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

Diagnosis: UTI /peritoneal carcinomatosis
Treatment: Inpatient admission
The insurer denied coverage for: Inpatient admission
The denial is : Upheld
This is an adult with patient has a history of congestive heart failure (CHF), uterine cancer, and recent hysterectomy. The patient presented to the emergency room (ER) with abdominal pain. The patient's exam was noted to be afebrile with stable vital signs, there was no rebound or guarding. The patient's labs showed anemia with low albumin, and a urine analysis was positive for a urinary tract infection (UTI).  A scan showed peritoneal carcinomatosis. The patient stated they had been trying to see an oncologist as an outpatient but could not so the patient presented to the ER, and the patient was admitted. The request is for inpatient hospital admission.

There is no need for acute-level care for the management of an uncomplicated urinary tract infection (UTI). There is no basis for a hospital admission to manage a newly diagnosed metastatic recurrent uterine sarcoma. 

Per Uterine Neoplasms, Version 1.2023, NCCN Clinical Practice Guidelines in Oncology "For patients with known or suspected uterine neoplasms, the initial preoperative evaluation/workup for known or suspected malignancy includes a history and physical examination, complete blood count (including platelets), consideration of liver function tests/renal function tests or chemistry profile, expert pathology review with additional endometrial biopsy as indicated, imaging, recommendation of genetic evaluation of tumor and for inherited cancer risk, and consideration of germline testing and/or multigene panel testing (see "Initial Evaluation" and "Principles of Imaging" in the NCCN Guidelines for Uterine Neoplasms, available at NCCN.org).14 Preoperative imaging and biopsy may help to identify uterine sarcomas, although biopsy sensitivity is less than that for endometrial cancer. An expert pathology review will determine whether a patient has a malignant epithelial tumor or a stromal/malignant mesenchymal tumor."

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 hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class II malocclusion
Treatment: Braces
The insurer denied: Braces
The denial is overturned.

The patient is an adolescent female. The request is for orthodontic treatment. The patient has a Class II malocclusion with a deep bite, moderate upper and mild lower crowding. The prior denial was due to a handicapping index scale of 13 points.

The requested health service is medically necessary.

The patient's upper front incisors are sticking very far out. This will make them very prone to trauma such as fracturing and/or loosening over time. This condition needs to be corrected so no trauma can affect these teeth. Orthodontic treatment is needed to correct this problem and the case has medical necessity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary Tract Infection

Treatment: Inpatient admission 

The insurer denied coverage for inpatient admission 

The denial is upheld 

The patient presented to the hospital for worsening dysuria and flank pain. The patient was diagnosed with a urinary tract infection (UTI) and was treated with intravenous (IV) fluid and antibiotics. The patient was subsequently discharged in stable condition.

The patient was admitted for urinary tract infection.  The patient's temperature on arrival was 103.1 Fahrenheit (F) and heart rate (HR) was 105.  The patient's labs revealed a white blood cell (WBC) count was 11.17 and the urinalysis was positive for a urinary tract infection.  During this hospital stay, the patient remained hemodynamically stable and responded appropriately to antibiotic therapy. The medical records did not show that the patient had severely abnormal vital signs or severe sepsis which required inpatient level of care. 

Patients with an uncomplicated UTI are treated as outpatients (if no other indication for admission is present) [1,2]. Some patients with an uncomplicated upper UTI (e.g., hemodynamically stable, able to maintain hydration orally) do not require inpatient admission [3]. Database analysis including 572,479 adult visits to an emergency department for UTI found an inpatient admission rate of 17% [4]. Another analysis of a national database found that out of more than 1.5 million visits to the emergency department for pyelonephritis, 27% were admitted to inpatient care [5].

Therefore, per standard of care and evidence-based literature, inpatient admission was not medically necessary and lower level of care was more appropriate. 

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 inpatient is not substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Neuropathy, biopsy proven Sjogren's Syndrome, 
POTS, Rheumatoid Arthritis and Mast Cell Activation Syndrome
Treatment: Octagam Injection (J1568) Immune Globulin (IVIG)
The insurer denied: Octagam Injection (J1568) Immune Globulin 
(IVIG)
The denial is overturned.

The patient is an adult female who is being evaluated for a second opinion for the treatment of what is thought to be chronic biopsy proven small fiber neuropathy related to a diagnosis of 
Sjogren's or other autoimmune disease. Additional diagnoses which have been assigned to this patient have included, postural orthostatic tachycardia syndrome (POTS), Rheumatoid Arthritis 
and Mast Cell Activation Syndrome, Ehlers-Danlos syndrome, cyclic citrullinated peptide (CCP) positive rheumatoid arthritis, chronic migraines, positive anti-nuclear antibodies (+ANA), 
Raynaud's syndrome, fibromyalgia, spinal fusion skull to cervical three (C3), increased immunoglobulin G4 (IgG4) with other abnormal immunoglobulin (Ig) levels. The patient did have a faint band in Kappa immunoglobulin G (IgG). The patient was additionally diagnosed by electromyogram (EMG) 2 years ago and increased immunoglobulin A (IgA) level with right peroneal superimposed mild sensory neuropathy with progressive symptoms. Ultimately, she lost reflexes in her left leg, and developed progressive weakness distally in left and right flexion extension. She has a history of bilateral complex regional pain syndrome (CRPS) symptoms, and right foot pain that started after right hip surgery 2 years ago. She also is having persistent complex regional pain syndrome (CRPS) flare-ups despite steroid. She has also tried Plaquenil, Lyrica (Pregabalin), nonsteroidal anti-inflammatory drugs (NSAIDS), Humira 
complicated by infection, Orencia, sympathetic nerve blocks, and sacroiliac (SI) injections. There has been synovitis on exam, increased C reactive protein (CRP) and erythrocyte sedimentation rate (ESR). The provider is seeking authorization to treat with intravenous Immune Globulin (IVIG) which is the subject of this review.

The health plan should cover the proposed treatment.

Since there are limited options for this patient and the patient has multiple conditions which could gain benefit from a reasonable but limited trial of Immune Globulin (IVIG) (Octagam), the 
plan should cover the therapy for a trial period of six months at most while requiring objective evidence of improvement. If there is no measurable improvement at that time, alternative therapies such as Imuran, CellCept, Cytoxan or Rituxan could be considered. There is no standard of care therapy for this patient's rare disease. The patient does not just have Sjogren's syndrome. She has undifferentiated connective tissue disease with features of rheumatoid arthritis, lupus, and Sjogren's. There is no standard of care therapy for her condition.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Breast Cancer
Treatment: Zoladex
The insurer denied Zoladex.
The determination is overturned.

This is a female patient with a history of an estrogen receptor (ER) positive (+) / progesterone receptor (PR)+/ human epidermal growth factor receptor 2 (HER2) negative (-) left breast cancer Oncotype DX Recurrence Score 24. She has undergone a lumpectomy and received adjuvant chemotherapy and radiation. The patient was taking adjuvant tamoxifen but developed a thrombosis. Goserelin plus an aromatase inhibitor was initiated. Gosererlin (Zoladex) is under review for medical necessity.
There are multiple reasons this goserelin (Zoladex) is indicated for this patient.
1) This patient has had a thrombotic event while on tamoxifen. As tamoxifen is no longer an option for this pre-menopausal patient, an aromatase inhibitor is only an option with ovarian suppression as aromatase inhibitors are not effective in patients with functioning ovaries. Goserelin suppresses ovarian function thereby allowing for use of an aromatase inhibitor.
2) Ovarian function suppression is a National Comprehensive Cancer Network (NCCN) endorsed adjuvant endocrine therapy option for patients with high-risk breast cancer. Two trials have evaluated this - the Suppression of Ovarian Function Trial (SOFT) and the Tamoxifen and Exemestane Trial (TEXT) trial, which included 5600 patients combined. These trials demonstrated an improvement in disease free survival and overall survival. These more recent trials echoed results of the 1007 Early Breast Cancer Trialists' Collaborative Group meta-analysis that demonstrated a reduced risk of recurrence with ovarian suppression. The authors of UpToDate state "...Given the available data, we utilize ovarian function suppression (OFS) with endocrine therapy for high-risk, hormone receptor-positive premenopausal patients...." As this patient had an increased Oncotype DX recurrence score, this patient can be considered high risk thus meeting criteria for therapy.
For these reasons, medical necessity for goserelin has been established.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Periodontal Disease. 
Treatment: D4341/lower left (scaling & root planing). 
The insurer denied coverage for D4341/lower left (scaling & root planing), 
The denial is upheld. 

 
Based on the submitted documentation which includes copies of periodontal charting, medical history, full mouth series radiographs, intraoral clinical photographic images, narrative letter from the dentist and insurer correspondence, it appears that this patient presented for evaluation for dental services and periodontal therapy. The dentist reported periodontal chartings indicating 2-3 millimeter (mm) generalized periodontal pocketing with focal 4-6 mm depth readings. The recommended treatment was scaling and root planing in the left mandibular quadrant. The insurer has denied the service as the information provided does not show evidence of moderate to severe periodontal disease or other clinical or radiographic criteria to justify the services such as bone loss and therefore does not meet clinical criteria to support scaling and root planing. 

Upon review of the submitted documentation, both the radiographs and periodontal probing depths, there is minimal if any loss of alveolar bone height affecting these teeth. There is no evidence of radiographic calculus. The focal 4-6 mm increased pocket depths likely represent pseudopocketing due to superficial calculus accumulation and poor oral hygiene as documented by the doctor. The insurer has correctly applied the clinical criteria in denying scaling and root planing services. 

Uphold denial of coverage for D4341/lower left (LL) quadrant as not medically necessary as the clinical and radiographic documentation does not support or substantiate scaling and root planing services. 

The health care plan acted reasonably and with sound medical judgement and in the best interests of the patient. 

D4341/lower left (LL) quadrant is not considered medically necessary for this patient. 

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 D4341/lower left (LL) quadrant is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Autoimmune encephalitis.
Treatment:  Intravenous Immunoglobulin Injection.

The insurer denied Intravenous Immunoglobulin Injection.  The health plan's determination is overturned. 

The patient is a male who has a diagnosis of probable seronegative autoimmune encephalitis. 

Intravenous Immunoglobulin Injection is medically necessary for this patient.
According to the provider, the patient has had a relatively acute onset of cognitive decline and severe psychiatric symptoms which have posed a danger to himself and his family. He has not had a significant response to psychotropic medication, but he has shown improvement with immunomodulatory medications. Diagnostic workup has reportedly excluded other possible causes of neuropsychiatric symptoms, and the working diagnosis is probable seronegative autoimmune encephalitis, possibly following Covid.
According to Graus et al., diagnostic criteria for autoimmune encephalitis include the following:
Diagnostic criteria for possible autoimmune encephalitis:
Diagnosis can be made when all three of the following criteria have been met:
1) Subacute onset (rapid progression of less than 3 months) of working memory deficits (short-term memory loss), 2) altered mental status*, or psychiatric symptoms - CRITERIA MET, BY REPORT, and 3) At least one of the following:  a) New focal central nervous system (CNS) findings - ABNORMAL EYE MOVEMENTS DOCUMENTED, b) Seizures not explained by a previously known seizure disorder -NO SEIZURES, BUT ABNORMAL EEG, WITH BACKGROUND SLOWING, c) Cerebrospinal fluid (CSF) pleocytosis: NOT REPORTED, d) MRI features suggestive of encephalitis: NORMAL BY REPORT, e) Reasonable exclusion of alternative causes CRITERIA MET.

Cellici et al. discuss the differences in presentation between children and adults with possible autoimmune encephalitis. The authors note that "Children may have autoimmune encephalitis caused by antibodies that have not yet been identified and may meet criteria for probable antibody-negative pediatric autoimmune encephalitis."
Lee et al reviewed 46 pediatric patients with probable autoimmune encephalitis (AIE). they described that "Nine (19.6%) of the 46 patients were diagnosed as seropositive AIE. All of the patients with seropositive AIE had anti-N-methyl-D-aspartate receptor antibodies. Commonly identified neuropsychiatric symptoms were altered mental status, cognitive dysfunction, seizure, speech dysfunction, and psychotic disorder in both the seronegative and seropositive groups. Immunotherapy produced favorable treatment outcomes in both the seropositive and seronegative AIE patients. Treatment outcomes for first-line immunotherapy were better in seronegative AIE than seropositive AIE patients, and hence a smaller proportion of seronegative patients required second-line treatment.
In conclusion, IVIG is medically necessary. His response to treatment should be monitored carefully, and the ongoing need for treatment be re-evaluated after a maximum of a 6-month trial of infusions.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Dementia
Treatment:  Home health care

The insurer denied Home Care / Personal Care Level 2 Personal Care Services Increase to 63 Hours per Week.  The health plan's determination is overturned. 

This is a female patient with a history of progressive dementia, heart failure, hypertension, hyperlipidemia, hypothyroidism, osteoarthritis, knee pain, discogenic spine disease, pancreatic insufficiency, bowel and urinary incontinence, and tremor. She lives alone. The patient was previously approved for Personal Care Services 36 hours per week. The patient and her care team requested Personal Care Services of 63 hours per week.

Home Care / Personal Care Level 2 Personal Care Services Increase to 63 Hours per Week are medically necessary for this patient.
There is documentation in the Uniform Assessment System (UAS) of the patient requiring limited assistance with tasks of walking, locomotion, transfer toilet, and toilet use. Therefore, the patient has unscheduled and unpredictable care needs that span a continuum of time and the Plan failed to document a plan to meet these unscheduled and unpredictable care needs. A tasking tool should not have been utilized to calculate hours given that the patient has unscheduled and unpredictable care needs. There is documentation from the patient's PCP (primary care provider) of medical necessity of increased PCA (personal care assistant) services. The patient lives alone and does not have informal support for the entire time outside of the previously assigned Personal Care Assistance hours. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in Personal Care Services is not solely for safety and supervision but to assist the patient with activities of daily living (ADL).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Varicose Veins
Treatment: Endoluminal radiofrequency ablation

The insurer denied endoluminal radiofrequency ablation.  The determination is overturned.

The patient is a male, who was evaluated for symptomatic left leg varicose veins. The patient reported worsening of his left leg varicose veins and throbbing that interferes with his daily activities. He has used compression stockings with minimal relief of symptoms. The patient was noted to have moderate varicosities in the left thigh and medial calf.
Vascular lab studies demonstrated left greater saphenous vein reflux with refluxing varicosities. The patient was diagnosed with symptomatic left lower extremity varicose veins with pain.
The provider recommended left greater saphenous vein radiofrequency ablation and phlebectomy. At issue is the medical necessity of the endoluminal radiofrequency ablation.
The requested endoluminal radiofrequency ablation is medically necessary.
The patient has symptomatic left lower extremity varicose veins and venous insufficiency. The recommended treatment is medically necessary and is the standard of care for the treatment of symptomatic varicose veins and venous insufficiency. Vascular lab studies demonstrated left greater saphenous vein reflux with refluxing varicosities. The patient was diagnosed with symptomatic left lower extremity varicose veins with pain.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain. 
Treatment: Inpatient admission.

The insurer denied the inpatient admission.  The health plan's determination is upheld. 

The patient is a male with a history of a cholecystectomy. He presented to the emergency department with abdominal pain for four days, nausea, and diarrhea, as well as a fever three days prior. Vital signs were unremarkable. Physical examination was notable for diffuse abdominal tenderness. Labs showed an unremarkable complete blood count and comprehensive metabolic panel. Computed tomography scan of the abdomen and pelvis showed mild pancolitis with terminal ileitis with differential diagnosis of inflammatory bowel disease and infectious ileitis/colitis, and prior cholecystectomy. He was treated with intravenous fluids, Zosyn, and famotidine. 

The inpatient hospital admission was not medically necessary. The patient presented with abdominal pain, diarrhea, nausea, and fever. He was stable, with a normal blood count and normal hemodynamic status. Testing revealed enterotoxigenic Escherichia coli, which was appropriately treated with supportive care. There was no suspected or established complication such as hemodynamic decompensation, gastrointestinal perforation, intra-abdominal abscess, toxic megacolon, bowel obstruction, peritonitis, sepsis, or other complications warranting inpatient level of care. The measures which were undertaken, such as observation, monitoring, labs, specialist consultations, empiric antibiotic therapy, and intravenous fluid administration could have been performed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bilateral cervical lymphadenitis. 
Treatment: Inpatient admission. 
The insurer denied coverage for inpatient admission. 
The denial is overturned. 

This is a female child who presented with bilateral cervical lymphadenopathy for 10 days, associated with fatigue and intermittent fevers. No sick contacts or travel. Review of systems was otherwise negative. She had a past history of low cortisol but had a normal adrenocorticotropic hormone (ACTH) stim test and had been "cleared by endocrinology." 

In the emergency department (ED) she had a temperature of 100.6 degrees Fahrenheit, Blood Pressure 118/79, Pulse 121 and Oxygen saturation of 100% (percent) on room air. She was reported as active and well-developed with palpable nodes on each side of her lateral neck which were soft, non-mobile, and shotty. Pharynx had oropharyngeal exudate with 2+ tonsils bilaterally. She had an otherwise normal exam. 

Laboratory results showed Group A Strep antigen positive, borderline elevated white blood cells (WBC) 15.2 thousand, and a moderately elevated platelet count 501,000.  She had elevated inflammatory markers erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). 
Computerized tomography (CT) of the neck showed diffuse lymphadenopathy with mass effect on internal jugular veins. 

A decision was made to admit, but the record is lacking in any explicit Medical Decision Making to support this plan of management. It appears the admission was for the purpose of monitoring vital signs, to complete an Oncology work-up and for social concerns. While there was concern for the cervical lymphadenopathy causing mass effect on the jugular veins, she was also evaluated by Computerized tomography (CT), Surgery and Vascular Surgery, both of whom felt there was no acute concern given patency of vessels. 

The patient had acute bilateral cervical lymphadenitis without evidence of a deep neck or otherwise invasive bacterial infection. As discussed in recommendations by Healy et. al., this is most often caused by a "self-limited viral upper respiratory infection and requires only monitoring unless it is accompanied by severe symptoms, progresses, or persists."  There is no specific treatment required. The elevated inflammatory markers could be attributed to viral infection. The lymphadenopathy was consistent with a viral infection. Even if the etiology is uncertain in a child after the initial evaluation and lymphadenitis has persisted for several weeks, a biopsy should be considered to rule out malignancy, but this is not an emergent procedure. 

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 inpatient admission is not substantiated.