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

Diagnosis: Central Nervous System/Neuromuscular Disorder/Cerebral Palsy/Cerebral palsy and spasticity due to birth complications.
Treatment: Physical Therapy/aquatic therapy/exercises times (x) 37.
The health plan denied the requested aquatic therapy/exercises x37 as not medically necessary. 
The health plan's determination is overturned.

The patient is a male with spastic quadriplegic cerebral palsy (CP) with documented constructers, difficulty controlling upper extremities and dystonia. His movement specialist neurologist documented the importance of at least 2 times/week therapies for his habilitative nature for him to keep moving. His aqua therapy notes demonstrate how excited he is during aqua therapy and the areas he works on including core strength, head control, stretching, range of motion and use of extremities.
At issue is the medical necessity for 37 aquatic therapy/exercise sessions.

I overturn, in whole, the health plan's previous determination of medical necessity.

The requested health service/treatment of aquatic therapy/exercise times 37 is medically necessary for this patient. 
It is extensively documented in peer reviewed literature how beneficial aquatic therapy is for patients with cerebral palsy. "Exercise in water appeals to children with CP because of the unique quality of buoyancy of water that reduces joint loading and impact, and decreases the negative influences of poor balance and poor postural control." [1] "Aquatic therapy is effective in supporting walking, balance, emotional status and health-related quality of life, spasticity, and physiologic indicators. In comparison with land-based interventions, aquatic therapy shows superior effectiveness on balance, walking, muscular strength, proprioception, health-related quality of life, physiological indicator, and cardiorespiratory fitness." [5] Results indicate that the pediatric aquatic therapy group had greater average 66-item Gross Motor Function Measure following intervention than the control group...Pediatric aquatic therapy can be an effective and alternative therapy for children with cerebral palsy even with poor Gross Motor Function Classification System level. [4]
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cerebral Palsy.
Treatment: Therapeutic Exercise, Neuromuscular Re-Education, Therapeutic Activities.
The insurer denied: Therapeutic Exercise, Neuromuscular Re-Education, Therapeutic Activities.
The denial is: Upheld.

The patient is a male with cerebral palsy due to birth complications per record.  He has spasticity, dystonia, contractures, feeding difficulties, and epilepsy.  He has undergone many interventions for spasticity and utilizes power chair for mobility.  The subject under review is the medical necessity for therapeutic exercise, neuromuscular re-education, and therapeutic activities.

The requested services are not medically necessary based on the documentation. 
Cerebral palsy has widely accepted practice guidelines in regard to the application of therapeutic exercise, neuro-muscular re-education, or therapeutic exercise to enable developmental progress.
While the patient would benefit from continued therapies, the notes submitted show little detail other than a brief summary at the bottom of each page. The billed codes do not show any detail of facilitated movements, or neuromuscular re-education. Additionally, the records submitted show no ongoing scales which would document functional progress through nationally accepted scales such as Gross Motor Function Classification System (GMFCS), or Manual Ability Classification System (MACS). The notes do indicate short term goals and progress. However, it cannot be determined from the records even what interventions were undertaken with patient, and thus medical necessity for the requested services cannot be supported. No documentation of gains in standardized assessments were detailed in the provider notes. The notes reviewed only showed selected boxes of areas worked on, along with a short description of trunk control gains. The notes provided do not detail functional gains, nor do they provide evidence of the selected therapeutic codes being provided during these sessions. In summary, the records are not detailed enough to support the use of the submitted codes. Expectations for clinical care would include an initial evaluation, or re-evaluations to determine the functional level of the patient, along with detailing episodes of care.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: cerebral palsy.
Treatment: physical therapy.
The insurer denied physical therapy. 
The health plan's determination is overturned. 

The patient is a male with spastic quadriplegic cerebral palsy that affects all areas of his function. Neurology notes document his spasticity, dystonia and motor impairments, and his movement specialist neurologist notes the importance of at least 2x/week rehabilitation therapies for him to maintain his overall function, range of motion and endurance. His aquatic therapy notes indicate he in an enthusiastic participant in sessions, and they document the areas that they are working on in therapy sessions including core strength, head control, stretching, range of motion, and use of extremities. They also note working on balance, endurance and mobility including taking steps in the pool.

The requested Physical Therapy Services are medically necessary for this patient.
There is extensive evidence in peer reviewed literature that aquatic therapy is extremely beneficial for patients with cerebral palsy, even the most severe GMFCS (Gross Motor Function Classification System) levels. In this case, the patient was making measurable progress in working on mobility, balance, strength and endurance. Therefore, the requested Physical Therapy Services were medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

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


This is a patient with a history of hypertension, type 2 diabetes, chronic systolic heart failure due to non-ischemic, viral related cardiomyopathy with a recovered ejection fraction (EF), who presented to the emergency department (ED) with complaints of a severe headache for 2 weeks associated with left periorbital swelling. Initial vital signs were notable for severe hypertension 216/146. The patient was treated with intravenous (IV) Labetalol with improvement in this blood pressure to 171/104. In the emergency department (ED), lab results were negative for target organ damage, and a computed tomography (CT) angiogram which was negative for vessel occlusion. A CT scan of the head was negative for an acute intracranial abnormality. Before the workup was completed, the patient decided to leave against medical advice (AMA). At issue is the medical necessity of an inpatient stay.

An inpatient level of care of care was not medically necessary in this case. While the patient presented with severe hypertension consistent with hypertensive urgency, his blood pressure did improve soon after presentation, with treatment, and there were was no evidence of target organ damage. For these reasons, an inpatient level of care was not medically necessary. The patient presented to the ED with hypertensive urgency and a headache. There was no evidence of stroke or target organ damage, and his blood pressure did improve in the ED after initiation of treatment indicating that observation level of care for blood pressure monitoring and treatment was safe. According to the 2017 American College of Cardiology (ACC) / American Heart Association (AHA) / American Academy of Physician Assistants (AAPA) /Association of Black Cardiologists (ABC)/ American College of Preventive Medicine (ACPM)/ American Geriatric Society (AGS) / American Pharmacists Association (APhA) / American Society of Hematology (ASH) / American Society of Preventive Cardiology (ASPC) / National Medical Association (NMA) / Preventive Cardiovascular Nurses Association (PCNA) guideline for the prevention, detection, evaluation, and management of high blood pressure in adults, a lower level of care in this case would have been medically appropriate and safe (1). The patient presented with hypertensive urgency without evidence of target organ damage, and his blood pressure began to improve prior to the patient leaving against medical advice (AMA). The inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endometriosis
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

The patient is an adult female. She presented for elective hysterectomy for endometriosis. She also had a trans obturator tape for stress incontinence and bilateral salpingectomy 
and bilateral ovarian cystectomy. She had extensive adhesions, and a general surgeon was called in to the surgery to help with the dissection near the rectosigmoid. The surgery was 420 minutes in duration, and blood loss was 800 cc (cubic centimeters). Post-operatively, the patient was transferred to recovery and required telemetry. She had a Foley catheter 
and IV (intravenous) fluids. She required IV (intravenous) pain medication. She had serial blood tests as well. Her post-operative white blood cell was elevated, and her hemoglobin revealed anemia at 9.4. This was repeated and stable at 4 hours. She had another repeat in the morning that was stable. Her Foley was removed the next day. Vaginal packing was also removed. She was able void and ambulate, her pain was controlled, and she was hemodynamically stable on post-operative day 1. She was then discharged with outpatient follow up.

The Inpatient Hospital Admission was medically necessary.

In review of the medical record, the patient underwent minimally invasive surgery. However, this was a more complicated procedure than anticipated. There was extensive operative time, anesthesia time, and blood loss. There were severe adhesions to the rectosigmoid, which increased the risk of bowel injury and post-operative ileus. These factors increased the postoperative risk for hemorrhage, hemodynamic instability, infection, and blood clots, thus making an inpatient hospital stay warranted.
The patient required close nursing assessments to ensure hemodynamic stability. She was on telemetry given the long anesthesia to ensure no heart arrhythmia. She had a Foley catheter to closely monitor her urine output, given the procedure on the bladder, but also excessive blood loss. She also required IV (intravenous) pain medication. Therefore, her care required more than what an outpatient setting, or observation setting would have been safely able to provide. Therefore, the 
safest level of care, given these unique clinical factors, was an inpatient level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes Mellitus Type 1.
Treatment: Trulicity.
The insurer denied Trulicity.
The determination is upheld.

This is a patient with a history of hypertension, hyperlipidemia, and type 1 diabetes on insulin pump therapy. He has experienced weight gain and fluctuations in his glucose levels leading to retinopathy requiring injections. His hemoglobin A1C(HbA1C) is 7.7 percent (%). At issue is the medical necessity of Trulicity.

This request is for Trulicity for the treatment of type 1 diabetes in the setting of glucose variability and weight gain. The Trulicity prescribing information does not support the use of Trulicity for type 1 diabetes or weight loss. There are other commercially available medications that are Food and Drug Administration (FDA)-indicated for weight loss. Trulicity has risks, including nausea and vomiting. Therefore, the requested Trulicity is not medically necessary for this patient.
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 female patient with no past medical history (PMH) who was admitted with complaints of (c/o) left leg pain and erythema after a fall and scrape; the patient received an outpatient antibiotics prescription prior to admission but did not fill it. Her vital signs were unremarkable. The physical exam was notable for left lower extremity (LLE) edema and erythema, no acute distress. Lab work was notable for an elevated erythrocyte sedimentation rate (ESR) / C-reactive protein (CRP). Imaging studies included a chest x-ray (CXR) which was unremarkable, left lower extremity (LLE) radiographs showed tissue swelling, dopplers were negative for deep vein thrombosis (DVT) bilaterally, a computed tomography (CT) scan of the LLE showed an abscess. The patient was diagnosed with left lower extremity (LLE) cellulitis and was treated with intravenous (IV) antibiotics. General surgery was consulted and recommended an incision and drainage (I&D) for the abscess, which the patient refused. The patient was discharged against medical advice (AMA). At issue is the medical necessity of an inpatient level of care.

The hospital stay was not medically necessary at an acute inpatient level of care. The patient presented to the emergency department (ED) with c/o left leg pain and erythema after a fall and scrape. She was afebrile, did not appear toxic, had no unstable comorbidities, did not have a limb-threatening infection, there was no septicemia, life-threatening infection, necrotizing fasciitis, leukocytosis, features of systemic inflammatory response syndrome (SIRS), animal or human bite with extensive damage, high risk location (face, neck, hand, genitals), pain out of proportion to clinical findings, crepitus, neutropenia, immune-suppression, marked systemic toxicity or worsening symptoms, or inability to take oral medications. This patient was treated with intravenous (IV) antibiotics and surgical consultations, and this could have been safely provided at a lower level of care. Observation is ideal for the management of cellulitis infections because it allows frequent reevaluation to assess response to therapy while avoiding inpatient admission. Overall, this patient could have been safely treated at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension
Treatment: Inpatient admission
The insurer denied inpatient admission
The insurer's denial was overturned 
 
The patient presented to the emergency department (ED) with a severe headache, photophobia, nausea, vomiting and weakness over the right side of her body. Upon arrival to the ED, the patient was hypertensive 193/111. Physical examination was significant for altered mental status and numbness and weakness over the right upper and lower extremities. Laboratory testing demonstrated no abnormality. A computed tomography (CT) of the head revealed no acute stroke and no intracranial bleed. The patient was treated with intravenous labetalol and admitted to the hospital for hypertensive encephalopathy. Her blood Pressure (BP) was controlled with oral antihypertensive agents and symptoms resolved.   

Hypertensive emergency is defined as BP>(greater than) 180/120 with target organ damage. This patient presented with hypertension, disabling headache and right sided weakness and numbness. The goals of treatment of hypertensive emergency are to minimize progressive or additional target organ damage while preventing consequence of rapid BP correction. Admission to the hospital for aggressive blood pressure management was necessary. In fact, American Heart Association guidelines recommend admission to the ICU (intensive care unit) for management of hypertensive emergencies. In conclusion the inpatient admission was medically necessary.

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

The insurer's denial of coverage for the inpatient admission is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

This is a patient who presented to the emergency department with 3-4 days of right sided abdominal pain. His vital signs were stable with only some mild hypertension. No tenderness to palpation was noted on the abdominal exam by the emergency department (ED) physician. The white blood cell (WBC) count was 12. A computed tomography (CT) scan of the abdomen and pelvis demonstrated mild hyperenhancement of the wall of the appendix without significant adjacent inflammatory changes. Early appendicitis could not be excluded. The patient was hospitalized with the consulting general surgeon for serial abdominal exams. The patient was still having abdominal pain and the surgical team decided that an appendectomy was indicated. The patient underwent a laparoscopic appendectomy, lysis of adhesions, laparoscopic peritoneal lavage and transabdominal preperitoneal (TAPP) block without complication. The patient was monitored overnight and discharged home the next day. At issue is the medical necessity of an inpatient stay.

Inpatient stay was not medically necessary for this patient. The patient had acute appendicitis, but did not have evidence of other complications. The patient did very well after surgery and was able to be discharged home the next day. He achieved discharge criteria in a reasonable amount of time. He did not have any evidence of complicated appendicitis and he did not have any evidence of active comorbidities requiring inpatient management. There were no complications such as a wound infection, wound dehiscence, enterocutaneous fistula or continued ileus. There is no evidence that additional complex testing or therapy other than the surgery was performed. There is no evidence that a complicating event occurred before, during, or after the procedure that required a higher level of care. There is no documentation that the treating team identified conditions or problems specific to the patient that would have required inpatient care. The patient did not have significant dehydration, hemodynamic instability, severe pain requiring frequent or high doses of narcotics, signs of intestinal obstruction, peritonitis, or bacteremia. The provided documentation does not support the medical necessity of inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic Dermatitis.
Treatment: Dupixent Syn 300.
The insurer denied: Dupixent Syn 300.
The denial is upheld.

The patient is a young adult male with atopic dermatitis, 35% body surface area (BSA), treated with topical steroids and topical calcineurin inhibitors as well as topical Opzelura. The provider 
is requesting Dupixent. The health plan requires use of phototherapy and at least two systemic immunosuppressants.

The proposed treatment with Dupixent is not medically necessary.

According to the recommendations provided by Simpson et al (2017), steps taken before commencing systemic therapy include considering alternate or concomitant diagnoses, avoiding trigger factors, optimizing topical therapy, ensuring adequate patient/caregiver education, treating coexistent infection, assessing the impact on quality of life, and considering phototherapy. A trial of phototherapy would be appropriate; there is no documentation of failed phototherapy. 
While oral immunosuppressive medications may not be specifically Food and Drug Administration (FDA) approved for the treatment of atopic dermatitis, their use is considered standard and well supported in the medical literature. However, Dupixent is not medically necessary at this time as a trial of phototherapy would be appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma exacerbation.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

Patient has a history of asthma and marijuana use and presented to the hospital with complaints of shortness of breath for about 1 week, wheezing, chest tightness and cough with yellow-green sputum. Patient had been seen at urgent care the previous week and had been treated with steroids and oral antibiotics. The patient came to the emergency department (ED) as he was not feeling better.

At presentation to the ED vital signs were Temperature 97.8 degrees Fahrenheit, Blood Pressure (BP) 122/82, Heart Rate (HR) 102, Respiratory Rate (RR) 23, oxygen (O2) saturation 97 % on room air. The patient was in no acute distress, awake, alert, and was speaking in full sentences. No accessory muscle use seen. Lung exam revealed bilateral wheezes. The patient's peak expiratory flow (PEF) was 250. The patient was treated with intravenous (IV) steroids, bronchodilators via nebulizer, magnesium and IV antibiotics.

The patient did improve with treatment in the ED. PEF improved to 300. Later that evening PEF was 400. The patient was reporting some shortness of breath with ambulation and was admitted to hospital for asthma exacerbation.

The patient was in no acute distress. No jugular venous distention. Lungs were described as clear. Cardiovascular system was normal. The patient was alert and oriented. Non focal exam. White blood cell count (WBC) was 4, Hemoglobin 14.9, electrolytes within normal limits. Venous Blood Gas (VBG) 7.42/42/51/27. Chest x-ray (CXR) revealed no acute infiltrates, hyperinflated lung fields. Patient remained stable after admission and was discharged home on oral (PO) medications.

This patient did not need acute inpatient hospitalization. He could have been placed in Observation status while diagnostic testing and treatment were initiated. Observation could be for up to 48 hours. Patient was afebrile and hemodynamically stable, was not hypoxic. WBC were normal. No pneumonia on CXR. No carbon dioxide retention on VBG. The patient was tolerating food and fluids. After 24 hours, the patient was stable, afebrile, with BP 125/78, RR 18, O2 saturation 97 % on room air. The patient was on PO Azithromycin.

This patient could have been placed on PO steroids, and PO antibiotics along with Symbicort and discharged home with close follow up in an outpatient setting. Asthma exacerbation was not severe. 

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: Overturned

Diagnosis: dental issues
Treatment: Braces, Monthly Visits, and Retainer 
The insurer denied Braces, Monthly Visits, and Retainer. The health plan's determination is overturned. 

The patient in question is a male with an anterior crossbite on tooth 7. He presents with a skeletal Class I malocclusion with moderate crowding in the maxilla and mandible. 

Braces, Monthly Visits, and Retainer are medically necessary for this patient.
This patient presents with an anterior crossbite on tooth 7. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects.
If left untreated the damage that will likely occur to the patient's teeth will be much more time consuming and difficult to correct than the patient's existing orthodontic problem. For this reason, the requested treatment is medically necessary.