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

Diagnosis: moderate ovarian hyperstimulation syndrome

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld. 

This female patient has a history of thyroid disease, secondary infertility, and polycystic ovary syndrome (PCOS) who presented to the Emergency Department (ED) with complaints of urinary retention status post first egg retrieval for in vitro fertilization (IVF) performed. The patient endorsed bladder distention and bilateral flank pain. Transabdominal and transvaginal sonography of the pelvis revealed enlarged bilateral ovaries with multiple cysts with associated moderate intra-abdominal ascites raising concern for ovarian hyperstimulation syndrome. The patient was admitted to Medicine for suspected mild to moderate ovarian hyperstimulation syndrome. During the hospital course, the patient was given Lovenox prophylactically and was able to void spontaneously after the administration of intravenous (IV) fluids. Discussions were had with the patient's Reproductive Endocrinologist (REI) physician and it was felt that the patient was likely dehydrated due to pre-operative bowel prep. The patient was discharged with Reproductive Endocrinology follow-up.

Ovarian hyperstimulation syndrome (OHSS) is the most serious complication of controlled ovarian hyperstimulation (COH) for assisted reproduction. It is characterized by a broad spectrum of signs and symptoms that includes abdominal distention and discomfort, enlarged ovaries, ascites, and other complications of enhanced vascular permeability. Most OHSS cases are mild or moderate and can be managed on an outpatient basis. Mild OHSS is seen in many women undergoing ovarian stimulation for assisted reproduction. Mild OHSS is characterized by bilateral ovarian enlargement with multiple follicular and corpus luteum cysts, abdominal distention and discomfort, mild nausea, and, less frequently, vomiting and diarrhea. There are no biochemical abnormalities. Normally, these cases are self-limited and can be managed conservatively, with a goal of relieving symptoms. This patient had mild OHSS as her hematocrit was less than 40. For mild OHSS, analgesics and avoidance of heavy physical activity are usually enough. Patients should be instructed to call for any signs or symptoms of worsening (oliguria, abdominal distention, shortness of breath, or weight gain). This patient was stable. She was not in hemoconcentration as indicated by a normal hematocrit. IV hydration in the ED with some analgesics would have managed her symptoms. Admission to the hospital was not medically necessary.


The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: appendicitis 
Treatment: inpatient admission
The insurer is denied coverage for inpatient admission
The denial is upheld. 

This female patient has a history of pseudotumor cerebri and uterine fibroids who presented to the hospital with a 2 day history of worsening abdominopelvic pain associated with nauseas and vomiting. The surgical team recommended admission to the Obstetrics and Gynecology Service. The patient's admission diagnosis was: appendicitis, endometriosis. During the hospital course, Sonographic studies revealed large leiomyoma, and Computed Tomography (CT) showed uterine fibroid, possible ovarian cysts. The patient underwent diagnostic laparotomy, appendectomy and was found to have stage 4 endometriosis, large fibroid and appendicitis. The patient was treated with intravenous (IV) antibiotics. The patient received 2 units of packed red blood cells for a hemoglobin level of 7.2. The patient was discharged with Gynecology follow-up.

Progress note post-operatively showed that the patient was doing well with no complaints. Progress note again showed that the patient was stable. She was discharged. With a laparoscopic approach, most patients following an appendectomy are discharged within 24 to 48 hours of surgery. Patients may be started on a clear liquid diet post-operatively and advanced to regular diet as tolerated. Antibiotics are not required postoperatively in non-perforated appendicitis. This patient did not have a perforated appendix. Her procedure and postoperative course were both uncomplicated. So based on all the information submitted and the fact that the patient had a laparoscopic procedure, did not have a perforated appendix, was afebrile and asymptomatic after surgery and since she was tolerating oral intake, she could have been discharged. Continuous admission was not medically necessary.

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite
Treatment: Braces and Follow Up Visits, Pre-service
The insurer denied the Braces and Follow Up Visits, Pre-service
The denial is overturned. 

The patient is a female. The request is for orthodontic benefits.

Yes, the braces and follow-up visits are medically necessary.
There is an anterior crossbite (reverse bite) between teeth #s 10 and 23, which is causing attachment (gum) loss. This is an automatic qualifier according to the handicapping index scale.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: atrial fibrillation

Treatment: inpatient admission 

The insurer denied coverage for inpatient admission

The denial is overturned. 

This female patient has a history of hypertension, hyperlipidemia, supraventricular tachycardia, gastroesophageal reflux disease, mild peripheral artery disease, obesity, reactive airway disease and anomalous right coronary artery. The patient presented to the Emergency Department (ED) for palpations. In the ED, her vital signs were: blood pressure 148/95, pulse 150, temperature 36.7 degrees Celsius, respiratory rate 18, and oxygen saturation 100%. An electrocardiogram revealed atrial fibrillation, rapid ventricular response (RVR), with heart rate in the 150's. The patient was given a bolus of amiodarone and was admitted for rate control. During the hospital course, the patient was monitored on telemetry. She received amiodarone drip and was started on oral amiodarone once the drip was completed. She remained in normal sinus rhythm. She was evaluated by Cardiothoracic Services. The patient was discharged with Cardiology follow-up.

Patients presenting with atrial arrhythmia with ventricular rates up to 150 require acute therapy and further monitoring to ensure that medications control heart rate and rhythm without producing significant bradycardia. An analysis of 68 million Medicare patients admitted to the hospital for atrial fibrillation over a fifteen year period demonstrated an average length of stay of 3 days.(1) This analysis also demonstrated decreased mortality and readmission rates following admission to the hospital. The current standard of care is consistent with hospital admission when patients present with symptomatic rapidly conducted atrial fibrillation (AF). In this particular case, the patient had recent open heart surgery and attempts to manage post-operative AF were made in the observation unit but recurrent arrhythmia requiring inpatient treatment was required. Post-operative AF can be difficult to manage is associated with an increased rates of mortality and morbidity.(2)

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

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

Diagnosis: Crohn's Disease
Treatment: Skyrizi
The insurer denied the Skyrizi
The determination is upheld.

The patient is under evaluation and management for Crohn's Disease (CD). The patient has experienced severe perianal disease and is status/post (s/p) ileocolic resection due to fistulizing/stricturing disease. The patient has been treated in the past with Remicade, Stelara and Entyvio and was considered a non-responder. The patient has been on dual treatment with Entyvio and Humira.
The patient's provider is now recommending approval for Skyrizi (risankizumab) which is an interleukin (IL)-23 inhibitor. At issue is the medical necessity of Skyrizi.
The Skyrizi is not medically necessary. The patient was a non-responder to the interleukin (IL)12/IL23 inhibitor ustekinumab. The concept of interleukin 23 inhibition is based on genome-wide association studies associating gene olymorphisms of the interleukin 23 receptor with the development of Crohn's disease, and mechanistic studies identifying interleukin 23 as a key mediator in chronic intestinal inflammation. However, since the patient did not respond previously to IL23 inhibition, it is unlikely that risankizumab (an IL-23 inhibitor) would be effective. 
Although the patient is poorly responsive to conventional therapy, it does not appear that the use of rizankizumab would be efficacious.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart failure; Chronic kidney disease

Treatment: Personal Care Aide (PCA) Services Level II at 24 hours per split shift.

The insurer denied coverage for Personal Care Aide (PCA) Services Level II at 24 hours per split shift.

The denial is overturned.

This is a female patient with a past medical history of hypertension, heart failure, hyperlipidemia, chronic kidney disease, atrial fibrillation, iron deficiency anemia, melanoma, breast cancer, anxiety and gait instability.

According to the most recent New York State Department of Health's Uniform Assessment System (UAS) provided for review, the functional status report indicated patient is totally dependent or needs maximal assistance for most IADLs; except finances and medications (limited assistance), and phone use (setup help). For ADLs, she needs maximal assistance for bathing, lower body dressing, walking/locomotion and all toileting related tasks. Limited assistance is needed for personal hygiene and lower body dressing; supervision for bed mobility; setup help for eating.

The patient is dependent for activities of daily living (ADLs). She has a home health aide 42 hours per week (8.5 hours per day, 5 days per week). The patient needs more hours, as she has declined since her last office visit. She cannot ambulate independently. She uses a wheelchair at home which she cannot maneuver without assistance. She can use a walker for small distances but needs contact guarding due to her unsteady gait and fall risk. She needs assistance for toileting. She uses a commode because it is too strenuous to walk to the toilet. She needs weight-bearing assistance with transfer, including bed to commode. She is incontinent of bladder and bowel and wears diapers. The diapers must be checked frequently and changed when needed, as patient cannot change diaper on her own. She takes diuretics which can cause frequent urination; family reports patient urinates 5-6 times per night. 

The family is paying privately for additional care but cannot continue to pay privately. Without this additional help, patient is alone 15.5 hours per day on weekdays; and totally alone on weekends. If alone, the patient would either remain in a soiled diaper; or attempt transfer to the commode and risk injury. The patient was hospitalized for heart failure and she has deteriorated since then. She has no informal support to assist her on a regular basis. 24 hour split shift care is medically necessary.

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

The medical necessity for the requested Personal Care Aide (PCA) Services Level II at 24 hours per split shift is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

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

The patient has a past medical history (PMH) of non-obstructive coronary artery disease (CAD), severe esophagitis and gastritis, hypertension (HTN), diabetes mellitus type 2 (DM2), tobacco abuse, hyperlipidemia (HLD) and schizoaffective disorder and was admitted with complaints of (c/o) abdominal pain and an eight month history of dysphagia. His vital signs were unremarkable. The physical exam was notable for no apparent distress (NAD), well nourished, abdomen soft, non-distended, and non-tender. Lab work was notable for a creatinine of 1.61. A chest x-ray (CXR) showed no acute disease. The patient was diagnosed with dysphagia and an acute kidney injury (AKI) and treated with intravenous fluids (IVF) and a gastroenterology (GI) consultation. The patient left medical advice (AMA). At issue is whether the inpatient level of care was medically necessary.
The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with c/o abdominal pain associated with several months of dysphagia. The patient did not have associated high-risk features, such as severe acute renal failure, congestive heart failure, or liver failure, nor did the patient have any hemodynamic instability. In addition, the patient did not have electrolyte abnormalities, bowel obstruction, diabetic ketoacidosis, or appendicitis. He was hemodynamically stable, did not have pyelonephritis, ascending infection, toxic appearance, unstable vital signs, or immunosuppression. The patient presented with several months duration of dysphagia and mild AKI, was treated with IVF and expert consultation, and these interventions could have been safely and appropriately provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stage IV breast carcinoma involving the spine and brain.
Treatment: Radiation therapy for other metastases, other non-bone: 10 fractions (treatment sessions) of proton beam therapy- image guided radiation therapy (IGRT)
The insurer denied Radiation therapy for other metastases, other non-bone: 10 fractions (treatment sessions) of proton beam therapy- image guided radiation therapy (IGRT)
The determination is overturned.

The patient has a history of stage IV breast carcinoma involving the spine and brain. She had photon beam radiation for palliation to the thoracic (T) 9-lumbar (L) 1 and stereotactic radiosurgery (SRS) to the brain in 2019. She then developed leptomeningeal carcinomatosis where craniospinal radiation is recommended with reirradation and proton beam approach. She then declined and was admitted to the hospital where she received photon beam palliative reirradiation to the craniospinal axis. Proton beam therapy-image guided radiation therapy (IGRT) has been requested and is under review for medical necessity.

Based on a preservice evaluation on this patient and the request for proton beam radiation to her cranial spinal axis, this request for proton therapy with image guidance for daily set up would be considered medically appropriate and necessary.  This is supported by multiple studies published in peer reviewed journals based on the physical characteristics of proton radiation call the Bragg peak.  This is significant for this patient as she has had previous radiation therapy to part of her spine and brain.  With the physical characteristics of proton radiation the dosing of radiation to the previously irradiated areas can be better controlled with proton radiation as compared to photon beam approach and in turn will decrease her risk of side effects associated with potential very high dosing of radiation to the brain and spinal cord that was previously irradiated. The risks include seizures, brain necrosis, paralysis and death.  The image guidance is medically appropriate and necessary as the treatment of the spine and brain needs to be extremely precise and can only be accomplished with daily image guidance for daily radiation fields set up.  The requested services are medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hallux Valgus (Acquired), Left Foot
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a history of anxiety and depression and hypertension who underwent a left foot bunion correction procedure with second metatarsal shortening osteotomy and tendon transfers. There were no reported complications of the procedure. The patient was initially admitted as an outpatient. Postoperatively, due to the need for "intensive pain management" in the setting of chronic substance abuse and a slow resolving block, the client was admitted to the hospital. She received physical therapy, observation of neurologic status, and pain control. At issue is the medical necessity of an inpatient stay. 
The inpatient hospital admission was not medically necessary.
In the absence of a major complication, the requested length of stay in an acute care facility is excessive for this type of procedure and not within generally accepted standards of medical practice. The patient's postoperative pain and anxiety could have been managed in a less acute setting. Her neurologic status was intact and there were no major complications. There was no documentation of a limb threatening potential complication such as neuromuscular compromise, impending compartment syndrome, persistent dislocation, skin compromise or systemic condition that required close monitoring. Such reconstructive procedures are routinely done at a lower level of care. The Milliman Care Guidelines (MCG) Inpatient Surgical Care guidelines offer evidence-based criteria, goals, optimal care pathways, and other decision-support tools for  assessment of people facing hospitalization or surgery. The patient's pain could have been managed with narcotics and multiple-modal agents. It was documented that patient could ambulate 100 feet with ambulatory aids without much pain. Therefore, the inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Kidney Cancer
Treatment: Inpatient stay
The insurer denied the Inpatient stay.
The determination is overturned.

The patient was brought to the emergency department (ED) on  with left (L) flank and hip pain two days after a kidney biopsy for renal cancer. The pain was unrelieved by Tylenol, progressively worsening and similar to the pain he had prior the diagnosis. He had minimal hematuria. His vital signs were normal. His exam was normal except for moderate to severe tenderness to palpation of the left flank. The emergency department (ED) assessment was that pain was secondary to tumor versus bleeding versus biopsy complication, and that disposition was based on imaging and lab results and ability to control pain. He was given intravenous (IV) morphine in the emergency department (ED). His lab results and radiographs were reassuring. He was admitted to the hospital for pain control. He continued to receive scheduled Tylenol and received several doses of morphine IV for breakthrough pain. He also was started on a stool softener for possible constipation contributing to the pain. He felt better the next day and morphine was prescribed at discharge for home use if necessary. At issue is the medical necessity of an inpatient stay.
The inpatient stay was medically necessary.
This patient with newly diagnosed kidney cancer, two days post biopsy, was experiencing moderate to severe flank pain unrelieved by Tylenol at home. The overnight admission was for pain control and to establish a regimen for managing the pain at home. He received IV morphine in the ED and in the hospital and was discharged the next day on outpatient morphine after the parents had received appropriate training in the administration of opiates at home. He meets inpatient criteria by the Milliman Care Guideline P05-RRG, because the pain was not sufficiently responsive to non-opiates, IV opiates were required for the initial management. This management extended beyond observation in the emergency department (ED), and a home-based management plan for the pain had yet to be established.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Carnitine palmitoyl transferase 1A deficiency.
Treatment: Applied Behavior Analysis (ABA) Pre-service.

The insurer denied the Applied Behavior Analysis (ABA) Pre-service.  The denial is overturned.

The patient is a male child with complex medical history including premature birth
(emergent cesarean section due to placental abruption), carnitine palmitoyl
transferase 1A (CPT1A) deficiency (a disorder of long-chain fatty acid oxidation),
developmental delay including expressive language delay, and sensory integration
disorder.

While the patient has delays in a number of areas, he also has strengths, defying
specific diagnosis despite neuropsychological testing. He demonstrates strengths in
nonverbal reasoning and early academic skills. He has deficits in expressive and
receptive language as well as fine motor skills, he is inconsistent in his ability to
engage with others and in non-preferred activities, and he has sensory sensitivities.
There is no clear history of stereotyped or repetitive behaviors. There are concerns
with behavioral and emotional regulation difficulties, including frequent limit testing
and tantruming.

The patient has been involved with a social skills group and does not readily
engage with the other children. He does not currently carry a diagnosis of autism,
but ongoing speech and language and occupational therapies have been
recommended, as well as a highly-structured classroom setting.
Applied Behavior Analysis has been recommended to address all of the patient's
aforementioned challenges.

Yes, the requested applied behavior analysis is likely to be more beneficial.

Applied Behavior Analysis is a behavioral approach with a longstanding history of
application with children on the autistic spectrum. ABA (Applied Behavior Analysis)
programming utilizes scientifically validated methods that are incorporated into a
comprehensive individualized plan for the child. As a behavioral approach, ABA
(Applied Behavior Analysis) has also been applied to those with intellectual
disability. Like children with autism, children with intellectual disability have a higher
rate of behavioral issues, with similar response to therapy. Even though the
underlying disorder may be different, behavioral therapies are not targeted at
treating the disorder, rather the manifestations that result. In young children, the
goal is similar across diagnoses: "the goal of intensive, comprehensive intervention
is to improve cognitive, language, social, and self-help skills." (4)
This child is more likely to benefit from ABA (Applied Behavior Analysis) than any
other available standard therapies (e.g., social skills, speech and language therapy,
occupational therapy).