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

Diagnosis: Cyclic vomiting syndrome

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient had a history of cyclic vomiting syndrome and presented with vomiting. She was afebrile and the vital signs were stable. The abdominal exam was benign. The renal function was normal. The urine toxicology was positive for THC. She was treated with antiemetics. Protonix was given for gastroesophageal reflux disease (GERD). Intravenous (IV) hydration was given, and the metabolic acidosis improved. She was treated for anxiety with Ativan. Her symptoms improved and her diet was advanced. 

Medical necessity was determined using Milliman Care Guidelines (MCG) M-370 for Vomiting. Clinical indications for admission include having a significant metabolic derangement such as ketoacidosis, hemodynamic instability, severe vomiting that does not respond to antiemetics, severe electrolyte abnormalities, severe pain, bacteremia, stage 2 acute kidney injury, and an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

This patient had cyclic vomiting syndrome that may have been related to marijuana use. She required IV hydration and antiemetics. This could have been given with Observation status. She responded to the treatment and her symptoms improved. She did not meet MCG criteria for admission for Vomiting. 

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

The medical necessity for an inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Angina
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The health plan's determination is upheld.

The patient is a male with a medical history of hypertension (HTN), hyperlipidemia (HLD), alcohol use, and asthma who presented to the emergency room on with chest pain. He reported drinking alcohol the previous evening. He stated that the pain was burning in nature and occurs after he drinks alcohol. He stated that he had intermittent chest pain for two months. His blood pressure was 169/80, pulse 72 beats per minute (bpm), and his oxygen saturation 93 percent (%) on room air. The electrocardiogram (EKG) showed nonspecific changes. His high sensitivity troponin was 154. His repeat high sensitivity troponin was less than 5. His pain resolved after Famotidine. He left the emergency room (ER) against medical advice.

The health plan, its determination of medical necessity, acted reasonably, with sound medical judgment and in the best interest of the patient. 

The requested health service of an inpatient hospital admission is not medically necessary for this patient. The patient presented with atypical chest pain after drinking alcohol. He did have coronary risk factors and had the initial troponins (high sensitivity) which was elevated. However, the EKG did not show ischemic changes and the repeat troponins was negative. 
According to the Milliman guidelines, inpatient admission for chest pain is indicated for patients with hemodynamic instability, respiratory distress, chest pain indicative of a serious diagnosis, including aortic dissection, pulmonary embolus and others, or severe pain requiring inpatient management. In this case, the patient was hemodynamically stable, had resolution of his pain in the emergency room, and did not have clinical evidence of a critical cardiac or pulmonary diagnosis requiring inpatient admission. He did have elevation of the initial troponin level. However, the repeat troponin was normal, the patient's chest pain was atypical for angina and there were no definite ischemic changes on EKG. He does not meet criteria for an acute coronary syndrome but may have had demand ischemia. For these reasons, the full inpatient admission is not indicated. 

The health plan's determination of medical necessity is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back Pain
Treatment: Pain injections
The health plan denied: Pain injections
The determination is: Overturned

The patient is a male with a history of low back pain. He followed up with his doctor, where it was noted that the back pain radiated into the bilateral lower limbs. He was using Tramadol and Gabapentin for pain. He cannot use nonsteroidal anti-inflammatory drugs (NSAIDs) because of a history of stomach ulcers. He was treated with 19 sessions of therapy and has been performing home exercises since that time. Magnetic resonance imaging (MRI) of the lumbar spine revealed severe foraminal narrowing, and electromyography (EMG) revealed bilateral lumbar radiculopathy. A request was made for a lumbar transforaminal epidural steroid injection. 
At issue is the medical necessity of pain injections. 
The health plan's determination of medical necessity is overturned in whole. 
The requested health service/treatment of pain injections is medically necessary for this patient. 
Injections of steroids directly into the epidural space are used for treatment of radicular back or neck pain after failure with conservative management. The steroids are given with or without anesthetic agents for relief of pain. Epidural steroid injections have been considered a generally accepted standard of medical practice for many years. The results of clinical trials have been mixed. Although short-term relief of radicular pain may occur, long-term outcomes vary. No more than three-four injections should be given in a six-month period. Repeat injections after the initial therapeutic phase should be done at intervals of at least 2 months, provided that previous injections resulted in at least 50 percent (%) pain relief or functional improvement for at least 2 months. There is a risk of bleeding, infection, or spinal cord injury with this invasive procedure. Some practitioners may give epidural steroid injections blindly; however, the use of fluoroscopy for visualization of needle placement has been shown to reduce the risk and complications of the procedure. In this case, the patient had persisting complaints despite conservative treatment with positive findings on imaging and EMG; therefore, the epidural injection would be indicated.
Appeal type: Medical necessity
Decision: Overturned

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

This patient is a female with locally advanced pancreatic cancer status/post (s/p) neoadjuvant chemotherapy, radiation and percutaneous cholecystectomy tube placement. She presented for elective laparoscopic cholecystectomy and removal of percutaneous cholecystectomy tube. Surgery was uncomplicated, but per the hospital notes, the procedure took 3 hours 26 minutes which is longer than standard cholecystectomy.

The inpatient hospital admission was medically necessary. The procedure was complex given the history of radiation and the unresectable pancreatic cancer. She has a history of DVT (deep vein thrombosis) and was on Eliquis which has associated higher levels of post operative bleeding. Close monitoring was necessary.

Inpatient level care was necessary given the patients comorbidities and length of procedure > (greater than) 3 hours. As indicated by studies such as Lau et al, there is a risk for increased complications in procedures > (greater than) 60 minutes.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Spot on Liver
Treatment: Abdominal MRI (magnetic resonance imaging)
The health plan denied Abdominal MRI.
The determination is Upheld.

The patient is a female with an abnormal liver lesion found on ultrasound (US) and computed tomography (CT) scan after a work-up for right upper quadrant (RUQ) pain. The patient underwent magnetic resonance imaging (MRI) without a hepatobiliary phase and was found to have focal nodular hyperplasia versus a hepatic adenoma. The patient had been taking birth control pills, which she has now stopped. The provider is requesting a repeat MRI (magnetic resonance imaging) with hepatobiliary phase contrast - this was the recommendation received from the radiologist who interpreted the MRI (magnetic resonance imaging). 
At issue is the medical necessity of the abdominal MRI (magnetic resonance imaging).
The health plan's determination of medical necessity is upheld in whole. 
The requested health service/treatment of abdominal MRI (magnetic resonance imaging) is not medically necessary for this patient. This patient very likely has a hepatocellular adenoma as the radiographic features of Focal Nodular Hyperplasia (FNH) are not seen (central scar). Hepatic adenoma is an uncommon solid, benign liver lesion that develops in an otherwise normal-appearing liver. Typically, hepatic adenoma are solitary and are found in young women in association with use of estrogen-containing medications. The spectrum of presentation of hepatic adenoma ranges from asymptomatic individuals with incidental imaging findings to patients with acute, life-threatening hemorrhage resulting from adenoma rupture and intraabdominal bleeding. Most hepatic adenoma are seen in women of reproductive age who have a history of oral contraceptive (OC) use. Although contrast-enhanced multiphasic imaging (MRI-magnetic resonance imaging) can often distinguish between focal nodular hyperplasia and hepatic adenoma, further evaluation and/or intervention (surgical resection) may be required for definitive diagnosis. For a hepatic adenoma less than or equal to (<=) 5 centimeters (cm), treatment recommendations are to discontinue estrogen-containing medications. Regression of Hepatocellular adenoma (HCA) <= (less than or equal to) 5 cm (centimeters) has been observed after discontinuing these medications. For lesions greater than (>) 5 cm (centimeters), there is a risk of bleeding and the risk of malignant transformation from hepatic adenoma to hepatocellular carcinoma is approximately 5 percent (%) - risk factors include male sex and lesion size > (greater than) 5 cm (centimeters), among others. 
Approximately 6-12 months after the previous MRI (magnetic resonance imaging), a repeat MRI is indicated. At that time, the multiphasic MRI (magnetic resonance imaging) can include a hepatobiliary phase to confirm the diagnosis of hepatocellular adenoma and assess for regression off oral contraceptives. A repeat request should be submitted at the appropriate time interval.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Spinal Cord Injury.
Treatment: Personal Care Aide.
The health plan denied: Personal Care Aide.
The determination is: Overturned.

The patient is a female with medical history notable for cervical and spinal cord damage. The patient and her care team requested a personal care aide, and this request was denied by the health plan. This denial is the subject under review.
The patient's neurosurgeon provided a letter of support for this appeal. The letter states that the patient "would greatly benefit from homecare twice weekly to assist with activities of daily living (ADL) due to the diagnosis of ossification of the posterior longitudinal ligament (OPLL)." No further details were provided.
The patient's orthopedist also provided a letter. This letter states that the patient has cervical myelopathy and had cervical surgery to slow the progression of her condition. She also has spinal stenosis with resulting dysfunction of her lower extremities.
A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted via telehealth. The patient lives alone in an apartment. The patient was cognitively intact. From a functional standpoint, she requires maximal assistance with shopping. She requires extensive assistance with housework and stairs. Other instrumental activities of daily living (IADL) are independent. All of her ADL's are independent. She is continent of stool and urine.
The patient provided a letter of support on her own behalf. The letter states that she requested a personal care aide because she has had progressive worsening of her condition. Other case review notes state that her daughter lives 2 hours away and tries to help when she can, up to twice per week, but that she has no informal support.
At issue is the medical necessity of the personal care aide.
The health plan's determination of medical necessity is overturned in whole.
The requested health service of Personal Care Aide is medically necessary for this patient.
The patient's progress notes demonstrate that her condition is worsening. She is now reliant on others for assistance with housekeeping and shopping as demonstrated by the UAS. Her daughter has been providing this support informally but lives 2 hours away; the patient needs a reliable source of personal care assistance to help complete her IADL's. A small number of personal care hours is medically necessary and reasonable to assist the patient.
Appeal type: Medical necessity
Decision: Upheld

Orthopedic
Home health care

Diagnosis: decreased mobility
Treatment: home health care
The insurer denied Personal Care Aide (PCA) 12 hours a day, 7 days a week + 12 hours a day, 7 days a week (split shift) total 168 hours per week. The health plan's determination is upheld. 

The patient is a female with past medical history of wet macular degeneration with legal blindness, multijoint osteoarthritis, chronic pain syndrome constipation, breast cancer, osteoporosis, thyroid goiter, urinary incontinence, neuropathy, and anxiety who had been assigned PCA (personal care aide) services. 

Personal Care Aide (PCA) 12 hours a day, 7 days a week + 12 hours a day, 7 days a week (split shift) total 168 hours per week are not medically necessary for this patient.
There is no documentation of overnight care needs that would not allow a PCA 5 hours of uninterrupted sleep.  There is no documentation of lack of physical space for a PCA to sleep in the patient's residence. There is no documentation of overnight care logs specifically outlining timing and assistance needs with overnight activities of daily living (ADL) assistance. 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, PCA services 12 hours a day, 7 days a week + 12 hours a day, 7 days a week (split shift) total 168 hours per week are not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Digestive system
pharmacy/prescription drug

Diagnosis: irritable bowel syndrome, constipation-predominant
Treatment: lubiprostone
The insurer denied lubiprostone. The health plan's determination is overturned. 

The patient is a female with irritable bowel syndrome, constipation-predominant. She has had constipation, with up to five days between bowel movements. She has failed senna, stool softeners, fiber, and Miralax.

Lubiprostone is medically necessary for this patient.
Lubiprostone is indicated to restore colonic function in constipation, and is Food and Drug Administration (FDA) approved for the treatment of constipation-predominant irritable bowel syndrome (Li, et al). It has a different mechanism of action than osmotic laxatives, and can be effective even if those have failed (Cash, et al). The use of lubiprostone is recommended by the American College of Gastroenterology guidelines for treatment of irritable bowel syndrome, without necessarily attempting a bulk-forming or stimulant laxative first (Ford, et al). Additionally, American Gastroenterological Association guidelines for the treatment of irritable bowel syndrome constipation-predominant recommend lubiprostone for the treatment of irritable bowel syndrome constipation-predominant (Chang, et al).
In this case, the patient has attempted a stimulant laxative, osmotic laxative, and fiber with ongoing constipation, and the use of an advanced laxative such as lubiprostone is supported. For these reasons, lubiprostone is supported as medically necessary for the treatment of the patient's constipation-predominant irritable bowel syndrome in this case.
Appeal type: Medical necessity
Decision: Overturned

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

The patient is a male with a past medical history significant for uncontrolled type II diabetes mellitus, prior history of left hip septic arthritis, GBS (Guillain-Barre syndrome), and bacteremia who presented to the hospital with redness, swelling, and pain in his right leg, which had been going on for one week. It was mentioned that the patient had chronic leg swelling that was intermittent.

The inpatient hospital admission was medically necessary. Based on the accepted standards of care, admission for treatment of acute cellulitis is required for patients with uncontrolled diabetes mellitus whose hemoglobin A1c is greater than 10% due to high chances of adverse outcomes. In this clinical case, the patient had a hemoglobin A1c of 11.2.
Therefore, admission at the acute inpatient level of care was appropriate since the patient had severely uncontrolled diabetes mellitus that increased the chances of adverse outcomes if not adequately treated. Therefore, the patient received treatment with intravenous antibiotics and was monitored for signs of clinical improvement until he was deemed safe to be transitioned to oral antibiotics.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: 3-minute fetal deceleration
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

The patient was a young adult who was brought by emergency medical services (EMS) at 31.3 weeks gestation after an episode of loss of consciousness in the setting of severe nausea and vomiting. 

The patient was previously admitted with a similar episode. She was evaluated at that time by cardiology and neurology with no significant findings. While in triage, a 3-minute fetal deceleration was noted. It was decided to admit the patient for observation and continuous monitoring. The tracing was noted to be appropriately reactive without deceleration. Biophysical profile was 8/8.  Patient was discharged home.

This patient has been previously admitted and evaluated for syncope as well as for nausea and vomiting. The reason for admission was that the patient had a 3 minute fetal heart deceleration.

According to Milliman Care Guidelines (MCG) admission is indicated for one or more of the following:

1) Condition requiring premature delivery 2) Fetal distress or demise 3) Preterm prelabor rupture of membranes 4) Significant maternal disease 5) Vaginal bleeding 6) Complications of tocolytic treatment 7) Continued fetal monitoring that require inpatient care 8) Tocolytic therapy needed that requires inpatient care 9) Inability to stop preterm labor.

This patient did not have any of the above. There was 1 episode of fetal deceleration. However, the biophysical profile was 8/8 and continuous monitoring showed a reactive tracing with no additional decelerations. The patient could have been observed for a few hours, hydrated, and once the provider ascertained that the fetus was doing well, the patient could have been sent home with adequate outpatient follow-up. Admission for monitoring was not medically necessary.

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

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

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

The patient presented with abdominal pain and constipation. She was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. There was no leukocytosis. An abdominal computed tomography (CT) scan showed a possible colonic stricture that was felt to be inflammatory in nature. Antibiotics were given for colitis. A COVID (Coronavirus disease) test was positive. A chest infiltrate was found, although there was no chest pain, shortness of breath (SOB), or coughing. Laxatives were given for the constipation and the abdominal pain resolved. There was a plan for an outpatient colonoscopy. 

Clinical indications for admission for Undiagnosed Abdominal Pain per Milliman Care Guidelines (MCG M-05) include hemodynamic instability, peritoneal signs, inability to maintain oral hydration after observation care, and bacteremia. The patient did not have these conditions. 

Clinical indications for admission for Gastroenteritis (MCG M-170) include having a suspected severe infection such as bloody diarrhea, peritoneal signs, hemodynamic instability, severe vomiting, severe dehydration, severe electrolyte abnormalities, and an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

This patient had CT scan evidence of colitis and constipation. She was started on antibiotics but was stable to have been treated with a course of oral antibiotics as an outpatient. She was then treated for constipation and improved. A laxative regimen could also have been given as an outpatient. The chest infiltrate could have been treated with oral antibiotics as an outpatient. She did not meet MCG criteria for admission for either Undiagnosed Abdominal Pain or Gastroenteritis. 

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

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

Diagnosis: Eosinophilic esophagitis
Treatment: Dupixent Syn (syringe) 300
The insurer denied coverage for Dupixent Syn 300.
The denial is upheld.

The patient had a history of dysphagia with food impaction and an esophageal tear. The patient was treated with Omeprazole with initial improvement of the symptoms. An endoscopy revealed esophageal eosinophils and a Schatzki ring. The patient underwent an esophageal dilatation. The patient did not feel well on a Proton Pump Inhibitor (PPI) (medications such as omeprazole) and was switched to famotidine. An endoscopy was done which showed eosinophilic esophagitis. 

UpToDate has an article titled "Treatment of eosinophilic esophagitis." The pharmacologic therapy was reviewed. Most patients start treatment with a PPI. Afterwards, if symptoms persist, topical glucocorticoids are advised. The article states that most patients with eosinophilic esophagitis respond to topical glucocorticoids as demonstrated by a decrease in the eosinophil count. Budesonide oral suspension is available and is generally well tolerated. Patients will usually have symptomatic improvement within several days. The article also states an option for non-responders is to give Dupilumab. It is best used in patients who are refractory to other treatments. 

This patient has eosinophilic esophagitis and has not responded well to PPI therapy. However, the usual next step in therapy is to give a topical steroid such as Budesonide. Since there is no record that the patient has tried and failed Budesonide, giving Dupixent at this time is not medically necessary.

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

The medical necessity for Dupixent Syn (syringe) 300 is not substantiated.