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

Diagnosis: Lower Abdominal Pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld. 

The patient was seen with complaint of fever and lower abdominal pain. The patient was 24.3 weeks gestation. The plan was to admit the patient for treatment for possible pyelonephritis. However, the patient signed out against medical advice (AMA). The patient returned the following day for evaluation. The patient reports no fever but was still complaining of pain on urination. A urine culture from two days prior was negative. The patient was afebrile. Coronavirus disease (COVID) testing was negative. The patient was admitted for observation. The patient was started on intravenous (IV) antibiotics with a presumed diagnosis of pyelonephritis. The patient was later discharged home.

It is unclear why the patient was admitted.

Acute pyelonephritis is suggested by the presence of flank pain, nausea/vomiting, fever (greater than (>) 38o (degree) Celsius or 100.4o Fahrenheit), and/or costovertebral angle (CVA) tenderness, with or without the typical symptoms of cystitis, and is confirmed by the finding of bacteriuria in the setting of these symptoms. This patient on presentation was afebrile. Urine culture was negative.

There was no elevated neutrophil count, flank or CVA tenderness, and no bacteriuria in the urine. The patient could have been hydrated and observed. Once the provider ascertained that there was no evidence of pyelonephritis, the patient could have been sent home on oral antibiotics. Admission to the hospital was not medically necessary.

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 admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psychosis, Dehydration

Treatment: Inpatient admission

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

This patient reportedly was admitted to this inpatient hospital reportedly was brought in by police and ambulance due to physical aggression as they were chasing 4 police officers with a knife and had to be tased 4 times, had severe agitation, psychotic symptoms including disorganized thinking, speech, and behavior, delusional thoughts, poor impulse control, fluctuating mental status, and poor insight and judgment. The patient reportedly also had dehydration, acute renal failure, high anion metabolic acidosis, hypokalemia, elevated creatinine and magnesium, elevated creatine kinase (CK), and rhabdomyolysis secondary to crack/cocaine use. The patient reportedly had a diagnosis of Schizophrenia and cocaine use disorder and had a positive toxicology for cocaine and cannabis. The patient also reportedly had a history of alcohol use. The patient reportedly had a recent hospitalization. The patient reportedly was arrested and in police custody while in the hospital, as police were present in their room. The patient reportedly had past drug overdoses and withdrawal syndromes. The patient reportedly received intravenous (IV) Haldol and IV Ativan as well as IV fluids. The patient reportedly was taking Abilify Maintena, Naltrexone, and Venlafaxine. The patient reportedly had psychiatric consultation and eventually was medically cleared for discharge and was discharged to police custody then.

The insurer denied coverage for inpatient hospital treatment as not medically necessary treatment then. They stated that all the testing in the emergency department (ED) did not identify a condition requiring 24-hour hospital treatment then. They recommended a less restrictive level of care then.

The medical records provided did support that the patient could not care for themselves and was considered a danger to others and self, and that they had severe psychiatric symptoms including disorganized thinking, speech, and behavior, delusional thoughts, physical aggression, severe agitation, fluctuating mental status, rhabdomyolysis secondary to cocaine use, had past drug overdose and withdrawal symptoms, active medical issues, and a past recent hospitalization a few days prior to this admission so this patient required inpatient hospital treatment. It did not appear that the insurer acted reasonably, with sound clinical judgment, or in the best interests of this patient then.

Based on the above, the insurer's denial must be reversed. 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 an inpatient is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary tract infection, COVID 19
Treatment: Inpatient Hospital Stay

The insurer denied Inpatient Hospital Stay.  The determination is upheld.

The patient is a female with a history of hypertension (HTN) who presented to the emergency room (ER) with complaints of nausea, vomiting, fevers, myalgias, and a cough. 
Labs showed a positive coronavirus disease (COVID) test, a urinalysis (UA) showed small leucocytes, potassium (K) 3.2, blood glucose (BG) 222. She received intravenous (IV) Rocephin, IV (intravenous) fluids and Decadron 16 milligrams (mg). The oxygen saturation on room air (RA) was 100 percent (%), a chest x-ray (CXR) was normal, the white blood cell count (WBC) was normal, the lactate was 1.2. She was subsequently admitted with diagnoses of acute encephalopathy secondary to urinary tract infection (UTI) versus COVID rule out (r/o) encephalitis. Infectious disease (ID) was consulted, and intravenous (IV) fluids continued, and additional labs were ordered. She was seen by ID and started on Paxlovid, pulmonary embolism (PE) was also ruled out. Throughout the stay, her WBC was normal, and she remained on room air (RA). Her UTI was treated with Rocephin; she was also started on Lisinopril for HTN. She was subsequently discharged home.
An inpatient stay was not medically necessary. Care and management could have been safely and appropriately rendered at a lower level of care.
The patient presented with a cough, fever, myalgia and was noted to be drowsy; however, she was able to give a full history, follow commands and had a normal neurologic exam. She was found to have a positive COVID test without the need for oxygen and no infiltrate on CXR. ID had, therefore, recommended Paxlovid. She was noted to have a UTI, had no evidence of pyelonephritis and a normal WBC, was not vomiting and was able to take medications orally. Throughout her stay, she was hemodynamically stable, AAO (awake, alert and oriented), had no oxygen needs, no mental status changes, normal WBC, normal lactate level, improvement in the HR after fluids in the ER and no clinical evidence of encephalitis.
As a result, care at an inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Type 2 Diabetes Mellitus
Treatment: Mounjaro.
The insurer denied Mounjaro.
The determination is upheld.


This is a male patient diagnosed with type 2 diabetes mellitus (T2DM). This request is for Mounjaro. As reported, he is currently on Metformin and Mounjaro (he is paying out of pocket). He failed Rybelsus due to constipation. He failed Byetta due to severe stomach pain, diarrhea and rash. He failed Jardiance, Glimepiride and Tradjenta (did not help). At issue is the medical necessity of Mounjaro.
The request is not medically necessary.
The requested medication Mounjaro (Trizepatide) is Food and Drug Administration (FDA) approved for the treatment of adults with type 2 diabetes. It is a Glucagon-like peptide-1 (GLP-1) and gastric inhibitory polypeptide (GIP) receptor agonist. It has been shown in clinical trials to lead to improvement in hemoglobin A1c as well as weight loss (1-3).
There are no studies demonstrating the superiority of the requested medication over the formulary alternatives. The most recent American diabetes Association guidelines recommend using GLP-1 receptor agonists as a 1st line agent. There is no preference for the requested medication over GLP-1 receptor agonists(4).
The patient can try two formulary alternatives including: Ozempic, Trulicity and Victoza. The request is not consistent with generally accepted standards of medical practice and is, therefore, not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma
Treatment: Inpatient Hospital Stay

The insurer denied Inpatient Hospital Stay.  The determination is upheld.

The patient is a male with a history of asthma, congestive heart failure (CHF), atrial fibrillation, and polysubstance abuse. His presenting complaint was dyspnea unable to be managed at home. He had recently eloped (less than 24 hours prior) from an inpatient admission for an asthma exacerbation but found he could not manage his symptoms at home, and he did not have any medications.  The physical exam was notable for diffuse wheezing. Lab results were unremarkable. Radiology was notable for an unremarkable chest x-ray. At issue is the medical necessity of an inpatient stay.

The inpatient hospital stay was not medically necessary for this patient. The patient presented with signs and symptoms of a moderate acute asthma exacerbation in the setting of recent hospital elopement. He did not have effective outpatient management of his condition because he left the hospital without medications for his nebulizer machine. The patient experienced symptomatic improvement in the emergency department with use of nebulizer. He did not demonstrate respiratory distress, hypoxia or hypercarbia, need for noninvasive ventilation, or other high-risk features. A lower level of care would have been appropriate to monitor the patient and establish an outpatient plan of action including discharge medications. The inpatient level of care was not medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Diabetes
Treatment: Formulary exception for Mounjaro 5mg (milligrams)/0.5ml (milliliter) Pre-Filled Pen Solution
The insurer denied Formulary exception for Mounjaro 5mg (milligrams)/0.5ml (milliliter) Pre-Filled Pen Solution.
The denial is upheld.

The patient is an adult female diagnosed with type II diabetes. This request is for Mounjaro. As reported, she has had T2DM (type 2 diabetes mellitus) for 6 years, HTN (hypertension), obesity, and hyperlipidemia. She has been on Trulicity for 3 years with ineffective response. She was also on Metformin causing her side effects. Her A1C (glycated hemoglobin) was 7.8 % (percent).

The health plan should not cover the Formulary exception for Mounjaro.

While the patient is reported to have failed the formulary alternative Trulicity, the patient is not documented to have tried and failed Victoza. Victoza would not reasonably be expected to be ineffective to the patient. The formulary alternative Victoza would be reasonably expected to be as effective as the requested non-formulary Mounjaro. The formulary alternative Victoza would not be reasonably expected to have adverse effects on this patient. The health plan's formulary requires the trial and failure of two formulary alternatives, including Victoza and Trulicity. The patient is reported to have failed Trulicity. There is no documentation of the trial and failure of Victoza. The request does not meet the formulary requirements. The requested medication Mounjaro (Trizepatide) is FDA (United States Food and Drug Administration) approved for the treatment of adults with type 2 diabetes. It is a GLP-1 (glucagon-like peptide 1) and GIP (glucose-dependent insulinotropic polypeptide) receptor agonist. It has been shown in clinical trials to lead to improvement in hemoglobin A1c (glycated hemoglobin) as well as weight loss (1-3). There are no studies demonstrating the superiority of the requested medication over the formulary alternatives. The most recent American Diabetes Association guidelines recommend using GLP-1 (glucagon-like peptide 1) receptor agonists as a first-line agent. There is no preference for the requested medication over GLP-1 (glucagon-like peptide 1) receptor agonists (4). The patient can try the formulary alternative Victoza. The formulary alternative would reasonably be expected to be as effective as the non-formulary drug, as there are no studies demonstrating superiority. The formulary alternative, Victoza, would not be reasonably expected to have adverse effects on this patient. The request is not consistent with generally accepted standards of medical practice and is therefore not medically appropriate. The health plan should not cover the formulary exception request, as the patient has not had trial and failure through the formulary alternative Victoza.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back Pain
Treatment: Pain management injection 
The insurer denied Pain management injection.
The determination is upheld. 

The patient is a female with a diagnosis of back pain and treatment plan which includes a left lumbar (L) 4-5 transforaminal epidural steroid injection. At issue is the medical necessity of the pain management injection. 
No, a left L4-5 transforaminal epidural steroid injection is not medically necessary for this patient at this time.
The patient presented to the hospital with acute onset low back pain with associated radicular leg pain. She was seen in clinic and reported pain. The treatment plan included a home exercise program, pain medicine and magnetic resonance imaging (MRI) of the lumbar spine. The patient's pain had decreased to a 3/10. There was documentation that the patient "has failed 6 plus (+) weeks of conservative management with physical therapy (PT) and home exercises" but there are no physical therapy notes. As pain has decreased (without any mention of impact on activities of daily living), it is reasonable to continue a conservative treatment program.
The pain is considered acute pain. The pain score was 3/10 which is not considered severe pain. Additionally, the patient has only completed a home exercise program and not formal physical therapy for this episode of pain (with notation that physical therapy was completed years ago).
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Chronic constipation.
Treatment: Chronic constipation.
The insurer denied Motegrity.
The determination is overturned.

This is a female patient with chronic constipation, central abdominal pain, bloating, and abdominal distention; she has a diagnosis of irritable bowel syndrome, constipation-predominant. She has failed Miralax, magnesium citrate, magnesium hydroxide, senna, Linzess, and Trulance. Coverage is requested for Motegrity 2 milligrams (mg) daily for the treatment of constipation. At issue is whether the formulary drugs will be or have been ineffective, would not be as effective as the non-formulary drug, Motegrity, or would have adverse effects.

The request for Motegrity is supported as the formulary alternatives Trulance and Linzess (which have the same mechanism of action) have already been attempted by the patient in this case. Motegrity is indicated for and is Food and Drug Administration (FDA)-approved for the treatment of constipation [1]. Motegrity has a different mechanism of action than Trulance and Linzess [2]. Guidelines for the treatment of constipation recommend the use of Motegrity regardless of whether Trulance or Linzess have been effective [3]. Multiple high-quality studies have found Motegrity to be safe and effective for the treatment of chronic constipation, and Trulance and Linzess have never proven safer or more effective than Motegrity in a direct comparison [4-10]. For these reasons, the request for Motegrity is supported in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Low Back Pain
Treatment: Pain Injections (62323 x [times] 1)
The insurer denied Pain Injections (62323 x 1).
The denial is overturned.

The patient is an adult female. She presented with a history of low back pain and leg pain. Her pain is rated 8/10 and is aggravated with standing and walking. The patient had completed more than four weeks of therapy over a year. Physical therapy was not effective. The patient participates in a home exercise program that is still ongoing. The patient had a prior epidural steroid injection with 90% (percent) improvement for five months. It allowed the patient increased activity and functionality with pain. Her diagnosis includes bilateral sacroiliitis, chronic pain, lumbar disc degeneration, lumbar radiculopathy, spondylosis of lumbar region without myelopathy or radiculopathy, and spondylosis without myelopathy or radicular lumbosacral region.

The requested pain injections are medically necessary.

Based on the documentation provided, the requested epidural injection is recommended in this case. The patient has a history of low back pain with radicular symptoms, and it was noted that the patient had prior epidural steroid injection with greater than 90% (percent) relief for five months. The patient has tried prior therapy and continues with a home exercise program.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back pain and urinary retention
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

This is a female patient with low back pain and left (L) leg radiation into the buttocks and foot. She reported associated numbness. She has a past medical history (PMH) significant for alcoholism (sober, in Alcoholics Anonymous (AA)), drug use, depression, obstructive sleep apnea (OSA), chronic obstructive pulmonary disease (COPD), hypertension (HTN), coronary artery disease (CAD), aortic dissection, diabetes, gout, Factor VII deficiency, anxiety, gout, hyperlipidemia, tobacco use. Previous treatment includes injections, physical therapy (PT), and medication management. She was diagnosed with severe neurogenic claudication. She presented for an elective lumbar (L) 4/5 minimally invasive decompression. No complications were reported. Post-operatively the patient did well. The patient was discharged following the surgery. 
She returned to the hospital with severe pain and urinary hesitancy.  Magnetic resonance imaging (MRI) with plans for potential operative intervention were made, however, the patient upon admission was able to void spontaneously with improvement in her pain after intravenous (IV) Tylenol and steroids were given.  Pain control was provided overnight and physical therapy (PT) was consulted.  No medical or surgical complications occurred.  She was discharged home. The inpatient stay was denied by the health plan due to a lack of medical necessity and is under review.  
An inpatient level of care was not medically necessary. The patient upon admission was able to void spontaneously with improvement in her pain after intravenous (IV) Tylenol and steroids were given. The patient was admitted overnight for pain control without an acute event.  No operative intervention was required.  The care could have been provided at a lower level of care than inpatient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low back pain

Treatment: Magnetic resonance imaging, spinal canal and contents, lumbar; without contrast material, code 72148

The insurer denied coverage for magnetic resonance imaging, spinal canal and contents, lumbar; without contrast material, code 72148

The denial is upheld

According to the Milliman Care Guidelines (MCG) Ambulatory Care 27th Edition: Lumbar Spine magnetic resonance imaging (MRI) Ambulatory Care Guideline (ACG): A-0059 - Clinical Indications for Procedure, Lumbar spine MRI may be indicated for 1 or more of the following:
.	Pain localized to low back or radicular in nature, subacute or chronic, as indicated by ALL of the following: Failure to improve after 6 or more weeks of nonoperative treatment, as indicated by 1 or more of the following: Activity modification)
.	Exercise
.	Pharmacotherapy for example ((e.g.), analgesics, anti-inflammatory medications)
.	Physical therapy
.	Patient being considered for invasive treatment (e.g., epidural steroids, surgery) 
.	Significant interference with daily function

Per the cited references, in 2007, the American College of Physicians (ACP) and American Pain Society (APS) issued an evidence-based guideline to optimize lumbar spine (LS) MRI use for low back pain (LBP). This guideline is supported by the American Association of Family Physicians and the American Board of Internal Medicine's Choosing Wisely initiative to improve quality of care through reducing unnecessary testing, treatment, and procedures. It also meets seven of eight Institute of Medicine standards for trustworthiness. Imaging recommendations in the ACP-APS guideline are concordant with the American College of Radiology's appropriateness criteria for LBP and also include a range of pharmacologic and nonpharmacologic therapies for LBP.  Imaging clinical decision support (CDS) combines guideline evidence with pertinent clinical history to provide brief, automated, and actionable feedback that can optimize provider decisions and management.

In this case, the patient is an adult diagnosed with acute on chronic low back pain. The patient presented with complaints of pain in the neck, back, and legs for 4 days. The pain level was noted to be 8 to ten out of 10 (8-10/10). The patient has used ice, heat and Advil with improvement for 4 hours. The patient reported that pain radiates to the left and right thigh. The examination findings were not noted.  There is a lack of clinical examination findings and a lack of clinical rationale to support urgent diagnostic imaging. As such, the denial of coverage for magnetic resonance imaging, spinal canal and contents, lumbar; without contrast material, codes 72148 is upheld as not medically necessary.

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 magnetic resonance imaging, spinal canal and contents, lumbar; without contrast material, code 72148 is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Headache.
Treatment:  Inpatient Hospital Stay.

The insurer denied inpatient hospital stay.  The determination is upheld.

The patient is a female with chronic dizziness, who was instructed to go to the emergency room by her outpatient psychiatrist for evaluation of dizziness and headache. In the emergency department, psychiatry evaluated the patient and determined that the patient did not qualify for an acute psychiatric admission. The patient had a normal evaluation. Afterward, the patient was admitted to the hospital for further evaluation of chronic dizziness and headache. In the hospital, the patient was treated with intravenous fluids, ketorolac, anti-emetics, and antihistamine drugs. The patient underwent a magnetic resonance imaging (MRI) scan of the brain that was normal. Neurology was consulted. The patient received multiple administrations of headache medications. The patient was subsequently discharged with a resolution of a headache. At issue is the medical necessity of an inpatient stay.

Acute inpatient hospitalization for the treatment of headaches and chronic dizziness is not medically necessary. The patient presented to the hospital with complaints of a headache. The patient also complained of dizziness but had a history of chronic dizziness. The patient, who was sent to the emergency room by her outpatient psychiatrist, was cleared by psychiatry and not deemed to have any acute psychiatric needs. She had a normal neurologic examination and initial imaging in the emergency department. The patient did not have any significant vital signs or laboratory abnormalities. While in the hospital, the patient received intravenous fluids and standard intravenous medications used to treat a headache. The services administered to the patient resolved the headache. The services did not meet the intensity of an acute inpatient admission. Treatment of a headache is appropriate for a lower level of care. There was no acute neurologic process other than a headache.