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

Diagnosis:  Obesity.
Treatment:  Wegovy 2.4 mg (milligrams)/0.75 ml (milliliter) pen injector.

The insurer denied the Wegovy 2.4 mg (milligrams)/0.75 ml (milliliter) pen injector.  The determination is upheld.

This is a female patient with a past medical history of fibromyalgia, obstructive sleep apnea (OSA), obesity, gastroesophageal reflux disease (GERD), sacroiliitis, chronic kidney disease stage II, hypertension, gout, and hypothyroidism, who had been approved for treatment with Wegovy. The insurance approval stated recertification would require continued physician verified 5 percent (%) weight loss, as well as continued participation in a complete weight management program. The insurer sent an initial adverse determination for coverage of Wegovy 2.4/0.75 pen injection, stating the policy for coverage states the patient's physician must show that the patient has had continued 5% weight loss every 6 months, for up to a maximum of 2 years of therapy. In addition, the denial stated the patient's body mass index (BMI) must still be 27 or more, and the patient must still be enrolled in a qualified complete weight management program. Notes from insurer stated the provider's appeal stated the patient weighed 160 pounds, and the current weight was 154, which was a reduction of 3.75%. The insurer sent a final adverse determination continuing to deny coverage for Wegovy 2.4 milligrams (mg) /0.75 milliliters (ml).  At issue is the medical necessity for Wegovy.

The services are not medically necessary.

The patient had not lost greater than 5% of weight in a 6-month period of time. The drug policy stated for continued coverage of Wegovy 2.4 milligrams (mg)/0.75 ml the patient must maintain a weight loss of greater than 5% over a 6-month period of time, which did not occur. "If a patient responds well to a weight loss medication and loses 5 percent or more of their body weight after three months, the medication should be continued. If the medication is ineffective or the patient experiences side effects, the prescription should be stopped and an alternative medication or approach considered" (4).  Furthermore, it is the industry standard to assess successful weight loss with any intervention by having a weight loss of 5% or more in 3-6 months.  It is not medically necessary for the patient to continue Wegovy 2.4 mg/0.75 ml.
Appeal type: Medical necessity
Decision: Upheld

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

This is the case of an adult who as per the triage note presented to the emergency department (ED) with abdominal pain. Vital signs were stable, and the patient was afebrile. The patient came from home and was sent in by her primary doctor for complaints of (c/o) mild abdominal pain with nausea for 2 (two) days. The patient denied vomiting or diarrhea. As per the ED (emergency department) provider note, the patient had a gastric bypass and has a history of gastritis and cholecystectomy and presented to the ED (emergency department) complaining of epigastric burning pain with nausea for the past 2 (two) days. The pain was non radiating and not associated with vomiting or decrease in appetite. The patient was currently on omeprazole. Exam revealed the abdomen to be soft with minimal tenderness. The plan was labs, computed tomography (CT) of the abdomen and nothing by mouth (NPO).

Labs were unremarkable. CT (computed tomography) of the abdomen revealed no evidence of mechanical obstruction or acute inflammatory disease. There were several mildly enlarged likely reactive mesenteric lymph nodes with mild dilation of several jejunal loops which may reflect acute enteritis.

The provider noted that the family did have suspected gastroenteritis last week with a bout of nausea and diarrhea. She recovered but now presented with 2 (two) day history of epigastric pain, burning quality. She attempted liquid intake, but it was very limited by worsening epigastric burning sensation. Exam revealed mild tenderness in the epigastrium but otherwise normal. The provider noted that lab and vitals were reassuring. The plan was to admit to bariatric surgery, telemetry, NPO (nothing by mouth), Gastroenterology for endoscopy in the morning.

Gastroenterology saw the patient and noted that the last Esophagogastroduodenoscopy (EGD) was done earlier this year prior to gastric bypass and the patient stated it was normal. EGD (Esophagogastroduodenoscopy) was done and showed a marginal ulcer.

Progress note stated that the patient was tolerating clear liquids with minimal pain. No severe pain, nausea or emesis was noted. The plan was Carafate and proton pump inhibitors (PPI) with follow up in the office in 2 (two) months for repeat EGD (Esophagogastroduodenoscopy). The patient was discharged.

Based upon the records the full inpatient admission was not justified as this patient could have been managed in an ambulatory/observation setting. She presented for abdominal pain and the question of marginal ulcer was confirmed by endoscopy. She did not have an acute abdomen and once the diagnosis was made, she was discharged the following day. She did not need any inpatient admission but rather observation. 

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 the full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis of Knee.
treatment: Orthovisc (Hyaluronan or Derivative).
The insurer denied Orthovisc (Hyaluronan or Derivative). 
The health plan's determination is upheld. 

This case describes a female patient with a complaint of bilateral knee pain. Magnetic resonance imaging (MRI) scans of both the right and left knee were completed which confirmed advanced bilateral knee osteoarthritis. The patient had undergone prior Hyalgan injections for both knees. Her orthopedic provider recommended performing Orthovisc injections for both knees. The health plan denied coverage for these injections stating that they are not medically necessary.

The requested Orthovisc was not medically necessary for this patient. This determination is based upon the documentation in the provided records and the recommendations of the peer-reviewed literature. The records document that this female patient has a diagnosis bilateral knee osteoarthritis. The provided records do not document any conservative treatment modalities offered to the patient such as oral medications, activity modifications, or physical therapy as recommended by Brophy and colleagues in the most recent American Academy of Orthopedic Surgeons Guideline on the management of osteoarthritis of the knee. Thus, the medical necessity of the Orthovisc injections is not established.
Appeal type: Medical necessity
Decision: Upheld

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

This is a female patient who presented to the emergency department (ED) with upper abdominal pain of 2-days duration. She had been seen in an ED the day prior to this presentation but left prior to treatment. Comorbid health conditions included bipolar disorder and fibromyalgia. At the time of presentation, the patient was without a fever and her vital signs were normal. She had tenderness in the right upper quadrant. The white blood cell (WBC) count was normal at 6.5 thousand (K). The complete metabolic panel identified elevated liver enzymes and bilirubin. An abdominal ultrasound showed gallstones within the gallbladder and no gallbladder wall thickening. The common duct was 0.4-centimeters (cm). She was admitted to the hospital with the diagnosis of cholecystitis and was started on intravenous (IV) antibiotics.
The patient was evaluated with a surgery consultation. Magnetic resonance cholangiopancreatography (MRCP) was performed showing mild intrahepatic duct dilatation, no common duct dilatation, and no common bile duct stones. The patient underwent a laparoscopic cholecystectomy. The operation was performed without complication with findings of cystic duct stones and acute/chronic cholecystitis. The patient's diet was advanced following surgery and her pain was controlled with oral medications. The patient remained clinically stable and was discharged from the inpatient setting with planned short term surgical follow up. At issue is the medical necessity of an inpatient stay.

An inpatient level of care was not medically necessary in this case.
This patient presented to the hospital with abdominal pain. She was determined to have cholelithiasis/cholecystitis. Initial lab data identified elevated serum transaminases and bilirubin. MRCP showed no common duct stones and surgery was performed. The patient had consistently normal vital signs and white blood cell count (WBC) count. She did not require additional intervention such as endoscopic common duct stone extraction. There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care. Additionally, there is no documentation of failure to achieve discharge criteria, conversion to open surgery, care for comorbidities, or any other condition requiring inpatient admission. The indication for cholecystectomy was established. Following a thorough diagnostic evaluation, she underwent surgery to remove the gallbladder. The patient responded favorably to treatment and was stable for discharge from the hospital on the first post-surgical day, with planned follow up. Acute inpatient care was not medically necessary for this patient as the care and treatment provided could have been rendered with a lower level of care. A lower level of care would have provided for ED assessment, surgical assessment and monitoring, imaging, laparoscopic cholecystectomy, provision of IV antibiotics and fluid, and overnight care.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: Class I occlusion
Treatment: braces/monthly visits
The insurer denied braces/monthly visits. The health plan's determination is upheld. 

The patient in question is a young male with a Class I occlusion. He has 4 millimeter (mm) overbite and 4 mm overjet. He has minor maxillary and severe mandibular crowing. He is treatment planned for Braces and Monthly Visits to correct his malocclusion. 

Braces and monthly visits are not medically necessary.
There is no medical reason to correct his malocclusion with braces. The patient does have a deep bite, however, that alone is not a medical necessity to treat. There are functional problems that can occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. This patient presents with none of those conditions. The photographs do not illustrate any damage to the teeth or soft tissue damage from their current position. The patient has a slightly excessive overjet but this amount of overjet does not negatively affect oral health related quality of life. If his teeth were aligned it would provide an esthetic improvement but it would not create a medically significant improvement to the patient's health. Therefore, the Orthodontic treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's disease
Treatment: Rinvoq
The insurer denied Rinvoq.
The health plan's determination is overturned. 

This patient is a young male with a history of Crohn's disease and atopic dermatitis. He has tried and failed numerous therapies, including Humira and Stelara. He is being considered for bowel resection.

Rinvoq is medically necessary for this patient. The off-label use of this class of medications in refractory cases of inflammatory bowel disease in children is reasonable/appropriate. This patient has a severe and refractory case of inflammatory bowel disease and atopic dermatitis. He has already tried and failed every possible therapy. The use of Rinvoq in this case is reasonable and can help this child avoid bowel resection. Rinvoq is FDA (Food and Drug Administration) approved for atopic dermatitis, which is present in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Clippers
Treatment: Inpatient rehabilitation
The health plan denied inpatient rehabilitation.
The denial is overturned.

The patient is a male child with history of Clippers, a rare neuroimmune disorder characterized by chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids. This disorder affects brainstem, cerebellum and spinal cord and manifests itself with ataxia, spinal cord dysfunction and behavior aberrations.

The child has been followed by a transdisciplinary group of practitioners in a tertiary academic medical center for foot-drop gait and proximal weakness. An inpatient rehabilitation option has been contemplated, but it was not approved. Hence, the child has been receiving outpatient therapy. Medical records point out a continuation of symptoms including clumsiness and fatigue. The child had positive findings on MRI (magnetic resonance imaging) scan of the brainstem and spinal cord.

In this case of a child with a rare medical disorder affecting central nervous system and gait, he has been evaluated by the qualified and skilled providers for the purposes of inpatient rehabilitation options. Clinical records contain specific information that qualify this child to receive inpatient rehabilitative interventions. The child is capable of sustaining at least 15 hours of skilled therapeutic interventions in structured settings under supervision of a pediatric physiatrist. The child will require medical supervision for the treatment of the rare neuroimmune disorder. The child has both short- and long-term goals in rehabilitation. Clinical records clearly demonstrate the need for structured rehabilitation including but not limited to skilled physical and occupational therapy interventions. Lower level of care did not lead to improvement in functional abilities.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Asthma
Treatment: Alvesco (ciclesonide)
The health plan denied the request for Alvesco (ciclesonide).
The determination is upheld.

This is a patient with a history of asthma. The request is for Alvesco (ciclesonide). This is preferred due to lactose allergy and a concern for bone health.

The health plan's determination is upheld in whole, as Pulmicort can be used.

"Asthma is characterized by variable airway obstruction, airway hyperresponsiveness, and airway inflammation. Management of persistent asthma requires avoidance of aggravating environmental factors, use of short-acting 2-agonists for rapid relief of symptoms, and daily use of inhaled corticosteroids. Other controller medications, such as long-acting bronchodilators and biologics, may be required in moderate and severe asthma. Patients with severe asthma generally benefit from consultation with an asthma specialist for consideration of additional treatment, including injectable biologic agents" (McCracken, et al, 2017).

While she has a lactose allergy, the Pulmicort package insert does not indicate that it contains lactose. There is a lack of robust studies to show that Alvesco is more effective.
Flovent does contain lactose and would have adverse effects.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient is a male with a past medical history significant for bipolar disorder, seizure disorder, intravenous drug abuse, and opioid dependence on methadone maintenance therapy who presented to the emergency department with complaints of right-hand pain, redness, and chills.

Vitals on presentation included a Temperature of 98.3 degrees Fahrenheit, blood pressure115/72, pulse 75, respiratory rate18, oxygen saturation of-98% on room air. Laboratory results included a white blood cell count of-12.3, hemoglobin-13.2, hematocrit-39.8, creatinine-1.0. 

The patient was started empirically on intravenous (IV) antibiotics (vancomycin and ceftriaxone) for hand cellulitis. X-ray of the hand showed mild osteoarthritis of the interphalangeal joints. Hand Surgery evaluated the patient and deemed no surgical intervention was required since there was "no evidence of deep space infection or gas at this time." The patient remained afebrile (without fever), hemodynamically stable, and clinically improved. The patient "eloped" from the hospital.

Based on the documentation, there was no evidence of a disseminated infection, the patient was able to tolerate oral intake, and no surgical intervention was deemed necessary. Based on these findings, patient did not meet criteria for acute care hospitalization. The patient met criteria for observation level of management.

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

Diagnosis: Missed abortion. 
Treatment: Inpatient admission. 

The health plan denied inpatient admission. The denial is upheld. 

The patient is an adult G2P0101 (2 pregnancies, one preterm delivery, one living child, currently pregnant) female. She was referred to the emergency department from her physician's office due to a missed abortion. The pregnancy was 14 weeks 4 days based on the last menstrual period and the fetus was 11 weeks' size with no fetal heart activity, which would normally be visualized at this point. She had experienced some vaginal bleeding and spotting, which had resolved.

The patient was taken to the operating room, where a suction dilitation and curretage was performed without complications. Her postoperative course was uncomplicated, and she was discharged the day of admission.

The health plan contends that the admission was not medically necessary. The facility contends that the admission was medically necessary due to need for emergent surgical intervention.

The presentation and clinical course including the surgical procedure and postoperative course were entirely uncomplicated. Surgical intervention for early missed abortion is typically and safely performed on an outpatient basis unless significant maternal co-morbidities are present or complications occur and neither were present with this case. Therefore, the inpatient admission was not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: fever/diarrhea.
Treatment: inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

This is the case of a young male who presented to the emergency department (ED) with fever and diarrhea. Symptoms began 5 days prior. There was some associated vomiting at symptom onset.
The ED vitals were T (temperature)101.1oF (Fahrenheit) rectal, heart rate (HR) 106, respiratory rate (RR) 26, and O2 (oxygen) saturation 97% on room air. The exam was unremarkable. The patient was given Zofran and oral fluids which were not tolerated. Therefore, he was started on intravenous fluids (IVF). Labs showed COVID and Adenovirus positive, bicarb=16, and urine with specific gravity (SG)=1.032. Due to the continued refusal of oral intake, the patient was admitted to the hospital for overnight IV(intravenous)hydration.

The inpatient hospital admission was not medically necessary. A lower level of care was appropriate. This patient presented with gastroenteritis and dehydration. Vital signs showed an initial fever but were otherwise stable. Labs supported mild to moderate dehydration. The ED notes indicate initial disposition to home; however, the patient was admitted due to refusal to take fluids orally. Given the patient's well appearance, stable vital signs, and uncomplicated medical history, this case could have been handled at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is Upheld

This is an adult female patient with a history of asthma, gastric sleeve, and anxiety who was recently diagnosed with deep vein thrombosis (DVT) and was using anticoagulation therapy. The 
patient presented with dizziness which changed with position. The patient had nausea / vomiting, diarrhea and lightheadedness. The patient's esophagogastroduodenoscopy (EGD) 2 years ago had shown esophagitis, erosive and gastritis. 
In the emergency room, the patient's vital signs were as follows: blood pressure (BP) 97/62, heart rate (HR) 68, respiratory rate (RR) 20, oxygen saturation (SpO2) 100 percent, and temperature (T) 95.5. The labs were as follows: white blood cell (WBC) count 4.5, hemoglobin (Hgb) 6.9 (baseline 9.0 per patient), hematocrit (Hct) 20.3, and platelets 104. Two units of packed red blood cells (RBCs) were ordered. Gastroenterology was consulted. The anticoagulation was held. Six months ago, the patient underwent esophagogastroduodenoscopy which showed one linear esophageal ulcer, diffuse mildly erythematous mucosa without bleeding in the gastric body, and normal duodenum. Colonoscopy was unremarkable. The diet was advanced, and the plan was for proton pump inhibitor (PPI) therapy for one month.

The proposed treatment was not medically necessary.

The medical records do not support that the acute inpatient admission was medically necessary. The patient did not require services of such intensity that could have been safely and effectively provided only on an inpatient level of service. The health, safety, and medical condition of the patient would not have been threatened by providing the care given in a lower level of care setting. The patient did not require any surgical intervention, did not have active and ongoing bleeding, did not have any high-risk endoscopic features (i.e., risk for re-bleeding) on upper endoscopy, did not have intolerance to oral intake, and did not require further monitoring after undergoing esophagogastroduodenoscopy and colonoscopy. Therefore, acute inpatient admission was not medically necessary.