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

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


This is a female patient with a past medical history (PMH) of diabetes mellitus type 2 (DM2), hypertension (HTN), systemic lupus erythematosus (SLE), lupus nephritis, avascular necrosis of femoral heads, and bipolar disorder (d/o) who was admitted with complaints of (c/o) a two-week history of low back pain associated with pain radiation to the left lower extremity (LLE). The patient had been seen previously on an admission for same pain. The vital signs were unremarkable. The physical exam was notable for no focal deficits, acute distress, non-toxic appearing, mild left lower extremity (LLE) weakness. Lab work was unremarkable. Imaging studies included a chest x-ray (CXR) showed no acute disease, Magnetic resonance imaging (MRI) of the lumbar (L) spine showed no acute abnormality. An electrocardiogram (EKG) showed normal sinus rhythm (NSR). The patient was diagnosed with sciatica and treated with intravenous fluids (IVF), Flexeril, gabapentin, non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy, and intravenous (IV) pain medications. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with c/o back pain without evidence of severely compromised neurological function. The patient received a thorough diagnostic and imaging work-up, which did not demonstrate any acute fractures or dislocations. The patient did not have an abdominal aortic aneurysm, aortic dissection, cauda equina syndrome, epidural abscess or hematoma, acute spinal fracture, meningitis, osteomyelitis, progressive neurologic deficits, fever, discitis, or tumor. The patient received intravenous (IV) pain control, steroids, physical therapy, pain management consultation, and radiologic work-up, all of which could have been safely provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart Failure

Treatment: Inpatient admission

The insurer denied coverage for an inpatient admission

The denial is overturned

This is an adult patient who presented to the hospital complaining of progressive shortness of breath and pedal edema. Past medical history was relevant for hypertension, diabetes mellitus, atrial fibrillation, polysubstance abuse, Chronic Obstructive Pulmonary Disease on home oxygen therapy and systolic congestive heart failure with a reduced left ventricular ejection fraction of 13%. On arrival the blood pressure was 106/80 and the pulse was irregular at 66 beats per minute. Physical exam revealed pedal edema with pitting to the thighs. A 12-lead electrocardiogram revealed atrial fibrillation with a rapid ventricular rate of 119. Serum blood testing revealed an elevated Pro-B type natriuretic peptide (BNP) of 6230 picograms per milliliter (pg/ml). The patient was treated with intravenous diuretic therapy. The patient was admitted to the hospital for treatment of decompensated heart failure and transitioned to oral diuretic therapy and Entresto. The patient was discharged with cardiology follow up two days after presentation.

The health plan did not act reasonably and with sound medical judgment and in the best interest of this patient. This patient presented with complaints of dyspnea and pedal edema up to the thighs. Upon presentation, physical exam and laboratory testing confirmed fluid overload due to systolic congestive heart failure. The patient required treatment with intravenous diuretic therapy and was ultimately discharged on oral guideline directed medical therapy. Failure to admit and treat this patient would have resulted in excess morbidity or even mortality. Patients with chronic congestive heart failure have a high risk of adverse outcomes warranting a higher level of care. In one study, patients presenting with congestive heart failure and an elevated BNP level were found to have an increased morbidity and mortality in the subsequent 90 days. In conclusion, this patient had decompensated congestive heart failure and an elevated BNP level. An inpatient hospital admission was medically necessary.

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 inpatient admission is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Type 2 Diabetes. 
Treatment: Jentadueto XR. 

The insurer denied Jentadueto XR. 
The denial is upheld. 

This is an adult male patient diagnosed with type 2 diabetes. This request is for Jentadueto extended release (XR). As per a recent visit note, the patient was diagnosed with type 2 diabetes mellitus (T2DM) 5 years ago; he is on Janumet extended release (XR) 100-1000 every day and metformin extended release (ER) 500 milligrams (MG) every day (QD). The patient's glycated hemoglobin (A1C) 2 years ago was 6.7 percent; 3 years ago, it was 7 percent; and last month was 6.6 percent. 

The health plan should not cover the proposed treatment. 

Dipeptidyl peptidase four (DPP IV) inhibitors have similar efficacy. There are no trials showing superiority of one dipeptidyl peptidase four inhibitor over another including linagliptin (Tradjenta), saxagliptin (Onglyza), vidagliptin or sitagliptin (Januvia) [1, 2]. The American Association of Clinical Endocrinologists consensus statement regarding treatment of patients with type two diabetes [3, 4] recommends the use of metformin followed by the use of a dipeptidyl peptidase four inhibitor or a glucagon-like peptide-one (GLP 1) agonist. 
The policy criteria require the trial and failure of Janumet and Janumet extended release (XR). The patient is currently on Janumet extended release 100-1000 with a glycated hemoglobin of 6.6. The formulary alternatives are as effective as the requested non-formulary drug. There is no documentation of trial and failure of both formulary alternatives. The request does not meet the policy criteria or the standard of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Duchenne Muscular Dystrophy.
Treatment: Occupational therapy - 26 home health visit(s).

The insurer denied Occupational therapy - 26 home health visit(s).  The denial is overturned.

The patient is an adult male with history of Duchenne Muscular Dystrophy (DMD), cardiac transplant, immunosuppression and osteoporosis, who has weakness of intrinsic hand muscles - left side was emphasized, associated with contracture, decreased muscle strength and lacking fine motor and dexterity movements and has orthotics. The patient has generalized weakness and contractures in all his four limbs due to the Duchenne Muscular Dystrophy and is wheelchair bound. Even though he is dependent for most of his activities of daily living (ADLs), he is able to use his arms to operate his power-assist wheelchair and is able to operate small devices and type with his hands. The request for continued occupational therapy (OT) and physical therapy (PT) each three times a week is more preventative to prevent worsening contractures, maintain pulmonary health and prevent further bone loss. It is noted that progress is limited. The patient has gone through 28 home visits for occupational therapy. At occupational therapy assessment, it was noted that the patient required assistance with most tasks while he is able to set up medications, use keyboard on a computer, use his cell phone, write checks to manage his finances and perform other handwriting tasks.

The proposed occupational therapy is medically necessary.

The requested occupational therapy is medically necessary as a recommended part of management of Duchenne Muscular Dystrophy, as it is a progressive neuromuscular disease where the need for regular physical therapy and occupational therapy is essential to maintain the independence and functionality of the patients.
Alemdaroglu et al. in a randomized controlled trial concluded that their results "demonstrate that upper extremity training with an arm ergometer is more effective in preserving and improving the functional level of early-stage DMD patients compared to ROM exercises alone".

Birnkrant et al. in Lancet emphasized the need for physical therapy and occupational therapy to be involved in personalized rehabilitation therapies because of the progressive nature of the disease.

Therefore, the health plan should continue to provide coverage for the request occupational therapy in-home towards the above goals.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: atopic dermatitis.
Treatment: Prescription medication, Adbry.
The health plan denied the requested medication, Adbry as not medically necessary. 
The health plan's determination is upheld.

The patient is a male with moderate to severe atopic dermatitis (over 10% body surface area involvement) that includes the hands, feet, and face, and which flares a few days prior to each injection of the Dupixent he now takes. The patient is uncontrolled on Dupixent and topical steroids (Mometasone). Mometasone was switched to Betamethasone and with Pimecrolimus to be used to his feet.

The health plan's determination of Adbry is recommended to be upheld.

The patient has no documented treatment failure with, or true medical contraindication to, either topical calcineurin inhibitors, or standard, first-line oral medications used for moderate to severe atopic dermatitis (such as Methotrexate, Azathioprine, or Mycophenolate Mofetil), or to second-line systemic therapies Rinvoq. Adbry is not proven to be superior to all other formulary alternatives (such as Dupixent used with more potent topical steroids) or Rinvoq as per comparative, controlled studies. The aforementioned first-line oral/systemic therapies are also available for use consistent with current medical literature, [2-6] and neither Dupixent nor Adbry are proven to be of superior efficacy compared to these longstanding treatments, or to the more recently Food and Drug Administration (FDA) approved oral/systemic therapy that is Rinvoq.
Therefore, as per the patient's health plan policy language, [1] and consistent with current standards of care, [2-6] the requested Adbry is not medically necessary and is not more effective than all formulary alternatives, is not demonstrated to have fewer adverse effects, and therefore does not meet the health plan coverage requirements. [1]
Appeal type: Medical necessity
Decision: Upheld

Cardiac/Circulatory Problems/chest pain.
inpatient admission.
The health plan denied the requested inpatient admission as not medically necessary. 
The health plan's determination is upheld.

No medical records were provided for review. The following information was obtained from case notes. This woman presented to the emergency department (ED) complaining of chest pain, palpitations and dizziness. She had just been discharged from the hospital the day prior after undergoing an appendectomy for acute appendicitis. Per the information provided her heart rate was in the 170s beats per minute (bpm) when she was seen in triage. Her ED vitals included a blood pressure of 104/51 millimeters of mercury (mmHg) with a heart rate of 105 beats/minute. An electrocardiogram showed atrial fibrillation with a rapid ventricular rate. The patient was treated with intravenous fluid and Heparin and was admitted to the hospital. A transesophageal echocardiogram was performed. Presumably, this was followed by electrical cardioversion; however, this was not documented in the information provided. The patient was discharged.
The medical necessity for an inpatient admission is at issue.

Based on the limited information provided, I uphold, in whole, the determination that an inpatient level of care was not medically necessary.

No. Based on the limited information provided, an inpatient level of care was not medically necessary.
This patient presented with atrial fibrillation (AF) with a rapid ventricular rate. She was hemodynamically stable. The information provided does not mention any evidence of ischemia, decompensated heart failure, structural heart disease or high short-term risk for thromboembolism. For stable patients presenting with acute AF, the safety of observation level care or discharge to home with close follow-up has been well demonstrated. As stated by Lin et al, "There is growing evidence to suggest that outpatient management is a safe and effective alternative to hospital admission for the management of many patients with acute AF or atrial flutter. Protocols for early rhythm control, clinical decision rules to guide the decision to initiate antithrombotic therapy, and low molecular weight Heparin and direct oral anticoagulants have reduced the need for acute inpatient hospitalization." Likewise, Conti et al, based on an observational study of 3475 patients concluded, "In patients with AF, beyond the standard approach, the novel organization with an additional intensive observation unit for early pharmacological interventions and an outpatient clinic for elective treatment and short-term follow-up significantly reduced admission irrespective of independent predictors of hospitalizations."
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diverticulitis
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is upheld.

This patient presented to the emergency room (ER) with 2 days of left lower quadrant abdominal pain, nausea, vomiting and diarrhea. On exam, the patient appeared stable. The exam was notable for left lower quadrant tenderness on palpation without guarding or rebound. The laboratory evaluation showed leukocytosis of 17. The patient was treated with intravenous (IV) antibiotics and their diet was kept nothing by mouth (NPO). 
A computed tomography (CT) of the abdomen revealed sigmoid diverticulitis with evidence of perforation. A surgery consultant recommended medical management and to advance diet to clear liquids. The patient was doing well without complaints and leukocytosis resolved. The patient was discharged to home with instructions to take 5 days of antibiotics. At issue is the medical necessity of the inpatient hospital stay.

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

The patient had localized diverticulitis without complication. There was no need for surgical or interventional radiology intervention. The patient's exam never suggested peritonitis. The patient's diet was quickly advanced.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Non-displaced right greater trochanter fracture
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient who sustained a ground level fall and complained of pain in his right hip. Plain radiographs obtained in the emergency department revealed a non-displaced right greater trochanter fracture. The patient was admitted to the hospital for further work up and care. An orthopedic consultation was obtained, and non-operative management was recommended for the non-displaced right greater trochanter fracture. Physical therapy for weight bearing as tolerated and gait training was recommended in addition to discharge planning to a rehabilitation facility. The patient had an uneventful hospital stay and was eventually discharged. At issue in this case is the medical necessity of the inpatient hospital admission.

The inpatient hospital stay was not medically necessary in this case. The provided records document that this patient sustained a non-displaced right greater trochanter fracture as a result of a ground level fall. An orthopedic surgery consultation was obtained, and non-surgical management was recommended. This treatment plan was consistent with the current standard of care for a non-displaced greater trochanter fracture as documented by Saad and colleagues in the Journal of Clinical Orthopedic Trauma in 2021. The patient was gait trained with supervised physical therapy and remained in the hospital for discharge planning purposes. The patient had normal vital signs and lab values during his hospital stay and no major medical or surgical interventions were required. Therefore, the medical necessity of the inpatient hospital admission was not established in this case based on the provided medical records.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal/Stomach Pain
Treatment: Inpatient Hospital Stay
The health plan denied: Inpatient Hospital Stay
The determination is: Overturned

The patient is a male who presented to the emergency room (ER) with complaints of right lower quadrant (RLQ) pain for 3 weeks. The patient was found to have leukocytosis and findings of acute appendicitis with the decision to proceed with a laparoscopic appendectomy. The appendix was perforated with phlegmon and abscess present. The patient was treated with intravenous (IV) antibiotics with normalization of his white blood cell (WBC) count, at which time he was transitioned to oral antibiotics and discharged home on post operative day 5.
At issue is the medical necessity of the inpatient admission.
The health plan's determination of medical necessity is overturned in whole.
Yes, the requested health service/treatment of inpatient admission was medically necessary for this patient. The patient had complicated appendicitis with phlegmon and abscess. The patient had leukocytosis and was treated with IV antibiotics until normalization of his WBC count. The patient required inpatient care for IV antibiotics for treatment of complex appendicitis, which could not have been provided at an alternate level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Transient Ischemic Attack
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

The patient is an adult female, who presented with complaint of unsteadiness for the last 3 days. The head computed tomography (CT) was unrevealing. Brain magnetic resonance imaging (MRI) revealed a diffusion deficit to indicate an acute infarct. The patient was admitted and given intravenous (IV) fluids, IV Zofran, and aspirin.

There was no documentation of severe neurological finding such as papilledema, mass effect, bleeding, vasospasm. There was no requirement for parenteral anticoagulants. There was no documentation of treatment-monitoring requiring inpatient admission due to continuous intravenous infusion of a platelet inhibitor, and arrhythmia medications, or cerebral bleed, or increased intracranial pressure.

Coutts S. B. (2017), "Up to a 10% risk of recurrent stroke exists after a transient ischemic attack (TIA), and up to 80% of this risk is preventable with urgent assessment and treatment. Imaging of the brain and intracranial and extracranial blood vessels using CT, CT angiography, carotid Doppler ultrasound, and MRI is an important part of the diagnostic assessment. Treatment options include anticoagulation for atrial fibrillation, carotid revascularization for symptomatic carotid artery stenosis, antiplatelet therapy, and vascular risk factor reduction strategies."

Panuganti, K. et al. (2022), "The main aim of treatment of TIA is to decrease the risk of subsequent stroke or TIA. Early treatment after a TIA can significantly reduce the risk of early stroke. Post TIA, the risk of stroke within 3 months has been reported to be around 20%, with approximately 50% of these strokes occurring within the first 2 days after the initial presentation. It is extremely important to evaluate the vessel status and look for atrial fibrillation when a patient comes with TIA. This will significantly reduce future strokes. Management of TIAs should focus on treating underlying etiologies.]"

"Observation was meant to be a short period of time for providers to assess whether patients required admission for inpatient care or could be discharged. Typically, this was meant to last fewer than 24 hours and only rarely spanned more than 48 hours." (Society of Hospital Medicine, 2021).

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

Diagnosis: Acute Coronary Syndrome (ACS)
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is Upheld

The patient is an adult male with a submitted diagnosis of Acute Coronary Syndrome (ACS). He presented to the emergency department for evaluation of left-sided chest pain associated with deep breaths, cough or certain movement after having lifted a heavy object a few days prior. His past medical history was pertinent for known CAD (coronary artery disease) with CABG (coronary artery bypass graft) surgery, hypertension, 
hyperlipidemia and type 2 diabetes mellitus. Initially, the patient's blood pressure was elevated to 174/89 followed by 152/82, respiratory rate 20, O2 (oxygen) saturation 100% and temperature 96.6 degrees. EKG (electrocardiogram) showed RAE (right atrial enlargement). CXR (chest x-ray) was negative. Labs revealed magnesium 1.7 and glucose 193. Treatment included oral magnesium and cardiology consultation, who recommended outpatient workup. The requested coverage for inpatient hospitalization was denied by the health plan as not medically necessary. The denial is being appealed.

The Inpatient Hospital 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 is 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 care is considered appropriate. In this particular case, there was no clinical decline or inadequate response to treatment which required inpatient hospitalization. 
The care he received 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 Hospital Admission was not medically necessary.