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

Diagnosis: Chest pain.
Treatment: Inpatient hospital admission.

The insurer denied the inpatient hospital admission.  The denial has been upheld. 

The proposed treatment was not medically necessary.

This male was hospitalized from for congestive heart failure (CHF).  He presented to the emergency department (ED) for evaluation of shortness of breath for two days.  His past medical history was remarkable for known congestive heart failure, implantable cardioverter defibrillator (ICD), hypertension, chronic kidney disease (CKD) and gout.  The patient's blood pressure was 126/90, and respiratory rate was 22 to 32. The patient's exam revealed lungs with bibasilar crackles and legs with trace bilateral edema. Chest film showed cardiomegaly with mild pulmonary vascular congestion without effusions or infiltrate. Labs revealed blood urea nitrogen (BUN) 34, creatinine 2.01, brain natriuretic peptide (BNP) 1554.9. Treatment included intravenous Lasix, and his shortness of breath resolved. The requested coverage for inpatient admission was denied based on his policy, and the patient is appealing the decision.

Based on the peer reviewed medical literature, the documentation submitted for review does not establish the requested acute inpatient hospital stay was medically necessary for this patient. According to the Milliman Care Guidelines (MCG) titled: Heart Failure (ORG: M-190), inpatient admission was not medically necessary, because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. Criteria for inpatient stay are not met, including documentation of hemodynamic instability, respiratory distress, change in mental status, severe heart failure, cardiac arrhythmias of immediate concern, myocardial ischemia or myocardial infarction, positive troponin not explained by chronic kidney disease (CKD) and congestive heart failure (CHF), hypertension requiring inpatient hospitalization, cerebral vascular accident (CVA), pulmonary embolism, aortic dissection, pneumonia, severe electrolyte abnormalities or any other medical condition or other medical instability or acute care needs for which would require acute inpatient management. 

In this particular case, there was no clinical decline or inadequate response to treatment which required continuation of the hospital stay. The care the patient received for mildly decompensated chronic left ventricular (LV) systolic heart failure (HF) is routinely provided safely and effectively at a lower level of care. Therefore, the proposed treatment was not medically necessary.       

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

There was no clinical decline or inadequate response to treatment which required inpatient hospital stay. The care the patient received for mildly decompensated chronic left ventricular (LV) systolic heart failure is routinely provided safely and effectively at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back and leg pain. 
Treatment: Subacute rehabilitation continued stay. 
The insurer denied coverage for the subacute rehabilitation continued stay. 
The denial is upheld. 
 
The patient is an adult admitted from the hospital for rehabilitation (rehab) for back and leg pain. After three (3) weeks, he was ambulating 125 feet with a walker. He was noted to have weakness in his left lower extremity, but he was able to do transfers. 

The patient had 45 days of subacute rehab approved per the plan. It was decided the subacute rehab would stop and a 14-day appeal extension was denied. It was noted the patient was able to move himself in and out of a bed to a chair, walk 200 feet with a walker and complete personal care such as bathing and dressing on his own. 

The patient is at a community ambulation distance. Documentation did not support the subacute rehabilitation continued stay. 

The subacute rehabilitation continued stay going forward is not considered medically necessary for this patient. The patient had 45 days of subacute rehab approved per the plan. It was noted the patient was able to move himself in and out of a bed to a chair, walk 200 feet with a walker and complete personal care such as bathing and dressing on his own. 

Therefore, subacute rehabilitation continued stay going forward is not considered medically necessary for this patient. 

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 subacute rehabilitation continued stay is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right upper quadrant tenderness. 
Treatment: Inpatient admission. 
The insurer denied coverage for inpatient admission. 
The denial is upheld. 

This is the case of an adult male who presented to the emergency room, scheduled for elective gall bladder surgery the next month, and reported having increased right upper quadrant (RUQ) pain, vomiting, and chills over the past 2 days. He was afebrile with white blood cell (WBC) count of 8.06, hematocrit 44.8, aspartate aminotransferase/alanine transaminase (AST/ALT) 18/15. Right upper quadrant (RUQ) sonogram findings were: gallbladder was normal, and he had negative Murphy sign. The plan was to admit, nothing by mouth (NPO), pain control and possible laparoscopic cholecystectomy. 

During the brief hospitalization the patient had no medical conditions with clinical characteristics that required inpatient level of care. He required short term monitoring, diagnostic evaluations, acute treatments and reassessment. 

According to the guidelines of MCG (Milliman Care Guidelines) Health Inpatient and Surgical Care- 27th edition Gall bladder or bile duct inflammation or stone ORG: M-555 (ISC) patients may be discharged to a lower level of care (either later than or sooner than the goal) when it is appropriate for their clinical status and care needs. 

Milliman Care Guideline (MCG) General recovery care 27th edition Ambulatory surgery exception criteria GRG:CG-AEC (ISC GRG) notes that potentially ambulatory procedure or surgery warrants inpatient care due to 1 (one) or more of the following: Inpatient care needed for clinically significant preoperative disease or condition; Complex surgical approach or situation anticipated; Procedure is not low risk and patient at high anesthetic risk; Presence of drug-related risk; Inadequate outpatient care situation; Postoperative event, condition, or finding that warrants inpatient stay. 

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: Shoulder Problem/Pain
Treatment: Inpatient emergency admission
The health plan denied Inpatient emergency admission.
The determination is Upheld.

The patient is a female who failed conservative treatment for right shoulder rotator cuff arthropathy. She opted to undergo elective right reverse total shoulder arthroplasty (TSA). The surgery was completed successfully with no documented complications. She was deemed stable for discharge home the following day. At issue is the medical necessity of the inpatient hospital admission.
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of an inpatient hospital admission was not medically necessary for this patient. The provided medical records document that this female patient opted to undergo elective right reverse total shoulder replacement surgery. There were no documented complications of this operation. The progress notes document that there were no signs of infection, and that the patient's pain was controlled. She was deemed stable for discharge the following day. The records do not support the medical necessity of an inpatient hospital admission for this patient. In addition, the current, peer-reviewed orthopedic literature has not found that inpatient status for total shoulder replacement surgery is most effective for patients. A recent article published by Willenbring and colleagues in the Journal of Shoulder and Elbow Surgery, concluded that "Postoperative complications and emergency department (ED) returns were not significantly different between inpatient and outpatient TSA (total shoulder arthroplasty). Each 1-year increase in age increased the odds of postoperative surgical complications by 14 percent (%), regardless of surgical setting. Outpatient TSA (total shoulder arthroplasty) was found to be safe for appropriately selected patients aged greater than or equal to (>=) 65 years, and re-evaluation of TSA (total shoulder arthroplasty) as an inpatient-only procedure should be considered." 
A second article authored by Cimino and associates in the Journal of Shoulder and Elbow Surgery determined that "Outpatient TSA (total shoulder arthroplasty), in an appropriately selected patient population, is safe and results in comparable patient outcomes to those of inpatient shoulder arthroplasty. Given the expected increase in the number of patients requiring TSA (total shoulder arthroplasty), surgeons, hospital administrators, and insurance carriers should strongly consider the merits of a cost- and care-efficient approach to total shoulder replacement." Therefore, based upon the documentation in the records and the recommendations of the peer-reviewed literature, the inpatient hospital admission was not medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Functional impairment for all daily activities. 
Treatment: Home health care (HHC)/ personal care - level 2 personal care services, per 15 minutes increase to 24 hours per day (split shift). 

The insurer denied coverage for home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 24 hours per day (split shift). 

The denial is overturned. 

This elderly female has extensive medical history associated with functional impairment for all daily activities. The patient lives alone and has been receiving personal care services (PCS) 84 hours per week to assist with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). 

The patient is totally dependent for ordinary housework, meal preparation, managing finances, shopping; she needs maximal assistance for managing medications, phone use, transportation, equipment management; extensive assistance for stairs.  She needs maximal assistance for bathing, personal hygiene, dressing upper/lower body, toilet use; extensive assistance for walking, locomotion, transfer toilet, bed mobility, eating.

The patient's decision-making for daily tasks is described as moderately impaired - decisions consistently poor or unsafe, cues/supervision needed at all times.  She had short term and procedural memory problems; oriented to person. She was able to make her needs known and direct care in simple situations. It was noted that her mental function varies over the course of the day. 

The patient has poor vision and needs a walker and hands on assistance to walk. 

The records indicate the patient has very limited vision, with history of macular degeneration. The daughter reported the patient is almost blind. 

She has severe fatigue, which may be at least partly due to her chronic lung disease. The patient needs extensive assistance for toilet transfer; maximal assistance for toilet use (which includes incontinence care); and she has frequent bladder and bowel incontinence. 

The patient has frequent toileting/incontinence care needs; she needs extensive assistance with and patient has chronic pain that she is unable to manage without help.  

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 home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 24 hours per day (split shift) services is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's disease
Treatment: Full Hospital Admission
The insurer denied the full hospital admission.
The health plan's determination is overturned.

The patient is a male who presented to the hospital for chronic diarrhea, abdominal pain and weight loss. The patient was also dizzy and lightheaded. His laboratory studies showed a normal hemoglobin and normal electrolytes. His inflammatory markers were elevated. He underwent an endoscopic evaluation and he was diagnosed with Crohn's disease. He was started on intravenous corticosteroids.

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

The full hospital admission was medically necessary. The patient presented for chronic diarrhea, weight loss, abdominal pain, decreased oral intake and dizziness. The patient's condition was highly concerning for chronic inflammatory bowel disease. Due to the presenting concerning signs, weight loss and decreased oral intake, continued outpatient management was not appropriate.
The patient's care included intravenous fluids, a bowel cleanout, endoscopic evaluation and immune suppressive therapy (intravenous corticosteroids). The patient's evaluation and management were complex and required close medical attention and a high level of care. The management was not possible at an alternate level of care.

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

Diagnosis: Papillary Thyroid Carcinoma.
Treatment: Inpatient Hospital Admission.
The insurer denied the inpatient hospital admission.
The health plan's determination is overturned.

The patient is a female with a medical history of hypertension, diabetes mellitus, schizophrenia, osteopenia, and biopsy proven papillary thyroid cancer. She underwent a right hemi-thyroidectomy.  She was admitted to the hospital for overnight monitoring for multiple factors including elevated blood pressure, concern for dysphagia/aspiration given new right vocal cord paralysis, monitoring of surgical drain output, and post- operative hypocalcemia. 

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

The requested health service/treatment of an inpatient hospital admission was medically necessary for this patient. During surgery, the cancer was noted to have invaded adjacent structures including the right recurrent laryngeal nerve, which was ultimately sacrificed.
This patient met multiple criteria necessitating admission including acute onset of right vocal cord paralysis with concern for dysphagia, aspiration, need to monitor surgical drain output, worsening of baseline hypertension, and post operative hypocalcemia requiring replenishment.

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

Diagnosis: Sinusitis

Treatment: Dupixent

The insurer denied coverage for Dupixent

The denial is overturned

According to the medical records, the patient is an adult who presented with chronic sinusitis. The patient has had sinus surgery. Symptoms include chronic sinusitis and congestion. Medications trialed include steroids, antibiotics, and saline irrigations. Physical examination and computed tomography demonstrated nasal polyposis. The request of this review is to determine medical necessity of Dupixent for control of symptoms.

The patient has had sinus surgery before, has severe complaints, nasal polyposis, and has failed conventional medical intervention. Dupixent is well-supported in the literature.      

Dupixent is considered medically necessary for this patient. The patient has chronic sinusitis. The patient has had sinus surgery. Symptoms include chronic sinusitis and congestion. Medications trialed include steroids, antibiotics, and saline irrigations. Physical examination and computed tomography demonstrated nasal polyposis. Further, the literature supports its usage:

According to Bachert et al (2019), "In adult patients with severe Chronic rhinosinusitis with nasal polyps (CRSwNP), dupilumab reduced polyp size, sinus opacification, and severity of symptoms and was well tolerated. These results support the benefits of adding dupilumab to daily standard of care for patients with severe CRSwNP who otherwise have few therapeutic options."

According to Laidlaw et al (2021), "Dupilumab improved upper and lower airway outcome measures and Health-related quality of life in patients with severe CRSwNP and comorbid asthma and was well tolerated."

According to Bachert et al (2016), "Among adults with symptomatic chronic sinusitis and nasal polyposis refractory to intranasal corticosteroids, the addition of subcutaneous dupilumab to mometasone furoate nasal spray compared with mometasone alone reduced endoscopic nasal polyp burden after 16 weeks."                                                         

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

Diagnosis: Crohn's Disease.
Treatment: Uceris.
The insuer denied: Uceris.
The denial is: Upheld.

The patient is a female with severe ileocolonic Crohn's disease. She is being started on infliximab with a prednisone bridge. She has symptoms of proctitis. Hence, the attending provider would like to use Uceris foam to treat this patient's proctitis. The subject under review is the medical necessity for Uceris in this case.

The requested health treatment of Uceris is not medically necessary for this patient. Uceris foam is not indicated for Crohn's disease and is Food and Drug Administration (FDA) approved only for ulcerative colitis. Crohn's disease results from a pathological immune response to luminal antigens in genetically predisposed individuals. Since the causes of Crohn's disease are complex and only partially understood, treatment is based on the empiric use of anti-inflammatory drugs. Although multiple therapies for Crohn's disease currently exist, a substantial proportion of patients are unresponsive to conventional agents. The current treatment options for patients with moderate-to-severe inflammatory bowel disease (IBD) have substantial limitations: many individuals are refractory to available therapies, develop drug resistance, or experience adverse effects that limit quality of life and/or treatment.

Uceris rectal foam is a glucocorticosteroid indicated for the induction of remission in patients with active mild to moderate distal ulcerative colitis extending up to 40 centimeter (cm) from the anal verge. Therefore, the use of budesonide foam to treat Crohn's disease in this patient is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Problems with Veins in Legs
Treatment: Venous Ablation times 5.
The insurer denied venous ablation times 5. 
The health plan's determination is upheld.

The patient is a female who was evaluated for right leg swelling and pain. She complained of some raw skin and pain in her lower abdominal area. The patient was noted to have warm bilateral lower extremities and palpable dorsalis pedis (DP)/posterior tibial (PT) pulses. There were no ulcerations or venous stasis changes.
The right leg reflux study that was performed documented: no venous volumetric index (VVI) in the right lower extremity (RLE) and deep veins. No VVI was seen in the right greater saphenous vein (GSV). The GSV becomes superficial at the mid-thigh with no VVI seen in right small saphenous vein (SSV) and there was right ankle edema.

The patient was seen for a follow up. She was treated for right leg cellulitis. A note was made of a reflux study that illustrated venous insufficiency. The provider recommended right leg ablation.

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

The requested health service/treatment of venous ablation times 5 is not medically necessary. There is no report or documentation of a lower extremity venous insufficiency study demonstrating lower extremity venous insufficiency. The clinic visit notes documented no venous insufficiency on the right leg reflux study. There is no evidence of venous insufficiency. 
The patient was noted to have a sign of a cellulitis infection to her right leg. She was given a prescription for Augmentin for three weeks. The results of the ultrasound were discussed with the patient. It did not demonstrate VVI to the right lower extremity. The patient was instructed to return for a follow up in one month.

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

Diagnosis: Breast Cancer
Treatment: Proton treatment delivery; simple without compensation and non-diagnostic positron emission tomography (PET)/computed tomography (CT).
The insurer denied: Proton treatment delivery; simple without compensation and non-diagnostic positron emission tomography (PET)/computed tomography (CT).
The denial is: Upheld

The patient is a female with history of tumor (T)3 necrosis (N)1 T0N0 estrogen receptor (ER)/progesterone receptor (PR)negative (-), human epidermal growth factor receptor 2 (HER2) positive (+) left breast cancer status/post (s/p) neoadjuvant systemic therapy followed by surgical resection. She has been recommended to proceed with a course of postoperative external beam radiotherapy with curative intent. Request is for approval of proton beam radiation therapy. Also under review is medical necessity for non-diagnostic positron emission tomography (PET)/computed tomography (CT).

The requested proton radiation and non-diagnostic PET/CT is not medically necessary for this patient. These procedures have not been proven to yield superior clinical outcomes in the patient's setting. Proton radiation is the subject of ongoing clinical trials for management of the member's breast cancer in an effort to determine its safety/efficacy as compared to standard of care photon radiation. The treating provider has not supplied a proton/photon plan comparison to show that photon radiation is unable to provide adequate safety/precision; the provided plan comparison is for a case control patient and is not specific to this patient. The patient has not received prior radiation to the thoracic region, nor does she have a genetic/comorbid condition that increases her risk for normal tissue toxicity.