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

Diagnosis: Choledocholithiasis/cholangitis
Treatment: Inpatient hospital stay.
The insurer denied the Inpatient hospital stay. 
The health plan's determination is overturned. 

This patient is a female with a past medical history significant for gastric bypass who presented with right upper quadrant pain and fever in the setting of computed tomography (CT) scan findings concerning for choledocholithiasis/cholangitis. She was admitted to the inpatient floor and completed a diagnostic magnetic resonance cholangiopancreatography (MRCP), and received intravenous (IV) fluids, IV antiemetics, IV analgesics, broad-spectrum IV antibiotics, and urgent gastrointestinal (GI) and surgery consultation. GI recommended laparoscopic-assisted endoscopic retrograde cholangiopancreatography (ERCP) for further evaluation.
At issue is the medical necessity of the Inpatient hospital stay.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of Inpatient hospital stay was medically necessary for this patient.
This is a patient with a surgical history noted for gastric bypass, a history of intraductal papillary mucinous neoplasm (IPMN), and diabetes, who presented with acute choledocholithiasis/cholangitis. She was at risk for complications of choledocholithiasis/cholangitis, which include abdominal abscesses/peritonitis, sepsis, and death. Her clinical presentation required urgent and detailed inpatient care such as IV fluids, IV analgesic, IV antibiotics, serial monitoring labs, diagnostic imaging, and GI and surgical consultation. Most importantly, she needed a laparoscopic-assisted ERCP due to a history of gastric bypass. This complex and detailed inpatient care cannot be provided at a lower level of care without increasing mortality or morbidity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Syncope.
Treatment:  Inpatient admission.

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

This patient presented to the hospital following an episode of syncope. The patient was standing in the bathroom, felt confused and lightheaded and then lost consciousness, fell and hit their head.  Past medical history was significant for a previous syncopal episode with head trauma and a concussion six months earlier in the setting of alcohol use and volume depletion, diabetes mellitus, anxiety, depression and active marijuana use. On arrival to the hospital vital signs were stable: blood pressure (BP) 121/86 and pulse 68.  Finger stick glucose was 170. Physical examination revealed no abnormalities.  12 lead electrocardiogram (ECG) revealed normal sinus rhythm, normal intervals and no ST or T wave abnormalities. Serum blood testing demonstrated a blood urea nitrogen (BUN) of 17 and a Creatinine of 0.79. The patient was admitted to the hospital for telemetry monitoring and additional testing.  Computed tomography (CT) head revealed no abnormalities. An electroencephalogram (EEG) was within normal limits.  Echocardiogram demonstrated no wall motion abnormalities and a preserved left ventricular ejection fraction (55-60%). No abnormalities were noted on telemetry monitor. The etiology of syncope was thought to be due to volume depletion, and the patient was discharged home with follow up. 

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient. This patient presented with syncope that occurred while standing. The patient had symptoms of lightheadedness prior to losing consciousness and a similar episode several months earlier that was diagnosed as volume depletion.  Physical examination and serum blood testing revealed no major abnormalities.  Echocardiography revealed a structurally normal heart with a normal left ventricular ejection fraction. This patient falls into a low to intermediate risk group for syncope. According to American Heart Association/American College of Cardiology/Heart Rhythm Society (AHA/ACC/HRS) guidelines, such patients should be managed utilizing a structured emergency department (ED) observational protocol (Reference 1).  In a study of individuals presenting to the emergency room, patients that were low risk or intermediate risk for cardiac events had an excellent prognosis and did not require admission to the hospital for further testing (Reference 2).  In this case, the patient had a normal echocardiogram and 12 lead ECG. The clinical presentation was consistent with an etiology of volume depletion. Acute inpatient admission was not 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 inpatient hospital admission is not substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Other - Chronic Eustachian Tube Dysfunction
Treatment: Nasal and/or sinus endoscopy surgical with dilation (eg balloon dilation) maxillary, frontal and sphenoid sinuses (sinus surgery) 

The health plan denied: Nasal and/or sinus endoscopy surgical with dilation (eg balloon dilation) maxillary, frontal and sphenoid sinuses (sinus surgery) 
The determination is: Overturned

The patient is a female with a history of recurrent acute sinusitis/chronic sinusitis. She had been treated with multiple courses of oral antibiotics, intranasal corticosteroids for several weeks, intranasal saline rinses, oral antihistamines, and subcutaneous immunotherapy without sufficient improvement in symptoms. Nasal endoscopy demonstrated exam findings consistent with chronic rhinitis/chronic sinusitis. A computed tomography (CT) scan of the sinuses was performed, which showed bilateral pansinusitis with partial obstruction of the osteomeatal complexes. The treating Otolaryngologist is requesting balloon sinuplasty bilaterally.

At issue is whether the proposed health service or treatment is likely to be more beneficial than any standard treatment for the patient's condition.
The health plan's determination regarding the proposed health service or treatment is overturned in whole.
The proposed health service/treatment of bilateral balloon sinuplasty (maxillary/sphenoid/frontal balloon sinuplasty) is likely to be more beneficial than any standard treatment for the patient's condition/disease. The proposed health service/treatment of balloon sinuplasty is not investigational/unproven. The Food and Drug Administration (FDA) approved balloon sinuplasty with appropriate indications in 2005. Given the patient's diagnosis and current health status, the proposed procedures are appropriate. The patient has received a thorough workup including physical examination and a CT scan of the sinuses which have all demonstrated chronic sinusitis. The patient has a history of recurrent acute sinusitis. The patient has undergone maximal medical therapy including undergoing treatment with multiple prolonged courses of oral antibiotics, intranasal corticosteroids, oral antihistamines, subcutaneous immunotherapy, and nasal saline rinses, without sufficient improvement in symptoms.

The American Academy of Otolaryngology clinical consensus statement (last published in 2018) states that balloon sinus dilation is appropriate as a standalone procedure in patients with chronic sinusitis.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Other - Chronic Eustachian Tube Dysfunction
Treatment: Nasal and/or sinus endoscopy surgical with dilation (eg balloon dilation) maxillary, frontal and sphenoid sinuses (sinus surgery) 

The health plan denied: Nasal and/or sinus endoscopy surgical with dilation (eg balloon dilation) maxillary, frontal and sphenoid sinuses (sinus surgery) 
The determination is: Upheld

M142

The patient is a female with a diagnosis of chronic sinusitis. Medical management has included oral antibiotics, oral antihistamines, and oral and nasal steroids. She has also been on immunotherapy. Her nasal exam was normal. A computed tomography (CT) scan reported minimal mucosal thickening of the maxillary, frontal, and sphenoid sinuses.
At issue is whether nasal and/or sinus endoscopy surgical with dilation - maxillary, frontal and sphenoid sinuses (sinus surgery) is likely to be more beneficial than any standard treatment for the patient's condition.
The health plan's determination regarding the proposed health service or treatment is upheld in whole.
No, the proposed health treatment is not likely to be more beneficial than any standard treatment for the patient's condition. Balloon sinuplasty has not been shown to be more beneficial than standard sinus surgery in well-designed studies. Balloon sinuplasty has been shown to be equivocal, but it has not been shown to be more beneficial. Standard sinus surgery is considered the standard of care treatment for chronic sinusitis that is refractory to medical management.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Neck pain.
Treatment:  Facet Joint Injection.

The insurer denied Facet Joint Injection. The health plan's determination is overturned. 

This patient is a female who has a long-standing history of chronic neck pain for 10 years. Her pain level is 4/10. She had tried physical therapy (PT), chiropractic manipulation, and pain medications, none of these provided her with adequate pain relief. Physical exam (PE) was unremarkable except neck pain with flexion and extension. She underwent right side facet injection with significant pain relief. Magnetic resonance imaging (MRI) revealed multilevel degenerative disc disease (DDD), facet arthritis and severe right, moderate left C (cervical)5/6 foraminal stenosis. 

The Facet Joint Injection is medically necessary for this patient.

This patient has long-standing history of neck pain. She had tried extensive treatment including physical therapy (PT) without adequate pain relief.  She has symptoms consistent with facet arthritic pain. MRI revealed findings of facet arthritis. Further treatments are medically necessary to improve her pain and suffering. The requested facet joint injection is the standard of care in this clinical setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder
Treatment: Braces and monthly visits
The insurer denied Braces and monthly visits.
The determination is upheld.

This is a female patient with a Class I occlusion. She has a 3-millimeter (mm) overbite and 4 mm overjet. She has minor maxillary and severe mandibular crowing. Her maxillary canines are displaced to the labial. She is treatment planned for 24-36 months of orthodontics to correct her malocclusion. At issue is the medical necessity of braces and monthly visits.
There is no medical reason to correct the patient's malocclusion with braces. She does have a deep bite, however, that alone is not a medical necessity to treat. The photographs do not illustrate any damage to the teeth or soft tissue damage from their current position. There are functional problems that can occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. (1) This patient presents with none of those conditions. Aligning her teeth will likely not increase chewing efficiency since masticatory efficiency is already the highest in patients with a Class I occlusion. (2) The patient has a slightly excessive overjet but this amount of overjet does not negatively affect oral health related quality of life. (3) If her teeth were aligned, it would provide an esthetic improvement but it would not create a medically significant improvement to the patient's health. Orthodontic treatment is not medically necessary.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Polyp of nasal cavity.
Treatment: Xhance Nasal (fluticasone propionate).

The insurer denied coverage for Xhance Nasal (fluticasone propionate).  The denial is overturned.

The patient is an adult male, who has a history of polyps and presented with nasal congestion. The patient has been using nasal lavage and Xhance and has not had recurrence of polyps on examination. The request for Xhance Nasal (fluticasone propionate) is under review.

The formulary drug is not likely to cause the patient an adverse reaction. All of the formulary drugs have a safe profile and are approved for treatment of congestion and polyposis.      

The formulary drug has not been ineffective based on the patient's clinical history. A letter written by the provider states the alternatives have not been trialed, but that Xhance has been successful in the past.     

The requested drug would be more effective than the formulary drug.

The patient has been using the requested medication (Xhance) and nasal lavage without reoccurrence of polyps. The medical literature supports usage of Xhance in patient's with a similar profile.

As such, the request for Xhance is approved. 

Per Sher, M. R., et al. (2020), "Exhalation Delivery System - Fluticasone (EDS-FLU) twice daily (BID) in the treatment of Chronic Rhinosinusitis (CRS) with or without polyps was safe, well-tolerated, and produced substantial improvement across a broad range of both objective and subjective measures."

Sindwani, R., et al. (2019) states, "All EDS-FLU doses produced significant improvement in both coprimary end points (P < .05) and in SNOT-22 total score (P <= .005). EDS-FLU significantly improved all 4 cardinal symptoms of NP (P < .05), including congestion/obstruction, facial pain/pressure, rhinorrhea/post-nasal drip, and hyposmia/anosmia. Approximately 80% of subjects reported improvement with EDS-FLU, with 65% reporting "much" or "very much" improvement by week 16. Adverse events were generally local in nature and similar to other intranasal steroids studied for similar durations in similar populations, with the most common being epistaxis."

"Sinus surgery removes inflamed tissue, restores airflow, and improves delivery of medication into surgically opened spaces. The exhalation delivery system with fluticasone (EDSFLU; XHANCE) uses a novel delivery system to create closed palate, positive pressure, bidirectional mechanics that significantly alter the deposition of the topically acting anti-inflammatory medication" (Ow, R. A., et al. 2023). 

Finally, Up to Date in a discussion regarding delivery systems noted that while direct evidence supporting EDS beyond standard nasal sprays is limited, the data do suggest that EDS did result in additional symptom control. 

The carrier's denial of a request for a Formulary Exception for Xhance Nasal (fluticasone propionate) for use in the treatment of polyp of nasal cavity is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Cardiac/Circulatory Problems/Congestive Heart Failure (CHF).
Treatment:  Inpatient Admission.

The health plan denied the requested inpatient admission.  The health plan's determination is overturned.

This case involves a female with a past medical history significant for chronic heart failure with mildly reduced left ventricular ejection fraction (LVEF) 49% (percent), hypertension, schizoaffective disorder, ethyl alcohol abuse, polysubstance abuse, suicidal ideations who was brought to the emergency department (ED) after cutting herself at home with a knife and reporting she wanted to die. She also reported increasing shortness of breath, paroxysmal nocturnal dyspnea, leg swelling, and not compliant with her home heart failure medical therapy. In the ED, her vital signs were stable, but the patient was agitated, requiring administration of intravenous (IV) sedatives to prevent further self-harm. On physical examination, the patient was found to have bilateral rales and leg edema. Her brain (or B-type) natriuretic peptide (BNP) was high at 2,727. She was admitted under inpatient level of care on telemetry service for evaluation and treatment of acute on chronic heart failure with volume overload and was placed on 1:1 observation for a psychiatric evaluation, given suicidal attempts. The patient was treated with IV Lasix, restarted on her home guided directed medical therapy (GDMT), monitored on telemetry, ruled out for C. difficile, and was cleared by the inpatient psychiatry service. After adequate decongestion, the patient was discharged. The patient's health plan has denied coverage for inpatient level of care due to a lack of medical necessity.

I recommend that the health plan's determination of medical necessity be overturned, in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Upper Gastrointestinal Bleed.
Treatment: Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

This is a male patient with a past medical history (PMH) of coronary artery disease (CAD) status/post (s/p) stents times (x) 2, cerebrovascular accident (CVA), gastroesophageal reflux disease (GERD), peptic ulcer disease (PUD), major depressive disorder (MDD), and generalized anxiety disorder (GAD) who was admitted for positive blood cultures (1/2 bottles) from a prior emergency department (ED) visit several days before for chest pain, generalized weakness, and syncope.  The patient was diagnosed with symptomatic anemia due to an upper gastrointestinal bleed (UGIB) without overt signs of gastrointestinal (GI) blood loss and was treated with hemoglobin and hematocrit (H&H) monitoring, intravenous fluids (IVF), proton pump inhibitor (PPI), holding anti-platelets, intravenous (IV) iron, and GI consultation. Of note, the patient had an admission for similar complaints earlier in the month and received both an esophagogastroduodenoscopy (EGD) and a colonoscopy, which showed a non-bleeding gastric ulcer. A GI consultation during this admission recommended supportive care and did not perform an EGD due to a lack of overt signs of GI bleeding and/or hemodynamic instability. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) due to positive blood cultures (1/2 bottles) from a prior ED visit and was found to have a drop in his hemoglobin and positive FOBT (fecal occult blood test). The patient did not have associated high-risk features, such as renal failure, congestive heart failure, or liver failure, nor did the patient have any hemodynamic instability. In addition, the patient did not have a bowel obstruction, diabetic ketoacidosis, or appendicitis. The patient was hemodynamically stable and did not have sepsis, pyelonephritis, ascending infection, toxic appearance, unstable vital signs, abnormal mentation, sustained tachycardia, or immunosuppression. He presented with symptomatic anemia with a small drop in his hemoglobin from a prior discharge, which remained stable throughout the hospital stay, did not require a blood transfusion, and did not require any invasive intervention from GI, while GI deferred a work-up to the outpatient setting. Cardiology evaluated the patient and did not recommend any acute interventions and the patient denied chest pain and shortness of breath (SOB). Given the patient's clinical stability, non-high-risk Rockall score, non-ischemic electrocardiogram (EKG), negative troponin, lack of active bleeding, and benign imaging, clinical findings, and lack of need for a red blood cell (RBC) transfusion, this patient could have been safely treated at a lower level of care and received H&H monitoring, IVF, PPI, holding anti-platelets, intravenous (IV) iron, and GI consultation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Motor Vehicle Collision. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the Inpatient Hospital Stay. 
The determination is upheld. 

This is a male patient who presented to the emergency department (ED) following a high speed car collision. At the time of presentation, he was awake and alert with a Glasgow coma score of 15. He was hemodynamically stable with a heart rate of 98 beats/minute and oxygen saturation of 98 percent (%). Imaging identified a nondisplaced left first rib fracture and trace bilateral pneumothoraces. There was a scalp laceration that was closed in the emergency department (ED) with three staples.
He was admitted to the hospital. His diet was advanced. He remained clinically stable with normal vital signs. Pain management was with oral medications. He was discharged from the hospital. 

At issue is the medical necessity of an inpatient stay. 

Inpatient hospital stay was not medically necessary for this patient.
The care and treatment provided during this time could have appropriately been rendered with a lower level of care. This patient had no comorbid health conditions. He presented as a hemodynamically stable patient having been involved in a high speed car collision. His injuries included 1 rib fracture, trace bilateral pneumothoraces, and a concussion. 

He was clinically stable throughout the period of monitoring as noted in physician and nursing progress notes. He was cleared to ambulate by the physical therapy service and was tolerating a diet with adequate pain management with oral medications. The small bilateral pneumothoraces were expected to resolve without intervention. The scalp laceration was closed with three staples. Based on the documented injuries, patient age, and comorbid health status, it was appropriate to monitor this patient with provision of analgesia and follow up imaging. However, this could have been provided with a lower level of care than inpatient status. 

Per the referenced Milliman Care Guidelines (MCG), clinical indications for inpatient admission include: hypotension, pneumothorax caused by associated lung disease, traumatic pneumothorax that is moderate or large or expanding, tension pneumothorax, hypoxemia, altered mental status, significant comorbidity, dyspnea or tachycardia, infection, severe pain, intervention needed for pneumothorax beyond the observation care time frame. In this case, none of these indications existed to warrant an inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma. 
Treatment: Xolair. 
The insurer denied the Xolair. 
The determination is overturned. 

This is a male patient with a history of severe persistent asthma. He formerly smoked. His presenting complaints were chronic cough and wheezing. These symptoms were persistent despite being on Trelegy, which is an inhaled corticosteroid/long-acting muscarinic agonist/long-acting beta agonist combination inhaler. The medical record also describes the patient as being on dexamethasone, an oral corticosteroid. He is described as having multiple exacerbations requiring oral steroids. His spirometry is reported as normal. The physical exam was notable for coughing and wheezing. Lab results were notable for absolute eosinophilia of 800, immunoglobulin (Ig) E level of 335. There is also a description of laboratory-confirmed allergies to dogs and cats (it's not stated whether this is in vitro or skin testing); also with absolute eosinophilia of 1500. At issue is the medical necessity of Xolair. 
Xolair is medically necessary for this patient. 
The patient has severe persistent asthma with a demonstrably high IgE level, severe symptoms, consistent use of steroid inhalers, recurrent use of oral corticosteroids, multiple exacerbations, report of environmental allergy positivity (unclear if in vitro or skin-test). He meets every metric described in the formulary guide for Xolair. International Global Initiative for Asthma (GINA) guidelines for asthma care offer high dose inhaled corticosteroids as an equal adjunct to biologics rather than a step needed prior to biologics, so the dose of inhaled corticosteroid is not relevant.