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

Diagnosis:  Non-reducible bleeding hemorrhoid.
Treatment:  Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is upheld.
 
According to the documentation submitted, this patient presented as a transfer to Bellevue on with the admitting diagnosis of hemorrhoids. As per the history and physical (H and P) the patient is an adult with asthma and hemorrhoids since childhood.  The patient presented with an episode of a non-reducible, bleeding hemorrhoid for 6 days. The patient has been using preparation H and sitz baths but has not been able to resolve or reduce the bulging. The patient does have a history of substance abuse and requires a high level of pain control. Vital signs were stable. On exam the patient had external hemorrhoids not actively bleeding, and a large protruding non-reducible hemorrhoid.

The patient was taken to the operating room for examination under anesthesia (EUA) and excision of hemorrhoid. Surgery was uneventful. The patient did well postoperatively and was discharged in stable condition.

Based upon the information provided, the acute inpatient admission was not medically necessary. The patient should have been treated in an observation stay. The patient had hemorrhoids that were bleeding, non-reducible and needed to have it excised. This is an outpatient procedure and did not require a 2 day inpatient stay. The patient should have been cared for in an observation status and did not require an acute inpatient admission. The patient was stable and could have been observed and discharged without an acute admission but rather a 23-hour observation stay. 

According to Milliman Care Guidelines (MCG) Health General Recovery Guidelines 27th edition General Surgery or Procedure GRG: SG-GS (ISC GRG), Operative Status Criteria is ambulatory for many procedures. Examples include: Endoscopic procedures; Embolization procedures; Most biopsy procedures; Many elective operations; including Stoma  repair, Fistula repair, Lymph node surgery; Hernia repairs in the absence of ALL of the following: Emergency procedure (e.g. strangulated hernia), Severe co-morbid disease (e.g., severe infection), Complex approach (e.g., morbid obesity, large chronic incarceration); Hemorrhoid or rectal surgery; Most breast procedures; Percutaneous and dilation procedures; Liver biopsy.  The patient was hemodynamically stable throughout and did not need an acute admission but rather observation. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left arm pain
Treatment: Physical therapy (97116 x 6)
The insurer denied coverage for: Physical therapy (97116 x 6)
The denial is: Upheld

This is an adult patient with reported "left arm pain."  The treating physician recommended physical therapy, that was denied by the insurer; leading to an external review.  

The physical therapy treatment notes made available for review fail to provide objective clinical information to support the medical necessity for skilled physical therapy services. The physical therapy treatment notes do not establish the medical necessity of continuing a structured out-patient physical therapy treatment program. The physical therapy note provides limited clinical information and minimal (if any) clinical support for the provision of skilled physical therapy treatments. The other visit note submitted for review is nearly a month later. The patient's impairment score, disabilities of arm shoulder and hand (DASH) actually increased. It is also not clear if the modest improvement with strength and range of motion (ROM) over the prior approximately 5 months period is due to skilled therapy services, time or other possible interventions (e.g., rest, ice, home exercise, steroid injections, non-steroidal anti-inflammatory drugs [NSAIDs], etc..). There remains no substantial clinical support for the medical necessity of skilled therapy services in this particular case.   

From a physical medicine & rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, physical therapy (97116 x 6) is not medically necessary.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for physical therapy (97116 x 6) is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asymmetric spastic diplegia cerebral palsy and right 
equinovarus foot deformity
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is a school age female with asymmetric spastic diplegia cerebral palsy and right equinovarus foot deformity. She underwent right split tibialis anterior tendon transfer to the cuboid, right gastroc soleus recession, and right tibialis posterior fractional lengthening with neuraxial block. Following surgery, the patient was transferred to the post anesthesia care unit (PACU) on the floor. She received intravenous fluids and intravenous pain medication as well as postoperative antibiotics.
On the next day, the patient was evaluated by physical therapy, and received additional intravenous pain medications. On day #3 the patient had physical therapy and was cleared for discharge.
The request is for inpatient status. This was denied stating that the patient could have been under observational status.

The requested health service was not medically necessary.

According to the included documentation, the requested inpatient status was not medically necessary. Although the entirety of the patient's treatment, including care in a hospital, was medically indicated and with sound medical judgment, there is insufficient documentation supporting the need to upgrade the patient to inpatient status. The observation in the facility, intravenous fluids, pain medication administration, and physical therapy could have been performed under observation status. The documentation does not include support for one of the Milliman Care Guidelines (MCG) Health General Recovery Care 26th Edition Ambulatory 
Surgery Exception Criteria. Therefore, the requested health service was not medically necessary.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Multiple sclerosis

Treatment: Zeposia

The insurer denied coverage for Zeposia.

The denial is overturned.
 
There was a prior authorization request which noted that the patient's diagnosis was multiple sclerosis (MS). It was noted that Zeposia coverage was requested as it was a continuation of an effective therapy. 

The patient has a diagnosis of multiple sclerosis. The patient has been prescribed Zeposia and it has been an effective therapy. This is a continuation of an effective disease modifying therapy. Switching effective disease-modifying therapies is not recommended as switching carries risk of relapse, disability, and death. Therefore, the request for Zeposia is medically necessary. 

Rae-Grant A, Day GS, Marrie RA, Rabinstein A, Cree BAC, Gronseth GS, Haboubi M, Halper J, Hosey JP, Jones DE, Lisak R, Pelletier D, Potrebic S, Sitcov C, Sommers R, Stachowiak J, Getchius TSD, Merillat SA, Pringsheim T. (2018), "Page 96, statement 1b: Clinicians should advocate that people with MS who are stable (that is, no relapses, no disability progression, stable imaging) on [disease modifying therapy] DMT should continue their current DMT unless the patient and physician decide a trial off therapy is warranted (Level B)."      

The formulary drugs are not expected to cause adverse effects. 

The formulary drugs were not tried, and the patient did not have an adverse reaction or contraindication.

The formulary drug is not expected to be ineffective.

The non formulary drug is expected to be more effective than the formulary alternatives.

The carrier's denial of a request for a Formulary Exception for Zeposia to treat multiple sclerosis is reversed.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Diabetes

Treatment: Mounjaro (tirzepatide)

The insurer denied coverage for Mounjaro (tirzepatide).

The denial is upheld.
 

This is an adult male diagnosed with Type 2 diabetes mellitus(T2DM). This request is for Mounjaro. No medical records were provided. 

The health plan acted reasonably with sound judgment in their denial as the patient does not have documentation of trial and failure of the preferred formulary alternatives.

The requested medication Mounjaro (Trizepatide) is Food and Drug Administration (FDA) approved for the treatment of adults with type 2 diabetes.  It has been shown in clinical trials to lead to improvement in glycated hemoglobin (hemoglobin A1c) as well as weight loss (1-3).There are no studies that clearly demonstrate the superiority of the requested medication over the formulary alternatives as summarized in Up to Date. The most recent American Diabetes Association guidelines recommend using Glucagon like peptide 1 (GLP-1) receptor agonists as a 1st line agent. There is no preference for the requested medication over GLP-1 receptor agonists(4). The patient can try three formulary alternatives including Ozempic, Rybelsus, Trulicity, Victoza. The request is not consistent with generally accepted standards of medical practice.

The formulary drugs are not expected to cause adverse effects. 

The formulary drugs were not tried, and the patient did not have an adverse reaction or contraindication.

The formulary drug is not expected to be ineffective.

The non- formulary drug is not expected to be more effective than the formulary alternatives.

The carrier's denial of a request for a Formulary Exception for Mounjaro (tirzepatide) is upheld.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Gunshot wound
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is partially overturned.

This patient is a male who presented to the emergency department (ED) as a priority 1 trauma patient following an incident in which he was shot in the back/buttock. He had been hypotensive during the period of pre-hospital transport to the hospital.
The ED trauma evaluation included a computed tomography (CT) scan that identified retroperitoneal bleeding and a possible right external iliac vein injury and possible intra-abdominal injury to the rectosigmoid colon.
Trauma and vascular surgery consultations were obtained. A second CT scan with rectal contrast was performed and showed stability in the size of the retroperitoneal hematoma and no evidence for rectal injury. Based on the mechanism of injury and the imaging findings, the surgical service recommended a diagnostic laparoscopy to assess for an intra-abdominal bowel injury.
A diagnostic laparoscopy was performed. There was no apparent intra-peritoneal penetration or injury. He was monitored in the trauma intensive care unit (ICU) following surgery. A duplex ultrasound showed no deep vein thrombosis and was a normal study. The patient was transferred out of the ICU to the surgical floor. He was without new complaints. He was provided a regular diet. He was started on oral anticoagulation with Eliquis.The patient was discharged from the hospital with arrangements for vascular surgery follow up.
At issue is the medical necessity of an inpatient stay.

The inpatient stay was medically necessary in part. The first 2 days of the stay were medically necessary, then the patient could have been discharged. The Milliman Care Guidelines (MCG) Multiple Trauma 26th edition state that hospital admission is indicated when a patient with significant multiple trauma requires inpatient admission for major surgical and postprocedural care or nonoperative care of significant injury.
This was a patient who sustained a gunshot wound to the back/buttock that required emergent evaluation for a potentially significant vascular injury. Additionally, he required emergent surgery to definitively assess for intra-abdominal injury from the GSW. He required the coordinated care of multiple surgical (Trauma, Vascular Surgery) and ancillary disciplines to optimize his care and outcome. He required assessment and re-assessment consistent with trauma guidelines to guide the care and treatment provided. The intensity of service provided for the first 2 days of the stay and the consequences of missed vascular or intra-peritoneal injury did warrant an inpatient designation during this time. His condition and the mechanism of injury, based on the results of the initial vital signs and CT scan, carried high risk for acute decompensation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: reported Vitamin D deficiency

Treatment: vitamin D level testing

The insurer denied coverage for vitamin D level testing

The denial is upheld 


This is an adult female, reportedly feeling well, who presented for annual physical exam. The medical records provided did not show that the patient had a condition which would benefit from Vitamin D testing such as osteoporosis or osteopenia.

There was no documentation of conditions which would increase risk for vitamin D deficiency and bone fracture such as malnutrition, alcoholism or use of systemic steroids.

The United States Preventive Services Task Force guidelines, a nationally recognized standard, did not recommend routine screening as a preventive health measure.

There is no evidence-based literature to support routine screening of vitamin D level and this request is not medically necessary.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for vitamin D level testing is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever, COVID 19
Treatment: Inpatient Hospital
The insurer denied Inpatient Hospital.
The determination is upheld.

This is a male infant born at term who presented to the emergency department (ED) with a two-day history of fevers to 102 degrees Fahrenheit (F). It started after he was given vaccines.  He was feeding less with decreased wet diapers and no stool for two days. The examination was significant for crying with exam, regular heart rate and rhythm, clear lungs, benign abdomen, and non-focal neurologic exam. He was treated with a normal saline bolus.
Rapid viral testing was positive for coronavirus (COVID) 19. A urinalysis was unremarkable. Urine and blood cultures were pending.
He was still not drinking well, taking an ounce over ninety minutes. His mother was not comfortable with his poor feeding, so he was admitted for further management. Admission orders included Tylenol as needed, encouraging breastfeeding with supplemental formula, routine vital signs. He did well overnight, with improved feeding and activity. He had no respiratory issues, and his exam was unremarkable. A urine culture was reported as possible contamination. He was deemed stable later that night and discharged home with family. At issue is the medical necessity of an inpatient stay.

Inpatient hospital admission was not medically necessary for this patient.
With the introduction of various vaccines, the epidemiology of acute febrile illness in infants and young children up to 36 months of age has changed. There has been a dramatic decrease in serious infections due to Streptococcus pneumoniae and Hemophilus influenza type b. Urinary tract infections are now the most common bacterial infection in young infants under three months of age, and pneumonia is most likely in infants and children three to 36 months. Fever is considered to be clinically significant if at least 100.4 degrees Fahrenheit (F) or 38 degrees Celsius (C) taken rectally. The other means of checking temperature are considered to be unreliable. A history of fever is as clinically significant as a fever at the time of evaluation, particularly in neonates. While guidelines historically stratified children into three groups (neonates less than 30 days old, young infants up to 90 days old, and older infants and toddlers up to 36 months old), with the advent of the latest vaccines, the boundaries are blurring.
This young male infant presented with two-day history of fever that started after receiving his two-month vaccines. Testing was positive for COVID19. He was having difficulty feeding sufficiently, so was admitted for monitoring. While it was reasonable to monitor the infant in the hospital for adequacy of intake pending culture results, he was overall hemodynamically stable with no significant "red flags" as described above, no respiratory difficulties, no lethargy. He did not require acute inpatient admission and could have been safely managed at lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: community acquired pneumonia (CAP)

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
This is a patient with a history of nephrolithiasis.  The patient presented to the emergency department (ED) with complaints of vomiting.  The patient stated that their significant other had similar symptoms and was concerned about food poisoning.  The patient was awake and alert on presentation.  The patient denied any chest pain or shortness of breath. 

Vital signs per the patient's history and physical included: temperature (T) 97.5 (degrees) Fahrenheit (F), heart rate (HR) 77, blood pressure (BP) 116/79, and oxygen (O2) saturations 96 percent (%).  The patient was in no acute distress.  The patient was alert and oriented x 3.  The patient's lungs were clear.  The patient's abdomen was soft and non-tender.  Cardiovascular sounds were normal for S1 and S2.  The patient's neurological exam was non-focal.  

Laboratory results revealed the following: white blood cell (WBC) count was 11.2, hemoglobin (Hgb) was 11.1, electrolytes were within normal limits, liver function tests were within normal limits, lactate was 1.6, and there was a mildly elevated troponin.  There were no electrocardiogram (ECG) changes and no chest pain. A chest x-ray revealed some haziness in the right upper lobe concerning for pneumonia.  No other changes were noted.

The patient was admitted for treatment of community acquired pneumonia (CAP).  The patient was started on intravenous (IV) Levaquin and received IV hydration. The patient remained stable after admission and was seen by cardiology for a mildly elevated troponin and questionable demand ischemia.  There were no signs of acute myocardial infarction.  No further inpatient workup was recommended.  The patient was switched to oral medications and was discharged to home.

This patient did not need acute inpatient hospitalization and could have been placed in observation status.  It is unclear that the patient had a pneumonia as they were afebrile and had a WBC of 11.2 with normal differential.  There were no other signs of pneumonia, and even if there was some right upper lobe haziness, the pneumonia was very mild.  The patient's pneumonia severity index (PSI) score was very low. The patient had a Confusion, Urea, Respiratory Rate, Blood Pressure, Age greater than (>) 65 (CURB-65) score of 0.  The patient was not hypoxic, vital signs after admission remained stable and the lungs were clear.  The patient was able to tolerate oral intake.

The observation period can be for up to 48 hours.  This patient was stable for observation while diagnostic testing and treatment were initiated.  The patient could have been discharged home after a period under observation with a switch to oral antibiotics and follow-up as an outpatient.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

This is a case of a male admitted for diagnosis of cirrhosis and ascites. The patient presented with abdominal distention, abdominal cramping and pain. He was found to have a large amount of ascites on computed tomography (CT) scan of the abdomen. The patient underwent large-volume paracentesis with 5.6 L (liters) removed. There was no spontaneous bacterial peritonitis. Vital signs demonstrated temperature 36.1 degrees Celsius (C), pulse 78, respiratory rate 18, blood pressure 136 over 78 (136/78) and O2 (oxygen) saturation 100 percent (%). Physical exam showed no acute distress or altered mental status. 

The inpatient hospital admission was not medically necessary. The patient in this case presented to the emergency room with abdominal pain and distention and was found to have newly diagnosed cirrhosis with new onset ascites. There were no unstable vital signs, or evidence of peritonitis. There was no spontaneous bacterial peritonitis on fluid analysis. There was no acute bowel obstruction, mesenteric ischemia, perforation, myocardial infarction or ectopic pregnancy. After his large-volume paracentesis, he was then given albumin and recommended to follow up with gastroenterology on outpatient basis for a chronic liver disease evaluation. He was recommended to have an esophagogastroduodenoscopy (EGD) for varices evaluation on outpatient basis.
Although the patient required services in the hospital setting the monitoring, diagnostics testing, and therapeutic interventions prescribed could have been rendered at a lower level of care.