Persius/hicric huggingface dataset:
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Asthma
Treatment: Advair HFA
The insurer denied Advair HFA. 
The health plan's determination is upheld. 

This is the case of a male patient who suffers from asthma. The treating provider is requesting the coverage of Advair HFA. The patient has obstructive lung disease on PFT (pulmonary function tests). The patient had positive RAST (Radioallergosorbent) test. The patient has elevated FeNO (exhaled nitric oxide).

A formulary exception is not indicated in this case. There is no evidence that the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.
This patient suffers from asthma. There is no convincing or objective evidence in the submitted documents that the patient has contraindication to or a potential drug interaction with the preferred formulary medications (i.e. wixela, Trelegy, Breo, fluticasone propionate /salmeterol, budesonide/formoterol). There is no evidence that the patient is intolerant to or has had a confirmed adverse event with preferred formulary medications. There is no evidence that the patient has demonstrated an inadequate treatment response after a trial of preferred formulary.
There are no adequate or well-conducted randomized controlled or cohort trials in the prevailing peer-reviewed published medical literature that established the long term efficacy and safety of Advair HFA over preferred formulary medications for the treatment of this patient's asthma.
There is no high-quality literature showing an improvement in health outcomes with the use of Advair HFA over the preferred formulary medications.
There are no national guidelines that support the routine use of Advair HFA over the plan's preferred medications for the treatment of Asthma as in this patient case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity.
Treatment: Saxenda.
The insurer denied the request for Saxenda.
The health plan's determination is upheld.

The patient is a female with a history of obesity. She is requesting continued coverage for Saxenda to treat her obesity. The medical records were not provided.

The health plan, in its determination of medical necessity, has acted reasonably, with sound medical judgment, and in the best interest of the patient.

The requested health service/treatment of Saxenda (liraglutide) is not medically necessary for this patient. Plan language states that the approval criteria for continued coverage of Saxenda is after the initial 16 weeks of treatment if the patient lost at least 4 percent of the baseline weight or has continued to maintain an initial 4 percent weight loss. Approval for coverage requires that the patient's provider submit her baseline weight and the date it was measured, as well as the weight and the date measured after the initial 16 weeks. In this case no weight data has been included in the information provided. Therefore, based on the plan language, as well as the peer reviewed literature cited in the references, the Saxenda cannot not be considered medically necessary. There are no studies in the medical literature to support the safety and effectiveness of continued use of Saxenda if it has not been shown to reduce the baseline weight by at least 4 percent.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Displaced lateral condyle fracture
Treatment: Inpatient admission
The insurer denied coverage for an inpatient admission 
The denial is overturned

This is a child with no significant past medical history. The patient presented to the emergency room (ER) from an outside facility with complaints of a right arm supracondylar fracture after falling. The patient was admitted to the Pediatric Orthopedic unit with a supracondylar fracture. The patient was initially kept on nothing by mouth (NPO). Intravenous (IV) fluids were given. The patient underwent an open reduction internal fixation (ORIF) of the right elbow lateral condyle fracture under general anesthesia. The patient was discharged after a period of hemodynamic stability. 

A review of documentation shows the young child sustained a displaced lateral condyle fracture. He did not sustain a supracondylar fracture. He underwent open reduction internal fixation (ORIF) to the lateral condyle fracture. He received approximately 3 hours of general anesthesia. His post-surgical course was non complicated with a discharge home. 

The records show treatment was required for the displaced lateral condyle fracture. This required operative intervention. The services were complex. Although no operative report was submitted, the procedure requires a direct reduction with placement of screws or pins. Post operative monitoring would be required. Medications for pain and nausea were given. This service required acute intervention and could not be obtained in an ER. 

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 inpatient hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholecystitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld.

Acute cholecystitis and biliary complaints are common inpatient diagnoses. Acute cholecystitis is also estimated to attribute to millions of ambulatory visits each year and is a leading cause of hospital admissions [1]. Studies have shown that ambulatory laparoscopic cholecystectomy is safe and avoids an overnight hospital stay [2, 4, 5]. Factors that contribute to admission after laparoscopic cholecystectomy include drain placement, conversion to open surgery, persistent abdominal pain, nausea, and vomiting [3]. In patients without abnormalities of the bile duct or abnormal liver function tests (elevated alkaline phosphatase (ALP) and total bilirubin), ambulatory laparoscopic cholecystectomy is safe and feasible [5, 8]. A 50% (percent) increase in the liver function tests can be labelled as mild elevation and is considered negligible by many [9]. Ambulatory and/or outpatient laparoscopic cholecystectomies reduce hospital costs without compromising patient outcomes [6]. 

Per clinical documentation, this patient presented to the emergency department with right upper quadrant abdominal pain. There was associated nausea and vomiting. Vital signs in the emergency department (ED) were within normal limits with the exception of a mildly elevated blood pressure of 148/83. The patient was afebrile. Abdominal ultrasound demonstrated findings most consistent with acute cholecystitis. Initial liver function tests were within normal limits. The morning prior to surgery, liver function tests increased to an ALP of 212, total bilirubin of 2.1, Alanine transaminase (ALT) of 461, and Aspartate aminotransferase (AST) of 466. The patient underwent a laparoscopic cholecystectomy with intraoperative cholangiogram. There were no reported complications. There is no further clinical documentation of a need for inpatient admission. Per Milliman Care Guidelines (MCG) criteria, admission is indicated when common bile duct obstruction is indicated via imaging and there are signs of systemic inflammation [7]. Peer-reviewed literature and MCG criteria indicate that inpatient admission is not necessary in this circumstance. Per provided clinical documentation, inpatient admission was not medically necessary.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld

The patient is an adult female. She was hospitalized from for chest pain. She presented to the hospital ED (emergency department) for evaluation of constant chest pain reminiscent of her prior chest pain when she underwent PCI (percutaneous coronary intervention) with stent to LAD (left anterior descending) several months ago. Her past medical history is pertinent for mild HTN (hypertension), HLP (hyperlipidemia), GERD (gastroesophageal reflux disease) and hypothyroidism.
The patient's vital signs were stable: BP (blood pressure) 119/56, HR (heart rate) 59, RR (respiration rate) 18, oxygen saturation 95 percent (%) on RA (room air). EKGs (electrocardiograms) showed SR (sinus rhythm) and were normal. There were no arrhythmias reported. Troponin panel was negative. The clinical impression was GERD (gastroesophageal reflux disease)/gastritis. Treatment included PPI (proton pump inhibitor) and Carafate. The patient was discharged to home.
This is an appeal of the health plan's denial of coverage of the claim for requested acute inpatient hospital stay. The health plan denied coverage on the basis of medical necessity.

The inpatient admission was not medically necessary.

Based on the current peer reviewed medical literature, there was not a medical need for the acute inpatient hospital stay. The severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. Per the MCG (Milliman Care Guidelines) guidelines for Chest Pain, #M-89, criteria for inpatient admission are not met, including hemodynamic instability, respiratory distress, pulmonary edema, angina with acute coronary syndrome, chest pain that is indicative of a serious cardiac condition like pulmonary embolism or aortic dissection, acute myocardial infarction, pneumonia, hypertension requiring inpatient hospitalization or any other medical condition, 
symptom or finding for which inpatient admission is considered appropriate. In this particular case, there was no clinical decline or inadequate response to treatment which required inpatient hospitalization. The care that the patient received, including management of chest pain felt to be from gastritis/GERD (gastroesophageal reflux disease) like in this case, is routinely provided safely and effectively at a lower level of care. Therefore, based on the submitted information and the current published medical literature, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypercalcemia
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld

This adult female was admitted for hypercalcemia work up and pain. She presented with nausea, vomiting, and abdominal pain. Vital signs were stable and afebrile. The patient's heart rate was 146. The patient's exam was remarkable for periumbilical, right lower quadrant, and left lower quadrant the tenderness. The patient was treated with hydration in the emergency room. The repeat heart rate was 111. The patient's pertinent labs were calcium at 12.2, sodium at 133, potassium at 3.8, and blood urea nitrogen (BUN) / creatinine (Cr) at 23/1.3. The electrocardiogram (EKG) showed sinus tachycardia, QTc (corrected for heart rate) at 545. Abdominal/pelvic computed tomography (CT) showed episodic appendicitis. 
The patient was admitted. Plan of care included work up of hypercalcemia. On Day #2, the patient's vital signs were stable. The heart rate was 108. The patient was continued on intravenous (IV) fluids. The patient was on ceftriaxone for positive urinalysis. Hypercalcemia resolved. Acute kidney injury improved. The patient was continued on metoprolol. On Day #3, the patient's vital signs were stable. The patient continued with 
right lower quadrant pain. She was tolerating diet. The patient was discharged the next day.

The proposed treatment is not medically necessary.

The patient was admitted after presenting with gastrointestinal symptoms and findings of hypercalcemia and acute kidney injury. The plan denied admission due to failure to meet guidelines for abdominal pain and electrolyte disorder. At time of admission the patient was hemodynamically stable and had mild tachycardia. She was afebrile. Abdominal exams showed tenderness, but no peritoneal signs. Labs were remarkable for hypercalcemia and acute kidney injury. There were no acute findings on imaging. The patient did not have uncontrollable pain or inability to tolerate oral intake (PO). The intervention of intravenous hydration and additional diagnostic studies did not require an 
inpatient level of care. The patient's hypercalcemia and acute kidney injury resolved on day #2. The patient remained clinically stable through discharge. She had not failed a lesser level of care. The patient did not receive intervention that required an acute inpatient level of care.  Inpatient hospital admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ventral hernia

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
According to the patient's medical record, this is an adult male who presented to the emergency department (ED) with the complaint of umbilical hernia. The patient has had the hernia for years and it occasionally caused him pain but today it was much worst. He was afebrile with stable vital signs. As per the ED provider note the patient was diagnosed with an abdominal hernia last year at North Shore University Hospital (NSUH) with one day of worsening supraumbilical pain without nausea or vomiting or fever.  Exam revealed tender to palpation supraumbilical pain without skin changes. Labs included White blood cells (WBC) 4.02. The assessment was incarcerated ventral hernia. The provider noted computed tomography (CT) from last year showed a moderate size fat and omentum containing supraumbilical hernia with minimal inflammatory change immediately subjacent to the hernia, with a question of mild omental infarct. Additionally, just superior right lateral to the supra umbilical hernia, there was minimal skin thickening with a superficial fat density focus, with questionable fat necrosis. There was also a small fat containing umbilical hernia.

Today's CT revealed moderate ventral wall defect), midline, and fat/omentum containing supraumbilical ventral wall hernia. Mild subjacent inflammatory change and vascular engorgement was minimally progressed raising the possibility of incarceration. 

The patient was placed on the scheduled for the OR tomorrow afternoon indicating a lack of urgency to resolve this problem.

Post op note indicated the patient was doing well without severe abdominal discomfort, tolerating diet. The patient was noted to be passing flatus. The plan was to discharge to home today.

Based upon the records provided, the patient did not require inpatient hospital admission but rather 23-hour observation following an uneventful ventral hernia repair was appropriate. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Central nervous system
Inpatient hospital

Diagnosis: syncope
Treatment: inpatient stay
The insurer denied an inpatient stay. The health plan's determination is overturned. 

This patient is a female with a past medical history of intracranial hemorrhage, dementia, diabetes mellitus, hyperlipidemia, and hypertension who presented to the hospital due to a syncopal episode. The patient lives with her daughter, who observed that the patient felt generally weak and had experienced two episodes of non-bloody diarrhea earlier in the day. The syncopal episode occurred while the patient was sitting and eating breakfast. She lost consciousness and hit her head on the table, and had approximately 2 minutes of unresponsiveness. According to the daughter, the patient had "twitching" in her right upper extremity and the right side of her face. The patient regained consciousness, and by the time emergency medical services arrived, she had returned to her baseline. A similar episode had occurred a few weeks before the presentation, and the patient was transferred to another medical center at that time due to her history of intracranial hemorrhage.

The inpatient hospital admission was medically necessary for this patient. The patient presented with new-onset seizures directly related to acute and subacute intracranial hemorrhage, as confirmed by the magnetic resonance imaging (MRI) of the brain. This diagnosis served as a clear indication for inpatient admission according to nationally accepted standards of care. The patient required immediate treatment with antiseizure medications, intravenous Decadron, and close observation. Given the necessity for timely intervention and close monitoring, the admission at the acute inpatient level of care was justified.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma. 
Treatment: Full hospital admission. 
The insurer denied coverage for the Full hospital admission. 
The denial is upheld. 
 
Patient is an adult female with a history of asthma, diabetes and hypertension who presented to the emergency department (ED) with complaints of shortness of breath (SOB), chest tightness and wheezing. 

At presentation to the ED the patient's vital signs were: Temperature 99.5 degrees F (Fahrenheit), Respirations 20, Pulse 120, Blood Pressure 136/84. Oxygen saturation was 95% on room air. The patient was treated with intravenous (IV) steroids, Duo Nebs, and magnesium. The patient was described to be in no acute distress. Lung exam revealed some decreased breath sounds and mild bilateral wheezes. The patient was speaking in full sentences. No use of accessory muscles was described. She was alert and oriented to person, place and time. 

Peak expiratory flow was 120; baseline about 200. She was continued on steroids, Montelukast, magnesium and bronchodilators. Tamiflu was started for Influenza. Labs: White blood cells (WBC) 7.2, Influenza A positive, troponins negative and venous blood gases 7.42/40/51. Chest x-ray had no acute infiltrates and electrocardiogram showed no acute changes. 

This patient remained stable after admission, was continued on same treatment and discharged home after a few days. 

This patient did not need acute inpatient hospitalization. She could have been placed in observation status while diagnostic testing and treatment were initiated. She was afebrile and hemodynamically stable. Was speaking full sentences. Not hypoxic or hypercarbic. This patient could have been treated with steroids, bronchodilators (BD), Tamiflu and once stabilized by day 2 could have been discharged home on oral (PO) steroids and other BD and Tamiflu. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease, heart failure and kidney disease 
Treatment: split shift 24-hour personal care services (two 12-hour shifts), for a total of 168 hours per week 
The insurer denied coverage for split shift 24-hour personal care services (two 12-hour shifts), for a total of 168 hours per week 
The denial is overturned 
 
This is an elderly patient with multiple medical problems including Alzheimer's disease, heart failure and kidney disease. The patient lives alone in a 1-bedroom apartment. The insurer deceased her personal care services (PCS) from split shift 24-hour personal care services (two 12-hour shifts), for a total of 168 hours per week to 8 hours/7 days/week for a total of 56 hours/week.  The request is for re-instatement of split shift 24-hour personal care services (two 12-hour shifts), for a total of 168 hours per week. 

According to the Uniform Assessment System (UAS) report, the patient's cognition is described as moderately impaired. She is totally dependent for performing Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.  The patient is totally dependent for locomotion and non-ambulatory.  Maximal assistance is needed for bathing, lower body dressing, toilet transfer/use. She requires extensive assistance for personal hygiene and, upper body dressing.  Limited assistance is needed for bed mobility and eating. The patient is frequently incontinent of urine and occasionally incontinent of bowel. 

The patient's clinical condition and functional deficits are at a level and unpredictable as to require the continuation of  PCS 7 days per week, 24 hours per day split shift. This physician was also persuaded by the letters from her treating physicians documenting the patient's clinical condition, multiple impairments and limited effectiveness of the insurer's remedial  recommendations. She requires routine repositioning in bed at least every 2-3 hours. Based on the clinical records, a live-in personal care aide (PCA) is unlikely capable of obtaining approximately 5 hours of uninterrupted sleep over the course of a 24-hour shift and any reduction in the patient's current PCS would place her at increased risk for injury. Attention to the patient's functional needs is more appropriately provided and maintained by continuing PCS 12 hours per day- 7 days per week (split shift) for a total of 168 hours per week.

Based on the above, the insurer's denial must be reversed. 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 split shift 24-hour personal care services (two 12-hour shifts), for a total of 168 hours per week is substantiated.