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

Diagnosis: Shortness of Breath
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient is a male. He was hospitalized for acute on chronic CHF (congestive heart failure). He presented to the ED (emergency department) for evaluation of progressive shortness of breath and bilateral leg edema. His PMH (past medical history) includes known CHF (congestive heart failure), ICD (implantable cardioverter defibrillator), atrial fibrillation treated with Eliquis, alcohol abuse disorder and drug-seeking behavior, treatment for alcohol withdrawal, alcoholic liver disease with jaundice and prediabetes.

The patient was not in any acute distress and was breathing comfortably, lungs were clear and he had mild tremors and anxiety. His treatment included IV (intravenous) Lasix and IV (intravenous) Ativan. However, by day three, he left AMA (against medical advice).

The health plan denied coverage of the inpatient admission on the basis of medical necessity. This is a review of an appeal of that denial.

No, the Inpatient admission was not medically necessary.
Based on the peer-reviewed medical literature and this reviewer's expert medical opinion, 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), the 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 he received for mildly decompensated chronic CHF (congestive heart failure) complicated by mild alcohol withdrawal/chronic drug-seeking behavior is routinely provided safely and effectively at a lower level of care. Hospitalization for patient, physician or hospital convenience does not establish medical necessity, and so the denial for coverage for the inpatient admission is upheld, when the same care can be provided in a lesser intense setting.

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

Diagnosis: Plantar fasciitis. 
Treatment: Custom Shoe Inserts (L3000 x2). 

The insurer denied coverage for Custom Shoe Inserts (L3000 x2). 

The denial is overturned. 

The patient is a female with long history of foot and ankle pain. There is a history of ankle sprain, metatarsalgia, painful calluses, bunions, and plantar fasciitis. The patient has tried good supportive shoes and compression socks to no avail, along with over-the-counter pain medications and continues to have arch pain. Furthermore, the notes outline that the deformity of the foot was such that even with the use of a prefabricated orthotic there was complete collapse of the arch.  As such, custom orthotics were recommended. 
 
A review of the literature reveals that while there is a vast amount of research with regard to conservative therapy for plantar fasciitis, there is no optimal answer when it comes to specific orthotic therapy for plantar fasciitis. While some patients may benefit from over-the-counter orthotics, others may get no better without the use of custom orthotics. In the case of this patient, it is clear from the medical records made available that the prefabricated orthotics made little difference and the patient needs a good custom orthotic to help with her plantar fasciitis by providing her more support. Given the available literature on this topic and this patients history, in this reviewer's expert opinion it is best that the orthotics are approved, so that the patient can get the treatment she needs to resolve her plantar fasciitis. 

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 Custom Shoe Inserts (L3000 x2) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Obstructive Pulmonary Disease (COPD) and Community Acquired Pneumonia (CAP). 
Treatment: Inpatient Admission. 

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

The patient has a history of COPD, Hypertension (HTN), and history of Covid who presented to the hospital with complaints of worsening shortness of breath (SOB), cough with some blood streaked sputum for 3 days. Some subjective chills and fever. Vital signs in the emergency department (ED) Temperature 98.8, Heart Rate (HR) 107, Respiratory Rate (RR), 18 Blood Pressure (BP) 140/83, Oxygen saturation (O2) 94% on room air (RA). Patient was in no acute distress (NAD). Lungs were clear. Cardiac showed no abnormality. Neurologic examination noted no deficit. Labs: white blood count (WBC) was 19.7K (thousand), Electrolytes within normal limits (WNL) with blood urea nitrogen/Creatinine (BUN/Cr) 11/0.6. 

Chest x-ray (CXR) showed left lower lobe pneumonia (PNA). Computed Tomography (CT) Chest showed no acute pulmonary embolus. 

The patient was admitted to the hospital for COPD and CAP. 

The patient was started on intravenous (IV) Levaquin, Steroids, Bronchodilators and COPD inhalers and IV hydration. 

The patient remained stable after admission and seen by Pulmonary who recommended to switch to oral (PO) antibiotics and continue oral steroids for 5 more days. They recommended follow up in outpatient setting. The patient was discharged. 

This patient did not need acute inpatient hospitalization. She could have been placed in Observation status while diagnostic testing and treatment were initiated. 

The patient remained stable after admission. Her CURB 65 (confusion, blood urea >42,8 mg/dl(milligrams per decilitre), respiratory rate> 30/min (minute), blood pressure < 90/60 mm Hg (millimeters of mercury), age> 65) score was Zero. Remained afebrile. Not hypoxic with oxygen saturations 96% on room air. She was switched to oral medications. The patient could have been discharged home after a period in observation (which could be for up to 48 hours). Acute inpatient hospitalization was not 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 admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting. 
Treatment: Inpatient admission. 

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

The patient is a female with a past medical history of hypertension, diabetes mellitus, hyperlipidemia, and psoriasis. She presented to the emergency room for non-bloody and non-bilious vomiting.  The patient had abdominal pain x 1 week with poor oral intake. 

The patient's CT (computed tomography) abdomen / pelvis showed a 2 x 2.7 cm (centimeter) cystic lesion in the uncinate process of pancreas with mild interval increase in size. The patient was treated with proton pump inhibitors, Zofran, intravenous repletion of the patient's electrolytes. 

It was noted that the patient felt better without nausea / vomiting and was able to tolerate liquids.  The patient had some discomfort in the belly but no pain.  The plan was to obtain MRI/MRCP (magnetic resonance imaging/Magnetic Resonance Cholangiopancreatogram). 

EGD (esophagogastroduodenoscopy) was performed, which was relatively normal. 

The patient's nausea had improved, but the PO (oral) intake was still low. 

It was noted that the patient was having serious nausea / vomiting and abdominal pain.  There as a concern about QT prolongation (a measure of delayed ventricular repolarization), and Zofran was stopped. 

No, the Inpatient admission was not medically necessary. 

On day three, it was noted that the patient felt better without nausea / vomiting and was able to tolerate liquids.  The patient had some discomfort in the belly but no pain. 

The patient went on to have further work up including an UGI (upper gastrointestinal) series, MRI (magnetic resonance imaging)/ MRCP (Magnetic Resonance Cholangiopancreatogram), and EGD (esophagogastroduodenoscopy).  These could have been accomplished as an out-patient.  The patient could have been managed at an observational level of care given lack of complications associated with pancreatitis, and absence of significant symptoms. 

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: Anemia (vertigo)
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

The patient in this case is a woman. She presented to the hospital with a two to three week history of vertigo.

The patient's evaluation on admission was notable for anemia with a hemoglobin of 8.5g/dl (grams per deciliter). Vital signs were notable for mild tachycardia at the time of admission. Neurologic examination was unremarkable. Head CT (computed tomography) and head MRI (magnetic resonance imaging) done at the time of admission were also unremarkable. Vertigo was felt due to vestibular neuronitis and she was treated with meclizine plus prednisone. She had no history of bleeding prior to admission.

The patient was admitted and while in the hospital underwent upper and lower endoscopy without any acute source of bleeding identified. She was found to have iron deficiency and was treated with intravenous iron. Records also note that she was diagnosed with a urinary tract infection before admission, for which she had been treated with an oral antibiotic. She was treated with IV (intravenous) iron over several days then discharged.

No, the Inpatient admission was not medically necessary.
This patient had anemia with a drop in hemoglobin from 11 to around 8.5g/dl (grams per deciliter) in a two to three week period, but without any clinical bleeding. She was hemodynamically stable and was treated with intravenous iron. She also had vertigo, and central causes were ruled out at the time of admission. She was treated with prednisone and meclizine for her vertigo. Those treatments, along with intravenous iron, did not require acute care inpatient hospitalization. This patient could have been treated in the outpatient setting once central causes of vertigo were ruled out. That is based on her lack of clinically evident bleeding and lack of hemodynamic instability.

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

Diagnosis: Skin Disorders. 
Treatment: Opzelura 1.5% cream. 
The insurer denied Opzelura 1.5% cream. 
The denial is upheld.

The formulary drugs, such as Eucrisa ointment, would not be ineffective. Eucrisa would not be as effective as the non-formulary drug (Opzelura 1.5% [percent] cream). Eucrisa would not have adverse effects.
According to the American Academy of Dermatology Atopic Dermatitis Clinical Guidelines and dermatology literature, the formulary alternatives, such as crisaborole (Eucrisa), are effective treatments for the management of atopic dermatitis. (1, 2)
According to Paller et al. "Crisaborole demonstrated a favorable safety profile and improvement in all measures of efficacy, including overall disease severity, pruritus, and other signs of atopic dermatitis (AD)." (3)
It is noted that the patient has tried and failed fluocinolone ointment. However, the patient has no true contraindications to the other formulary medications which have been shown to be effective for the treatment of atopic dermatitis. The evidence-based literature is consistent and in line with the patient's formulary choices. The formulary alternatives are appropriate agents for the treatment of the patient's atopic dermatitis.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lung cancer
Treatment: Cancer Screening
The insurer denied Molecular Comprehensive Genomic Profile. The health plan's determination is overturned.

The patient is a female with past medical history of hypertension, hyperlipidemia, asthma, and 15 years of smoking (2-3 packs per day) who was diagnosed with stage I lung cancer, poorly differentiated adenocarcinoma of the right upper lobe. She underwent surgery. She received adjuvant chemotherapy with regimen of Carboplatin and Pemetrexed.

Molecular Comprehensive Genomic Profile is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Next generation sequencing (NGS) testing [such as Foundation One CDx (companion diagnostic)] is now a standard practice in management of newly diagnosed lung cancer. National Comprehensive Cancer Network (NCCN) and ESMO (European Society of Medical Oncology) recommend routine testing of molecular profiling at the time of diagnosis. NGS testing allows identification of molecular alteration for targeted therapies. NGS also provides prognostic tools and many patients are able to enroll in clinical trials based on the discovery of molecular targets if standard Food and Drug Administration (FDA) approved therapies are not available. Obtaining information of the mutations status of following genes is a crucial step in formulating treatment plans for first line and subsequent line setting in lung cancer.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lung cancer
Treatment: Cancer Screening
The insurer denied Molecular Comprehensive Genomic Profile. The health plan's determination is upheld. 

The patient is a woman with adenocarcinoma of the RUL (right upper lung). She underwent a RUL lobectomy and lymph node sampling on that date. The pathologic stage was Stage IA3.

The proposed Molecular Comprehensive Genomic Profile is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
For patients with Stage IA non-small cell lung cancer who undergo resection consisting of lobectomy and lymph node dissection, without high risk factors, adjuvant chemotherapy is not recommended. The records do not demonstrate any high-risk features.
National Comprehensive Cancer Network (NCCN) guidelines do not recommend molecular testing in Stage IA lung cancer patients. If adjuvant therapy is recommended in more advanced cases, then testing for EGFR (epidermal growth factor receptor) is recommended.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lung cancer
Treatment: Cancer Screening

The insurer denied Molecular Comprehensive Genomic Profile. The health plan's determination is upheld. 

This is a female with a resected RUL (right upper lung) stage IA Non-small-cell lung carcinoma (NSCLC). The patient has undergone lobectomy and next generation sequencing was obtained for evaluation. 

Molecular Comprehensive Genomic Profile 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 use of next generation sequencing gene panels to guide the treatment of patients with early stage lung cancer has not been demonstrated to be of benefit. In early stage disease, only EGFR (epidermal growth factor receptor) and PD-L1 (Programmed death-ligand) testing is accepted and recommended by national guidelines and the peer-reviewed literature.
Based on the paucity of supporting data, neither the National Comprehensive Cancer Network (NCCN) nor the authors of UpToDate recommend the use of the Foundation Medicine next generation sequencing (NGS) assay in this clinical scenario. Treatment based on published literature and guideline recommendations has been encouraged.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skin Disorders. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Humira. 
The denial is overturned.

The patient is a male with hidradenitis suppurativa. The hidradenitis suppurativa is Hurley Stage II. The skin of the scrotum and axillae are affected. He has tried and failed doxycycline and benzoyl peroxide gel. He has also failed minocycline, Bactrim, and clindamycin solution. The subject under review is the medical necessity for Humira.

The health plan's determination is overturned in whole. 

The requested treatment of Humira is medically necessary for this patient. The patient has already tried and failed the conventional systemic therapies doxycycline, Bactrim and minocycline.
Use of Humira is considered standard of practice after treatment failure of oral antibiotics for this patient's diagnosis of hidradenitis suppurativa. Hidradenitis suppurativa is a scarring, debilitating and disfiguring skin disease.
The evidence is strong enough for Humira to be used for treatment for hidradenitis suppurativa in this patient. There are several reports in the dermatology peer-reviewed literature that show that Humira is effective for the management of hidradenitis suppurativa, and it is indicated for this purpose (1-3).
Kimball et al. writes "Treatment with adalimumab (40 milligrams [mg] weekly), as compared with placebo, resulted in significantly higher clinical response rates in both trials at 12 weeks; rates of serious adverse events were similar in the study groups" (1). Zouboulis et al. writes in "Adalimumab dose intensification in recalcitrant hidradenitis suppurativa/acne inversa" that "Continuous weekly dosing with adalimumab (ADA), 40 mg, is a reasonable treatment option for long-term control of moderate-to-severe HS" (2). A negative tuberculosis test from several months ago is provided.
Therefore, based on the standard of care Humira is medically appropriate and necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pancreatitis. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the Inpatient Hospital Stay. 
The determination is upheld. 

The patient has a medical history of chronic alcohol use and alcoholic pancreatitis. He presented to the emergency department with severe nausea, vomiting, diarrhea, and abdominal pain with the inability to tolerate oral intake. He last had alcohol two days prior. His vital signs were notable for tachycardia with a pulse rate of 128 beats/minute. The physical examination was notable for an uncomfortable appearance, tongue fasciculations, fine resting tremor in the hands, and left-sided tenderness and guarding in the abdomen. Lab results showed a low sodium of 129 millimoles per liter (mmol/L), elevated creatinine of 1.11 milligrams per deciliter (mg/dL), elevated aspartate aminotransferase of 146 units per liter (U/L), elevated alanine aminotransferase of 102 U/L, elevated bilirubin of 1.6 mg/dL, elevated lipase of 76 U/L, elevated D-dimer of 574 nanograms per milliliter (ng/mL), and elevated troponin of 0.08 ng/mL.
A computed tomography scan of the chest with angiogram showed no pulmonary embolus, airspace consolidation, pleural effusion, or other acute findings. A computed tomography scan of the abdomen and pelvis showed hepatic steatosis, distended gallbladder with edema concerning for acute cholecystitis, and edema of the pancreatic tail with thickening of the left anterior pararenal fascia suggestive of pancreatitis. An ultrasound of the abdomen showed hepatomegaly with distended gallbladder and pericholecystic fluid. 

He was treated with intravenous fluids, ketorolac, morphine, and lorazepam. He was made nil per os (NPO). He reported no pain. Lab results showed a low hemoglobin of 12.5 g/dL and hematocrit 35.5%, low sodium of 135 millimoles per liter (mmol/L), low potassium of 3.3 mmol/L, elevated aspartate aminotransferase of 85 U/L, elevated alanine aminotransferase of 76 U/L, and elevated troponin of 0.06 ng/mL. The patient left against medical advice (AMA). At issue is the medical necessity for an inpatient stay. 

No, the inpatient level of care was not medically necessary for this patient. 

The patient presented with symptoms and imaging consistent with acute pancreatitis [1]. He was appropriately treated, with intravenous fluid administration, and subsequent improvement in pain [1-5]. However, there was no hemodynamic instability or other complications such as pseudocyst, pancreatic necrosis, thrombosis, ascending cholangitis, abscess, active gastrointestinal bleeding, peritonitis, or sepsis, which would require a higher level of care [4-8]. Imaging showed possible acute cholecystitis, but a cholecystectomy was not deemed necessary [8]. He did not have persistent signs or symptoms of acute alcohol withdrawal [9,10]. The interventions performed, including labs, imaging, intravenous fluids, and monitoring, could have been performed without the inpatient level of care, at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Autism and Focal Epilepsy. 
Treatment: Consumer Directed Personal Assistance Program (CDPAP) 56 hours per week. 

The insurer denied coverage for CDPAP 56 hours per week. 

The denial is upheld. 

The patient is a male diagnosed with autism and focal epilepsy. He lives in a 1-bedroom apartment with his mother and attends school Monday-Friday. The insurer increased his CDPAP hours to 21 per week. Under review is the requested CDPAP increased to 56 hours per week. 

According to the Uniform Assessment System (UAS) report, the patient requires maximal assistance for bathing. Activities such as personal hygiene, dressing and toilet transfers/use, require extensive assistance. He is continent of bowel and bladder. Activities such as bed mobility, transfers and ambulation are at the supervision to independent level. His treating physician submitted a letter indicating the patient requires supervision due to his underlying medical condition as well as assistance with activities of daily living. The increased CDPAP hours to 21 per week is clinically appropriate; given the patients' functional impairments. As noted by the insurer, aide hours are not provided for the purpose of supervision, childcare, or to replace care responsibilities of the school or the patient's parents. The clinical records do not substantiate a level of physical impairment, debility or significant functional decline to warrant the medical necessity of an increase in CDPAP hours to 56 per week. 

From a physical medicine and rehabilitation perspective, the denial of coverage for CDPAP 56 hours per week was clinically appropriate. 

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

The insurer's denial of coverage for CDPAP 56 hours per week is upheld. Medical Necessity is not substantiated.