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

Diagnosis: Syncope
Treatment: Inpatient Admission
The health plan denied the requested inpatient admission as not medically necessary. The health plan's determination is overturned, in part.

At the time of his admission, the patient was diagnosed with schizophrenia and catatonia, was brought to the emergency department the evening before with multiple episodes of unresponsiveness lasting up to fifteen minutes. He was on Abilify and a selective serotonin reuptake inhibitor (SSRI) with a slow tapering of Abilify by psychiatry, as he showed slow improvement. Vital signs at triage were normal and his exam was normal; although he was non-verbal, he followed commands and had an otherwise normal neurologic exam. This was baseline according to family. Laboratory was notable for an elevated creatine kinase (CK). Differential diagnosis was seizures, given the elevated CK, versus exacerbation of his underlying psychiatric illness, although it was noted that catatonia is not typically episodic. He was admitted to pediatrics, where his vital signs and physical exam were normal and mental status remained baseline. Neurology consulted and recommended admission for "24-hour observation for additional events" and a magnetic resonance imaging (MRI)/electroencephalogram (EEG). Given the severity (length) and multiplicity of the events, cardiology was consulted, and noted the electrocardiogram (EKG) was normal. A bedside echocardiogram was normal, and cardiology signed off. Neurology continued the EEG to capture an epileptiform event, should it occur, corresponding to symptoms. Subsequently, Psychiatry saw him for the first time, and cleared him for discharge home.
At issue is the medical necessity for the inpatient stay.

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

The first day's admission was medically necessary, given the multiple events and unusual length (for the patient) of the events.

Cardiology signed off on the day of admission after reviewing the EKG and performing an echocardiogram. Neurology saw the patient on the day of admission and stated that the patient should have a period of observation for further events and possibly an MRI and EEG. The patient did not have further events, but the neurology team decided to go ahead and do an MRI and multi-day EEG as part of the overall workup, a workup which could have been completed electively as an outpatient rather than as an acute inpatient. The length of stay was directly related to the length of the elective EEG. The first day was medically necessary to ensure neuropsychiatric stability. The rest of the days were not.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endocarditis secondary to Staphylococcus aureus.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is overturned.

The patient is an adult male whose inpatient admission is under review. The patient was originally admitted with endocarditis secondary to S. aureus (Staphylococcus aureus), which had several complications including septic emboli to the lungs as well as a spinal epidural abscess. He was transferred to another hospital for possible valve replacement, which was not performed (the doctors preferred a watch and wait for plan) and sent back.
Given the multiple complications, the patient was to be treated with eight weeks of IV (intravenous) antibiotics. By the fifth hospital day, the social worker noted that the patient had been rejected by 30 short-term facilities, and he was finally discharged after they finally found a place he could receive the remainder of his IV (intravenous) antibiotic course.

The inpatient hospital admission was medically necessary.
The patient had endocarditis with complications including septic emboli and abscesses. Treatment of eight weeks via IV (intravenous) infusion is recommended and standard of care (1). In addition, patients who are unable to receive this as an outpatient will need hospital admission for IV (intravenous) treatment. The patient was unable to be sent as an outpatient (because of IV [intravenous] substance abuse), and social work was unable to place him. The Standard of care in these cases is for the patient to continue receiving IV (intravenous) treatment in the hospital.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Preterm Contractions and Spotting
Treatment: Inpatient Admission
The insurer denied coverage for inpatient admission.
The denial is upheld.

The patient is a female at 34 weeks and 1 day of gestation with a history of complete placenta previa, iron deficiency anemia, and asthma. She presented to the emergency room (ER) with complaints of feeling faint while sitting. She reports no food intake that day. Blood pressure was normal. Fetal heart tracing was reactive. Vaginal examination showed a closed cervix. Irregular contractions were noted. The patient reported good fetal movements. The patient is known to be anemic. Repeat examination 4 hours later did not show any change in cervical examination.

She was admitted to labor and delivery (L&D). She had vaginal bleeding with contractions. Antenatal corticosteroids were given for fetal lung maturity. The patient was noted to have Ehlers-Danlos Syndrome Type III. She had an echocardiogram which was within normal limits (WNL). She was discharged.

The patient was not in labor, the patient was not actively bleeding. Her initial evaluation did not show any concern. Placenta previa is an indication for admission if the patient is actively bleeding but this was not the case.

This patient's vital signs were stable, fetal heart tracing was reassuring. The patient was not in labor since there was no evidence of cervical changes. Once the provider ascertained that there was no acute issue, the patient could have been observed for few hours and then sent home to be followed as an outpatient.

According to Milliman Care Guideline (MCG) admission is indicated for one or more of the following: Condition requiring premature delivery, Fetal distress or demise, Preterm prelabor rupture of membranes, Significant maternal disease, Vaginal bleeding, Complications of tocolytic treatment, and continued fetal monitoring that require inpatient care, Tocolytic therapy needed that requires inpatient care, Inability to stop preterm labor.  Observation care is appropriate for patients with one or more of the following: Condition requiring premature delivery suspected, Preterm premature rupture of membranes suspected, suspected maternal infection, Ongoing uterine contractions (tocolytic therapy needed, monitoring of cervical changes needed), Fetal distress suspected, and Suspected placenta previa, vasa previa or placenta accreta.

Based on the above, admission to the hospital was not medically necessary. This is in accordance with standard of care and Milliman guidelines. The patient does not fulfill any of the criteria for admission.

The health plan acted reasonably with sound medical judgment 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: Upheld

Diagnosis: lung cancer

Treatment is Foundation One CDx lab test code 0037U

The insurer denied coverage for Foundation One CDx lab test code 0037U
 
The denial is upheld.

According to the clinical documentation provided for review, the patient has been seen and treated for lung cancer (CA). The patient's treating provider ordered FoundationOne testing, which was performed on a lymph node. The treating provider recommended and ordered Foundation One CDx lab test code 0037U which is used to determine the presence of certain gene mutations related to cancer. 

Foundation One CDx lab test code 0037U, is a test that was used to determine if the patient had certain gene mutations related to cancer, is not considered medically necessary for this patient.

The plan considers NGS (Next-generation sequencing) with 50 or fewer genes to be appropriate. The clinical standards of the plan, the information provided concerning the patient, the attending physician's (treating provider) recommendation, and applicable generally accepted practice guidelines developed by the federal government, national or professional medical societies, boards, and associations make the denial reasonable and sound. The request is denied because the larger than 50 genes is not medically necessary. The National Comprehensive Cancer Network (NCCN) provides a list of recommended tests which are appropriate.

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

The insurer's denial of coverage for the Foundation One CDx lab test code is upheld. Medical Necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Acute migraine
Treatment: Nurtec 75 milligrams (MG) orally (OR) disintegrating tablets (TBDP)
The insurer denied Nurtec 75 MG OR TBDP. 
The denial is overturned. 

The patient is a woman prescribed Nurtec for treatment of acute migraine. The patient tried and failed Maxalt due to throat tightness. The health plan denied Nurtec 75 milligrams (MG) orally (OR) disintegrating tablets (TBDP) because the patient has not tried and failed two formulary alternatives. The provider appealed the determination.

At issue is whether the formulary drugs will be or have been ineffective, would not be as effective as the non-formulary drug or would have adverse effects.

The health plan's determination is overturned in whole.

Nurtec ODT (orally disintegrating tablets) is prescribed for acute treatment of migraine. As such, Aimovig, Ajovy, and Emgality will not be effective because they are not United States Food and Drug Administration (FDA) approved for acute treatment of migraine. These drugs are for preventative treatment of migraine and not FDA or literature approved for the prescribed indication.

The remaining formulary alternatives are triptans or triptan derivatives and not appropriate in this patient who reported an anaphylactic reaction to triptans. Re-challenge with triptans or triptan derivatives is not medically appropriate. As such, all of the remaining formulary alternatives are either not approved for the member's condition or contraindicated due to an anaphylactic reaction.

Therefore, the formulary drugs (almotriptan tablet, dihydroergotamine mesylate injection, eletriptan tablet, ergotamine with caffeine tablet, frovatriptan tablet, naratriptan tablet, rizatriptan ODT/tablet, sumatriptan injection/nasal spray/tablet, zolmitriptan ODT/tablet, zolmitriptan nasal spray, Aimovig, Ajovy, Emgality) will be ineffective or not as effective as the non-formulary drug, Nurtec, and would have adverse effects.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay
The determination is overturned.

The patient has a past medical history (PMH) of hypertension (HTN), hyperlipidemia (HLPD), diabetes mellitus type 2 (DM2), and polysubstance abuse who was admitted with complaints of (c/o) right lower extremity (RLE) swelling associated with subjective fevers and chills. Vital signs were notable for a pulse of 103. The physical exam was notable for ill-appearing, right lower extremity (RLE) warm with tenderness to palpation (TTP). Lab work was significant for a white blood cell count (WBC) of 22.87, erythrocyte sedimentation rate (ESR) 55, C-reactive protein (CRP) 237, lactate 2.3, and blood cultures negative. Imaging studies, a right lower extremity (RLE) radiograph showed diffuse soft tissue swelling, an ultrasound (US) showed no evidence of deep vein thrombosis (DVT). The patient was diagnosed with severe non-purulent cellulitis and treated with broad-spectrum intravenous (IV) antibiotics. The patient was discharged against medical advice. At issue is the medical necessity of an inpatient level of care.
The hospital stay was medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with complaints of RLE swelling associated with subjective fevers and chills. Given the patient's presentation, this patient met sepsis criteria, met the Infectious Diseases Society of America (IDSA) definition of severe cellulitis, and the expected length of stay was greater than 48 hours. In addition, the presence of diabetes and ill-appearance further indicates that the patient had a severe enough infection, especially given the clinical need to rule out osteomyelitis, to justify an inpatient stay, rather than a lower level of care. Overall, this diabetic patient with severe cellulitis required immediate treatment for the infection with intravenous antibiotics and radiological work-up and an inpatient level of care was required for safe medical evaluation and treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis.
Treatment: Home Health Care
The health plan denied the request for an increase in personal care assistant hours. 
The health plan's determination is overturned.

The patient is a female with a past medical history of gastroesophageal reflux disease (GERD), coronary artery disease, peripheral vascular disease, urinary incontinence, rheumatoid arthritis, diabetes mellitus type 2, osteoarthritis, hypertension, hyperlipidemia, chronic obstructive pulmonary disease (COPD), low back pain, and obesity who had been assigned personal care assistant (PCA) services.

PCA services 30 hours/week are medically necessary for this patient. 

There is documentation from the patient's primary care physician (PCP) and healthcare advocate of the patient's worsening physical functioning related to her multiple chronic medical problems including rheumatoid arthritis and osteoarthritis. There is documentation from the health plan's own assessment indicating an increased need of assistance in tasks of managing medication, phone use, transportation, dressing upper/lower body, walking, and locomotion when comparing the current assessment  to the previous assessment. In addition, the health plan's summary of hours calculated increased by approximately 8 hours. The patient requires assistance with all activity of daily living (ADL) and instrumental activities of daily living (IADL) tasks except for bed mobility and eating and the patient lives alone and has no informal help. The requested increase of PCA services to 30 hours/week is medically necessary for this patient. The requested increase in PCA services cannot be met solely with adaptive equipment and medical supplies. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 30 hours/week are medically necessary for this patient. 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.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Functional Dyspepsia
Treatment: Esophagogastroduodenoscopy (EGD) (43239)
The insurer denied the Esophagogastroduodenoscopy (EGD) (43239)
The denial is upheld

The patient is a female with who was seen for functional dyspepsia. The patient had an esophagogastroduodenoscopy (EGD) for dyspepsia which showed esophagitis and gastritis. The appeal letter has no clinical details about the indication aside from the procedure note which shows dyspepsia.

No, the proposed esophagogastroduodenoscopy (EGD) (43239) was not medically necessary.

Per the American College of Gastroenterology (ACG) Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease:
" 1. For patients with classic GERD (Gastroesophageal reflux disease) symptoms of heartburn and regurgitation who have no alarm symptoms, we recommend an 8-week trial of empiric PPIs (proton pump inhibitors) once daily before a meal (strong recommendation, moderate level of evidence).
2. We recommend attempting to discontinue the PPIs (proton pump inhibitors) in patients whose classic GERD (Gastroesophageal reflux disease) symptoms respond to an 8-week empiric trial of PPIs (conditional recommendation, low level of evidence).
3. We recommend diagnostic endoscopy, ideally after PPIs (proton pump inhibitors) are stopped for 24 weeks, in patients whose classic GERD (Gastroesophageal reflux disease) symptoms do not respond adequately to an 8-week empiric trial of PPIs or whose symptoms return when PPIs (proton pump inhibitors) are discontinued (strong recommendation, low level of evidence)."

This patient was not put on an eight-week empiric trial of proton pump inhibitors (PPIs) prior to proceeding with upper endoscopy, and thus the proposed treatment was not medically necessary per the current clinical guidelines.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient. Per the current clinical guidelines, the proposed treatment was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute kidney injury

Treatment is an inpatient admission 	

The insurer denied coverage for 
 
The denial is overturned

This is a patient with a history of osteoarthritis of the right hip, benign prostatic hyperplasia (BPH), hypertension, cardiac surgery, and left hip surgery. He presented to the hospital and underwent a right hip resurfacing procedure. He received 24 hours of prophylactic antibiotics post-operatively. He was found to have an acute kidney injury and elevated creatinine. He was given a fluid bolus and maintenance fluids. A renal ultrasound was negative for hydronephrosis, and a renal consult was obtained. 

The medical records demonstrated a post-surgical event that required diagnosis and additional treatment. The patient was found to have AKI (acute kidney injury). He had undergone hypotensive anesthesia with subsequent decrease in renal function. His BUN (blood urea nitrogen) and Creatinine became elevated. He required monitoring and additional treatments beyond the normal post-surgical management of hip arthroplasty. Subspecialty consultations were requested. Changes in medications were required and additional laboratory tests were ordered. He also underwent diagnostic studies to assist in determining the etiology of his kidney problem. 

These services could not be completed at a lower level of care. The inpatient stay was substantiated by his clinical condition and course. 

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

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

Diagnosis: Viral Respiratory Illness

Treatment: Inpatient Admission

The insurer denied coverage for inpatient admission

The denial is upheld

This is the case of a male patient who only needed 3 combivent nebulizer plus steroids in the emergency department. Afterwards, the patient showed remarkable improvement and only had some suprasternal retractions. His physical exam was positive only for rhonchi. In the medical record, the physician present wrote "pt [patient] arrived in stable condition". There was no persistent hypoxia and no need for continuous positive airway pressure (CPAP) or high flow nasal cannula (HFNC). There was no need for pressors nor multiple boluses. There was also no need for Magsulfate or Epinephrine. The patient did not have any abnormal lab values that persisted. There was no documentation about ordering an arterial blood gas or the presence of hypoventilation or hypercarbia. All of the patient's oxygen saturation levels were greater than 90 percent. In addition, there was no documentation for concerns of dehydration or that a basic metabolic panel report was done. The patient was progressing as expected for a viral respiratory illness, in this case influenza. If one were to take the pediatric respiratory assessment measure (PRAM) score to assess this patient's pediatric asthma, it would be in the category of mild asthma. If one were to take the pediatric early warning score (PEWS), it would have been a desirable result that also indicated an expectant and stable course in the hospital. The patient was continuing in an expected clinical trajectory while in the hospital.  Due to the above reasons, it is deemed that this patient could have been treated in an observational status.

The health plan acted reasonably with sound medical judgment 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: Upheld

Diagnosis: Viral Respiratory Illness

Treatment: Inpatient Admission

The insurer denied coverage for inpatient admission

The denial is upheld

This is the case of a male patient who only needed 3 combi nebs plus steroids in the emergency department. Afterwards, the patient showed remarkable improvement and only had some suprasternal retractions. His physical exam was positive only for rhonchi. In the medical record, the physician present wrote "pt [patient] arrived in stable condition". There was no persistent hypoxia and no need for continuous positive airway pressure (CPAP) or high flow nasal cannula (HFNC). There was no need for pressors nor multiple boluses. There was also no need for Magsulfate or Epinephrine. The patient did not have any abnormal lab values that persisted. There was no documentation about ordering an arterial blood gas or the presence of hypoventilation or hypercarbia. All of the patient's oxygen saturation levels were greater than 90 percent. In addition, there was no documentation for concerns of dehydration or that a basic metabolic panel report was done. The patient was progressing as expected for a viral respiratory illness, in this case influenza. If one were to take the pediatric respiratory assessment measure (PRAM) score to assess this patient's pediatric asthma, it would be in the category of mild asthma. If one were to take the pediatric early warning score (PEWS), it would have been a desirable result that also indicated an expectant and stable course in the hospital. The patient was continuing in an expected clinical trajectory while in the hospital.  Due to the above reasons, it is deemed that this patient could have been treated in an observational status.

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

The insurer's denial of coverage for the inpatient admission is upheld. Medical Necessity is not substantiated.