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

Diagnosis: Left breast erythema.

Treatment: Inpatient admission.

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

Patient is a female with past medical history significant for asthma and recent pregnancy termination who presented to the emergency room with complaints of left breast swelling and tenderness. 

Vitals on presentation included: T (temperature) 97.9 F (Fahrenheit), BP (blood pressure)123/73, P (pulse) 93, RR (respiratory rate) 20, O2 (oxygen) sat (saturation) 98% on RA (room air). Laboratory results included the following: WBC (white blood cell count) 14.6, HGB (hemoglobin) 12.5, HCT (hematocrit)-37.3, creatinine 0.81, glucose 89.

The patient had an ultrasound of the breast, and a needle aspiration was performed. She was started on intravenous antibiotics (vancomycin). Wound cultures were sent for diagnosis. Patient remained afebrile, hemodynamically stable and was discharged to continue outpatient management.

According to the documentation, the patient presented to emergency department with complaints of left breast erythema. Otherwise, she was afebrile and hemodynamically stable. Laboratory results were only notable for a mildly elevated WBC. There was no evidence for a systemic infection, and she had no significant co-morbid conditions or risk factors. Based on above findings, the patient met criteria for observation level of management. 

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: Orthopedic/Musculoskeletal. 
Treatment: Prosthetics. 

The insurer denied right lower limb prosthesis. 
The denial is upheld. 

The patient is a female bilateral amputee with history of right lower limb above the knee amputation and left lower limb below the knee amputation treated with left lower limb below the knee prosthesis. She has right flaccid hemiplegia after a stroke.  The community health assessment stated that she was nonverbal and had recent left below the knee amputation and right 3rd and 5th toe amputations. Her cognitive skills were described as "severely impaired-never or rarely makes decisions". She had memory problems. She had severely declined since the left below the knee amputation and only responded to simple questions. She was rarely or never understood when communicating. She sometimes understood simple direct communication only. She was non-verbal. She was non-ambulatory. She was totally dependent with ambulation, bathing, lower body dressing, and transfers. She was maximum assistance with hygiene, upper body dressing, bed mobility, and eating. She was incontinent of bowel and bladder. At issue is whether the requested right above the knee lower limb prosthesis is medically necessary for this patient. 

The health plan's determination is upheld. 

The requested service of right lower limb prosthesis is not medically necessary for this patient. 
The patient does not have the potential to ambulate or transfer safely with or without assistance. She has right lower residual limb flaccid paralysis due to a stroke and does not have adequate right lower residual limb strength to participate with transferring, walking, or both, utilizing a right above the knee prosthesis. Prior to her right lower limb amputation, she was non-ambulatory and totally dependent for transfers according to the assessment performed. Further, she has severe cognitive deficit and does not have the cognitive capacity to ambulate, or transfer using a right above the knee prosthesis and left below the knee prosthesis. The peer-reviewed medical literature does not support the prescription for right above the knee prosthesis. Further the medical standard of care in the United States at this time would not include a right above the knee prosthesis.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory System. 
Treatment: Home Health Care. 
The insurer denied T1019-Consumer Directed Personal Care Services (CDPAS) at 120 hours per week. 
The denial is overturned. 

The patient is a male with a past medical history is significant for ventilator dependent respiratory failure and quadriplegia. The subject under review is the medical necessity for Consumer Directed Personal Care Services (CDPAS) at 120 hours per week. The patient has been approved for 97.5 hours a week. Additional services were denied by the plan based upon medical necessity.

The requested health service is medically necessary for this patient.
The patient is quadriplegic and ventilator dependent requiring complete care. Even though the patient's nursing assessment noted a total 97.5 hours a week, the patient cannot function for himself independently due to his underlying medical condition.  Insurance denied the request for 120 hours a week stating the following, your needs can be met in 97.5 hours per week.
Uniform Assessment System (UAS) State of New York was reviewed.
Patient is quadriplegic and unable to perform any independent functions, Instrumental activities of daily living (IADLs) or activities of daily living (ADLs). He is completely dependent on others for his care. His past medical history significant for stage four (IV) pressure ulcer with a need for frequent turning to prevent breakdown. The patient has no noted active ulcers at this time. The patient is high risk for recurrent pressure ulcer without turning on a regular basis.
The patient has no informal help. His mother has been staying with them until he can be properly cared for. Patients with quadriplegia cannot function independently and need to be turned on a frequent basis to prevent breakdown of the skin, every 2 hours. Based on the information provided the increase to 120 hours a week is medically necessary for this patient's condition.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hyperlipidemia, chronic atrial fibrillation, respiratory failure. 
Treatment: Continued Skilled Nursing Facility Services. 

The insurer denied the Continued Skilled Nursing Facility Services.  The denial is overturned. 

The patient is a male with past medical history (PMH) of hyperlipidemia (HL),
chronic atrial fibrillation, anxiety, bipolar disorder, gastroesophageal reflux disease (GERD) and benign prostatic hyperplasia (BPH). He reportedly had respiratory failure secondary to COVID-19 infection. The patient's medications include Flomax, Protonix, valproic acid, duonebs, and olanzapine. 

This review is for continued skilled nursing facility services. 

Yes, the proposed continued skilled nursing facility services are medically necessary. 

The patient has significant weakness after acute respiratory failure and COVID-19 infection. He is maximum assist with all his activities of daily living (ADLs). The patient still needs help with feeds and has problems with swallowing. He is on a mechanical soft diet. He needs close supervision. He still has physical therapy (PT) and occupational therapy (OT) needs to improve his strength and range of motion. The patient still has significant weakness and mobility problems. He is participating in physical therapy and showing improvement. Continued skilled nursing care facility services are medically appropriate. 

The recommended length of approval for the proposed continued skilled nursing facility services is approximately a week. At that time, medical necessity should be reassessed for continued signs of progress. 

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient. 

The patient still has skilled nursing care facility needs.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain

Treatment: Diagnostic esophagogastroduodenoscopy (EGD), procedure code 43239

The insurer denied coverage for diagnostic EGD, procedure code 43239

The denial is upheld

The patient was presented with upper abdominal pain. There is a family history that a cousin had colon cancer and his uncle had stomach cancer. The patient underwent endoscopy and colonoscopy. Biopsies of the stomach and esophagus showed mild chronic inflammation. Helicobacter Pylori was not found. 

Milliman Care Guidelines (MCG) guideline ACG: A-0203 lists indications for Upper Gastrointestinal (UGI) endoscopy. Dyspepsia is an indication if it is associated with a risk factor. These risk factors include age 60 years old, failure of medical therapy, family history of UGI cancer in a first degree relative, and persistence of pain for 3 months or longer.

The submitted documentation states that the patient was not on any medications. He did not try and fail proton pump inhibitor (PPI) therapy. The abdominal exam was benign. He had an uncle with an upper gastrointestinal (GI) malignancy but did not have a first degree relative. He did not meet MCG criteria for doing an Upper GI endoscopy. 

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

The insurer's denial of coverage for diagnostic esophagogastroduodenoscopy (EGD), procedure code 43239 is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Home Health Care. 

The insurer denied increase in Consumer Directed Personal Assistance Services to 24 hours per day, 7 days a week (split shift). 
The denial is overturned. 

The patient is a female with past medical history of corticobasal syndrome, blind loop syndrome, Parkinson's disease and major depressive disorder. Review is regarding medical necessity increase in Consumer Directed Personal Assistance Services to 24 hours per day, 7 days a week (split shift). 

The requested health service/treatment of increase in Consumer Directed Personal Assistance Services to 24 hours per day, 7 days a week (split shift) is medically necessary for this patient. 

The patient is dependent for mobility, activities of daily living (ADLs) and instrumental activities of daily living (IADLs). Due to her cognition, also requires redirection. She has no informal helpers, and her daughter can no longer provide assistance. She is incontinent of bowel and bladder and would require frequent changes in diapers to avoid skin breakdown. She also cannot turn in bed independently and would need overnight assistance for repositioning. 
The requested increase in assistance was not solely for safety and supervision but to assist the patient with the safe completion of ADLs and IADLs. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, Consumer Directed Personal Assistance Services to 24 hours per day, 7 days a week (split shift) is medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Crohn's ileitis

Treatment: the laboratory test for the measurement of serum concentrations of Ustekinumab (UTS) levels and antibodies of Ustekinumab (ATU) (lab test that measures antibodies) code 84999

The insurer denied coverage for the laboratory test for the measurement of serum concentrations of Ustekinumab (UTS) levels and antibodies of Ustekinumab (ATU) (lab test that measures antibodies) code 84999

The denial is overturned

The patient was diagnosed with Crohn's ileitis. He was previously on Humira and Entyvio. He remained with active disease and was switched to Stelara. Computed Tomography (CT) enterorrhaphy showed active Crohn's ileitis. A Stelara level showed that the drug was in the therapeutic range and no antibodies were detected. He was treated with a course of steroids for a flare up.

The physician has submitted an article from Clinical Gastroenterology and Hepatology; titled "Association Between Ustekinumab Trough Concentrations and Clinical, Biomarker, and Endoscopic Outcomes in Patients with Crohn's Disease." The conclusion was that maintaining a maintenance trough concentration of ustekinumab above 4.5 ug/ml (micrograms per milliliter) was associated with biomarker reductions and an endoscopic response of disease activity.

The Journal of Clinical Medicine has an article titled "Update on Therapeutic drug Monitoring with Ustekinumab, Vedolizumab, and Tofacitinib in Inflammatory Bowel Disease." The article evaluates ustekinumab treatment in ulcerative colitis. Serum concentrations were correlated with clinical, biochemical, and histological remission. A week 8 post induction concentration of 3.7 ug/ml was associated with a response to the drug. A maintenance concentration of 1.3 ug/ml was correlated with increased rates of clinical remission. It was advised that experts agree to target ustekinumab concentrations of at least 3-7 ug/ml at week 8 and 1-3 ug/ml during maintenance for both Crohn's disease and ulcerative colitis.

The scientific literature supports the use of ustekinumab levels and antibody
levels for improvement in health outcomes in patients with Crohn's disease. It is a CLIA [Clinical Laboratory Improvement Amendments] approved laboratory test. The patient has already failed multiple biologic therapies, so it is important to optimize the ustekinumab treatment. The test is useful for ensuring that the patient is receiving the best outcome from treatment. There are no adverse risks to obtaining serum levels and antibody concentrations. Obtaining serum and antibody levels of ustekinumab has been shown to be useful in patients with refractory Crohn's disease.

The requested testing is likely to be more beneficial than any other standard services.
The carrier's denial of the laboratory test for the measurement of serum concentrations of Ustekinumab (UTS) levels and antibodies of Ustekinumab (ATU) (lab test that measures antibodies) code 84999 performed should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Crohn's ileitis

Treatment: the laboratory test for the measurement of serum concentrations of Ustekinumab (UTS) levels and antibodies of Ustekinumab (ATU) (lab test that measures antibodies) code 84999

The insurer denied coverage for the laboratory test for the measurement of serum concentrations of Ustekinumab (UTS) levels and antibodies of Ustekinumab (ATU) (lab test that measures antibodies) code 84999

The denial is upheld

This case involves a male who has been diagnosed with Crohn's ileitis.  He was seen for a follow-up.  A colonoscopy revealed a normal colon except for diverticulosis.  A computed tomography (CT) enterography performed did reveal interval resolution of small bowel obstruction and stable moderate edema the terminal ileum with mild mucosal hyperemia consistent with Crohn's ileitis.  The Stelara level obtained noted therapeutic range and no antibody detection.  He was seen where it was noted he had an intermittent exacerbation of symptoms with abdominal cramping as well as pain, nausea and vomiting. Symptomatically, he was improved with a short course of prednisone.  The physician indicated he may need to consider changing therapy.

The American Gastroenterology Association (AGA) and American College of Gastroenterology (ACG) Guidelines comment on the utility of drug monitoring to optimize treatment within a therapeutic class.  This involves adjusting the dose or schedule of a biologic.
 
The question whether to change classes or optimize within the TNFa [tumor necrosis factor alpha] class is answered by utilization of drug concentration and antibody assessment.
 
There are no adverse risks associated with acquisition of drug concentration or antibody levels.

The AGA and ACG Guidelines comment on the utility of drug monitoring to optimize treatment within a therapeutic class.  This involves adjusting the dose or schedule of a biologic. This would allow for optimization of the biologic within the class before switching, this allows for more options in the future since Crohn's is a challenging disease requiring changes in the utilization of various biologics.

The carrier's denial of the laboratory test for the measurement of serum concentrations of Ustekinumab (UTS) levels and antibodies of Ustekinumab (ATU) (lab test that measures antibodies) code 84999 should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Carcinoma of base of tongue.
Treatment: Proton Beam Therapy.
The insurer denied the Proton Beam Therapy.
The determination is upheld.

The patient has base of tongue squamous cell carcinoma. He has no evidence of distant disease. He is on a clinical trial. Radiation therapy and concurrent chemotherapy are recommended as definitive treatment and proton beam radiation is requested.
At issue is the medical necessity of the proton beam therapy.
The requested health service of proton beam therapy is not considered medically necessary for this patient.
The recommended proton beam radiation therapy for this patient for base of tongue carcinoma is not considered medically necessary as there are a lack of any significant studies published in peer reviewed medical literature supporting the benefits and safety of proton beam radiation therapy as compared to conventional photon beam radiation therapy. There are ongoing clinical trials that need to mature and be evaluated as well as published in peer reviewed journals to determine the efficacy and safety of proton beam radiation therapy for this patient's clinical scenario. Therefore, the requested proton beam therapy is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient emergency admission. 
The denial is upheld.

The patient is a male with a history of extreme premature birth at 24 weeks gestation. He required a prolonged course in the Neonatal Intensive-Care Unit (NICU). Due to neurologic complications of his prematurity, he has secondary cerebral palsy, cognitive impairment, and epilepsy. He had the onset of his seizure disorder in childhood years but was not started on any anticonvulsant medication at that time. Since then, he has continued to have occasional seizures, which have occurred about once every six months and consist of whole body shaking. He had a seizure  for which Keppra was prescribed as prophylaxis against further seizures. However, the patient's mother administered the Keppra inconsistently.  The patient was seen in the office of a neurologist who recommended that he be admitted to the hospital for evaluation. His vital signs were all normal and he was at his neurologic baseline. He was admitted to the hospital, where an attempt was made to obtain an electroencephalogram (EEG). However, he did not tolerate the EEG and repeatedly pulled the EEG leads off. Therefore, no EEG was obtained. He remained clinically stable throughout the hospitalization and was discharged to home the following day. The subject under review is the medical necessity for the inpatient emergency admission.

The inpatient emergency admission was not medically necessary for this patient. He was medically stable. An EEG was a reasonable test to do, but this could have been done at a lower level of care status.
When a child is having intermittent seizures, then it is customary and reasonable to obtain an EEG on that patient, in order to determine what type of seizure the patient is having and to determine which anticonvulsant would most likely be most efficacious. However, it is not necessary for a patient under those circumstances to be admitted to the hospital for the EEG. EEGs for patients who are having only intermittent seizures can be obtained on an outpatient basis. At the time of the patient's admission to the hospital, he was not ill. His vital signs were normal and stable. He was at his neurologic baseline. He did not require hospitalization to assess his neurologic disorder or any other medical issue.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems//Other/Malocclusion
Treatment: Dental/Orthodontic Procedure
The health plan denied the requested dental treatment plan as not medically necessary. The health plan's determination is upheld.

The patient is a female with a Class II malocclusion, mild maxillary crowding and moderate mandibular crowding, moderate overjet and severe overbite.
The subject to be determined is the medical necessity for braces, retainer, and visits.

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

Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score an 18 with no auto qualifiers. Auto qualifiers include cleft palate deformity or cranio-facial anomaly, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9mm or greater and underbite 3.5mm (millimeters) or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary. Thus, according to the standard of care, braces, retainer, and visits are not medically necessary for this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Breast cancer

Treatment: Inpatient hospital admission

The insurer denied coverage for an inpatient hospital admission.

The denial is upheld. 

The patient has been diagnosed with a history of metastatic breast cancer. The patient was sent from her oncology office to the emergency room (ER) due to elevated liver function tests (LFTs). The patient was hemodynamically stable. Imaging revealed progressive hepatic metastases with no areas amenable to decompression. The patient was seen by liver service, and then discharged.

The patient's condition could reasonably be expected to be stabilized within 24 hours, acute inpatient was not medically necessary, and observational status would have been the appropriate level of care.      

The inpatient admission was not medically necessary for this patient.

"Generally, a person is considered to be in inpatient status if officially admitted as an inpatient with the expectation that he or she will remain at least overnight. The severity of the patient's illness and the intensity of services to be provided should justify the need for an acute level of care. An inpatient admission solely because the patient has been kept in observation status over 23 hours would not be considered medically necessary." [American Health Information Management Association, 2018]

The health plan acted reasonably, with sound medical judgment, and 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.