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

Diagnosis: Coronary artery disease. 
Treatment: Repatha Sure Inj (Pre-service). 

The insurer denied the Repatha Sure Inj. 
The denial is overturned. 

The patient is a female with coronary artery disease (CAD), peptic ulcer disease (PUD), and severe dyslipidemia with low density lipoprotein (LDL) cholesterol level on labs of 197 milligrams per deciliter (mg/dL) and total cholesterol level of 267 milligrams per deciliter (mg/dL). The patient had evidence of coronary artery disease (CAD) on cardiac computed tomography (CT) scan, as well as non-obstructive carotid disease. She had prior trials of high intensity statins - atorvastatin and rosuvastatin - which she could not tolerate due to myalgia and they were discontinued. Use of Repatha is being requested. As per the Plan's denial letter, a trial of ezetimibe is required for coverage of Repatha. 

Yes, the proposed treatment with Repatha is medically necessary. 

REPATHA is indicated as an adjunct to diet and maximally tolerated statin therapy for the treatment of adults with heterozygous familial hypercholesterolemia (HeFH) or clinical atherosclerotic cardiovascular disease (CVD), who require additional lowering of low density lipoprotein cholesterol (LDL-C). 

This patient has a known diagnosis of severe hyperlipidemia, and her lipid levels are uncontrolled while not on therapy, as documented by the laboratory tests. Furthermore, prior attempts have been to initiate high intensity statin therapy, which would be required for sufficient lowering of her severely elevated low-density lipoprotein cholesterol (LDL-C), as lower intensity agents or ezetimibe would not provide sufficient control. However both of these agents have not been tolerated by the patient due to myalgia. The patient has documented coronary artery disease, as documented by the cardiac computed tomography (CT) scan. Also, she has coronary artery disease risk equivalent, i.e. carotid disease history.   The patient has atherosclerotic cardiovascular disease (CVD). 

Given the patient's history and the findings as documented in the attached medical records, the patient meets criteria for the use of the requested agent, and thus the use of Repatha in this clinical scenario would be considered to be medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low back pain. 
Treatment: Back surgery, Pre-service. 

The insurer denied the back surgery. 
The denial is upheld. 

The patient is a female with low back pain for several months.  She has tried home exercises, epidural injections, trigger point injections, facet injections/ablations, and medications.  Magnetic resonance image (MRI) of the lumbar spine shows Modic type I and II changes at L4-5 and L5-S1 with facet degeneration and evidence of prior surgery.  Her pain ranges between five and nine out of ten.  The clinical note from the provider states the patient has not had chiropractic or physical therapy.  The attending physician (AP) recommends Intracept (intraosseous ablation of basivertebral nerve) procedure at L4, L5 and S1. 

No, the proposed treatment is not medically necessary. 

There is no evidence present that the patient has had an appropriate course of conservative care including physical therapy.  Without an appropriate course of conservative care, surgery is not warranted. 

This patient has not had an appropriate course of conservative care including physical therapy.  Without a sufficient trial of non-operative treatment, the procedure is not indicated.  The clinical note states the patient has not had physical therapy or chiropractic treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumonia

Treatment inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This is the case of a female patient with a past medical history significant for hypertension, coronary artery disease, status post (s/p) myocardial infarction, s/p stents, and osteoarthritis who presented to the Emergency Department (ED) with complaints of chills, dizziness, nausea, vomiting, and shortness of breath.  Vitals on presentation included: temparture-39.1 Celsius (C), blood pressure-139/55, pulse-64, respiratory rate-24, oxygen (O2) saturation-91% (percent) on room air. Laboratory values were notable for the following: white blood cell (WBC) count-9.12, hemoglobin-12.2, hematocrit-37.5, creatinine-0.76, sodium-125, and glucose-89.

The patient was empirically started on intravenous (IV) antibiotics (Levaquin- due to penicillin allergy) for possible pneumonia. Chest x-ray (CXR) showed streaky airspace opacities noted at the lung bases concerning for multifocal pneumonia. Head computed tomography (CT) scan showed atrophy and chronic microvascular ischemic disease, otherwise, no acute findings. The patient remained afebrile and hemodynamically stable. She was discharged to continue outpatient management. 

According to medical records, the patient presented with fever (39.1 C), borderline bradycardia, and low O2 saturation on room air (91%). Laboratory results were notable for hyponatremia (sodium-125) and CXR findings were suggestive of pneumonia. 

Based on these findings in a high-risk patient with multiple co-morbid conditions, hospital admission was medically necessary for administration of IV antibiotics and other diagnostic evaluation.  

The health plan did not act reasonably with sound medical judgment and 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: Overturned

Diagnosis: Asthma exacerbation
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned. 

The patient is a female with a history of chronic persistent asthma and eczema who presented to the emergency room with severe asthma exacerbation after initial treated at urgent care with nebulized treatment for labored breathing, wheezing, fever and upper respiratory tract infection symptoms.  The patient was treated in the emergency department (ER) with epinephrine, nasal saline, magnesium sulfate, and was hospitalized and discharged with an uneventful hospitalization.

Yes, the proposed in-patient hospitalization was medically necessary.
According to the emergency room triage records, the patient presented with multiple system complaints such as rapid breath with 38-40 breath per minute, labored breathing (which is a sign of rapid decompensation in young patient), and dry skin (a sign of systemic compromise due to volume contraction such as low blood pressure).  She required 100% supplemental oxygen on presentation and use of epinephrine as well as magnesium sulfate.  She also has signs of hemodynamic instability with temperature of 100.3 Fahrenheit.  A white blood cell count of was 22.3 and a predominant neutrophil signifying potential infection source, heart rate of 164 with EKG (electrocardiogram) showing sinus tachycardia. Her pulmonary examination was noted to show bilateral wheezing.   According to the admission history and physical (H&P), the patient's symptoms improved with the initial treatments received in the emergency room.  However, the patient was requiring intravenous (IV) medication due to inability to tolerate oral steroids (vomiting), as well as normal saline administration via intravenous line to prevent volume contraction.  She also required nebulized treatment every two hours.  Based on the criteria for inpatient admission service such as: respiratory distress, bronchospasm or hemodynamic instability, as well as the documented requirement for intravenous fluid support and medication frequency, the level of inpatient admission is medical necessity.

The patient is at high risk of decompensation based on the initial presentation of labored breathing, elevated white blood cell count, fever, tachycardia, and inability to tolerate oral medication, and the requirement for intravenous medication.  The close monitoring and availability for rapid response during inpatient hospitalization post initial treatment is crucial to minimize adverse outcome as well as re-admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary Tract Infection (UTI)

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

This is a patient with past medical history of hypertension, benign prostatic hyperplasia (BPH), status post cerebrovascular accident (CVA), and depression. The patient presented to the emergency department with a 4-day history of fever, nausea abdominal pain, and flank pain. The patient was admitted for further assessment/management. All of the workup suggested that the patient's symptoms were due to a urinary tract infection (UTI). The patient was treated with antibiotics, his symptoms improved, and he was discharged home with instructions to follow up with his Urologist. 

Per Milliman Care Guidelines (MCG) Urinary Tract Infection (UTI), the patient fails to meet clinical indications for admission to inpatient care. There was no hemodynamic instability, altered mental status that is severe or persistent, immune compromised state, urinary systemic illness (Hypotension) or delayed recovery as indicated by ureteral obstruction (stone), renal or perinephric abscess, pyonephrosis, prior stent placement, anatomic abnormality, or transplanted kidney.

The health care plan acted reasonably, with sound medical judgement, and in the best interest of the patient.

The inpatient hospital admission was not considered medically necessary for this patient.

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

Diagnosis: Head Injury

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

The patient fell on the ice with loss of consciousness. The patient presented to the emergency department (ED) where he remained non focal on exam with negative computerized tomography (CT) head and magnetic resonance imaging (MRI) cervical spine. The patient was recommended for physical therapy (PT) and analgesic management and discharged in stable condition.

Root, B. K., et al noted "Compared to hospital admission, observing mTBI [mild traumatic brain injury] patients with minor radiographic findings in the EDOU [emergency department observation unit] was associated with significantly shorter time to interval scanning, shorter length of stay, and lower encounter charges, but no difference in observed clinical outcome. The overall risk of hemorrhagic progression in this subset of mTBI was very low. Using this approach can reduce unnecessary admissions while potentially yielding patient care and economic benefits. When designing a protocol, close attention should be given to clear inclusion criteria and a formal mechanism for patient follow-up." 

The HealthPlan acted reasonably. There are no clear inpatient care needs noted other than observation on date of presentation. The patient had no focal neurological deficits, no hemorrhage or injuries noted on CT head and cervical spine, and even a negative MRI spine. Therefore, the patient remained hemodynamically and neurologically stable, no infection or active bleeding was noted, no drips were needed, no urgent surgery was needed, pain was under control medically. Therefore, the healthcare plan acted reasonably, with sound medical judgment, and in the best interest of the patient.      

There are no clear inpatient care needs noted other than observation on date of presentation. Therefore, the inpatient admission is considered not medically necessary for this 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: Cellulitis.

Treatment full hospital admission.

The insurer denied coverage for full hospital admission.

The denial is upheld.

This is the case of a male patient with a past medical history significant for chronic lymphedema, atrial fibrillation, asthma, and extended spectrum beta-lactamase (ESBL) bacteremia who presented to the Emergency Department (ED) with complaints of right lower extremity swelling and erythema.  Vitals on presentation were temperature (T) 98.6 Fahrenheit, blood pressure (BP) 121/78, pulse 82, respiratory rate (RR) 16, oxygen (O2) saturations 94% (percent) on room air (RA). Laboratory results included white blood cell (WBC) count of 16.2, hemoglobin (Hgb) 13.4, hematocrit (Hct) 40.9, creatinine 0.8, glucose 114, and lactic acid 2.4. 

The patient was started empirically on intravenous (IV) antibiotics (Invanz) for possible lower extremity cellulitis. Cultures remained negative. Urology also evaluated patient for renal calculi. They recommended outpatient cystoscopy and an elective ureteroscopy. Infectious Diseases also consulted and discontinued IV ertapenem. The patient remained afebrile, clinically, and hemodynamically stable. He was discharged to continue oral antibiotics (Linezolid and fluconazole) as an outpatient.
 
According to documentation, the patient presented with possible right lower extremity cellulitis. Otherwise, he remained afebrile, and hemodynamically stable. Laboratory results were notable for an elevated WBC (home medications included prednisone 20 mg (milligrams) daily). The patient had a localized infection, and no surgical intervention was necessary. All cultures remained negative. Infectious Disease consult noted "incidental right lower extremity inflammation which is relapsing issue nut nowhere as severe as on prior admissions... Based on above findings, the patient met criteria for observation level of management. He did not fulfill criteria for acute hospital admission. 

The health plan acted reasonably, with sound medical judgement and in the best interest of the patient.

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

Diagnosis: Small gallstones

Treatment inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

This is the case of a female patient who presented with epigastric pain. She was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. There was no leukocytosis. The liver enzymes were elevated. Imaging revealed a dilated common bile duct (CBD) and small gallstones. Magnetic resonance cholangiopancreatography (MRCP) showed small choledocholithiasis. An endoscopic retrograde cholangiopancreatography (ERCP) was performed with a sphincterotomy and balloon sweep. No complications were reported.

Clinical indications for admission Gallbladder or Bile Duct Inflammation or Stone (M-555) include having acute cholecystitis or acute cholangitis. These conditions need to be indicated both by the presence of stones and systemic signs of inflammation such as fever or leukocytosis. 

In this case, the patient did not have systemic signs of inflammation. She also did not have a calculus causing hemodynamic instability, severe vomiting, severe dehydration, severe pain, or bacteremia.

The patient had small stones in CBD that needed to be removed with an ERCP. This procedure could have been done on an ambulatory basis. She did not have sepsis or acute cholangitis. She did not meet Milliman Care Guidelines (MCG) Criteria for admission for Gallbladder or Bile Duct Inflammation or Stone. 

The healthcare plan acted reasonably and with sound medical judgement. An inpatient admission was not medically necessary.

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

Diagnosis: Obesity, pre-operative evaluation
Treatment: 93458--Heart Catheterization and Ventriculography (Pre-Service)
The insurer denied the 93458--Heart Catheterization and Ventriculography (Pre-Service)
The denial is upheld. 

The patient is a female with a history of obesity, who underwent a nuclear stress test for pre-operative evaluation prior to bariatric surgery. There was a history of burning sensation in her chest. The patient had no chest pain during stress. Stress test revealed no electrocardiogram (ECG) changes, but a small in size, fixed apical defect. Normal wall motion was reported. Cardiac catheterization was requested.

No, the proposed cardiac catheterization with ventriculography (93458) is not medically necessary.

The patient was evaluated with a nuclear perfusion stress test with a finding of a small, mild in severity apical defect with normal wall motion. There was no evidence of ischemia. There was no documented medical therapy for coronary artery disease (CAD). There is no history of any non-invasive anatomic testing, such as coronary computed tomography angiography (CTA), to further assess this finding. Therefore, the medical necessity of cardiac catheterization with ventriculography in this clinical scenario could not be established.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Elevated Blood Pressure

Treatment: inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is upheld.

The patient is an adult female who presented four days after delivery with complaints of high blood pressure and headache. In the triage area, the systolic blood pressures were in the 140s. Laboratory evaluation was within normal limits. The patient was started on a magnesium sulfate drip and Procardia. She was discharged after a period of medical stability. 

This patient presented four days after delivery with elevated blood pressure. Delayed postpartum preeclampsia can be defined as signs and symptoms of the disease leading to readmission more than two days but less than six weeks after delivery.

The diagnosis of preeclampsia is based on the new onset of hypertension and either proteinuria or end-organ dysfunction after 20 weeks of gestation in a previously normotensive woman: 

1)	Systolic blood pressure (greater than or equal to) >=140 mmHg (millimeters of mercury) or diastolic blood pressure >=90 mmHg, and

2)	Proteinuria >=0.3 grams in a 24-hour urine specimen or protein: creatinine ratio >=0.3, or 

3)	Signs of end-organ dysfunction (platelet count (less than) <100,000/microliter, serum creatinine (greater than) >1/1 mg/dL (milligrams per deciliter) or doubling of the serum creatinine, elevated serum transaminases to twice normal concentration).

This patient had elevated blood pressure, no protein in the urine was documented and no elevated liver function tests (LFTs) and no end organ dysfunction. This patient did not have a diagnosis of preeclampsia. She had significant elevation in her blood pressure.

Ideally this patient would have been observed in the Emergency Department (ED). Once her blood pressure was controlled, the patient could have been discharged home on home blood pressure monitoring and to return if any worsening of her blood pressure. Admission to the hospital was not medically necessary. 

The health care plan did act reasonably, with sound clinical judgment, and in the best interest of the patient. An inpatient admission was not medically necessary. 

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

Diagnosis: Family history of Factor V Leiden
Treatment: 81241-F5 coagulation Factor V gene analysis, Leiden variant
The insurer denied the 81241-F5 coagulation Factor V gene analysis, Leiden variant
The denial is overturned

This female has no personal history of thromboembolism, thrombophilia, deep vein thrombosis, or coagulopathy. She has not had an activated protein C level. However, her paternal aunt had right peroneal vein venous thrombosis and an unprovoked left calf vein thrombosis. She is a factor five Leiden heterozygotes/carrier. This patient's uncle has factor five Leiden deficiency as well but no history of clots. Her father carries the factor five Leiden mutation and has had venous clots, as does the maternal grandmother and her father's two siblings, who have a history of venous clots. A paternal great aunt had deep vein thrombosis (DVT) and then multiple venous thromboembolisms after recent spinal surgery at unknown age. Her attending physician (AP) has requested factor five Leiden testing in her to determine her risk of deep vein thrombosis/coagulopathy in the future during pregnancy and delivery and or surgery.

Yes, the health plan should cover the proposed treatment.
The markedly positive paternal family history for the common Factor V Leiden mutation/variant and venous thromboembolism renders molecular genetic testing for Factor V Leiden deficiency in this patient as clinically appropriate.

Yes, the requested health service is more beneficial than any standard treatment for the insured's condition or disease.
Factor V Leiden deficiency is the most common inherited disorder predisposing to venous thromboembolism and thrombosis. The association and causation of Factor V Leiden mutations/variants with an increased risk for venous thromboembolism is well established in the medical literature, is consistently and well supported by authoritative, peer-reviewed, published medical literature, as well as policy statements from the American College of Medical Genetics. 

Therefore, given this patient's markedly positive paternal family history for venous thromboembolism with onset and the relevant medical literature cited below, molecular genetic testing for Factor V Leiden deficiency in her is medically indicated and clinically appropriate and not experimental, investigational, or unproven.