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

Diagnosis: Altered Mental Status
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a patient who presented to the hospital with a change in mental status. She was noted to be lethargic, not moving properly, was disoriented to time in situations and did not follow commands. She used alcohol earlier that day. Her neurological examination on admission revealed no focal findings except for the altered mental status. A head computed tomography (CT) scan performed on presentation revealed no acute findings.
A brain magnetic resonance imaging (MRI) scan was performed and was interpreted as revealing no acute changes. There is no documentation of any other treatment or testing performed on that date.
She was seen by neurology and was diagnosed with syncope for which an electroencephalogram (EEG) and an echocardiogram were ordered.
The echocardiogram was performed and was interpreted as revealing normal left ventricular size and function, left atrial size and function, right ventricular size, wall thickness and systolic function, right atrium size and function, pulmonary valve, atrial and ventricular septum, aorta and vena cava with trace mitral and tricuspid regurgitation.
During her hospitalization, she was seen by physical therapy and cleared. She was discharged. At issue is the medical necessity of an inpatient stay.
An inpatient stay was not medically necessary. The patient presented with a change in mental status. The differential diagnosis was stroke versus encephalopathy (alcohol use). Acute stroke required exclusion and was ruled out with a head CT scan and brain MRI. Once an acute stroke was ruled out, there was no need for an acute inpatient hospitalization. There was no expectation of neurological worsening. There was no evidence that the patient had any hemodynamic, neurological, or cardiac or pulmonary reasons for a continued admission. She did not require urgent neurochecks. She did not require any other intensive monitoring. There were no electrolyte or other lab abnormalities requiring further follow-up. She did not need any intravenous medications or and or antibiotics. The patient could have had her encephalopathy treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Skin disorder
Pharmacy/Prescription drugs

Diagnosis: psoriatic arthritis.
Treatment: Otezla.
The insurer denied Otezla. 
The health plan's determination is upheld. 

The patient is a female with a history of severe erosive psoriatic arthritis. The issue in this case is that Otezla is being denied by the health plan.
Prior tx (treatment) (has tried and failed): SSz (sulfasalazine), methotrexate (MTX), Plaquenil, Arava, Enbrel, Humira, Xeljanz and Cosentyx. Per the doctor's letter , the patient is currently on Cosentyx and MTX with a 'decreased but not resolution of swollen joints/pain at her fingers. However, she is still not able to perform all of her activities of daily living (ADL). The provider is requesting to add Otezla onto her current regimen of Cosentyx and MTX to obtain better control of her psoriatic arthritis (PsA).

Otezla is not medically necessary for the patient as prescribed with MTX and cosentyx. There is not adequate data supporting use of all three of these drugs together. 
Otezla has not been shown to have a significant infectious risk compared to placebo and no significant increase in laboratory parameters, such as leukopenia or elevated liver function tests. While not Food and Drug Administration (FDA) approved, there is data showing it would be reasonable to add on Otezla to a biologic. For example, there was a study published that concluded that 'apremilast can be safely combined with all biologic agents in patients with plaque psoriasis or psoriatic arthritis not responding adequately to biologics alone'. Another study published in J Dermatol found 'that the combination therapy of apremilast and biologics could be a safe, effective option for the management of patients with psoriasis showing biologic fatigue'. However, these studies did not include MTX in addition to a biologic and Otezla, thus the safety of combing MTX plus a biologic plus Otezla remains uncertain.
At this time, it's reasonable to consider switching cosentyx to one of the drugs on the formulary, including stelara, Simponi, Taltz, Otezla, Cimzia or Orencia as this would be consistent with the FDA's recommendations for use of these medications.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic Dermatitis (AD).
Treatment: Dupixent Syn 300, Pre-service.
The insurer denied the Dupixent Syn 300, Pre-service.
The denial is overturned. 

The patient is a female with severe atopic dermatitis (AD) affecting the face, chest, and hands. She has tried and failed topical and systemic steroids, topical calcineurin inhibitors, and topical Eucrisa, as well as phototherapy. The request is for Dupixent injections.

Yes, the proposed treatment with Dupixent is medically necessary.

The patient has severe atopic dermatitis affecting multiple areas of the body. She is a candidate for systemic therapy as the body surface area (BSA) is too large for reasonable control with topical medications. Topical therapies are not appropriate therapy for severe, widespread atopic dermatitis, affecting sensitive areas, which should be treated with systemic therapy. 

Dupilumab is a monoclonal antibody that inhibits IL-4 (interleukin-4) and IL-13 (interleukin-13) signaling by blocking the shared IL-4Ra (interleukin-4 receptor) and originally demonstrated efficacy in phase II clinical trials. It was approved by the US Food and Drug Administration (FDA) for adults with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable. It is a subcutaneous injection administered initially at a dose of 600 milligrams (mg) and then every two weeks thereafter.

Approval of dupilumab was based on clinical trials investigating dupilumab as monotherapy (SOLO 1 and SOLO 2) and in concomitant administration with topical corticosteroids (CHRONOS). Results from the SOLO 1 (n=671) and SOLO 2 (n=708) trials showed 36-38% of patients who received dupilumab had scores of zero or one (clear or almost clear) on the Investigator's Global Assessment scale compared with placebo (8-10%) (P < .001). Additionally, improvement from baseline to week 16 of at least 75% on the Eczema Area and Severity Index (EASI) was reported in significantly more patients who received each regimen of dupilumab than in patients who received placebo (P < .001).

Given its unprecedented efficacy, dupilumab is now a first-line therapeutic for moderate-to-severe AD. The patient has failed topical steroids, calcineurin inhibitors and phototherapy.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.

Cyclosporine, azathioprine, methotrexate, and mycophenolate mofetil are not FDA-approved for use in atopic dermatitis (Insufficient data exists to firmly recommend optimal dosing, duration of therapy, and precise monitoring protocols for any systemic immunomodulating medication. Strength of Recommendation: B Level of Evidence: I or II, depending on agent), while Dupixent is.

Systemic steroids and cyclosporine are not a reasonable long-term treatment for moderate to severe atopic dermatitis due to their severe side effect profile.

For the reasons above, Dupixent is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic low back pain
Treatment: Pain Management ('trigger point injections' to lower back), Pre-service
The insurer denied the Pain Management ('trigger point injections' to lower back), Pre-service.
The denial is overturned. 

The patient is a male with chronic low back pain who underwent trigger point injections greater than six weeks prior with good results. He returned with low back pain. Trigger point injections have been recommended.

Yes, the pain management ('trigger point injections' to lower back) is medically necessary.

The patient is a male with chronic low back pain who underwent trigger point injections greater than six to eight weeks prior with good results, and who returns with low back pain. Trigger point injections have been recommended and have given him 80% relief. He has done conservative treatment including taking muscle relaxants, as well as opiates. Increasing opiate medications are not without risk. Trigger point injections (TPIs) are a minimally invasive treatment used when the patient's pain, or at least component of their pain, is muscular and has failed conservative treatment. Given the above, the requested TPI is medically necessary.

Please see above. The patient has had over 80% relief with the previous treatments. Withholding the treatment will lead to other more invasive procedures, and potentially increasing opiate medications, which carry an inherent risk.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a woman. Her medical history included asthma, dyslipidemia, gastroesophageal reflux disease, obesity, tobacco use, and chronic cholecystitis. Her surgical history included C-section.

The patient presented to an emergency room with a one-month history of right upper quadrant abdominal pain, nausea, vomiting, and chills. Her physical examination demonstrated tenderness to palpation of the epigastrium and right upper quadrant of the abdomen. Her vital signs were as follows: temperature 98.4, pulse 63, blood pressure 137/69, respirations 18, oxygenation 97% on room air. Serum laboratories demonstrated a normal white blood cell count of 6.4. Abdominal ultrasound was consistent with acute-on-chronic cholecystitis.

The patient was admitted at an acute inpatient level of care with the diagnosis of acute-on-chronic cholecystitis. She was made nil per os (NPO) and provided with intravenous fluids, antibiotics, and analgesics.

The patient underwent laparoscopic cholecystectomy. Surgery and recovery were uncomplicated. Having returned to her baseline health and function, she was discharged home in good and stable condition with outpatient surgical follow-up and prescriptions for oral analgesics and stool softeners.

No, the inpatient admission was not medically necessary.

According to the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), "patients undergoing uncomplicated laparoscopic cholecystectomy for symptomatic cholelithiasis may be discharged home on the day of surgery" [1]. Insofar as the patient did not demonstrate significant co-morbidities or physiologic derangements, and insofar as surgery and recovery were uncomplicated, the patient could have been treated at a lower level of care, precluding the need for admission at an acute inpatient level of care.

Based on the provided medical documentation and in accordance with national guidelines, for this patient, admission at an acute inpatient level of care was not necessary. The patient could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain.
Treatment: Hospital admission.

The insurer denied coverage for the hospital admission.  The denial is upheld.

This is a female patient with a past medical history notable for hypertension, hyperlipidemia, migraine headaches, and diabetes mellitus. The patient presented to the Emergency Room (ER) with complaints of chest pain, which had commenced 3 days prior. The patient had associated shortness of breath and tingling of the left arm. The patient's pain was described as throbbing, and she rated it as 8/10 in intensity. The patient's physical examination was notable for bilateral lower extremity edema. The patient's vital signs were stable. The patient's initial troponin level was negative. The patient's electrocardiogram (EKG) demonstrated normal sinus rhythm without acute ischemic changes. The patient was given aspirin and was admitted to rule out myocardial infarction. The patient's subsequent cardiac troponin levels remained normal. The patient was evaluated by cardiology, and underwent a recommended coronary computed tomography (CT) angiogram. This demonstrated a coronary calcium score of 1, with no obstructive coronary artery disease. The patient's echocardiogram revealed normal left ventricular systolic function with an ejection fraction of 60%, mild diastolic dysfunction, and mild pulmonary hypertension. It was felt that the patient's symptoms were likely non-cardiac in nature, and she was subsequently discharged home after a period of medical stability. It was advised that the patient follow-up with cardiology as an outpatient.  

The patient presented to the ER with chest pain and shortness of breath. The patient remained clinically and hemodynamically stable during her evaluation in the ER. Further evaluation in the ER was unremarkable, including a non-diagnostic EKG and negative cardiac biomarkers. Though it was appropriate and medically indicated for the patient's symptoms to be evaluated to rule out myocardial infarction, inpatient admission was not medically necessary in this instance. The patient's care could have been provided under observational level of service, allowing for additional diagnostic testing. There were no high-risk or concerning findings on diagnostic testing to suggest acute coronary syndrome or the need to necessitate further inpatient evaluation. During the patient's initial evaluation and subsequent hospitalization, there was no objective evidence of hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions warranting acute inpatient level of care. 

As per review above, hospital admission was not medically necessary for this patient.

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

The medical necessity for the hospital admission is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Endocrine/Metabolic/Nutritional-Diabetes
Treatment: Inpatient hospital stay
The inpatient stay was denied by the health plan as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

This is a patient with a history of Hypertension, Diabetes, deep vein thrombosis, and Pulmonary embolism who presented to the emergency department (ED) with complaints of feeling weak and nauseous. Her doctor called her and reported that her glucose level was over 1000. Vital signs in the ED were Temperature 98.2 Fahrenheit, pulse 59, respiratory rate 15, blood pressure 116/69, and pulse oximetry 97% on room air. Physical examination showed lung rhonchi. Abnormal laboratory values included sodium 127, blood urea nitrogen 36, creatinine 2.0, and glucose 586. The patient was admitted and treated with intravenous fluids and long acting insulin. The next day creatinine was 1.4 and glucose levels in 300's. The patient was also seen by Endocrinology and insulin dosage was increased. 

This patient presented to the hospital with hyperglycemia and acute kidney injury. The patient was treated with intravenous fluids and insulin. The patient's glucose levels and renal function improved on the day following admission. The patient was hemodynamically stable without evidence of acidosis or ketonuria. There was no evidence of altered mental status. The patient was able to tolerate oral intake. There was no evidence of persistent or severe dehydration. This patient did not have any clinical needs that required inpatient care. Since the patient did not have any clinical needs that would have required an inpatient admission, the requested health service/treatment of Inpatient stay was not medically necessary for this patient. This patient could have been monitored and treated at a lower level of care with subsequent follow-up as an outpatient.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Respiratory Problems. 
Treatment: Surgical Services (implantation of a hypoglossal nerve stimulator). 

The insurer denied surgical services (implantation of a hypoglossal nerve stimulator).  The denial is overturned.

The patient is a female with a history of obstructive sleep apnea initially diagnosed with sleep study. This showed an apnea hypopnea index (AHI) of 32.8. The minimum oxygen desaturation was 86%. Other pertinent vitals include a body mass index (BMI) of 29.87 The examination of the patient showed a normal palate, normal tonsil tissue, straight septum. Past medical history was significant for gastroesophageal reflux disease. The patient was not candidate for an oral appliance. The patient didn't sleep well and turned frequently at night. This behavior caused the mask to become dislodged, and the machine noise caused the patient to wake up. While at work, the patient was very sleepy and wanted naps.

Sleep endoscopy was performed which showed no complete collapse of the upper airway (favorable finding for hypoglossal stimulator implant).

The subject under review is the Inspire Upper Airway Stimulation implant, and whether this technology is likely to be more beneficial for the patient than any standard treatment.

The health plan's determination is overturned.

The treatment is likely to be more beneficial for this patient. There is sufficient evidence to support upper airway surgery (UAS) in certain instances. Current articles by Woodson and Strollo et al. (2015) have shown significant safety and benefit for patients with obstructive sleep apnea (OSA). Other authors have even commented that "once it becomes a standard therapy, its advantages might prove sufficient to challenge continuous positive airway pressure (CPAP) as the first-line therapy." (Mwenge et al. 2015). In patients with a lower BMI and a severe AHI (such as this patient), the study published by Soose et al. further supports the use of UAS surgery. They found that in those patients with "severe OSA and body mass index less than or equal to (<=) 32 kilograms per square meter (kg/m2), hypoglossal cranial nerve stimulation therapy can provide significant improvement in important sleep related quality-of-life outcome measures and the effect is maintained across a 2-year follow-up period." A more recent 2 year follow up study by Steffen et al. 2019 confirmed previously published studies finding about 76% of patients at 2 years and 68% of patients at 3 years met the criterion of therapy success defined as an AHI below 15.

The adverse risks of the requested health care service are substantially increased over those of available standard treatments for this patient's diagnosis. However, the patient is at risk for worsening sleep apnea, risk for diabetes, cognitive decline, and cardiac events if left untreated. Furthermore, this treatment (hypoglossal stimulation) is considered to be more efficacious for patients who have previously failed available treatment (CPAP, oral appliance). (Yu and Thaler 2020)
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Respiratory Problems. 
Treatment: Surgical Services (implantation of a hypoglossal nerve stimulator). 

The insurer denied surgical services (implantation of a hypoglossal nerve stimulator).  The denial is overturned.

The patient is a female with a known history of severe obstructive sleep apnea with an apnea hypopnea index (AHI) of 32 based on a sleep study. There were no central sleep apneas. The patient is unable to tolerate continuous positive airway pressure (CPAP) therapy due to not keeping the mask on at night. She reports excessive daytime sleepiness. A progress note showed she had a body mass index (BMI) of 29.8. The patient underwent a drug-induced sleep endoscopy which showed no concentric collapse of the velopharynx. The current treatment plan is placement of a hypoglossal nerve stimulator (Inspire) for treatment of obstructive sleep apnea (OSA). The issue is whether treatment plan will be more beneficial for the patient than any standard therapy.

The health plan's determination is overturned.

The proposed treatment is more likely to be beneficial than any standard treatment for the patient's severe OSA. The first line treatment for OSA is CPAP, and since the patient has failed this, then surgical options are then considered.
The patient meets all Food and Drug Administration (FDA) indications for the implantation of this device which are:  1)  CPAP/bi-level positive airway pressure (BiPAP) intolerance, 2)  OSA with AHI 15-65, 3)  Age greater than (>)22, 4)  BMI less than (<) 32, 5)  Non concentric collapse of the velopharynx (documented in op note), and 6)  < 25% central or mixed apneas.

Other surgical procedures for the treatment of OSA have poorer outcomes with higher morbidity. 

Untreated sleep apnea is associated with a significantly increased risk of sudden death, hypertension, stroke, coronary artery disease, congestive heart failure, type 2 diabetes, depression, motor vehicle accidents, occupational accidents, lost productivity, and decreased quality of life.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital admission. 
The denial is upheld. 

The patient is a female with a past medical history significant for tobacco use disorder and cholecystectomy who was brought to the emergency department after she had two syncopal episodes. The first episode occurred two days before the presentation, and the second one took place on the day of admission. Each episode lasted a few seconds. It was associated with intermittent dizziness and lightheadedness. When seen by the admitting physician the patient denied orthopnea or paroxysmal nocturnal dyspnea.

The patient was admitted to the telemetry floor. The patient was seen by a neurologist who suggested that electroencephalogram (EEG) can be performed as an outpatient. The neurologist recommended cardiology consultation and follow-up in the office.
The patient was evaluated by a cardiology service who suggested that the patient had a near-syncope. The cardiologist stated that the physical exam and electrocardiogram (EKG) looked benign. The cardiologist recommended smoking cessation and follow-up in the office.
During the hospital stay, the patient remained in satisfactory clinical condition and was discharged from the hospital on the next day after the day of admission.
The subject under review is the medical necessity for the inpatient hospital admission.

The health plan's determination is upheld.

The inpatient hospital admission was not medically necessary for this patient. 
In order to determine if the patient required admission at the acute inpatient level of care for the evaluation of the syncopal episode, the San Francisco Syncope Rule, was utilized, which is a risk stratification tool. It predicts risk for serious outcomes at 7 days in patients presenting with syncope or near-syncope. Based on the calculations, this patient received zero points. This means that the patient belonged to a low-risk group for serious outcomes. Therefore, the workup could have been performed at a lower level of care status. In this particular situation, the patient had recurrent near syncopal episodes. Therefore, the admission for monitoring was reasonable, primarily for cardiac monitoring, however this did not require an inpatient admission and could have been completed at a lower level of care status.
Overall, this patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.