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

Diagnosis: Infertility
Treatment: IVF (in vitro fertilization) - follicle puncture oocyte retrieval
The insurer denied coverage for IVF- follicle puncture oocyte retrieval
The denial is upheld

This is a patient with a history of infertility and stage IV (4) endometriosis. Her husband has male factor infertility. She currently has one embryo that is available for transfer. The patient is requesting coverage for in vitro fertilization (IVF) with oocyte retrieval.

Since the aim of this patient is to conceive a healthy child (rather than to collect embryos) and since with the availability of 1 euploid embryo, the odds of conception and live birth are excellent, additional IVF cycles are not medically necessary. The patient should proceed with the transfer of her embryo. If she does not conceive, then she will undergo a second IVF cycle. Note that if transfer of this embryo fails, this will only lead to a delay of 2-3 months and such a delay should not significantly affect this patient's ovarian reserve.
This patient should proceed with an embryo transfer rather than more IVF cycles: This is consistent with the standard of care.

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

In vitro fertilization (IVF) - follicle puncture for oocyte retrieval is not considered medically necessary for this patient.

The insurer's denial of coverage for in vitro fertilization (IVF) - follicle puncture for oocyte retrieval is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Carpal tunnel.
Treatment: transcutaneous electrical nerve stimulation (TENS) unit. 

The insurer denied transcutaneous electrical nerve stimulation (TENS) unit.  The health plan's determination is upheld. 

This case describes a female patient who underwent elective left cubital and carpal tunnel surgery for persistent numbness and tingling in the left hand. The treating physician placed a transcutaneous electrical nerve stimulation (TENS) unit on the left upper extremity to assist with pain control after the operation. The patient's health plan denied coverage of the post-op TENS unit with a determination that it was not medically necessary. 

The requested Transcutaneous Electrical Nerve Stimulator (TENS) Unit is not medically necessary for this patient. The provider recommended the use of a post-operative TENS unit for this patient after elective carpal and cubital tunnel release surgery. The provided records contain no rationale for the use of this device. In addition, the current, peer-reviewed literature, including an article published by Huisstede and colleagues and by Koca and associates has not shown that TENS unit use is effective for the treatment of this patient's condition. Therefore, it is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hand cellulitis

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.  The denial is overturned.

Patient is a male with no significant past medical history, who presented to the emergency room with complaints of left-hand pain and swelling. 

Vitals on presentation included: Temperature 98.3 Fahrenheit, blood pressure 152/105, pulse 112, respiration rate 16, Oxygen saturation 98% on room air. Laboratory results included the following: white blood cell (WBC) count 14.1, hemoglobin 14.1, hematocrit 42.7, creatinine 0.67, glucose 100. 

The patient was started empirically on intravenous (IV) antibiotics (Ancef) for hand cellulitis. X-ray of the hand showed an old, healed phalanx fracture. Infectious Diseases consulted and switched antibiotics to vancomycin and meropenem. The patient remained afebrile, hemodynamically stable, and clinically improved and was discharged to continue oral antibiotics (linezolid and ciprofloxacin) as an outpatient. 

According to documentation, the patient was admitted with a left-hand infection. He was afebrile, not hypertensive with tachycardia. Laboratory findings were notable for an elevated WBC. Antibiotics were broadened to IV vancomycin and meropenem. Based on these findings the patient did meet criteria for acute care hospitalization.

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

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

Diagnosis: Substance Abuse
Treatment: Residential Substance Use Treatment
The insurer denied: Residential Substance Use Treatment
The denial is upheld.

The patient is an adolescent male. He was admitted to substance abuse residential treatment level of care. The patient's primary diagnosis was major depressive disorder, recurrent, severe without psychotic features, cannabis use disorder, severe, unspecified anxiety disorder, ADHD (attention deficit hyperactivity disorder) combined type, and parent child relational problems. The patient said he started feeling overwhelmed, and told his therapist. The therapist recommended residential treatment. The patient said that he was depressed, and then the COVID pandemic occurred. He turned to online gambling, made money and started smoking weed. He has no history of psychiatric hospitalizations. He has a history of passive suicidal ideation and cutting with the last cutting episode having been two weeks prior. He says he has had wishes of wanting to be dead, but he never went to the plan stage. He identified problems with anxiety, cannabis abuse, and unresolved issues with his sister. He also wants to work on issues with his parents. Prior to admission, he drank vodka and Red Bull until he blacked out.

The Residential Substance Use Treatment was not medically necessary.
At the time of admission, the patient did not present with symptoms that require substance abuse residential treatment level of care. The patient did not present with active withdrawal symptoms or life-threatening withdrawal symptoms. The patient did not present with significant post-acute withdrawal symptoms. The patient did not have active suicidal or homicidal ideation with intent or plan. He did not have worsening aggression or self-injurious behavior. While the patient did present with symptoms of depression and anxiety, the patient did not require 24/7 treatment in a residential setting. The patient could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right leg cellulitis

Treatment is an inpatient admission 

The insurer denied coverage for an inpatient admission 
 
The denial is overturned.

This is a patient with a past medical history significant for diabetes mellitus and a right great toe amputation who presented to the emergency room with complaints of fever, chills, and right lower extremity swelling.

Vitals on presentation included: Temperature 103.1 F (farenheit), Blood Pressure 117/68, Pulse 119, Respiratory Rate 18, oxygen (O2) saturation 94% (percent) on Room Air. Laboratory results included the following: white blood cell count (WBC) 13.2, HGB (hemoglobin) -11.9, HCT (hematocrit)-36.8, creatinine-1.0, glucose-212. 

The patient was started empirically on intravenous antibiotics (vancomycin and Zosyn) for right leg cellulitis. A doppler of the lower extremities was negative for deep vein thrombosis (DVT). The patient was started on intravenous fluids. Blood cultures were drawn. A Computed tomography (CT) angiogram was negative for pulmonary embolism. The patient remained afebrile, hemodynamically stable, and clinically improved. The patient was discharged to continue antibiotics as an outpatient.

According to documentation, the patient was admitted for a worsening right leg infection. Based on findings in a high-risk patient with co-morbid conditions, hospital admission was medically necessary. 

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 the hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn' s Disease.
Treatment: Humira Pen Injection 40MG (milligrams) - Quantity 4 Every 28 Days.
The insurer denied: Humira Pen Injection 40MG (milligrams) -  Quantity 4 Every 28 Days.
The denial is overturned.

The patient is an adult male with severe Crohn's, status post resection two times (x2). The patient had ongoing active disease on Humira 40 milligrams (MG) every other week and has been doing well on Humira 40 milligrams weekly, with minimal symptoms and no active disease on the most recent colonoscopy.  The attending physician (AP) is requesting to continue Humira 40 milligrams weekly.

The proposed treatment with Humira 40 milligrams (quantity four every 28 days) is medically necessary.
Medical literature supports dose intensification of Humira in patients who do not respond to Food and Drug Administration (FDA) approved dosing. Twenty to twenty-five percent (20-25%) of patients with Crohn's disease treated with Humira require dose intensification. Humira is safe and effective at doses as high as 80 milligrams weekly.

This patient had a loss of response with Humira 40 milligrams every other week and is doing well on Humira 40 milligrams weekly. Therefore, as the requested dose and frequency of Humira are supported by current peer-reviewed medical literature, and clinical practice guidelines, and are standard of care, the requested Humira 40 milligrams weekly is clinically appropriate, the accepted standard of care, and medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient Admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female who presented to the emergency department (ED) with complaint of abdominal pain. Her past medical history is notable for Crohn's disease, and she is status post umbilical hernia repair. At the time of presentation, the patient was without fever and vital signs were normal. There was tenderness and fluctuance around the umbilicus. There was no erythema and no drainage. The surgical incision was well healed.

Imaging with computed tomography (CT) scan showed a rim enhancing abdominal wall collection with surrounding inflammatory changes. The differential diagnosis was cellulitis, possible abscess and lymphangitis. The white blood cell (WBC) count was normal at 9.4 thousand (K). Surgical consultation was obtained. She was treated with intravenous (IV) antibiotics and aspiration of serous fluid from the abdominal wall fluid collection. This was performed at the bedside in the ED. She was considered to be stable for discharge from the ED following this intervention.

The health plan's determination is upheld in whole. 

The records do not support the medical necessity for the inpatient admission for this patient. The patient was clinically stable at the time of presentation and remained stable throughout the period of monitoring.
The patient presented to the hospital ED with abdominal pain. The submitted records support that the patient was clinically stable at the time of presentation. She had normal vital signs, and the WBC count was normal. While the CT scan suggested a rim enhancing fluid collection in the setting of prior umbilical hernia repair, aspiration of this fluid collection revealed only serous fluid. Consequently, the patient was discharged from the ED.
The care and treatment provided could have reasonably been rendered with a lower level of care and did not require inpatient hospital admission. This lower level of care would have provided for ED evaluation, provision of antibiotics and surgical assessment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Syncope
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is overturned

The patient is an adult female with past medical history of type II diabetes and hypertension. She was admitted due to an episode of loss of consciousness that lasted 30 minutes. She also endorsed chest pain.
The patient had an abnormal EKG (electrocardiogram), and given her CAD (coronary artery disease) risk factors, she was admitted to rule out cardiac etiology.
The hospital admission was denied coverage by the health plan, as it did not meet the plan's definition of medical necessity. The denial is being appealed.

The inpatient admission was medically necessary, given the need for continuous telemetry which is one of the indications for inpatient hospitalization according to MCG (Milliman Care Guidelines) guidelines 25th edition for syncope. There are many causes of syncope both neurological and cardiac that could potentially be dangerous and would not be ideally managed in the outpatient setting due to potential morbidity and mortality should another event occur.

Therefore, given the above, the inpatient admission was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebral vascular accident
Treatment: Home Care/Personal Care (HHC) - Level 2 Personal Care Services (PCS), per 15 Minutes: 84 Hours/Week 
The insurer denied HHC - Level 2 PCS, per 15 minutes: 84 hours/week.
The health plan's determination is overturned. 

The patient is a male with past medical history of atrial fibrillation, macular degeneration, dementia, urinary incontinence, osteoarthritis, hypothyroidism, gastroesophageal reflux disease (GERD), hypertension, cerebrovascular accident (CVA), hearing loss, and aortic stenosis who had been assigned PCA (personal care assistant) services.

Home Care/Personal Care (HHC) - Level 2 Personal Care Services (PCS), per 15 minutes: 84 hours/week are medically necessary for this patient.

There is documentation of worsening cognitive and physical functioning following recent hospitalization. The assessment documented a decline in activities of daily living (ADLs) status and deterioration in overall self-sufficiency over the last 90 days at the recent assessment. The patient's PCP (primary care provider) documented medical necessity of increased PCA services. The patient required at least limited assistance with walking, locomotion, transfer toilet, and toilet use and therefore had unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and instrumental activities of daily living (IADLs). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 84 hours/week are medically necessary for this patient. PCS are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in his own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma

Treatment is an inpatient admission 	

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

This is a patient with a history of (H/O) Asthma who presented to the emergency department (ED) with complaint of (C/O) shortness of breath (SOB) and wheezing. The patient had been seen at another facility the previous day where she was given 1 dose of IV (intravenous) steroids and was supposed to be discharged (dced) on oral (PO) Prednisone but as computers were down, she could not get the prescriptions. The patient was using her bronchodilators at home but as her symptoms did not get better, she came to ED.

Vital signs (V/S) at presentation Temperature 97.7F (Fahrenheit), Heart Rate 120, Respiratory Rate 20, Blood Pressure 130/94 mm Hg (millimeters of mercury) oxygen (O2) saturations 98 % on Room Air (RA). The patient was noted to have bilateral (B/L) wheezing on the lung exam. The patient was awake alert with a non-focal neuro exam.

Patient was treated with intravenous (IV) Fluids, BD (bronchodilator) - Combivent via Nebs, IV Magnesium and IV Steroids.

Initial Labs white blood cell count (WBC) 9.5K (thousand) Electrolytes within normal limits (WNL), BUN (blood urea nitrogen) / Creatinine (within normal limits), Lactate was elevated at 8.9.

A chest x-ray revealed (CXR) no acute infiltrates or effusions.

The patient reported some improvement after treatment in the ED with O2 sats 97 % on RA. The patient was having unlabored breathing and was able to speak full sentences. The patient was admitted to hospital for treatment of Asthma exacerbation.

The patient remained stable after admission. She was continued on IVF (intravenous fluids), Steroids and BD.

The patient refused further IV medications. WBC was 17 (likely from Steroids)
Lactate had normalized to 1.6. The patient was dced home on PO meds

This patient did not need acute inpatient hospitalization. She could have been placed in observation status while diagnostic testing and treatment were initiated. Observation could be for up to 48 hrs. The patient had started improving after initial treatment in the ED and remained afebrile and was HD (hemodynamically) stable after admission. She was ambulatory, tolerating PO, not hypoxic. No evidence of Pneumonia or CXR abnormality. By the next day, she was stable enough to be dced home on PO Meds. This patient could have been placed in observation status and dced home the next day once she remained stable and had improved.

The insurer's denial is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Fractured teeth
Treatment: Root canal (on front tooth) and white glass with high gold content crown, tooth #7 and #10)
The insurer denied the Root canal (on front tooth) and white glass with high gold content crown, tooth #7 and #10)
The denial is overturned, in part.

The patient is a male requesting a root canal procedure and crowns on teeth #7 and #10. The denial was due to lack of evidence for need according to plan documents.

Yes, in part; the proposed crowns on teeth #7 and #10 are medically necessary.  However, no in part; the root canal procedure is not medically necessary.

Although the photos presented are of poor quality, they do show the teeth in question have fractured. Their incisal edge portions to the extent that the dentin (tooth layer below the enamel) is most probably exposed. High quality photos from the providers office would help to show this. When these teeth are fractured into the dentin, then the sensitivity and pain the patient is experiencing makes sense. The need for crowns to restore the lost tooth structure is medically necessary.

However, before root canal procedures are needed, temporary crowns should be placed on these teeth to see if the symptoms subside. These teeth may not need the root canal procedures done to them.  If placing the temporary crown covers up the exposed dentinal tubules (i.e. the "pores" of the teeth) and the symptoms go away, then the root canal procedures are not needed.  If, however, the teeth remain sensitive after the temporary crowns are in place, then the root canal procedures are needed. The photos and x-rays presented do not show cracks in the teeth or any infections, so the symptoms the patient feels could be from the missing tooth structure on the tooth edges. Condemning the teeth for root canals before testing is incorrect treatment. The root canals are not medically necessary at this time.

Yes, in part; the health plan acted reasonably, with sound medical judgment and in the best interest of the patient for the root canals, however, not for the crowns.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Hypertension.
Treatment: Carvedilol ER (extended release), pre-service.
The insurer denied the Carvedilol ER (extended release), pre-service.
The denial is upheld.

The patient is a male for which carvedilol extended release (ER) is under review. There was treatment failure to Micardis and amlodipine.

No, the health plan should not cover the proposed formulary exception for Carvedilol.
There are multiple beta blockers for the treatment of hypertension. However, no single beta blocker has been established as standard of care towards more effective treatment of hypertension or towards overall improved hypertension related outcomes. The following formulary drugs would be as effective: atenolol, bisoprolol, carvedilol, labetalol, metoprolol succinate extended-release, metoprolol tartrate, nadolol, nebivolol, pindolol, propranolol, and propranolol extended-release. The formulary drugs would be as effective as the requested non-formulary drug. The adverse effects would be no greater than the non-formulary drug. As such carvedilol extended release (ER) is considered not medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: dementia.
Treatment: Home health care.
The insurer denied Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes Increase to 24 Hours per Day (Split Shift). 
The health plan's determination is overturned. 

The patient is a female with past medical history of Alzheimer's dementia, hypothyroidism, bladder incontinence, bowel incontinence, hypertension, hyperlipidemia, and vision loss of the left eye who had been seen following a syncopal spell. 

Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes Increase to 24 Hours per Day (Split Shift) medically necessary for this patient.
There is documentation from the patient's family, primary care physician (or provider) (PCP), and neurologist of worsening cognitive and physical functioning. There is documentation from the patient's neurologist and PCP of medical necessity for increased PCA hours. Due to the patient's medical diagnosis of severe dementia, the patient does not have a normal sleep schedule and is up in the overnight hours requiring assistance with walking, locomotion, transfer toilet, toilet use, and eating. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The patient's neurologist had adjusted the patient's medication without improvement in sundowning and sleep/wake cycle disruptions. The requested increase in services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) and Instrumental activities of daily living (IADL). Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes Increase to 24 Hours per Day (Split Shift) medically necessary. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.