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

Diagnosis: Digestive System/Gastrointestinal-Abdominal/stomach pain
Treatment: Inpatient hospital stay
The health plan denied the inpatient stay as not medically necessary. 
The reviewer has overturned in whole the health plan's determination.

The patient has a history of chronic abdominal pain, status post recent cholecystectomy, presented to the emergency department (ED) with severe abdominal pain. The pain was 10/10 in severity. It was a stabbing pain that began earlier that night, waking her from sleep. In the ED she was tachycardic (heart rate (HR) = 138) and tachypneic (respiratory rate (RR) =28), though afebrile. Her abdomen was tender to palpation on examination. Her labs returned with leukocytosis (white blood cell count (WBC) = 19.3). A computed tomography scan of the abdomen/pelvis was suggestive of infectious or inflammatory enteritis of the ileum. She was given fentanyl for severe pain. An NG(nasogastric) tube was placed due to concerns for obstruction, but it only put out 100 cubic centimeters of content. The ED note then says she was given Toradol for her intractable pain. She was started on intravenous (IV) antibiotics, blood cultures were drawn. The patient was seen by a Gastroenterology consultant who noted that the patient's abdominal pain was unchanged. She was tender to palpation on his examination. Her HR was still in the 130's at times. The leukocytosis had resolved to 6.6. Stool cultures were still pending. The consultants ordered a bowel prep to arrange for colonoscopy the following day.  The patient was still experiencing 10/10 abdominal pain and had IV Dilaudid for pain management. She was continued on IV antibiotics and fluids. Later she underwent the colonoscopy. This showed internal hemorrhoids and areas of fissured appearance in the terminal ileum. Multiple biopsies were taken. After the colonoscopy she tolerated a regular diet and then left the hospital against medical advice (AMA). 

This patient required inpatient admission. She presented with severe abdominal pain that did not respond to initial treatments. This persistence of severe pain warrants inpatient admission for further workup. Indeed, the gastroenterology consultant recommended inpatient colonoscopy for such workup, in addition to stool cultures.
On admission her leukocytosis was severely high at 19.3 and infection was in the differential. She required IV antibiotics and fluids. It is possible that this patient had early sepsis, since she was tachycardic, tachypnea, and had a high leukocytosis. Blood cultures were ordered due to concerns for the possibility of a severe infection. She was started on IV antibiotics for possible severe infection. Abdominal infections can require several days of IV antibiotics for adequate treatment, depending on the cause. The complexity of a patient with possible sepsis and with uncontrolled 10 out of 10 abdominal pain not responding to strong analgesics, warrants inpatient admission for further workup and close monitoring for decompensation to a worsening state, such as septic shock.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Physical Therapy. 

The insurer denied physical therapy visits. 
The denial is upheld. 

The patient is a female with right shoulder adhesive capsulitis status post right shoulder manipulation and lysis of adhesions. At issue is the medical necessity of continued physical therapy for this patient. 

The requested physical therapy is not medically necessary for this patient.  The patient's right shoulder adhesive capsulitis status post right shoulder manipulation and lysis of adhesions is a chronic condition. On one visit her pain level was 3-10/10. Right shoulder passive flexion was 90 and external rotation was 0. On another visit, right shoulder active flexion was 115 and abduction 105. Right shoulder passive flexion was 145, abduction 120, internal rotation 70 and external rotation 25. Right upper extremity strength was 4/5-5-/5. Her pain level was 0. On another visit right shoulder passive flexion was 140, abduction 115, external rotation 15, and internal rotation 60. Right shoulder active flexion was 115, abduction 110, and internal rotation to thoracic (T) 12. She was compliant with her home exercise program daily. 

On another visit, the patient had functional right shoulder range of motion and strength. Her pain level was 0.  She was compliant with her daily home exercise program. Continuing physical therapy would be considered a service to maintain function by using routine, repetitive procedures, exercise, conditioning or gym programs for stable chronic conditions (lasting longer than 3 months since initial onset) and would not be considered medically necessary. The peer reviewed literature and the medical standard of care does not support continuing physical therapy in this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Deep pockets.
Treatment: Cleaning of Tooth Roots (Deep Cleaning) for the Whole Mouth, Pre-service.
The insurer denied the Cleaning of Tooth Roots (Deep Cleaning) for the Whole Mouth, Pre-service.
The denial is upheld. 

The patient is a female requesting periodontal coverage for four quadrants of scaling and root planning.

No, the proposed Cleaning of Tooth Roots (Deep Cleaning) for the Whole Mouth is not medically necessary.
Deep cleaning is reserved for patients with a quadrants of four or more teeth with pocket depths five millimeters or more. There are no areas (quadrants) of this patient's mouth that have four more teeth with pocket depths of five millimeters (mm) or more. The Plan criteria are consistent with all medical literature; these codes are the standard for periodontal issues. Therefore, periodontal benefits cannot be applied.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lower Back Pain
Treatment: 72148 - Magnetic Resonance Imaging (MRI) of the lower back without contrast (dye), pre-service
The insurer denied the MRI of the lower back without contrast, pre-service.
The denial overturned. 

The patient is a female with history of low back pain after a motorcycle accident, localized to the dorsa-lumbar area and sometimes radiating into both legs. She was seeing her treating Chiropractor who performed manual manipulation, adjustment and low-tech physical rehabilitation started. She was not showing progress, with her pain continuing at an eight out of ten (8/10), and a plain x-ray of the lumbar spine was requested. The x-ray of the lumbar was read as negative.

With no improvement to her pain, Valsalva tests, Kemp tests, Straight leg tests all being positive, the treating chiropractor requested a magnetic resonance image (MRI) of the lumbar spine. Approval was sought for the MRI.

Yes, the proposed MRI is medically necessary.

According to the American College of Radiologists, patients presenting with acute, subacute, or chronic low back pain (LBP) and radiculopathy who have failed 4-6 weeks of conservative care and with physical examination signs of nerve root irritation should be imaged if they are believed to be candidates for surgery or if diagnostic uncertainty remains. MRI of the lumbar spine has become the initial imaging modality of choice in complicated low back pain, displacing myelography and computed tomography (CT) in recent years. Accurate diagnosis of disc disease can be provided by MRI.

In this instance, the patient sustained low back pain after a motorcycle accident and started conservative treatment that included chiropractic manipulation. With no improvement to her pain, Valsalva tests, Kemp tests, Straight leg tests all being positive, the treating chiropractor requested a MRI of the lumbar spine. Approval was sought for the MRI. A prior x-ray of the lumbar spine was read as negative.

No, the health plan did not act reasonably and it lacked sound medical judgment which was not in the best interest of the patient because the MRI of the lumbar spine is medically necessary and likely to be more beneficial than any standard imaging in line with the rationale stated above and also the American College of Radiologists.
Appeal type: Medical necessity
Decision: Overturned

Aphakia
Treatment: Cataract Surgery
The insurer denied Cataract Surgery.
The determination is overturned.

The patients aphakia for whom coverage of a secondary intraocular lens implantation (CPT 66985) is the subject of review. Following trauma, the patient underwent cataract surgery. The provider states that the level of her injury precluded simultaneous intraocular lens implantation at that time. Surgery was previously denied as it was understood the requested surgery was cataract removal. The provider states that the patient is suffering progressive permanent visual loss due to the lack of an intraocular lens, and further delay will only worsen her permanent vision loss. Vision was 20/25-2 right eye (oculus dexter) and 20/60-1 left eye (OS). A left exotropia and right hypertropia was noted. The patient was identified as having good capsular support for an intraocular lens scheduled to be placed.

A secondary intraocular lens implantation (CPT 66985) is established as medically necessary in this case. According to the Preferred Practice Patterns of the American Academy of Ophthalmology, the standard of care in cataract surgery in the United States is to replace the cataract with an intraocular lens (IOL). Secondary intraocular lens implantation is indicated for trauma patients with crystalline lens loss as in this case, where such intraocular lens implantation could not be performed at the time of original cataract extraction because of the level of the patient's trauma. Once the lens is removed, an eye can no longer focus light inside the eye. It is not unusual for a child to develop some degree of amblyopia and may need to patch to strengthen the weaker eye. High anisometropia requiring a contact lens (which has to be removed and cleaned regularly) or thick spectacle lenses makes amblyopia management difficult and less efficient. So, a permanent secondary intraocular lens is placed, per standard, of care, when the patient's condition allows.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital admission for medical necessity. 
The denial was upheld. 

This patient is a male admitted for a diagnosis of acute bronchitis and viral upper respiratory infection. The patient presented with symptoms of shortness of breath, runny nose, and body aches for one week prior to admission. His vital signs demonstrated a temperature at 97 Fahrenheit (F), pulse was 74, respiratory rate was 19, blood-pressure was 98/60 and pulse oxygen (O2) saturation was 97% on room air. The physical exam showed no acute distress or altered mental status.
His chest x-ray showed streaky/linear opacities. His complete blood count (CBC) was normal, and the basic metabolic panel (BMP) showed a creatinine at 1.40. The patient was treated with intravenous fluids for his creatinine elevation, which was thought to be due to dehydration.
It was noted that the patient had no fever and his vital signs remained stable during the admission. The patient was treated with azithromycin and nebulizers for his acute bronchitis. The coronavirus 2019 (COVID-19) testing was negative. The patient was then discharged.
At issue is the medical necessity of the Inpatient stay.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Inpatient stay was not medically necessary for this patient.
According to UpToDate, 2021, "Staging Criteria, Using the Kidney Disease: Improving Global Outcomes (KDIGO) criteria, acute kidney injury (AKI) is staged as follows: Stage 1 - Increase in serum creatinine to 1.5 to 1.9 times baseline, or increase in serum creatinine by =0.3 milligrams (mg)/deciliter (dL) (=26.5 micromole/liter), or reduction in urine output to < 0.5 milliliter (mL)/kilogram (kg)/hour for 6 to 12 hours. Stage 2 - Increase in serum creatinine to 2.0 to 2.9 times baseline, or reduction in urine output to less than (<) 0.5 mL/kg/hour for =12 hours. Stage 3 - Increase in serum creatinine to 3.0 times baseline or increase in serum creatinine to =4.0 mg/dL (=353.6 micromole/liter), or reduction in urine output to < 0.3 mL/kg/hour for =24 hours, or anuria for =12 hours, or the initiation of kidney replacement therapy, or, in patients < 18 years, decrease in estimated glomerular filtration rate (eGFR) to < 35 mL/minute/1.73 square meter (m2)."
The patient in this case had an unknown baseline creatinine but initial creatinine elevation was up to 1.4. This would place the patient in a stage I acute kidney injury classification which is generally appropriate for outpatient care. He required intravenous fluids during the hospital stay as the kidney injury was thought to be from a pre-renal etiology. The patient did not have intrinsic kidney disease or vasculitis contributing. The patient was treated for acute bronchitis and was not noted to have lobar pneumonia on his x-ray.
Therefore, medical necessity of an Inpatient stay has not been established.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism Spectrum Disorder.
Treatment: Occupational therapy (2) visits.
The insurer denied the Occupational therapy (2) visits.
The denial is overturned.

The patient is a male child with history of autism diagnosed several years prior. He receives occupational therapy services twice weekly to improve functional skills. Areas of concern include executive functioning, problem solving, bilateral skills for ADLs (activities of daily living), balance, upper body strength, strengthening for hands, motor coordination, and attention. In addition, he exhibits anxiety and has difficulty with self-regulation and modulation; he is in the care of a psychologist to work on his anxiety. His current goals include the following: improve upper body strength for daily activities, able to sit without use of a back rest for 10 minutes during a functional activity (25% achieved); improve problem solving skills, able to find a solution to items missing in a familiar activity or task (25% achieved); and complete visual scanning and figure-ground activity in order to improve independence with scanning his home environment for items or scanning his clothing for ADLs (activities of daily living) (25% achieved). New goals continue to be added as he achieves success with existing goals.

While the patient has made steady progress with habilitative goals, as well as with self-regulation and modulation, he continues to have significant weakness in his upper body, he continues to become upset with difficulty problem-solving when presented with a clinical situation, he is not yet independent in self-care skills, and he requires assistance organizing his work area. He continues to have difficulties with motor planning, impacting his safety in the community as well as his fine motor skills and how he uses his hands. Ongoing occupational therapy intervention has been recommended to facilitate acquisition of age appropriate habilitative skills, improve his independence with activities of daily living, and improve his strength and dexterity.

Yes, the Occupational therapy (2) visits is medically necessary.
Ongoing occupational therapy remains medically necessary and appropriate for this male child.

This young male child with autism and possibly also ADHD (attention deficit hyperactivity disorder) has a number of challenges and difficulties that negatively impact his ability to perform age appropriate activities of daily living, to function safely in the community, to interact competently with his environment, and to achieve age appropriate independence. Occupational therapy is ideally suited to facilitate functional gains, with its focus on fine and gross motor skills, balance, strength, motor planning, and self-regulation. He has made consistent progress with these interventions to date but continues to lag behind same age peers. The interventions he receives with his occupational therapist are supported by his home program but cannot be replaced by his home program. The requested services are thus medically necessary and appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Eating disorder
Treatment: Continued Inpatient Hospitalization 
The insurer denied. The health plan's determination is upheld.

The patient is a female with a request for MH (mental health) inpatient level of care. The patient was admitted for eating disorder behaviors. The patient was noted to be of stable weight on admission and eating 3 meals a day. There was also a note from the patient that her mother wanted her to go to a therapeutic boarding school. The patient was diagnosed with Depressive disorder, unspecified, attention deficit hyperactivity disorder (ADHD), GAD (general anxiety disorder), Cluster B personality traits in adolescent, histrionic and history of eating disorder. There is also a diagnoses of DMDD (Disruptive mood dysregulation disorder) given. On admission, blood pressure (BP) was 123/81 with a pulse of 87. Temp was 98.8F. The patient had a body mass index (BMI) of 19.99. The patient had numerous hospitalizations for suicidal ideation, attempts, and taking a knife to school. The patient was most recently discharged from inpatient a residential eating disorder program. 

The continued inpatient hospitalization is not medically necessary. The patient had no active suicidal ideation with plan, homicidal ideation with plan or command hallucinations. The patient was not physically aggressive, acutely manic or sexually inappropriate. The patient had no significant medical instabilities. The patient had not required emergency medications, restraints or seclusions. The patient was compliant with medications. The patient did not have any electrolyte abnormalities or significant biomedical instabilities. The patient was not at a dangerously low body weight. Treatment could have been addressed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back Pain
Treatment: Physical Therapy
The insurer denied the Physical Therapy
The denial is overturned

The member is a female with history of chronic low back pain radiating to the right lower extremity with recent exacerbation affecting her functionality.
The referral to PT was made by her treating physician.
At the initial review at PT, pain level was 4/10, with increasing progress and improving strength after 7 PT sessions.

Yes, the 7 Physical therapy sessions were medically necessary because the member was referred by a treating physician for acute exacerbation of chronic low back pain with evidence of progression and improvement documented at the end of the 7th PT session.
The goals for PT included improved pain and functionality, which were documented by the physical therapists.

No. The health plan has not acted reasonably in this instance and its decision lacked sound medical judgment, which was not in the best interest of the patient based on the above rationale because the patient as a 14-year old in pain was referred by her treating physician for physical therapy to alleviate the pain and improve her functionality. The goals were met within reasonable 7 PT sessions and pain down to 1/10.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Gastroparesis; Constipation
Treatment: Formulary exception for Motegrity
The insurer denied the Formulary exception for Motegrity
The denial is upheld.

The patient is a female with chronic constipation and gastroparesis. She has failed Miralax, Colace, Senna, Dulcolax and Linzess. She is unable to take Amitiza due to low blood pressure and syncope. She has been doing well on Trulance in combination with Motegrity. Her provider is requesting continuation of Motegrity.

No, the health plan should not cover the formulary exception for Motegrity.

The patient has failed the formulary drug Linzess. She is doing well with regard to constipation on Trulance, but still has gastroparesis. Amitiza would not help with gastroparesis. There are no formulary preferred medications offered for gastroparesis.

Carbone et al. looked at a cohort of 31 patients, with predominantly idiopathic gastroparesis, and found that four weeks of prucalopride treatment significantly improved symptoms and quality of life and enhanced gastric emptying compared with placebo. Motegrity, however, is not FDA (United States Food and Drug Administration)-approved or compendia-supported. It is still undergoing clinical trials for use in gastroparesis, and is unproven.  There also is no medical literature supporting the use of Motegrity in combination with Trulance to treat constipation. Therefore, the requested Motegrity is not medically necessary and should not be covered by the health plan.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's Disease.
Treatment: Stelara, Pre-service.

The insurer denied the Stelara, Pre-service.  The denial is overturned.

The patient is a male with moderate to severe Crohn's disease, status post resection. He has failed treatment with Entocort, Prednisone and Pentasa, and was a primary non-responder to anti-TNFs (tumor necrosis factors). He failed Humira despite adequate drug levels and no antibodies. His provider is requesting treatment with Stelara.

Yes, the requested Stelara is clinically appropriate, accepted standard of care, and medically necessary, over the plan preferred Renfelxis, Inflectra, Avsola and Entyvio, in this patient with moderate to severe Crohn's disease who has failed Humira.
The patient has moderate to severe Crohn's disease and has failed Humira, an anti-TNF (tumor necrosis factor). He failed Humira despite having no antibodies and having adequate drug levels. Medical literature supports changing to a biologic agent with a different mechanism of action in patients who have failed anti-TNFs (tumor necrosis factors) despite adequate drug levels and no antibodies. Therefore, Stelara would be a better option than Renfelxis, Inflectra and Avsola, plan-preferred medications that are anti-TNFs (tumor necrosis factors). The other plan preferred agent is Entyvio. Biemans et al. showed that Stelara was associated with superior effectiveness outcomes when compared to Entyvio, while safety outcomes were comparable after 52 weeks of treatment in CD (Crohn's disease) patients who have failed anti-TNF (tumor necrosis factor) treatment. Therefore, the requested Stelara is clinically appropriate, accepted standard of care, and medically necessary, over the plan preferred Renfelxis, Inflectra, Avsola and Entyvio, in this patient with moderate to severe Crohn's disease who has failed Humira.

Because Stelara is medically necessary and more appropriate than the preferred formulary alternatives, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.