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

Diagnosis: Diabetes Mellitus. 
Treatment: Inpatient Hospital Admission. 
The insurer denied coverage for inpatient hospital admission. 
The denial is overturned. 

The patient is a young adult female diagnosed with type I diabetes mellitus and celiac disease. The patient presented to the emergency room (ER), with complaints of a four (4) day history of chest heaviness. The patient was hyperglycemic. She reported running out of insulin Basaglar three 3 days prior to arrival. The patient reported only using Novolog. The patient was hemodynamically stable. She was admitted with diabetic ketoacidosis (DKA). The patient was placed on an insulin drip. The patient's condition improved after treatment, and she was discharged. 

The patient met diagnostic criteria for Diabetic ketoacidosis (DKA) based on the American Diabetes Association (ADA) and hospital admission guidelines. The patient's blood glucose (BG) was greater than 250 milligrams per deciliter (mg/dl), (greater than 13.9 millimoles per liter (mmol/L)) with: an arterial potential hydrogen (pH) less than 7.35, venous pH less than 7.30, or serum bicarbonate level less than 15 milliequivalents per liter (mEq/L) and had ketonuria and/or ketonemia. 

Specifically, the patient's BG was 341, with a low venous pH of 7.23. She had a low carbon dioxide (CO2) or bicarbonate of 14, and an anion gap of 21. The patient also had elevated beta hydroxybutyric acid levels and required an insulin drip. 

"Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are acute metabolic complications of diabetes mellitus that can occur in patients with both type 1 and 2 diabetes mellitus. Timely diagnosis, comprehensive clinical and biochemical evaluation, and effective management is key to the successful resolution of DKA and HHS. Critical components of the hyperglycemic crises management include coordinating fluid resuscitation, insulin therapy, and electrolyte replacement along with the continuous patient monitoring using available laboratory tools to predict the resolution of the hyperglycemic crisis. Understanding and prompt awareness of potential of special situations such as DKA or HHS presentation in comatose state, possibility of mixed acid-base disorders obscuring the diagnosis of DKA, and risk of brain edema during the therapy are important to reduce the risks of complications without affecting recovery from hyperglycemic crisis. Identification of factors that precipitated DKA or HHS during the index hospitalization should help prevent subsequent episode of hyperglycemic crisis." (Gosmanov, A.R. et al. 2018). 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient hospital admission services is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypersomnia
Treatment: Modafinil 100 mg (milligrams), one tablet by mouth daily for one year.
The insurer denied the Modafinil 100 mg, one tablet by mouth daily for one year.
The health plan's determination is overturned.

The patient is a male who is seeking approval for Modafinil for hypersomnia. The medication was deemed not medically necessary by the health plan because the Multiple Sleep Latency Test (MSLT) did not meet the criteria. A visit noted no concern for obstructive sleep apnea (OSA) and recommended sleep hygiene and polysomnogram (PSG) /MSLT. A polysomnogram (PSG) noted no OSA. A Mean sleep latency of 8.7 minutes was noted. A follow up visit noted idiopathic hypersomnia.

Modafinil 100 milligrams (mg), one tablet by mouth daily for one year is medically necessary per current literature and standard of care. According to Mayer et al., (2015), Inoue et al., (2021), and Trotti et al., (2021), the patient's presentation and testing is most consistent with idiopathic hypersomnia. Modafinil is indicated for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atypical Chest Pain
Treatment: Inpatient admission
The insurer denied coverage for the inpatient admission.
The denial is upheld.

This is a patient with a past medical history of hypertension who presented to the hospital with chest pain after running out of anti-hypertensive medications. The patient reported mid-sternal chest pain radiating to the left jaw, left arm and left leg while preparing food. On arrival to the hospital, the vital signs were blood pressure 188/111 and a pulse of 68 beats per minute. Physical examination revealed no major abnormality. A 12-lead electrocardiogram (ECG) revealed sinus rhythm with no evidence of ischemic ST (interval on ECG) or T (interval on ECG) wave abnormalities. Serum troponin levels were not elevated (<0.01 nanogram/milliliter) and computed tomography (CT) chest revealed no evidence of pulmonary embolism or aortic dissection. Echocardiogram demonstrated a normal left ventricular ejection fraction (LVEF) with no evidence of valvular abnormalities. The patient was treated with antihypertensive medication and was discharged with cardiology follow up.

Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati et al. (Reference 3). This patient presented with atypical chest pain and hypertension. The patient's pretest probability of coronary artery disease was low (Reference 1). Utilizing the HEART (history, ECG, age, risk factors, troponin) score, the patient was considered low risk (Reference 2). Utilizing the TIMI (thrombolysis in myocardial infarction) risk score, the patient also had a low risk of developing major adverse cardiac events in the subsequent 30 days (Reference 3). 
Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death in the six weeks following presentation. Using the TIMI risk score, this patient would have a low risk of major cardiac events (myocardial infarction, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation. In conclusion, an inpatient admission was not medically necessary. This patient could have been treated at a lower level of care. 

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

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

Diagnosis: Acute left dysmetria
Treatment: Inpatient admission
The insurer denied coverage for the inpatient admission.
The denial is upheld.

This case involves an adult male who presented to the emergency department complaining of hypertension and numbness. He had a past medical history significant for immunocompromised status with an undetectable viral load along with hypertension, and hyperlipidemia. He complained of one day of left dysmetria and reported that his blood pressure at home was 144/89. He took his blood pressure medication [amlodipine 5 milligram (mg)] and his abdomen subsided. He claimed to have weakness at the time of dysmetria, but this also subsided after blood pressure medications. He denied headache, blurry vision, slurred speech, with no other extremity involvement. He was symptom-free upon arrival at the emergency department. The report stated that blood pressure was 157/111, cranial nerves II through XII are intact with motor strength and sensation intact throughout. Computed tomography (CT) of the head was negative. A neurology consult placed. The patient was subsequently admitted for further work-up and treatment to include continuing telemetry monitoring, monitoring vital signs closely, frequent neuro checks, obtaining a magnetic resonance imaging (MRI) scan of the head, magnetic resonance angiography (MRA) of the head and neck, carotid Doppler and echocardiogram. The use of aspirin, Plavix, and Lipitor were recommended. He would also undergo physical and occupational therapy evaluations.

According to the Milliman Care Guidelines, hospital admission was not medically necessary. The patient did not meet criteria for acute level of care based upon his presenting symptoms to the emergency department. While the appeal letter claimed that further work-up cannot have been completed in an outpatient setting, the information provided for the review did not support that the patient was displaying any significant abnormalities that would justify inpatient care. His work-up and treatment could have been rendered on an observational basis and even an outpatient basis with the opportunity to upgrade the patient to inpatient status should the need arise. However, given that the patient symptoms had resolved before he presented to the emergency department and he responded to the use of blood pressure medications, he did not require admission throughout the timeframe of question.

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.

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

Diagnosis: Uveitis. 
Treatment: Humira 40 milligram (mg), quantity exception. 

The insurer denied coverage for Humira 40 mg, quantity exception. 

The denial is upheld. 

The patient is reported to have been receiving treatment with Humira 40 mg every other week, with good effect. Humira Pen - psoriasis/uveitis 40 mg/0.4 milliliters (mL) every week is requested. 

The insurer has denied coverage for Humira 40 mg, quantity exception. In their denial letter, they write that the requested quantity, Humira 40 mg weekly, exceeds the plan-approved limit. The plan will cover Humira 40 mg every other week for a duration of 12 months. 

The current Food and Drug Administration (FDA) approved dose of Humira for uveitis is 40mg every other week. The clinical trials (1, 2, 3) used to assess Humira in patients with non-infectious uveitis, Humira was dosed at 40mg every 2 weeks. (Jaffe 2016, Nguyen 2016, Suhler 2018) Immunomodulatory therapy like Humira is currently the recommended treatment for uveitis by the American Uveitis Society and other authorities in the field. Although it is generally given as 40 mg/0.8mL every 2 weeks, this can be increased to 40 mg/0.8 mL weekly in cases of refractory uveitis. (Liberman 2020). 

Provider documentation noted that the patient has had a good response at this dose of Humira 40mg every other week. There is insufficient evidence to support the need to increase the dose of Humira to weekly. 

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 Humira 40 mg, quantity exception is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Low Back Pain. 
Treatment: Pain treatment (implantation of spinal neurostimulator - procedure code 63655). 

The insurer denied: Pain treatment (implantation of spinal neurostimulator - procedure code 63655). 
The denial is overturned. 

The patient is an adult female. She presented with back and right leg pain. The patient attempted multiple non-surgical treatments without improvement. The patient had a spinal nerve stimulator trial, which provided 50% pain relief. Her exam reveals no focal deficits. MRI (magnetic resonance imaging) shows levoscoliosis, and positive sagittal balance with severe spinal L4-5 stenosis. The patient was recommended implantation of a dorsal column stimulator for chronic pain. 

The requested Pain treatment (implantation of spinal neurostimulator - procedure code 63655) is considered medically necessary. 

The patient has multiple causes for pain, including scoliosis, positive sagittal balance, and stenosis. During the attempted spinal cord stimulator trial, the patient had 50% pain relief, which is a significant amount, considering the significant pathology in her spine. Due to her improvement with a spinal cord stimulator trial, it is appropriate and medically necessary to allow her to undergo a permanent SCS (spinal cord stimulator) placement. This patient has demonstrated improvement with the placement, and therefore, should benefit from permanent placement of the SCS (spinal cord stimulator).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Hypertensive crisis.
Treatment:  Inpatient admission.

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

The patient was an adult who presented to the hospital complaining of headache, lightheadedness and palpitations. Past medical history was significant for hypertension. Upon arrival to the hospital the patient was hypertensive with a blood pressure (BP) of 224/117 and pulse was 61. Physical exam revealed no abnormalities. A 12 lead electrocardiogram showed normal sinus rhythm with left ventricular hypertrophy and non-specific ST- T wave abnormalities. Serum blood testing revealed acute renal insufficiency with creatinine 1.39 and hyperglycemia (197). The patient was treated with multiple doses of intravenous labetalol and hydralazine therapy. Despite this, blood pressure remained elevated, and a nitroglycerin infusion was initiated. The patient was then admitted to the hospital for treatment of hypertensive crisis. 

Hypertensive emergency is defined as BP greater than 180/120 with target organ damage. (Reference 1) In this patient, creatinine was elevated consistent with acute renal insufficiency and target organ damage. The goals of treatment of hypertensive emergency are to minimize progressive or additional target organ damage while preventing consequences associated with rapid BP correction. (Reference 2) Given this patient's failure to respond to initial medical therapy, admission to the hospital for aggressive blood pressure management was necessary. 

American Heart Association guidelines recommend admission to the intensive care unit (ICU) for management of hypertensive emergencies. (Reference 1)

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

Diagnosis: Chronic obstructive pulmonary disease (COPD)
Treatment: Personal Care Aide (PCA): 12 hours per day - 7 days per week - for a total of 84 hours per week
The insurer denied the Personal Care Aide (PCA): 12 hours per day - 7 days per week - for a total of 84 hours per week.
The denial is overturned.

The patient is a male with a with a past medical history of chronic obstructive pulmonary disease (COPD), oropharyngeal cancer and osteoarthritis who had been assigned personal care services.

The patient underwent assessment, he was assessed as maximal assistance with meal prep, total dependence with housework; maximal assistance with managing medications, maximal assistance with bathing, personal hygiene, dressing upper body, dressing lower body, walking, toileting transfers, maximal assistance with toilet use, maximal assistance with bed mobility and extensive assistance with eating. He is frequently incontinent with bladder and occasionally incontinent with bowel. It was noted that he has had worsening bladder and bowel incontinence. Activities of daily living (ADL) status in the last 90 days has declined, with deterioration in self-sufficiency. No falls in the last 90 days. He is on pureed diet with thickened liquids. He was noted with 2 small pressure ulcers in sacrum and buttock.
His physician wrote a letter of medical necessity stating that patient has been in the hospice program for laryngeal cancer and is hard of hearing. Physician stated that patient will benefit from an increase in aide services because he needs turning and positioning every 2 hours to avoid further skin breakdown and to assist with ADLs. The physician also stated that patient lives with an elderly friend who cannot provide sufficient assistance.

This review is for the medical necessity of request to increase in Personal Care Aide (PCA) services for a total of 84 hours per week.

The health plan's determination is overturned.

The requested service of increase in Personal Care Aide (PCA) services for a total of 84 hours per week is medically necessary for this patient. The patient requires maximum assistance to total dependence for all ADLs and instrumental activities of daily living (IADLs). The patient has had a decline in functional status as shown in the tasking tool, now requiring more hands on assistance for all tasks. The patient does not have readily available informal caregivers. Additionally, the patient has pressure ulcers and requires assistance with bed mobility, thus requiring frequent turning to prevent worsening of skin ulcers and to avoid development of new ulcers. Additional hours are medically necessary to enable the patient to remain in the community.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pelvic Recurrence of Rectal Adenocarcinoma
Treatment: Continued Inpatient Admission
The insurer denied coverage for continued inpatient admission.
The denial is upheld.

The patient presented to the hospital for elective surgery after pelvic recurrence of rectal adenocarcinoma. The patient underwent an open abdominoperineal resection, hysterectomy, and posterior vaginectomy. Clinical notes noted that subacute rehab was recommended for the patient, however they were being optimized for home physical therapy. Clinical examination notes indicated that cefadroxil and Flagyl were started for incisional redness. However, there is no indication of wound complications on physical examination. Clinical examination noted "blanching fullness, induration in anterior aspect of left mons." Clinical management remained the same, and the patient continued to participate in physical therapy. The patient underwent an incision and drainage of the wound. There were no reported complications after the procedure. The patient was discharged. 

Per Milliman Care Guidelines (MCG) Health Wound and Skin Care: Common Complications and Conditions, inpatient admission is necessary for clinically significant infection with vital sign abnormality or when procedure or treatment is required, such as percutaneous placement of closed-suction drains. [1] Surgical site infections complicate the course of recovery and increase postoperative morbidity and mortality. Management may include hospital admission, intravenous antibiotics, and sometimes surgical reintervention. [2] Surgical site infections have been shown to increase hospital costs. Early management and intervention have been shown to decrease inpatient length of stay and morbidity and mortality rate. [3, 4] 

The patient met criteria for initial inpatient admission due to the initial surgical procedure. There is no clinical documentation to support continued admission. 

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 inpatient services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes.
Treatment: Tradjenta.
The health plan denied Tradjenta.
The determination is overturned.

The patient has stage 3 chronic kidney disease and type 2 diabetes. The request is for continuation of Tradjenta. The request was denied as the patient has not tried and failed Nesina. The provider is appealing this determination as this patient has stage 3 chronic kidney disease. At issue is the medical necessity of Tradjenta.

This requested Tradjenta is not medically necessary. Per the Nesina prescribing information, chronic kidney disease is not a contraindication to the use of Nesina. Nesina does require adjustment of dosing based on renal function. The Nesina dose for moderate renal impairment, for example, is 12.5 milligrams (mg) once daily. The American Diabetes Association clinical guidelines do not recommend the use of Trajdenta over Nesina, which is expected to have similar safety and efficacy in this clinical situation. Therefore, the requested Tradjenta is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rashes
Treatment: Panniculectomy (excess skin removal)
The insurer denied: Panniculectomy (excess skin removal)
The denial is: Upheld

The patient is a male who has lost over 100 pounds following bariatric surgery. He complains of skin laxity and an abdominal pannus. He has discomfort, sweating and occasional rashes treated with over-the-counter (OTC) creams. His surgeon recommends panniculectomy. The subject under review is the medical necessity for panniculectomy.

The health plan's determination is upheld.

No. The panniculectomy (excess skin removal) is not medically necessary. The medical records do not provide documentation in the form of primary care physician (PCP) or dermatology progress notes that describe ongoing clinically significant dermatologic problems that have either never responded to physician directed topical therapy or despite initial response, have recurred and caused significant functional impairment. Supervised medical management for rashes is not documented in any of the progress notes. The patient is not sick from the excess skin, and has not had ulcerations, panniculitis or sepsis from infections. A dermatologist has not evaluated the rashes. The patient has not required hospitalization or treatment with intravenous (IV) or oral antifungal or antibiotic medications. The excess skin has not jeopardized health.

Physician supervised treatment is the simplest, safest method of managing this patient's problems, and conservative treatment with appropriate hygiene and topical medications has a reasonable likelihood of correcting the condition. In a multiple regression analysis of postoperative complications after body-contouring surgery written by Parvizi et al the authors found that the overall rate for major complications that required operative revision and/or antibiotics was 10.2%. In addition, 41% had minor complications, such as seromas, hematomas, wound healing problems, and wound dehiscences. Therefore, in accordance with the standard of care, conservative, non-operative treatment would be recommended, such as improved hygiene, topical creams or powders, and watchful waiting. Surgical lipectomy should be reserved for patients that have failed optimal medical management for intertrigo, which is not documented to be the case for this patient. Summary treatment letters and member appeal testimonies in the absence of physician office note documentation of specific dates of treatments and medications prescribed do not provide sufficient documentation to confirm the failure of medically supervised care.