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

Diagnosis: Difficulty Breathing
Treatment: Inpatient Hospital Services
The insurer denied: Inpatient Hospital Services
The denial is: Overturned

The patient is a male who presented with difficulty breathing.
He was well until 2-3 days prior to presentation when he developed a cough and congestion. He then developed difficulty breathing. He was seen by his pediatrician and was given an albuterol nebulized treatment with no response. He was subsequently sent to the emergency department for further care.
In the emergency department his temperature was 99 degrees Fahrenheit (F) with a respiratory rate of 38 and a heart rate of 145 beats per minute (bpm). He was noted to have retractions with wheezing and coarse breath sounds. He was given an albuterol / Atrovent nebulized treatment, however on reassessment he had no improvement. He was subsequently placed on 2 liters (L) of high flow oxygen by nasal cannula, which improved his work of breathing. He was also given a bolus of normal saline. A chest x-ray and laboratory values were obtained. He was diagnosed with viral bronchiolitis versus pneumonia and was admitted for acute respiratory failure requiring high flow oxygen.
Upon admission he was continued on high frequency nasal cannula oxygen and maintenance intravenous fluids. By the next day he was able to wean to 2 L of 21% oxygen by nasal cannula, and his intravenous fluids were discontinued as his oral intake had improved. He remained stable on room air. He continued to have good oral intake and was felt to be stable for discharge to home with follow up as an outpatient.
The subject under review is the medical necessity for the inpatient hospital services.

The health plan's determination is overturned.

The requested health service/treatment of Inpatient Hospital Services was medically necessary for this patient. This is a patient who presented with wheezing and respiratory distress. He continued to have increased work of breathing despite bronchodilator therapy in his treating physician's  office and in the emergency department, and he required high flow oxygen to support his respiratory effort. Due to continued respiratory distress and the need for high flow oxygen, he was  admitted. He also required intravenous fluids to maintain his hydration status.
High flow oxygen has the ability to offload the work of breathing for patients with respiratory distress therefore, it may be used in patients who are not responsive to disease-specific therapies (e.g., bronchodilators). Close monitoring and frequent reassessment is an essential component of proper delivery of high flow nasal cannula (HFNC) and required an inpatient setting for this patient.
The decision making at the time of admission for this patient was consistent with his age, the presence of respiratory distress that continued despite appropriate treatments, and the need for high flow oxygen, intravenous fluids, and close monitoring for potential deterioration of clinical status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes
Treatment: Ozempic INJ (injection) 2/1.5 mL (milliliters)
The insurer denied Ozempic INJ 2/1.5 mL.
The denial is upheld. 

The patient is a male with type 2 diabetes treated with metformin ER (extended release) 500 mg (milligrams) twice daily and Ozempic 0.5 mg (milligrams) weekly. The request for Ozempic is under review.

The patient's A1C (glycated hemoglobin) was 6.8% (percent).

The prior request was denied coverage by the health plan because approval on criteria requires a history of failure to metformin at a minimum dose of 1500 mg (milligrams) daily for 90 days or a contraindication or intolerance to metformin and a failure for 90 days to two of the following: Adlyxin, Victoza 1.2 mg per day, or Trulicity or contraindication or intolerance to two of the following: Adlyxin, Victoza 1.2 mg per day, or Trulicity. The provider is appealing this determination.

This request is for Ozempic for the treatment of type 2 diabetes. The preferred alternatives include Trulicity, which is in the same class as Ozempic and is expected to have similar safety and efficacy as Ozempic. The American Diabetes Association clinical guidelines do not support the use of Ozempic over Trulicity. Therefore, no, the requested Ozempic is not medically necessary.

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

The requested Ozempic was appropriately denied, as it was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bilateral sensorineural hearing loss.
Treatment: Monaural digital hearing aid (code V5257).
The insurer denied coverage for monaural digital hearing aid (code V5257).
The denial is overturned.

This is a case of an adult male with bilateral sensorineural hearing loss. He has Speech Reception Threshold (SRT) of 40 decibel (dB) on left and SRT of 45 dB on right. Patient had a 30-day trial of hearing aids with good results. Bilateral hearing aids have been recommended.

Per American Academy of Audiology, patients are recommended to have hearing rehabilitation if they have SRT of 35 dB or above. The patient has sensorineural hearing loss and has SRT of 40 dB on one side and 45 dB on the contralateral side. The patient meets criteria for medical necessity.

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 monaural digital hearing aid (code V5257) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Umbilical Hernia

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is upheld

Umbilical hernias are common surgical complaints. These hernias can become symptomatic and therefore are at an increased risk of incarceration and subsequent strangulation. Therefore, surgical repair is indicated. [1] Emergency repair has been associated with an increased risk of mortality, reoperation, and readmission. [2] Bowel compromise can occur regardless of the hernia size, and the belief that larger hernias do not incarcerate is inaccurate. [3]

Per clinical documentation, this patient presented to the emergency department with abdominal pain. The patient left against medical advice prior to obtaining results from imaging studies. The patient returned with generalized abdominal pain. The patient was noted to have an incarcerated umbilical hernia. There was no associated nausea or vomiting. Vital signs were within normal limits. Laboratory values were significant for an elevated white blood cell count of 19.1. The patient was admitted and taken to the operating room for repair and reduction of incarcerated incisional hernia. There were no reported complications postoperatively. The patient was discharged home the following day. According to clinical documentation, the patient was treated under observation standards. Peer-reviewed literature indicates that the greatest variable associated with hospital admission is totally dependent baseline functional status. [4] The patient was not noted to have any functional impairments. Therefore, the requested hospital stay should be billed as observation status. Inpatient admission is not medically necessary.

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

Diagnosis: Motorcycle accident

Treatment is an inpatient admission 	

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

Per clinical documentation, the patient presented to the emergency department after a motorcycle accident. The patient was noted to be intoxicated. The patient was not the driver. The patient complained of diffuse pain and was unsure if there was head trauma. Vital signs were within normal limits. There was noted to be a large laceration to the left lower extremity. Head and abdominal CT (computed tomography) scans were within normal limits. An x-ray of the right foot noted a comminuted oblique fracture of the distal third of the fifth metatarsal. Podiatry was consulted and there was no operative management indicated. Crutches and non-weight bearing status was recommended. Due to alcohol abuse, the patient was evaluated by psychiatry. However, no immediate inpatient treatment was warranted. The patient was evaluated by rehab for training with crutches. A simple laceration repair of the left leg was performed with two sutures. Per MCG (Milliman Care Guidelines) general trauma and general admission criteria, a hospital admission is indicated when a patient with significant multiple trauma requires inpatient care for one or more of the following: major surgical and postprocedural care, nonoperative care of significant injury, or multiple trauma and one or more general admission criteria. [1, 2] Per provided clinical documentation, the patient did not undergo any major surgical procedures. The patient did not meet any general admission criteria. Per provided clinical documentation, the inpatient admission was not medically necessary. The health plan acted reasonably.

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

Diagnosis: Bipolar disorder, hyperlipidemia, Lyme disease, and Alzheimer's disease
Treatment: Consumer direct, 1 client 168 hours/week, 12 hours x 2 x 7 days split shift
The insurer denied coverage for consumer direct, 1 client 168 hours/week, 12 hours x 2 x 7 days split shift
The denial is overturned

This case involves a male with a history of bipolar disorder, hyperlipidemia, Lyme disease, and Alzheimer's disease. The provider stated that they saw the patient for neurological evaluation and follow-up. He had been diagnosed with dementia, severe cervical radiculopathy/lumbar radiculopathy. He reported difficulty walking. His condition was worsening. Due to his medical condition, 4 hours of home attendant were not enough to convert his medical care and all his daily living tasks as well as doctor appointments. The patient needed frequent extensive assistance to toilet day and night. During the day, he required assistance positioning himself on his side so that he could relieve himself into the urinal. 

Per the referenced guidelines, to qualify for a split shift or continuous personal care services, the patient must require uninterrupted care by more than one personal care aide for more than 16 hours in a calendar day with tasks such as toileting, walking, transferring, turning, or positioning with such frequency that an in-living 24-hour personal care aide would not be able to obtain on a regular basis 5 hours daily of uninterrupted sleep during the 8-hour sleep. Lower care hours may be indicated depending on the patient's clinical needs and presentation. In this case, the patient was diagnosed with dementia, severe cervical radiculopathy, and severe lumbar radiculopathy. His condition was worsening. It was stated that it was medically necessary for the patient to get 12 hours a day for 7 days home attendant. He required assistance for ambulation.  He required extensive assistance with managing medications, phone use, bathing, personal hygiene, dressing, locomotion, and toilet use. He was recently approved for 42 hours a week. However, the patient requested 84 hours a week of split shift care. The patient reported that they required assistance for toileting and transferring safely. The documentation identified that the patient needed assistance with transfers, walking, and toileting. These activities are not limited to 12 hours/day. It is usual for nighttime toileting needs to increase as a person ages. For patients with dementia, their nighttime behaviors can be unpredictable. Fall prevention should be a priority for the patient given his history of recent falls. Given the patient's worsening symptoms and need for extensive assistance including activities of toileting and ambulation, the requested 168 hours/week are medically necessary. As such, the insurer's denial of coverage for consumer direct, 1 client 168 hours/week, 12 hours X 2 X 7 days split shift is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Miscarriage
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient is a female who was pregnant with her third child and has had two abortions/miscarriages (G3P0020). She presented to the emergency department (ED) with cramping and worsening vaginal bleeding at approximately 5 weeks gestation.  She had undergone in vitro fertilization (IVF) and has a known history of fibroids and hypothyroidism.  

The patient was evaluated and found to have had a miscarriage with passage of fetal tissue but retained placenta.  She was brought to the operating room (OR) for a suction dilation and curettage (D&C).  She received a unit of packed red blood cells and methergine.  Her post operative blood levels were stable.  By later the same day she was tolerating orally, pain was controlled, and her bleeding was stable.  She was discharged home with follow up.

The inpatient admission is being denied.  This is being appealed.

No, the proposed inpatient hospital admission was not medically necessary.
In review of the medical record, the patient received acute care with a suction dilation and curettage (D&C) for retained products.  She was hemodynamically stable.  She was not admitted for greater than 24 hours.  

An outpatient observation bed is an alternate level of healthcare compromising of short stay encounters for patients who require close nursing observation or medical management.  It is an area where the patient is observed and assessed following surgery to determine a need to be admitted to the hospital as an inpatient.  

The patient in question was taken to the operating room and underwent an uncomplicated procedure for a retained placenta.  She did receive one unit of blood.  After surgery, the patient required observation and nursing care to assist with her ambulation and medical management.   This could have been done in an observation status.  By later on post operative day #0 the patient was ready for discharge requiring less than a 24 hour stay.  Therefore the patient did not require an acute inpatient stay, as the same care could have been provided under an observation status.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
The health plan denied the inpatient hospital stay reasonably with sound medical judgement.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Glaucoma
Treatment: Corticotropin (H.P. [highly purified] Acthar Gel) 
The insurer denied Corticotropin (H.P. Acthar Gel).
The health plan's determination is overturned. 

The patient has a history of corneal graft failure, keratoconjunctivitis, filamentary keratitis, dry eye and glaucoma of the left eye. The patient has been treated with prednisolone acetate and Flarex drops without success. The treating physician is requesting Acthar Gel to help improve the patient's eye disease. 

Acthar Gel is medically necessary for this patient. The patient has failed current therapy and is facing a corneal graft rejection in the presence of anterior segment inflammation. Acthar Gel would be considered an effective alternative to the current failing treatment. Acthar Gel has been used in ophthalmology for the treatment of severe acute and chronic allergic and inflammatory processes involving the eye and its adnexa such as: keratitis, iritis, iridocyclitis, diffuse posterior uveitis and choroiditis, optic neuritis, chorioretinitis, and anterior segment inflammation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholecystitis with cholelithiasis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld
 
This is the case of a patient who presented to the emergency department (ED) with complaints of abdominal pain. As per the ED provider note the patient was seen for abdominal pain earlier in the day and returned as the pain returned. This female returned complaining of nausea, severe epigastric/ right upper quadrant (RUQ) pain in context of cholelithiasis. The patient reported she has had similar episodes in the past and had full workup confirming large gallstone, but the patient clinically had much improved, so she went home. The pain returned and she was unable to eat anything, so she returned for evaluation. The assessment was cholelithiasis and the plan was to repeat labs, intravenous (IV) Morphine, Zofran, fluid and surgery consult, and refer to surgical observation. A progress note indicated the pain was better controlled but the patient remained tender in the RUQ. Surgery evaluated the patient in the ED and advised Mefoxin and surgical observation.

The patient was taken to the operating room and underwent an uneventful laparoscopic cholecystectomy with a Jackson Pratt (JP) drain placed. Pathology revealed acute cholecystitis with cholelithiasis. The post op notes indicated the patient was resting comfortably and tolerating clear liquid diet and ambulating. The plan was to advance the diet in the morning.

Progress notes indicated the patient had no acute events overnight and the patient has been afebrile, and pain was well controlled. There was no nausea or vomiting and the patient has been tolerating diet. The plan was to discontinue the JP and discharge to home.

Based upon the records, the inpatient admission was not justified as this patient should have been managed as noted by the insurer in an ambulatory/observation setting as she presented and was not taken to the operating room until the following day. She got converted to a full admission after being observed when she should have had the surgery sooner. Thus, she did not need the inpatient admission but rather observation.

According to the guidelines of Milliman Care Guideline (MCG) Health Inpatient and Surgical Care- 26th edition Gall bladder or bile duct inflammation or stone ORG: M-555 (ISC), this patient did not need to be admitted as she could have been managed with an outpatient/ ambulatory basis with observation as she did not have initially elevated liver enzymes. In addition, according to MCG Inpatient and Surgical Care 26th Edition cholecystectomy by laparoscopy the operative status criteria is ambulatory, and in this case the patient did not require inpatient stay but rather ambulatory status with observation.

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

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

Diagnosis: Multiple myeloma
Treatment: Formulary exception for Eliquis
The insurer denied the formulary exception for Eliquis. 
The denial is overturned.

The health plan should cover the proposed formulary exception for Eliquis.
The patient in this case is a male with multiple myeloma and also pulmonary embolism. He has been treated previously with enoxaparin and also Xarelto. The records note that the patient also had a history of gastrointestinal (GI) bleeding while being treated with anticoagulation and that he required close monitoring for this. The patient did not take Xarelto regularly as it caused constipation. Eliquis was prescribed.
This patient has taken Xarelto but could not tolerate it based on the provided records noting noncompliance due to constipation. There is ample evidence showing that Eliquis is more effective and also associated with a significant reduction in risk of major bleeding compared to warfarin, the other formulary alternative. Given these considerations, the health plan should cover the proposed treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Excess Abdominal Skin.
Treatment:  Panniculectomy.

The health plan denied the panniculectomy.  The health plan's determination is overturned.

This female has lost weight. Her weight is stable. She has skin rashes in skin breakdown in the areas of her abdominal pannus where she has skin on skin contact. She has been treated for rashes with oral antibiotics and topical medications. Primary care physician (PCP) and plastic surgery notes document rashes or a history of rashes in the pannus fold. Photos show skin changes in the pannus fold. A panniculectomy is planned.
At issue is the medical necessity for the requested panniculectomy.

I overturn, in whole, the health plan's determination of medical necessity.

A panniculectomy is medically necessary. According to the American Society of Plastic Surgeons (ASPS) Position Paper "Treatment of Skin Redundancy For Obese and Massive Weight Loss Patients," "When surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patient's appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature and not a compensable procedure." For example, a panniculectomy to eliminate a large hanging abdominal panniculus and its associated symptoms would be considered reconstructive. In situations where a circumferential treatment approach is utilized to also treat the residual back and hip rolls or the ptotic buttock tissue, only the anterior portion of the procedures would be considered reconstructive, the remaining portion of the procedure would be considered cosmetic. Only in rare circumstances will buttock, thigh or arm lifts be needed to treat functional abnormalities. Typically, these procedures are performed to improve appearance and are therefore cosmetic in nature." The records indicate that the patient has failed conservative treatment for her longstanding rashes, including treatment by her PCP. Photos show skin changes under the pannus fold. A panniculectomy will eliminate her rashes. The patient's condition also meets the Milliman Care Guidelines (MCG), 26th edition guidelines for a panniculectomy.
Per the guidelines: Panniculectomy may be indicated when ALL of the following are present:  1)  Patient has complications from panniculus (e.g., chronic or recurrent intertrigo, other skin infection, ulceration, or skin irritation that has been persistent despite nonsurgical treatment), 2) Pannus interferes with activities of daily living, and 3) Patient's weight has reached stable plateau, and 1 or more of the following: a)Adherence to multidisciplinary nonsurgical program of weight maintenance, and b) One year or more has elapsed following bariatric surgery.

The patient has persistent rashes despite medical treatment including prescription topical and oral medications. The records confirm problems with activities of daily living. Photos show a female with skin changes under her pannus. Her weight is stable based on the clinical notes.

Based on the ASPS, and MCG guidelines, a panniculectomy is medically necessary for this patient.