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

Diagnosis: Cellulitis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient with a past medical history (PMH) of chronic obstructive pulmonary disease (COPD) on 2 liters of oxygen, severe pulmonary hypertension (PHTN), congestive heart failure (CHF), diabetes mellitus type 2 (DM2), obstructive sleep apnea (OSA), chronic pulmonary embolism (PE) on oral anticoagulation (OAC) status/post (s/p) inferior vena cava (IVC) filter, and substance abuse disorder who was admitted with complaints of (c/o) ruptured blisters on his left leg. His vital signs were unremarkable. The physical exam was notable for mild bilateral expiratory wheezes and bilateral lower extremity (LE) edema with multiple ruptured blisters with clear fluid, no apparent distress (NAD). Lab work was unremarkable. Imaging studies included a chest x-ray (CXR) that showed pulmonary congestion, unchanged from a prior exam, lower extremity (LE) ultrasound (US) that showed no deep vein thrombosis (DVT). The patient was initially diagnosed with LE cellulitis and treated with intravenous (IV) antibiotics, but subsequently the left lower extremity (LLE) ulcers were considered to be non-infected and he was then treated for an acute congestive heart failure (CHF) exacerbation with diuresis. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

The admission was not medically necessary at an acute inpatient level of care. This patient with a known history of heart failure presented to the emergency department (ED) with ruptured blisters on his left leg. The patient was not in acute distress and was hemodynamically stable. The patient was initially thought to have cellulitis and have stable CHF, but then subsequently was thought to have no infection but a CHF exacerbation. The patient was not severely compromised, did not have a significantly elevated blood urea nitrogen, low admission systolic blood pressure, significantly elevated creatinine, significant hyponatremia, cardiac ischemia, airway instability, cardiac arrhythmias requiring continuous intravenous (IV) intervention, or inadequate systemic perfusion, nor did the patient require vasodilator therapy. The patient's Ottawa Heart Failure Risk Scale (OHFRS)-Heart Failure Risk Score was 0, indicating a low-risk for serious adverse events. Overall, this patient was monitored, received intravenous (IV) diuresis and this could have been safely provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure
Treatment: Inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

This is a case of a female admitted for diagnosis of seizures. The patient presented with a chief complaint of seizures. The patient presented with her spouse due to a witnessed seizure which was described as tonic-clonic body movements. There was no tongue biting, fecal or urinary incontinence. There was no head trauma or postictal change in mental status. She was previously prescribed Xanax and the plan was to wean off this medication. She had not taken any for several days. 

The inpatient hospital admission was not medically necessary. The patient in this case had a seizure prior to hospitalization but did not have a prolonged postictal state. There was no incomplete recovery or serious seizure related injury. Mental status was fully present at the time of admission and there was no status epilepticus, neurological illness, meningitis or other neurological disease requiring additional evaluation. The patient simply was being weaned off of benzodiazepines and symptoms resolved with re-initiation of medication. There was no airway compromise, tongue biting or incontinence. The patient was prescribed Xanax and recommended to follow up on outpatient basis.
Although the patient required services in the hospital setting the monitoring, diagnostics testing and therapeutic interventions prescribed could have been rendered at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overdose, Drowsiness, Dizziness
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a male patient with a past medical history (PMH) of bipolar disorder who was admitted with complaints of (c/o) a possible unintentional drug overdose of olanzapine and Seroquel without suicidal ideation (SI) (4 tablets). The vital signs were notable for tachycardia and blood pressure (BP) 82/44. The physical exam was remarkable for drowsiness. Lab work was remarkable for leukocytosis. Imaging studies included a chest x-ray (CXR) which showed no acute process and a computed tomography (CT) scan of the head which showed mild diffuse atrophy. An electrocardiogram (EKG) showed sinus tachycardia. The patient was diagnosed with a possible overdose and was treated with intravenous fluids (IVF) and poison control recommended following the QTc, seizure, and/or respiratory distress. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

The hospital stay was medically necessary at an acute inpatient level of care. This patient, with a known psychiatric history, presented to the emergency department (ED) after an unintentional overdose of two different medications. This patient was symptomatic with tachycardia, hypotension, and drowsiness. In addition, the two medications the patient overdosed on are known to prolong the QTc, exposing the patient to a potentially fatal arrhythmia, while the drugs were also associated with sudden cardiac death and seizure. This is further complicated by the patient's risk of respiratory depression and need for close clinical monitoring. Overall, this patient could not have been safely treated and monitored at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Altered Mental Status
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The health plan's determination is upheld.

The patient is a male with a history of end stage renal disease (ESRD) on dialysis who presented to the hospital and was noted to have a change in mental status and slurred speech while on dialysis. He did not recall the event and feels he may have fell asleep while on dialysis. He did not endorse slurred speech on arrival, he also denied dizziness, chest pain, fever, chills, headaches, blurry vision, weakness, nausea, vomiting, palpitations, or mood changes. His exam was unremarkable. His lab results showed a white blood cell count (WBC) of 11.9, a hemoglobin of 14.4, a creatinine of 7.16, and a blood urea nitrogen (BUN) of 25. A computed tomography (CT) scan of the brain did not show any acute intracranial changes. A chest x-ray did not show any acute cardiopulmonary findings. An electrocardiogram (EKG) showed normal sinus rhythm. The patient was admitted. Cardiology, neurology and nephrology were consulted. His work up was unremarkable and he was discharged home in stable condition. At issue is the medical necessity of an inpatient stay.

The inpatient stay was not medically necessary based upon the documentation provided. The patient presented after being noted to have slurred speech and a change in mentation on dialysis. This event was reported as brief with complete resolution by the time he presented to the emergency room. He was hemodynamically stable. He had not noted neurologic deficits. He did not have any cardiac arrhythmias of clinical concern. He did not have documented orthostasis or severe dehydration requiring inpatient monitoring and management. He did not have severe electrolyte or metabolic abnormalities. He underwent a workup which did not require inpatient monitoring or management, nor did he have any findings that necessitated inpatient treatment. He could have been managed at a lower level of care with subsequent outpatient follow-up.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Visual Changes
Treatment: Full Hospital Admission
The insurer denied the full hospital admission.
The health plan's determination is upheld.

The patient is a male who presents with 2 days of blurry vision in his left eye and he was evaluated by an ophthalmologist who sent him to the emergency room (ER) for evaluation of a non-ophthalmologic cause. The patient had the flu for the days prior. The physical examination shows esotropia of the left eye and mild deconjugate gaze.
The computed tomography (CT) of the head was negative. His laboratory studies are remarkable for a C-reactive protein (CRP) of 13.07 and his erythrocyte sedimentation rate (ESR) was 38. The patient was seen by neurology, who thought the patient may have extraocular inflammation from influenza. The magnetic resonance imaging (MRI) was negative. The patient was given a short course of Prednisone and he was set up with outpatient neurology and outpatient neuro-ophthalmology follow up visits.

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

The full hospital admission was not medically necessary for the patient. The observation level of care is medically appropriate. The patient was admitted for a work-up of impaired ocular movement of the left eye that would not be expected to require greater than (>) 2 midnights as the work-up includes an MRI of the brain to assess for tumor, aneurysm or inflammation of the cranial nerves. The patient had an MRI of the brain that was negative.

The patient was known to have a recent influenza infection, and inflammation of the ocular muscles causing impairment of movement of the eyes is a known complication (Senda et al 2018, Migita et al 2001). Treatment is conservative with steroids and he had gradual improvement (Senda et al 2018). As the patient is not expected to require an admission > 2 midnights for an MRI and measurement of inflammatory markers, the patient would not meet criteria for the inpatient level of care by Centers for Medicare and Medicaid Services (CMS) guidelines.

The health plan's determination of medical necessity is upheld in whole.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class II malocclusion with extreme overjet
Treatment: D8020 Braces
The insurer denied: D8020 Braces
The denial is overturned

The patient is a preteen female. The request is for orthodontic benefits. She has a Class II malocclusion with extreme overjet. The health plan's prior denial of coverage for the request was due to "no evidence of handicapping malocclusion." The denial is being appealed.

The requested braces are medically necessary.

The patient has multiple permanent anterior teeth that are impacted, where extraction is not indicated (all 4 permanent canines). These are "automatic qualifiers," according to the handicapping index scale. The patient also has an excessive overjet, where her upper front teeth stick out too far, which makes biting food very difficult. This qualifies as a handicapping malocclusion. This case has medical necessity, and orthodontic treatment is needed to correct the patient's dentition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Palpitations
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

The patient suffers with a history (hx) of homelessness, hypertension (HTN), hyperlipidemia (HDL), active smoker, chronic obstructive pulmonary disease (COPD), Graves' disease with prior thyroid storm (TS), intravenous (IV) drug use, asthma, and congestive heart failure (CHF) with eight prior intubations in the past. This review is requesting approval for inpatient hospital admission for treatment of palpitations, fever, malaise, and CHF.

The patient presented to Emergency Department (ED) for an emergency evaluation due to (d/t) palpitations, fevers, and malaise. 

On examination, the patient appears cachectic with a 4x1 centimeter (cm) sacral ulcer stage II (2). The laboratory studies were remarkable for low thyroid stimulating hormone (TSH) of 0.00, elevated free T4 (free thyroxine) of 2.6, hyperglycemia with a glucose of 139, hypokalemia (potassium) of 3.4, hypomagnesemia (Magnesium) of 1.6, hypophosphatemia (phosphorus) of 2.0, low high-density lipoprotein (HDL) of 38, low low-density lipoprotein (LDL) of 82, leukocytosis (white blood cell count) of 11.3, anemia with a hemoglobin of 8.9, thrombocytosis (platelets) at 425, alkalosis (pH) of 7.49, and an elevated alkaline phosphatase of 152. 

An electrocardiogram (ECG) demonstrated sinus rhythm with left ventricular hypertrophy, and a QTc (interval on an ECG) of 460. The chest radiograph (CXR) demonstrated no evidence of acute pulmonary pathology. The Burch Wartofsky score was 25, borderline suggestive of impending thyroid storm. 

In the ED, endocrinology was consulted, and the patient was administered Propranolol, Methimazole, and Hydrocortisone. The treating provider's clinical impression was emergently concerned for thyrotoxicosis, TS, volume overload, cardiac disease, acute coronary syndrome, sepsis, bacteremia, and drug intoxication. The treating physician's evaluation plan and treatment course for the patient consisted of endocrinology consultation, propranolol treatment, methimazole treatment, hydrocortisone IV treatment, and serial vital sign monitoring. Despite recommendations to remain inpatient for further workup and management, the patient left against medical advice. 

In this case, the patient has a history of uncontrolled hyperthyroidism and substance abuse with recurrent admissions for thyrotoxicosis. However, the patient did not have acute TS, contrary to the evidence, as there was no hyperpyrexia or altered mental status or cardiovascular dysfunction.      

"Classic features of TS include fever, marked tachycardia, heart failure, tremor, nausea and vomiting, diarrhea, dehydration, restlessness, extreme agitation, delirium or coma." (De Groot, et al, 2022).

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 is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neck pain. 
Treatment: Cervical Spine Magnetic Resonance Imaging (MRI). 

The insurer denied: Cervical Spine Magnetic Resonance Imaging (MRI). 
The denial is upheld. 

The patient is an adult female with neck pain. She has undergone at least six weeks of physical therapy. The request for an MRI (magnetic resonance imaging) was previously denied coverage by the health plan, as specific dates of cervical exercises were not documented. The denial is being appealed. 

The requested Cervical Spine Magnetic Resonance Imaging (MRI) is not medically necessary. 

The provided records note physical therapy being done for an ankle injury. No notes specifically mentioned neck pain. The medical records and accompanying information do not support the request. The provided records are orthopedics and physical therapy notes related to an ankle injury. 

Therefore, given the above, the requested Cervical Spine Magnetic Resonance Imaging is not supported as medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Nasal Polyposis, Chronic Rhinosinusitis.
Treatment: Dupixent.
The insurer denied Dupixent. 
The health plan's determination is overturned. 

The patient is a female with a history of chronic rhinosinusitis. Previous treatment has included Xhance and mometasone nasal spray. The patient reported no benefit with either nasal spray. Other treatment included saline rinses. Of note, the prior treatment prescription directions for mometasone were 2 sprays once a day.
Past surgical history is significant for prior endoscopic sinus surgery with findings of significant polyposis. Based on the failure of traditional medical therapy, the provider has recommended Dupixent therapy. 

Dupixent is medically necessary for this patient.
Current clinical guidelines suggest that patients who fail conservative medical therapy (nasal steroids, oral steroids, saline rinses, oral antibiotics) are appropriate candidates for dupilumab to treat chronic rhinosinusitis with nasal polyposis. 
In the case of this patient, all of the criteria set out by the plan's policy were met, except for twice a day dosing of mometasone (patient was treating once a day). However, given the severity of the patient's disease and the lack of response to the once a day dose of the nasal steroid, Dupixent is medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lumbar spinal stenosis
Treatment: Back Surgery (procedure code 0275T)
The insurer denied coverage for back surgery
The denial is upheld

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome.

Back Surgery (procedure code 0275T) has final approval from the appropriate regulatory bodies for this diagnosis.  It has approval for marketing but there are no recommendations nor guidelines for use. 

This patient is not a good candidate for a back Surgery (procedure code 0275T).

The records show no defined pain generator. It is extremely important to recognize how the Pain Management Physician has not commented on the Orthopedic Surgeon's recommendation for bilateral hip replacements. It is extremely likely her symptoms have arisen from the hips. It is extremely important to recognize how the Pain Management Physician has not reported the significance of spinal imaging studies. The magnetic resonance imaging (MRI) shows pathology to every level. There is stenosis and disc protrusion with associated degenerative changes thoughout the person's spine. To perform this procedure to a single level is not likely to provide pain relief. There is also the report of degeneration to the sacro iliac joints. This could be another source of pain. 

A back Surgery (procedure code 0275T) is not the best available treatment for this patient at this time. No spinal procedure would be recommended until the specific pain generator has been defined. Surgery based on the indication of "pain" without defined pathology has poor result and prognosis. If there is confirmation for spinal stenosis, the gold standard would be multilevel laminectomy. The proposed procedure is not recognized by the practicing Orthopedic or Neurosurgical community. There are no guidelines nor recommendations by any National Organizations. Note the proposed procedure consists of removing limited bone and ligament from posterior column. There are no long term followups. There are limited numbers of patients evaluated. No conclusions can be made regarding this procedure. 

There are adverse risks increased over standard treatment/services. There can be neurologic damage, breakage of instruments, infection and anesthesia complications. 

In summary, the denial of a back Surgery (procedure code 0275T) and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are substantially increased over standard treatments.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lumbar spinal stenosis
Treatment: Back Surgery (procedure code 0275T)
The insurer denied coverage for back surgery 
The denial is upheld

This patient has chronic low back pain and leg pain secondary to lumbosacral radiculopathy and spinal stenosis with neurogenic claudication. The patient reported 8 out of 10 pain level and has tried oral analgesics, analgesic ointments, physical therapy and a home exercise program with partial benefit. A magnetic resonance imaging (MRI) was performed that showed broad-based central lumbar (L) 1-2 disc extruded disc herniation with cephalad extension to the superior L1 level, with approximate 40-50% (percent) thecal sac effacement; Moderate L4-5 thecal sac narrowing. Bilateral L4-5 foraminal disc extension. The physician recommended the minimally invasive lumbar decompression (MILD) procedure.

Ehrhardt et al (1) reviewed the efficacy of this procedure and concluded:

"To summarize, recent publications have bettered our understanding of the role of the Minimally Invasive Lumbar Decompression (MILD) procedure in treating patients with lumbar spinal stenosis. As with any relatively new treatment, further research is needed. Additional randomized controlled trials comparing MILD to alternative treatments will bolster the quality of evidence and further inform clinicians. Reports of patient outcomes at greater post-procedure time points will also help in valuation of the MILD procedure." 

In summary, the denial of a back Surgery (procedure code 0275T) and coverage for the requested treatment should be upheld. 

Peer reviewed literature does not support a result of improvement in health outcomes with the requested procedure. Back Surgery (procedure code 0275T) has final approval from the appropriate regulatory bodies for this diagnosis. It has approval for marketing but there are no recommendations nor guidelines for use.

This patient is not a good candidate for the requested procedure.  It is not the best available treatment for this patient at this time.

This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risk are  substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: decreased mobility
Treatment: Personal Care Services, Level 2 - 24 Hours per Day, 7 Days per Week (Split-Shift), Total of 168 Hours per Week 
The insurer denied Personal Care Services, Level 2 - 24 Hours per Day, 7 Days per Week (Split-Shift), Total of 168 Hours per Week. The health plan's determination is upheld. 

This is a case review for a female with medical history notable for gait dysfunction and frailty. The patient and her care team requested an increase to 24 hours per day (2-12 hour split-shift), 7 days per week (168 hours per week) of personal care services.

The requested health service of Personal Care Services, Level 2 - 24 Hours per Day, 7 Days per Week (Split-Shift), Total of 168 Hours per Week is not medically necessary for this patient.
The patient does not have any demonstrated night time personal care needs. The records reflect that she is frequently awake throughout the night with anxiety, but she does not have toileting or turning/repositioning needs that would warrant split-shift personal care aides. She is a mutual case and her spouse has split-shift care, and the plan is correct that for the occasional night time bathroom need her spouse's aide can cover. Safety monitoring and social support are not covered personal care functions in the absence of a demonstrated personal care need.