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

Digestive system
Inpatient hospital

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

The patient was a male with medical history of gastric ulcer complicated by perforation status post-surgical repair, anemia, and intravenous heroin addiction treated with methadone. He presented to the emergency department with abdominal pain unrelieved by medication and heroin, nausea, vomiting, loss of appetite, shaking, restlessness, chills, and chest pain. He was using heroin daily, with most recent use on the prior day. Vital signs were notable for elevated blood pressure of 145/93. Physical examination was notable for generalized and epigastric abdominal tenderness. Labs showed elevated white blood cell count of 11.6 with 80% neutrophils, low sodium of 135, and elevated calcium of 10.5. Urinalysis was notable for 2+ (plus) ketones, 3 white blood cells per high-power field, and negative leukocyte esterase. Computed tomography scan of the abdomen and pelvis showed a large amount of stool in the colon, no extraluminal air or intraperitoneal fluid to suggest duodenal perforation, and no evidence of intra-abdominal pathology to explain his pain. He was treated with intravenous fluids.

The inpatient level of care was medically necessary. The patient presented with symptoms of opioid withdrawal, including abdominal pain, in the setting of history of peptic ulcer disease complicated by perforation. He was treated appropriately with monitoring and buprenorphine, but had risk of complications of withdrawal. The inpatient level of care was more appropriate than observation care for monitoring. He did not have resolution of withdrawal signs and symptoms until two days after presentation. For these reasons, the inpatient level of care is supported in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alopecia. 
Treatment: Xeljanz. 

The insurer denied Xeljanz. The health plan's determination is upheld. 

The patient is a female with alopecia areata universalis. The patient has tried and failed topical, oral, and intralesional steroids for this condition. The patient has chronic eye irritation and inflammation due to the lack of eyebrows and eyelashes associated with this condition, and psychological depression is also an issue. The use of Xeljanz is under review. 

Xeljanz is not medically necessary for this patient. 
While it is understandable to consider Xeljanz for this patient's condition, its use merits further study before being presumed acceptable for widespread clinical use. The long-term outcomes, safety, and efficacy is not well-defined at this time. Neither Food and Drug Administration (FDA) -approval nor American Academy of Dermatology (or other specialty society consensus) exists supporting Xeljanz as standard of care for alopecia areata at this time. At this time, the long-term safety of this medication is not as confirmed. Alopecia areata is notoriously difficult and unpredictable to treat, as well as unpredictable in its response to treatment. Oral immunosuppressants, light therapy, contact allergen treatment and related therapies have all resulted in variable and unsatisfactory outcomes, and self-resolution is often the only choice a patient has (along with hairpieces) for severe cases. 

At this time, Xeljanz is only FDA-approved for rheumatoid arthritis patients who have failed methotrexate, and for psoriatic arthritis, and for ulcerative colitis--all three conditions have indications whereby the safety risks of not using treatment are significantly greater than treatment itself. Xeljanz has recently been recommended to be used with lower dosing in rheumatoid arthritis patients. 

The same cannot be said for Xeljanz in the treatment of alopecia areata, where physical/functional impairment and overall health impacts are minimal to nonexistent--despite the social/psychological impacts that can occur in some patients. The proper dosing, anticipated side effects and long-term outcomes are not known at this time for Xeljanz in the treatment of alopecia areata, as well as short-term and long-term safety risks of relevance to this patient's overall health. There are no large, randomized, controlled, prospective trials demonstrating and proving the safe and effective treatment of alopecia areata with a specific dosing of Xeljanz.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Head and face paresthesia
Treatment: CPT-70470 Computed Tomography (CT) with and without Contrast Dye, Pre-service
The insurer denied the CPT-70470 Computed Tomography (CT) with and without Contrast Dye, Pre-service.
The denial is upheld. 

The patient is a male with the complaint of head and face paresthesia. There is a family history of intracranial vascular malformation. A computed tomography (CT) of the brain showed two hypo-dense areas.

No, the requested CPT-70470 Computed Tomography (CT) with and without Contrast Dye is not medically necessary.

The patient has already had two CT head studies demonstrating stable hypo-densities. There are no standard of care guidelines to support a repeat CT of the head in this clinical case (Ellis, et al). This study would not contribute to an evaluation of the cerebral vasculature or rule out an intracranial vascular malformation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pain, deformity and decreased motion to right arm
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

This is a female who sustained an injury to her right arm. She had slid down a bannister. She was found to have pain, deformity and decreased motion. She was diagnosed with a displaced supracondylar elbow fracture. The patient was admitted to the hospital. She underwent a closed reduction with percutaneous pinning and was splinted. Her post surgical course was noncomplicated with discharge.

No, the proposed inpatient admission was not medically necessary.

The records show the young female sustained an isolated closed injury to her right elbow. It was of low energy. There were no open wounds. A diagnosis was established and treatment plan implemented. The procedure was a closed reduction with percutaneous pinning. There was no extensive surgical incision nor dissection. The pins were placed directly through skin. There was no blood loss.

There were no post surgical complications. This includes bleeding, infection or fever. There was no change in neurovascular status. The child was able to tolerate oral pain medication. There was no need to obtain additional studies or treat an underlying medical condition. 

These findings would support the service as Observation and not acute inpatient.   There were no extenuating circumstances to warrant the service as acute inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Generalized Weakness, Palpitations, and Excessive Sweating.
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

This is a female who smokes with human immunodeficiency virus (HIV), hyperthyroidism, diabetes, and depression who presented with a one day history of generalized weakness, palpitations, diaphoresis, and diarrhea. Her blood pressure (BP) was 183/89 and heart rate was 124. Thyroid stimulating hormone (TSH) was 0.12 and T4(Thyroxine Test) was 12.3 (6-12). The patient received magnesium supplementation for a magnesium of 1.2. She was given methimazole and beta blockers. She was on sliding scale insulin. She was discharged on metoprolol 50 millimgras (mg) daily and methimazole. Inpatient stay is the topic of this review.

No, the proposed inpatient stay was not medically necessary.

This patient presented with weakness, palpitations, and diaphoresis in the setting of known hyperthyroidism. She was found to be mildly hyperthyroid and she had tachycardia. She was treated with oral methimazole and beta blockers. Her heart rate improved to 103 beats per minute and her blood pressure to 116/74 millimeters of mercury (mmHg). Her heart rate normalized at 80 beats per minute. She did not have thyroid storm. Her records do not indicate that she failed a lower level of care. She was discharged the day after admission. Therefore, the proposed inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

This patient is a female. At the time of services under review, the patient presented to the emergency department (ED) with the complaint of severe abdominal pain. She reported chronic right sided abdominal tightness for
several months. She was status post bilateral reduction mammoplasty. She also
had a history of prior sleeve gastrectomy performed for the diagnosis of morbid
obesity.

The patient's vital signs at the time of presentation were essentially normal. The
heart rate was 98 beats per minute. Examination revealed a nontender abdomen.
The white blood cell (WBC) count was normal at 8.1 thousand (K). Abdominal
ultrasound showed gallstones. Surgical consultation was obtained. The patient
was admitted to the hospital.

The patient's diet was advanced. Vital signs were normal. It was the surgical
opinion that the patient was of musculoskeletal origin and was possibly related to
her recent reduction mammoplasty procedure. She was discharged from the
hospital.

The health plan rationale for denial of inpatient care was based on MCG (Milliman Care Guidelines) Abdominal Pain, Undiagnosed.

No, the proposed inpatient admission was not medically necessary.

In this case inpatient care on was not medically necessary. The care and treatment
provided during this time could have been rendered with a lower level of care and
did not require an inpatient designation. This lower level of care can allow for
surgical assessment and follow up, lab and imaging, and arrangements for
outpatient follow up.

The medical records support that this patient could have been reasonably and
safely monitored with a lower level of care.

This patient presented with abdominal pain. Her evaluation with examination, lab
data, and ultrasound did not identify a definitive etiology. Although the ultrasound
showed gallstones, the nature of her pain complaints did not suggest a biliary
source. She did not require acute surgical intervention. She was clinically stable
during the period of monitoring and was able to be discharged with arrangements
for outpatient follow up.

This patient's clinical needs could have been satisfied with a lower level of care.
This lower level of care would have provided for clinical assessment and
monitoring.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary Tract Infection (UTI). 
Treatment: Inpatient admission. 

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

This is a female with type 1 diabetes on insulin pump therapy and continuous glucose monitor. She had recently restarted Trulicity after stopping for a few weeks and presented with nausea/vomiting. She had a previous episode of hypoglycemia with glucose in 60s. 

The patient's blood pressure was 147/64. Glucose was 191 milligrams per deciliter (mg/dL) and creatinine was 0.78. Mucous membranes were dry. Her urine was positive for glucose, ketones, protein, leukocyte esterase, white blood cells, and red blood cells. She was treated with Zofran, fluids, Pepcid, ceftriaxone, and promethazine. She was nauseated but tolerated clear liquids and she was discharged home on cefpodoxime. Inpatient stay is the topic of this review. 

No, the proposed inpatient stay was not medically necessary. 

This patient presented with nausea/vomiting in the setting of Trulicity use, which is a known side effect of Trulicity. She was hemodynamically stable. She did not have diabetic ketoacidosis. She had an episode of mild hypoglycemia at home. She did not have persistent hypoglycemia during her admission. She was diagnosed with a urinary tract infection. She was not septic. She had dehydration that responded to intravenous fluids. She did not have acute renal failure. She tolerated a clear diet the day after admission and was discharged on oral antibiotics. The records do not indicate that she failed a lower level of care. Therefore, no, the proposed inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Varicose Veins.
Treatment: Stab Phlebectomy.
The insurer denied the Stab Phlebectomy.
The denial is overturned. 

The patient is a male. He presents with symptomatic varicose veins of the right leg. He has a remote history of DVT (deep vein thrombosis) treated with Coumadin. He has failed a trial of compression therapy. Exam shows large varicose veins. Duplex shows segmental reflux of the short saphenous vein (SSV) and varicose tributaries. The provider has recommended stripping of a portion of the SSV and phlebectomy. Only the phlebectomy is under review at this time.

Yes, the phlebectomy is medically necessary.

The provider has proposed right SSV ablation and phlebectomy for this patient. In order to evaluate the medical necessity of the service, widely accepted standards [1-3] are applied. Under these standards, phlebectomy is appropriate when:

a) There is no axial saphenous reflux, or any associated axial reflux will be treated concomitantly with the phlebectomy. If axial reflux has been treated in the past, a sufficient waiting period (usually four to six weeks minimum) should elapse to allow for evaluation of the patient's residual leg symptoms. b) The patient has symptoms of venous insufficiency severe enough to interfere with normal function. c) The patient's varicose veins are large enough to account for the symptoms. d) The patient has failed a trial of medical grade compression stockings.

Requirement (a) has been met. The patient has severe reflux affecting the mid-portion of the SSV. This segment communicates with varicose branch veins.

Requirement (b) has been met. The office note states that the patient has "symptomatic" varicose veins. The appeal letters describe the symptoms in greater detail and state that the patient has symptoms of venous insufficiency severe enough to adversely affect normal function. The appeal letters therefore corroborate and elaborate upon the history reported in the office notes.

Requirement (c) has been met. The physician has documented that the veins are bulging. The venous duplex also confirms the presence of large (4.0 mm [millimeter]) varicosities in both legs.

Requirement (d) has been met. The record shows that the patient has been using prescription-grade compression stockings and elevation regularly with only minimal relief of symptoms.

Therefore, in summary, the patient meets published, well-accepted criteria for performance of phlebectomy.

The denial of phlebectomy by the health plan was based on the notion that the patient either did not have axial reflux or did not have a plan for treatment of axial reflux. However, the patient does have axial reflux, and the provider described a plan for treating it. Therefore, the patient meets criteria for phlebectomy.
Appeal type: Step Therapy
Decision: Upheld

Diagnosis: Migraine headache disorder
Treatment: Emgality Injection 120 (mg) - Quantity 1 for 30 Days (Pre-service)
The insurer denied the Emgality Injection 120 (mg) - Quantity 1 for 30 Days (Pre-service).
The denial is upheld. 

The patient is a female with migraine headache disorder. She has tried topiramate, propranolol and zonisamide for migraine prevention. The attending physician (AP) is requesting Emgality.

No, the proposed treatment with Emgality is not medically necessary.

Treatment with Emgality at this time would not be in accordance with generally accepted standards of medical practice.  Standard of care guidelines support adequate trials of oral migraine preventive agents prior to the use of calcitonin gene-related peptide (CGRP) inhibitors. The documentation does not support an adequate trial duration of any oral migraine preventive agent (Schwedt). 

There is no reason the patient cannot be treated with an adequate trial of standard, oral migraine preventive agents prior to the use of calcitonin gene-related peptide (CGRP) inhibitors. The documentation does not support an adequate trial duration of any oral migraine preventive agent (Schwedt).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcohol abuse
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

This is a homeless female with a history of alcohol abuse and multiple presentations for intoxications with recent admission for alcohol withdrawal.  The patient presented to the emergency department (ED) complaining of generalized weakness associated with abrasions on limbs as a result of lying on the sidewalk.  Emergency department (ED) evaluation was remarkable for white blood cell (WBC) count 13.77, hemoglobin (Hgb) 11.1, arterial blood gas (ABG) pH 7.437, partial pressure (tension) of carbon dioxide (PCO2) 57.7, bicarbonate (HCO3) 38.3, lactate 2.5, sodium (Na) 131, blood urea nitrogen (BUN)/creatinine (Cr) 13/.35, and lipase 656.  Chest x-ray (CXR) showed no abnormality detected (NAD).  

The patient was treated with intravenous fluids (IVF) and was admitted.  History and physical (H&P) vital signs (VS) revealed: temperature 98.1, pulse. 90, respiratory rate 18, blood pressure 142/83, and oxygen saturation 98%.  Exam was remarkable for being disheveled, and having abrasions on shoulder, knee and hips.  The patient's diagnoses included severe protein calorie malnutrition.  Plan of care included intravenous fluids (IVF), Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol, and nutrition consult.  Sodium (Na) was 133, potassium (K) 2.9, blood urea nitrogen (BUN)/creatinine (Cr) 6/.18. There were no signs of withdrawal. The patient was seen by physical therapy (PT). The patient was awaiting placement for sub-acute rehab (SAR).

No, the proposed inpatient admission was not medically necessary.

Medically necessary services are those which are:
1) safe 
2) effective
3) generally accepted national standard of medical practice 
4) not provided primarily for convenience of the patient or the practitioner 
5) the least intensive and/or most appropriate alternatives among diagnostic and treatment option.

The requested inpatient admission was not medically necessary because it was not in accordance with generally accepted national standard of medical practice for this patient's scenario.

This patient, who is homeless and with a history of alcohol abuse, was admitted after presenting to the emergency department (ED) with weakness.  The patient was hemodynamically stable and afebrile.  She had normal oxygenation.  She was found to have scattered abrasions, but no evidence of infection.  She had mild electrolyte abnormalities and mild dehydration.  She did not have alcohol intoxication or withdrawal.  During her hospital stay, the patient was treated with intravenous fluids (IVF) and potassium replacement.  She remained hemodynamically stable, dehydration resolved and her electrolytes normalized.  She did not receive intervention that required an acute inpatient level of care.  The patient's severity of illness and  intervention provided did not require an acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Genitourinary/Kidney Disorder
Inpatient hospital

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

The patient is a woman who presented to the hospital. She had a history of opioid abuse and was on Suboxone, and she presented with severe pain in the right lower quadrant. She also reported nausea and vomiting. She denied fevers, chills, chest pain and shortness of breath. On physical exam, heart was regular, breath sounds were normal, and the abdomen was soft with tenderness in the right lower quadrant. Labs showed glucose 121, creatinine 0.61, sodium 141, potassium 3.5, white blood cell (WBC) 13.97, hemoglobin 13.6, and platelets 214. A computed tomography (CT) imaging of the abdomen showed moderate right hydronephrosis and normal liver and pancreas. There was a 3 millimeter (mm) stone at the UV (ureterovesical) junction. The patient was admitted for renal colic. 

The inpatient stay was not medically necessary.

The patient was admitted for partially obstructing ureteral stone but there was no documentation in the progress notes of a complication related to this stone, such as sepsis, significant acute kidney injury, or uncontrolled pain. She underwent cystoscopy and stent placement, which can be performed on an outpatient basis in the absence of significant complications.

The patient had opioid abuse disorder, but had no other significant comorbidities and was hemodynamically stable with no evidence of acute kidney injury or acute infection. She therefore could have undergone evaluation and treatment of the obstructing stone at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Digestive System
Inpatient hospital

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

The patient is a woman who initially presented to an outside hospital and underwent laparoscopic cholecystectomy. She had an extensive past medical history of celiac disease, diabetes, hyperparathyroidism, insulinoma, MEN1 (multiple endocrine neoplasia type 1), and metastatic malignant neuroendocrine tumor to regional lymph nodes. She developed abdominal pain in the early post-surgical period and presented to the outside hospital but was subsequently transferred to a higher level of care. She was diagnosed with common bile duct stones (choledocholithiasis) with a 5 x 4- millimeter (mm) obstructing stone at the ampulla. She was transferred due to the anticipated need for endoscopic retrograde cholangiopancreatography (ERCP) to treat the common bile duct (CBD) stones. At the time of presentation, the patient was without fever and vital signs were normal. The patient had thrombocytopenia with a white blood cell (WBC) count of 3.1. The complete metabolic panel identified elevated transaminases and alkaline phosphatase. The diagnosis was that of choledocholithiasis. An magnetic resonance cholangiopancreatography (MRCP) was performed showing mild biliary ductal dilatation but no definite CBD stones. 

An inpatient level of care was not medically necessary in this case on the dates in question.
This patient is a woman with a complex past endocrinology history who presented to the hospital with suspected choledocholithiasis (elevated liver enzymes, dilated bile duct on imaging). She was appropriately transferred from another hospital due to the anticipated need for endoscopic retrograde cholangiopancreatography (ERCP). In the course of her evaluation, it was identified that magnetic resonance cholangiopancreatography (MRCP) no longer identified common bile duct (CBD) stones. Endoscopic ultrasound determined that there were no retained CBD stones. Her post-endoscopy course was uncomplicated. Diet was advanced. Vital signs remained normal. The patient's condition, the intensity of services rendered, and the lack of need for emergent endoscopic or surgical intervention are consistent with a lower level of care. There was no prolonged period of nothing by mouth (NPO) status, need for prolong intravenous (IV) fluid administration, pain that required frequent parenteral analgesics, or other medical condition that mandated an inpatient level of care.