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

Diagnosis: Heart failure.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male was hospitalized for abdominal pain and a CHF (congestive heart failure) exacerbation with mild LE (lower extremity) edema. His PMH (past medical history) includes liver cancer with chemo pending, AVR (aortic valve replacement) x3 for bicuspid AS (aortic stenosis), HFrEF (heart failure with reduced ejection fraction) with EF (ejection fraction) of 40-45%, CAD (coronary artery disease), old MI (myocardial infarction), pacemaker, HTN (hypertension), HLP (hyperlipidemia) and anemia.

The patient's vitals showed he was hypertensive and otherwise, were stable. O2 (oxygen) saturation 99% on RA (room air) and lungs were clear. CT (computed tomography) of the abdomen showed multiple liver masses and a left sided hepatic subcapsular hematoma. Treatment included IV (intravenous) Lasix followed by PO (oral) and he was discharged to home the next day.

The request for coverage for inpatient hospitalization was denied by the health plan as not medically necessary, and the decision is being appealed.

No, the Inpatient admission was not medically necessary.

Based on the peer reviewed medical literature, the documentation submitted for review do not establish the requested Acute Inpatient Hospital Stay was medically necessary for this patient. According to the MCG (Milliman Care Guidelines) Guidelines titled: Heart Failure (ORG: M-190), inpatient admission was not medically necessary, because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay per the guideline. Criteria for inpatient stay are not met, including documentation of hemodynamic instability, respiratory distress, change in mental status, severe heart failure, cardiac arrhythmias of immediate concern, myocardial ischemia or myocardial infarction, positive troponin not explained by CKD (chronic kidney disease) and CHF (congestive heart failure), hypertension requiring inpatient hospitalization, CVA (cerebrovascular accident), pulmonary embolism (PE), aortic dissection, pneumonia, severe electrolyte abnormalities or any other medical condition or other medical instability or acute care needs for which emergency and observation care have failed or are not considered appropriate and that would require acute inpatient management. The care that the patient received for mildly decompensated chronic LV (left ventricle) systolic HF (heart failure) in the setting of stable liver cancer is routinely provided safely and effectively at a lower level of care. Therefore, the inpatient admission was not medically necessary, based on the submitted information and the current published medical guidelines.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System. 
Treatment: Inpatient Hospital. 
The insurer denied Inpatient Stay. 
The denial is upheld. 

The patient is a male with asthma, a previous Intensive Care Unit (ICU) admission for the same, and obesity, who presented to the emergency room with a moderate asthma exacerbation in the context of viral upper respiratory symptoms and vomiting. He received aggressive asthma treatment in the emergency room and was then admitted for inpatient treatment. He improved over the next 24-36 hours and was then discharged. The inpatient admission was denied as not medically necessary, and the hospital is appealing that decision.
At issue is the medical necessity of the Inpatient Stay.

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

The requested health service/treatment of Inpatient stay was not medically necessary for this patient.
While the nature of care is not in question, the records do not support that the patient was severely ill enough to require an acute inpatient admission. As noted in Hasegawa et al, "patients with a lesser degree of response to the emergency department (ED) management and with mild to moderate symptoms should be repeatedly reassessed ... With an improvement in objective measurement, appropriate self-management knowledge/skills, and supportive home environment, such patients can often be discharged home. In addition, extended treatment and serial monitoring in an observation (or short stay) unit may be appropriate." The documentation does not support an inpatient stay.
Therefore, the requested health service/treatment of Inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Paroxysmal atrial fibrillation
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a history of hypertension (HTN), hyperlipidemia (HLD), coronary artery disease (CAD) with previous coronary artery bypass graft (CABG) and mitral valve annuloplasty, and transcarotid artery revascularization. He also has atrial fibrillation, complete heart block and has a permanent dual chamber (left bundle) pacemaker.
He presented for elective catheter ablation for symptomatic, paroxysmal atrial fibrillation. Pulmonary vein isolation was performed as well as a cavotricuspid isthmus ablation for atrial flutter. The procedure was performed without complication and he was discharged.
At issue is the medical necessity of an inpatient stay.

No, inpatient stay was not medically necessary for this patient who presented for elective catheter ablation for paroxysmal atrial fibrillation. The procedure was uncomplicated and he was discharged on the same day. This is generally considered an outpatient or observation status procedure, per Milliman Guidelines and standard of care, as noted in the multicenter, retrospective study by Bailey, et al. (reference 3 below). Care could have been provided at a lower level than inpatient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic Dermatitis
Treatment: Dupixent (Dupilumab) 300MG (milligrams) /2ML (milliliters) SC (subcutaneous) SOPN (Solution Pen-injector), pre-service
The insurer denied the Dupixent 
The denial is overturned.

The requested Dupixent (Dupilumab) is medically necessary.
The patient is a male with atopic dermatitis, 95% (percent) BSA (body surface area), treated with topical steroids, topical calcineurin inhibitors, and Eucrisa. His provider is requesting Dupixent. The health plan denied the request due to requirement for use of phototherapy or systemic immunosuppressive therapy.

This patient has severe disease, and phototherapy would not be appropriate for the extensive body surface area with facial and groin involvement. Systemic immunosuppressants can be used but are not technically FDA (United States Food and Drug Administration)-approved for atopic dermatitis, and are not the safest therapies in light of the current COVID (coronavirus disease) pandemic.

Dupilumab is United States Food and Drug Administration indicated for treatment of recalcitrant atopic dermatitis, approved approximately five years ago. Two trials, SOLO-1 and SOLO-2, demonstrated that patients treated with Dupilumab experienced significant, clinically meaningful improvements in their atopic dermatitis at week 16 as measured by the EASI score (Eczema Area and Severity Index). Dupilumab was well tolerated with the most commonly reported side effects including injection site reactions and conjunctivitis. 

Dupilumab is a novel interleukin-4 and interleukin-13 blocker, which inhibits the arm of the immune system responsible for atopic dermatitis. In clinical trials, after 12 weeks of monotherapy with dupilumab, 85% of patients had a greater than 50% reduction in eczema severity and pruritus scores decreased by 57.1%. 

In phase III clinical trials, dupilumab led to a 75% improvement in eczema severity, when compared to placebo, and decreased symptoms of anxiety and depression. It also led to a significantly decreased use of topical corticosteroids. The safety and efficacy were supported in a recent meta-analysis of all published dupilumab papers (Han et al).

Dupixent would be the most appropriate therapy given the patient's severe disease.
Appeal type: Medical necessity
Decision: Overturned

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

The patient is a male who presented with evidence of cholelithiasis and passed a stone through the common bile duct. On admission, he had abdominal pain, scleral icterus and transaminitis (alanine aminotransferase (ALT) 213 and aspartate aminotransferase (AST) 92) along with chemical pancreatitis (amylase 415 and lipase 563). He also had an elevated C-reactive protein (CRP) at 1.4. He was appropriately treated with nothing by mouth (nil per os - NPO) status so as not to irritate the pancreas (by stimulating it to secrete) and intravenous (IV) ABX (antibiotics) (Ceftriaxone and Flagyl) given his fever. After resuscitation with intravenous fluids (IVF) and treatment with antibiotics, he was taken to the operating room for a cholecystectomy. 

The inpatient hospitalization is medically necessary and standard of care for this patient. The patient was jaundiced. The patient had chemical pancreatitis. This surgery would be classified as non-elective surgery triage (NEST) 5 semi-urgent category for triage to the operating room. This means should be within 48 hours of presentation and this is not something that could be sent home and scheduled. The Pathology confirmed acute cholecystitis on the pathology report.

There was evidence of infection (jaundice, fever, elevated CRP level). Surgery could not wait a few days. There was also evidence of blockage of the common bile duct.
On the ultrasound (US), the common bile duct (CBD) was 4 millimeter (mm). On pathology, the stones were 0.2-0.4 millimeter (mm). Therefore, the elevated transaminases and pancreatitis were related to the small stones passing through the common duct. During surgery, it is not uncommon that these get pushed through into the intestine during the procedure. An inpatient stay is the standard of care in this scenario.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes. 
Treatment: Long term custodial care. 

The insurer denied long term custodial care. The health plan's determination is overturned. 

The patient is a male with past medical history of poorly controlled diabetes, hypertension, hyperlipidemia, peripheral vascular disease, cerebrovascular accident (CVA), anemia, seizure disorder, bipolar disorder and schizoaffective disorder who was in custodial care following amputation of his first and second toe of the right foot and had a right heel diabetic ulcer. The patient had received intravenous (IV) antibiotics for approximately 6 weeks. 

Long Term Custodial Care Services is medically necessary for this patient. 

There is documentation of ongoing wound care to the patient's right lower extremity following right heel diabetic ulcer with osteomyelitis, and newly diagnosed osteomyelitis at the distal third metatarsal head. The patient was not able to perform wound care to himself. Notes indicate that the patient was constantly needing redirection and orientation. The guiding principal of members of a managed care organization are to determine the most appropriate setting for the receipt of services, equipment and supplies. The patient's needs continued to be met at long-term custodial care. The insurer must consider the most integrated and least restrictive setting to meet the patient's needs. Recommendation for discharge from long-term custodial care is based upon medical necessity, functional criteria and the availability of services in the community. Based on the current assessments and evaluations, long-term custodial care services are medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left knee pain.
Treatment: Knee Surgery (29881, 29876, 29879).
The insurer denied the Knee Surgery (29881, 29876, 29879).
The denial is upheld.

This patient is a male with left knee pain. He was evaluated and was provided with a cortisone injection. The physical examination was significant for: joint tenderness, swelling, decreased motion and varus deformity. Magnetic resonance image (MRI) noted meniscal tears.  X-rays showed decreased joint space. The physician recommended arthroscopic surgery. 

Of note, the physician injected amnion allograft.

No, the proposed treatment was not medically necessary.

The patient underwent three procedures. Surgical indications require a period of conservative management prior to operative intervention. This patient was evaluated for his left knee. This was the first visit to address his left knee pain. He had previously received treatment for his right knee. The treatment provided was "home exercises and a cortisone injection". He then underwent the operation. The records thus show two weeks of treatment for his left knee. This would be insufficient as per several medical guidelines.

Surgery for meniscal pathology is not recommended in the presence of osteoarthritis. The records show joint space narrowing and chondromalacia grade III to femoral condyle. People who undergo arthroscopic surgery for meniscal pathology with associated arthritis have much worse outcomes. The only indication would be if there was a mechanical block or lock to the knee. This was not present. 

Based upon the clinical record, there would be no indication for any arthroscopic procedure.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion.
Treatment: Braces.
The insurer denied the braces.
The denial is upheld.

The patient is a male. The request is for orthodontic benefits. He has a Class II skeletal malocclusion, with a deep bite and excessive overjet.

The health plan's reason for prior denial of coverage was a revised handicapping score of 13.

No, the Braces are not medically necessary.
The patient does not score 26 or higher on the handicapping index scale, and the "automatic qualifier" of excessive overjet more than 9mm (millimeters) is not accurate. The overjet, while excessive does not measure 9mm (millimeters) or more according to the cephalometric x-ray. Therefore, there is no medical necessity for this case.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Esophagogastroduodenoscopy (EGD)
The insurer denied coverage for an esophagogastroduodenoscopy (EGD)
The denial is upheld 

The patient was having epigastric pain, nausea, and abdominal bloating. An endoscopy revealed esophagitis, and gastritis. 

UpToDate has an article titled "Approach to the adult with dyspepsia." The article states that endoscopic evaluation of patients under 60 is reserved for patients with weight loss, overt gastrointestinal bleeding, or an alarm feature. Alarm features include unintentional weight loss, dysphagia, odynophagia, iron deficient anemia, persistent vomiting, palpable mass, or a family history of upper gastrointestinal cancer. The patient did not have these conditions. 

MCG (Milliman Care guideline) ACG: A-0203 discusses indications for Upper GI (gastrointestinal) Endoscopy. Dyspepsia is an indication if there is an associated risk factor. This can be age of 60, dysphagia, failure of medical therapy, family history of upper GI cancer, iron deficient anemia, long term symptoms, vomiting, and weight loss.

The physician has sent a letter stating that the patient has epigastric discomfort, nausea, and dyspepsia. However, there is no mention as to how long the symptoms have been present. There is also no documentation that the patient has tried and failed empiric treatment prior to the endoscopy being done. There are no alarm features listed in the physician's letter. The health care plan acted reasonably and with sound medical judgment. Since the patient is under age 60 and does not have alarm features or a documented failure of controlling her symptoms with a PPI (proton pump inhibitor), the procedure is not medically necessary. 

The denial is upheld.

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

The insurer's denial of coverage for procedure code 43239, esophagogastroduodenoscopy (EGD) is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Deep bite
Treatment: Braces
The insurer denied the braces
The denial is upheld

The patient is a female. The request is for orthodontic benefits. She has a Class I molar relationship and Class II canine relationship on left side. She has a deep bite.

The health plan's reason for denial of coverage was a score of 10 on the handicapping index scale.

No, the Braces are not medically necessary.
The patient does not have a deep, impinging overbite as was described by the provider. The handicapping score is only 10. There is no medical necessity for this case.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Polycystic kidney disease
Treatment: Abdomen MRI
The insurer denied the Abdomen MRI
The denial is upheld.

The patient is a female with autosomal dominant polycystic kidney disease.  The Plan denied the requested magnetic resonance image (MRI) of the abdomen without gadolinium as no documentation regarding inability to do a renal ultrasound as the first test was provided. The physician is appealing the determination.

No, the proposed magnetic resonance image (MRI) is not medically necessary.
The requested MRI is not medically necessary as supported by current medical literature or standard of care that the requested drug be used without meeting applicable requirements.  It would not be a generally accepted national standard of medical practice and would be provided primarily for convenience of the patient or the practitioner.  It is not the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Based on notes the imaging is being completed for cyst volume, cyst rupture, infected cyst or kidney stone. There is no data or studies to show that ultrasound of the kidney would not provide the required data or information requested. Based on available notes, there is no documentation that this imaging exam is for total kidney volume for which computed tomography (CT) scan without contrast or magnetic resonance image (MRI) without gadolinium are the preferred options in autosomal dominant polycystic kidney disease.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension.
Treatment: Inpatient admission.
The insurer denied coverage for an inpatient admission.

The denial is overturned.

Asked to review the case of a woman with a history of hypertension that presented to the hospital complaining of cough, shortness of breath, and sore throat.  Vital signs on presentation were BP (blood pressure) 188/108 mmHg (millimeters of mercury) and Pulse 99 bpm (beats per minute). Physical examination was unremarkable. 12 lead electrocardiogram (ECG) revealed normal sinus rhythm with left ventricular hypertrophy and associated repolarization abnormalities. QTc (interval on an ECG) was prolonged at 477 milliseconds. Serum blood testing revealed hypokalemia (2.9mEQ (milliequivalents/L (liter)) and abnormal high sensitivity troponin level (30ng (nanograms)/L). The patient was admitted to the hospital for observation and treatment. Potassium was repleted and BP was controlled with oral medications. Echocardiogram revealed a left ventricular ejection fraction of 75% with diastolic dysfunction and mild to moderate aortic regurgitation. Perfusion testing revealed no evidence of ischemia. Following treatment, QTc (interval on ECG) normalized, blood pressure was well controlled, and the patient was discharged with follow up. 

The health plan did not act reasonably with sound medical judgment and in the best interest of the patient. Hypertensive emergency is defined as BP>180/120 with target organ damage. (Reference 1) In this patient, troponin was elevated consistent with myocardial stress and target organ damage. The goals of treatment of hypertensive emergency are to minimize progressive or additional target organ damage while preventing consequence of rapid BP correction. (Reference 2) Given this patients symptoms and elevated risk of coronary artery disease admission to the hospital for aggressive blood pressure management and diagnostic evaluation was necessary. Utilizing the HEART (history, age, risk factors, troponin) risk score this patient would have an intermediate risk of for major adverse cardiac events or death due to any cause. (Reference 3). In addition, the patient was noted to be hypokalemic with a prolonged QT interval on electrocardiogram and required electrolyte repletion and monitoring on cardiac telemetry. This patient's presentation and overall risk of future cardiac events were sufficient to warrant inpatient hospital admission. It was medically necessary to treat this patient at the inpatient level of care.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

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

Diagnosis: Heartburn. 
Treatment: Esophagogastroduodenoscopy (EGD) (43239). 
The insurer denied the Esophagogastroduodenoscopy (EGD) (43239). 
The denial is overturned. 

The patient is a female with heartburn and dysphagia. The attending physician (AP) requested to perform esophagogastroduodenoscopy (EGD). 

Yes, the proposed esophagogastroduodenoscopy was medically necessary. 
The patient had gastroesophageal reflux disease (GERD) with dysphagia. Esophagogastroduodenoscopy (EGD) is clinically appropriate and an accepted standard of care in the evaluation of patients with GERD associated with dysphagia. The differential in such patients includes a peptic stricture and malignancy, and urgent esophagogastroduodenoscopy (EGD) is accepted standard of care to evaluate for possible malignancy, as well as to perform a balloon dilation to improve  the dysphagia, depending on the findings. Therefore, the proposed esophagogastroduodenoscopy (EGD) is medically necessary. 

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient. 

As the esophagogastroduodenoscopy (EGD) was medically necessary, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient by denying it.