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

Diagnosis: Gastroesophageal reflux disease (GERD) with gastrointestinal bleeding.
Treatment: Gastric procedure (43239).
The insurer denied coverage for gastric procedure (43239).
The denial is overturned.

The patient presented with chest burning. He also reported having blood in his stools. An endoscopy revealed gastritis with Helicobacter Pylori. The physician's note states that he is not on medications. 

Milliman Care Guideline (MCG) ACG: A-0203 lists indications for upper gastrointestinal (GI) endoscopy. Dyspepsia is an indication if the patient is 60 years old, has dysphagia, has failed proton pump inhibitor (PPI) therapy, has a family history of a first degree relative with an upper GI malignancy, has vomiting, or weight loss. Gastroesophageal reflux is an indication for endoscopy if there is anemia, dysphagia, failure of medical therapy, gastrointestinal bleeding, recurrent vomiting, and weight loss. 

There is no documentation that he failed medical therapy. However, the chart does document that he was having blood in his stools. Since the patient has GERD with gastrointestinal bleeding, he met the indication for having an upper GI endoscopy. 

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 gastric procedure (43239) is overturned. Medical Necessity is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Chronic Prostatitis
Treatment: Formulary exception for Xenleta 600mg Tablet, pre-service
The insurer denied the Formulary exception for Xenleta 600mg Tablet, pre-service
The denial is upheld.

The patient is a male with chronic prostatitis. He has been recommended non-formulary Xenleta 600 mg (milligrams). He has been treated with ceftriaxone, ertapenem, and gentamicin. A culture grew enterococcus and Klebsiella. He has tried azithromycin, clindamycin, fosfomycin, linezolid, Augmentin, Bactrim, Levaquin, ciprofloxacin, and doxycycline.

No, the health plan should not cover the Formulary exception for Xenleta.
Per the Prescribing Information, "XENLETA is a pleuromutilin antibacterial indicated for the treatment of adults with community-acquired bacterial pneumonia (CABP) caused by susceptible microorganisms. (1.1)". This indication was not met.

Coverage was denied by the health plan, because the patient had not tried the formulary alternatives ciprofloxacin, levofloxacin, ofloxacin.

The Plan's denial states in full, "The policy states that this medication may be approved when: The member has a clinical condition or needs a specific dosage form for which there is no alternative on the formulary or the listed formulary alternatives are not recommended based on published guidelines or clinical literature or The formulary alternatives will likely be ineffective or less effective for the member or The formulary alternatives will likely cause an adverse effect or The member is unable to take the required number of formulary alternatives for the given diagnosis due to a trial and inadequate treatment response or contraindication or The member has tried and failed the required number of formulary alternatives."

Although the patient has tried multiple antibiotics, the sensitivity profiles do not indicate that the requested antibiotic will be effective.

Therefore, given the above, the health plan should not cover the Formulary exception for Xenleta.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anemia.
Treatment: Inpatient admission.

The insurer denied coverage for an inpatient admission.  The denial is overturned.

This patient presented to the hospital from another facility. He reported black stools and dizziness. Vital signs were remarkable for a blood pressure of 60/40.  His hemoglobin at the prior facility was 5.6 and he had received 2 units of packed red blood cells. When he presented to the alternate hospital, his hemoglobin was 7.5. He was admitted with acute blood loss anemia secondary to a gastrointestinal bleed. Gastroenterology was consulted. An endoscopy was performed which revealed multi clean-based gastric ulcers. A duodenal ulcer with active oozing was noted. The patient had sclerotherapy and electrocautery with successful hemostasis. He required an additional transfusion of packed red blood cells which increased his hemoglobin to 8.2. He was treated with Protonix and placed on a clear liquid diet. He was deemed stable for discharge.

Per the cited literature, an admission for gastrointestinal bleeding is recommended when there is hemodynamic instability that cannot readily be corrected by appropriate treatment. If there is ongoing active bleeding, if mechanical ventilation is necessary, if there is a peptic ulcer with high risk endoscopic features such as with active bleeding, if there is a need for endoscopic hemostatic therapy, and if there is a need for coagulopathy that is not quickly reversible. In this case, the patient presented from another facility. He reported black stools, dizziness, and vomiting. It was argued that the inpatient admission was medically necessary. The patient presented to the emergency department secondary to anemia. He was vomiting, had black stools, and reported dizziness. He was referred from an outside facility for gastrointestinal evaluation.  He was placed on continuous cardiac monitoring.  His hemoglobin and hematocrit were monitored. He required continuous intravenous fluids and pantoprazole. The patient was found to have a duodenal ulcer that was oozing.  The patient had sclerotherapy and electrocautery with successful hemostasis.  He required an additional transfusion of packed red blood cells which increased his hemoglobin to 8.2. It was indicated that admission to the hospital was appropriate. Based on the clinical findings, an admission to the hospital was medically necessary and meets MCG (Milliman Care Guidelines). The patient had a peptic ulcer with active bleeding and required endoscopic hemostatic therapy.  As such, an admission was appropriate and recommended. Therefore, the denial of coverage for the inpatient admission was not appropriate and is overturned.

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 the inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia.
Treatment: Inpatient admission.

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

The patient is a male with a history of hypertension, anemia, and polysubstance abuse who presented to the emergency department (ED) with complaints of worsening fatigue and cough. 

The patient denied fever, chills, shortness of breath and chest pain. He was in no acute distress. His lungs were clear, and his cardiovascular system was normal. The patient was awake and alert.

The white blood count (WBC) was 7.5K (thousand), hemoglobin (Hb) 8.1, blood urea nitrogen (BUN)/ creatinine (Cr) 14/1.08. A Chest x-ray (CXR) noted bilateral basal infiltrates.

An electrocardiogram (EKG) showed no acute ischemic changes. A urine antigen strep pneumonia was positive.

The patient was admitted for treatment of pneumonia and was started on intravenous (IV) Rocephin and Azithromycin. 

The patient remained stable after admission. The patient was discharged home on oral antibiotics. 

This patient did not need acute inpatient hospitalization. He could have been placed on Observation status while diagnostic testing and treatment were continued. This patient was afebrile and hemodynamically stable, with oxygen (O2) saturations of 97% on room air (RA).

The patient was tolerating oral intake. His CURB (confusion, blood urea nitrogen, respiratory rate, blood pressure, and age) 65 score was Zero. There were no signs of alcohol withdrawal.

This patient did not have any history of failed outpatient management. The patient could have been under observation status for up to 48 hours. 

The patient could have been switched to oral antibiotics and discharged home with close follow up in an outpatient setting.

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

The insurer's denial of coverage for the inpatient emergency admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male status post transurethral prostatectomy who presented to the emergency department with suprapubic pain, urinary retention, hematuria, and bladder distention for one day. A 20 French three-way catheter was placed with drainage of 400 cubic centimeters of urine, irrigated with removal of 200 cubic centimeters of clot and placed on continuous bladder irrigation. The patient's hemoglobin/hematocrit was 11.5/34.2, creatinine was normal; the patient was hemodynamically stable and afebrile. 

The patient was admitted for continuous bladder irrigation and monitoring for bleeding. A computed tomography (CT) scan demonstrated no intra- or retroperitoneal bleed and bladder findings consistent with cystitis. The patient's repeat hemoglobin was 10.7 and hematocrit was 30.9. The patient did not require transfusion, remained hemodynamically stable and afebrile. The patient was discharged to home with an indwelling catheter draining clear urine. 

The acute inpatient stay was denied due to a lack of documentation of a severe medical condition that required inpatient management and that could not be evaluated and managed within an observational stay. 

No, the proposed inpatient hospital admission was not medically necessary. 
The patient did not have any defined medical co-morbidities, was afebrile and was hemodynamically stable. The patient could have been managed at a lower level of care. The literature supports an average length of stay of 48 hours which is consistent with observational level of care. 

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient. 
The health plan is not denying that the patient required monitoring but based on the severity of illness the patient could have been managed at a lower level of care. The patient was afebrile, hemodynamically stable and responded to irrigation of the initial clots and continuous bladder irrigation. His renal function was normal. There is no documentation of co-morbidities that would have required a higher level of care. The literature supports an average length of stay of 48 hours which is consistent with observational level of care.
Appeal type: Medical necessity
Decision: Overturned

Dental
Dental/Orthodontic

Diagnosis: anterior and posterior crossbites
Treatment: braces/monthly visits
The insurer denied Braces and Monthly Visits. The health plan's determination is overturned.

The patient in question is a male with anterior and posterior crossbites. He has severe crowding and tooth #11 is blocked out to the labial. He is severely crowded. He is treatment planned for Braces and Monthly Visits (12 Units) to correct his bite. 

Braces and Monthly Visits (12 Units) are medically necessary for this patient. 
This patient presents with anterior and posterior crossbites, crowding, and constricted arches. He would be an excellent candidate for orthopedic rapid maxillary expansion to assist with orthodontic correction. Such a procedure can only be performed before the patient reaches skeletal maturity, otherwise the ability to achieve orthopedic expansion is greatly reduced. The patient is nearly at the end of the time that orthodontics alone can correct his crossbite. Therefore, the requested treatment is medically necessary at this time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: anterior and posterior crossbites
Treatment: braces/monthly visits
The insurer denied Braces and Monthly Visits. The health plan's determination is overturned.

The patient in question is a male with anterior and posterior crossbites. He has severe crowding and tooth #11 is blocked out to the labial. He is severely crowded. He is treatment planned for Braces and Monthly Visits (12 Units) to correct his bite. 

Braces and Monthly Visits (12 Units) are medically necessary for this patient. 
This patient presents with anterior and posterior crossbites, crowding, and constricted arches. He would be an excellent candidate for orthopedic rapid maxillary expansion to assist with orthodontic correction. Such a procedure can only be performed before the patient reaches skeletal maturity, otherwise the ability to achieve orthopedic expansion is greatly reduced. Given that the patient is 16 years old, and skeletal maturity in males usually occurs around 17-18 years old, he is nearly at the end of the time that orthodontics alone can correct his crossbite. Therefore, the requested treatment is medically necessary at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Trauma/Injuries/Ingestion.
Treatment: Inpatient Hospital.
The health plan denied the requested inpatient stay as not medically necessary. 
The health plan's determination is upheld.

The patient is a male child with a medical history significant for constipation who presented to the emergency department (ED)  for bloodwork. He was found the night before holding a bag of rat poison pellets and told his mother that he had eaten some. He was taken to the ED at that time, asymptomatic, had lab work done, and was told to return after 18 hours for repeat studies. Prothrombin time (PT)/international normalized ratio (INR) at that time was within normal limits. He remained asymptomatic. Vital signs included temperature of 37.1C., a heart rate of 109 beats per minute (bpm), and a respiratory rate of 24/minute. The examination was unremarkable. Coagulation studies were obtained, found to be slightly increased from previous normal values (PT 15.6, INR 1.6, partial thromboplastin time (PTT) 40.6, all elevated). Poison Control was contacted with recommendations to admit for repeat labs and monitoring. Poison Control also recommended treating with vitamin K administration every 12 hours. Metabolic panel and complete blood count (CBC) were overall unremarkable except for elevated alkaline phosphatase. Admission orders included regular diet, repeat coagulation studies the following morning, enteral vitamin K every 12 hours, and routine vital signs. He did well overnight. Repeat coagulation studies had normalized (PT 10.8, INR 1.0, PTT 27.0). The patient remained on enteral vitamin K supplementation with daily coagulation studies. Repeat coagulation studies remained within normal limits the following day (PT 10.6, INR 1.0, PTT 26.8) and he remained clinically stable. The patient was cleared for discharge in conjunction with Poison Control recommendations.
At issue is the medical necessity for the inpatient stay.

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

No. The patient could have been safely managed at an alternate level of care. This young male child reportedly ingested  rat poison pellets. The active ingredient in rat poison is brodifacoum, a "super warfarin" compound that causes coagulopathy. Patients may present with bleeding and/or abnormal coagulation studies (PT, PTT, INR). Treatment includes administration of vitamin K to reverse the coagulation effects. When this child was initially taken to the ED, his coagulation profile was within normal limits. The family was instructed to return for repeat lab studies, and at that time, his coagulation profile revealed prolongation of PT, INR, and PTT. In conjunction with Poison Control recommendations, he was treated with vitamin K and admitted for close monitoring and serial coagulation studies. While it was medically necessary and appropriate to monitor this child in the hospital, he was overall hemodynamically stable, asymptomatic, with no bleeding. He did not require acute inpatient admission and could have been safely managed at an alternate level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Knee Pain.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a past medical history (PMH) of lung cancer, coronary artery disease (CAD) status/post (s/p) coronary artery bypass graft (CABG), and prior cerebrovascular accident (CVA) on oral anticoagulation (OAC) who was admitted with complaints of (c/o) right knee pain. Her vital signs were unremarkable. The physical exam was notable for no apparent distress (NAD), right knee edema. Lab work was noted for transaminitis, elevated white blood cell count (WBC). Right knee radiographs showed no fracture or dislocation and degenerative changes, an ultrasound (US) of the right lower extremity (RLE) showed no deep vein thrombosis (DVT), a computed tomography (CT) scan of the right knee showed an effusion. The patient was diagnosed with a gouty effusion and treated with prednisone, physical therapy, and pain control. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

No, the hospital stay was not medically necessary at an acute inpatient level of care. The patient presented to the ED with c/o right knee pain. The patient was afebrile, did not appear toxic, had no unstable comorbidities, did not have a limb-threatening infection, there was no septicemia, life-threatening infection, necrotizing fasciitis, did not meet systemic inflammatory response syndrome (SIRS) criteria, there was no animal or human bite with extensive damage, high risk location (face, neck, hand, genitals), pain out of proportion to clinical findings, crepitus, neutropenia, immune-suppression, marked systemic toxicity or worsening symptoms, or inability to take oral medications. This patient was treated with prednisone, physical therapy, and pain control, and this could have been safely provided at a lower level of care, which would allow for frequent reevaluation to assess response to therapy.. Overall, this patient could have been safely treated at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 
The insurer denied comprehensive orthodontic treatment and visits. 
The denial is overturned.

The patient is a female with a Class I malocclusion and a posterior crossbite on the left. She has a mandibular deviation to the left. She had moderate crowding. She is treatment planned for orthodontics to correct her crossbite. Treatment was denied by the health plan on the basis that treatment is not medically necessary. The subject under review is the medial necessity for comprehensive orthodontic treatment and visits.

The health plan's determination is overturned.

The requested treatment is medically necessary. There is strong medical evidence that that early correction of unilateral posterior crossbites with a shift reduces the need for future treatment. This is beneficial for patients that have a crossbite with functional shift making treatment at a younger age the preferable option[1]. This patient presents with a posterior crossbite, crowding, and constricted arches. Therapy should be performed before the patient reaches skeletal maturity, otherwise the ability to achieve orthopedic expansion is greatly reduced[2]. Therefore the requested treatment is medically necessary at this time.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female who presented to the emergency department (ED) with complaints of recurrent, sudden onset of palpitations and shortness of breath associated with sensation of facial and throat tightness. It had resolved by the time she arrived in the ED. In the ED, the patient reported the pain to be 5/10 at rest and with activity. Her blood pressure (BP) was 183/75, heart rate (HR) was 95 beats per minute (BPM), temperature was normal, O2 (oxygen) saturation was 100% (percent). Her physical examination revealed normal general exam without distress, clear lungs and regular rhythm and rate. Abdomen was soft and right arm was slightly edematous.

The requested inpatient hospital admission was not medically necessary for this patient. The patient presented with chest pain, which was suggestive of unstable angina. The patient had multiple coronary risk factors, including hypertension (HTN), diabetes mellitus (DM), HLD (hyperlipidemia) and history of stroke. The patient also had elevated BP upon presentation.

However, her electrocardiogram (ECG) was normal. Her Troponin in series was normal. Her chest x-ray (CXR) was normal. Her echocardiogram, which was done recently, was normal. The patient's BP was controlled with oral medications. Her condition improved and chest pain resolved. Her right arm venous duplex was negative for deep vein thrombosis (DVT).

Based on above, the diagnosis should be "non cardiac chest pain". The patient's condition and level of care provided during this admission did not meet criteria for inpatient hospital admission. A lower level of care would be more appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ovarian Cyst
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is upheld.


The patient presented to the emergency department with complaints of right pelvic pain with nausea and vomiting. She had a history of diabetes and anemia. Her blood pressure was elevated but stable and her lab results showed a slightly elevated white blood cell count of 13.16. A pelvic ultrasound showed a 3.6 centimeters (cm) right ovarian cyst. A computed tomography (CT) scan showed a right ovarian cyst. She was admitted as an inpatient for the ovarian cyst and she had a laparoscopic ovarian cystectomy. After surgery she was doing well and was discharged home. At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient hospital stay is not medically necessary for this patient.

The patient did not need medical inpatient monitoring and could have been monitored under outpatient or extended monitoring. She had no hemodynamic instability and the vital signs were normal. She had no hemorrhage. She had no pulmonary, renal or hepatic dysfunction. The procedure is an outpatient operation without the need for inpatient monitoring. In addition, there were no operative complications such as an infection, hemorrhage, nor pulmonary concerns. She tolerated anesthesia well without complications. She could have had the procedure and then been discharged from the post-anesthesia care unit (PACU) without the need for inpatient admission.