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

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

The patient is a female with documented symptomatic tachyarrhythmias, on no cardiac medications.  She was admitted electively for EP (electrophysiology) procedure, including ablation. The procedure was uncomplicated. She was admitted for observation. She was discharged the same day. No cardiac medications were listed on discharge.

The patient did have asymptomatic low blood pressure, which was stable and near her baseline. Pre-procedure BP (blood pressure) was less than 100 systolic . She was considered to be hemodynamically stable through her hospital course.

No, the Inpatient admission was not medically necessary.
The same day scheduled uncomplicated procedure was performed without incident. The patient's low BP (blood pressure) was at baseline per notes, and she was treated as hemodynamically stable throughout. Her EKG (electrocardiogram) and labs were normal. The only care that was provided was telemetry. No advance care was required.

The letter of appeal was carefully reviewed, but it did not offer any evidence that inpatient level of care was necessary to treat this patient. Common medical practice and community standards are consistent with outpatient level of care for this patient's clinical scenario.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: menorrhagia
Treatment: Inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is overturned. 

The patient is a female who underwent an open abdominal supracervical hysterectomy. The procedure, done for menorrhagia and suspected adenomyosis, was reported to have been performed without complication. The patient was admitted to the hospital.

The inpatient hospital admission was medically necessary for this patient.
The two-night inpatient stay for this patient after open hysterectomy was medically necessary, and an observation designation would not be reasonable. The standard for such a surgery is a two day stay in the hospital (some literature puts the average at 3 days), commanding an inpatient level of care. The procedure was reported to be performed via a Pfannestiel incision (a lower transverse incision, usually 10-14 centimeter (cm) wide), rather than a mini-laparotomy or laparoscopic approach. There is no literature or basis in current practice for ambulatory or overnight observation discharge of patients after full gynecologic laparotomy. These incisions generate a significant amount of pain, requiring medication and nursing assistance that just cannot be provided at home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient Hospital
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient presented to the emergency department complaining of chest pain. Her medical history was remarkable for diabetes, hypertension, hypothyroidism, coronary artery disease, myocardial infarction and percutaneous coronary intervention. Her blood pressure was 145/65 millimeters of mercury (mmHg) with a heart rate of 91 beats/minute. Her room air oxygen saturation was 100%. Her physical exam was unremarkable. An electrocardiogram showed sinus rhythm and was a normal tracing. Her serum troponin level was normal. The patient was admitted to the hospital to rule out acute coronary syndrome. Lower extremity edema was noted and furosemide was prescribed. The patient was seen by a cardiologist who documented clear lungs, no jugular venous distension and no peripheral edema. There was chest wall tenderness to palpation. Myocardial perfusion imaging (MPI) and an echocardiogram were recommended. A repeat troponin level was normal. The echocardiogram showed normal left ventricular systolic function and no significant valve disease. MPI showed no evidence of ischemia. The patient was discharged. At issue is the medical necessity of an inpatient stay.

Based on the information provided, an inpatient level of care was not medically necessary for this hemodynamically stable patient with a normal electrocardiogram and normal cardiac biomarkers.
This patient, with known coronary artery disease, presented with atypical symptoms that were thought to be suspicious for acute coronary syndrome (ACS). Observation until ACS could be ruled out was reasonable and prudent. On the other hand, she was hemodynamically stable, with normal cardiac biomarkers, and a normal electrocardiogram. She did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received did not require an inpatient admission and could have been provided at a lower level of care. This approach has been shown to be safe and is in accordance with the 2014 American Heart Association (AHA) / American College of Cardiology (ACC) Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Thalassemia
Treatment:  Formulary exception for Jadenu
The insurer denied the  Formulary exception for Jadenu.
The denial is upheld.

The patient in this case is a male with thalassemia who has required chronic transfusions.  He has secondary iron overload.  He has been on treatment with luspatercept for approximately a year.  Records indicate that this has resulted in significant improvement in iron overload and his transfusion requirements. He has been on treatment for iron overload with Jadenu and deferoxamine.

A few months ago the patient's ferritin was 234. It was recommended that he continue treatment with Jadenu.  This medication was denied because it is not covered for treatment of iron overload if the ferritin level is consistently below 500. This decision was appealed but there is no information provided regarding the specific reason that this patient's physician feels continued treatment with Jadenu is necessary for this patient.

No, the health plan should not cover the Formulary exception for Jadenu.
This patient has been successfully treated for iron overload.  Records indicate that he no longer has iron overload based on serum ferritin, and records also indicate that hepatic iron content has improved significantly.  His transfusion requirements have also significantly improved.  Given all of those factors, there is no clear indication for continuation of Jadenu at this time.  There is no evidence indicating that continued use of Jandenu for this patient, rather than using it as needed based on iron overload status, can improve health outcomes.

Given lack of any ongoing iron overload, continued use of Jadenu should not be covered.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Chronic Migraines
Treatment: Formulary exception for Ubrelvy 100mg OR TABS
The insurer denied the Formulary exception for Ubrelvy 100mg OR TABS.
The denial is upheld.

The patient is a female with migraine headache disorder. She has tried and failed Fioricet, acetaminophen and tizanidine for abortive therapy. The provider is requesting Ubrelvy. The requested medication was denied coverage as she has not tried and failed the preferred medications. The provider indicated that the patient cannot use triptans due to a history of carotid dissection.

No, the health plan should not cover the Formulary exception for Ubrelvy.
There is no documented reason as to why the patient cannot be treated with the preferred formulary agents. A history of carotid dissection is not a contraindication to the preferred medications. All of the preferred agents are considered first-line, standard-of-care migraine abortive agents (Thorlund et al.).  There are no high-quality clinical trials or standard-of-care guidelines supporting the preferential use or superiority of Ubrely relative to the preferred oral agents (Dodick et al.).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest and Abdominal Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female. She presented to the emergency department with chest pain.

A cardiac source of the patient's chest pain was ruled out. On ultrasound, she was found to have cholelithiasis without inflammation. WBC (white blood count) was elevated at 16.9.

The patient underwent laparoscopic cholecystectomy, finding a distended inflamed gallbladder, leaving a JP (Jackson Pratt) drain.  The JP (Jackson Pratt) drain was removed, and the patient was discharged home without complication.

No, the Inpatient admission was not medically necessary.
The patient did not meet inpatient criteria, as she did not have a complicated postoperative course, or any other acute medical problems requiring inpatient admission.

The patient was hemodynamically stable. None of the patient's workup for ACS (acute coronary syndrome) or interventions that she received were consistent with acute inpatient care. Treating the patient at a lower level of care would not have jeopardized the patient's health, safety, or care. All of the care that the patient received was consistent with a lower level of care. A lower level of care would have been consistent with the standard of care in the medical and surgical communities.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion

Treatment braces and monthly visits

The insurer denied coverage for braces and monthly visits

The denial is upheld

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The Orthodontist recommended comprehensive orthodontics due to impacted permanent anterior. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of impacted permanent anterior where extraction is not indicated. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining only 20 points on review by internal reviewer.

It is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, a Handicapping Labiolingual Deviation Index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.   For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.

In this case, the treating orthodontist claims an automatic qualifying condition of impacted permanent anterior where extraction is not indicated. This reviewer finds this automatically qualifying condition criterion is not met and does not support comprehensive orthodontic care. This reviewer attained a score of 20 points on the HLD index (3 points overjet, 4 points overbite, 10 points anterior crowding, 3 points labiolingual spread).

The clinical circumstance as presented does not substantiate medical/dental necessity of orthodontic care. The healthcare plan acted reasonably and with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the braces and monthly visits is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain, Shortness of Breath and Abdominal Pain. 
Treatment: Inpatient Admission. 

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

The patient is a female with a past medical history significant for HTN (hypertension), obesity and CHF (congestive heart failure), with EF (ejection fraction) of 40% on recent echocardiogram. She presented to the ER (emergency room) for evaluation of non-exertional chest pain. The patient reported no associated symptoms or modifying factors. 

The patient's ECG (electrocardiogram) revealed normal sinus rhythm with no ischemic changes. Cardiac troponins were negative. Chest X-ray revealed no acute cardiopulmonary disease. The patient was admitted to rule out ACS (acute coronary syndrome). Her oral medications for CHF (congestive heart failure) were continued. No stress test or cardiac catheterization was planned. The patient was ruled out for ACS (acute coronary syndrome) by serial ECG (electrocardiogram) and cardiac enzymes. She was discharged home with a plan for outpatient follow-up. 

No, the Inpatient admission was not medically necessary. 

This patient presented for evaluation of chest pain. The diagnosis of an acute MI (myocardial infarction) was ruled out by cardiac enzymes, which were negative. There was no plan for inpatient ischemic work-up, such as stress test or cardiac catheterization. There was no evidence of acute myocardial infarction, ACS (acute coronary syndrome), decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission, and the care required could have been provided at an observational level of care, as suggested in the letter from the plan.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Multiple Sclerosis
Treatment: Vumerity 231MG OR CPDR
The insurer denied the Vumerity 231MG OR CPDR
The denial is upheld. 

The patient is a female with a documented diagnosis of multiple sclerosis (MS). She has not been treated with any disease modifying agent. The provider is requesting treatment with Vumerity. The requested medication was denied coverage as the patient has not tried and failed the required preferred medications.

No, the proposed treatment is not medically necessary.
There is no reason the patient cannot be treated with the preferred formulary agents for her condition. All of the preferred agents are Food and Drug Administration (FDA) approved for the patient's condition based on high quality clinical trials published in the peer reviewed medical literature (Rae-Grant et al.). There are no high quality clinical trials or standard of care guidelines supporting the preferential use or superiority of Vumerity relative to the preferred agents. There is no evidence that switching to a preferred agent would jeopardize her clinical stability.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: purulent drainage from an incision over the natal cleft

Treatment: inpatient site of service 

The insurer is denied coverage for inpatient site of service

The denial is overturned. 

This female patient has a history of anemia who presented to the Emergency Department (ED) for evaluation of weakness, dizziness, and drainage from her incision site two months after buttock augmentation surgery. 

The admission meets the MCG 25th Edition Cellulitis criteria because she required immediate initiation of IV therapy and monitoring was necessary due to her anemia, hypotension and renal insufficiency. In addition, her presentation was consistent with a suspected necrotizing soft tissue infection.  The associated incision and drainage was not amenable to outpatient care due to the need for postoperative wound irrigation.  The admission meets several of the MCG criteria for admission to treat a rapidly progressing infection. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

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

The carrier's denial of coverage for the inpatient site of service is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female who has a history of ulcerative colitis. She also had a medical history of breast cancer on tamoxifen after chemotherapy, radiation and lumpectomy and cholecystectomy. The patient presented with abdominal pain rated 7 out of 10.

Abdominal fluid was noted on CT (computed tomography) scan.  Surgery suggested a paracentesis. Colitis was also noted on the CT (computed tomography) scan, and gastroenterology was consulted. The patient was admitted for supportive care. Stool studies were normal.  A repeat CT (computed tomography) scan of the abdomen did not show the ascites as originally noted. The patient received IV (intravenous) steroids and pain medication. Once improved, the patient was discharged home.

No, the Inpatient admission was not medically necessary. The care as provided was medically appropriate; however, the level at which the care was rendered was not medically necessary.
Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had abdominal pain and a history of colitis; yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for a prolonged NPO (nothing by mouth) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission.  As such, the care could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcoholism. 
Treatment: Inpatient admission. 

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

This patient is a male with a history of alcoholism who presented for detox.  He complained of nausea and tremors. 

The patient's vital signs were as follows: temperature 36.9 Celsius, pulse 115, respiratory rate 20, blood pressure 112/67, and oxygen saturation 100%.  His exam was normal.  Labs revealed the following: sodium (Na) 143, potassium (K) 3.3, and blood urea nitrogen (BUN) / creatinine (Cr) 9.4/.74.  His complete blood count (CBC) was unremarkable. Urine toxicology was positive for cannabinoids.   Electrocardiogram (EKG) showed sinus tachycardia.  There were no signs of delirium tremens (DTs). 

The patient was admitted. His plan of care included Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol.  Day one, the patient's vital signs were as follows: temperature 36.7 Celsius, pulse 70, respiratory rate 12, and blood pressure 117/72.  The patient reported minimal tremors.  He was cleared for discharge the next day. 

No, the proposed treatment is not medically necessary. 

This patient with a history of alcohol abuse and withdrawal was admitted after requesting detox. He was not acutely intoxicated. The patient was hemodynamically stable and afebrile. He had mild tachycardia but no arrhythmia. There were no signs of delirium tremens (DTs).  He did not have comorbid conditions. The patient was admitted with a plan for Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol.  During his hospital stay, he did not have findings of acute alcohol withdrawal. He was being managed with oral medication assisted treatment. The patient was clinically stable and discharged the next day. He did not have symptoms that required an acute inpatient level of care and had not failed a lesser level of care. The acute inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Keloid scar. 
Treatment: Surgical removal of keloid scar, code 14020. 

The insurer denied coverage for surgical removal of keloid scar, code 14020. 

The denial is overturned. 

This case involves a patient who sustained injuries in a golf cart accident, which resulted in scars to the knee, wrist, and shoulder.  The patient previously underwent injection to the scars on the shoulder and knees.  The scars on the knee improved, but the shoulder scar did not.  The treating physician was requesting surgical removal of the keloid scar.  A notice of action was received, stating that the requested health services did not meet the medical criteria given that the scar was not causing functional impairment.  Letter stated that the location of the keloid is on the patient's right shoulder over a bony prominence.  In addition to persistent pruritus, the location of the keloid has impacted her daily ability to wear a bra/clothing with straps.  Also causes discomfort rolling onto the right shoulder, which had not improved with initial treatment efforts, and required specialized treatments at excision with plastic surgery.  A letter to whom it may concern stated that the keloid forced the patient to keep the shoulder covered at all times in a highly visible location, which was causing her a great emotional distress.  The patient was very involved in water sports as a camp sailing instructor, and with swimming in the winter.  Her bandage, which is required to wear at all times, will fall off and cause her anxiety as she feared she would get cancer as a result of not having an extra Band-Aid.  She endorsed shame and felt bad about the body she was once confident about.  The anxiety and fear of not fitting in because of the scar was causing her social anxiety.  An appeal letter was sent, stating that the patient had a 2-cm (centimeter) keloid scar on the right shoulder with raised edges and well-defined borders.  The area was tender to direct palpation.  An undated letter from the patient's mother stated that the scar was making it impossible for the patient to wear her bra, dress for the season, and function normally.  She stated that the issue has caused stress and discomfort, leading the patient to tears and frustration every day. 

The surgical excision was appropriate given that the scar was a result of trauma, was painful, and the patient failed conservative treatment.  Additionally, the information confirmed that the patient was developing social anxiety because of the injury, which could lead to additional treatment requirements to address any mental health issues attributed to the associated scar.  Based upon this information, it was determined that the medical necessity of the surgical removal of keloid scar, code 14020 was medically necessary.  The health plan did not act reasonably or in the best interest of the patient. 

The insurer's denial of coverage for surgical removal of keloid scar, code 14020 is overturned.  Medical Necessity is substantiated.