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

Diagnosis: general weakness and gait abnormality
Treatment: Continued Subacute Rehabilitation Admission
The insurer denied the Continued Subacute Rehabilitation Admission
The denial is upheld.

The patient is a male with history of general weakness and gait abnormality after a fall, and was on the floor for five to six days before he was found.  He was admitted with sepsis, dehydration, hypernatremia, malnourished, and in starvation ketoacidosis.

The patient had a relevant past medical history of sepsis, ulcers, diabetic neuropathy, type II diabetes, embolism/deep vein thrombosis (DVT), malnutrition, hypertension, major depressive disorder, alcohol dependence, urinary incontinence, peripheral vascular disease, fecal incontinence, dysphagia, gastroesophageal reflux disease (GERD), anemia, etc.  He was on mechanical soft diet with thin liquids.  Prior to admission, the patient was living alone in an apartment with 12 steps to enter.

The patient was admitted to skilled nursing facility (SNF) with total dependence and some maximum assistance with activities of daily living (ADLs).  The patient was total dependent for transfers, for ambulation, required maximum assistance for toileting, required moderate assistance for bed-mobility, requiring contact guard for hygiene/grooming, minimum assistance for upper body dressing, and supervision for feeding.  The discharge plan is for long-term care versus alternate living facility versus home.

No, the proposed treatment was not medically necessary.

The requested continued skilled nursing facility admission was not medically necessary because the patient had not met all the criteria for continued sub-acute rehabilitation care under INTERQUAL Criteria for Subacute/SNF Criteria Acute Neurological (SAC-SNF).  

The discharge plan was for long-term care versus alternate living facility versus home.

The patient has not shown tangible improvement in rehabilitation.  He was still dependent on mobility and requiring maximum assistance for some activities of daily living (ADLs).  The Plan was to discharge the patient to a long-term care or an alternate living facility.

Yes, the health plan acted reasonably in this instance, and its decision was with sound medical judgment which was in the best interest of the patient.
The continued stay in skilled nursing facility rehabilitation was not medically necessary with clinical evidence as stated above showing lack of tangible improvement in rehabilitation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute cholecystitis

Treatment: Inpatient admission 

The insurer denied coverage for an inpatient 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. [1] Studies have shown that ambulatory laparoscopic cholecystectomy is safe and avoids an overnight hospital stay. [2, 4, 5] Factors that contribute to admission after laparoscopic cholecystectomy include drain placement, conversion to open surgery, persistent abdominal pain, nausea, and vomiting. [3] In patients without abnormalities of the bile duct or abnormal liver function tests, ambulatory laparoscopic cholecystectomy is safe and feasible. [5] Ambulatory and/or outpatient laparoscopic cholecystectomies reduce hospital costs without compromising patient outcomes. [6]

Per clinical documentation, this patient presented to the ED (emergency department) with a one-day history of right upper quadrant/epigastric abdominal pain. There was associated nausea without vomiting. The patient also has a history of GERD (gastroesophageal reflux disease). Vital signs in the ED were within normal limits. The patient had a CT (computed tomography) scan that demonstrated cholelithiasis within a distended gallbladder. An ultrasound on indicated findings highly suspicious for acute cholecystitis. Liver function tests were normal. White blood cell count was elevated at 15.1. The patient was taken to the operating room for a laparoscopic cholecystectomy. There were no reported complications. The patient was discharged. There are no indications of complications or indications for inpatient admission. Peer-reviewed literature indicates that laparoscopic cholecystectomy can successfully be performed as an outpatient procedure. Therefore, the requested inpatient hospital stay is not medically necessary.

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

The insurer's denial of coverage for inpatient emergency admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stab Wound.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

This patient is a previously healthy male, who presented to the emergency department (ED) by Emergency Medical Services (EMS) as a trauma activation following a fall onto a sharp object that penetrated his back. There was a bleeding left flank/back wound. The patient's vital signs were significant for a heart rate of 97 beats per minute at presentation.  The patient was evaluated with physical exam in the emergency department (ED), ultrasound examination and computed tomography (CT) scan in addition to lab data.  The laceration measured 5.7 centimeters (cm) in length and 1.2 centimeters deep per the computed tomography (CT) report. There was noted to be herniation of mesenteric fat between the 11th and 12th ribs on the left side.  The patient's hemoglobin was 15.1.

The wound was locally explored at the bedside in the emergency department (ED). The wound was closed while in the emergency department. The patient was admitted to the hospital for monitoring and remained clinically stable. The hemoglobin value on day two was 14.1. The patient left the hospital against medical advice (AMA) on day two.

The health plan rationale for denial is that the patient's condition and ongoing care needs did not warrant inpatient admission. Rather, the patient's clinical needs could have been appropriately satisfied with a lower level of care. The denial letter references InterQual Acute Adult, General Trauma Criteria.

No, the proposed inpatient admission was not medically necessasry.
Inpatient level of care was not medically necessary for this patient.

Yes, the health plan acted reasonably and with sound medical judgment and in the best interest of this patient with its determination.
A lower level of care would have satisfied the clinical needs of this patient.  This lower level of care would provide for monitoring with repetitive vital signs, lab data, imaging, surgical treatment if required, and overnight care.  

An inpatient designation was not medically necessary or mandated by generally recognized standards of medical care. This patient was clinically stable at the time of presentation and remained stable throughout the period of hospitalization. The wound imaged by computed tomography (CT) scan was not treated with surgical repair other than the bedside exploration in the emergency department (ED). The patient did not have hemodynamic instability and the hemoglobin value remained stable. There was no medical condition that required inpatient care and the patient left the hospital within one day of presentation.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Type II diabetes mellitus
Treatment: Humalog
The insurer denied Humalog. The health plan's determination is upheld.

This is a male diagnosed with type II diabetes mellitus. Humalog is being requested. As reported; he is currently on Ozempic, Lantus, and Humalog. He has previously demonstrated significant deterioration in glucose control when substituting Humalog for either generic Lispro and Novolog. 

A formulary exception is not indicated in this case. There are no studies demonstrating superiority of one rapid acting insulin analog over another (1-4).
The patient is reported to have failed Novolog; however, the medical records do not support this. There is no documentation of trial and failure to Fiasp. Fiasp is not associated with more side effects than Humalog. The patient can try Fiasp. The request is therefore not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nausea, Vomiting.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a medical history of cannabinoid hyperemesis syndrome. She presented to the emergency department with epigastric pain, nausea, and multiple episodes of vomiting. She was using marijuana earlier. Vital signs were notable for an elevated blood pressure of 143/88 millimeters of mercury (mmHg). The physical examination was notable for a soft abdomen with epigastric tenderness and normal bowel sounds. Lab results showed an elevated white blood cell count of 12.6 thousand per microliter (K/uL), low chloride of 110 milliequivalents per liter (mEq/L), and low bicarbonate of 15 mEq/L. She was treated with intravenous morphine, Ativan, and fluids. Lab results showed an elevated white blood cell count of 10.9 K/uL, low chloride of 111 mEq/L, and low bicarbonate of 18 mEq/L. She felt better than the prior day. Lab results showed a normalized white blood cell count and unremarkable basic metabolic panel. She had nausea, better after hot showers. She was discharged on ondansetron, with a plan for Primary Care follow-up. At issue is the medical necessity for the inpatient level of care.
The inpatient stay was not medically necessary in this case.
Although the patient presented with nausea and vomiting, she did not have persistent hypotension, organ failure, or other stigmata of severe volume depletion. The presenting gastrointestinal symptoms of nausea and vomiting were consistent with inflammation (esophagitis, gastritis, duodenitis, peptic ulcer disease), cannabinoid hyperemesis syndrome, gastroparesis, or gastroenteritis [1-6]. However, the patient did not have evidence of bowel obstruction, peritonitis, abscess, fistula, sepsis, ongoing gastrointestinal bleeding, or other complications warranting inpatient level of care [7,8]. She had gradual improvement in her symptoms with conservative therapy, consistent with the standard of care [3-8]. All of the measures that were undertaken, including monitoring, labs, and antiemetic therapy, could have been performed without the inpatient level of care.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Gastroesophageal reflux disease (GERD). 

Treatment: Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (LINX Reflux Management System) including cruroplasty (code 43284) and an associated one-day stay. 

The insurer denied coverage for laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (LINX Reflux Management System) including cruroplasty (code 43284) and an associated one-day stay. 

The denial is overturned. 

The patient has been having reflux symptoms for 2 years. Proton pump inhibitor (PPI) therapy has not provided relief. An endoscopy with biopsies was negative for Barrett's esophagus. An esophageal manometry was normal. A 24-hour pH (potential of hydrogen) impedance study revealed a DeMeester score of 40.3. Various treatment options were discussed with the patient, and she has chosen to proceed with the LINX procedure. 

The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) conducted an updated Safety and Effectiveness Analysis of the Linx Reflux Management System in March 2017. With regards to safety, the conclusion was that long-term follow up supports the FDA (Food and Drug Administration) conclusion that the device is safe. With regards to efficacy there were several conclusions. The LINX implant results in pH normalization, improved quality of life, and cessation of regular PPI use on a consistent basis. When compared to laparoscopic fundoplication, rates of success in alleviating gastroesophageal reflux disease (GERD) symptoms and dysphagia are similar following LINX. The long-term follow-up data demonstrates that the LINX Reflux
Management System is effective in the management of GERD. 

The LINX procedure has been shown to be beneficial for patients with GERD who have not responded adequately to PPI therapy. The scientific literature supports the use of the LINX procedure and results in improvement of health outcomes. The procedure has Food and Drug Administration (FDA) approval. There are several procedures available for the treatment of GERD, but the LINX procedure has been shown to be safe and effective. The LINX Reflux Management System has been shown to be beneficial in patients with chronic reflux who have not responded to PPI therapy. This procedure is likely to be more beneficial than any other standard procedure without increased risk. 

The carrier's denial of laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (LINX Reflux Management System), including cruroplasty (code 43284) and an associated one-day stay should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Spinal stenosis

Treatment: outpatient procedure 20553 x 1, trigger point injection

The insurer denied coverage for outpatient procedure 20553 x 1, trigger point injection

The denial is overturned

This woman has a history of spinal stenosis and diabetes. She had a telemedicine visit with the Pain Management physician for a follow up evaluation of back pain. Pain was rated at a level of 9 out of 10. The patient reported that pain has been so severe that she felt like it was causing glucose intolerance. Her measured Glucose level was greater than 300. The physician recommended a lumbar trigger point injection to treat back pain. Her previous trigger point injection gave her greater than 50% relief for over 6 weeks. She has tried medications, home exercise program, physical therapy (PT), activity modification, exercise, and other modalities for greater than 10 weeks without relief. Gabapentin has not helped her.

The patient wrote that she experienced 4-6 months of pain relief.

The Health Plan denied the request using the Centene guideline: "Trigger Point Injections for Pain Management". That guideline uses a criteria of greater than 50% pain relief for more than 6 weeks. The patient met this criteria.

Staal et al. (1) found only weak evidence to support the use of trigger point injections but the common definition of success was a 50% pain reduction for 6 weeks as in the previously cited guideline.

American College of Occupational and Environmental Medicine (ACOEM) evidence-based practice guidelines on low back disorders, effective 2021, state that trigger and/or tender point injections are not recommended for treatment of acute low back pain. These injections may be reasonable as second or tertiary options for subacute or chronic low back pain that is not resolving with conservative treatment (e.g., NSAID (non-steroidal anti-inflammatory drug), progressive aerobic exercises, and other exercises). The guideline states that injections should consist solely of topical anesthetic (e.g., bupivacaine), and that there is no evidence that steroid is required for efficacy of these injections. Repeat injections should be linked to subjective and objective improvements and be a component of an active therapy program. The ACOEM guideline recommends an interval of at least three to four weeks between injections. If the results are unsatisfactory after the first set, the injections may be repeated. If subjective and objective improvements are not seen, further injections are not recommended.
The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for outpatient procedure 20553 x 1, trigger point injection is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Maxillary transverse deficiency
Treatment: Interceptive treatment
The insurer denied coverage for interceptive treatment. 
The denial is overturned.

This is a teenaged female with no documented medical history. She presented to the Orthodontist's office for an evaluation. X-rays and pictures were taken. The treating Orthodontist recommended interceptive treatment of adolescent dentition. 

Review of the submitted x-rays and clinical photos indicates the patient has a constricted maxilla and an open bite.

Treatment timing of intervention for interceptive and functional treatments has been reported to be a critical issue in orthodontics when dealing with several types of malocclusions. Generally, optimal treatment timing for maxillary transverse deficiency, palatally displaced canines, and skeletal Class III malocclusion should be early (i.e. [that is], pre-pubertal), whereas optimal (functional) treatment timing for skeletal Class II malocclusion should be late (i.e., pubertal). This patient has a maxillary transverse deficiency. Treatment is indicated.

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

The insurer's denial of coverage for interceptive treatment is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity
Treatment: Saxenda
The insurer denied the Saxenda.
The denial is overturned.

This female has obesity.  She is appealing denial of Saxenda.  The most recent progress report notes the member has obstructive sleep apnea, hypertension, and pre-diabetes.  Body mass index equals 31.4.  She is exercising regularly.  The member provided a statement of participating in Weight Watchers.

Yes, the proposed treatment with Saxenda is medically necessary.

No, the health plan did not reasonably, with sound medical judgment, or in the best interest of the patient.

Saxenda is Food and Drug Administration (FDA) approved as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index or 30 or greater or body mass index (BMI) of 27 in the presence of at least one weight-related comorbid condition.  

The requested Saxenda is medically necessary because it is consistent with broadly accepted medical standards for this patient who has a body mass index (BMI) greater than 30 and has instituted behavioral modification with diet and exercise.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumomediastinum.
Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.
The denial is overturned.

This patient has a one day history of chest and abdominal pain and difficulty breathing. He was sick with a sore throat, shortness of breath and cold symptoms. He was seen by his pediatrician one day prior to the hospital admission and was started on amoxil. He was taking the antibiotic at home but when his symptoms did not improve, he was taken to the emergency room (ER) for evaluation.

In the ER, he complained of coughing and chest pain. On physical examination he was noted to be wheezing. He was begun on treatment for an acute episode of asthma with a high flow nasal cannula at 10 liters. He was administered an IV (intravenous) bolus of normal saline, dexamethasone and 3 doses of combivent. When his clinical symptoms did not improve the high flow nasal oxygen treatment was increased from 10 to 15 liters. A chest x-ray was performed which showed subcutaneous emphysema, pneumomediastinum and a pneumothorax. He was breathing at an elevated respiratory rate of 30 and he continues to complain of chest and abdominal pain. The decision was made to admit him to the hospital for monitoring, oxygen therapy and pain management. The next day when his symptoms had improved, he was discharged home. 

The patient was treated appropriately in the emergency room for an acute onset of a pneumomediastinum. He was in pain and was noted to have wheezing by the medical staff. He was also being treated for his first episode of wheezing and he was receiving oxygen with a high flow nasal cannula. The decision to admit the patient for observation and treatment with 15 liters of oxygen via a rebreathing mask was related to the presence of a pneumothorax that was noted on his chest x-ray. There is a risk for pneumothorax to progress during an acute episode of asthma into a tension pneumothorax which can be life threatening. Since the patient had wheezing and a pneumothorax in addition to the pneumomediastinum admission to the hospital for close monitoring was consistent with the standard of care. 

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

The acute inpatient admission is medically necessary.

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

Diagnosis: Cardiac/Circulatory Problems.
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Eliquis (apixaban). 
The denial is overturned. 

This patient is a female with a history of persistent atrial fibrillation, atrial fibrillation ablation, embolic stroke, hypertension, hyperlipidemia, coronary artery disease (CAD), internal carotid artery (ICA) dissection, and lung cancer, who has been treated with apixaban for the last several years. The patient has done well on apixaban without recurrent stroke or bleeding. The patient's provider has requested an exception request for continued coverage for apixaban. The patient's health plan has denied coverage for the non-formulary medication apixaban on the grounds it did not meet established plan criteria. The patient's provider is appealing this denial.
At issue is whether the formulary drug will be or has 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.

Based on the patient's medical history, the formulary drugs, warfarin and Xarelto, would be both less effective and associated with an increased risk for adverse events including bleeding and stroke for this patient compared to apixaban. This patient has a history of embolic stroke due to atrial fibrillation but has done well on apixaban without recurrent stroke or bleeding. Switching to either of the formulary anticoagulants would be associated with an increased risk of stroke during the transition period. Given the increased bleeding risk and greater risk of stroke associated with the formulary anticoagulants, warfarin and Xarelto, apixaban is the safest and most effective therapy for this patient based on peer-reviewed medical literature and the 2019 American Heart Association (AHA)/American College of Cardiology (ACC)/Heart Rhythm Society (HRS) focused update on the management of patients with atrial fibrillation. (1, 2) Eliquis (apixaban) is the safest, most effective anticoagulant to protect the patient from stroke and bleeding when compared to the formulary alternatives.
Therefore, the formulary drugs would not be as effective as the non-formulary drug, Eliquis (apixaban).