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

Diagnosis: cellulitis

Treatment inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

This case involves a male who presented to the emergency department to treat left hand pain from an injection site due to intravenous drug use.  He was discharged the following day.  However, he presented 1 day later with complaints of an abscess.  The documentation indicated he is on Suboxone and stated his medication got wet, so he injected it into his left hand.  He has since had swelling and pain.  He did endorse fever as well as chills and malaise.  The physical examination revealed a pulse of 84 with a temperature of 99.4.  Oxygen was 94% (percent) on room air.  There was swelling to the dorsal aspect of the left hand with induration on the medial aspect of the base of the fifth digit.  There was no palpable fluid collection however there was warmth and tenderness.  The physician indicated he likely had cellulitis and sepsis due to an unspecified organism.  It was recommended he undergo additional laboratory diagnostic studies.  Laboratory studies revealed a high white blood cell count with a low anion gap.  The x-ray revealed diffuse soft tissue swelling.  There was no soft tissue gas or foreign body.  It was recommended he start treatment with IV (intravenous) fluids and IV antibiotics.  He was admitted for further treatment.  He continued with treatment that included IV antibiotics.  He was on vancomycin every 8 hours.  The documentation indicated he was discharged with instruction to follow-up given improvement and no further significant adverse events.

The patient has a history of intravenous drug use and was seen in the emergency room for left hand swelling and redness after self-injection of Suboxone on this site. In addition to local left-hand findings, he presented with unremarkable systemic signs other than a low-grade fever and mild leukocytosis of 12,400 cells/ml (milliliters). His imaging studies did not show the presence of gas, abscess, or foreign bodies. He was given intravenous fluids and started on antibiotics. He was not operated. The patient showed signs of improvement and was eventually discharged on oral amoxicillin clavulanate with trimethoprim sulfamethoxazole. This patient did not have fever greater than 100.5 Fahrenheit and chills with sustained tachycardia, rapid progression of erythema, progression of clinical findings after 48 hours of oral antibiotic therapy or inability to tolerate oral therapy.  In summary there were no clinical, laboratory or imaging findings to qualify this admission as medically appropriate and the prior determination is upheld.

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

Diagnosis: Atypical Chest Pain. 
Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

This patient is a female that presented to the hospital with palpitations, chest pain, diaphoresis, and dyspnea.  Past medical history was significant for hypertension, and atrial myxoma resection surgery. Upon arrival to the hospital, vital signs were stable, blood pressure (BP) 123/91millimeters of mercury (mmHg), Pulse 78 bpm (beats per minute).  Physical examination revealed no abnormality. A 12-lead electrocardiogram revealed normal sinus rhythm with no ST (interval on EKG [electrocardiogram] or T (interval on EKG) wave abnormalities. Serum blood testing was significant for hypokalemia, potassium (K) 3.3 milliequivalents per liter (mEQ/L). High sensitivity troponin was not elevated x (times) 3 (< [less than] 1ng/L [nanograms per liter]).  Echocardiogram revealed a preserved left ventricular ejection fraction (LVEF) of 60% (percent) without significant valvular abnormalities. 

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

This patient presented with atypical chest pain and a past medical history of hypertension. Her pretest probability of coronary artery disease was low (Reference 1).  Utilizing the history, EKG, Age, risk factors and troponin (HEART) score, she was considered low risk (Reference 2).  Utilizing the thrombolysis in myocardial infarction (TIMI) risk score, she also had a low risk of developing major adverse cardiac events in the subsequent 30 days  (Reference 3). Risk assessment of patients presenting with chest pain and no significant ST changes on electrocardiogram (EKG) was reviewed by Hedayati et al. (Reference 3).  Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation.  Using the TIMI risk score, this patient would have a low risk of major cardiac events (all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation.  In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary. In conclusion, this patient could have been treated at a lower level of care. 

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

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital Admission. 

The health plan denied the inpatient hospital admission as not medically necessary. The reviewer has overturned in whole the health plan's determination. 

The patient was admitted to the hospital. The patient has a history of (H/O) of a cerebrovascular accident (CVA) with right sided weakness. The patient presented with 1 day of constant right lower quadrant (RLQ) pain associated with nausea and vomiting and was unable to eat or drink for 4 days. He was using nonsteroidal anti-inflammatory drugs (NSAIDs). Some blood streaking in vomitus. On presentation he had stable vital signs and was not ill-appearing. On physical exam there was tenderness in the RLQ without guarding or rebound. On labs he was found to have an alanine aminotransferase (ALT)=386, and aspartate aminotransferase (AST)=252. The patient underwent a computed tomography (CT) scan which showed duodenitis. He underwent an esophagogastroduodenoscopy (EGD) which demonstrated The Los Angeles (LA) grade of reflux esophagitis (LA Grade D) esophagitis, gastritis with erosions, and duodenitis. He also had an ultrasound which had no acute findings. Nausea and vomiting were resolved. the hemoglobin (Hgb) was stable around 14. Viral hepatitis studies were negative. The patient had mild abdominal pain and some nausea but no vomiting. Diet was advanced and the patient was discharged. 

Yes, the inpatient hospital admission was medically necessary.  The patient presented with 4 days of persistent nausea and vomiting and inability to keep any solids or liquids down. Endoscopy revealed severe esophagitis and erosions in the stomach as the etiology. In addition, he had unexplained liver function test (LFT) abnormalities that were 10 times the upper limit of normal and it is possible hepatitis was contributing to his symptoms. There was no way to know whether he was going to experience worsening of liver function. Inpatient management, including all services provided could not have been safely accomplished at a lower level of care stay.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: Cancer
Treatment; radiation therapy
The insurer denied radiation therapy. 

The health plan's determination is overturned. 

This patient is a man with a locally advanced adenocarcinoma of the rectum with no evidence of distant metastases. Radiation therapy with concurrent chemotherapy is recommended preoperatively and intensity modulated radiation therapy (IMRT) is requested to deliver the radiation therapy.

The requested radiation therapy (IMRT) is medically necessary for this patient. There are very good studies published in peer reviewed journals supporting the use of IMRT over 3D (three dimensional) conformal radiation for patient with rectal carcinomas. Theses studies are randomized or meta analysis and have a significant number of patients with results showing lower rates of side effects to critical vital structures with IMRT as compared to 3D conformal radiation with concurrent chemotherapy.
A comparison radiation plan for 3D and IMRT have been performed for this patient showing the significant decrease in high doses of radiation for the bladder, colon and small intestine. This recommended radiation therapy is considered a medically necessary approach of treatment for this patient and his clinical scenario. This is also supported by National Comprehensive Cancer Network (NCCN) Guidelines with category 2a support.

The health plans determination of medical necessity is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic Dermatitis. 
Treatment: Dupixent 300MG/2ML SOSY. 

The insurer denied the Dupixent 300MG/2ML SOSY. 
The denial is upheld. 

The patient is a male with atopic dermatitis to the face, extremities and neck, treated with topical steroids, systemic steroids, Eucrisa, Opzelura, and tacrolimus. His provider is requesting Dupixent. The health plan denied coverage, as the patient is under the appropriate age. 

No, the requested Dupixent is not medically necessary. 

This patient has not demonstrated an adequate trial and failure to all other standard of care measures for atopic dermatitis. The documentation does not support aggressive topical measures with emollients and wet-to-dry wraps, bleach baths, and phototherapy, which are considered first and second line therapies for eczema. Systemics such as cyclosporine can also be used in atopic dermatitis. 

According to the recommendations provided by Simpson et al, steps taken before commencing systemic therapy include considering alternate or concomitant diagnoses, avoiding trigger factors, optimizing topical therapy, ensuring adequate patient/caregiver education, treating coexistent infection, assessing the impact on quality of life, and considering phototherapy. 

Dupixent is not appropriate or medically necessary for this patient. 

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope.
Treatment: Inpatient stay.

The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

The patient is a man with polysubstance abuse including cocaine and alcohol, and childhood history of seizures. He presented to the emergency department (ED) with syncope while in the shower. He was at the detox center, and during the episode, he ended up biting his tongue but had no loss of bowel or bladder function.
He was brought into the emergency department, his head and neck were scanned, showing no major abnormalities that could be contributing to the syncope. Vital signs on admission were normal. On exam, the patient is well-developed and well-nourished for his age. Lungs are clear to auscultation bilaterally; the cardiac exam is unremarkable. There are no signs of external trauma. Laboratory studies show a normal complete blood count (CBC), chemistry panel without major electrolyte derangements. Liver function tests (LFTs) are remarkable for borderline elevated alanine aminotransferase (ALT) at 54. Imaging of the chest shows no infections or pneumothorax. The patient was admitted to the hospital for syncope. 

The requested inpatient hospital admission is not medically necessary for this patient.
A lower level of care is appropriate for syncopal episodes. The patient essentially experienced a syncopal episode at the detox center. There are no signs of head trauma, neck trauma, no major electrolyte derangements, no evidence of acute coronary syndrome or major arrhythmias. The echocardiogram was completely normal. An electroencephalogram (EEG) was planned but not performed in the hospital, but the patient had no further episodes, and no antiepileptic medications were initiated. The patient had no evidence of seizure activity and no documentation describing severe alcohol withdrawal. The patient was hemodynamically stable throughout the hospital stay and had normal laboratory studies.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neck/arm pain. 
Treatment: Osteopathic Manipulative Therapy. 

The insurer denied Osteopathic Manipulative Therapy. 
The health plan's determination is upheld. 

The patient is a female with neck and arm pain. Under review is the medical necessity of Osteopathic Manipulative Therapy. 

The requested Osteopathic Manipulative Therapy is not medically necessary for this patient. The patient has neck and arm pain. The patient previously received treatment. However, there was no documentation provided concerning this prior treatment. Her pain level was 5/10. Right and left shoulder range of motion (not stated whether active or passive) was moderately reduced. Cervical spine range of motion was not documented. Strength and function were not documented. The medical documentation provided does not demonstrate any meaningful improvement in pain levels, strength, range of motion, or function. Therefore, the Osteopathic Manipulative Therapy is not medically necessary. The patient could be treated with a home exercise program including strengthening and range of motion exercises.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Chronic pain
Treatment: Levorphanol
The insurer denied Levorphanol. The health plan's determination is overturned. 

The patient is female with a history of chronic pain. She was seen via televisit by her provider. The documentation indicates that she has been on other non-narcotic and narcotic pain medication in the past which were not tolerated or were ineffective. 

A formulary exception is indicated in this case. Levorphanol is approved for use in moderate to severe pain where an opioid analgesic is appropriate. Levorphanol has a wide range of activities including opioid agonism, delta agonism, kappa1 and kappa3 receptor agonism, N-methyl-d-aspartate receptor antagonism and reuptake inhibition of both norepinephrine and serotonin. This multimodal profile might prove effective for pain syndromes that are refractory to other opioid analgesics, such as central and neuropathic pain and opioid-induced hyperalgesia. Levorphanol is well suited as a first-line opioid and can also be used during opioid rotation. It has no known effect on the cardiac QT interval or drug-drug interactions involving hepatic cytochrome P450s enzymes. In these regards, levorphanol may offer a superior safety profile over methadone and other long-acting opioids.
In this case, the documentation clearly indicates that the patient had been stable on Levorphanol 2mg (milligrams) TID (three times a day) which improved function and quality of life. The other medication on the Health Plan formulary caused side effects or were ineffective.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Morbid Obesity

Treatment inpatient revenue code 00111 (Medical/Surgical/Gyn)

The insurer denied coverage for inpatient revenue code 00111

Denial is upheld

This is a patient with a history of morbid obesity, hypercholesterolemia, gastroesophageal reflux disease (GERD) and asthma. She was by her physician assistant (PA) for preop visit where it was noted she has morbid obesity which has been refractory to diet, exercise and medical therapy. Her body mass index (BMI) was 44.21.

Based upon the records provided and MCG (Milliman Care Guidelines) guidelines, the patient does not meet the criteria and indications for bariatric surgery.  According  to MCG Health Inpatient and Surgical Care 26th Edition Gastric Restrictive Procedure, sleeve gastrectomy by laparoscopy the procedure is indicated by ALL of the following: Severity of obesity judged appropriate for procedure as indicated by 1 or more of the following: adult patient has BMI of 40  or greater, or  adolescent patient ...has BMI of 40 (or 140% (percent) of the 95th percentile in an age and sex matched growth chart) or greater, or adult Patient has BMI of 35 or greater and clinically serious condition related to obesity (e.g. type 2 diabetes, obesity hypoventilation, obstructive sleep apnea, nonalcoholic steatohepatitis, pseudo tumor cerebri, severe osteoarthritis, difficult to control hypertension), or adolescent patient ...has BMI of 35 (or 120% of the 95th percentile in an age and sex matched growth chart) or greater and a clinically serious condition related to obesity (e.g. type 2 Diabetes, obstructive sleep apnea, nonalcoholic steatohepatitis, pseudotumor cerebri, Blount disease (tibia vara), slipped capital femoral epiphysis), or ... Although this patient has a BMI greater than 40 which would justify bariatric surgery there is no evidence in the multidisciplinary program of mental health consultation. Perhaps the records were not sent. However, given the lack of mental health consultation she has not met MCG guidelines for bariatric surgery.  Thus, the patient does not meet MCG criteria or the insurer's policy and should not have had bariatric surgery.

Based upon the records submitted and also based upon the fact that Cloud Med does not reference a mental health consultation, it appears that the patient has not met criteria for bariatric surgery with a mental health consultation. 

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

The insurer's denial of coverage for inpatient revenue code 00111 provided is upheld. Medical necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Atrial fibrillation
Treatment: Eliquis
The insurer denied Eliquis.
The determination is upheld.

The patient has a history of paroxysmal atrial fibrillation, hypertension, obesity and closure of a patent foramen after an embolic stroke several years prior. He has been treated with abixaban (Eliquis) for thromboprophylaxis after his atrial fibrillation was diagnosed. At issue is whether the formulary drugs will be or have been ineffective, would not be as effective as the non-formulary drug, Eliquis, or would have adverse effects.

The formulary alternatives include warfarin, a vitamin K antagonist, and rivaroxaban (Xarelto), which, like apixaban (Eliquis), is a direct oral anticoagulant (DOAC).

Warfarin would be expected to be less safe and less effective in this instance as compared to apixaban. Data from multiple randomized controlled trials have shown that use of DOACs, as compared to warfarin, for thromboprophylaxis in atrial fibrillation has been associated with fewer ischemic events and fewer severe bleeding episodes. While retrospective studies have suggested that apixaban is superior to rivaroxaban when used for thromboprophylaxis in patients with atrial fibrillation, there have been no randomized controlled trials comparing the two and direct comparison is confounded by differences in enrollment criteria in the different studies. Thus, at this time, it is not clear that rivaroxaban would be less safe or less effective in this particular case. Current guidelines do not endorse the use of one DOAC over another in this situation. Moreover, the medical literature does not suggest that transitioning from one DOAC to another is associated with a significant increase in the risk for adverse events.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe Aortic Valve Stenosis. 
Treatment: Procedure code 33363 (transcatheter aortic valve replacement with prosthetic valve, percutaneous femoral artery approach/ open axillary artery approach). 

The insurer denied coverage for procedure code 33363. 

The denial is overturned. 

This is the case of a male with severe aortic valve stenosis that was scheduled for transcatheter aortic valve replacement. Past medical history was significant, coronary artery disease, hypertension, diabetes mellitus and squamous cell lung cancer. The patient reported symptoms consistent with New York Heart Association (NYHA) class III heart failure. Echocardiogram revealed severe aortic stenosis with an aortic valve area of 0.9cm2 and aortic valve velocity of 4.5m/se (meter per second). 

This patient has severe aortic stenosis and symptoms of shortness of breath consistent with NYHA class III functional status. Findings on echocardiography were consistent with severe aortic stenosis. (1) Severe aortic stenosis is associated with increased morbidity and mortality. (2) According to American Heart Association and American College of Cardiology and supported by recent literature, this patient has a class I indication for transcatheter aortic valve surgery. (3,4,5) Procedure code 33363 encompassing transcatheter aortic valve replacement with hospital admission is medically necessary in this case. 

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 procedure code 33363 and a hospital admission on a date yet to be determined is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: COVID Pneumonia (lung infection).
Treatment: Continued inpatient admission.
The insurer denied the Continued inpatient admission.
The denial is upheld.

The patient is a male with shortness of breath. He was seen in the ER (emergency room) two days prior to presenting to the ER (emergency room) again with worsening shortness of breath.

The patient was found to have multifocal infiltrates from COVID 19 pneumonia and was hypoxic with oxygen levels at 91% (percent). The patient was admitted to the hospital for the management of hypoxic respiratory failure due to COVID 19 pneumonia. The patient was treated with IV (intravenous) remdesivir, decadron and antibiotics. The patient remained in the hospital.

The continued admission for the dates in question was denied coverage by the health plan due to lack of medical necessity. This denial is being appealed.

No, the Continued inpatient admission was not medically necessary.
For the dates in question, the patient was hemodynamically stable. The patient was not on supplemental oxygen. The patient was tolerating diet and was ambulating. The inflammatory markers were trending down. The continued inpatient admission for the management of COVID-19 pneumonia was not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.