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

Diagnosis: Bilateral Upper Lid Ptosis
Treatment: Procedure code 67904, repair of blepharoptosis; (tarso) levator resection or advancement, external approach
The insurer denied coverage for procedure code 67904, repair of blepharoptosis; (tarso) levator resection or advancement, external approach.
The denial is overturned.

This is an adult with a history of bilateral upper eyelid ptosis. The patient presented to the ophthalmologist's office follow up, Humphrey visual field (HVP)/intraocular pressure (IOP) testing. The standard for the medical documentation shows ptosis and dermatochalasis, superior visual field defect that improved with taping of the upper eyelids. Eyelid margin reflex distance (MRD1) was noted to be 2mm (millimeters) bilaterally. The patient also self-reported visual function impairment from ptosis.

The patient was seen for peripheral vision changes. Visual field testing showed temporal hemifield defect. Magnetic resonance imaging (MRI) of the brain was requested. Visual acuities were 20/25 right eye (OD) and 20/30 left eye (OS). Visual field testing showed significant improvement in temporal deficit in both eyes (OU). Later, visual acuities were 20/20 OD and 20/25 OS. Exam showed marginal reflex distance (MRD) of 2mm both eyes (OU). There was dermatochalasis and ptosis, with brow recruitment OU. Levator function was 15mm OU, and palpebral fissure was 8mm OU. Visual field testing showed defect that improved with taping of the lids.

The visual field test showed superior visual field defects improved with taping of the eyelids both eyes (OU). Diagnosis of bilateral upper lid ptosis was noted and recommended bilateral upper lid ptosis repair.

The doctor stated that the patient complained of drooping of her upper lids affecting her vision. Exam showed 2+ dermatochalasis and marginal reflex distance of 2.5mm both eyes (OU). Levator function was 15mm OU. She has decreased superior visual field with improved with manual elevation of the lids. Bilateral upper lid ptosis repair was recommended to improve her field of vision.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for procedure code 67904, repair of blepharoptosis; (tarso) levator resection or advancement, external approach services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right Testicular Mass
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

This is a male patient with the past medical history of irritable bowel syndrome (IBS), heart failure (HF), right testicular mass. The patient presented to hospital for a preop workup and medical clearance for a planned right orchiectomy. The patient was cleared for surgery by cardiology, taken to operating room (OR) for right radical (inguinal) orchiectomy. Surgery was tolerated well, without complications. The patient was taken to the post anesthesia care unit (PACU) postop, then recovered uneventfully. He tolerated diet, ambulated and voided without difficulty. He was discharged home with outpatient Urology follow up. The insurer has denied coverage for the inpatient as not medically necessary. Insurer noted uneventful surgery and recovery and stated that patient could have been treated at the observation level. 

The following Milliman Care Guidelines (MCG) (25th Edition) were referenced:  1) Urologic surgery procedure: the patient is noted to have met the discharge parameter within 24 hours post procedure. 2) Orchiectomy - patient meets the discharge parameter within 24 hours post procedure.  According to Milliman Care Guidelines (MCG) guidelines, this procedure is performed in the ambulatory surgery setting. (Goal length of stay (LOS) = ambulatory)

The health care plan acted reasonably and with sound medical judgment and in the best interests of the patient.  The inpatient admission is not considered medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Epigastric Abdominal Pain, Nausea and Vomiting
Treatment: Inpatient admission
The insurer denied the Diagnosis: Epigastric Abdominal Pain, Nausea and Vomiting
The denial is upheld.

The patient is a female with no significant history. She was admitted with abdominal pain and noted with elevated creatinine of 1.98 mg/dl (milligrams per deciliter). The patient had abdominal imaging and was started on intravenous fluid hydration. Renal function stabilized, and the patient was discharged to home.

No, the Inpatient admission was not medically necessary.
The patient was admitted with abdominal pain and noted with elevated creatinine of 1.98 mg/dl (milligrams/deciliter). The patient had abdominal imaging and was started on intravenous fluid hydration. Renal function stabilized, and the patient was discharged to home.

Based on available data there was no reported hemodynamic instability, documentation of altered mental status, significant volume overload or respiratory distress, cardiac arrhythmias or persistent fevers that required inpatient care. The patient's renal function was stabilizing. There was no documentation of anuria. The patient was tolerating oral intake. There were no specific therapies or treatments that required inpatient level of care. The patient could have been safely and effectively managed at a lower level of care.

Inpatient level of care in this patient's case would not be considered a generally accepted national standard of medical practice, and would be provided primarily for convenience of the patient or the practitioner. It was not the least intensive and/or most appropriate alternatives among diagnostic and treatment options. Therefore, the Inpatient admission was not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System/Chronic Obstructive Lung Disease/COPD
Treatment: Inpatient Hospital Admission
The health plan denied the requested inpatient stay as not medically necessary. The health plan's determination is upheld.

The patient is a woman with hypertension (HTN) and asthma (no prior admissions or intubations) who presented with 3-4 days of dyspnea and wheezing.
In the emergency department (ED), her temperature was 97.8F., with a blood pressure (BP) of 151/84 millimeters of mercury (mmHg), a heart rate (HR) from 120-140 beats per minute (bpm), a respiratory rate (RR) of 26/minute, and an oxygen saturation of 96% on room air (RA). She was in no distress, her heart was regular, wheezing was noted, and she was alert and oriented. Labs included a white blood cell count (WBC) of 7.5, a sodium of 143, a bicarb of 28, and a blood urea nitrogen (BUN)/creatinine of 6.8/0.81. COVID and flu testing were negative. A chest x-ray (CXR) showed mild vascular congestion, no infiltrates.
In the ED, the patient was given intravenous (IV) Magnesium, Azithromycin, Furosemide, Methylprednisolone, and fluids as well as nebulized bronchodilators. Wheezing persisted, so she was admitted. The patient was diagnosed with an asthma exacerbation and was started on IV steroids, nebulized bronchodilators, and oral Azithromycin.
The next day she still had chest heaviness and was still wheezy on exam. Her HR was down into the 90s bpm, she was afebrile, and was saturating well on room air. Treatments continued.
The patient was much improved, there was no wheezing on exam, and she was discharged on Azithromycin and Prednisone.
At issue is the medical necessity for the inpatient stay.

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

An inpatient admission was not medically necessary. The patient presented with dyspnea and was diagnosed with an acute asthma exacerbation. There were no additional or alternative diagnoses. She was tachycardic at presentation (this resolved over an observation care time frame) but otherwise had no other indicators of severe disease such as encephalopathy, hemodynamic instability (she was tachycardic but not unstable, hypotensive, labile BP or HR, dysrhythmia), respiratory distress or gas exchange abnormality, or acute kidney injury or electrolyte abnormality. She had no historical features that would suggest she was high risk (prior intubation, recent prednisone use, poor compliance). She improved over an observation care time frame.
With a low severity of illness at presentation, low risk of worsening, and lack of alternative diagnoses, the patient did not need an inpatient admission for testing, monitoring, or treatment. With an improvement over an observation care time frame, she did not need an inpatient admission for prolonged care.
An alternative level of care would have been reasonable.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes Mellitus and Alzheimer's Dementia
Treatment: Personal Care Worker (PCW) services 12 hours per day, 7 days a week
The insurer denied coverage for PCW services 12 hours per day, 7 days a week.
The denial is overturned.

This elderly patient has diabetes mellitus and Alzheimer's dementia.  She lives alone in a 2-bedroom apartment.  The insurer approved personal care worker (PCW) services 8 hours/day, 7 days/week for a total of 56 hours/week and the request is for personal care worker (PCW) services 12 hours per day, 7 days a week.

In the Uniform Assessment System (UAS) report, the patient's cognitive status is described as "minimally impaired." However, she is "disoriented to time". All decisions and finances are managed by member's son and his wife. She requires maximal assistance for bathing, lower body dressing and toilet use. Extensive assistance is needed for personal hygiene, upper body dressing, and toilet transfer. She is frequently incontinent of bowel and bladder. Limited assistance is needed for bed mobility and eating. According to a physical therapy note, the patient was able to ambulate with a rolling walker 75 feet with minimal assistance. The patient's condition and functional needs are at a level, unpredictable and declining.   

Based on the enclosed documents reviewed, the patient's health and safety can be more appropriately provided and maintained by the requested increase in PCW services, 84 hours/week.    

The insurer's denial is overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for PCW services 12 hours per day, 7 days a week is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic Dermatitis
Treatment: Dupixent 300MG (milligrams)/2ML (milliliter) SC (subcutaneous) SOPN (Solution Pen-Injector)
The insurer denied: Dupixent 300MG (milligrams)/2ML (milliliter) SC (subcutaneous) SOPN (Solution Pen-Injector)
The denial is overturned

The patient is an adult female diagnosed with moderate to severe atopic dermatitis.  She has tried and failed clobetasol and triamcinolone, and is now being prescribed Dupixent.  The request for Dupixent was denied because the patient has not tried other formulary alternatives.  The provider is appealing the denial.

The proposed treatment with Dupixent is medically necessary.
Dupixent is Food and Drug Administration (FDA) approved for patients with moderate to severe atopic dermatitis who have failed topical therapy. The formulary alternatives are not Food and Drug Administration (FDA) approved for the patient's condition and impose more risks that would deem them not medically necessary when safer and more appropriate medications are available. In addition, Tacrolimus is less potent than the treatments tried and failed and would thus put the patient at risk for further destabilization to delay effective systemic therapy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status post tracheoesophageal fistula (TEF) repair

Treatment: Continued stay in a skilled nursing facility

The insurer denied coverage for continued stay in a skilled nursing facility

The denial is upheld

This is a patient with Trisomy 21 and VACTERL (vertebral abnormalities anal atresia cardiac defects trachealesophageal abnormalities) status post tracheoesophageal fistula (TEF) repair. She is status post patent ductus arteriosus (PDA) ligation and ventricular septal defect (VSD) repair, status post tracheostomy and who was hospitalized the first 19 months of her life due to complex medical and nursing needs. She uses a continuous positive airway pressure (CPAP), and requires care for tracheostomy, positioning, and medications. She is maintained on Keppra, as an electroencephalogram (EEG) confirmed presence of seizures. She has had esophageal dilations since TEF repair, due to strictures. Family training was completed, but the family is still anxious about caring for the patient at home.

The patient uses a CPAP, and requires care for tracheostomy, positioning, and medications. Family training was completed.  Ongoing care could have been addressed at a lesser setting such as home health nursing, or placement at a custodial center.

National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Health Care Services; Committee on Improving Health Outcomes for Children with Disabilities; Byers E, Valliere FR, Houtrow AJ, editors. (2018), "Children with disabilities, especially those with severe disabilities, often require home- and community-based services "services or other supports to help people with disabilities of all ages to live in the community"

Foster, C. C., Fuentes, M. M., Wadlington, L. A., Jacob-Files, E., Desai, A. D., Simon, T. D., & Mangione-Smith, R. (2020), "When home healthcare was accessible, respondents experienced it as effective in improving patient and family daily life and minimizing use of emergency and hospital services." 

Continued stay in a skilled nursing facility is not considered medically necessary for this patient. 

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

The insurer's denial of coverage for continued stay in a skilled nursing facility is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System - Respiratory distress.
Treatment: Inpatient Hospital.
The insurer denied Inpatient Hospital Admission.
The denial is upheld. 

The male infant was born by vaginal delivery to a Gravida 6 now Para 5 female. The mother had prenatal care, and the pregnancy was complicated by gestational thrombocytopenia. Maternal serologies were unremarkable.
Initially, he had spontaneous respirations. He was then noted to be cyanotic and apneic after delivery and again was apneic while being held by the mother. He was taken to the warmer bed, received positive pressure ventilation (PPV), and the oxygen was increased to 40% (percent). He then became pink with weak cries. PPV continued to be administered, and the oxygen weaned to 21%. He was then weaned to unassisted room air, and his oxygen saturations were 98%.
He was taken to the Neonatal Intensive Care Unit (NICU) for observation and evaluation of initial respiratory distress. A complete blood count (CBC) was within normal limits. The cord blood potential hydrogen (pH) was 7.435 with a base deficit of 0.9. His initial glucose was 54 milligrams (mg)/deciliter (dL). A capillary blood gas had a pH of 7.30, bicarbonate of 26 and lactic acid of 2.6. No antibiotics were initiated. The infant remained hemodynamically stable and was permitted to ad lib feed. He received routine newborn infant care and was discharged. He failed a right ear hearing screen, and a follow-up audiology appointment was made in addition to a follow-up appointment with the pediatrician.
At issue is the medical necessity of the Inpatient Hospital Admission.

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

No, the requested health service/treatment of Inpatient Hospital Admission was not medically necessary for this patient.
The requested Inpatient Admission to NICU Level II was not medically necessary for this patient. The patient was hemodynamically stable, breathing unassisted room air prior to admission to the NICU and remained stable until discharge from the NICU. The infant required transitional care and observation after receiving brief PPV in the delivery room within the first minutes of life. The neonate's care consisted of observation post-delivery for successful transitioning from in uterine life to extra-uterine life.
Therefore, the requested health service/treatment of Inpatient Hospital Admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pilon fracture. 
Treatment: Inpatient admission. 

The insurer denied: Inpatient admission.  The denial is upheld. 

The patient is an adult male with a past medical history of asthma and Covid-19. A friend fell on top of him. He went to the emergency room and was diagnosed with a Pilon fracture. He was splinted in the ER (emergency room). He underwent external fixation to the right ankle. Ten days later he was admitted to the hospital and underwent removal of external fixator from his left lower extremity, irrigation debridement of the pin sites of the left lower extremity, open reduction internal fixation of the fibula and tibial pilon fracture. He also underwent bone grafting for the fracture. The procedure was performed under regional anesthesia and took approximately 4.75 hours. Drains were placed at the end of the procedure. 

The patient was returned to the OR (operating room) for revision, foreign body removal and wound closure. One of the drains met resistance and had to be removed in the OR (operating room). The patient was placed on a Dilaudid PCA (patient-controlled analgesia) postoperatively. 

The patient was admitted to the hospital. He initially was admitted as an outpatient. He was converted to inpatient status after his procedure for drain, pain management, physical therapy and return to the OR (operating room) for revision. 

The inpatient admission was denied coverage by the health plan as not medically necessary. The reason for denial states the care and surgery can be done without a full hospital admission. The denial states the plan clinical criteria consider a full hospital admission medically necessary when there are severe problems. The denial is being appealed. 

The inpatient admission was not medically necessary. 

The inpatient admission was not in accordance with the generally accepted standards of medical practice. Based on the records provided, there is no documentation that there were severe perioperative complications that would necessitate an inpatient level of stay such as bleeding, hypotension, hypertension, myocardial infraction, stroke, hypoxemia, fever, altered mental status or uncontrolled pain. Based on the records provided, the generally excepted standards of medical practice would be treatment at a lower level of care. 

"Inpatient care, rather than outpatient care, is required only if the beneficiary's medical condition, safety, or health would be significantly and directly threatened if care was provided in a less intensive setting." (2) 

The inpatient admission was not clinically appropriate, in terms of its type, frequency, extent, site and duration and considered effective for the patient's injury and pathology. There is no documentation supporting inpatient level of care based on the records provided. 

The inpatient admission was more intensive than an alternative drug, service or supply that is at least is likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the patient's sickness, injury, disease or symptoms. The patient could have been treated in a lower level of care.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Crohn's Disease
Treatment: Stelara 90mg every six weeks
The insurer denied Stelara 90mg every six weeks
The denial is Overturned.

The patient is a male with severe ileocolonic Crohn's disease. He has previously tried and failed steroids and an anti-tumor necrosis factor (TNF) agent (infliximab). He was started on Stelara and did well initially on Stelara at standard dosing every 8 weeks but recently lost response. He had evidence of active inflammation on magnetic resonance (MR) Enterography and elevated inflammatory markers (C-reactive protein [CRP]) and fecal calprotectin). Hence the attending provider is requesting the use of Stelara at the escalated dose of 90 milligrams (mg) subcutaneous (SC) every 6 weeks to treat this patient's severe Crohn's disease.

The proposed health service or treatment Stelara 90 milligram per milliliter (MG/ML) syringe (1 syringe for 42 days - 90 mg every six weeks) is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

Since this patient was not responding to standard dosing of Stelara, it is reasonable to increase the dose of Stelara to 90mg every 6 weeks. Dose escalation in biologic therapy used in inflammatory bowel disease can be done either based on clinical symptoms or laboratory markers or endoscopic or radiological features with or without therapeutic drug monitoring. Dose escalation is done either by increasing the dose of the medication or shortening the interval between doses or sometimes a combination of both. There are only a finite number of biological agents used to treat inflammatory bowel disease and the standard of care is to optimize dose of the biological agent before switching to another agent. Therefore, it is medically necessary to use Stelara 90mg SC every 6 weeks to treat this patient's severe Crohn's disease.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Crohn's Disease
Treatment: Stelara 90mg every six weeks
The insurer denied: Stelara 90mg every six weeks
The denial is Overturned.

The patient is a male with Crohn's disease diagnosed four years ago. He failed high-dose infliximab. He changed to Stelara every 8 weeks. Colonoscopy showed a cecal stricture with friability and active ulceration in the ascending colon with pseudopolyps; he required corticosteroid therapy (budesonide). Magnetic resonance enterography showed mucosal thickening and enhancement of the terminal ileum, cecum, and proximal ascending colon. Fecal calprotectin was markedly elevated at 1,240 micrograms per gram (ug/g). He has had moderate to severe periumbilical abdominal pain daily, as well as occasional blood in stool. The subject under review is whether the requested Stelara 90 milligrams (mg) every six weeks for the treatment of Crohn's disease is likely to be more beneficial for this patient than any standard treatment.

Current medical literature supports dose escalation of Stelara to 90 mg every 6 weeks as likely to be more beneficial than any standard treatment or treatments for the patient's Crohn's disease. A large randomized controlled trial demonstrated safety and efficacy for induction and maintenance of remission in patients with moderate-severe Crohn's disease that was resistant to anti-tumor necrosis factor (TNF) therapy (Sandborn, et al.). Another study showed a 73% (percent) response in patients with anti-TNF-resistant Crohn's disease, and 80% of responders maintained remission for 1 year (Kopylov, et al.). The mechanism of Stelara (ustekinumab) is entirely different than that of anti-tumor necrosis factor medications, which the patient has failed (Tuskey, et al.).

Continuation of dosing every 8 weeks or discontinuation of Stelara (even if an alternative is attempted immediately) may result in loss of disease control, with complications such as stricture, fistula, bowel obstruction, flare, hospitalization, need for surgery, or other complications. For these reasons, Stelara 90 mg every 6 weeks is supported as likely to be more beneficial than any standard treatment or treatments for the patient's Crohn's disease.