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

Diagnosis: Seizure. 
Treatment: Inpatient Hospital Admission. 

The insurer denied: Inpatient Hospital Admission. 
The denial is upheld. 

The patient is an adult male who presented to the emergency department due to cough and fatigue in the setting of COVID. He was noted to have a witnessed seizure with loss of consciousness. His Glasgow Coma Scale was 15 (GCS15). The patient was given Ativan and was admitted for further workup. Neurologic examination was non-focal and the patient was alert and oriented to personal, place and time (AAOx3). The patient's magnetic resonance image (MRI) of the brain did not reveal acute stroke. The patient's electroencephalogram (EEG) was negative. Inpatient admission was denied as it did not meet level of care by the plan. 

The inpatient admission was not medically necessary. 

The patient had a seizure with return to baseline. Furthermore, neurologic examination did not show any deficits. The Milliman Care Guidelines (MCG) 26th edition Neurology and Seizure, recommend inpatient admission in the setting of progressive or severe neurologic deficits and seizure without return to baseline or multiple seizures which did not apply to patient. Care could have been carried out at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abnormal Kidney Function. 
Treatment: Inpatient Hospital Admission. 

The insurer denied: Inpatient Hospital Admission. 
The denial is upheld. 

The patient is an adult male. He was admitted for abnormal kidney function and was started on intravenous fluid. Nephrology consult was requested and recommended to continue with intravenous hydration. On Day #2, the patient's creatinine was improving, and the patient was discharged in stable condition. 

The proposed treatment was not medically necessary. 

The gold standard for the distinction between prerenal disease secondary to volume depletion and post-ischemic and nephrotoxic acute tubular necrosis (ATN) is the response to fluid repletion per Kidney Disease Improving Global Outcomes (KDIGO) and National Kidney Foundation guidelines. If sufficient fluid is given to reverse any signs of volume depletion (e.g., hypotension, cool extremities, low urine-sodium concentration), return of the serum creatinine to the previous baseline within 24 to 72 hours is considered to represent a correction of prerenal disease, whereas persistent acute kidney injury (AKI) is considered to represent acute tubular necrosis (ATN). This patient's kidney function improved back to baseline in 24 hours, which is not consistent with serious, irreversible acute tubular necrosis which may benefit from inpatient admission to monitor kidney function and the need for renal replacement therapy. In addition, the patient was hemodynamically stable, with normal oxygenation and negative cultures; he did not have significant electrolytes disturbance or change in kidney function. He did not have cardiac arrhythmias, no altered mental status or persistent nausea and vomiting with dehydration. There was no documentation of refractory pain, and the patient was able to tolerate oral diet and did not require total parenteral nutrition. The patient's condition could have been treated safely under a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right Humerus Fracture.
Treatment: Inpatient Hospital Stay.
The insurer denied the inpatient hospital stay.
The health plan's determination is overturned.

The patient is a male who fell from a bicycle and sustained a displaced right Type 3 supracondylar humerus fracture. The initial physical examination did not show any evidence of nerve or vascular injury. His Coronavirus (COVID) test was positive. The patient was brought to the operating room and underwent a closed reduction and percutaneous pinning. He was placed in a cast and later discharged to home.

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 requested health service/treatment of inpatient hospital services was medically necessary for the patient. A Type 3 supracondylar humerus fracture may be associated with substantial swelling, and there is some risk of ischemia and compartment syndrome. Close monitoring after surgery, assessing perfusion, pain level, and movement is required. The patient also was positive for COVID, which may require additional monitoring and resources before, during, and after the surgery. Under these circumstances, the inpatient hospital admission is required.
The health plan's determination of medical necessity is overturned in whole.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Gastroesophageal Reflux Disease/GERD
Treatment: LINX Procedure
The health plan denied: LINX Procedure
The determination is: Overturn

The patient is a male who has dysphagia in the cervical area. The patient is on Dexilant and Protonix for gastroesophageal reflux disease (GERD). An esophagogastroduodenoscopy (EGD) showed grade A esophagitis. He has a DeMeester score of 26.8.
At issue is whether the LINX procedure is experimental/investigational.
The health plan's determination regarding the proposed health service or treatment is overturned in whole.
The proposed health service or treatment LINX procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
This patient has GERD based on 24-hour potential hydrogen (pH) study. The patient is already on the maximum medications. A LINX procedure will help this patient.
As per the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES):
Longer-term (3-5 years) experience with the LINX Reflux Management System confirms the initial safety profile that led to Food and Drug Administration (FDA) approval of the device. The LINX device has been demonstrated to result in long-term GERD control based on symptomatic outcomes, proton pump inhibitor (PPI) utilization, and pH studies.
LINX is a reasonable treatment option for appropriately selected patients with GERD who meet indications for antireflux surgery. The LINX procedure is part of the armamentarium in the treatment of GERD. As such, it should be performed by surgeons familiar with the workup and different management alternatives of GERD and not offered in isolation.
Implantation of the LINX device should be covered and reimbursed by insurance for appropriate patients who meet the selection criteria as described above.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Gastroesophageal Reflux Disease/GERD
Treatment: LINX Procedure
The health plan denied: LINX Procedure
The determination is: Upheld

This patient is a male with a history of dysphagia. A 24-hour potential hydrogen (pH) study revealed an elevated DeMeester score of 26.8, consistent with gastroesophageal reflux disease (GERD). An endoscopy revealed grade A esophagitis. The upper gastrointestinal (UGI) study did not reveal GERD or hiatal hernia. Manometry could not be performed and was aborted secondary to intolerance.
At issue is whether the LINX procedure is experimental/investigational.
The health plan's determination regarding the proposed health service or treatment is upheld in whole.
The proposed health service or treatment LINX procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. This patient reports symptoms consistent primarily with dysphagia. The patient does not report classic symptoms of GERD or improvement with anti-reflux medications. It is unclear whether there is a component of abnormal gastric emptying or esophageal motility concerns. Both of these would contribute to surgical failure or worsening of dysphagia. Atypical preoperative symptoms, such as dysphagia, should prompt a motility evaluation. In addition, this patient risks a higher chance of permanent or worsening dysphagia post-anti-reflux procedure.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Atopic Dermatitis.
Treatment:  Dupixent 300 milligrams (mg)/2 milliliters (ml) subcutaneous (SC) solution pen injector (SOPN).

The insurer denied coverage for Dupixent 300 mg/2 ml SC SOPN.  The denial is overturned.

The patient is an adolescent with a diagnosis of atopic dermatitis (AD) affecting the face, arms, and legs. The patient has failed therapy with oral prednisone, topical steroids, and tacrolimus ointment. The requested medication is Dupixent 300 milligrams (mg)/2 milliliters (ml) subcutaneous (SC) solution pen injector (SOPN).

The patient has moderate AD that involves a large surface area, including the face. The patient requires systemic therapy given the extent of involvement, and the use of Dupixent is reasonable given that it is a Food and Drug Administration (FDA) approved medication for the treatment of AD and is FDA-approved for treatment in the patient's age group. The request for Dupixent is supported by the medical literature and specialty society guidelines. Dupixent is the first systemic therapy approved by the FDA for the management of AD. The FDA approved Dupixent for treatment of patients with moderate-to-severe AD who are inadequately controlled with topical treatments (1-3). According to consensus guidelines, "Dupilumab (Dupixent) has shown strong efficacy and safety for treatment of moderate-to-severe AD. Considering the safety profiles of conventional systemic therapies, which are not FDA-approved for AD treatment, it is recommended that dupilumab be used as a first-line systemic treatment for patients with moderate-to-severe AD who are uncontrolled with topical therapies" (1). The decision is overturned, and Dupixent is approved at the medical discretion of the physician based on the standard of care and the provided medical documentation.    

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. 

The medical necessity for Dupixent 300 mg/2 ml SC SOPN is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Diverticulitis.
Treatment:  Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is overturned.
 
This is an adult who presented with abdominal pain. On presentation, the patient was noted to be afebrile and hemodynamically stable. On physical examination, the patient's abdomen was noted to have left lower quadrant (LLQ) tenderness to deep palpation. The white blood cell (WBC) count was 11.8. A computed tomography (CT) Scan revealed small, localized areas of micro perforation at the level of the descending colon. There was no evidence of focal fluid collection. The patient was admitted and made Nothing by mouth (NPO). The patient was given multiple fluid bolus and then was given intravenous fluids at 125 milliliters per hour (ml/hr). The patient also received intravenous antibiotics. The patient was able to tolerate a regular diet and was able to be discharged to home.

The patent received the standard of care for acute diverticulitis.

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 the full hospital admission  is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Atrial Fibrillation.
Treatment:  Inpatient Hospital Admission.

The insurer denied the inpatient hospital admission.  The denial is upheld.

The patient is an adult male for whom an inpatient hospitalization is under review. There was no past medical history, and the patient was admitted with rapid atrial fibrillation. He was started on Cardizem. His electrolytes were normal. His chest x-ray was negative. His heart rate improved. He was transitioned to metoprolol. The patient's blood pressure (BP) was mildly elevated, and the oxygen saturation was normal. The patient was also treated for a COVID infection. He remained stable and was discharged.

The proposed treatment was not medically necessary.

This patient presented with atrial fibrillation and had improvement of his heart rate and symptoms. He remained stable. There was no myocardial infarct (MI), acute coronary syndrome, congestive heart failure (CHF), hemodynamic instability, need for prolonged intravenous (IV) medication, cerebral vascular accident (CVA), altered mental status, respiratory distress, recent thrombo-emboli, severe underlying structural heart disease, need for acute anticoagulation, introduction of high risk antiarrhythmic medication requiring in hospital monitoring, need for ongoing oxygen support, severe electrolyte abnormality, or a recurrent unstable arrhythmia. In the setting of this case, an acute inpatient level hospitalization has not been established as standard of care towards improved cardiac outcomes. It is therefore also considered not medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bronchopulmonary dysplasia
Treatment: Synagis (palivizumab)
The insurer denied Synagis (palivizumab).
The determination is overturned.

This is a male infant born prematurely with a medical history significant for respiratory distress syndrome, bronchopulmonary dysplasia, and umbilical and inguinal hernias. He was hospitalized in the Neonatal Intensive-Care Unit (NICU) for almost two months, complicated by anemia of prematurity, hyperbilirubinemia requiring phototherapy, a urinary tract infection with a negative renal ultrasound, and right hydrocele. He received his first dose of palivizumab just prior to discharge. He was subsequently admitted for a surgical procedure a month later and received his second dose of palivizumab just prior to discharge. His diuretic therapy was discontinued after this surgery. He was approved for three additional doses of palivizumab in the outpatient setting, but was only given two. His fifth dose was not administered because the approval expired. According to his health care team, respiratory syncytial virus (RSV) has still been circulating in their community. At issue is the medical necessity of Synagis (palivizumab).

Yes, palivizumab is medically necessary and appropriate for this infant.
This young male infant was born prematurely. He was diagnosed with respiratory distress syndrome that progressed to bronchopulmonary dysplasia, discharging on diuretic therapy. His diuretics were discontinued about a month after discharge. He started his five-dose course of palivizumab for RSV prophylaxis just prior to discharge from the NICU. Because of the nature of the approval, he was only given four doses. The Centers for Disease Control and Prevention (CDC) data for his home state is partially incomplete. His provider has stated that there is still RSV circulating in their community. Due to the unusual interseasonal spread of RSV, the CDC has recommended consideration for longer courses of palivizumab administration for eligible infants as well as dosing according to presence of RSV in the community. Based on the information available, with RSV still circulating in the community, the fifth dose of palivizumab is medically necessary for this eligible ex-premature male infant with history of bronchopulmonary dysplasia.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Type 1 diabetes mellitus without complications
Treatment: T: Slim X2
The health plan denied the requested prescription drug, T: Slim X2 as not medically necessary.
The health plan's determination is overturned.

This is a female diagnosed with type 1 diabetes mellitus (T1DM). This request is for Cartridges T-slim X2. As reported; she can only use these cartridges with her current insulin pump (T-slim).

At issue is whether the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.

The formulary alternative would not be as effective as the requested product, as they would not work with the patient's insulin pump.

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

Diagnosis: Prader Willi syndrome, Ventilator dependent.

Treatment: Continued stay for acute rehabilitation (inpatient medical rehabilitation).

The insurer denied coverage for continued stay for acute rehabilitation (inpatient medical rehabilitation).

The denial is overturned.

This is an adolescent male with Prader Willi syndrome and Obstructive Sleep Apnea. He also has Diabetes mellitus, hypothyroidism and morbid obesity. He has a tracheostomy tube and is ventilator dependent on high positive end - expiratory pressure (PEEP) settings. There is a history of pulmonary hypertension, episodes of ventricular tachycardia and a respiratory arrest which occurred when he had an episode of pneumonia. He also has a Gastrostomy tube. He was admitted to the hospital. There was a plan to transfer him to another health Care facility in Houston Texas, but this facility was not available to accept this patient. The parents have been involved in his care and they have given permission to pursue other possible options for placement at a Long-Term Care facility. The staff have been actively evaluating the options, but this patient has not been accepted for transfer because of the complex nature of his chronic illness.

Continued stay for acute rehabilitation (inpatient medical rehabilitation) is considered medically necessary for this patient.

The medical record indicates that the patient is a medically fragile child who has chronic respiratory failure and is currently dependent on a tracheostomy tube, ventilator support and gastrostomy tube feedings. Given the medical complexity of this adolescent, the patient should remain for ongoing care until a suitable lower-level Long Term Care facility will have a vacancy and will be able to accept this patient for transfer and ongoing care. 

Chronic ventilator care for pediatric patients with chronic respiratory failure is complex and not considered custodial care. These skilled nursing requirements are considered Custodial Care Plan exclusions.

The care has been appropriate, and the denial of ongoing care should be overturned. Based on the New York State Department of health Principles for Medically Fragile Child health plans should not base determinations solely based on review standards applicable to adults. Determinations have to take into consideration the specific needs of the child.

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 continued stay for acute rehabilitation (inpatient medical rehabilitation) is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back pain
Treatment: pain injection (62323 x 1)
The insurer denied coverage for pain injection (62323 x 1)
The denial is overturned 

This patient has chronic low back pain. The patient has had physical therapy (PT) and is doing a home exercise program. The medication trials have included Flexeril, Tylenol, Aleve and Tizanidine. The magnetic resonance imaging (MRI) shows multi-level spinal stenosis as well as degenerative changes with the sacral (S)1 nerve root compression and right lumbar (L)5 nerve root compression. The patient has had several Epidural steroid injections over the past 2 years which have provided excellent pain relief. The health plan has denied the request for another epidural steroid injection (ESI) stating that continuation of injections past 12 months are not covered.

Clinical practice guidelines (1) and a Cochrane review (2) support the performance of an Epidural Steroid injection in this patient. The evidence-based practice guidelines do not limit the therapy to one year.

Manchikanti et al (1) state: Disc herniation: Based on relevant, high-quality fluoroscopically guided epidural injections, with or without steroids, and results of previous systematic reviews, the evidence is Level I for caudal epidural injections, lumbar interlaminar epidural injections, lumbar transforaminal epidural injections, and cervical interlaminar epidural injections with strong recommendation for long-term effectiveness.

Olivera et al (2) concluded: A review of 25 placebo-controlled trials provides moderate-quality evidence that epidural corticosteroid injections are effective, although the effects are small and short-term.

The injection is medically reasonable and necessary.

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 pain injection (62323 x 1) is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back pain

Treatment: pain injection (62323 x 1)

The insurer denied coverage for pain injection (62323 x 1)

The denial is upheld 

This patient has chronic low back pain. The patient has had physical therapy (PT) and is doing a home exercise program. The medication trials have included Flexeril, Tylenol, Aleve and Tizanidine. The magnetic resonance imaging (MRI) shows multi-level spinal stenosis as well as degenerative changes with the sacral (S)1 nerve root compression and right lumbar (L)5 nerve root compression. The patient has had several Epidural steroid injections over the past 2 years which have provided excellent pain relief. The health plan has denied the request for another epidural steroid injection (ESI) stating that continuation of injections past 12 months are not covered.

Clinical practice guidelines (1) and a Cochrane review (2) support the performance of an Epidural Steroid injection in this patient. The evidence-based practice guidelines do not limit the therapy to one year.

Manchikanti et al (1) state: Disc herniation: Based on relevant, high-quality fluoroscopically guided epidural injections, with or without steroids, and results of previous systematic reviews, the evidence is Level I for caudal epidural injections, lumbar interlaminar epidural injections, lumbar transforaminal epidural injections, and cervical interlaminar epidural injections with strong recommendation for long-term effectiveness.

Olivera et al (2) concluded: A review of 25 placebo-controlled trials provides moderate-quality evidence that epidural corticosteroid injections are effective, although the effects are small and short-term.

The injection is medically reasonable and necessary.

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 pain injection (62323 x 1) is substantiated.