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

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

The patient is a female with a history of anemia, migraines, and recurrent pregnancy, who presented to the emergency department with a possible seizure. The patient experienced shaking, preceded by a headache, lightheadedness, and dizziness. On assessment in the emergency department, the patient appeared in no acute distress, with a normal cardiopulmonary exam. Neurologically she was alert and oriented times 3. The differential diagnosis of the emergency room (ER) was syncope versus seizure versus rigors. The medical team assessed the patient and documented that the patient felt dizzy upon standing up in class, lost consciousness, and then woke up in the hospital. The patient reported urinary incontinence. There is no prior history of personal or family history of seizures. The vital signs on admission were stable. Laboratory studies revealed a normal white blood cell count, hemoglobin of 11.2, and stable electrolytes. Liver function tests were fairly unremarkable, and amylase and lipase were normal. A transvaginal ultrasound was performed due to pregnancy for fetal viability, showing 12-week intrauterine pregnancy. Twelve-lead electrocardiogram (EKG) showed normal sinus rhythm. The medical team ordered a urine drug screen, electroencephalogram (EEG), neurology consultation, and brain magnetic resonance imaging (MRI).

The neurologist assessed the patient and noted that she had witnessed shaking of her limbs, lasting 6 minutes, and returned to baseline 4 minutes later. They recommended seizure precautions, with seizure medications as needed, and if the seizure recurs, initiation of anti-epileptic drugs.
The patient was reexamined the following day and noted no acute events overnight. Vital signs remained stable. The imaging studies and EEG were unremarkable. The patient remained in the hospital for an additional 24 hours and was subsequently released home with appropriate follow-up. No anti-epileptic treatment was prescribed on discharge.

The subject under review is the medical necessity for the inpatient admission.

The health plan's determination is upheld.

The inpatient admission was not medically necessary. The patient experienced seizure-like activity, which was thought to be a first-time seizure. Typically, first-time seizures do not require hospital admission or anti-epileptic medication initiation. Given the patient's pregnancy, it was reasonable to monitor overnight and obtain brain imaging for structural disease and an EEG for residual or subclinical seizures. All of this can be performed under a lower level of care status. The findings were unremarkable; the patient was safely released home. There is no evidence of intractable seizure activity, recurrent seizures, administration of anti-epileptic medications, seizure-terminating medication such as benzodiazepines, impairment of mental status, or a systemic process threatening the patient's life. Therefore, inpatient hospitalization is not indicated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a female who presented to the emergency department (ED) with diarrhea and lower abdominal pain complaints. The patient was diagnosed with Clostridium (C.) difficile infection and completed a course of Flagyl 2 weeks before this presentation. The patient also had an assessment at another emergency department the day before and was diagnosed with cyclical vomiting syndrome. On assessment, the abdomen was mildly distended and tender to the lower quadrants with no rebound or guarding. Vital signs included a temperature of 37.4, a heart rate of 104, and a blood pressure of 93/57 in the emergency department. She was given Zofran and Reglan for nausea symptoms and oral vancomycin for the possibility of recurrent C. difficile. The patient was reportedly unable to tolerate the vancomycin due to vomiting. Chest x-ray showed subtle haziness at the right lung base, which could represent atelectasis or early pneumonia. Computed tomography (CT) of the abdomen showed diverticulitis of the descending and sigmoid colon with no obstruction. The subject under review is the medical necessity for the inpatient admission.

The health plan's determination is overturned.

Inpatient admission was medically necessary. Based on the provided documentation, the patient has severe nausea and vomiting symptoms, precluding her from achieving appropriate nutrition and the medical team from switching to an oral antibiotic regimen for appropriate discharge home. Without the ongoing treatment in the hospital, there is a high risk of worsening the diverticulitis, as the patient would not have taken the oral antibiotic regimen. Therefore, ongoing medical admission under an inpatient level of care was necessary and appropriate for this presentation. Nausea and vomiting caused the rate of controlled atrial fibrillation with chronic anticoagulation to be uncontrolled. The inability to tolerate oral medication worsened this underlying condition and exposed the patient to a risk of stroke. Furthermore, the patient experienced a syncopal episode related to atrial fibrillation, satisfying the criteria for inpatient admission.
Overall, a multi-specialty approach was necessary to stabilize the patient's nausea and vomiting symptoms and acute diverticulitis and mitigate the risk of recurrent C. difficile.
In conclusion, the inpatient admission was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Cardiac/Circulatory Problems/Arrhythmia/Irregular Heart Rhythm/Atrial Fibrillation
Treatment: Inpatient Admission
The health plan denied the requested inpatient admission as not medically necessary. 
The health plan's determination is upheld.

This man presented to the emergency department complaining of a sudden onset of lightheadedness. His medical history was remarkable for hypertension and obesity. He had a family history of premature coronary artery disease. His blood pressure was 162/124 millimeters of mercury (mmHg) with a heart rate of 142 beat/minute. His room air oxygen saturation was 99% (percent). An electrocardiogram showed atrial fibrillation with a rapid ventricular rate. His serum troponin level was normal. His brain (or B-type) natriuretic peptide (BNP) level was 163. A chest X-ray showed no acute pathology. The patient was treated with Enoxaparin and intravenous Diltiazem and was admitted to the hospital. Oral Metoprolol was prescribed. He remained in atrial fibrillation. His blood pressure was 124/93 mmHg with a heart rate of 82 beats/minute. The Diltiazem was discontinued, and his Metoprolol dose was increased. He was discharged home with plans for outpatient follow-up.
The medical necessity for an inpatient admission is at issue.

I uphold the health plan's determination of medical necessity, in whole. 

No. Based on the documentation provided, an inpatient level of care was not medically necessary.
This man presented with acute atrial fibrillation (AF). He hemodynamically stable, there was no evidence of acute ischemia, he was not in decompensated heart failure, had no evidence of structural heart disease and was not at high short-term risk for thromboembolism. While his initial blood pressure was markedly elevated, there were no signs of acute end-organ damage. For patients presenting with acute AF, the safety of observation level care or discharge to home with close follow-up has been well demonstrated. As stated by Lin et al, "There is growing evidence to suggest that outpatient management is a safe and effective alternative to hospital admission for the management of many patients with acute AF or atrial flutter. Protocols for early rhythm control, clinical decision rules to guide the decision to initiate antithrombotic therapy, and low molecular weight heparin and direct oral anticoagulants have reduced the need for acute inpatient hospitalization." Likewise, Conti et al, based on an observational study of 3475 patients concluded, "In patients with AF, beyond the standard approach, the novel organization with an additional intensive observation unit for early pharmacological interventions and an outpatient clinic for elective treatment and short-term follow-up significantly reduced admission irrespective of independent predictors of hospitalizations."
An inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vasovagal Syncope
Treatment: Inpatient Admission
The insurer denied coverage for inpatient admission
The denial is upheld.

This case involves an adult female with a history of hypertension and panic attacks who presented to the emergency room with reports of a syncopal episode. She was given Tylenol, received intravenous fluid bolus, losartan, and prophylactic Lovenox. She was subsequently admitted with vasovagal syncope. Echocardiogram and imaging of the head/brain were within normal limits. The patient's laboratory testing did not identify any significant abnormalities. She remained on inpatient status until discharge. 

According to the Milliman Care Guidelines, inpatient care for patients with reports of syncope are indicated for those individuals with hemodynamic instability, altered mental status that is severe or persistent, when to have cardiac disease or findings that indicates necessity of immediate intervention, when they have pacemaker or automatic implantable cardioverter-defibrillator (AICD) malfunction, and heritable cardiovascular conditions predisposing the patient to arrhythmias diagnosed or suspected, when the patient has dehydration that is severe persistent, or syncope has caused an injury that required hospitalization.  The evidence provided for the review did not support that the patient met any of the above criteria. While she was noted to have a history of hypertension and panic attacks along with generalized anxiety disorder, her complaint of a syncopal episode did not support the need for an inpatient level of care. She could have safely had her care rendered on an outpatient basis or at most on an observational basis. This would allow for appropriate treatment, diagnostic work-up, and access to a higher level of care if so needed. After a review of the provided documentation and in a reference to the Milliman Care Guidelines regarding syncope, the denial of coverage for the inpatient admission was appropriate.

The prior determination is upheld. 

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

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

Diagnosis:  Bilateral knee osteoarthritis.
Treatment:  Hyaluronic Acid (Supartz) Intra-Articular knee injections.

The insurer denied Hyaluronic Acid (Supartz) Intra-Articular knee injections. The health plan's determination is upheld. 

This case descries a female patient with a diagnosis of bilateral knee osteoarthritis. Her orthopedic provider performed a series of Supartz injections for both knees. The patient's health plan denied coverage for the injections. 

The requested Hyaluronic Acid (Supartz) Intra-Articular knee injections were not medically necessary for this patient. Per the records provided, there is no need for the viscosupplementation injections. The recommendations of the current, peer-reviewed literature. recent articles published by Tammachote and colleagues in the Journal of Bone and Joint Surgery in 2016 concluded that "Triamcinolone acetonide provided similar improvement in knee pain, function, and range of motion compared with hylan at the 6-month follow-up, with better pain control in the first week and better knee functional improvement in the second week." A second article published by Jevsevar and associates in the Journal of Bone and Joint Surgery in 2015 concluded that "Meta-analysis of only the double-blinded, sham-controlled trials with at least sixty patients did not show clinically important differences of hyaluronic acid (HA) treatment over placebo. When all the literature was added to the analysis, the overall effect was greater but was biased toward stronger treatment effects because of the influence of non-blinded or improperly blinded trials." Lastly, the most recent American Academy of Orthopedic Surgeons clinical practice guideline did not endorse viscosupplementation injections as highly recommended intervention for the treatment of know osteoarthritis. Thus, the requested knee injections are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal - Back Pain
Treatment: Surgical Services - Radiofrequency Ablation
The health plan denied the requested radiofrequency ablation as not medically necessary.
 The health plan's determination is upheld.

The patient is a female with severe chronic low back pain who was recommended for basivertebral nerve (BVN) ablation treatment. She has failed epidural steroid injections (ESI), medications, and lidocaine patches. Magnetic resonance imaging (MRI) of the lumbar spine shows L4-S1 modic changes. A computed tomography (CT) scan of the lumbar spine shows L1 compression deformity. An x-ray of the lumbar spine shows L1 acute fracture suspicion.
At issue is the medical necessity of the requested radiofrequency ablation.
The health plan's determination is upheld as a whole.
The requested health service/treatment of radiofrequency ablation is not medically necessary for this patient. There are numerous other potential causes for the ongoing low back, pain such as the multiple levels of the lumbar degenerative disc disease and foraminal stenosis, L1 fracture, and potential hip and sacroiliac (SI) joint pathology. These must be ruled out before any ablation treatment in this case. Becker et al. noted, "Ablation of the BVN for the treatment of chronic lumbar back pain significantly improves patients' self-reported outcome early in the follow-up period; the improvement persisted throughout the 1-year study period." More studies are needed to show the benefit in this patient cohort, with varying other problems described that can be contributing to causing the low back pain. Therefore, radiofrequency ablation is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of Breath.
Treatment: Inpatient Admission.
The health plan denied the requested inpatient admission as not medically necessary. 
The health plan's determination is upheld.

The patient is a woman with a history of heart failure, asthma, sleep apnea, obesity, chronic low back pain, iron deficiency anemia, hypertension, anxiety, and depression. She presented to the emergency room with chest pain, abdominal pain, shortness of breath, and leg swelling. The family raised concerns about medication noncompliance. Vital signs revealed a blood pressure of 141/101 millimeters of mercury (mmHg), a respiratory rate of 24/minute, and a body mass index (BMI) of 40. She was afebrile and the oxygen saturation was 98%. She did not appear to be in acute distress. The physical exam was remarkable for decreased breath sounds, rales, and bilateral lower leg edema. Labs were notable for a hemoglobin of 9.6 and a brain (or B-type) natriuretic peptide (BNP) of 682. The chest x-ray revealed mild cardiomegaly, small bilateral pleural effusions, and mild pulmonary vascular congestion. The electrocardiogram (EKG) was negative for acute ischemia or significant arrhythmia. The echocardiogram showed a moderately decreased left ventricular ejection fraction, moderate global hypokinesis of the left ventricle, and mild pulmonary hypertension. The patient was admitted for further treatment and evaluation.
Upon admission to a monitored bed, the patient was treated with intravenous Furosemide and oral medications. The shortness of breath resolved with intravenous Furosemide. A several-day hospitalization ensued. Other than some abdominal discomfort, which resolved with antacid medication, the remainder of the stay was clinically uneventful, and the patient was discharged.
At issue is the medical necessity for inpatient admission.

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

No, the requested health service/treatment of an inpatient stay was not medically necessary for this patient.
Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or EKG of an imminently life-threatening cause of the patient's complaints that required acute inpatient admission. The patient responded promptly to straightforward treatment, and it was very likely that the worsening heart failure was due to medication noncompliance versus other more serious causes of exacerbation. There was no hypoxia, acute cardiac ischemia, pneumonia, mental status changes, or severe metabolic disarray. The services provided, including the relatively brief course of intravenous Furosemide, were not at the acute inpatient level of intensity. The abdominal discomfort and anemia did not require acute inpatient admission. Therefore, based on the standard of care, and the peer-reviewed literature cited in the references, the acute inpatient level of care was not medically necessary, and the patient could have been managed at an alternate level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac Catheterization.
Treatment: inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

The patient is a male for which an inpatient stay is under review. She had a history of coronary artery disease (CAD), myocardial infarction, and percutaneous interventions. There was also hypertension, hyperlipidemia, and diabetes. She had an abnormal myocardial perfusion imaging exercise test. She was admitted electively for cardiac catheterization. She underwent an uncomplicated cardiac catheterization demonstrating nonobstructive coronary artery disease. The blood pressure (BP) was mildly elevated, and other vital signs and oxygen saturation were essentially normal. He remained stable and was discharged.

The inpatient stay was not medically necessary. This patient underwent a successful elective and non-emergent catheterization without complications and was monitored for an adequate post-procedure period. There were no vascular complications, acute coronary syndrome, congestive heart failure (CHF), hemodynamic instability, cerebrovascular accident (CVA), severe bleeding, renal failure, need for urgent revascularization, need for prolonged intravenous medications or oxygen support, or introduction of high-risk medications requiring prolonged in-hospital monitoring. Therefore, an inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Menorrhagia

Treatment: Slynd

The insurer denied coverage for Slynd

The denial is overturned.

The patient is a teen with chief complaint of heavy periods associated with dysmenorrhea. In addition, the patient is reported to have migraines with aura. The provider prescribed the oral contraceptive Slynd. According to the provider, the patient has "tried and failed" norethindrone.

The insurer has denied coverage of Slynd. According to the insurer: Approval for zero cost-share requires that the patient be using this medicine for contraception. The records do not indicate that the patient meets this requirement.

Combined hormonal contraception with estrogens significantly increases the risk of stroke in women with migraine with aura. For those patients a progestin only, oral contraceptive is recommended.

Slynd is a progestin indicated for use by females of reproductive potential to prevent pregnancy. However, oral contraceptives have been used routinely to manage irregular periods, painful periods, as well as heavy periods. The first line of treatment for managing periods' abnormalities is to use an oral contraceptive. This is considered standard of care and there are thousands of scientific articles to that effect. Based on the above, Slynd is medically necessary for this patient.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the Slynd is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Facial numbness
Treatment: inpatient stay
The insured denied the inpatient stay. 

The health plan's determination is upheld. 

This case involves a woman with no major medical history who presented to the hospital with a 3-day history of facial numbness, paresthesias, and headaches. There were no clear inciting events and no alleviating or exacerbating factors were reported.

The inpatient hospital admission was not medically necessary. This is a young patient with new onset sensory paresthesias to the face, who had lesions on a non-contrasted MRI, which could support a new diagnosis of multiple sclerosis. The patient was empirically given IV Solu-Medrol while awaiting additional studies. The contrast-enhanced MRI failed to show any enhancing lesions; therefore, the IV corticosteroids were stopped. The appropriate autoimmune labs were ordered before releasing the patient home.
A new diagnosis of multiple sclerosis is typically evaluated in the outpatient setting. IV corticosteroids can be administered in an outpatient setting, typically at home with a home-visiting nurse. There is no indication for inpatient hospitalization for this condition. The patient, in this case, had no focal motor deficits, preventing her from receiving care at home. Vital signs were stable. The deficits are purely sensory to the face. There is no difficulty swallowing, airway compromise, ambulatory disability, or inadequate pain control. There is no evidence of systemic neurologic infection, stroke, intracranial bleeding, or increased intracranial pressure.
The patient's condition can be managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Infertility
Treatment: Insemination cycle with donor sperm; medicine to stimulate ovaries 
The insurer denied insemination cycle with donor sperm; medicine to stimulate ovaries.
The determination is overturned. 

The patient is undergoing fertility therapy for azoospermia in her partner. They have elected to do superovulation (SO) induction with therapeutic donor insemination (TDI). At issue is the medical necessity of superovulation in this clinical scenario.

Yes, the requested service is medically necessary. Though the patient has "normal" testing by most indices, her Anti-Mullerian hormone (AMH) testing result was 1.2. In the most recent study specifically looking at the efficacy of superovulation with therapeutic donor insemination (TDI), "Medicated cycles were less likely to result in pregnancy in women younger than 40 years or with an antimullerian hormone (AMH) level greater than (>) 1.2." Her AMH was 1.2, not less than 1.2. She fits the guidelines of individuals that benefit from SO with TDI. Superovulation provides an opportunity to recruit more than 1 follicle, and possibly recruit a better quality follicle. This drive to push the ovaries a little harder helps compensate for diminishing ovarian reserve.