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

Diagnosis: Cobalamin C deficiency
Treatment: Hydroxocobalamin Acetate 
The insurer denied Hydroxocobalamin Acetate.
The health plan's determination is overturned.

The patient is a female child with medical history significant for cobalamin C deficiency, autism, speech and language deficits, and developmental delay. She receives comprehensive supportive therapy services through her school. Her treatment regimen includes leucovorin, levocarnitine, betaine, folate, and hydroxycobalamin (currently at 10 mg [milligrams] dosing).

Hydroxycobalamin Acetate is medically necessary for this patient.

Cobalamin C deficiency is a type of remethylation defect inherited in an autosomal recessive pattern. This deficiency involves an impaired methylation of homocysteine to methionine resulting in accumulation of homocysteine. Patients with remethylation defects typically present with developmental and neurocognitive impairment, feeding difficulties with failure to thrive, neurological problems such as seizures and movement disorders, visual impairment, and hematological abnormalities. Patients specifically with cobalamin C deficiency may be prone to microangiopathic diseases such as atypical hemolytic uremic syndrome. Treatment involves early administration of hydroxycobalamin with a starting dose of 1000 mcg (micrograms; or 1 mg) intramuscularly daily for neonates titrated to effect, sometimes requiring significantly higher dosing and intervals of administration up to a week. Additional medications may include folate, betaine, and carnitine. The current standard involves treatment with hydroxycobalamin and betaine, with less evidence for the utility of carnitine treatment and dietary manipulations.

This young girl has been diagnosed with cobalamin C deficiency. Appropriate treatment involves hydroxycobalamin intramuscular injection. For her, the dose has been titrated up to 10 mg to achieve the desired clinical effects and prevent progression of the disease. Intramuscular injection in the most humane way entails using the more concentrated formulation (10 mg/mL [milligrams/milliliter] rather than 1mg/mL). This formulation is medically necessary and appropriate to achieve patient compliance and adequate management of a potentially devastating disease.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Pain and Anemia
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned.

The patient is a male with a past medical history of chronic pericarditis with associated elevated troponin, human immunodeficiency virus (HIV) / autoimmune acquired immunodeficiency syndrome (AIDS) on highly active antiretroviral therapy (HAART), Kaposi Sarcoma, and deep vein thromboses (DVTs). He presented to the emergency department for evaluation of sharp chest pain with radiation to his left arm which woke him up from sleep. He also reported associated shortness of breath and palpitations. He stated that his symptoms were similar to his prior symptoms of pericarditis. 

On arrival to the emergency department, the patient was afebrile and hemodynamically stable. He was saturating 99% (percent) on room air. His physical examination was unremarkable. His initial labs were notable for a hemoglobin of 10.3, and a troponin of 0.29 with a significantly elevated erythrocyte sedimentation rate (ESR). Twelve-lead electrocardiogram (EKG) demonstrated normal sinus rhythm. Chest x-ray showed minimal left infrahilar infiltrate versus atelectasis. He was given intramuscular (IM) Toradol and was loaded with aspirin and was admitted to the inpatient unit for further care. A transthoracic echocardiogram was ordered for further evaluation. Before treatment and work up of this patient could be completed, he left the hospital against medical advice.

Yes, there is sufficient clinical data to support medical necessity for inpatient level of care.
This patient with prior history of pericarditis and myopericarditis presented with worsening chest pain. His work up was notable for significantly elevated inflammatory markers and an elevated troponin. The constellation of these findings is consistent with a diagnosis of myopericarditis. 

Myopericarditis is a condition characterized by inflammation of the pericardium with concurrent involvement of the adjacent myocardial layer which manifests as an elevated troponin level. While the treatment is essentially the same as pericarditis, patients who have myocardial involvement are at an increased risk of mortality and they must be ruled out for acute coronary syndrome as well. Given the higher associated mortality with these patients, inpatient hospitalization is warranted for close monitoring of the hemodynamics as well as assessing response to treatment. Consequently, admission to inpatient level of care was appropriate and medically necessary in this case.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
The best interest of the patient in this case would be inpatient admission given elevated mortality risk associated with myopericarditis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Deep vein thrombosis (DVT)
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld.

This case involves a female who presented to the emergency room complaining of 2 witnessed seizures. Upon assessment in the emergency room, the patient was afebrile and hemodynamically stable. Laboratory testing results were within normal limits with imaging of the chest and had shown no abnormalities. The patient was administered Keppra and subsequently admitted for care. Records stated the patient was kept overnight on seizure precautions with continuous Keppra after which she was discharged following a period of hemodynamic stability. The inpatient hospital stay was denied coverage with claims that the patient could have been placed on observation under monitoring due to a lack of hemodynamic instability, pulmonary complications, metabolic abnormalities, or neurological reasons to treat her on acute level of care. 

The Milliman Care Guidelines state that indications for admission for inpatient care for an individual who has suffered a seizure includes one or more the following to include that they are hemodynamically unstable, are status epilepticus, have a brain disorder, have an etiology that requires monitoring or intervention, has altered mental status that is severe persistent, has no focal neurologic deficits, and metabolic disorder that persists despite observation care, is having recurrent seizures in the emergency department or under observation care, when outpatient antiepileptic regimen cannot be established, with neurosurgical bleeding, hydrocephalus, or requires vasospasm monitoring, or when the patient has increased intracranial pressure or requires cerebral edema monitoring.  
The information provided for the review did not support that the patient required inpatient level of treatment. The administration of Keppra and ongoing monitoring could have been rendered on an observational basis. There were no records indicating that the patient continued to have seizures in the emergency department with evidence showing that she had normal diagnostic test results and normal laboratory work-up. Based upon the provided information, the medical necessity of the request was not established as care could have been safely rendered at a lower level of service.  

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

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

Diagnosis: Psoriasis Vulgaris
Treatment: Stelara SQ 45MG
The insurer denied the Stelara SQ 45MG
The denial is overturned.

The patient is a female with psoriasis, treated with topical steroids and Taltz.  Her clinic note states she was following up after starting Stelara and is "better with medication."  The health plan denied coverage of the request due to lack of documentation of improvement on medication.

Yes, the requested Stelara is medically necessary.
The patient was documented to have improved on the medication approximately 6 months ago.  Stelara is a safe, effective and widely used therapy for psoriasis.  It is reasonable and medically necessary to continue this therapy.

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: Upheld

Diagnosis: Seizures

Treatment: Inpatient admission 

The insurer denied coverage for an inpatient admission 
The denial is upheld.

This case involves a female who presented to the hospital for symptoms related to seizures. She had been doing well off of medications and was free of seizures for the past 6 years. Approximately 1 month ago, she developed an episode of hypertonicity that woke her up during the night associated with drooling and up rolling of the eyes. The episode lasted for 15 minutes. She was aware of her surroundings and was able to recall the events that occurred but was not able to talk. Medical advice was not sought at the time. On the day of admission, she developed 2 episodes each lasting 15 minutes that occurred in the morning. The episode resolved spontaneously and was followed by weakness and fatigue that lasted for 1 hour. Updated imaging was recommended to rule out any masses or structural defects. A video electroencephalogram was suggestive of bilateral temporal lobe epilepsy. A magnetic resonance imaging of the brain revealed dilation of the central canal. She was started on levetiracetam and deemed stable for discharge.  

Per the cited references, a hospital admission for seizures is recommended for hemodynamic instability, febrile seizures, status epilepticus, and a significant brain disorder that requires monitoring or intervention available only at inpatient level of care. Also, it is recommended for etiology that requires monitoring or intervention and persists despite observation care, altered mental status that is severely persistent, new focal neurological deficit, metabolic disorder that persists despite observation care, recurrent seizures, and when there is increased intracranial pressure or cerebral edema.  

The documentation did not identify that the patient was hemodynamically unstable, required monitoring or intervention available only at inpatient level of care, had altered mental status that was severe persistent, had new focal neurological deficit, or had recurrent seizures that were observed during the emergency department or observation care. Thus, the patient's care could have occurred at a lower level of care such as observation.  As such, the denial of coverage of inpatient admission was appropriate and is 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 admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis
Treatment: Tremfya
The plan denied treatment with Tremfya
The denial is upheld.

The patient is a female with psoriasis. She also has psoriatic arthritis of the left wrist. Body surface area affected is 5%. The subject under review is the medical necessity for Tremfya.

The health plan's determination is upheld.

The requested health treatment of Tremfya is not medically necessary for this patient. According to the American Academy of Dermatology Psoriasis Guidelines and dermatology literature, the preferred medicines such as methotrexate covered by the patient's insurance plan are effective treatments for the management of psoriasis (1, 2).
Within the peer-reviewed literature, West et al. 2016 conducted a review of eleven comparative, controlled studies that passed a Cochrane risk of bias analysis. They concluded that methotrexate achieved significant improvement in reducing psoriasis plaques. Methotrexate is a preferred treatment, and based on data analysis, 45.2% [95% confidence interval 34.160.0] of patients achieve psoriasis area and severity index (PASI) 75 at primary endpoint, Thus, methotrexate is an effective first-line treatment for the management of psoriasis (3). There is no documentation provided that would justify the patient requiring treatment with Tremfya over the plan alternatives such as methotrexate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Breast Cancer
Treatment: Radiation Therapy (Initial phase: 25 fractions Proton Beam Therapy.  Boost phase: 10 fractions Proton Beam Therapy.  Image Guided Radiation Therapy for initial and boost phase.)
The insurer denied: Radiation Therapy (Initial phase: 25 fractions Proton Beam Therapy.  Boost phase: 10 fractions Proton Beam Therapy.  Image Guided Radiation Therapy for initial and boost phase.)
The denial is upheld.

The patient is an adult female with ductal carcinoma in situ (DCIS) of the left breast and pT2pN1a (Invasive tumor greater than 2.0 centimeters but 5.0 centimeters in greatest dimension, metastases in 1 to 3 axillary lymph nodes) invasive ductal carcinoma of the right breast status post bilateral lumpectomy and right sentinel node biopsy.

Proton beam therapy is being requested to treat bilateral breast and regional nodes for the right breast.

The requested proton beam therapy is not medically necessary.

Currently, clinical outcomes evidence in the peer-reviewed medical literature is insufficient to allow for definitive conclusions regarding the relative safety/efficacy of proton beam radiotherapy for management of breast cancer, as compared to standard of care photon-based radiotherapy.

Peer-reviewed publications that are reporting on the clinical outcomes of proton therapy for breast cancer are derived from non-randomized studies and dosimetric and biological considerations that are theoretic.

These published studies suggest that proton beam radiation offers superior dosimetry to photon radiation treatment dosimetry, and side effects of proton beam therapy are evidenced to offer potentially fewer local side effects compared to photons in several types of malignancy. However, no clinical outcomes studies on proton vs. photon (3-D RT [three-dimensional radiotherapy] or IMRT [intensity modulated radiotherapy]) have been published to conclusively state any advantage of protons to the current standards photon radiation therapy that exist for breast cancer. It is, therefore, not possible to draw any conclusions on the benefits of proton beam therapy compared to photon RT (radiotherapy) in this patient's case.

The health plan's reason for denial of coverage is consistent with the current published clinical outcome evidence.

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

Diagnosis: Crossbite
Treatment: Braces and Monthly Visits
The insurer denied: Braces and Monthly Visits
The denial is: Overturned

The patient in question is a male. He is class I with a blocked out mandibular first premolar (#28). The lower midline is shifted to the right and the right posterior segment is in crossbite. He has a functional shift to the right. He is treatment planned for 30-36 months of orthodontics to correct his crossbite. The subject under review is the medical necessity for braces and monthly visits for this patient.

The requested treatment with braces and monthly visits is medically necessary for this patient. Research has shown that early intervention is beneficial for patients that have a crossbite with functional shift making treatment at a younger age the preferable option. 1 This patient presents with crowding and partially blocked out #28. Most significant is the unilateral posterior crossbite on the patient's right side and corresponding mandibular midline shift to the right. There is strong medical evidence that that early correction of unilateral posterior crossbites with a shift reduces the need for future treatment.1 The evidence shows if such a crossbite is not corrected before the patient reaches skeletal maturity, the ability to achieve orthopedic expansion is greatly reduced.2 Given the patients age and when skeletal maturity occurs, the patient is nearing the end of the time that orthodontics alone can correct his crossbite. Therefore, the requested treatment is medically necessary at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain

Treatment is an inpatient admission 

The insurer denied coverage for an inpatient admission 
 
The denial is upheld

The patient presented with epigastric pain, vomiting, and diarrhea. She was fasting for Ramadan and received glucose in the ER (emergency room) for hypoglycemia. She was afebrile and the vital signs were stable. The abdominal exam was benign. An abdominal CAT (computed tomography) scan was negative for acute disease. There was no leukocytosis. The renal function was normal. An endoscopy revealed a mild gastropathy. Proton-pump inhibitor (PPI) therapy was given for gastritis. An outpatient gastric emptying study was planned. 

Clinical indications for admission for Undiagnosed Abdominal Pain (MCG (Milliman Care Guidelines) M-05) include hemodynamic instability, inability to maintain oral hydration after observation care, bacteremia, and the need for a procedure that cannot be performed on an ambulatory basis. 

Clinical indications for admission for Gastritis (MCG M-560) include having a suspected gastric outlet obstruction, perforation, peritoneal signs, severe dehydration, severe electrolyte abnormalities, and severe vomiting that does not respond to antiemetic therapy. 

This patient was treated for gastritis and required a workup for abdominal pain and vomiting. Treatment with PPI therapy and having an endoscopy could have been done with observation status. She did not meet MCG criteria for admission for either Undiagnosed Abdominal Pain or Gastritis.

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

Diagnosis: Ankle Fracture.
Treatment: Hospital Admission.
The insurer denied Hospital Admission.
The denial is: Upheld.

 The patient is a female who sustained a left ankle bimalleolar fracture after slipping on the front steps of her home. She was seen at an urgent care facility and then referred for definitive treatment and care. The patient was admitted to the hospital. Subsequent open reduction and internal fixation of the left ankle fracture were performed. The patient was subsequently discharged from the hospital. The subject under review is the medical necessity for hospital admission.

The requested health service/treatment of hospital admission was not medically necessary for this patient. The medical records do not document the reason for the delay between her admission and her surgery. This patient had a reported medical history of eczema and seasonal allergies. Her admission labs and vital signs were within normal limits. She sustained a closed bimalleolar fracture of the left ankle with no nerve or vascular compromise. Based upon the current, peer-reviewed orthopedic literature, including recent articles published by Malik and colleagues in the Journal of Foot and Ankle Surgery in 2020 and by Qin and associates in the Orthopedic Clinics of North America in 2018, this ankle fracture would be best treated at a lower level of care status. Thus, the entire hospital admission, in this case, was not medically necessary based on the provided records and the recommendations of the peer-reviewed literature. The management of this patient could have been accomplished at a lower level of care status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Neck Problem/Pain. 
Treatment: Spinal Cord Neurostimulator. 

The health plan denied the requested health service/treatment of outpatient procedure- spinal cord stimulator placement as not medically necessary. The health plan's determination is overturned. 

The patient is a male with a history of chronic neck pain secondary to disc herniation and stenosis. He was treated with 3 cervical epidural steroid injections and had a consultation with a neurosurgeon who did not recommend surgery. He is currently on opiate pain medication, and his treating provider is recommending a spinal cord stimulator trial. 

At issue is the medical necessity of the requested health service/treatment of outpatient procedure - spinal cord stimulator placement. 

The health plan's determination of medical necessity is overturned in whole. 
The requested health service/treatment of outpatient procedure - spinal cord stimulator placement is medically necessary for this patient. Chronic severe pain results in a detrimental effect on the patient's quality of life. Such patients have to take a large number of medications, including opioids, often without satisfactory effect, sometimes leading to medication abuse and the pain worsening. Spinal cord stimulation (SCS) is one of the most effective technologies that, unlike other interventional pain treatment methods, achieves long-term results in patients suffering from chronic neuropathic pain. The first described mode of SCS was a conventional tonic stimulation, but now the novel modalities (high-frequency and burst), techniques (dorsal root ganglia stimulations), and technical development (wireless and implantable pulse generator-free systems) of SCS are becoming more popular. The improvement of SCS systems, their miniaturization, and the appearance of new mechanisms for anchoring electrodes results in a significant reduction in the rate of complications and revision surgeries, and the appearance of new waves of stimulation allows not only to avoid the phenomenon of addiction, but also to improve the long-term results of chronic SCS. Therefore, the requested health service/treatment of outpatient procedure - spinal cord stimulator placement is medically necessary for this patient.