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

Diagnosis: Obesity
Treatment: Wegovy
The insurer denied: Wegovy
The denial is upheld.

The patient is an adult female with obesity with a body mass index of 30. She also has postsurgical hypothyroidism on levothyroxine. She has tried and failed phentermine, metformin, and naltrexone. She has seen a nutritionist. She has failed lifestyle intervention for 26 months including walking daily. Her TSH (thyroid stimulating hormone) level was 0.2 last year. The request for Wegovy is under review. 
The prior request was denied coverage by the health plan, because "This medication was denied because the provider has not submitted clinical documentation showing the following specifically: (1) member has been evaluated for potential medical causes of weight gain and for medications that cause weight gain, (2) documentation of BMI [body mass index] greater than or equal to 30 kg/m2 [kilograms per square meter], or a BMI [body mass index] greater than or equal to 27 kg/m2 [kilograms per square meter] with at least one weight-related comorbid condition within the last month, however given obesity diagnosis in medical claims, could accept this criterion as being met) (3) documentation of baseline body weight within the last month, (4) trial and failure of at least six months of lifestyle modification, (5) documentation of body weight before and after lifestyle modifications, (6) documentation the patient will be taking the requested medication with lifestyle modifications, and (7) the medication will not be used at the same time with other weight loss products such as prescription/non-prescription medications or herbal preparations (patient has rejected claims for phentermine, a review of the patient's past pharmacy claims history reveals paid claims for levothyroxine 75mcg micrograms], Estradiol / Norethindrone, Sertraline tab 100mg [milligrams], Rizatriptan, Venlafaxine cap 75mg [milligrams] ER [extended release], Victoza injection 18mg [milligrams]/3ml [milliliters], and Topiramate tab 25mg [milligrams]). 1) Deny because no clinical documentation or 2) Approve/overturn denial because complex patient, with diagnosis of obesity + metabolic syndrome with extensive history and clear trial of weight loss medications in the past." The provider is appealing this determination. The patient is 66 inches tall, with weight of 178 pounds. 

The requested Wegovy is not medically necessary. 

This request is for Wegovy for the treatment of an elevated body mass index. The patient's weight is 178 pounds with a height of 66 inches, which calculates to a body mass index of 28.7. This patient does not have a weight-related co-morbidities that would necessitate the need for weight loss medication as listed in the Wegovy prescribing information or the Endocrine Society guidelines on the management of obesity. Wegovy has risks, including nausea and vomiting. Therefore, no, the proposed Wegovy is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Stay.
The determination is upheld.

This is a female patient with a medical history of anemia. She presented to the emergency department with right upper quadrant abdominal pain and back pain, vomiting, and difficulty walking. The vital signs were unremarkable. The physical examination was notable for right upper quadrant and epigastric tenderness, and positive Murphy's sign. A right upper quadrant ultrasound showed cholelithiasis with slightly thickened gallbladder wall, normal caliber bile ducts, negative Murphy's sign, heterogeneity of hepatic parenchyma, 1.2 x 1.2 x 1.0 centimeter (cm) echogenic mass in the left lobe of the liver which may be incidental hemangioma, and poorly visualized pancreas.
She was treated with intravenous Toradol, Zofran, and fluids. She was made nil per os. A pediatric surgery consultation recommended monitoring the vital signs, magnetic resonance imaging to evaluate the liver mass, and admission to pediatrics. She was in no acute distress, with no abdominal pain, back pain, and nausea; she was advanced to a regular diet. A gastroenterology consultation noted concern for autoimmune hepatitis given elevated transaminases and globulins, unlikely choledocholithiasis, and downtrending transaminases with normal coagulation labs; the recommendation was blood tests to assess for liver disease, possible cholecystectomy at some point, liver biopsy when possible, and outpatient follow-up. She was discharged. At issue is the medical necessity for the inpatient level of care.

The inpatient level of care was not medically necessary. The patient presented with right upper quadrant abdominal and back pain, elevated transaminases, gallstones, and possible cholecystitis; choledocholithiasis was not established. Magnetic resonance imaging with cholangiopancreatography was planned but deferred to outpatient, but there was no hemodynamic instability, ascending cholangitis, hepatic abscess, active gastrointestinal bleeding, peritonitis, fistula, or sepsis; a cholecystectomy was not performed during the stay, so there were no risk for postoperative complications such as postoperative pneumonia, bile leak, and bleeding. Lab workup for liver disease was appropriately performed, and transaminases trended downward; the bilirubin normalized. The care provided, including monitoring, labs, imaging, and specialist consultations, could have been performed in sequence after presentation, without the need for the inpatient level of care. For these reasons, the inpatient level of care is not supported, and the care provided could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

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

This case involves a man with alcohol use disorder admitted to the hospital after suffering a seizure event and head laceration. The patient reported alcohol binging, followed by abrupt cessation and withdrawal. He experienced four seizures, and his mother found him on the floor of his home. The patient complained of headaches and tremors. He denied chest pain or shortness of breath. The cardiopulmonary exam was normal, and neurologically, the patient could move all four extremities with no focal deficits. He appeared tremulous.

The inpatient hospital services were medically necessary. The patient experienced an alcohol withdrawal seizure, appears tremulous and has moderately elevated CIWA scores. It was reasonable to expect greater than 48-hour monitoring in the hospital and treatment of alcohol withdrawal with the potential for recurrent seizures while in the hospital. The standard of care for treating alcohol withdrawal seizures includes frequent neuro checks, monitoring of CIWA scores, and administration of around-the-clock benzodiazepine medications. The patient's symptoms were severe enough to warrant monitoring in an inpatient setting, rather than expecting a quick turnaround within 24 hours, safely discharged home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fever, Rash, Cellulitis of Left Thigh. 
Treatment: Inpatient Hospital Admission. 

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

The patient is a female who presented to the emergency department (ED) with a 1 day history of fever and rash on the left thigh. She had a fever of 100.6 orally that was noted at home, then a rash on the thigh thought to be from an insect sting. 

Her ED vital signs were temperature 38.9 degrees Celsius, heart rate (HR) 155, blood pressure (BP) 106/75, respiratory rate (RR) 20 and her peripheral capillary oxygen saturation (SpO2) was 97 percent (%) on room air. The physical examination noted areas of induration on the left thigh, 9 by 7 centimeters (cm) and 7 by 6 cm in size with tenderness and warmth. Her white blood cell count (WBC) was 9.9 with mild neutrophilia. Her erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were slightly elevated. The patient was started on intravenous (IV) Unasyn, and she was admitted to the hospital for further management. 

The health plan, in its determination of medical necessity, did not act reasonably or with sound medical judgment in the best interest of this patient. 

The inpatient hospital admission was medically necessary for this patent. The patient presented with fever and rash consistent with acute cellulitis to the left anterior thigh. The patient showed systemic signs of illness, with concern for systemic inflammatory response syndrome (SIRS) and she required close monitoring and IV antibiotic treatment to ensure no decompensation. Given the concern for SIRS, an inpatient admission with IV antibiotics was medically necessary in this case. 

The health plan's determination of medical necessity is overturned in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: female infertility
Treatment: In Vitro Fertilization (IVF) Freeze All Cycle
The insurer denied In Vitro Fertilization (IVF) Freeze All Cycle. The health plan's determination is upheld. 

The patient is a woman seeking fertility treatment. At issue is the medical necessity of In Vitro Fertilization (IVF) Freeze All Cycle.

Considering this patient's multiple failed cycles and her persistently poor-quality embryos and her age, IVF is not medically necessary as her clinical scenario warrants a very poor chance of successful pregnancy.
There are multiple factors in determining diminished ovarian reserve. This can be determined by labs (follicle-stimulating hormone (FSH), estradiol, AMH (anti-Mullerian hormone) levels, antral follicle counts), or it may be determined based on past performance in IVF cycles (both quality and quantity of embryos created). Though this patient has good blood levels and she does produce embryos, the quality of the embryos are consistently poor in either morphology or chromosomally. According to recent data, cumulative live birth rates per oocyte retrieval cycle and per patient are extremely low for the patients of this age irrespective of patients with normal or diminished ovarian reserve.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: sinusitis
Treatment: inpatient stay
The insurer denied the inpatient stay. 

The health plan's determination is upheld. 

This is the case of a male with asthma and attention deficit hyperactivity disorder (ADHD) who presented to the emergency department (ED) with headache and eye swelling. The patient was diagnosed with influenza and sinusitis 3 weeks prior. A headache began 3 days prior. He was prescribed antibiotics for sinusitis, but never took them. He was using a nasal spray for symptoms. Eye swelling with increased tears began the day prior to presentation.

The inpatient hospital admission was not medically necessary. This patient could have been safely treated in the ED and at a lower level of care. This otherwise healthy male presented with acute eye swelling and sinusitis. He had been non-compliant with outpatient recommendations and treatment. He was otherwise stable with normal vital signs and labs consistent with diagnosis of acute sinusitis which imaging also supported. This patient could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Scrotal Pain and Swelling
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult male who underwent vasectomy and presented to emergency department four hours after vasectomy with complaint of scrotal swelling. The patient was noted to be tachycardic with heart rate of 146. His blood pressure was 156/98. He had an elevated white blood cell count at 18.6, hemoglobin was 14.1, and glucose was 134. A scrotal ultrasound demonstrated a 10.2-centimeter heterogeneous collection posterior to the testis and diffuse scrotal wall edema consistent with hematoma. The patient was admitted for intravenous antibiotics and monitoring. Overnight, the patient remained hemodynamically stable. A repeat hemoglobin on the next day was 12.4. The patient was discharged on day #3 with a hemoglobin of 12.1 and white blood cell count of 11.8. The patient was discharged to home with scrotal supporter.

The proposed inpatient hospital admission was not medically necessary.

This patient warranted monitoring given the large size of the hematoma and the elevated white blood cell count. However, the patient did not have significant co-morbidities or display symptoms of sepsis or hemodynamic instability. He could have been monitored at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain and vomiting
Treatment: Inpatient Hospital Admission
The insurer denied Inpatient Hospital Admission.
The denial is Upheld.

The patient is an adolescent female who presented to the emergency department (ED) with abdominal pain and vomiting. She was evaluated with vitals which were stable, lab work which revealed no anemia or elevated white blood cell count, and normal liver kidney function. She had a negative pregnancy test and urine revealing blood and ketones. She had a computed tomography (CT) scan performed revealing a 4.5 centimeters (cm) cystic lesion in the right adnexa with mild to moderate surrounding fluid. Gynecology (Gyn) consult was performed, and the patient was admitted for observation with vital signs, pain medication, and repeat blood work. The plan was for an ultrasound; however, this was unable to be performed. A bedside ultrasound was performed and ruled out a torsion of the ovary. The patient was feeling better. She had stable vital signs and no evidence of infection or internal bleeding. She was discharged home with follow up in two weeks. The inpatient hospital stay was denied as not medically necessary. This is being appealed.

The proposed treatment was not medically necessary.

An outpatient observation bed is an alternate level of healthcare compromising of short stay encounters for patients who require close nursing observation or medical management. It is an area where the patient is observed and assessed to determine a need to be admitted to the hospital as an inpatient. The distinction between inpatient versus observation status is not always clear-cut. Patients undergoing short hospital stays may be treated similarly to inpatients but classified as outpatients receiving observation services. Under the two-midnight rule, established by the Centers for Medicare and Medicaid Services (CMS), hospital inpatient admissions are considered reasonable and necessary for patients whose stays cross two midnights. Stays expected to span less than two midnights under the rule are generally considered outpatient. The patient in question presented with abdominal pain but had stable vital signs and was without an acute abdomen. She required monitoring and ongoing assessment given her pain, however there was not any evidence upon initial evaluation that her care would need to span across two midnights. Therefore, there is no evidence that an acute inpatient admission was necessary. The same outcome could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Obstructive Pulmonary Disease, heart disease and hypothyroid.

Treatment: 24 hours per day, 7 days per week (split-shift), total 168 hours per week, Personal Care Services (PCS), level 2.

The insurer denied coverage for 24 hours per day, 7 days per week (split-shift), total 168 hours per week, Personal Care Services (PCS), level 2.

The denial is overturned.

This is a geriatric patient with Chronic Obstructive Pulmonary Disease, heart disease and hypothyroidism. The patient lives alone in a 1-bedroom apartment. The patient was hospitalized due to congestive heart failure and subsequently transferred to a skilled nursing facility (SNF). The patient was again hospitalized due to Coronavirus infection and pneumonia. The patient was transferred to a SNF, then readmitted to the hospital due to respiratory distress. The insurer approved Personal Care Services (PCS) 5 hours per day, 5 days per week: 4 hours per day, 1 day a week and 3 hours per day, 1 day a week for total of 32 hours per day. The request is for 24 hours per day split-shift. 

The Uniform Assessment System (UAS) was reviewed. The patient's cognition is described as modified independent. The patient is totally dependent for much of the Instrumental Activities of Daily Living (IADL) tasks including ordinary housework, meal preparation and shopping. Maximal to extensive assistance is needed for bathing, personal hygiene, dressing, bed mobility, locomotion, ambulation, and toilet transfer/use. The patient is frequently incontinent of bladder and continent of bowel. The functional ability has declined compared to the previous UAS reports. In addition, the patient has been hospitalized on 2 additional occasions since the UAS report. The approved PCS 5 hours/day, 5 days/week; 4 hours/day, 1 day a week and 3 hours/day, 1 day a week (32 hours/day) are inadequate to meet the patient's functional needs. Based on the clinical records and the anticipated continued functional decline after the 2 recent hospitalizations, PCS 24 hours per day (split-shift) is the appropriate level of service to meet the patient's health and safety needs in a home setting. 

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 24 hours per day, 7 days per week (split-shift), total 168 hours per week, Personal Care Services (PCS), level 2 is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion
Treatment: Braces and Monthly Visits
The insurer denied: Braces and Monthly Visits
The denial is overturned

The patient is an adolescent female. The request is for orthodontic benefits, including monthly follow-up visits. She has a skeletal Class II malocclusion, as well as mild upper and moderate lower crowding. She has excessive overjet. The health plan's prior denial of coverage for the request was due to handicapping index score of 16. The denial is being appealed.

The requested braces and monthly visits are medically necessary.

The patient has a deep, impinging overbite with soft tissue damage to the palatal gum tissues. This is an automatic qualifier according to the handicapping index scale. This case has medical necessity and needs orthodontic treatment with monthly visits to correct the problems.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Mandibular crowding and several unerupted permanent teeth.
Treatment:  Braces/monthly visits.

The insurer denied braces/monthly visits. The health plan's determination is upheld. 

The patient is a female with maxillary and mandibular crowding and several unerupted permanent teeth. The orthodontist mentioned in the diagnosis that teeth #6 and #11 are impacted. The patient was treatment planned for Braces and Monthly Visits.

Braces and Monthly Visits are not medically necessary for the patient at this time. She is in the process of losing her remaining primary teeth, as they are replaced with permanent teeth.  The patient is in the mixed dentition phase of development. Neither teeth #6 nor #11 appear to be erupting at a poor angle on the radiograph, and it is too early to determine if it will require an exposure, as maxillary canines usually erupt at 11-12 years of age. There is still much time to see if the tooth will erupt successfully on its own without orthodontic intervention.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

This is an adult patient who presented to the urgent care complaining of palpitations, headache and left upper extremity weakness. Upon arrival to the hospital, the patient was hypertensive with blood pressure (BP) of 232/164 and pulse of 79. Physical exam was significant for 4/5 strength in the left upper extremity. The patient was treated with a single dose of labetalol and the BP dropped to 158/121. The left upper extremity weakness resolved. A computed tomography (CT) of the head demonstrated no acute abnormality. Serum blood testing revealed normal renal function with a creatinine of 0.7 milligrams per deciliter and no elevation in Troponin < (less than) 0.01. The patient was admitted for hypertensive urgency and treated with oral nifedipine. A neurology consultation was sought, and they made recommendations for Magnetic Resonance Imaging (MRI) of the brain. The patient signed out against medical advice prior to undergoing the MRI.

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient. A hypertensive emergency is defined as BP> (greater than) 180/120 with target organ damage. This patient complained of headache and left upper extremity weakness. No acute stroke was noted on the CT scan and symptoms resolved rapidly after arrival. The patient was diagnosed with hypertensive urgency. Treatment goals for hypertensive urgency are to institute antihypertensive medications in an outpatient setting. American Heart Association/American College of Cardiology (AHA/ACC) guidelines state: "There is no indication for referral to the emergency department, immediate reduction in BP in the emergency department, or hospitalization for such patients". Admission to the hospital for aggressive blood pressure management was not medically necessary. In conclusion 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: Right Hand Cellulitis
Treatment: Inpatient Admission
The insurer denied: Inpatient Admission
The denial is: Upheld

The patient is a male with a history of diabetes. He presented to the emergency room with a six-day history of worsening right hand pain and swelling after he opened with a needle a "pimple" that developed on the palm. In addition, his glucometer reading was 422. The temperature was 99.2 degrees, pulse was 107, and blood pressure was 149/88. He was alert and in no acute distress. Physical exam was remarkable for swelling and erythema of the right palm with lymphangitic spread up the forearm. Other than a glucose of 334 and a minimally elevated erythrocyte sedimentation rate (ESR), the labs were non-contributory. The right hand films, extremity ultrasound, and chest x-ray were normal. The electrocardiogram (EKG) was negative for acute ischemia or significant arrhythmia. The patient was admitted for further treatment and evaluation.
Upon admission, the patient was treated with intravenous and oral antibiotics, and insulin coverage. The infectious disease consultant evaluated the patient and recommended continuing the antibiotics, along with better with better glucose management. The remainder of the stay was clinically uneventful and the patient was discharged.

The requested inpatient admission was not medically necessary for this patient. Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or EKG of an imminently life-threatening cause of the patient's complaints that required acute inpatient admission. There was no hemodynamic instability, mental status changes, or severe metabolic disarray such as acidosis. The services provided - intravenous antibiotics, insulin - were not at the acute inpatient level of intensity. Therefore, based on the standard of care, as well as the peer reviewed literature cited, the acute inpatient level of care was not medically necessary and the patient could have been managed at a lower level of care.