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

Diagnosis: Fall.
Treatment: Full hospital admission. 

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

This case involves a male who was brought to the emergency department (ED) after he had fallen down 6 steps. The documentation indicated he cried for approximately 5 minutes and was lethargic for 25 minutes. The submitted documentation indicated the father was walking downstairs when he tripped and fell. The father reported that he noted the child seemed more lethargic than normal. The physical exam revealed he was well-appearing in no distress. He was interacting appropriately. There was ecchymosis superior to the orbits bilaterally. The patient did undergo multiple diagnostic studies which were all unremarkable. There was no evidence of fracture or hemorrhage noted. A computed tomography (CT) scan of the spine also did not reveal any findings. The documentation indicated upon reevaluation it was recommended he be admitted for further observation. He was admitted and discharged the following day due to no further adverse events noted. He was recommended to continue monitoring and follow-up. 

According to referenced literature, a pediatric patient may be admitted when there is concern for a traumatic brain injury, if there is evidence of altered mental status. This does include lethargy per criteria. The documentation indicated this patient was brought into the ED after suffering a fall. The documentation indicated upon physical examination it is noted the infant was lethargic in addition to having findings of ecchymosis around the bilateral orbits. The short admission note was appropriate given the need for continuous monitoring in the event of rapid intervention needed. 

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

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Home Health Care. 

The insurer denied an Increase in Personal Care Services(PCS): 12 hours a day, 7 days a week for at a total of 84 hours. The denial is overturned. 

The patient is a female with a past medical history of hypertension, diabetes, abnormal gait, dorsalgia, and frequent falls. The patient had been assigned personal care assistant (PCA) services based on assessment tool assessing the patient as minimally impaired with no memory problems. She has minimal hearing and vision difficulties. She requires total dependence with task of ordinary housework and maximal assistance with meal preparation. The patient was assessed at extensive assistance with task of bathing, limited assistance with personal hygiene, extensive assistance with dressing upper body, maximal assistance dressing lower body, extensive assistance with walking and locomotion, transfer to the toilet, maximal assistance with toilet use and limited assistance with bed mobility and independent with eating. She was noted with no change in activities of daily living (ADL) status in the last 90 days, with no change in self-sufficiency. She is frequently bladder incontinent and occasionally bowel incontinent. A total of 46 hours was assessed. 

A letter from the patient's daughter reported that her mother's health has worsened and has tremendous difficulties caring for herself. She noted that she is very weak and unable to move about or get out of bed without assistance. She also has limited mobility, incontinence and utilizes a diaper. She also reports she is in pain from her wounds and has developed bed sores. 

The patient was evaluated by primary care. It was noted that she required a cane and rollator for ambulation. Physical therapy was recommended and an increase home care services. 
At issue is the medical necessity of Increase in Personal Care Services(PCS): 12 hours a day, 7 days a week for at a total of 84 hours. 

The health plan's determination is overturned in whole. 

The requested health service/treatment of Increase in Personal Care Services(PCS): 12 hours a day, 7 days a week for at a total of 84 hours is medically necessary for this patient. 

The assessment tool performed indicated the patient requires assistance needs with several tasks, including, bathing, dressing upper/lower body, locomotion, transfer to the toilet, and toilet use. She was also assessed at maximal assistance for toileting, and frequently is bladder incontinent, which increases the risk of decubitus ulcers if not appropriately managed. The requested increase in services is to assist the patient with safe completion of ADLs and Instrumental activities of daily living (IADL)s. Taking into account the clinical standards, and all information provided regarding the patient, Personal Care Services(PCS): 12 hours a day, 7 days a week for at a total of 84 hours are medically necessary for this patient. 

Therefore, the Increase in Personal Care Services (PCS): 12 hours a day, 7 days a week for at a total of 84 hours is medically necessary.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Cardiac/Circulatory. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Eliquis. 
The denial is overturned.

The patient is a with a history of atrial fibrillation and atrial flutter for the last 2 years status post recent transesophageal echocardiogram (TEE)/electrical cardioversion, ablation, hypertension, hyperlipidemia, diabetes mellitus type 2. For the last 2 years, the patient has been treated with apixaban (Eliquis) to prevent stroke and systemic embolism and done well on this therapy. The patient's health plan has denied prescription benefit exception request for apixaban on the grounds that the patient does not meet established criteria documenting treatment failure, intolerance, or anticipated adverse reaction to the formulary anticoagulants, warfarin and Xarelto. The patient's provider is appealing this denial.

The health plan's denial is overturned.

Review of documentation provided for this case show that the patient has been doing well on treatment with apixaban to prevent stroke and systemic embolization. Furthermore, the patient's records indicate a recent episode of atrial fibrillation requiring hospitalization and TEE/cardioversion to restore normal sinus rhythm. Post cardioversion, the patient remains at high risk of stroke and interruption of anticoagulation in order to change to an alternative formulary anticoagulant would not be safe and would be contraindicated. In addition, the 2014 American Heart Association (AHA)/American College of Cardiology (ACC)/Heart Rhythm Society (HRS) guideline for the management of patients with atrial fibrillation indicates that apixaban is superior to warfarin in reducing the risk of stroke along with a lower risk of life-threatening bleeding events (1). Furthermore, a recently published large cohort study comparing the safety and efficacy of Xarelto to apixaban in patients with atrial fibrillation demonstrated that patients treated with Xarelto experienced a greater risk of both ischemic and bleeding events (2). Therefore, in this case, continued treatment with apixaban would be the most effective and safest choice of anticoagulation to prevent stroke and systemic embolism for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System. 
Treatment: Inpatient Hospital. 
The insurer denied Inpatient Stay. 
The denial is upheld. 

The patient is a female with asthma (no prior admissions or intubation), who presented with 2 days of shortness of breath (SOB) and wheeze after exposure to a family member with a upper respiratory infection (URI). In the emergency department (ED), her temperature was 98.1, blood pressure (BP) was 131/83, heart rate (HR) was 108, respiratory rate (RR) was 18, peripheral capillary oxygen saturation (SpO2) was 98% on room air (RA). She was not in distress, was breathing comfortably, alert, and oriented. Bicarb was 22, blood urea nitrogen (BUN) /Creatinine was 5/0.68. The chest x-ray (CXR) was clear. She was diagnosed with an asthma exacerbation and started on prednisone and nebulized bronchodilators.
She was discharged on prednisone.
At issue is the medical necessity of Inpatient Stay.

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

The requested health service/treatment of Inpatient Stay is not medically necessary for this patient.
The patient presented with shortness of breath (SOB) and was diagnosed with an asthma exacerbation, no additional or alternative diagnoses. She was not severely ill at presentation (no encephalopathy, hemodynamic instability, respiratory distress or gas exchange abnormality, or acute kidney injury or electrolyte abnormality). She was not at high risk for worsening by routine clinical predictors. With no additional/alternative diagnoses, a low severity at presentation, and a low risk of worsening, she did not require inpatient only testing, monitoring, or treatment. Given this, an inpatient admission was not appropriate.
Therefore, the requested health service/treatment of Inpatient Stay is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: obsessive compulsive disorder (OCD).
treatment: Deep Brain Stimulation (DBS) and inpatient level of care.
The insurer denied Deep Brain Stimulation and inpatient level of care. 
The health plan's determination is upheld. 

The patient has refractory Obsessive Compulsive Disorder (OCD). He has had numerous medication trials, trial of routine Transcranial Magnetic Stimulation (TMS) and has engaged in outpatient psychotherapy. Deep Bran Stimulation (DBS) is requested as next method of treatment. The request was previously denied by the health plan as DBS is considered experimental/investigational.

Deep Brain Stimulation and inpatient level of care are not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. While DBS is noted to be Food and Drug Administration (FDA) approved for treatment of OCD, the literature on efficacy of this treatment is mixed. Additionally, only 50-60% of patients have a clinically meaningful response to DBS treatment.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: obsessive compulsive disorder (OCD).
treatment: Deep Brain Stimulation (DBS) and inpatient level of care.
The insurer denied Deep Brain Stimulation and inpatient level of care. 
The health plan's determination is overturned. 

The patient is a male with a history of severe, intractable, treatment resistant obsessive-compulsive disorder (OCD) since age 14. Case notes document that the patient has struggled with severe and intractable OCD since the early teens years. His symptoms have included progressive, intrusive, sexual, scrupulous, blasphemous thoughts, imagines of harm to people close to him which were increased while praying. These ego-alien assaultive thoughts from his OCD have been especially impairing to him. His symptoms in high school required him to have extra help to graduate. His intrusive thoughts occupy 3 to 5 hours per day. His sleep is impaired from anxious thoughts. His intrusive obsessional thoughts require neutralizing attempts to stop thinking about unacceptable areas of life. He avoids crowds and lives with his parents, implying functional impairment in his social life. He has been treated without any lasting benefit from all known treatment modalities.

DBS and inpatient level of care is likely to be more beneficial than any standard treatment for the insured's disabling condition. Every standard treatment has been tried and failed in this case. For this patient, DBS is the only option. There are not alternatives at this point. Sufficient evidence is available in the medical literature of published studies by accredited and qualified providers that demonstrate that 60% of patients undergoing DBS have had on the average a decrease of 40% in the YBOCS score (Yale Brown Obsessive Compulsive Scale), which is remarkable for treatment resistant patients who have shown no benefits from other modalities.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: obsessive compulsive disorder (OCD)
treatment: Deep Brain Stimulation and inpatient level of care
The insurer denied Deep Brain Stimulation and inpatient level of care. The health plan's determination is overturned. 

The case involves an adult male with a history of treatment refractory obsessive compulsive disorder (OCD). The patient has had multiple medication trials with selective serotonin reuptake inhibitor (SSRI), serotonin norepinephrine reuptake inhibitor (SNRI) , and a TCA (tricyclic antidepressant) and MAOI (Monoamine oxidase inhibitors). He has also received augmentation treatment with atypical antipsychotic medications and transcranial magnetic stimulation (TMS) with 45 sessions. The patient has received cognitive-behavioral therapy (CBT) and exposure response processing therapy (ERP) combined with his psychotropic medications and/or TMS without sustained benefit and continued severe symptoms of OCD persisting for over 16 years with YBOCS (Yale-Brown Obsessive Compulsive Scale) scores in the severe range as high as 29.
There is no report of other psychiatric conditions or general medical co-morbidity or co-occurring substance use disorder in this case.
The patient's clinician has recommended treatment with deep brain stimulation (DBS) including the procedure placing electrodes to be carried out in an inpatient setting.

The Deep Brain Stimulation and inpatient level of care, is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The patient is an adult male with a history of treatment refractory obsessive compulsive disorder (OCD). The patient has had multiple medication trials without sustained benefit. He has also received augmentation treatment with atypical antipsychotic medications and rTMS. The patient has received evidence-based psychotherapy CBT and ERP) combined with his psychotropic medications. None of these standard treatments have produced a sustained response or remission or sustained therapeutic benefit. Thus, the proposed Deep Brain Stimulation including the inpatient level of care is a reasonable treatment plan, and is in the patient's best interest, and reflects sound medical judgment with regard to the next step in management of the patient's treatment refractory OCD. DBS treatment in this case is supported by the scientific literature including randomized clinical trials and standards of medical practice, as asserted in the appeal with supporting documents. The proposed treatment is likely to produce a clinical response or remission in this case than other standard treatments.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anaphylaxis. 
Treatment: Inpatient Stay. 

The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a male who presented to the emergency department by ambulance with anaphylaxis. He was well until the day of admission when he ate a cookie and began to tremble and vomit. He also had throat irritation at that time. He had a known nut allergy and had had similar reactions in the past to nut exposure. 
His past history was significant for a nut allergy that presented at 10 months of age. He saw an allergist at that time, and had a few additional episodes with stomach pain and lethargy. He had an Epi pen prescribed. 

On examination in the emergency department, he was initially noted to be in slight distress with rhinorrhea. He subsequently vomited and was given Zofran. Upon reassessment, he was also noted to have lethargy, diffuse hives on his trunk, and wheezing. He was given albuterol and epinephrine at that time as well as intravenous fluids. Benadryl and solumedrol were also ordered. His rash improved and his wheezing resolved. He was admitted to the hospital for further care and monitoring for possible biphasic anaphylaxis. 

This is a young boy with a known nut allergy who presented with anaphylaxis after eating a cookie. He developed increased symptoms while under observation in the emergency department, including lethargy, hives, and wheezing, and required intensive treatments including epinephrine, diphenhydramine, and solumedrol. Due to the severity of his presentation and development of additional severe symptoms, he required hospital admission for continued treatments as well as close monitoring for a biphasic allergy reaction. 

The decision making at the time of admission for this patient was consistent with his young age, the presence of a severe anaphylactic reaction due to a probable nut exposure, and the need for ongoing intensive treatments including parenteral therapies, along with close monitoring for potential deterioration of clinical status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: s/p (status post) Angiogram; Catheterization
Treatment: Inpatient admission

The insurer denied the inpatient admission.
The denial is upheld.

Patient is a male. He underwent elective peripheral angiogram and diagnostic cardiac catheterization. He received stents to right common iliac artery and right external iliac artery. Post-procedural hematoma required 18 minutes manual compression. The patient was admitted inpatient for continued telemonitoring.

The health plan denied coverage of the inpatient admission on the basis that it was not medically necessary. The health plan posits that the patient could have been treated at an observation level of care. The treating facility appealed this decision, contending that the inpatient admission was medically necessary.

No, the Inpatient admission for continued telemonitoring following successful manual compression of post-procedural hematoma was not medically necessary.
Following successful manual compression of post-procedural hematoma, it is standard clinical practice to treat a patient such as this under observation care. There was no evidence of hemodynamic instability documented in this patient's case. Therefore, full inpatient admission was not medically necessary.

Yes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient.
The health plan did endorse continuation of care under observation instead of full admission. Therefore, health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal/Bone Fracture/Break
Treatment: Inpatient Hospital Stay
The health plan denied the requested inpatient hospital stay as not medically necessary. The health plan's determination is upheld.

This case describes a female patient who sustained an initial ankle fracture. She had an external fixator placed on the left ankle. She returned to the hospital for removal of the fixator and partial fixation of the ankle fracture. She was then admitted to the hospital for one week and returned to the operating room for a definitive open reduction and internal fixation of the ankle fracture and fixation of a syndesmotic ligament disruption. She was then deemed stable for discharge home.

At issue in this case is the medical necessity of the inpatient hospital admission.

I uphold, in whole, the health plan's determination of medical necessity in this case.

The requested health service/treatment of an inpatient hospital stay was not medically necessary for this patient. This determination is based upon the provided medical records which fail to document the medical necessity for an inpatient hospital stay following removal of an ankle external fixator. Definitive ankle fixation was completed, however, the patient could have been discharged after the external fixator removal and brought back for outpatient open reduction and internal fixation of the left ankle fracture. This process is supported by the current, peer-reviewed orthopedic literature as documented by Qin and colleagues in the Journal of Bone and Joint Surgery in 2016. The authors of this study concluded that "In patients with closed fractures and minimal comorbidities, outpatient open reduction internal fixation (ORIF) was associated with reduced risk of select 30-day medical morbidity and no difference in surgical morbidity, reoperations, and readmissions relative to inpatient." Therefore, the inpatient hospital admission was not medically necessary for the patient in question and the denial should be upheld. This determination is based upon the provided medical records and the recommendations of the current, peer-reviewed literature.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female with papillary thyroid carcinoma who underwent total thyroidectomy with nerve monitoring, central node dissection and auto implantation of parathyroid tissue. She was admitted as an inpatient. In recovery, she was found to have low parathyroid hormone (PTH) and was started on calcium supplements and Calcitrol. The following day, she was tolerating a diet and her calcium levels were adequate. She did not have any perioral numbness, paresthesias or odynophagia. She was discharged home.

The Inpatient Hospital Admission was not medically necessary for this patient.
The patient has papillary thyroid carcinoma. She underwent total thyroidectomy with nerve monitoring, central node dissection and auto implantation of parathyroid tissue without any intra operative complications. The patient could have been admitted under observation status to monitor her calcium levels. She did not have any perioral numbness, paresthesias or odynophagia. She responded appropriately to calcium supplements and calcitriol medications. If the patient had hypocalcemia or post operative complications beyond the 48 hours after her surgery, inpatient status would have been indicated. However, this was not the case. A lower level of care was appropriate.