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

Diagnosis: Atypical pneumonia (PNA)

Treatment: Full hospital admission

The insurer denied coverage for full hospital admission

The denial is overturned

The patient with history of (H/O) chronic obstructive pulmonary disorder (COPD), congestive heart failure (CHF), Asthma, Chronic hypercapnic and hypoxic respiratory failure, obstructive sleep apnea (OSA) on nocturnal bilevel positive airway pressure (BIPAP). The patient also has H/O invasive breast cancer (Ca) with metastases to the bone.  The patient is on home oxygen (O2) 4L (liters) by nasal cannula (NC). The patient has recent H/O hospitalization about a month ago and needed intubation for COPD exacerbation.

The patient presented to the hospital with C/O (complaint off) worsening shortness of breath (SOB), Cough with sputum production and sore throat. Vital signs (V/S) at presentation: the patient was in some mild distress. O2 saturations 92 % (percent) on 4L. Lung exam revealed bilateral (B/L) wheezing. Labs: white blood cell count (WBC) 4.8K (thousand) Hb (hemoglobin) 10.4, ABG (arterial blood gas) 7.38/PCO2 (pressure of carbon dioxide) 70 PaO2 (pressure of oxygen) 47 on FIO2 (Fraction of inspired oxygen) 40% chest x-rays revealed (CXR) revealed some ill-defined peripheral opacities. Impression was Viral versus (Vs) Atypical pneumonia (PNA).

The patient was treated with intravenous (IV) Steroids, BD (bronchodilator) Via Nebs, Magnesium. The patient also received IV (intravenous) antibiotics (Abx) Rocephin and Levofloxacin. The patient was also given IV Lasix for some worsening CHF (congestive heart failure).

Due to patient's hypercapnic and Hypoxic respiratory failure he was also placed on BIPAP. The patient was continued on IV Abx, Steroids, Respiratory support.
Given the patient's multiple medical problems which included COPD with chronic Hypoxic Resp failure, CHF, Asthma, Metastatic Breast Ca and presentation with significant hypercarbia with PCO2 in 70's with B/L air space disease with a differential diagnosis (DDX) of Atypical Vs Viral PNA and CHF it was appropriate to admit him to a higher level of care than emergency department (ED) or Observation.

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

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

The patient is a male who was admitted from the inpatient psychiatric unit for concerns of rhabdomyolysis. Pertinent history included admission to inpatient psychiatric unit for acute suicidal ideations. Additional history included depression and schizoaffective disorder. Initial vital signs revealed a temperature of 97.6 F (degrees Fahrenheit), heart rate (HR) 76, blood pressure (BP) 105/65, respiratory rate (RR) 16, and peripheral capillary oxygen saturation (SpO2) 97% on room air. Initial laboratory testing revealed a white blood cell count (WBC) 3.6, HGB 14.0, blood urea nitrogen (BUN) 25.8, Cr (creatinine) 1.16 (1.22 a day prior), Na (sodium)141, K (potassium) 4.1, carbon dioxide (CO2) 25, aspartate aminotransferase (AST) 105, alanine aminotransferase (ALT) 121, and creatine kinase (CK) 2743 (6037 a day prior). The admitting diagnoses included rhabdomyolysis and psych (psychiatric) disorder. 

The inpatient hospital stay was medically necessary.
The patient was admitted to an inpatient psychiatric unit for acute suicidal ideations and was subsequently found to have rhabdomyolysis with a CK of 6037.
Parekh et al. note rhabdomyolysis is a potentially life-threatening condition caused by a breakdown of skeletal muscle and the release of the intracellular contents into the circulatory system. There are many possible causes, including crush injury, excessive muscular activity, medications, infections, and varied metabolic, connective tissue, rheumatologic, and endocrine disorders. Optimal crystalloid selection is still debated, but immediate, aggressive intravenous volume expansion is indicated to prevent myoglobinuric renal failure. Serum potassium levels must be obtained and electrocardiograms must be evaluated to identify life and limb-threatening complications of hyperkalemia. When recognized and treated early, rhabdomyolysis carries an excellent prognosis. With the exception of hyperkalemia-related death or the rare complication of disseminated intravascular coagulation, acute kidney injury is the most serious complication of rhabdomyolysis, regardless of etiology. Mortality data for patients with renal failure vary widely in the literature according to the study population, etiology, presence of multiple causing agents, and comorbidities; however, long term survival among patients with rhabdomyolysis and acute renal injury tends to be very good when timely management is provided.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of Breath
Treatment: Inpatient Emergency Admission
The insurer denied: Inpatient Emergency Admission
The denial is: Upheld

The patient is a male with a past medical history significant for arthritis, bradycardia, and asthma with no history of prior Intensive Care Unit (ICU) admissions, intubations, or hospitalizations who presented to the emergency department with shortness of breath, wheezing, and cough associated with the production of clear white mucus.
The patient denied any recent history of travel or sick contacts. The review of systems was negative for fever or chills. When seen by the admitting physician the patient was afebrile. Respiratory rate was 22 breaths/minute, pulse rate 80 beats per minute, blood pressure 147/101, and oxygen saturation 95% on room air.
The patient was in no acute distress and was able to speak in full sentences, although with frequent cough and wheezing. The patient had a regular rate and rhythm, without murmurs, rubs, or gallops. There were bilateral expiratory wheezes, but the rest of the physical exam was unremarkable.
Laboratory evaluation revealed that white blood cell count was 6.2, hemoglobin 13.7, hematocrit 42.0, platelets 240. Sodium was 142, potassium 4.0, chloride 107, blood urea nitrogen (BUN) 12, creatinine 0.93, glucose 102.
Chest x-ray revealed clear lungs. Electrocardiogram (EKG) revealed sinus rhythm.
The patient was admitted to the hospital with shortness of breath and a productive cough. The patient was treated with Solu-Medrol, bronchodilators, and cough syrup.
During the short hospital stay, the patient's clinical condition improved, and the patient was transitioned to outpatient care.

The health plan's determination is upheld.

The inpatient emergency admission was not medically necessary for this patient. Based on the clinical information, the patient had mild asthma exacerbation that was not associated with severe respiratory distress.
There was no evidence that the patient had severe tachypnea, dyspnea, abnormal breathing patterns, or significant hypoxemia. The mild asthma exacerbation was not associated with hemodynamic instability or abnormal heart rhythm.
There was no evidence that the patient had any underlying infiltrates on the chest x-ray consistent with pneumonia. There was no evidence of pneumothorax. The patient did not require ventilatory support.
Overall, the patient's hospital stay was rather short and the patient did not need any procedures or diagnostic studies that would necessitate admission at the acute inpatient level of care. The patient could have been safely managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low back pain.
Treatment: Basivertebral Ablation Treatment 

The insurer denied Basivertebral Ablation Treatment.
The health plan's determination is upheld. 

The patient is a female with chronic back pain. The pain is across the low back bilaterally, which is worse with increased activity, prolonged sitting, and leaning forward. Bilateral leg pain and leg cramps continue to occur. The patient has had multiple injections to the low back. Physical exam demonstrated a decreased range of motion with pain on flexion and extension and facet loading bilaterally positive. A magnetic resonance imaging (MRI) of the lumbar spine demonstrated multilevel degenerative disc disease and facet arthropathy in the lumbar spine.

Basivertebral Ablation Treatment is not medically necessary for this patient.

Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. A Food and Drug Administration (FDA) investigational device exemption trial examined 225 chronic low back pain patients with type I or II Modic changes who were randomized to the requested procedure or sham treatment, resulting in decreased Oswestry disability index (ODI) of 20.5 and 15.2 points, respectively. The authors noted that these marginally clinically meaningful improvements suggested some potential as a minimally invasive treatment, however, there is a lack of data to recommend this procedure as a treatment modality. In general, there is a lack of substantial support for this procedure, and it is currently not considered standard of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ulcerative colitis

Treatment is an inpatient admission 

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

The patient has ulcerative colitis and was on Entyvio. He presented with increased rectal bleeding. He was afebrile and the vital signs were stable. The abdominal exam was benign. There was no leukocytosis. The hemoglobin was 12.1. A flexible sigmoidoscopy was performed, and colitis was found. There was a plan to increase the Entyvio dose and he was started on a course of oral steroids. 

Clinical indications for admission for Inflammatory Bowel Disease  ((Milliman Care Guidelines) MCG M-565) include hemodynamic instability, acute severe ulcerative colitis as manifested by systemic illness, abscess, toxic megacolon, intestinal perforation, intestinal obstruction, peritoneal signs, severe electrolyte abnormalities, severe vomiting, acute renal failure, and bacteremia. The patient did not have these conditions. 

This patient had a flare of his ulcerative colitis. He required having a flexible sigmoidoscopy and then being started on a course of oral steroids. This could have been done on an outpatient basis. He did not meet MCG criteria for admission for Inflammatory Bowel Disease. The health care plan acted reasonably and with sound medical judgment. An inpatient admission 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 an inpatient hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain

Treatment is an inpatient admission 

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

The patient presented with RLQ (right lower quadrant) abdominal pain for 4 days. She went to another hospital the previous day and was told that she had appendicitis and an ovarian cyst. She was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. There was no leukocytosis. A CAT (computed tomography) scan was now equivocal for appendicitis. Antibiotics and pain medications were given. She was able to tolerate a regular diet. 

Clinical indications for admission for Undiagnosed Abdominal Pain (MCG (Milliman Care Guidelines) M-05) include hemodynamic instability, peritoneal signs, inability to maintain oral hydration after observation care, bacteremia, and the need for a procedure that cannot be performed on an ambulatory basis. The patient did not have these conditions. 

There was a concern that this patient had appendicitis. However, the CAT scan was equivocal, there were no peritoneal signs, and there was no fever or leukocytosis. She did not require any surgical interventions at this time, and if she did need an appendectomy, it could have been done as ambulatory surgery. She could have been treated with a course of oral antibiotics as an outpatient. IV (intravenous) hydration and pain control could have been given with an observation status. The health care plan acted reasonably and with sound medical judgment. An inpatient admission 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 an inpatient hospitalization is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma exacerbation from influenza
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay.
The health plan's determination is upheld.

The patient is a female who was admitted to the hospital for asthma exacerbation from influenza. She has a past history of asthma. On presentation, she had a few days of shortness of breath and wheezing. She was given bronchodilators, intravenous (IV) steroids, and Tamiflu. Her oxygen saturation was 90% (percent) at the lowest. The vitals were otherwise stable. Chest x-ray was clear. The patient's condition improved, and she was stable at discharge.

The inpatient hospital admission was not medically necessary for this patient. According to CDC (Centers for Disease Control and Prevention), Uyeki, and Ghebrehewet, et al, the patient's presentation was consistent with influenza which an asthma exacerbation. There were no severe features or extenuating circumstances requiring the acute inpatient level of care. There was no hypoxia or respiratory failure. A lower level of care would have been appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain. 
Treatment: Inpatient admission. 
The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a male with Crohn's status post colectomy with ileostomy, who presented with abdominal pain and increased ostomy output. He was hemodynamically stable, without evidence of intractable vomiting, dehydration, electrolyte abnormalities, obstruction or gastrointestinal (GI) bleeding. 

The patient's computed tomography (CT) and magnetic resonance enterography (MRE) revealed active uncomplicated Crohn's, without evidence of abscess, fistula perforation or obstruction.  The patient was hydrated and underwent esophagogastroduodenoscopy (EGD) with ileoscopy. Gastritis and ileitis were found, and the patient eloped. 

No, acute inpatient hospital admission was not medically necessary. 
The patient presented with a Crohn's flare. As there was no evidence of intractable vomiting, dehydration, electrolyte abnormalities, gastrointestinal (GI) bleeding, sepsis, hemodynamic instability or obstruction, acute inpatient hospital stay was not medically necessary. Observation status was medically appropriate, the patient was medically stable for discharge to outpatient care, for medical management of Crohn's. In summary, acute inpatient hospital stay was not medically necessary. 

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

As acute inpatient hospital stay was not medically necessary, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient by denying it.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Throat foreign body sensation
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient is a female with a history of presenting with a throat foreign body sensation.  This started after eating fish the day prior. A CT (computed tomography) was obtained, which noted a possible foreign body in the right lateral tongue.

The patient was sent to the OR (operating room) for a direct laryngoscopy with foreign body removal. The patient was admitted as an inpatient.  The request was previously denied and the provider is appealing the denial.

No, the Inpatient admission was not medically necessary.
All records were reviewed. The patient presented with a throat FB (foreign body) sensation after eating fish the day before.

The patient was able to manage her secretions and was afebrile. A foreign body lodged in the lingual tonsils was located by CT (computed tomography) and removed in the OR (operating room) without complication. There was no aspiration and no intraoperative or postop complications. Therefore, based on the information provided, the medical necessity of the inpatient admission cannot be confirmed, as the patient could have been cared for at a lower level of care.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
As the inpatient admission cannot be confirmed as medically necessary, it is confirmed that the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Prostate Cancer. 
Treatment: Outpatient ablation of malignant prostate tissue, transrectal, with high intensity focused ultrasound (HIFU) including ultrasound guidance. 

The insurer denied outpatient ablation of malignant prostate tissue, transrectal, with high intensity focused ultrasound (HIFU) including ultrasound guidance. 
The determination is upheld. 

The patient has newly recognized, clinically localized prostate cancer. High intensity focal ultrasound (HIFU) therapy was recommended as primary treatment. At issue is whether outpatient ablation of malignant prostate tissue, transrectal, with high intensity focused ultrasound (HIFU) including ultrasound guidance is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. 
Outpatient ablation of malignant prostate tissue, transrectal, with high intensity focused ultrasound (HIFU) including ultrasound guidance is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. The current guidelines of the American Urological Association (AUA) state that primary HIFU is only to be used in investigational settings. HIFU should be considered only for patients with radiation therapy failure as salvage therapy. Authors have opined," High-intensity focused ultrasound (HIFU) is an alternative option to radical surgery to treat prostate cancer. To date, however, data on side effects and comorbidities of this technique are still not conclusive."
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Prostate Cancer. 
Treatment: Outpatient ablation of malignant prostate tissue, transrectal, with high intensity focused ultrasound (HIFU) including ultrasound guidance. 

The insurer denied outpatient ablation of malignant prostate tissue, transrectal, with high intensity focused ultrasound (HIFU) including ultrasound guidance. 
The determination is upheld. 

The patient has a favorable intermediate risk (Gleason 3+4=7) prostate cancer has requested coverage for focal high intensity focused ultrasound (HIFU). He had an 8 millimeter (mm) apical lesion on the left identified on magnetic resonance imaging (MRI). One of twelve biopsy cores had malignancy. At issue is whether outpatient ablation of malignant prostate tissue, transrectal, with high intensity focused ultrasound (HIFU) including ultrasound guidance is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. 

Outpatient ablation of malignant prostate tissue, transrectal, with high intensity focused ultrasound (HIFU) including ultrasound guidance 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 is a patient with favorable intermediate risk prostate cancer. Per the American Urological Association (AUA) Guidelines, "13. Clinicians should inform patients with intermediate-risk prostate cancer considering whole gland or focal ablation that there are a lack of high-quality data comparing ablation outcomes to radiation therapy, surgery, and active surveillance. (Expert Opinion)." 
"Numerous ablative modalities, relying on differing energy sources/differing mechanisms of action, are currently available to patients with clinically localized prostate cancer. Patient selection criteria in reported studies have varied widely as has treatment planning approach (e.g., lesion-based focal therapy, hemi-ablation, whole-gland). The only properly powered randomized trial reported to date on prostate ablation was restricted to patients with low-risk prostate cancer and demonstrated that focal photodynamic therapy (PDT) lowered the likelihood of cancer progression and rates of surgery/radiation compared to active surveillance, at an expense of an increased likelihood of mild urinary or erectile dysfunction."
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Type 2 diabetes mellitus without complications
Treatment: Janumet (sitagliptin-metformin)
The insurer denied the Janumet (sitagliptin-metformin).
The denial is upheld.

This is a female with type 2 diabetes complicated by neuropathy who is being treated with Alogliptin/Metformin and Jardiance. Per a progress note, Alogliptin/Metformin was not working. The subject under review is the request for treatment with Janumet. 

The health plan's determination is upheld.

This request is for Janumet for the treatment of type 2 diabetes. The formulary alternatives are Jentadueto and Jentadueto extended release (XR). These alternatives are in the same drug class as Janumet. The alternatives are expected to be equally safe and effective as Janumet for the treatment of type 2 diabetes. The patient does not have a documented trial of or contraindication to the alternatives. The documentation does not support the use of Janumet over Jentadueto and Jentadueto XR. The American Diabetes Association clinical guidelines do not support the use of Janumet over Jentadueto and Jentadueto XR.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cerebrovascular accident (CVA)
Treatment: Consumer Directed Personal Care Aide Services: 88 Hours per Week
The insurer denied Consumer Directed Personal Care Aide Services: 88 Hours per Week. The health plan's determination is upheld.

The patient is a female with past medical history of cerebrovascular accident (CVA), post-traumatic stress disorder (PTSD), chronic pain, history of deep vein thrombosis (DVT), hypertension, nocturnal hypoxemia, Diabetes Mellitus Type 2, carotid artery disease, congestive heart failure (CHF), chronic anticoagulation, macular degeneration, osteoarthritis, and osteoporosis who had been assigned CDPAS (Consumer Directed Personal Care Aide Services) services. 

Consumer Directed Personal Care Aide Services: 88 Hours per Week is not medically necessary for this patient. 
The health plan stated is not disputing the need for 168 hours/week of care and has informed the patient to have aides sign up with 1 agency and once the aides sign up with 1 agency an updated approval would be issued for 168 hours in total hours from 1 fiscal intermediary/agency. The plan denied coverage for 88 hours/week of CDPAS services as New York State guidelines prohibit the use of 2 separate agencies. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAS services 88 hours/week are not medically necessary for this patient as the insurer plans to cover 168 hours/week once the patient's aides sign up with one fiscal intermediary agency.