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

Diagnosis: Chest Pain.
Treatment: Inpatient Admission.

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

This man had a history of hyperlipidemia treated with simvastatin, prior tobacco use, and a family history of coronary artery disease, also taking daily aspirin for prevention. He presented to the Emergency Department (ED) with complaints of intermittent pricking chest pain lasting 20 to 30 minutes, associated with profuse diaphoresis, dyspnea, shaking and nausea. Initial vital signs included blood pressure (BP) 134/98, heart rate 109, temperature 99.4 Fahrenheit and oxygen saturation on room air 99%. Electrocardiogram (EKG) was normal sinus rhythm and normal. Laboratory test results included white blood cell (WBC) count 11.1, hemoglobin 15.0, creatinine 1.21, and troponin less than 0.01, with subsequent troponin at 0.01. Treadmill nuclear stress testing was normal. He exercised for a total of 6 minutes, 41 seconds using a standard Bruce protocol, achieving maximum heart rate 153 (90%), with no myocardial perfusion defects or wall motion abnormalities and left ventricular systolic function 63%. He was discharged on atorvastatin and aspirin, for outpatient follow-up.

There is no evidence that this patient required an acute inpatient level of care to determine that his chest discomfort was not related to acute coronary syndrome. This should have been completed in the ED or at an observation level of care.

The denial of coverage for the inpatient admission is upheld because there is no evidence that this patient was at increased risk for short term adverse cardiovascular events requiring inpatient monitoring and management, based on his clinical presentation and results of testing performed in the ED. 

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

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

Diagnosis: Acetabulum Lesion. 
Treatment: Full Hospital Admission. 

The insurer denied coverage for full hospital admission.  

The denial is overturned. 

The patient is a female that had metastatic endometrial adenocarcinoma, diabetes, and hypertension. She presented to the emergency room (ER) with complaints of worsening right leg pain, which she could not control with previously prescribed oral opiates. Imaging revealed a right pelvic side wall mass and a new right acetabulum lesion. The patient was admitted to Gynecology service for an aggressive pain management regimen. She was given Gabapentin, Tylenol, and Morphine Sulfate (MS) Contin 15 milligram (mg). The patient reported that pain had improved. Orthopedic Surgery recommended further imaging and the tumor was found to have progressed into the right hip. Recommendations included no weight bearing on the right leg and trying to use a bedpan. Later, the pain was well controlled overnight with gabapentin, MS Contin 30 mg, and 4 mg of oral Dilaudid. Vital signs were stable. Radiation Oncology recommended no further episodes of palliative radiation to the right hip. Orthopedics recommended engaging in limited weight bearing activity with a walker. Physical Therapy evaluated the patient and noted that pain was a significant barrier to activity. Occupational Therapy would work with the patient 2-3 days a week. The patient was discharged. The health plan is denying the admission. 

The Milliman criteria for in-patient admission of Pain Management states Hospital admission is needed for appropriate care of the patient because of 1 or more of the following: - Severe pain requiring acute inpatient management as indicated by 1 or more of the following: - Inpatient intravenous opioid treatment required as indicated by ALL of the following: - Pain insufficiently responsive to non-opioid analgesia (eg, NSAIDs [non-steroidal anti-inflammatory drugs]) - Alternative routes (eg, oral, transdermal, or submucosal) for opioid treatment not appropriate or not sufficient - Intravenous opioid treatment needed beyond observation care time frame (ie, conversion to alternative routes or medications not appropriate or not successful) - Pain control regimen for next level of care not established (eg, after observation care) as indicated by 1 or more of the following: - Sufficient pain control not achieved (eg, active adjustments to medications, dose, and route are ongoing). 

This patient, with bone and liver metastases, met all of the admission criteria above. 

Whitehouse, et al also advises careful titration and observation of the effectiveness of opiate administration to avoid complications. 

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 full hospital admission is reversed. Medical necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lung Cancer
Treatment: Guardant 360
The insurer denied the Guardant 360.
The determination is upheld.

The patient has a diagnosis of stage IIIB non-small-cell lung carcinoma (NSCLC). The patient was offered standard of care therapy with cisplatin/pemetrexed along with concurrent radiation following durvalumab. The patient's treating physician recommended a Guardant 360 circulating tumor deoxyribonucleic acid (DNA) assay to assess for actionable mutations. This was denied by the health plan and is under review as to whether it is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Guardant 360 testing is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
This patient has a diagnosis of stage IIIB non-small-cell lung carcinoma and has been recommended to receive standard chemoradiation following my immunotherapy.
The National Cancer Network Guidelines (NCCN) do not suggest molecular profiling outside of an advanced or metastatic disease setting at this time. There are not targeted therapies approved for patients with stage IIIB NSCLC.
Therefore, the proposed health service is not likely to be more beneficial than any standard treatment for the insured's condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lung Cancer
Treatment: Guardant 360
The insurer denied the Guardant 360.
The determination is overturned

The patient presented with a cough. Further work up lead to the diagnosis of non-small cell lung cancer (adenocarcinoma) with mediastinal node metastasis, staged as III, tumor (T) 3 nodes (N) 3 metastasis (M) 0. Magnetic resonance imaging (MRI) of brain was negative for metastasis in the central nervous system (CNS) and a positron emission tomography (PET) scan showed no distant metastasis. Treatment with concurrent chemotherapy Cisplatin and Pemetrexed and radiation therapy was recommended. The treating physician ordered Guardant 360 Molecular profiling to identify genomic abnormalities.
Guarding 360 testing revealed epidermal growth factor receptor (EGFR) amplification, tumor protein (TP53 mutation and Cyclin E1 (CCNE1) amplification. microsatellite instability (MSI) high status was not detected. EFGR, anaplastic lymphoma kinase (ALK), C-ros oncogene 1 (ROS-1), Erb-B2 Receptor Tyrosine Kinase 2 (ERBB2), mesenchymal epithelial transition factor (MET), rearranged during transfection (RET) and v-raf murine sarcoma viral oncogene homolog B1 (BRAF) gene abnormalities were not detected. Guardant 360 testing is under review.
The proposed health service or treatment Guardant 360 testing is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Testing for Next Generation molecular Sequencing (NGS) such as Guardent-360 is a standard diagnostic tool for patient with newly diagnosed advanced lung cancer. The National Comprehensive Cancer Network (NCCN), American Society of Clinical Oncology (ASCO), and European Society for Medical Oncology (ESMO) guidelines recommend testing for EGFR, ALK, ROS-1, MET, ERBB2, RET and BRAF molecular testing for advanced lung cancer. Testing of these genes is a very important first step in managing newly diagnosed lung cancer to help formulate first line and subsequent lines of therapy. Many Food and Drug Administration (FDA) approved drugs are available to treat patient with the above mentioned genomic abnormalities. NGS also helps identify potential clinical trials for patient with advanced lung cancer.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 
The insurer denied braces. 
The denial is overturned.

The patient in question is a female with an anterior crossbite on teeth 7 and 10. She presents with a skeletal Class II malocclusion with mild crowding in the maxilla and mild spacing in the mandible. Tooth 19 is missing. She is treatment planned for orthodontics to address the crowding and crossbite, but the treatment was denied due to lack of medical necessity.

The health plan's determination is overturned.

The treatment with braces is medically necessary for this patient. This patient presents with an anterior crossbite on teeth 7 and 10, as well as significant crowding. 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.1,2,3
If left untreated the damage that will likely occur to the patients teeth will be much more time consuming and difficult to correct than the patient's existing orthodontic problem. For this reason, treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 
The insurer denied braces and monthly visits. 
The denial is overturned.

The patient is a female with an anterior crossbite on teeth 7 and 10. She presents with a skeletal Class I malocclusion with moderate crowding in the maxilla and the mandible. She is treatment planned of orthodontics with extraction of four first premolars to address the crowding and crossbite. The subject under review is the medical necessity for the braces and monthly visits.

The health plan's determination is overturned. 

This patient presents with an anterior crossbite on teeth 7 and 10, as well as significant crowding. 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.1,2,3
If left untreated the damage that will likely occur to the patients teeth will be much more time consuming and complicated to correct than the patient's existing orthodontic problem. For this reason, treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Orthopedic
Inpatient hospital

Diagnosis: inflammatory flexor tenosynovitis
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a woman who was admitted to the hospital. She presented with left index finger pain since the prior day. She denied symptoms of sepsis such as fevers and chills. She reported pain on movement of the index finger and there was also erythema present. She also reported eating a meal with alcohol and meat prior to onset of her symptoms. Vital signs showed blood pressure 148/90, heart rate 60, and temperature 97.8 Fahrenheit. Labs showed white blood cell count (WBC) 6.6, hemoglobin 14.1, platelets 209, glucose 86, sodium 134, creatinine 0.68, and calcium 9.1. COVID-19 testing was negative. The patient was admitted for inflammatory flexor tenosynovitis. 

The inpatient hospital admission was not medically necessary.
The patient presented with cellulitis/tenosynovitis but was hemodynamically stable and had no evidence of necrotizing fasciitis, involvement of the deep tissues, uncontrolled pain, or other acute complications. She was discharged with Augmentin and ibuprofen. She needed further care but it could have been safely and effectively provided at a lower level.
The patient needed further care for tenosynovitis and suspected gout in the setting of alcohol consumption and a high protein diet preceding her symptoms. However, her presentation of tenosynovitis was uncomplicated and she was treated with IV antibiotics and oral pain medication. There was no evidence of sepsis and no other complicating factors such as bacteremia or abscess formation. Inpatient hospital level of care was not medically necessary for her symptoms.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems-Nerve Treatment.
Treatment: Dental Orthodontic Procedure. 
The insurer denied Nerve treatment on molar, tooth #19 for medical necessity. 
The denial was overturned.

The patient is a female who presented to the dental office for evaluation and treatment of tooth #19. A full mouth panoramic radiographic image was done. The patient has decay on tooth #19 that extends into the pulp along with periapical periodontitis.
At issue is the medical necessity of Nerve treatment on molar, tooth 19.

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

The requested health service/treatment of Nerve treatment on molar, tooth 19 is medically necessary for this patient.
The patient has decay on tooth #19 that extends into the pulp along with periapical periodontitis, which is evidence of the diagnosis of irreversible pulpitis. In the situation where the patient has the diagnosis of irreversible pulpits, as long as the tooth is restorable, there is the requirement to treat the pulpitis through removal of the infected nerve, artery, vein, as well as the canal tooth structure, irrigate with sodium hypochlorite, and fill with gutta percha medicament as this is the only therapy that will treat the diagnosed pathology. If the therapy is not done, the pulpal infection can spread to the surrounding bone, which can lead to the presence of an abscess, with an array of sequential systemic sequela. Based on the evidence of irreversible pulpits, the therapy of nerve treatment is indicated.
Therefore, the requested health treatment of Nerve treatment on molar, tooth #19 is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Trauma/Injuries
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. The reviewer has overturned in whole the health plan's determination.

This is a case of a patient who presented to the emergency department (ED) with complaints of left forearm, left shoulder and left-hand pain and paresthesia after being assaulted with a baseball bat. Physical exam revealed right periorbital ecchymosis and a gross deformity of the left mid-forearm, and a sub-centimeter laceration of the left forearm. Lab abnormalities included leukocytosis of 18, elevated creatinine of 1.4, alcohol level of 0.07, a positive urine drug screen for tetrahydrocannabinol (THC). X-ray evaluation included a normal computed tomography (CT) scan of the head and cervical spine, x-ray of the left forearm showed no fracture, CT-angiogram showed no vascular injury of the forearm but a possible dissection of the right subclavian artery. X-ray of the left hand showed an angulated displaced fracture of the 4th metacarpal and carpal bone dislocation. Angiogram of the subclavian artery showed no injury there. An Orthopedic consultant prescribed a splint and non-weight bearing for the left forearm and surgical repair of the finger fracture. He was admitted to the Trauma Service for suspicion of forearm compartment syndrome and for expeditious hand surgery. During his hospital stay, his hand numbness resolved, as did concern for compartment syndrome and his hand surgery was postponed because of surgeon scheduling priorities. He was discharged to home with instructions to follow-up for surgical repair of his finger later in the week.

Yes, inpatient care was medically necessary for monitoring of compartment syndrome, for work-up and further evaluation of possible subclavian artery dissection requiring a second intravenous contrast injection in the setting of elevated creatinine, and for surgical repair of a displaced, angulated finger fracture. There are indeed notes suggestive of compartment syndrome supported by findings of paresthesia. Also, expeditious repair of the finger fracture was in the best interest of the patient, even though, unfortunately, other hospital priorities intervened. In addition, the need for follow-up evaluation for a possible subclavian artery dissection was needed and a second intravenous dye load was needed in the setting of already compromised kidney function.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems
Treatment: Dental/Orthodontic Procedure
The health plan denied braces as not medically necessary. The reviewer has upheld in whole the health plan's determination.

The patient in question has a Class II subdivision right occlusion with moderate overjet and a deep overbite. The maxillary and mandibular have very minor crowding. He is treatment planned for 24-30 months of orthodontics with elastics to correct his malocclusion, but this was denied on the basis that treatment is not medically necessary.

There is no medical reason to correct his malocclusion with braces.
The patient has minimal crowding. His bite is deep but there is no indication of damage to the incisors or the palate in the photographs, and his cephalometric radiograph show the lower incisors are contacting the maxillary teeth in occlusion, not the palate. There is no indication from the photographs provided there is severe soft tissue damage (or any soft tissue damage) on this patient.
The patient does have a deep bite, however, that alone is not a medical necessity to treat. There are functional problems that can occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence.[1] This patient presents with none of those conditions. The photographs do not illustrate any damage to the teeth or soft tissue damage from their current position. The patient has a 6-millimeter (mm) overjet, but this amount of overjet does not negatively affect oral health related quality of life.[2] If his teeth were aligned it would provide an aesthetic improvement, but it would not create a medically significant improvement to the patient's health. Orthodontic treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal/Ulcerative Colitis
Treatment: Pharmacy/Prescription Drugs
The health plan denied the requested increase in the prescription dose for Stelara. 
The health plan's determination is overturned.

This is a review for the use of Stelara (ustekinumab) to treat severe ulcerative colitis in a patient. This patient has severe ulcerative colitis (UC). He has previously tired and failed 5-ASA agents, steroids, Remicade (infliximab), Humira (adalimumab), Entyvio (vedolizumab) (despite dose escalation) and Xeljanz (tofacitinib). He was started on Stelara at standard dosing in January 2021 and initially responded but later lost response. He continues to have symptoms of active ulcerative colitis and 4-6 weeks after his injection. Hence, the attending provider would like to escalate the dose of Stelara to 90mg (milligrams) SC (subcutaneous) every 4 weeks.

Based on the clinical data provided, I overturn, in whole the health plan's determination of medical necessity.

Yes, the requested health service/treatment of Stelara SC 90mg is medically necessary for this patient. This patient has medically refractory ulcerative colitis and has failed every Food and Drug Administration (FDA) approved biological agent used to treat UC. Hence dose escalation of Stelara to 90mg every 4 weeks is appropriate and medically necessary.
Since this patient is not responding to standard dosing of Stelara, it is reasonable to increase the dose of Stelara to 90mg every 28 days (4 weeks). Dose escalation in biologic therapy used in inflammatory bowel disease can be done based on clinical symptoms or signs, endoscopic evaluation of mucosal healing or elevated inflammatory markers or based on therapeutic drug monitoring by either increasing the dose of the dose or shortening the interval infusions or sometimes a combination of both. While therapeutic levels of infliximab and adalimumab are well established in the medical literature, there are less data on appropriate therapeutic levels of ustekinumab since this medication and therapeutic drug monitoring of ustekinumab have been available for only a few years as opposed to over a decade for the anti TNF (tumor necrosis factor) agents.
Dose escalation in Stelara for Crohn's disease is well established in the medical literature. The medication was only approved for UC a little over a year ago. Ollech and colleagues showed that shortening the ustekinumab 90 mg dose interval to 4 weeks for patients with Crohn's disease who did not respond to doses every 8 weeks improved clinical and biological indices of disease activity. Patients who lose response to the standard dose of ustekinumab might benefit from dose interval shortening, which was effective and safe. Similarly, Kopylov and colleagues showed that Intensification of ustekinumab maintenance dosage was effective in over 50% of the patients with Crohn's disease who were not responding to standard dosing. This strategy should be considered in patients who are nonresponsive to every 8 weeks ustekinumab maintenance dosing.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fall
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a man who presented to the emergency department (ED) following a fall from standing height. He had previously broken his right shoulder and had surgery for this. He complained of right shoulder and mid back pain at the time of presentation. Comorbid health conditions included anxiety, depression and spinal stenosis. He was initially evaluated in the ED. His breathing was unlabored and symmetrical. Imaging with chest x-ray showed multiple old healed right sided rib fractures and acute displaced fractures of ribs 7, 8, and 9. Imaging showed the operative changes of prior surgery for the proximal right humerus. At the time of presentation, he was awake and alert with a Glasgow coma score of 15. He was hemodynamically stable. Vital signs showed a normal heart rate and temperature and elevated blood pressure. He was admitted to the hospital. 

The inpatient hospital admission is not medically necessary.
The care and treatment provided could have been rendered at a lower level of care. This patient presented to the ED following a slip and fall accident in which he sustained 3 right rib fractures. He was clinically stable at the time of presentation with normal heart rate and labs. He was able to ambulate and was able to tolerate a diet. He was provided pain medications and was able to participate with physical therapy. He was able to operate the incentive spirometer and participate with physical therapy. He was hemodynamically stable with normal pulse oximetry. He did not require operative intervention or an intensity of medical care that mandated inpatient admission. He remained clinically stable throughout the period of monitoring. A lower level of care would have provided for the care and treatment necessary for this patient.