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

Diagnosis: Chest Pain
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

This is the case of an adult male that presented to the hospital complaining of shortness of breath and retrosternal chest pain on exertion. Symptoms were accompanied by nausea and vomiting. The patient reported no past medical history. He actively abuses cocaine and ethanol. Upon arrival to the hospital, vital signs were stable [blood pressure (BP) 133/80, pulse 98 beats per minute (bpm)]. Physical examination was significant for a rash over the upper chest. A 12-lead electrocardiogram (EKG) revealed normal sinus rhythm with no ischemic ST (interval on EKG) or T (Interval on EKG) wave abnormalities. Serial serum troponin levels were not elevated). Urine toxicology was positive for cocaine. Coronavirus (COVID) disease antigen testing was positive, and the patient was admitted to the hospital for observation and treatment. He was ultimately released with outpatient follow up after COVID antigen testing was found to be negative.

This patient presented with intermittent chest pain in the setting of active cocaine use. His pretest probability of coronary artery disease is low (Reference 1). Utilizing the HEART (History, EKG, Age, Risk factors, and troponin) score, he was considered low risk (Reference 2). Utilizing the TIMI (Thrombolysis in Myocardial Infarction) risk score, he also had a low risk of developing major adverse cardiac events in the subsequent 30 days (TIMI score=1) (Reference 3). Risk assessment of patients presenting with chest pain and no significant ST changes on EKG was reviewed by Hedayati et al. (Reference 3) Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events [myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death] in the six weeks following presentation. Using the TIMI risk score, this patient would have a low risk of major cardiac events (all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation.  

Investigators studying more than 300,000 hospital admissions for chest pain in the setting of cocaine use, found that patients presenting with chest pain following cocaine use and no other significant risk factors had a low risk of major adverse cardiac events and mortality. They concluded that most patients did not require hospital admission (Reference 4).

In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary. 

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

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

Diagnosis: Pelvic fracture.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a patient who sustained a left hip injury when a motorized scooter fell over on them. The emergency department clinical note stated that the injury occurred the day prior. The patient reported an inability to walk and had severe pain rated 8/10. On examination, there was limited muscle strength in the left lower extremity due to pain, tenderness over the left hip and buttocks. The x-rays are noted to show a possible acetabular fracture. Orthopedics was consulted.
The report from states that there was limited range of motion at the hip and a positive log roll test. The provider notes that the x-rays are consistent with a transverse posterior wall acetabulum fracture. The patient was admitted to orthopedic service and advised to maintain a nonweightbearing status on the left lower extremity. The treatment plan included an examination under anesthesia with possible open reduction internal fixation of the left acetabulum tomorrow. Preoperative labs were ordered.
The operative report indicates that the acetabular fractures and left hip were stable on fluoroscopic imaging and manipulation and stress maneuvers. Therefore, it was decided to proceed with closed nonoperative treatment of the left acetabular fracture.
At issue is the medical necessity of an inpatient stay.

The documentation indicates that the patient was diagnosed with a transverse posterior wall acetabulum fracture which was deemed stable and appropriate for nonoperative management. There was no suggestion of an inability to manage this patient at a lower level of care. The operative report indicates that the acetabular fractures and left hip were stable on fluoroscopic imaging and manipulation and stress maneuvers. Therefore, it was decided to proceed with closed nonoperative treatment of the left acetabular fracture. A clinical note states that the pain was adequately controlled with pain medications and no complications were identified. The patient remained with posterior hip precautions and deep vein thrombosis (DVT) prophylaxis by Lovenox. A clinical note indicates that the pain was rated 4/10 and adequately controlled with medications. The patient was doing well status post examination and manipulation under anesthesia and discharge planning was taking place. The discharge summary states that the patient was deemed stable for discharge. The requested inpatient stay was not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Palpitations and lightheadedness
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is overturned.

This is the case of an adult female that presented to the hospital complaining of palpitations, lightheadedness, and hot flashes. Past medical history was significant for hypertension. Upon arrival to the hospital, the patient was noted to be tachycardic with an irregularly irregular pulse revealing blood pressure (BP) of 146/14 and heart rate (HR) of 145 beats per minute. Physical examination revealed no significant abnormality. A 12-lead electrocardiogram (EKG) revealed atrial fibrillation (A-fib) with rapid ventricular rate (RVR) and T wave inversions in the lateral leads. Serum blood testing revealed a thyroid stimulating hormone (TSH) of <0.01 and Free thyroxine (T4) hormone of 5.7 consistent with a diagnosis of hyperthyroidism. The patient was admitted to the telemetry unit for monitoring and treatment. Following treatment with methimazole and beta blocker therapy she reverted to normal sinus rhythm.

This patient presented with palpitations and lightheadedness. She was diagnosed with A-fib and RVR. Serum blood testing was significant for hyperthyroidism. Acute inpatient admission was necessary to treat this patient and ensure that she was on appropriate medical therapy for hyperthyroidism and atrial fibrillation.

Patients presenting with atrial arrhythmia and ventricular rates up to 145 require acute therapy and further monitoring to ensure that medications control heart rate and rhythm without producing significant bradycardia. An analysis of 68 million Medicare patients admitted to the hospital for A-fib over a fifteen-year period demonstrated an average length of stay of 3 days. (1) This analysis also demonstrated decreased mortality and readmission rates following admission to the hospital. The current standard of care is consistent with hospital admission when patients present with symptomatic rapidly conducted atrial fibrillation. In addition to A-fib, this patient had hyperthyroidism that required treatment. American Heart Association/ American College of Cardiology (AHA/ACC) guidelines for the management of A-fib recommend careful telemetry monitoring for patients that present with A-fib and RVR along with aggressive treatment of etiologies responsible for arrhythmia. (2) 
 
The health plan did not act reasonably with sound medical judgement and in the best interest of the patient.  

The insurer's denial of coverage for inpatient hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is: Upheld.

The patient is a male who presented to the emergency department complaining of five days of intermittent sharp, stabbing, non-exertional, pleuritic, right-sided chest pain that was worse on the day of presentation. His medical history was remarkable for coronary artery disease, myocardial infarction, percutaneous coronary interventions, diabetes, hypertension, hyperlipidemia and obesity. His blood pressure was 175/94 millimeters of mercury (mmHg) with a heart rate of 88 beats/minute. His room air oxygen saturation was 96%. His cardiopulmonary exam was unremarkable. An electrocardiogram showed sinus rhythm without acute changes. His serum troponin level was normal, as was his brain natriuretic peptide (BNP) level. Chest x-ray showed minimal left basilar atelectasis. The patient was treated with sublingual nitroglycerin, aspirin and acetaminophen and admitted to the hospital. Aspirin, Plavix and metoprolol were prescribed. He received one dose of intravenous hydralazine for hypertension. Lisinopril was prescribed for continued hypertension. His serum troponin level remained normal. An echocardiogram showed normal left ventricular systolic function. Coronary angiography was performed and showed a 90% proximal right coronary artery (RCA) stenosis, a 99% distal RCA stenosis and a 99% obstruction in the second obtuse marginal artery. All three lesions were treated with drug-eluting stents. The procedure was uncomplicated. The patient had no complaints. His blood pressure was 128/72 mmHg. He was discharged. Medical necessity for an inpatient hospital admission is at issue.

The health plan's determination is upheld.

An inpatient hospital admission was not medically necessary. This patient, with known coronary artery disease, presented with symptoms that were thought to be suspicious for acute coronary syndrome (ACS). Accordingly, monitoring until ACS could be ruled out was a reasonable approach. However, he was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. He did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received did not require an inpatient admission and could have been provided under a lower level of care status. This approach has been shown to be safe and is in accordance with current guidelines including the 2021 American Heart Association (AHA)/American College of Cardiology (ACC)/American Society of Echocardiography (ASE) /American College of Chest Physicians (CHEST)/Society for Academic Emergency Medicine (SAEM)/Society of Cardiovascular Computed Tomography (SCCT)/Society for Cardiovascular Magnetic Resonance (SCMR) Guideline for the Evaluation and Diagnosis of Chest Pain and the 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Epigastric pain; dyspepsia.
Treatment: EGD (esophagogastroduodenoscopy).
The insurer denied the EGD (esophagogastroduodenoscopy).
The denial is upheld.

The patient is a male. Per a clinic visit, epigastric pain and dyspepsia were noted reasons for EGD (esophagogastroduodenoscopy) evaluation. The patient denied dysphagia, weight loss. There is no mentioning of trial of PPI (proton pump inhibitors).

The appeal is for request for 43239, Endoscopy Procedures on the Esophagus, Esophagogastroduodenoscopy Procedures. The prior denial and initial appeal were upheld by the health plan due to lack of medical necessity.

No, the requested EGD (esophagogastroduodenoscopy) (43239) was not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
The American College of Gastroenterology (ACG) and the Canadian Association of Gastroenterology (CAG) guidelines on dyspepsia, in a joint ACG/CAG (American College of Gastroenterology/ Canadian Association of Gastroenterology) dyspepsia guideline, write, "We suggest that patients 60 years of age presenting with dyspepsia are investigated with upper gastrointestinal endoscopy to exclude organic pathology."

The standard of care is age > [greater than] 60, or failed PPI (proton pump inhibitor) therapy for 8 weeks.

The patient's age is less than 60. There was no Helicobacter pylori stool testing ordered. No PPI (proton pump inhibitor) trial of 8 weeks is documented. Therefore, the EGD (esophagogastroduodenoscopy) is not the standard of care in this case.

Therefore, given the above, the EGD (esophagogastroduodenoscopy) (43239)  was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prostate cancer

Treatment: Genetic testing of the prostate tissue with Oncotype DX for prostate cancer

The insurer denied coverage for genetic testing of the prostate tissue with Oncotype DX for prostate cancer.

The denial is upheld. 

According to the clinical documentation provided for review, the patient is a male with history of intermediate risk prostate cancer. He had Oncotype DX testing to guide the course of treatment. The insurer has denied coverage for genetic testing of the prostate tissue with Oncotype DX for prostate cancer as not medically necessary. The treating provider ordered, recommended, and is requesting plan approval for genetic testing of the prostate tissue.

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

The Oncotype DX is experimental and/or investigational for this patient. According to National Comprehensive Cancer Network (NCCN), molecular testing may be considered in patients with intermediate disease during the initial risk stratification. However, these have been developed using retrospective data. NCCN notes that "full assessment of their clinical utility requires prospective randomized trials". They also note that future comparative effectiveness research may allow these tests and others like them to gain additional evidence regarding their utility for better risk stratification of patients with prostate cancer. 

Therefore, the request is denied and not medically necessary for this patient.

Similar issues regarding the utility of other than Oncotype testing have also been noted in the literature. 

"The use of active surveillance (AS) is increasing in the United States and internationally. Long-term data show favorable outcomes with this approach, and it is supported by multiple guidelines. In 2016, the American Society of Clinical Oncology (ASCO) endorsed the Cancer Care Ontario guidelines, recommending AS for most patients with low-risk (Gleason 6) prostate cancer. However, they acknowledge that there is heterogeneity within this risk category and that further consideration should be given to younger men, black men, and those with high-volume disease. For patients with low-risk prostate cancer and a life expectancy less than 5 years, they recommend watchful waiting." (Loeb, 2018)                                                   

The insurer's denial of coverage for genetic testing of the prostate tissue with Oncotype DX for prostate cancer is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting

Treatment: Inpatient hospital admission 

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

The patient had a history of cyclic vomiting, gastritis, and marijuana use and presented with vomiting. He was having abdominal cramps. He had hypertension and tachycardia. The abdominal exam was benign. The WBC (white blood cell count) was 19.0. The BUN (blood urea nitrogen) was 21.9 with a creatinine of 4.0. His baseline creatinine was 2 and he was found to have a creatinine of 3.06. He was not compliant with his renal follow up. Intravenous (IV) hydration, Protonix, and Zofran were given. He left the hospital on the same day against medical advice. 

Clinical indications for admission for Vomiting [Milliman Care Guidelines (MCG) M-370] include vomiting due to a severe metabolic derangement, hemodynamic instability that is not readily corrected with treatment, severe electrolyte abnormalities, bacteremia, and acute kidney injury if certain criteria have been met. For acute kidney injury, there needs to be a two-fold increase in the serum creatinine along with another finding. This finding can be worsening clinical status, cardiac arrhythmias, altered mental status, or severe electrolyte or metabolic abnormalities that persist despite appropriate treatment. In this case, the patient had a two-fold increase in his serum creatinine from baseline. However, he did not fail a course of ER (emergency room) or observation treatment.

This patient had cyclic vomiting and dehydration. He required IV hydration, PPI (proton pump inhibitor) therapy, and antiemetics. This could have been given with observation care. He had chronic elevation of the serum creatinine. He did not meet MCG criteria for an admission for vomiting. The health care plan acted reasonably and with sound medical judgment. An inpatient hospital admission was not medically necessary. The denial is upheld.

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

Diagnosis: Cardiac/Circulatory Problems - Mixed hyperlipidemia.
Treatment: Lipitor
The insurer denied Lipitor.
The denial is overturned. 

This case involves a female patient with a past medical history of severe mixed hyperlipidemia, statin intolerances, and osteoporosis. Records provided for review of this case show that the patient has experienced significant intolerances to generic statin therapy including simvastatin, rosuvastatin, atorvastatin each causing severe myalgias prompting discontinuation. However, the patient has done well being treated with brand name Lipitor. Based on the patient's recent lipid panel showing severely elevated blood cholesterol levels (total cholesterol (TC) at 314, triglycerides (TG) at 200, low density lipoprotein (LDL) at 225), high intensity statin therapy in indicated for control of lipids and cardiovascular risk reduction. The patient's health plan has denied coverage for Lipitor on the grounds the patient did not meet prescription benefit exception criteria.
At issue is whether the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug.

The health plan's determination is overturned in whole.

Yes, the formulary drugs (atorvastatin, ezetimibe-simvastatin, Fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin) will be less effective, or have not been as effective as the non-formulary drug (Lipitor).
Documentation provided for review demonstrates that the patient has tried and failed 3 formulary statin medications (atorvastatin, simvastatin, rosuvastatin) due to severe myalgias. She has tolerated brand-name Lipitor in the past without side effects. Given her severe hyperlipidemia, high intensity statin is recommended to control cholesterol and reduce her risk of future cardiovascular events supported by the 2018 American Heart Association (AHA) / American College of Cardiology (ACC) guideline on the management of blood cholesterol. (1)
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Leukemia, osteoarthritis, heart disease
Treatment:  Consumer directed personal assistance services (CDPAS) to five days for 11 hours with two shifts and two days for ten hours with two shifts
The insurer denied: Consumer directed personal assistance services (CDPAS) to five days for 11 hours with two shifts and two days for ten hours with two shifts.
The denial is overturned.

This patient is an elderly female who has conditions including diabetes, hypertension, leukemia, anemia, heart disease, osteoarthritis, and osteoporosis. She was hospitalized after a syncopal episode. The patient is appealing denial of consumer directed personal care aide services (CDPAS) five (5) days for 11 hours with two (2) shifts and two days for ten hours with two shifts. The plan approved seven days for nine hours, a total of 63 hours per week.

A letter from patient's physician states the patient's heath is deteriorating. She has a history of multiple falls due to weakness. She was hospitalized previously this year. She has impairment and limited range of motion and pain in upper and lower extremities that affect ability to perform activities of daily living (ADLs). She wakes up at night and needs to urinate, eat and for sudden lower extremity cramps. She needs help at night for positioning and for assistance with cramps.  

A statement from the patient notes that she has a hard time doing things when the aid is gone for the day. She notes having leg cramps when she went to the gynecologist's (GYN) and not being able to urinate.

The proposed treatment is medically necessary.
Personal assistance services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services.  

This patient with multiple chronic conditions is appealing denial of increase in consumer directed personal care aide services (CDPAS) to five days for 11 hours with two shifts and two days for ten hours with two shifts. The plan approved seven days for nine hours, a total of 63 hours per week. An appeal statement from the patient's doctor notes that the patient's condition is deteriorating. It states the patient needs assistance with activities of daily living (ADLs) due to limited range of motion and pain in extremities. The provider also notes that the patient needs nighttime assistance with urination, sudden lower extremity cramps, and repositioning. The information provided supports that the patient has unscheduled nighttime needs that cannot be met with the approved consumer directed personal assistance services (CDPAS) seven days for nine hours, a total of 63 hours per week. The proposed increase in consumer directed personal assistance services (CDPAS) to five days for 11 hours with two shifts and two days for ten hours with two shifts is medically necessary because the patient needs frequent assistance with toileting, turning, and/or positioning which would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift.