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

Diagnosis: Crohn's Disease of the Small Intestine.
Treatment: Wireless Capsule Endoscopy (Pre-service).
The insurer denied the Wireless Capsule Endoscopy (Pre-service).
The denial is overturned. 

The patient is a male with a history of small bowel Crohn's disease maintained on Humira, proton pump inhibitor (PPI) and Pentasa.  He was evaluated by wireless capsule endoscopy which showed ulceration.  He is appealing for one-year repeat wireless capsule endoscopy (WCE) for surveillance.

Yes, the proposed treatment is medically necessary.
The overall detection rate by wireless capsule endoscopy in patients with known Crohn's disease was 55 percent in a large meta-analysis. Studies have been done comparing it with other modalities for small bowel Crohn's disease. A meta-analysis of 12 studies found that capsule endoscopy had an overall yield of 50 to 70 percent for findings of Crohn's disease. The yield was higher than the yield for barium radiography (22 percent), ileo-colonoscopy (48 percent), push enteroscopy (eight percent), or computed tompgrahy (CT) enterography / computed tomography (CT) enteroclysis (31 percent). In patients with known Crohn's disease who were being evaluated for a suspected recurrence, the yield for video capsule endoscopy (VCE) was 66 to 71 percent.  Using ileoscopy or surgery as the gold standard, videa capsule endoscopy (VCE) had a sensitivity of 100 percent for detecting terminal ileal Crohn's disease, which was significantly higher than that for computed tomography (CT) enterography (76 percent) and showed a trend toward being higher than the sensitivity for magnetic resonance (MR) enterography (81 percent). Overall, video capsule endoscopy (VCE) findings help identify patients who are likely to have a disease relapse. 

Mucosal healing and deep remission are associated with improved outcomes in Crohn's disease (CD). In a study of 56 patients were enrolled.  Moderate-to-severe small bowel inflammation was demonstrated in 11/52 (21.1%) of patients in clinical remission and in 1/21 (4.7%) of patients in clinical and biomarker remission using wireless capsule endoscopy.  This study shows that wireless capsule endoscopy can be used to detect small bowel inflammation, as well as assessing treatment response in patients with clinical remission, such as this patient who currently is asymptomatic on Humira.

The health plan denied the procedure stating that one of the requirements is to have active disease and since the progress note shows the patient is asymptomatic without active bleeding pain or bowel movement changes, the repeat capsule endoscopy is not necessary.  

However, in this case, the use of capsule endoscopy is beyond the initial evaluation of active disease; it is for the assessment of response to treatment, specifically Humira, and to determine if the patient continues to have small bowel inflammation which will dictate the next course of action.  Therefore, the use of the procedure has clinical implication on the treatment course which can directly affect the rate of remission versus relapse.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: febrile seizures

Treatment: hospital admission

The insurer is denied coverage for the hospital admission.

The denial is upheld. 

This female patient has a history of febrile seizures.

According to the guidelines provided by the Milliman Care Guidelines, the acuity of this case is considered to have required observation as the patient with a known or previous seizure disorder presented with an uncomplicated seizure that was resolved prior to arrival. Upon arrival the patient was not considered to be in status epilepticus. No events concerning for seizures were noted during the stay. Precautionary testing found mild abnormalities on the electroencephalogram and normal magnetic resonance imaging. No treatments were offered. The patient was described as interactive and at baseline upon discharge. The patient did not require an escalated level of care.

The current literature indicates a patient may be admitted when there is evidence of a metabolic disorder persisting despite observation, recurrent seizure, increased intracranial pressure, new focal neurologic deficits, altered mental status that is severe persistent or there is evidence of hemodynamic instability. The submitted documentation does not detail the patient had a trial and failure of care at a lower level such as observation. The patient was back at baseline and was discharged after 2 days. The requested inpatient admission would not be the most appropriate level of care.

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

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

Diagnosis: Aneurysms

Treatment: inpatient admission

The insurer denied coverage for inpatient admission.

The denial is overturned.

The patient is a female who presented to the emergency department (ED) for left chest pain radiating to the left arm, left sided weakness, heaviness and paresthesia.  She had recently received 2nd dose of the COVID-2019 (2019 Novel Coronavirus) vaccine a few days ago.  She had medical history of diabetes mellitus, tobacco abuse.  Stroke team was activated. Vital signs in the ED showed normal blood pressure (BP).  On exam, she had decreased sensation to the left side of face with weakness on the left arm/leg with associated sensory loss.  National Institute of Health Stroke Score (NIHSS) was 3.  Head computed tomography (CT) was negative.  Computed tomography angiography (CTA) of the head and neck did not reveal a large vessel occlusion or moderate/high grade stenosis. She was admitted to inpatient level of care for possible stroke. 

Given that the patient had persistent focal neurological deficits in the ED as evidenced by NIHSS 3 as well as past medical history of vascular risk factors, inpatient admission for clinical suspicion of acute stroke was medically necessary. 

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 the inpatient is reversed. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: blurry vision and headache.

Treatment: full hospital admission

The insurer is denied coverage for full hospital admission.

The denial is upheld. 

This male patient has a history of hypertension, coronary artery disease (CAD), testosterone deficiency, and scotoma.

Given that this was neurologically and hemodynamically stable with low ABCD3-I score as well as negative head CT (Computerized Tomography) without evidence of moderate to high grade stenosis or occlusion of a large vessel on the CTA (Computed Tomography Angiography) head/neck, inpatient hospital stay was not medically necessary, as the patient could have been safely and effectively managed on the observation level of care.

The health plan did act 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.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems-Chest pain.
Treatment: Inpatient hospital stay.

The health plan denied the inpatient stay as not medically necessary. The reviewer has upheld in whole the health plan's determination.

This patient presented to the emergency department complaining of four days of midsternal chest pain, cough and mild dyspnea. He reported one episode of nausea and vomiting. His medical history was remarkable for gastroesophageal reflux disease and obesity. His blood pressure was 143/97 millimeters of mercury (mmHg) with a heart rate of 99 beats/minute (beats per minute). His respiratory rate was 18/minute with a room air oxygen saturation of 98%. He was afebrile. An electrocardiogram showed sinus rhythm with inferolateral T wave inversions that had been present on prior tracings; the QT interval was prolonged. Cardiac biomarkers were normal. The patient's serum potassium level was 3.1 millimoles per liter (mmol/L); his sodium level was 130 mmol/L. His blood urea nitrogen (BUN) was 42 milligrams per deciliter (mg/dl) with a creatinine of 1.94 mg/dl. His liver function tests were mildly abnormal. Chest X-ray and computed tomography (CT) scan showed no acute pathology. Urine toxicology was positive for cannabinoids. The patient was treated with intravenous fluid, potassium supplementation and Protonix. He was admitted to the hospital with a diagnosis of atypical chest pain. His hyponatremia and elevated creatinine level were attributed to volume depletion. His renal function improved with hydration. His BUN fell to 36 mg/dl with a creatinine of 1.67 mg/dl. He was seen by a cardiologist who recommended an echocardiogram. His BUN was 24 mg/dl with a creatinine of 1.28 mg/dl. An echocardiogram was performed and was normal. The patient was discharged. Medical necessity for an inpatient admission is at issue.

Based on the records provided an inpatient level of care was not medically necessary.
This man presented with atypical chest pain that was thought to possibly represent acute coronary syndrome (ACS). Accordingly, observation of the patient until ACS could be ruled out was a reasonable approach. However, he was hemodynamically stable, with normal cardiac biomarkers, and no acute electrocardiographic changes. He did not require intensive monitoring or continuous infusion of intravenous cardioactive medications. The care this patient received for his chest pain did not require an inpatient admission and could have been provided under a lower level of care. This approach has been shown to be both safe and cost-effective and is in accordance with the 2014 American Heart Association (AHA) / American College of Cardiology (ACC) Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes.
Upon presentation the patient had evidence of acute kidney injury with elevated BUN and creatinine levels. This resolved with intravenous hydration. This did not warrant an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: cellulitis
Treatment: Inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is upheld.

The patient was a male who initially presented to the emergency department with concerns of left lower extremity swelling and erythema. Pertinent history included recurrent left lower extremity cellulitis, urinary tract infection a month prior, hypertension, and morbid obesity. Initial vital signs revealed a temperature of 97.2, heart rate (HR) 103, blood pressure (BP) 185/107, respiratory rate (RR) 20, and SpO2 99% on room air. Initial examination documented the patient as alert, oriented, with left lower extremity erythema, edema, and calf tenderness. Initial serology revealed a white blood cell (WBC) 15.6, Hemoglobin (HGB) 14.6, platelets (Plt) 258, blood urea nitrogen (BUN) 11.9, Cr (creatinine) 0.9, Glucose 98, and Lactic acid 1.2. Urinalysis revealed pyuria and bacteriuria. Duplex ultrasound did not reveal a deep vein thrombosis. The patient was placed in the hospital thereafter with an impression of cellulitis, urinary tract infection, hematuria, hypertension, and severe obesity. 

Based on the clinical documentation provided, evidence based literature and standards of care, the acute inpatient stay was not medically necessary.
Ramakrishnan et al. note inpatient treatment is necessary for patients who have uncontrolled infection despite adequate outpatient antimicrobial therapy or who cannot tolerate oral antibiotics. Hospitalization is also indicated for patients who initially present with severe or complicated infections, unstable comorbid illnesses, or signs of systemic sepsis. Broad-spectrum antibiotics with proven effectiveness against gram-positive and gram-negative organisms and anaerobes should be used until pathogen-specific sensitivities are available; coverage can then be narrowed. Intravenous antibiotics should be continued until the clinical picture improves, the patient can tolerate oral intake, and drainage or debridement is completed. In this particular situation, none of aforementioned criteria for hospitalization, or continued hospitalization, were present.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cystic Fibrosis

Treatment: Current Procedure Terminology (CPT) code 81220, genetic testing (FMR1 fragile X mental retardation 1 (e.g., fragile X mental retardation gene analysis)

The insurer denied coverage for CPT code 81220, genetic testing (FMR1 fragile X mental retardation 1 (e.g., fragile X mental retardation gene analysis)

The denial is upheld

The patient has no significant medical history.  The provider ordered carrier screening for cystic fibrosis (CF), Fragile X and spinal muscular atrophy (SMA).  There is no documentation that the patient has a personal or family history of inherited genetic disorders. 

Current consensus guidelines from professional genetics organizations recommend carrier screening only for women with a family history of fragile X syndrome or undiagnosed mental retardation, developmental delay, or autism or for those with ovarian insufficiency. 

The American College of Obstetricians and Gynecologists' Committee on Genetics (ACOG) recommends testing for fragile X syndrome as follows: 

Women with a family history of fragile X-related disorders, unexplained mental retardation or developmental delay, autism, or premature ovarian insufficiency are candidates for genetic counseling and fragile X premutation carrier screening. 

If a woman has ovarian insufficiency or failure or an elevated follicle-stimulating hormone level before age 40 years without a known cause, fragile X carrier screening should be considered to determine whether she has an FMR1 premutation. 

This patient does not have any of the above conditions. Testing for Fragile X syndrome was not medically necessary.

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

The insurer's denial of coverage for the CPT code 81220, genetic testing (FMR1 fragile X mental retardation 1 (e.g., fragile X mental retardation gene analysis) is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hepatitis
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a man who was admitted to the hospital. He had a history of gastritis, asthma, cholecystectomy and COVID-19 not requiring hospitalization. He was admitted as a transfer from an outside hospital for a possible endoscopic retrograde cholangiopancreatography (ERCP). He initially presented with abdominal pain weeks earlier. He reported stabbing pain in the epigastrium and right upper quadrant. At the outside hospital, labs were notable for aspartate aminotransferase (AST) 147, and alanine aminotransferase (ALT) 75. At that time, he was discharged with omeprazole for suspected gastritis but then presented again with worsening abdominal pain. He denied fevers, chills, nausea and diarrhea. Vital signs showed temperature 98.3 Fahrenheit, heart rate 62, blood pressure 100/63, and respiratory rate 16. On physical exam, heart was regular, breath sounds were normal and the abdomen was soft and nontender. Bowel sounds were present. Labs showed alanine aminotransferase (ALT) 1177, sodium 138, potassium 4.8, creatinine 0.77, glucose 96, and calcium 9.7. White blood cell count (WBC) was 5.3 and hemoglobin 14.8. The patient was admitted with acute hepatitis with concern for autoimmune hepatitis versus toxic/alcoholic hepatitis.

The inpatient hospital stay was medically necessary.
The reason is that the patient presented with acute hepatitis and concern for a toxic/metabolic process involving the liver. Acute hepatitis normally requires inpatient level of care when it is pronounced due to the risk of progressively worsening liver function, hepatic encephalopathy, and fulminant liver failure. Gastroenterology was involved in the patient's care and performed extensive diagnostic testing. This intensity of care is normally provided at the inpatient level of care.
Patients with pronounced acute hepatitis are at increased risk for fulminant liver failure, development of hepatic encephalopathy, and coagulopathy. The patient needed rapid diagnostic evaluation and close monitoring of laboratory values and testing for other possible causes of liver injury such as autoimmune and viral hepatitis. In addition, the patient required specialty care with gastroenterology. The patient's care was complex, and this complexity is normally provided at the inpatient hospital level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Infectious Disease.
Treatment: Inpatient Hospital. 
The insurer denied Inpatient hospital admission for medical necessity. 
The denial was overturned. 

The patient is a morbidly obese male with a history of poorly controlled diabetes mellitus (DM) who presented to the emergency department (ED)  with complaints of recurrent right testicular abscess. He had initially been prescribed Zyvox by infectious disease (ID) but could not afford it due to lack of insurance coverage. He stated he had a temp of 101.7 at home and took some Tylenol about 4 hours prior to presentation to the ED. On arrival, his temperature was 99.7, heart rate (HR) was 91, respiratory rate (RR) was 20, blood pressure (BP) was 100/65 and pulse oxygen (O2) saturation on room air (RA) was 96%. Pertinent findings on the physical exam noted right scrotal lesion, indurated and tender to touch.
His labs showed a leukocytosis of 16.2 with 80% Neutrophils, Lactic acid was elevated at 2.2, and the rest of his labs were stable. An ultrasound (US) showed a large heterogenous fluid collection within the right scrotum which likely represented scrotal abscess. He was then subsequently admitted to Urology and abscess was drained and packed at bedside. He was started on intravenous (IV) Vancomycin and Cefepime after blood cultures and wound cultures were collected, and ID was consulted. Progress notes by Urology showed the patient's wound cultures grew rare gram-positive cocci in pairs, white blood cell count (WBC) was down to 8.6 and the patient was feeling better, packing was changed daily, and Urology was planning to follow up with ID as to antibiotic regimen in light of lack of IV access. The patient was then switched to oral Cephalexin and Clindamycin and on recommendation of ID was advised to stay overnight. He was subsequently discharged.
At issue is the medical necessity of Inpatient stay.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of Inpatient stay was medically necessary for this patient.
The patient has a history of uncontrolled diabetes and a recurrent scrotal abscess and as such was at a high risk of progression of his condition due to his immunocompromised state. He gave a history of fever prior to presentation, had an elevated lactic acid level and leukocytosis of 16 and as such met criteria for sepsis. Appropriate treatment including incision and drainage (I+D), treatment with IV antibiotics, need for wound and blood cultures to direct treatment and control of diabetes made the inpatient management and treatment medically necessary.
Therefore, the requested health service of Inpatient stay was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Immunologic Disorders-Hereditary angioedema (HAE)
Treatment: Pharmacy/Prescription Drugs-Takhzyro
The health plan denied Takhzyro as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

This is a male patient who is requesting for Takhzyro for angioedema. He has Hereditary angioedema (HAE). There is a family history of HAE. He has been on danazol and cinryze. Labs are not available. He has had a history of intubation.

Takhzyro is not medically necessary for this patient.  In this case, there are no labs submitted for review to support the diagnosis of HAE.
"Hereditary angioedema (HAE) is an autosomal dominant disorder defined by a deficiency of functional C1 esterase inhibitor (C1 INH). Acquired angioedema is due to either consumption (type 1) or inactivation (type 2) of CI-INH. Both HAE and acquired angioedema can be life-threatening. Of the three types of HAE, type 1 is most common, occurring in approximately 85%of patients and characterized by decreased production of C1-INH, which results in reduced functional activity to 5-40% of normal. Type 2 occurs in 15% of cases; C1-INH is detectable in normal or elevated quantities but is dysfunctional. Also, HAE with normal CI-INH (previously called type 3 HAE) is rare and characterized by normal complement studies.
Specific genetic mutations have been linked to factor XII, angiopoietin1, and plasminogen gene. Patients with unknown mutations are classified as unknown. The screening test for types 1 and 2 is complement component C4, which is low to absent at times of angioedema and during quiescent periods. A useful test to differentiate HAE from acquired angioedema is C1q protein, which is normal in HAE and low in acquired angioedema. The management of HAE has been transformed with the advent of disease-specific therapies. On- demand therapy options include plasma and recombinant C1-INH for intravenous infusion; ecallantide, an inhibitor of kallikrein; and icatibant, a bradykinin receptor antagonist, both administered subcutaneously. For long-term prophylaxis, intravenous or subcutaneous C1-INH enzyme replacement and lanadelumab, a monoclonal antibody against kallikrein that is administered subcutaneously, are effective agents." (Patel, G., & Pongracic, J. A. 2019).
However, in this case, there are no labs to support the diagnosis. There is no record of C1 and C4 labs to show that the patient has HAE. Takhzyro is therefore not medically necessary.