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

Diagnosis: sickle cell disease
Treatment: inpatient stay
The insurer denied the inpatient stay.
The health plan's determination is upheld. 

The patient is a male who presented to the emergency department with concerns for sickle cell pain in the left leg. Pertinent history included sickle cell disease. Initial vital signs revealed a temperature of 99.1oF, heart rate (HR) 130, blood pressure (BP) 146/85, respiratory rate (RR) 18, and oxygen saturation 95% on room air. Initial examination documented the patient as alert and oriented. Initial laboratory testing revealed a white blood cell count (WBC) 16.3, Hemoglobin (HGB) 9.6, platelets (Plt) 448, blood urea nitrogen (BUN) 5, Cr (creatinine) 0.6, Na (sodium)141, and K (potassium) 4.5. A chest x-ray (CXR) revealed no gross pulmonary opacity or effusion. Intravenous fluids and analgesia were provided. 

The inpatient hospital admission was not medically necessary. Evaluation and management could have been performed at a lower level of care. The patient had a history of sickle cell disease who presented with left lower extremity pain. A comprehensive evaluation including laboratory testing and radiography was essentially unremarkable. Treatment plan included intravenous fluids and analgesia as needed. Following observation care, pain had resolved and the patient was discharged. No other issues or complications were documented.
Moreover, clinical indications for admission to inpatient care were not met. The patient did not have signs or symptoms of central nervous system acute injury, acute chest syndrome, hypoxemia, emergent surgery needed, splenic or hepatic sequestration, acute ischemia, acute renal failure, aplastic crisis, priapism or other vascular complications, traumatic hyphema, infection requiring inpatient treatment (eg, bacteremia), altered mental status, need for exchange transfusion, inability to maintain oral hydration despite observation care treatment, or pain insufficiently responsive to observation care treatment that requires treatment in inpatient setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Left nephrolithiasis.
Treatment:  Inpatient stay.

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

The patient is a young male with left nephrolithiasis, who underwent percutaneous nephrolithotomy with lithotripsy and placement of ureteral stent via cystoscopy and insertion of indwelling Foley catheter as an inpatient. The admission was not complicated by fever, sepsis, pain with parenteral medication requirement, or inability to tolerate oral intake.

The inpatient hospital admission was medically necessary for this patient. The potential for bleeding requiring transfusion, fever, sepsis are significant and may manifest after the intraoperative and perioperative period and require immediate therapy to preclude life threatening events. The small size of stents and urinary drainage catheters makes obstruction a real possibility with dire consequence if not addressed immediately. The inpatient hospital stay is medically necessary in this case for safe and effective care of pediatric patients undergoing nephrolithotomy percutaneously by literature and societal guidelines.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope.
Treatment: Inpatient Hospital Stay.
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

The patient is a male with migraines a history of testicular cancer, and partial inferior vena cava (IVC) thrombus, on Eliquis. He presented to the emergency room (ER) after a syncopal episode. A head computed tomography (CT) scan was performed showing no acute infarction, intracranial hemorrhage, or hydrocephalus. He had previously been admitted with dizziness and palpitations. At that time, he had undergone an echocardiogram (ECHO) showing mild left ventricular hypertrophy, normal left ventricular (LV) systolic function, ejection fraction (EF) 55-60%, and stress test which was negative for ischemia.
He was admitted to telemetry. He underwent an electrophysiology study which showed a sinus node recovery time (corrected) of 390 milliseconds (ms), normal. His Purkinje and atrioventricular (AVN) conduction. An insertable loop recorder was recommended to further assess his conduction system. He was discharged. At issue is the medical necessity of an inpatient stay.
Inpatient admission is not medically necessary for this patient.
The patient presented following a syncopal episode. He had a previous recent admission for dizziness and palpitations during which myocardial ischemia and significant structural heart disease had been ruled out. He was hemodynamically stable, and a head computed tomography (CT) scan (done in the ER) ruled out an acute intracranial process. He underwent electrophysiologic testing, which was negative. Per Milliman Guidelines, inpatient admission is indicated for patients with "syncope who have: hemodynamic instability, altered mental status that is severe or persistent, cardiac disease or finding (e.g., results of echocardiogram or cardiac monitoring performed in observation care) that indicates necessity of immediate (i.e., not as a scheduled elective procedure) intervention, Inheritable cardiovascular condition predisposing to arrhythmias diagnosed or suspected (e.g., Brugada syndrome, short QT syndrome, long QT syndrome), dehydration that is severe or persistent, or syncope causing injury requiring hospitalization." The patient does not have any of these conditions. The patient was admitted with syncope but was hemodynamically stable on admission. He had a recent previous cardiac workup within the past month before the current hospitalization and had an electrophysiology study in the hospital. He could have been managed at a lower level of care, rather than a full inpatient admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal Pain
Treatment: Emergency Room Visit
The insurer denied Emergency Room Visit.
The determination is overturned.

The patient is a male with a history of hypertension, hyperlipidemia, hypothyroidism, and diverticulosis who presented to the emergency department with the complaint of acute onset 2 out of 10 (2/10) left lower quadrant abdominal pain. He was evaluated and treated. He reported the pain would come and go and was associated with no bowel movement for 5 days. He denied any nausea, vomiting, diarrhea, hematochezia, urinary symptoms, or fevers. He denied any past surgical history. His vital signs were within normal limits. On physical exam, he was not to be in no acute distress. His cardiopulmonary exams were within normal limits. He had mild tenderness to his left lower quadrant. Lab work was performed and unremarkable. A computed tomography (CT) scan of the abdomen and pelvis was notable only for distention of the colon secondary to stool. He was discharged home in stable condition with the diagnosis of constipation and instructions to use a laxative and to follow up with his primary care physician. At issue is the medical necessity of the emergency room (ER) visit.

The Emergency Department visit was medically necessary to rule out a life threatening cause (bowel obstruction, abdominal aortic aneurysm, diverticulitis, perforated viscous) of his acute left lower quadrant abdominal pain.
The patient presented with 5 days of left lower quadrant abdominal pain with no bowel movement. The patient had a history of diverticulosis. According to the provided documentation, the patient was advised to go to the Emergency Department by his primary doctor due to the nature of his symptoms and lack of availability of outpatient appointments. He was noted to have tenderness on exam and the treating physician considered multiple life threatening conditions, including bowel obstruction and diverticulitis. Acute pain of 1 week or less warrants expedited and thorough work up (1). Labs and a computed tomography (CT) scan ruled out these emergency medical conditions, but testing was needed to do so.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: Morphea.
Treatment: Dupixent.
The insurer denied Dupixent.
The health plan's determination is upheld. 

The patient is a female with localized morphea and keloids, as well as widespread hyperpigmented patches and plaques of the anterior neck, bilateral shoulders, bilateral upper arms, forearms, and bilateral hips. The patient has tried and failed topical tacrolimus and Zoryve, as well as oral CellCept and Otezla, and also Phototherapy.

Dupixent is not medically necessary for this patient.
A fairly exhaustive review of the literature notes that minimal evidence exists to support the use of Dupixent (dupilumab) as even a third- or fourth-line therapy for the treatment of morphea/localized scleroderma. Furthermore, some case reports of morphea resulting from (or while on) Dupixent have been reported. Although there is now a Phase II study for the use of dupilumab in the treatment of morphea/scleroderma, the clinical utility and appropriate use of dupilumab in the treatment of the morphea/scleroderma spectrum is entirely unknown.
Of note to this patient's particular clinical scenario are the unanswered questions of how high the dosage of CellCept was used for this patient's condition, and/or if UVA (ultraviolet) phototherapy (which is the most well-documented, albeit hard to access, a form of phototherapy for morphea/scleroderma) was utilized. At times, Prednisone pulses, and/or a switch from CellCept to Methotrexate, may provide the patient with a treatment regimen far more proven than the requested Dupixent.
Accordingly, with so little reliable evidence for the use of Dupixent for this patient's condition, Dupixent is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: acute coronary syndrome
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is overturned. 

This case involves a male with a past medical history significant for hypertension, type 2 diabetes, and hyperlipidemia, who presented to the emergency department (ED) for evaluation of shortness of breath, chest pain, and palpitations occurring for 2 weeks. Vital signs in the ED demonstrated uncontrolled blood pressure, 182/121. The patient was tachycardic. Notable labs showed high pro- brain (or B-type) natriuretic peptide (BNP) 2,029, leukocytosis, and mildly elevated lactate 2.5. Cardiac troponins were negative. An electrocardiogram (ECG) demonstrated sinus tachycardia and left bundle branch block. Chest x-ray showed a small right pleural effusion with mild pulmonary edema. The patient was admitted to telemetry service under the inpatient level of care for evaluation of possible acute coronary syndrome (ACS), uncontrolled hypertension, and new onset acute heart failure.

The inpatient hospital admission was medically necessary. The patient presented with symptoms and signs consistent with acute heart failure, possible ACS, and hypertensive emergency. Given this high-risk cardiovascular presentation, the inpatient level of care would be considered standard of care for acute management to achieve optimal patient outcomes including reducing the patient's risk of short-term major adverse cardiac events. The inpatient level of care was medically necessary given hospital care services would span at least 2 midnights. The Inpatient level of care was medically appropriate and necessary for telemetry and hemodynamic monitoring, serial lab assessment and to complete an urgent evaluation for structural heart disease. For these reasons, based on this patient's high level of medical complexity, the inpatient level of care would be supported by peer-reviewed medical literature.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder. 
Treatment: Braces, monthly visits, and retainer. 
The insurer denied Braces, monthly visits, and retainer. 
The determination is overturned. 

This is a male patient in question who presented with a skeletal Class III malocclusion and mild spacing. He has an anterior open bite. Teeth 20 and 29 are missing and teeth K and T are retained. He is treatment planned for orthodontics to address the crowding and open bite. The treatment was denied due to a lack of medical necessity. At issue is the medical necessity of braces, monthly visits, and retainer. 

Patients with an anterior open bite are among the most difficult patients to treat. (1) One side effect of an anterior open bite is reduced maximum bite force with less muscle activity while chewing than patients without an open bite. (2) Orthognathic surgery or permanent teeth extraction are often the choice of treatment to treat patients with anterior open bite. (3) 
Studies have shown that patients with severe malocclusions, including anterior open bite, have significantly lower masticatory and gastrointestinal digestive function than persons with normal occlusion. However, it has also been shown that after orthodontic treatment, there was no difference in masticatory function and gastric emptying between the treated group and the control group with normal occlusion. Given the patient's malocclusion and the likelihood of significantly reduced masticatory function and digestive function, orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Facial fractures

Treatment: Inpatient hospital

The insurer denied coverage for inpatient hospital

The denial is upheld

 
This patient underwent open reduction and internal fixation (ORIF) to his Zygoma and maxillary area. His injury was 3 weeks old. He surgery was completed in the afternoon. The procedure and post anesthesia course was non complicated. 

The physician record noted "discharge tomorrow.". The discharge summary reported no complications with discharge. He was transferred to a skilled nursing facility (SNF). There were no conditions to support the admission and length of stay as provided. Services could have been completed at a lower level of care. The documentation provided showed surgical repair was completed to several facial fractures. There were no reported complications after the operation. There was no report of bleeding or wound problems. There was no report of inability to tolerate current pain regimen. There was no report of abnormal vital signs. There was no indication for additional subspecialty consultation, imaging, monitoring nor additional surgery. There were no extenuating circumstances to substantiate service at the acute level. A lower level of care would be appropriate considering diagnosis and recent treatment.

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

Diagnosis: Premenstrual tension syndrome

Treatment: Orilissa 200 milligrams (mg) for greater than 372 tablets per 720 days

The insurer denied coverage for Orilissa 200 milligrams (mg) for greater than 372 tablets per 720 days

The denial is overturned

 
This is an adult female diagnosed with premenstrual tension syndrome and is seeking coverage for Orilissa 200 mg twice daily.  The patient has incapacitating nausea and vomiting whenever she has her menstrual cycle. She cannot tolerate oral contraceptives (both combined and progestin only). She used them in the past but developed serious side effects necessitating hospital admission for management.

The request was denied because it is not in accordance with the criteria set forth in policy guidelines, the member's Certificate of Coverage, the Food and Drug Administration (FDA) and the recognized standards of care.

Orilisa induces a dose-dependent suppression of sex hormones in premenopausal females when consumed in regimens; 150 mg once daily, or 100, 200, 300, or 400 mg twice daily for 21 days as compared to placebo. Notably, maximum suppression was achieved with regimen starting from 200 mg twice daily or higher.

In women with severe symptoms, like this patient, who have not responded to or cannot tolerate oral contraceptives, agonist therapy or antagonist therapy is the next step. However, these medications should not be considered until the patient has first tried multiple oral contraceptives (OC). This patient had severe reactions to multiple OCs.

The first demonstration of benefit of "medical oophorectomy" with an  agonist or antagonist  in the treatment of premenstrual tension syndrome was made in a crossover study of eight patients. This finding has subsequently been replicated by several other investigators.

In a meta-analysis of seven trials, medical oophorectomy alone was effective for premenstrual tension syndrome.

It is obvious due to the severity of this patient's symptoms that very aggressive treatment is medically necessary. An agonist (e.g. Depot Lupron) or antagonist (Orilissa) is medically necessary as supported by current medical literature.

As stated above, Orilissa 200 mg twice daily will result in higher estradiol suppression.

Orilissa 200 milligrams (mg) twice a day is considered medically necessary for this patient. 

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 Orilissa 200 milligrams (mg) for greater than 372 tablets per 720 days is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: knee pain.
Treatment: Hyaluronan or Derivative, Monovisc, for Intra-Articular Injection, per Dose.
The insurer denied Hyaluronan or Derivative, Monovisc, for Intra-Articular Injection, per Dose.
The health plan's determination is upheld.

The patient is a male with a one year history of bilateral knee pain. He has undergone corticosteroid injections which last approximately 6 weeks. He has had a prior left knee arthroscopy and physical therapy following his surgery. On physical exam, the patient has full range of motion (0-130) and is palpably tender over the medial joint line. X-rays revealed mild right and moderate left knee Osteoarthritis. 

The requested hyaluronic acid injections (Monovisc) is not medically necessary for this patient.
Numerous studies have called the use of hyaluronic acid injections into question. Pereira et al (2022) reported that strong conclusive evidence indicates that viscosupplementation leads to a small reduction in knee osteoarthritis pain compared with placebo, but the difference is less than the minimal clinically important between group difference. Strong conclusive evidence indicates that viscosupplementation is also associated with an increased risk of serious adverse events compared with placebo. The findings do not support broad use of viscosupplementation for the treatment of knee osteoarthritis. Jevsevar et al (2015) added that meta-analysis of only the double-blinded, sham-controlled trials with at least sixty patients did not show clinically important differences of hyaluronic acid (HA) treatment over placebo. Andreani et al (2021) also noted that HA has provided good clinical outcomes and an improvement in the global assessment of the knee joint, but it doesn't seem to significantly modify the cartilage over time.
Therefore, based on the literature noted above, the requested injection is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: idiopathic short stature.
Treatment: Omnitrope.
The insurer denied Omnitrope.
The health plan's determination is overturned.

This is a young female diagnosed with idiopathic short stature (ISS). As per visit note, she has a history of adrenal insufficiency. She was on chronic steroid eye drops due to her history of corneal transplants. Her Cortrosyn stimulation test peaked at 13.7. Her growth hormone (GH) stimulation test peaked at 43.28. 

Omnitrope is medically necessary.
Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines. The Food and Drug Administration (FDA) approval for this indication is for "non-growth hormone-deficient short stature, defined by height standard deviation score (SDS) less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means."
The patient had a pretreatment height less than or equal to -2.25 SD. Her height at 5.909 y/o was 99.7 cm (-3.00 SDS) and at 6.42 y/o was 102.9 cm (-3.06 SDS). The patient has severe short stature. In addition, the patient has a history of adrenal insufficiency. The height and height velocity would not allow the patient to reach a normal adult height.
The request therefore meets idiopathic short stature criteria. Omnitrope is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fall
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

This patient is a female who presented to the emergency department (ED) following a trip and fall from standing height. She had complaints of left abdominal pain and left back pain. Her medical history includes chronic anemia with a hemoglobin on 8.5 grams per deciliter (g/dl). The clinical assessment included a physical exam that revealed initially normal vital signs. Lab analysis showed a hemoglobin of 3.7 grams per deciliter (g/dl). A computed tomography (CT) scan of the abdomen/pelvis showed multiple sites of splenic laceration without active extravasation and a moderate volume of hemoperitoneum. She was not taking blood thinner medications.
The patient was admitted to the hospital trauma service. The admitting diagnosis was hemorrhagic chock secondary to Grade II/III splenic lacerations and hemoperitoneum. There was noted transient hypotension with systolic blood pressure in the 90s that improved with blood transfusion. She was initially treated with fluid and blood product resuscitation and received 4 units of red blood cells. She was started on a diet and received the second two units of blood. Follow up hemoglobin after completion of the transfusion was 7.4 g/dl. The patient remained clinical stable after blood transfusion and was discharged from the inpatient setting with follow up appointments.
At issue is the medical necessity of an inpatient stay.
Inpatient stay was medically necessary and appropriate for this patient with splenic laceration and hemoperitoneum, profound anemia with a presenting hemoglobin of 3.7 g/dl and hypotension.
The patient was profoundly anemic with a presenting hemoglobin of 3.7 g/dl. She had the potential for rapid clinical deterioration. She required transfusion of 4 units of red cells, follow up lab and clinical assessment. The intensity of service associated with the care of this patient warranted an inpatient stay. This level of care is consistent with the standard of medical care in this case.
The patient had a ground level fall. Her evaluation and clinical work up identified grade II/III splenic lacerations with hemoperitoneum. In this case, the care and treatment provided was most appropriately rendered in the inpatient setting. The condition of splenic laceration carries the potential for rapid clinical deterioration with need for urgent surgical or other interventional procedure. The intensity of service associated with her initial evaluation, transfusion of blood products, and follow up assessment warranted an inpatient admission status.
Based on the submitted medical records, inpatient admission was appropriate, medically necessary and consistent with standards of good medical practice. This level of care was in accordance with generally accepted standards of medical practice, is consistent with the condition of splenic laceration as was documented in this case.