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

Diagnosis: Acute pancreatitis

Treatment: Inpatient admission 

The insurer is denied coverage for inpatient admission. 

The denial is upheld. 

The patient was then a postmenopausal female with a past medical history of diabetes mellitus, hypertension, dyslipidemia, thyroid disease (status post radiation to the thyroid). The patient presented to the Emergency Department (ED) with complaints of diffuse abdominal pain for a couple of days prior to presenting. The patient reported that she had tried over-the-counter Pepto-Bismol with no relief. The patient was afebrile, and her blood pressure was 116/80, heart rate was 92, and pO2 saturation was 97% on room air. The patient's physical examination noted that the patient was in obvious pain and discomfort. The patient had tenderness to palpation in the right lower quadrant and left lower quadrant; the patient's bowel sounds were normal with no abdominal distension. Follow up exam on admission showed that the patient's abdomen was soft with normal bowel sounds and no tenderness. The patient had a white blood cell count that was 10.4, and lipase of 21, creatinine of 0.82, potassium of 3.8 CO2 of 24, glucose of 177, and AST/ALT of 16/17. 

The patient underwent a gallbladder ultrasound which was negative. The patient underwent a computed tomography (CT) scan of the abdomen and pelvis with oral and intravenous contrast that showed peripancreatic inflammation that was suspicious for acute pancreatitis. The patient was treated with intravenous (IV) fluids, famotidine, and a single dose of 2mg of IV morphine. The patient was admitted for diagnosis of abdominal pain with possible acute pancreatitis. Initially, upon admission, the patient was to receive nothing by mouth. The patient was subsequently advanced to a clear liquid diet and then a regular diet by lunch. The patient was discharged. 

Based on the review of the medical record, the patient presented with abdominal pain and tenderness. The patient's labs were unremarkable. The patient's computed tomography (CT) scan raised question of pancreatitis in the correct clinical setting. The patient rapidly improved with no clinical evidence to support an acute abdominal process. The patient could have been managed in observation for additional workup. However, when testing completed along with clinical resolution, the patient could have been discharged home and proceeded with outpatient follow up. The inpatient admission was not medically necessary for this patient.

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

The carrier's denial of coverage for the inpatient admission is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic angle-closure glaucoma
Issue under review: Travatan Z 0.004% OP SOLN

Determination:
The health plan denied Travatan Z 0.004% OP SOLN. The health plan's denial was overturned.

The patient is an adult female with end-stage chronic angle-closure glaucoma of both eyes. Coverage of branded Travatan Z is requested. Coverage was previously denied, as it was not identified that the patient tried at least a 30-day trial of the generic drug or had an adverse event due to an inactive ingredient. Upon appeal, her provider states that the patient has had complete visual loss in her left eye, and that she is status post trabeculectomy and cataract extraction with intraocular lens insertion in the right eye.  

When last seen, the patient's vision was best corrected to 20/100 OD (right eye), and no light perception OS (left eye). Intraocular pressures were 10 mm Hg OD and 44 mm Hg OS. The visual field of her right eye was restricted to less than 10 degrees.  She has been using Travatan Z for many years and has documented history of allergies or adverse reaction to several alternatives, including BAK (benzalkonium chloride)-preserved timolol, Combigan, and Simbrinza. Therefore, the provider strongly recommends keeping the patient on Travatan which she has tolerated so far, to prevent further glaucomatous damage to the optic nerve and permanent visual field loss.

In this case, continued use of branded Travatan Z is requested for a functionally monocular patient with end-stage chronic angle-closure glaucoma for whom coverage of branded Travatan Z is requested. Coverage was previously denied as it was not identified that the patient tried at least a 30-day trial of the generic drug or had an adverse event due to an inactive ingredient. Upon appeal, it is identified that the patient's remaining sighted eye has a visual field restricted to less than 10 degrees, and her intraocular pressures are controlled at 10 mm Hg. Therefore, as the patient is already legally blind, and the risk of requiring the patient try and fail the health plan's step therapy with generics places the patient at too high of a risk of losing her remaining vision, the medical necessity of continued branded Travatan Z is established per standard of care as reflected in the principles set forth in the Preferred Practice Patterns of the American Academy of Ophthalmology.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Severe eczema of the scalp, trunk and extremities
Treatment: Dupixent Syn 300
The insurer denied Dupixent Syn 300. 
The denial is overturned.

The patient is a male with severe eczema of the scalp, trunk and extremities. Dupixent is requested. He has tried and failed two topical steroids (triamcinolone and clobetasol) and Elidel with another dermatologist in the past. 

Yes, the health plan should cover the Formulary exception for Dupixent Syn 300.
 
The patient has severe atopic dermatitis (AD) that warrants systemic therapy. He has failed multiple topical steroids and pimecrolimus in the past. He is not a candidate for topical therapies because of the severity of the atopic dermatitis. 

Dupilumab is a monoclonal antibody that inhibits IL-4 and IL-13 signaling by blocking the shared IL-4Ra and originally demonstrated efficacy in phase 2 clinical trials. In March 2017, it was approved by the US Food and Drug Administration (FDA) for children (12-17 years old) with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable. It is a subcutaneous injection administered initially at a dose of 400 mg and then 200 mg every two weeks thereafter (Dose: 200 mg SC q2wk; Start: 400 mg SC divided in 2 sites x1).

Approval of dupilumab was based on clinical trials investigating dupilumab as monotherapy (SOLO 1 and SOLO 2) and in concomitant administration with topical corticosteroids (CHRONOS). Results from the SOLO 1 (n=671) and SOLO 2 (n=708) trials showed 36-38% of patients who received dupilumab had scores of 0 or 1 (clear or almost clear) on the Investigator's Global Assessment scale compared with placebo (8-10%) (P< .001). Additionally, improvement from baseline to week 16 of at least 75% on the Eczema Area and Severity Index (EASI) was reported in significantly more patients who received each regimen of dupilumab than in patients who received placebo (P < .001).

Given its unprecedented efficacy, dupilumab is emerging as a first-line therapeutic for moderate-to-severe AD. The patient has failed topical steroids and tacrolimus. Cyclosporine, azathioprine, methotrexate, mycophenolate mofetil are not FDA-approved for use in atopic dermatitis (Insufficient data exists to firmly recommend optimal dosing, duration of therapy, and precise monitoring protocols for any systemic immunomodulating medication. Strength of Recommendation: B Level of Evidence: I or II, depending on agent), while Dupixent is. Therefore, Dupixent is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rule out acute coronary syndrome (ACS) 
Treatment: Inpatient hospital stay 

The insurer is denied coverage for inpatient hospital stay. The denial is upheld. 

The patient was then a female with a history of asthma, cardiomyopathy, coronary artery disease, mitral valve replacement, rheumatic fever, congestive heart failure, diabetes mellitus, and hypercholesterolemia. The patient presented to the Emergency Room (ER) with elevated blood pressure and right-sided chest pressure. The patient reported her blood pressure (BP) was 160's/120's at home. The patient also reported leg swelling. In the ED, the patient's blood pressure was elevated, at 179/90 on the left arm and 159/93 on the right arm. Otherwise, the patient's vitals were stable: afebrile, heart rate of 74, respiratory rate of 20, and oxygen saturation of 98% on room air. The patient's examination revealed no increased work of breathing, good air movement in all lung fields, and 1+ edema in lower extremities. The patient's blood work revealed troponin 0.013. The patient's electrocardiogram (EKG) showed sinus rhythm with 1st degree AV block with premature atrial complexes, unchanged from her prior EKG. The patient's chest radiography showed bilateral basilar infiltrates and cardiomegaly, consistent with heart failure. The patient was admitted to rule out acute coronary syndrome (ACS) and for further monitoring. The patient's repeat troponin level was negative. The patient had a negative stress test 1 month ago and a negative cardiac catheterization. The patient remained stable during her hospital stay. The acute coronary syndrome (ACS) was ruled out. The patient's blood pressure was under better control, and the patient was discharged. 

The patient presented with chest pain. The initial evaluation in the ER was unremarkable, including non-diagnostic EKG and cardiac biomarkers. Inpatient admission was not medically necessary for this patient. The patient's care could have been provided in the observational setting, allowing for additional diagnostic testing. Further evaluation was warranted, however inpatient admission criteria was not met.  There was no hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions warranting acute inpatient level of care. 

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

Based on the above, the medical necessity for the inpatient hospital stay is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain 

Treatment: Inpatient admission

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

This case involves then a male who presented as a direct admit from his outpatient physician for worsening abdominal pain.  The patient stated that his pain rated at 10 out of 10 in severity, and was localized to the left lower quadrant that comes and goes. The pain was associated with dizziness and chest pain. The patient reported that he was in the Emergency Room (ER) and underwent a computed tomography (CT) scan which showed kidney stone.   On exam, the patient's abdomen was non-tender to palpation and had no guarding or rebound tenderness; no mass was palpated.  It was recommended that the patient be admitted and undergo a gastroenterology (GI) consult as well as a CT angiogram to rule out ischemia.  The patient was also recommended to receive IV fluids and undergo an upper GI study.  The patient had a history of chronic systolic heart failure and was thus, recommended to continue on his home medications, Eliquis as well as metoprolol.  The patient's electrocardiogram (EKG) did not show ischemic changes, and the patient's initial troponin was negative. It was also recommended that the patient start Entresto.  The following day, the patient continued with additional evaluation and treatment. It was noted that the patient was supposed to undergo esophagogastroduodenoscopy (EGD)/colonoscopy but was canceled due to his rapid heartbeat.  The documentation detailed that the patient recovered quickly with a heart rate in the 80s.  The patient denied chest pain. The patient continued on treatment and underwent a CT angiogram which revealed no ischemic bowel. The patient continued to remain stable and was discharged with instruction to follow-up as outpatient.

Based on the review of the medical record and literature, inpatient admission was not medically necessary for this patient. The patient's symptoms did not indicate hemodynamic instability and there was no suggestion that this patient's labs were abnormal.  The patient's computed tomography (CT) scan of the abdomen did not show any abnormality. Due to this patient's significant vascular disease, bowel ischemia was a possibility. However, the suspicion was low considering this patient's unremarkable abdominal exam. Though the CT angiogram was an appropriate diagnostic testing, this could have been done earlier under Observation level care. The patient's clinical presentation and other findings did not warrant an inpatient admission. Given a lack of documentation to support that this patient could not have been treated at an Observation level of care, inpatient admission was not medically necessary.

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

Based on the above, the medical necessity for the inpatient admission is not substantiated.  The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Deep, impinging overbite with soft tissue damage to palate 
Treatment: Braces 

The insurer denied the braces. The denial is overturned. 

The patient is a male. The request is for orthodontic benefits. 

The patient has a deep, impinging overbite with soft tissue damage to his palate. This is an "automatic qualifier" according to the handicapping index scale. Orthodontic treatment is needed to correct this. The treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcohol withdrawal; history of polysubstance abuse
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female with a history of polysubstance abuse. She was admitted to the medical floor from detox for alcohol withdrawal after wanting to sign out AMA (against medical advice).  

The patient's VS (vital signs) were as follows: 97.9, 77, 18, 148/92, 96%. Her exam was unremarkable. She exhibited no signs of DTs (delirium tremens). She had no neurologic deficit. CBC (complete blood count) and BMP (basic metabolic panel) was unremarkable. EKG (electrocardiogram) revealed NSR (normal sinus rhythm). Head CT showed NAD (no active disease). The plan was for management with Librium tapering dose. The patient had no capacity per Psych evaluation. The patient was placed on one-to-one for elopement risk per psych. The plan was for consult psych for reevaluation. The patient's alcohol withdrawal resolved. She was cleared for discharge. 

This patient was admitted for management of alcohol withdrawal and discharged. The patient was hemodynamically stable and afebrile. She did not have tachycardia. She did not have persistent vomiting. She did not have gross tremor. Labs were unremarkable. The plan was for management with Librium taper. The patient was clinically stable and did not have findings of alcohol withdrawal. She did not have symptoms that required an acute inpatient level of care. The requested inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sarcoidosis.
Treatment: Inpatient hospital admission 
The insurer has denied coverage for inpatient hospital admission. 
The denial is upheld. 

The patient was a male who presented to the Emergency Department (ED) with 2-day history of chest pain. The patient reported that the pain was severe with 10 out of 10 pain severity, and was accompanied with some shortness of breath. The patient reported that he had been having chest pain on and off for many months. The patient had been evaluated at another hospital for this similar presentation. The patient's computed tomography (CT) of the chest had revealed a nodular density and the biopsy was non-conclusive. The patient was treated with Prednisone for suspected sarcoidosis.

In the ED, the patient's initial vital signs were: temperature 98.7 F, blood pressure 151/107, heart rate 99, respiratory rate 20, and oxygen (O2) saturations 99%. On exam, the patient was mildly distressed but was otherwise unremarkable. The patient's lab results showed white blood cell count (WBC) of 5K, hemoglobin of 16.1; the patient's electrolytes and BUN/Cr were within normal limits. The patient's troponin was negative, and the patient's electrocardiogram (EKG) showed no ischemic changes. The patient's computed tomography (CT) scan of the chest revealed a similar lung nodule in the left lung, which was unchanged from the CT scan done. The patient was treated with pain medications. The patient's clinical picture was consistent with sarcoidosis. That was also the assumption during his prior work up. The patient remained stable after admission, and was treated with oral medications. The patient was then discharged the following day. 

Based on the review of the medical record and the literature, this patient did not need acute inpatient hospitalization. The patient was stable to be discharged home after evaluation and treatment in Emergency Department (ED). The patient was hemodynamically stable and his lab and physical exam was unremarkable. The patient's computed tomography (CT) scan of the chest was unchanged from his previous CT scan for which the patient's workup was consistent for sarcoidosis. There were no new clinical findings that required inpatient level of care and monitoring. The patient had negative cardiac enzymes and a normal electrocardiogram. The patient's chest pain was not consistent with myocardial infarction. Inpatient admission was not medically necessary for this patient.

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

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain; rule out acute coronary syndrome

Treatment: Hospital admission 

The insurer is denied coverage for hospital admission 

The denial is upheld. 

The patient is a female with a history of diabetes, hyperlipidemia, hypothyroidism, morbid obesity, and status post appendectomy. The patient presented to the Emergency Room (ER) with complaints of intermittent chest pain x several days, shortness of breath, and cough. In the ER, the patient's vital signs were stable.  The patient was admitted several days prior to this ER presentation for chest pain; a computed tomography (CT) scan at that time was negative for pulmonary embolism. In the ER, the patient's bloodwork revealed troponin 0.00, d-dimer 1334, b-type natriuretic peptide 8.3, and white blood cell (WBC) count 7.7.  The patient's urine drug screen was negative.  The patient's electrocardiogram (EKG) showed normal sinus rhythm with no acute ST-T wave changes. The patient's chest x-ray showed no acute cardiopulmonary disease.  The patient was given aspirin and was admitted to Telemetry for chest pain, rule out acute coronary syndrome.  The patient was started on Lovenox and was seen by Cardiology and Pulmonary. The patient's repeat troponin levels were negative.  The patient remained stable during her inpatient stay.  Acute coronary syndrome was ruled out and the patient was discharged with instructions for outpatient follow-up.

Based on the review of the medical records and literature, inpatient admission was not medically necessary for this patient. The patient presented to the hospital with chest pain.  The patient's initial evaluation in the Emergency Room was unremarkable, including a non-diagnostic electrocardiogram (EKG) and cardiac biomarkers. Inpatient admission was not medically necessary for this patient. The patient's care could have been provided in the observational setting, allowing for additional diagnostic testing. Further evaluation was warranted, however inpatient admission criteria was not met.  There was no hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions warranting acute inpatient level of care. 

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

Based on the above, the medical necessity for the hospital admission is not substantiated.  The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:   Coronary artery disease (CAD)

Treatment: Inpatient hospital admission

The insurer is denied coverage for inpatient hospital admission. 

The denial is upheld. 

The patient is a male with a history of anemia, hypertension, hyperlipidemia, coronary artery disease, status post multiple percutaneous transluminal coronary angioplasty (PTCA) with stents and atherectomy, tobacco use, and status post coronary artery bypass graft (CABG) x3.  The patient had exertional chest pain for several weeks, dissipating with rest.  The patient's myocardial perfusion imaging (MPI) showed mild to moderate lateral ischemia with partial scarring. The patient presented to the hospital for a scheduled elective cardiac catheterization.   The procedure revealed 3-vessel coronary artery disease (CAD); patent graft to mid-left anterior descending (LAD), occluded graft to right coronary artery (RCA) - right posterior descending artery (RPDA), left main disease, occluded graft to LAD 1st diagonal, and in-stent restenosis of the left circumflex (LCX) obtuse marginal 1 (OM1).  

Interventions included percutaneous coronary intervention (PCI) with drug-eluting stent (DES) to obtuse marginal 1 (OM1) with extension into distal left main (LM), followed by PTCA of the ostial left anterior descending (LAD) and ostial left circumflex (LCX).  There were no complications.  The patient was admitted as an inpatient post-procedure.  A note by his cardiologist indicated that inpatient admission was necessary, as the intervention involved bifurcation lesions which were associated with very high risk of immediate cardiac events, including stent thrombosis, myocardial infarction (MI) or death.  The patient was monitored overnight, where he remained stable. The patient was subsequently discharged.  

Based on review of the medical record, inpatient admission was not medically necessary for this patient. As per the MCG guidelines for Angioplasty, Percutaneous Coronary Intervention ORG: M-52 (ISC), the procedure that this patient received was an outpatient, ambulatory surgery.  The patient's clinical presentation and peri-procedural course were unremarkable and uneventful. The patient was clinically stable. There were no extenuating circumstances in this case which warranted inpatient admission status following an elective cardiac catheterization and attempted angioplasty procedure.  An overnight stay in observation was an option if there was concern for the possibility of a complication. 

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

The carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated