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

Diagnosis: Right upper quadrant pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

This is a female who presented with history for right upper quadrant pain. This patient was found to have gallstones and elevated liver transaminases. This patient was admitted for evaluation. Magnetic resonance cholangiopancreatography (MRCP) was normal without choledocholithiasis and acute cholecystitis. This patient was admitted and discharged to be followed as an outpatient and possible future cholecystectomy electively. This is a review of the one day acute inpatient admission.

No, the acute inpatient admission was not medically necessary.
This patient could have been safely, efficiently, and effectively been placed in Observation Care especially since being in the emergency department, this patient was improving in pain, was remaining afebrile and hemodynamically stable, and did not require an acute surgical intervention. This patient presented as a classic example of needing Observation Care for ongoing monitoring and diagnostic assessment. 

As per the Milliman Care Guidelines (MCG) National Criteria: (Observation and Gastroenterology):
Observation care is indicated: Clinical care (eg, testing, monitoring, or treatment) needed beyond the usual emergency department time frame. 

The medical care this patient received after being evaluated in the emergency department including serial laboratory testing, magnetic resonance cholangiopancreatography (MRCP), and Gastrointestinal and Surgical Consultations did not require an acute inpatient admission. This patient was assessed as possibly passing a gallstone and needed in the future an outpatient follow-up and possible elective cholecystectomy.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Having this patient placed in Observation Care would be considered as safe, effective, and efficient medical care consistent with national medical criteria.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pancreatitis
Treatment: Acute inpatient stay

The insurer denied coverage for the acute inpatient stay.
The denial is overturned.

The patient presented with abdominal pain, nausea, and vomiting. Upper abdominal tenderness was present. The white blood cell (WBC) count was 29 and the lipase was 2865. A computed tomography (CT) scan was read as necrotizing pancreatitis. Intravenous (IV) fluids and pain control were given.

Clinical indications for admission for pancreatitis (MCG (Milliman Care Guidelines) M 250) include having acute pancreatitis as manifested by 2 or more of the following: Upper abdominal pain, pancreatic enzymes greater than 3 times the upper limit of normal, and characteristic findings on abdominal imaging. 

In this case, the patient had all 3 of the indications. He had upper abdominal pain, a lipase over 3 times the upper limit of normal, and an abnormal CT scan imaging of the pancreas. This met the MCG criteria for an inpatient admission.

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

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

Diagnosis: Loss of consciousness. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a male who was injured while jet skiing out of the country. There was reportedly loss of consciousness at the time of the injury. The patient was evaluated at a hospital in that country. At that facility, a computed tomography (CT) scan of the brain was negative. An x-ray of the right hip showed no fracture. An x-ray of the cervical spine showed no fracture. A chest x-ray was normal. The patient was diagnosed as having a "minimal concussion with some memory loss". He received intravenous fluid along with acetaminophen and Toradol for pain. He was admitted to the hospital overnight "for observation". The patient was discharged the following day. 

The patient was taken back to the United States, where he was evaluated. At this facility he was diagnosed as having a right inferior pubic ramus fracture as well as a sternal fracture. 

The patient's health plan denied coverage for an inpatient admission on the grounds that it was not medically necessary. The patient has appealed this denial. 

No, the proposed treatment (inpatient admission) was not medically necessary. 
At the time that this patient was kept in the hospital, he was clinically stable. Despite sustaining a head injury, the patient had normal vital signs and normal mental status. There is no documented concern that he could not protect his airway. He was alert and oriented. The patient was kept in the hospital overnight for observation. He was treated with acetaminophen and Toradol. There is no documentation of any other testing or consultations being planned for the patient. Following this patient's initial evaluation, it would have been reasonable to believe that this limited plan of care could be accomplished for a stable patient with a short stay in the hospital. For this reason, an inpatient admission was not medically necessary. The patient could have safely been managed at a lower level of care. 

Yes, the health plan did act reasonably in denying coverage for an inpatient admission.
For the reasons described above, the patient could have safely and effectively been managed at a lower level of care. There was no evidence of a serious head injury. Minimal testing and treatment was anticipated for him. The health plan acted reasonably in deciding that an inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rheumatoid Arthritis
Treatment: Otrexup

The insurer denied the Otrexup.
The denial is overturned.

This patient is a female with history of rheumatoid arthritis.  The patient has previously tried and failed oral methotrexate due to gastrointestinal upset.  The patient has been receiving Otrexup for approximately 36 months with good clinical activity.  She has also previously tried and failed conventional disease modifying anti-rheumatic drug (DMARD) hydroxychloroquine and targeted synthetic disease modifying anti-rheumatic drug (DMARD) Xeljanz and biologic disease modifying anti-rheumatic drugs (DMARDs) Remicade, Enbrel, Rituxan, Orencia and Cimzia.  She is currently receiving biologic disease modifying anti-rheumatic drug (DMARD) Simponi Aria.  The request for Otrexup was initially denied due to the patient not having tried generic methotrexate by mouth and it either did not work or caused a bad side effect.  The reason the provider is appealing the determination is because the patient has tried and failed oral methotrexate and the request for Otrexup is for continuation of care.

Yes, the proposed treatment is medically necessary.
The patient has rheumatoid arthritis.  Otrexup is Food and Drug Administration approved for treatment of rheumatoid arthritis.  The patient has previously tried and failed oral methotrexate due to gastrointestinal upset.  The patient is unable to prepare and administer generic injectable methotrexate.  The patient has been on Otrexup for approximately 36 months and clinically is doing well.  Therefore standard of care would recommend that the patient continue on current treatment of Otrexup which she has clinically been doing well on.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
The patient has been on Otrexup for three years.  The patient has previously tried and failed oral methotrexate.  Therefore standard of care would be for the patient to continue on therapy on Otrexup.  That would be in the patient's best interest.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

This patient has a history of fibroids, anemia, and gestational diabetes, as well as a finger wound, who presented with a hemoglobin (Hgb) of 6.3. She was symptomatic with shortness of breath (SOB), lightheadedness, and palpitations. The left finger was partially amputated and followed by plastic surgery. She reported having heavy menstrual periods. The hemoglobin level was 6.3, but she was transfused with 1 unit of red blood cells (RBC), and it went up to 7.7. 

The patient was admitted for a blood transfusion. She was found to be iron deficient and was started on intravenous (IV) Venofer. Her Hgb remained stable during the admission. She was discharged after a period of hemodynamic stability.

The transfusion of one unit of RBC could have been done in the emergency room (ER), and then followed as an outpatient or at observation level. The finger issue does not appear to have required an acute inpatient admission or management.

"Anemia is a common condition and is diagnosed on laboratory assessment. It is defined by abnormally low hemoglobin concentration or decreased red blood cells. Several classification systems exist. Laboratory markers provide important information. Acute anemia presents with symptoms owing to acute blood loss; chronic anemia may present with worsening fatigue, dyspnea, lightheadedness, or chest pain. Specific treatments depend on the underlying anemia and etiology. Iron is an alternative treatment for patients with microcytic anemia owing to iron deficiency. Hyperbaric oxygen is an option for alternative rescue therapy. Most patients with chronic anemia may be discharged with follow-up if hemodynamically stable." (Long, B., & Koyfman, A. 2018).      

The inpatient hospital admission was not considered medically necessary for this patient. The anemia could have been treated in the emergency room (ER) with a transfusion, as the symptoms documented to resolve, and then she could be discharged, or, alternatively, she could have been observed for less than 24 hours and followed as an outpatient.

"Iron deficiency anemia is common, and many patients can be treated effectively with oral iron. For selected patients with moderate-to-severe iron deficiency anemia, intravenous iron is safe and more effective than oral iron. Red blood cell transfusions should be used rarely for hemodynamically stable patients with iron deficiency irrespective of hemoglobin levels." (Boone, S. et al. 2019). 

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

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

Diagnosis: Lip Swelling and Rash (allergic reaction to medication). 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is overturned. 

The patient is a female. She presented with an allergic reaction (anaphylaxis vs. angioedema) concerning for possible drug allergy. The patient presented with nausea, vomiting, upper lip swelling, throat discomfort, and generalized body rash. Urticaria was noted on physical exam. Symptoms improved after initial treatment in the ER (emergency room) and ED (emergency department) observation. She was given epinephrine, benadryl, pepcid, prednisone. 

Yes, the inpatient admission was medically necessary. 

The patient presented with symptoms concerning for possible anaphylaxis vs. angioedema after being started on a new medication. She was given epinephrine. She was admitted to the hospital. Given anaphylaxis is a potentially life-threatening condition and rebound anaphylaxis can occur, it is reasonable to have had this patient admitted. 

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

The health plan should have covered this admission, as there is medical necessity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain, Vaginal Bleeding.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a past medical history (PMH) of diabetes and hypertension (HTN) who was admitted with complaints of (c/o) vaginal bleeding associated with abdominal pain, weakness, and nausea/vomiting. Her vital signs were unremarkable. The physical exam was notable for mild distress, abdomen soft, tender, no rebound/guarding. Lab work was notable for a hemoglobin of 12. Imaging studies, transvaginal ultrasound (TVUS) showed a large uterine fibroid. The patient was diagnosed with vaginal bleeding and treated with intravenous (IV) antibiotics, pain control, intravenous fluids (IVF), and anti-inflammatories. Obstetrics/Gynecology (OB/GYN) evaluated the patient and recommended a pelvic ultrasound and endometrial biopsy in an outpatient setting. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.
The inpatient hospital stay was not medically.
This patient presented to the ED (Emergency Department) with c/o vaginal bleeding associated with abdominal pain, weakness, and nausea/vomiting. The patient was found to have a low hemoglobin but had no history of hematochezia, hematemesis, or melena. The patient did have a history of heavy menstrual bleeding, but the hemoglobin was stable during the hospital stay and GYN recommended the patient follow-up as an outpatient to complete a work-up for possible malignancy. The patient did not have hemodynamic instability, persistent orthostasis, evidence of life-threatening bleeding in the ED (such as frequent episodes of hematemesis, melena, or bright red blood per rectum (BRBPR)), coagulopathy, or known esophageal varices. This patient could have been safely observed and received diagnostic work-up and consultation at a lower level of care. The patient did not have an active major hemorrhage (eg, postpartum hemorrhage) or hematocrit less than 25% (percent).
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Temporomandibular joint disorder

Treatment: J0585, Botulinum Toxin (Botox) injection

The insurer denied coverage for J0585, Botulinum Toxin (Botox) injection

The denial is upheld

This patient has temporomandibular joint (TMJ) dysfunction and has nocturnal Bruxism. She has tried nocturnal splints without success. She has had bilateral trigger point injections without sustained relief. The request is for injection of Botox.

This would be an off-label use of Botox. It is still experimental/ investigational in its use in this situation. Nongmeikapam et al (1) state: "much more to be discovered for its routine use."  Similarly, Ameer et al (2) state: "Although multiple small- and large-scale studies support (its use), there is still a need for evidence from large randomized clinical trials."

There are some positive reports, but it is still experimental/ investigational. Botox injection is not the best available treatment for this patient at this time. The adverse risks are not increased over standard treatment/services. The requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of J0585, Botulinum Toxin (Botox) injection should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Temporomandibular Joint Disorder

Treatment: J0585, Botulinum Toxin (Botox) injection

The insurer denied coverage for J0585, Botulinum Toxin (Botox) injection

The denial is upheld

Upon review of submitted documentation which includes treatment notes from the Physical Medicine and Rehabilitation (PM&R) physician, dental narrative report, copies of select peer reviewed literature, Excellus Pharmacy Management Drug Policy, and insurer correspondence, it appears that this patient has an underlying diagnosis of temporomandibular joint (TMJ) pain, bruxism, and myofascial pain. This patient has been under the care of physicians who are recommending Botox injections as enumerated above to treat her jaw/muscle pain. 

Upon review of peer reviewed literature, and including those submitted by the patient for review, there is a body of literature to suggest that Botox injections may be safely administered and possibly of some benefit in managing TMJ/ myofascial pain. However, most literature consists of case reports/anecdotal reports of its efficacy. There are no randomized controlled studies that report any benefit, nor any greater benefit than conventional treatments, and therefore Botox cannot be considered a standard treatment. In fact, most literature, including references noted below, report no clear efficacy of Botox in managing bruxism, TMJ or myofascial pain when compared to standard treatments. 

Given the current state of the literature, Botox does not appear to be more beneficial than any available standard treatment. As compared to conventional standard therapies, there is no greater improvement in outcome noted. There Is no need for final approval. Botox is not the best available treatment. The adverse risks are not increased over standard treatment/services. Botox (botulinum toxin) to treat myofascial pain is not considered to be more beneficial than standard treatment at this time.

The carrier's denial of J0585, Botulinum Toxin (Botox) injection should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Impetigo.

Treatment: Inpatient admission.

The insurer denied coverage for the inpatient admission.

The denial is upheld.

According to the documentation submitted, this is a male child with no significant past medical history. He presented to the emergency room (ER) with complaints of impetigo on the nose and elbow that had failed outpatient management. He was admitted and treated with intravenous (IV) Clindamycin and Bactroban ointment. The patient was discharged on three days later. 

According to the available records, this was a male child who presented to the emergency room with complaints of impetigo on the nose and elbow that had either failed outpatient antibiotics or was non-compliant (unclear which of these).  There was a 4x5 centimeter lesion on the elbow with crusting, oozing and central clearing and similar impetigo lesions in the nose. He was hemodynamically stable and not-ill-appearing.  He was admitted for intravenous (IV) Clindamycin every 8 hours and discharged three days later on oral Clindamycin. The diagnosis was impetigo. A wound culture was positive for Staphylococcus aureus. 

Although the patient's impetigo was relatively limited (Baddour, UpToDate), even if it is classified as "Extensive Impetigo" because 2 sites were involved, the treatment regimen recommended is an oral course of antibiotics. The reviewer agrees with the insurer that admission was not warranted. The ER treatment reason stated for full hospital admission is bacterial infection. No further justification is detailed.

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

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

Diagnosis: Arrhythmia/Irregular Heart Rhythm
Treatment: Inpatient hospital stay

The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

The patient has a past medical history of attention deficit hyperactivity disorder (ADHD), anxiety, and recent hospitalization for symptomatic sustained ventricular tachycardia in the setting of Adderall use. During her previous hospitalization, her ventricular tachycardia was worked up with a cardiac magnetic resonance imaging (MRI) scan and coronary angiography which were unremarkable. She was discharged home on metoprolol with outpatient follow up with electrophysiology. This time, she presented with rapid irregular heartbeat, nausea, and active vomiting. On Emergency Medical Services (EMS) arrival, she was noted to have runs of non-sustained ventricular tachycardia. By the time she had arrived in the emergency room (ER), she was in normal sinus rhythm, and her symptoms had abated. She was afebrile and hemodynamically stable. Her 12-lead electrocardiogram (EKG) did not demonstrate any ischemic changes. She was admitted to the inpatient unit where she remained asymptomatic and hemodynamically stable. There were no further episodes of ventricular tachycardia noted on telemetry. She was seen by the electrophysiology team, and per their assessment her ventricular tachycardia (VT) was likely idiopathic given normal left ventricular ejection fraction (LVEF). They recommended continuing metoprolol for VT suppression with outpatient follow up for possible ablation. 

This is a patient with a history of ADHD, anxiety, and a recent hospitalization for ventricular tachycardia. She presented with nausea, vomiting, and palpitations and was found to have episodes of non-sustained VT by EMS. On arrival to the emergency department (ED), she was hemodynamically stable, did not have evidence of end organ damage, and her symptoms had  abated. Additionally, she did not have any evidence of ischemia or malignant arrhythmias on her EKG or telemetry, and she had a recent cardiac work up (including MRI and coronary angiogram) which were unremarkable. The patient had short episodes of non-sustained ventricular tachycardia during which she was hemodynamically stable. There was also no evidence of ischemia or significant electrolyte abnormalities. Throughout the hospitalization, she remained hemodynamically stable. Consequently, based on the provided documentation, there is insufficient clinical data to support medical necessity for inpatient admission. A lower level of care would have been appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Compromised tooth #19. 
Treatment: D2750, crown- porcelain fused to high noble to tooth #19. 

The insurer denied coverage for D2750, crown- porcelain fused to high noble to tooth #19. 

The denial is upheld. 

Upon review of the documentation provided which includes copy of select bitewing, periapical radiographs, and insurer correspondence, it appears that this patient presented to the dentist for comprehensive care. The treating dentist recommended full coverage crown for #19. The insurer has denied these services stating the there is no clinical/ radiographic evidence, such as traumatic injury or decay, or history of root canal provided to support the necessity of this service and therefore the service does not meet medical necessity criteria. The patient is appealing. 

The objective documentation provided for review is a copy of poor quality periapical and bitewing radiographs. It appears that there is no evidence of fracture or other pathology specifically affecting #19 based on the images provided for review. There does not appear to be any radiographic evidence of caries. The radiographs do not substantiate the requested dental services as enumerated above and therefore the crown is deemed not medically necessary. 

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

The insurer's denial of coverage for D2750, crown- porcelain fused to high noble to tooth #19 is upheld. Medical Necessity is not substantiated.