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

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

The patient was an adult male with a past medical history of coronary artery disease, heart failure, hypertension, hyperlipidemia, diabetes, obstructive sleep apnea, asthma, renal cancer status post partial nephrectomy, and obesity. He presented to the emergency department for evaluation of chest pain and shortness of breath.

On arrival to the ED (emergency department), the patient was afebrile and hemodynamically stable. He was saturating well on room air. Twelve-lead EKG (electrocardiogram) showed normal sinus rhythm with T wave inversions in lead aVL (Augmented Vector Left). He was admitted to the inpatient unit and serial cardiac enzymes were obtained and were unremarkable. Cardiology was consulted and a TTE (Transthoracic Echocardiogram) was obtained which did not demonstrate any wall motion abnormalities or systolic dysfunction. He had a myocardial perfusion scan, which did not demonstrate evidence of ischemia or prior infarction. He was ultimately discharged with outpatient follow-up.

The Inpatient Hospital Admission was not medically necessary.

The patient was hemodynamically stable and was not hypoxic. There was no evidence of sepsis, no mental status changes and no end organ malperfusion. He was ruled out for acute coronary syndrome with serial troponins and his noninvasive testing did not demonstrate evidence of ischemia or heart failure. Consequently, based on the provided documentation, there is insufficient clinical data to support medical necessity for inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stage III colon cancer; nausea and vomiting
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient in this case is an adult female with stage III colon cancer. She developed nausea and vomiting the day before presenting to the emergency department and had multiple episodes both days before being seen in the emergency department. She presented to the emergency department, and it was noted that she was on active chemotherapy treatment, with the last chemotherapy having been given 5 days previously. She was not having any diarrhea. 

The patient's physical exam was unremarkable. Labs revealed no significant abnormalities. The patient had an x-ray done which revealed no evidence of bowel obstruction. She was treated with Reglan and Zofran in the emergency department and was admitted for further treatment with Zofran as needed along with intravenous pantoprazole. She was started on a clear liquid diet. 

Following admission, the patient was started on antibiotics given concern for possible Clostridium (C) difficile infection. She did not have diarrhea at the time of admission, but she noted it soon after admission.  She had leukocytosis but no fever and had been given Zarxio (white cell growth factor) before admission. Of note, urine toxicology testing was positive for cannabinoids and benzodiazepines, felt to possibly explain her nausea and vomiting. Progress notes do not document ongoing intractable nausea or vomiting.

The proposed treatment was not medically necessary.

This patient presented with nausea and vomiting and received treatment with antiemetics in the emergency department. There is no documentation in the provided progress notes indicating that the patient had ongoing intractable nausea or vomiting which would have necessitated acute care inpatient admission. She had no significant electrolyte disturbance, hemodynamic instability or acute kidney injury due to her nausea and vomiting. She developed diarrhea following admission. This is an expected side effect of her chemotherapy but could have been due to Clostridium difficile infection. However, the patient also had no significant electrolyte disturbance, acute kidney injury or hemodynamic instability due to this symptom. Given lack of that documentation, there is insufficient evidence to support the medical necessity of acute care inpatient admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ovarian torsion.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is overturned.

 
The patient presented to the emergency room (ER) with complaints of abdominal pain. Imaging revealed an ovarian cyst and possible ovarian torsion. She was taken to the operating room for an exploratory laparotomy with left ovarian cystectomy. On post-op day 1 the patient was stable. She was discharged home on post-op day 2. 

This patient underwent a laparotomy. Laparoscopies are ambulatory procedures, laparotomies are not. The standard of care is for patients who undergo an open procedure to stay in the hospital for 48 hours. On postoperative day 1, the Foley catheter is removed, the patient is encouraged to get out of bed and ambulate, clear liquids are started. On postoperative day 2, if the patient is passing flatus, and tolerating regular diet she is discharged home. The patient was managed as per the standard of care. The admission should be approved based on Milliman Care Guideline (MCG) Laparotomy.

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

Diagnosis: Cholecystitis.

Treatment: Full hospital admission.

The insurer denied coverage for full hospital admission.

The denial is upheld.

Acute cholecystitis is a common inpatient diagnosis. Acute cholecystitis is also estimated to attribute to millions of ambulatory visits each year and is a leading cause of hospital admissions. Studies have shown that ambulatory laparoscopic cholecystectomy is safe and avoids an overnight hospital stay. Factors that contribute to admission after laparoscopic cholecystectomy include drain placement, conversion to open surgery, persistent abdominal pain, nausea, and vomiting. In patients without abnormalities of the bile duct or abnormal liver function tests, ambulatory laparoscopic cholecystectomy is safe and feasible. Ambulatory and/or outpatient laparoscopic cholecystectomies reduce hospital costs without compromising patient outcomes.

Per clinical documentation, this patient presented to the Emergency Department (ED) with worsening right upper quadrant abdominal pain. Vital signs in the ED were within normal limits. The temperature was 99.6 degrees Fahrenheit. The patient had an abdominal ultrasound that demonstrated cholelithiasis with increasing gallbladder wall edema as compared to a previous study. White blood cell count was 13.2. The patient underwent a laparoscopic cholecystectomy with an intraoperative cholangiogram. There were no reported complications. Per Milliman Care Guidelines (MCG) criteria, admission is indicated for calculus or obstruction of gallbladder or bile duct and either hemodynamic instability, common bile duct obstruction, severe or persistent vomiting or dehydration, severe pain, or bacteremia. According to clinical documentation, the patient did not meet criteria for inpatient admission. Peer-reviewed literature indicates that laparoscopic cholecystectomy can successfully be performed as an outpatient procedure. Therefore, the requested hospital stay should have been observation status. 

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 full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pain.

Treatment: Hospital admission.

The insurer denied coverage for hospital admission.

The denial is upheld.

The health plan acted reasonably. Observation services is defined by Centers for Medicare and Medicaid Services (CMS) as care ordered by a physician and provided in a hospital bed (either inpatient or outpatient) to determine the need for inpatient admission. The care is expected to be completed within 24 hours, with exceptional cases requiring more than 48 hours. 

Per clinical documentation, the patient was admitted for postoperative pain control after a bilateral breast reduction, abdominoplasty, and abdominal and breast liposuction. Postoperative notes do not indicate that the patient had any pain. There is no indication that there was an increase or change in the pain medications. There is no indication of postoperative complications. Per Milliman Care Guidelines (MCG) criteria, inpatient admission is indicated when there are complications of the procedure or management of complex comorbidities. Per the provided clinical documentation, the inpatient admission was not medically necessary. Observation stay would be more 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 hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: End Stage Renal Disease.
Treatment: Personal Care Aide Level 2: 12 hours per day - 7 day(s) per week - a total of 84 hours per week.
The insurer denied: Personal Care Aide Level 2: 12 hours per day - 7 day(s) per week - a total of 84 hours per week. 
The denial is: Overturned.

The patient is a female with medical history notable for end stage renal disease on dialysis. The patient was approved for 6 hours per day, 7 days per week (42 hours per week) of level 2 personal care services. The patient and her care team requested an increase to 12 hours per day, 7 days per week (84 hours per week) and this request was partially denied by the health plan; the plan did approve an increase to 7.5 hours per day, 7 days per week (52.5 hours per week). This denial is the subject under review.

The health plan's determination is overturned.

Information was provided in the form of a letter from the patient's physician of the last 8 years. The letter describes her medical problems and states that she needs home care throughout the day and night. She needs assistance with all activities of daily living including toileting, transferring, bathing, and dressing. Because her needs are unscheduled, the physician states that she needs increased hours to address her needs. Additional medical records discuss her declining function and need for assistance with activities of daily living (ADLs) dating back to last year. Notes from last year also describe falls when attempting to perform ADL's independently, which were concerning given that she was on blood thinning medication. Numerous notes describe frequent falls and altered mental status. In light of this information, the determination of medical necessity is overturned in favor of the patient. There is sufficient documentation that the patient has been attempting to perform ADL's and Instrumental activities of daily living (IADLs) independently but has been unable to do so and falling, leading to injury. Her physician attested to the need for increased hours to meet her functional needs.  The requested health service is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: End Stage Renal Disease
Treatment: Personal Care Aide Level 2: 12 hours per day - 7 day(s) per week - a total of 84 hours per week.
The insurer denied: Personal Care Aide Level 2: 12 hours per day - 7 day(s) per week - a total of 84 hours per week.
The denial is upheld.

The patient is a female with medical history notable for end stage renal disease on dialysis. The patient was approved for 6 hours per day, 7 days per week (42 hours per week) of level 2 personal care services. The patient and her care team requested an increase to 12 hours per day, 7 days per week (84 hours per week) and this request was partially denied by the health plan; the plan did approve an increase to 7.5 hours per day, 7 days per week (52.5 hours per week). This denial is the subject under review.

The health plan's determination is upheld.

The requested health service/treatment of Personal Care Aide Level 2: 12 hours per day - 7 day(s) per week - a total of 84 hours per week has not been demonstrated to be medically necessary for this patient.

The patient has difficulty with completing numerous Instrumental activities of daily living (IADLs) and activities of daily living (ADLs) as outlined by the UAS. The UAS and its task tool recommend 52.5 hours which was approved as part of this appeal. There is no documentation that there are unmet personal care needs at this number of service hours. The health plan agreed to increase the hours to meet the recommendation of the task tool. There is not any established medical necessity for increasing the patient's service hours at this time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Migraine
Treatment: Botox
The insurer denied Botox.
The determination is overturned.

The patient is requesting treatment with Botox for prevention of chronic migraine. The drug was denied as the patient has not failed more than one oral preventative therapy. The documentation indicates that the patient has tried and failed the following drugs: metoprolol, gabapentin, and sertraline. The patient has a contraindication to the use of topiramate. At issue is the medical necessity of Botox.

Treatment with Botox is medically necessary. The patient has not responded to first-line therapies and there are no other medications that are as likely to be as effective as Botox for treatment of the member's condition. The drug is approved for the requested indication of prevention of chronic migraine. 

The patient has chronic migraine. She has tried and failed anticonvulsants (gabapentin) and beta-blockers (metoprolol). The patient cannot use other anticonvulsants such as topiramate due to history of kidney stones and Depakote extended release (ER) is generally avoided in younger women due to risk of pregnancy and teratogenesis. The patient is concurrently treated with sertraline, which contraindicates the use of a tricyclic antidepressant. The prior review indicates that treatment of zonisamide and candesartan are appropriate first-line therapies; however, neither of these drugs are first-line treatment for migraine or widely regarding as effective preventative agents. Despite treatment with three classes of medications (gabapentin, metoprolol, sertraline), the patient's migraines have not improved. As such, the use of Botox for the prevention of chronic migraine is reasonable. Botox is Food and Drug Administration (FDA) approved and literature supported for the prevention of chronic migraine. The patient does not have a contraindication to its use.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right mandibular fracture
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is overturned

Upon review of the submitted documentation which includes inpatient medical records of the patient, an appeal letter and insurer correspondence, it appears that this patient presented to the emergency department and upon examination it was identified the patient sustained a right mandibular fracture after an assault. The patient was admitted with a diagnosis of right mandibular angle fracture, nondisplaced and was admitted to the hospital where he underwent open reduction internal fixation surgery and extraction of #19. The insurer has denied coverage stating that the patient did not meet Milliman care guidelines of head and neck disease GRG. 

Upon review of the comprehensive medical record, it is clear that the patient sustained a right mandibular angle fracture status post assault. As per New York State medical necessity guidelines and requirements, and as per Milliman guidelines, the open reduction internal fixation surgery is medically necessary as it meets stated criteria for approval. Further, peer-reviewed literature, as referenced below, clearly identifies a standard of care in oral surgical practice of open reduction and internal fixation for mandibular angle fractures.

Overturn the denial and approve coverage for the inpatient admission as the submitted documentation substantiates and justifies the admission and surgical services, which are a standard of care in managing mandibular angle fractures.

Open reduction and internal fixation is a standard of care surgical service in management of mandibular angle fractures. The clinical circumstance as documented fulfills the Milliman care guidelines criteria for inpatient admission and surgical services. Further, peer-reviewed literature confirms open reduction internal fixation surgery as a standard of care.

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

Diagnosis: Diabetes, T12 fracture, coronary artery disease and atrial fibrillation

Treatment: Consumer Directed Personal Assistance Program (CDPAP): 12 hours per day - 7 days per week - for a total of 84 hours per week.

The insurer denied coverage for Consumer Directed Personal Assistance Program (CDPAP): 12 hours per day - 7 days per week - for a total of 84 hours per week.

The denial is overturned

This is a geriatric patient with medical problems that include diabetes, coronary artery disease and atrial fibrillation. The patient lives alone in a studio apartment. The patient was hospitalized due to a T12 fracture, diabetic ketoacidosis, and urinary tract infection. The plan approved consumer directed personal assistance program (CDPAP) 9.5 hours per day - 7 days per week - for a total of 66.5 hours and the request is for 12 hours per day- 7 days per week- for a total of 84 hours per week.

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive status is moderately impaired- decisions consistently poor or unsafe; cues/supervision required at all times. The patient is totally dependent to maximal assistance for Instrumental Activities of Daily Living (IADL) tasks including shopping, ordinary housework, and meal preparation. The patient is also totally dependent to maximal assistance for Activities of Daily Living (ADL) including bathing, personal hygiene, dressing, locomotion, and toilet transfer/use. The patient has an indwelling urinary catheter and is frequently incontinent of bowel. The patient is also non-ambulatory. The patient's ADL status and self-sufficiency have deteriorated and declined, respectively over the prior 90 days. The patient's condition, cognitive status and functional needs are at a level and unpredictable as to require the requested CDPAP 84 hours per week. The patient may actually require additional monitoring. Based on the enclosed documents reviewed, the patient's health and safety are more appropriately provided and maintained by increasing CDPAP 12 hours per day, 7 days per week, totaling 84 hours per week. 

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 consumer directed personal assistance program (CDPAP): 12 hours per day - 7 days per week - for a total of 84 hours per week is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Gout
Treatment: Kineret
The insurer denied: Kineret
The denial is: Overturned

This patient is a male with refractory gout and acute promyelocytic leukemia (APL). The patient has tried and failed colchicine, nonsteroidal anti-inflammatory drugs (NSAIDs) and prednisone. He then tried anakinra with improvement for an acute attack. He is on allopurinol 300 milligrams (mg) daily for uric acid lowering therapy. At issue is the requested/proposed health service, Kineret.

The patient has refractory gout and has not responded to first line treatment for flare ups, such as colchicine, nonsteroidal anti-inflammatory drug (NSAID) and prednisone. Anakinra 100 milligrams (mg) once daily until symptom improvement; usual duration: 3 to 5 days is now being given as an alternative for refractory cases of acute gout such as the one here. A study in Arthritis Rheumatology in 2021 concluded that, "...anakinra was not superior to triamcinolone for the primary end point, but had comparable efficacy in pain reduction and was favored for most secondary end points. Anakinra is an effective option for gout flares when conventional therapy is unsuitable". Another study in Curr Opin Rheumatology in 2015 found that "there is sufficient evidence supporting the use of Interleukin 1 (IL-1) blockers for treatment of acute gouty arthritis or for prevention of gout flares when starting urate-lowering therapy (ULT) in selected patients, with contraindications or intolerance to conventional therapy. More data are needed to assess safety and to specify their use in routine practice". Given the patient is not responsive to conventional therapy, anakinra is a reasonable treatment choice in this case for management of an acute gout attack.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Gout
Treatment: Kineret
The insurer denied: Kineret
The denial is: Overturned

This patient is a male with a history of gout, who had been taking allopurinol and had no gout symptoms for the past 1-1.5 years. He was recently diagnosed with acute promyelocytic leukemia that presented as pancytopenia, which was confirmed by biopsy. While in the hospital, he developed polyarticular gout that did not respond to colchicine or high-dose steroids up to 80 milligrams (mg) by mouth (po) daily, and oral nonsteroidal anti-inflammatory drugs (NSAIDs) were not considered due to his pancytopenia/thrombocytopenia. Anakinra was successfully used to treat the patient's gout while he was hospitalized. 

However, the patient was admitted to the hospital again with sepsis, methicillin-resistant staphylococcus aureus (MRSA) bacteremia, endocarditis, and gout flare-up. This time steroid therapy was not considered due to the increased risk of infection. Also, Nonsteroidal anti-inflammatory drugs (NSAIDs) were again, not considered because of patient's pancytopenia/thrombocytopenia. Colchicine was not considered as the patient did not respond previously to colchicine. Because the patient had previously responded to anakinra, a request was made to continue the treatment as an outpatient for the acute treatment of gout. At issue is the proposed health service or treatment, Kineret. 

Given that the patient did not respond to colchicine and high-dose steroids but showed a positive response to anakinra therapy during hospitalization, it is likely that continuing the treatment with Kineret/Anakinra would be more beneficial. Furthermore, due to recent sepsis with methicillin-resistant staphylococcus aureus (MRSA) bacteremia and endocarditis, steroids are contraindicated, and the patient cannot use oral nonsteroidal anti-inflammatory drugs (NSAIDs) due to pancytopenia/thrombocytopenia. Therefore, Anakinra/Kineret remains the best and preferred therapy in this case.