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

Respiratory
Inpatient hospital

Diagnosis: shortness of breath
Treatment: inpatient stay
The insurer denied the inpatient stay.
The health plan's determination is overturned. 

This is the case of a young male with asthma (on Symbicort) and obstructive sleep apnea (OSA) who presented with shortness of breath status/post tonsillectomy with adenoidectomy (T&A). The patient was in the operating room (OR) during the procedure when he had acute bronchospasm and the decision was made to defer the adenoidectomy. The patient was given Solumedrol and admitted to the hospital for further monitoring and management.

The inpatient hospital admission was medically necessary.
This child with known asthma and OSA was undergoing T&A procedure. He had multiple episodes of bronchospasm in the operating room (OR) that required aborting the adenoidectomy procedure and acute management of the bronchospasm with albuterol and steroids. Given the possibility of underlying allergic reaction, rebound swelling, or new complications such as post-operative bleeding, inpatient admission was medically necessary for this child to ensure safe transition to home.
Based on the patient condition with known chronic asthma and s/p tonsillectomy procedure that was complicated by acute bronchospasm episodes, inpatient hospitalization was medically necessary to ensure airway and breathing complications were stable and minimized. This child had potential for either rebound effects or new symptoms in the acute postoperative period.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Low Back Pain

Treatment: Surgical procedure to treat low back pain (procedure code 64628 and 64629)

The insurer denied coverage for surgical procedure to treat low back pain (procedure code 64628 and 64629)

The denial is upheld.


This patient is morbidly obese (body mass index (BMI) 42) and has chronic low back pain. The patient's pain medication is Tylenol. The patient cannot take non-steroidal anti-inflammatory drugs (NSAIDs) due to bariatric surgery. On magnetic resonance imaging (MRI), the patient has a herniated disc compressing the S (sacral) 1 nerve root and another compressing the L (lumbar) 2 nerve root. A compression fracture of the vertebral body at T (thoracic) 9 was also noted. The physician notes Modic changes at L2-L3, L4-L5 and L5-S1.  No surgical consultation addressing the disc herniation compressing the S1 nerve root is documented.

Conger et al (3) pointed out that all of the major studies while supportive, have been funded by the company:

"There is moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic low back pain who are selected based on type 1 or 2 Modic changes, among other inclusion and exclusion criteria used in the published literature to date. Success of the procedure appears to be dependent on effective targeting of the BVN. Non-industry funded high-quality, large prospective studies are needed to confirm these findings."

Similarly, a clinical practice guideline (4) while favorable pointed out the limitations of the current literature:

1)  Industry funding is a potential source of study bias for the available data reviewed.
2) Limited number of studies.
3)  Short-term follow up for the majority of studied patients.
4)  Unknown effect on the primary degenerative process.

Urits et al (5) also commented on the need for more research on this promising technique:  "reproducible large RCTs are still needed for clinicians to gain full confidence in utilizing this treatment in practice. Additionally, further research is needed on the anatomy of the vertebrae to optimize the method of treatment. These studies can help to elucidate the role of RF ablation in the management of chronic low back pain (CLBP) and improve the quality of life of CLBP patients in the near future."

In sum, this procedure is not likely to be more beneficial than the standard of care.

In summary, the denial of a surgical procedure to treat low back pain (procedure code 64628 and 64629) and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risk are substantially increased over standard treatments.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Severe Chronic Kidney Disease (stage 4). 
Treatment: Januvia. 
The insurer denied Januvia. 
The denial is upheld. 

The patient is an adult female with diabetes and chronic kidney disease. The patient has requested approval for Januvia. The health plan has denied this request as no documentation regarding trial, failure or contraindication to formulary alternative (Tradjenta). 

The health plan should not cover the proposed treatment. 

There is no documentation that the requested treatment has been ineffective for this patient nor that is not as effective as the requested non-formulary drug nor that there were adverse effects for this patient to Tradjenta. There is no documentation that the requested drug is safer or more effective than the formulary alternative.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Back Pain.
Treatment:  Inpatient admission.

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

The patient is an adolescent male, who presented to the emergency department (ED) by ambulance with complaints of back pain. The patient was reported to have exhibited odd behaviors including passing out and twisting of the trunk during transport. In the ED, the same patterns continued. In the ED, the patient was given ibuprofen, versed, sodium chloride, and Haldol. Cardiology and Neurology were consulted and recommended Benadryl and observation. The patient had ongoing agitation and abnormal movements with failure to achieve symptom improvement. The patient was then admitted for medical care and/or diagnostic services at the inpatient level of care for low back pain, dystonia, and altered mental status, elevated creatine kinase (CK) and elevated anion gap to 15. The admission determination was based upon the patient's admitting diagnosis, the severity of the signs, symptoms and laboratory data, the patient's contributing comorbidities and the risk of adverse events. The patient was observed in the Pediatric Intensive Care Unit (PICU) and had been free of symptoms for > (greater than) 24 hours. Psychiatry was consulted and cleared the patient for discharge. Follow up with Primary Care Physician (PCP) and Psychiatry were recommended.

The insurer denied the request for the inpatient hospital admission based on the fact that patient could have been placed in observation under monitoring. The patient did not have hemodynamic, pulmonary, metabolic, or neurological reasons requiring an acute level of care. The inpatient admission did not meet Milliman Care Guidelines (MCG) criteria for admission.

The clinical documentation does not support the inpatient admission criteria in accordance with the Milliman Care Guidelines. The documentation did not demonstrate that the patient's new onset of neurologic condition, symptoms, or findings had failed emergency and observation care to support an acute level of care. 

Although the patient exhibited emergent concerns for drug intoxication and other differential diagnoses, the admission for inpatient acute level of care did not meet the Milliman Care Guidelines criteria.

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: Upheld

Diagnosis: stone in the left distal ureter with moderate hydroureteronephrosis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
This adult female was admitted to hospital complaining of abdominal pain, Nausea/Vomiting, and left flank pain. In the emergency room (ER), the patient was afebrile with stable vitals. White blood cell count 18,300. Urinalysis nitrite negative, positive white blood cells/ red blood cells and positive bacteria. Computed tomography revealed a stone in the left distal ureter with moderate hydroureteronephrosis. Patient given intravenous fluids, intravenous Toradol/Tylenol/ Rocephin, patient admitted with stone/urinary tract infection. Patient continued to have pain, urine culture returned negative, patient taken to operating room for cystoscopy, left retrograde, left ureteroscopy, laser, stent placement. Patient tolerated procedure well with no complications. Postop she recovered well; pain controlled, voiding, tolerating oral intake, etc. She was discharged home later that day with outpatient urology follow up. The insurer has denied coverage for the inpatient admission as not medically necessary. They noted the lack of renal failure, sepsis or any serious medical condition. The appeal on behalf of the hospital is noted and read in detail. Per Milliman Care Guidelines (MCG) Health (26th): 

i)	Renal colic + kidney stone patient fails to meet guidelines for admission to inpatient care.

ii)	Urologic surgery or procedure - Patient meets the discharge parameter within 24 hours post procedure as per the guidelines, this procedure is performed in the ambulatory surgery setting.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain; appendicitis
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This patient is an adult female who presented to the emergency department with the complaint of abdominal pain of one-day duration. Examination revealed abdominal tenderness in the right lower abdomen. Vital signs identified a normal temperature at the time of presentation. The heart rate was normal at 79 beats per 
minute. The white blood cell (WBC) count was elevated at 12 thousand. Abdominal computed tomography (CT) scan was completed showing findings consistent with acute appendicitis. The patient was admitted to the hospital and was started on intravenous (IV) antibiotics. Surgical consultation was obtained.
On day #2, the patient underwent laparoscopic appendectomy. Operative findings included an acutely inflamed appendix. The operation was completed without complication. She was monitored following surgery and remained stable. The post-surgical note indicates that the patient was without new complaint. She had normal vital signs following surgery. She 
was started on a diet on day #2 following surgery. She was discharged from the hospital on day #3 following the initial surgical recovery with instructions for surgical follow. The Health Plan rationale for denial is that there is no documentation of need for an inpatient level of care and the care rendered could have been provided with a lower level of care. Per this letter, there were not post-surgical problems. This letter references Milliman Care Guidelines (MCG) Appendectomy without Abscess 26th edition.

The inpatient care was not medically necessary.

Inpatient care was not medically necessary. The submitted medical records do not indicate that there were hemodynamic, pulmonary, neurological, or metabolic reasons for an acute inpatient level of care. Vital signs were normal at the time of emergency department presentation. The evaluation with history and physical exam and computed tomography (CT) scan supported the indication for appendectomy. There were not complications of surgery, and this operation is typically performed without need for full inpatient admission. Inpatient care for this patient was not medically necessary based on the standard of care. The care provided during this time could have reasonably and appropriately been provided with a lower level of care. A lower level of care would have provided for emergency department assessment, provision of intravenous fluid and antibiotics, surgical consultation, surgery to remove the appendix and post-surgical monitoring. This patient was clinically stable at the time of presentation to the emergency department, she remained stable throughout the perioperative period and was able to be discharged from the hospital following an uncomplicated initial recovery on the first post-surgical day.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male who initially presented to the emergency department with dizziness and ringing in the left ear after being punched in the left ear. Pertinent history included prior cerebrovascular accident with residual right sided weakness. Initial vital signs revealed a temperature of 98.1F, heart rate (HR) 92, blood pressure (BP) 114/80, respiratory rate (RR) 18, and peripheral capillary oxygen saturation (SpO2) 99% on room air. Initial examination documented the patient as alert and oriented without evidence of cerebrospinal fluid (CSF), rhinorrhea, raccoon eyes, or hemotympanum but vertical nystagmus noted on CN (central nerve) 3, 4, and 6 testing. 

The inpatient hospital admission was not medically necessary. Evaluation and management could have been performed at a lower level of care. The patient presented with concerns of dizziness and tinnitus after being punched in the left ear. Initial examination documented the patient as alert, oriented, hemodynamically stable, and without physical evidence of an intracranial bleed. Initial evaluation revealed relatively unremarkable laboratory testing with computed tomography (CT) head imaging unremarkable for acute intracranial hemorrhage or ischemia, but did note a venous anomaly with stasis of blood flow mimicking an acute intracerebral hemorrhage. Subsequent magnetic resonance imaging (MRI) / magnetic resonance angiography (MRA) brain imaging ruled out acute intracranial pathology. Treatment was largely supportive while obtaining additional diagnostic testing. Neurology was consulted, documented initial CT head imaging was unremarkable or acute intracranial lesions, and recommended outpatient follow-up. Following observation care, the patient was deemed medically stable and discharged. No other issues or complications were documented.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary Tract Infection

Treatment: Inpatient admission

The insurer denied coverage for: Inpatient admission

The denial is: Upheld

This is a teenage patient with history of multiple urinary tract infections/pyelonephritis and left grade intravesical ureteric reimplantation (IVUR) presented to emergency department (ED) with complaint of right flank pain, urgency, chills, nausea. In ED the patient was febrile with tachycardia, white blood cell count 13,200, they had a urinalysis positive for nitrates, moderate leukocyte esterase (LE). The patient started intravenous (IV) Rocephin, cultures were sent, ultrasound (U/S) was negative for hydronephrosis, and the patient was admitted for further management of urinary tract infection. The patient improved on IV fluids, IV Rocephin, blood cultures returned negative. The patient transitioned to oral Keflex, was stable for discharge home, with outpatient urology follow-up 3 days later. The insurer has denied coverage for the inpatient hospital admission as not medically necessary. The appeal on behalf of the hospital is noted and read in detail. Per Milliman Care Guidelines (MCG) Health (27th) Urinary Tract Infection Pediatric, patient fails to meet clinical indications for admission to inpatient care. These include bacteremia, hemodynamic instability, altered mental status that is severe or persistent, urinary obstruction, etc.

The inpatient hospital admission is not considered medically necessary for this patient.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Knee pain

Treatment: Inpatient admission

The insurer denied coverage for Inpatient admission

The denial is overturned.

The medical records denote a complex revision knee arthroplasty was performed. The operation was not a primary knee replacement. There were underlying comorbidities which increase the risk of complication. Namely, this adult female is morbidly obese. Her BMI was greater than 40. Her anesthesia classification was American Society for Anesthesia (ASA) 3. 

The procedure itself was extensive requiring a large surgical exposure. There was evidence of post surgical bleeding which was to be expected. The medical record on post-operative day (POD) # (number) 1 noted the possibility of transfusion. She required ongoing pain medication. Her physician documented that the services would not be obtainable as an outpatient. 

Based upon the complexity of surgery and associated medical conditions, the admission and length of stay were appropriate and necessary.

Based on the above, the insurer's denial must be overturned. 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 the full hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma

Treatment: Dupixent pen (300mg [milligram] /2ml [milliliter] pen injector, 300mg via subcutaneous injection monthly for one year

The insurer denied coverage for Dupixent pen (300mg/2ml pen injector, 300mg via subcutaneous injection monthly for one year.

The denial is overturned.
 
Patient is an adult female who by history stated that she had childhood asthma at age 5.
Now with increased symptoms for about 5 years. The patient was seen in the doctor's office for a cough.  Hyperactive airways were noted, and she had been treated with steroids the prior month. Lungs were clear and oxygen saturation on room air was 96% (percent).  Her physical exam was unremarkable.  The diagnosis included: Asthma, Allergic Rhinitis and obstructive sleep apnea (OSA).

The patient's medications included bronchodilators via nebulizer, Advair, Singulair, Flonase and Albuterol inhaler as needed (PRN). This patient has an Obstructive Ventilatory defect.
Forced expiratory volume / forced vital capacity (FEV/FVC) ratio is 72% (percent). Patient also has improvement in FVC by 360 cubic centimeters (cc) (12% [percent]) post bronchodilator administration.
Both of these are indicative that this patient has an Obstructive ventilatory defect and is consistent with a diagnosis of Asthma.

The patient has been on multiple inhalers of different medication types. The patient also has elevated Absolute Eosinophil Count (AEC) of 700. She continues to have multiple exacerbations while on these medications and needs systemic steroids for rescue.

Dupixent is an appropriate addition to her regimen.

Based on the above, the insurer's denial must be overturned. 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 Dupixent pen (300 milligrams per 2 milliliters (mg/2ml) pen injector, via subcutaneous injection monthly for one year) is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Obesity
Treatment: Mounjaro
The insurer denied Mounjaro. 
The health plan's determination is upheld. 

This is a case review for a female patient being prescribed Mounjaro.

The patient is not currently being treated with the requested medication. There was no diagnosis code associated with the requested medication. There is a notation in the file that the patient had gastrointestinal upset with Ozempic. There were no office visit notes or letters provided as part of this appeal.

A formulary exception is not indicated in this case. The patient was reportedly not able to tolerate Ozempic. There are multiple other medications in the same medication class [GLP-1 (Glucagon-like peptide-1) receptor agonists] that are available on the plan formulary. Untried medications that are available on the formulary include Rybelsus, Trulicity, and Victoza. There is insufficient evidence that there is medical exemption to the plan criteria which require trial of a formulary drug before approval of a non-formulary drug in the same class. There is insufficient evidence that the formulary drug would be ineffective or not as effective as the non-formulary drug. Guidelines for the treatment of type 2 diabetes recommend considering a GLP-1 receptor agonist medication to help achieve target Hemoglobin A1c, but they do not specifically recommend the requested non-formulary medication over the formulary alternatives.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sciatica
Treatment: Spinal Surgery: Kyphoplasty, 2 Units

The health plan denied Spinal Surgery: Kyphoplasty, 2 Units.
The determination is Overturned.

The patient is a male with lower back pain (LBP) and left radiculopathy, a diagnosis of Lumbar 3 (L3) hemangioma, L2-3-disc disease, and a proposed treatment of L3 Kyphoplasty. The insurance company has denied the procedure recognizing that kyphoplasty is primarily used to treat vertebral fracture, and that no fracture exists at this time for the patient. Magnetic resonance imaging (MRI) showed no fracture, but it did show a central disc bulge at L2-3, and corresponding moderate canal stenosis as interpreted by the reading radiologist.
At issue is the medical necessity of the Spinal Surgery: Kyphoplasty, 2 Units.
The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of Spinal Surgery: Kyphoplasty, 2 Units is medically necessary for this patient. Typically, kyphoplasty is only performed when there is an identified acute or subacute vertebral body fracture, or tumor with impending fracture. This can be identified via (by way of Magnetic Resonance Imaging) MRI, computed tomography (CT) scan, or total body bone scan. Expansive tumors and painful hemangioma are indications for kyphoplasty. Evidence has been published since 2009, and the North American Spine Society recommends vertebral augmentation for kyphoplasty in its 2023 published guidelines. As stated in the North American Spine Society coverage recommendations, "today vertebral augmentation is performed across the world for the treatment of painful vertebral body fractures due to osteoporosis and neoplasms and other expansile tumors such as aggressive hemangiomas." Percutaneous treatment with vertebroplasty or kyphoplasty has been shown to be a minimally invasive and effective treatment of painful vertebral hemangiomas. Multiple hemangiomas are seen in 25-30 percent (%) of patients, but sacral involvement is uncommon. According to Jones, Bruel, and Vattam, their case series demonstrates a successful response to vertebral augmentation using balloon kyphoplasty when other treatment modalities failed. When compared to traditional first line treatments such as vertebroplasty or lytic therapies, kyphoplasty may offer fewer procedural risks such as a decreased exposure to radiation, a decreased risk of excessive hemorrhage, and a decreased risk of cement leakage which may make it the preferred treatment of painful vertebral hemangiomas in the future.
Therefore, the requested treatment is medically necessary.