritonitis, or bacteremia. The documentation does not suggest that the patient's care could not have been performed at a lower level care. There is no evidence that additional complex testing or therapy other than the surgery was performed. There is no evidence that a complicating event occurred before, during, or after the procedure that required a higher level of care. There is no documentation that the treating team identified conditions or problems specific to the patient that would have required inpatient care. The provided documentation does not support the medical necessity of inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma.

Treatment: Inpatient admission.

The insurer denied the inpatient admission.

The denial was reversed.

This is a young male patient with a history of obesity and asthma. It was reported that the patient had a recent admission to the Pediatric Intensive Care Unit (PICU) for an asthmatic episode. The patient was maintained on daily inhaled flovent. The patient had been sick with coughing and had 4 episodes of vomiting at school. The patient presented to the Emergency Room (ER) for evaluation and treatment of rapid breathing. It was reported that the patient was given albuterol at home but his wheezing did not improve.  In the ER, the patient was noted to be in moderate distress with suprasternal retraction, expiratory wheezing and decreased breath sounds. The patient was treated with 3 doses of inhaled duoneb and decadron. The patient's blood gas was significant for acidosis with a pH of 7.22 and an elevated pCO2 of 49.9. The patient's white blood cell (WBC) count was elevated at 17,000. The patient's lactic acid level was elevated at 8.4 and his HCO3 was low at 17 which confirmed the presence of a metabolic acidosis. The patient's respiratory distress did not improve in the ER; the patient with admitted to the hospital with a diagnosis of status asthmaticus and metabolic acidosis. He was treated with intravenous (IV) fluids and albuterol every 2 hours.  

Based on the review of the medical record, the patient was treated appropriately in the Emergency Room (ER) for a cough, wheezing and respiratory distress. When there was ongoing respiratory distress with wheezing and increased work of breathing and blood testing confirming the presence of metabolic acidosis, it was medically appropriate and consistent with the standard of care to admit the patient to the hospital for ongoing treatment with albuterol every 2 hours. The patient was not stable enough to be sent home in view of his metabolic acidosis and need for frequent dosing of albuterol. Thus, the literature supports that inpatient admission was medically necessary for this patient.

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

Based on the above, the medical necessity for the inpatient hospital admission is substantiated. The insurer's denial should be reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Drug overdose
Issue under review: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned. 

The patient is a woman. She has a past medical history of psychiatric disease including suicide attempts. She presented to the ED. The patient had intentionally ingested 15 of her own amlodipine tablets approximately seven hours earlier in a suicide attempt. She activated emergency services, because she was experiencing dizziness with standing. 

In the ED, the patient was hypotensive and tachycardic. She admitted to suicidal ideation. Blood work was significant for an elevated lactate level. An EKG (electrocardiogram) showed sinus tachycardia without signs of ischemia. The patient was treated with IV fluids. Supplemental calcium was not required. She was kept on constant observation. 

Following her ED evaluation, the patient was admitted to the Intensive Care Unit (ICU). Her admission note indicates that she would be monitored for worsening hypotension. She would be under constant observation. The patient would continue receiving IV fluid. She would receive IV calcium for hypotension not responsive to fluids. Throughout the day, the patient's blood pressure was maintained with IV fluid. Her lactate level improved. She was transferred to a general medical bed. Later, she was seen in consultation by psychiatrist, who felt that she required inpatient psychiatric care. The patient was medically cleared to be transferred to a psychiatric floor later in the day. She continued to require constant observation.

Yes, the inpatient admission was medically necessary.

At the time this patient was admitted, she was critically ill. She was hypotensive and tachycardic as the result of a calcium channel blocker overdose. She had impaired peripheral perfusion as evidenced by an elevated lactate level. She was at risk for cardiovascular collapse and death. The patient would require continuous monitoring. She would also require constant observation because of ongoing suicidal ideation. Serial lab tests and EKGs were planned. She was admitted to an Intensive Care Unit.

Following this patient's ED evaluation, she had a severity of illness that justified an inpatient admission. She had persistent abnormal vital signs. There was an elevated lactate level, suggesting impaired peripheral perfusion due to her overdose. She continued to endorse suicidal ideation. 

This patient had an intensity of required services that justified an inpatient admission. She required a degree of monitoring which could only safely be provided in an Intensive Care Unit. She required constant observation to be sure she did not harm herself. A psychiatry consultation was planned. Serial lab tests and EKGs were planned. 

An inpatient admission was medically necessary for this hemodynamically unstable patient.  She required monitoring in an Intensive Care Unit. The patient could not have safely been managed at a lower level of care. The Health Plan did not act reasonably in denying coverage for an inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Idiopathic Focal Dystonia

Treatment: Xyrem 500 milligrams per milliliter oral solution

The insurer denied the Xyrem 500 milligrams per milliliter oral solution.

The denial was upheld. 

This is a female patient with a long history of alcohol responsive abductor spasmodic dysphonia. Her past medical history included hypothyroidism and spasmodic dysphonia.  She consulted a provider with an interest in initiating sodium oxybate therapy. The patient's physical examination revealed isolated focal dystonia of the voice without evidence of spread to additional cranial cervical segments, or any additional notable signs of segmental/multifocal or syndromic dystonia. She reported that many years ago she had a "tic" in her voice, which developed into an occasional hesitation. The patient's symptoms worsened during her first pregnancy and she began to develop "heart stops" in her speech.  By her second pregnancy, the patient's symptoms were very noticeable and nearly constant and she developed significant anxiety as a result of this and their impact on her teaching ability. The patient had been seen by a number of doctors and had been treated with bilateral Botox, which was not effective.  The patient reported that her symptoms had responded well to benzodiazepines and alcohol in the past.  The patient had traveled to Boston to enter a sodium oxybate trial but was excluded when she reported having very occasional passive suicidal ideation without a plan or intent.  The patient had been seen by a provider who was not able to prescribe the sodium oxybate. The patient's diagnosis was noted to be likely idiopathic focal dystonia (or which spasmodic dysphonia is a subtype).  Given the patient's response to alcohol and the failure of botulinum toxin injections, it was opined that sodium oxybate was an appropriate treatment.

Based on the review of the medical record and the literature, the medical record does not support the use of this medication in this clinical scenario. The patient was diagnosed with idiopathic focal dystonia and there are no controlled studies supporting the use of Sodium oxybate for this patient's condition. The data supporting the use of sodium oxybate is essentially limited to one medical center based on a search of Pubmed.  While this center has reported success in one open label study, the limited data available and lack of confirming studies does not support its use in this setting. 

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

Based on the above, the medical necessity for Xyrem 500 milligrams per milliliter oral solution is not substantiated.  The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Cardiac /Circulatory problem.  Chest pain.
Treatment:  Inpatient Hospital.

The insurer denied the inpatient hospital stay.  The denial is upheld in whole.

The patient had chest pain.  He presented to the emergency department  with left (L) sided chest pain and weakness.  The patient woke up in the night with severe left sided chest pain radiating to his left arm and neck.  By different description, the chest pain was 9/10, radiating to the left arm and jaw.  It was not associated with activity.  The requested health service/treatment of the inpatient hospital stay was not medically necessary for this patient.

The patient presented with atypical chest pain.  The patient had known CAD, and he recently underwent stent placement.  There was significant residual disease.  However, there was no evidence of acute coronary syndrome, and the patient's troponin was negative.  The ECG did not reveal new ischemic changes.  Cardiology did not recommend any additional studies.  There was mild pulmonary vascular congestion on CXR, but clinically no evidence of heart failure.  Based on above, the patient did not have evidence of ACS and the inpatient admission was not medically necessary.  The patient was anemic and received one unit of blood.  However, there was no evidence of acute GI bleed.  No studies were done.  The patient had one kidney and his creatinine was chronically elevated.  There was no evidence of acute kidney injury.

The patient suffered from multiple medical problems, but all of them were chronic without exacerbation.  Inpatient level of care was not medically necessary; a lower level of care would be more appropriate in this particular case.