Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Type II achalasia 
Treatment: Peroral Endoscopic Myotomy (POEM) Procedure
The insurer denied Peroral Endoscopic Myotomy (POEM) Procedure
The health plan's determination is upheld. 

The patient is a female who has Type II achalasia documented on esophageal manometry. Therefore, the attending gastroenterologist would like to do a peroral endoscopic myotomy (POEM) procedure to treat her achalasia. 

The proposed POEM for achalasia is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Achalasia is a primary disorder of esophageal motility and typically presents with dysphagia to both solids and liquids but may be accompanied by regurgitation and chest pain. The gold standard for the diagnosis of achalasia is esophageal motility testing with manometry, which often reveals aperistalsis of the esophageal body and incomplete lower esophageal sphincter relaxation. The diagnosis is aided by complimentary tests, such as esophagogastroduodenoscopy and contrast radiography. Esophagogastroduodenoscopy is indicated to rule out mimickers of the disease known as "pseudoachalasia" (Example (eg), malignancy). Endoscopic appearance of a dilated esophagus with retained food or saliva and a puckered lower esophageal sphincter should raise suspicion for achalasia. Additionally, barium esophagography may reveal a dilated esophagus with a distal tapering giving it a "bird's beak" appearance. Several therapeutic modalities aid in the management of achalasia, the decision of which depends on operative risk factors.
Conventional treatments include medical therapy, botulinum toxin injection, pneumatic dilation, and Heller myotomy. Dilation and myotomy are the most definitive treatment options.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Shortness of breath
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial is overturned.

This is an adult female who reported shortness of breath. She was admitted to the hospital. She received several diagnostic studies, specialty consultations, and medication management.

The inpatient hospital admission was medically necessary.

The records show the patient was in congestive heart failure (CHF). She was brought to the hospital by ambulance. Concern was reported for ischemia to require several diagnostic studies. She underwent an emergency echocardiogram showing a reduced ejection fraction. She underwent an emergency cardiac catheterization (albeit the arteries were normal). Nevertheless, several medications were provided with changes in dosage. She also required telemetry showing "limited 4 beats of V tach [ventricular tachycardia]." Due to her acuity and clinical presentation, the level of service was appropriate and indicated. Therefore, the inpatient hospital admission was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal pain; nausea; vomiting.
Treatment: Inpatient admission.

The insurer denied Inpatient admission.  The denial is overturned.

The patient is an adult female. She has a past medical history of Helicobacter pylori infection, arthritis, endometriosis, fibroids status post hysterectomy, smoking, cyclic vomiting syndrome, and multiple admissions for abdominal pain. She was admitted for cyclic vomiting syndrome with possible cannabinoid hyperemesis syndrome. The patient presented to the emergency department with severe abdominal pain, nausea, and vomiting x2 days. Computed tomography (CT) of the abdomen / pelvis showed bowel wall thickening of the sigmoid and descending colon. White blood cell (WBC) count was 12.8, lactic acid was 6.4, magnesium was 1.5, and potassium was 3.3. She was treated with intravenous fluids, Zofran intravenous, famotidine intravenous, metoclopramide intravenous, morphine intravenous, magnesium sulfate intravenous, potassium chloride, haloperidol intravenous, and sucralfate. The patient was admitted to the inpatient service. Gastroenterology was consulted and recommended pantoprazole and Zofran intravenous. The patient's treatment plan including metronidazole intravenous every 12 hours, ceftriaxone intravenous every 24 hours, intravenous fluids with D5NS (5% dextrose in normal saline) with KCl (potassium chloride) at 75 cubic centimeters per hour, ondansetron intravenous every eight hours, pantoprazole intravenous every 12 hours, Ketorolac intravenous, magnesium sulfate intravenous, prochlorperazine intravenous, heparin subcutaneously, and nortriptyline. Clostridium difficile was negative. On day #5, the patient received the last dose of antibiotics, ondansetron intravenous, and pantoprazole intravenous.

The Inpatient admission was medically necessary.

The patient required inpatient level of care due to the need for intravenous antibiotics, intravenous fluids, and treatment with intravenous medications, including ondansetron intravenous every eight hours and pantoprazole intravenous every 12 hours. Therefore, the inpatient admission was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroenteritis
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is upheld.

According to the medical records, the patient has enteritis as the admitting diagnosis.  The patient had presented with the complaints of diarrhea and abdominal pain.  The note stated, "hypertension hyperlipidemia Congestive Heart Failure (CHF) coronary artery disease (CAD) status post cardiac stents and pacemaker gastric bypass and abdominal wall hernia presents complaining of 2 days of persistent crampy upper epigastric abdominal pain, nausea, vomiting, and diarrhea -  nonbloody nonbilious." Also, the computed tomography (CT) scan noted: "there are multiple fluid-filled mildly dilated small bowel loops with fecalization of the small bowel contents within several distal small bowel loops. There is no abrupt transition point to suggest a mechanical obstruction. Rather, there is a gradual transition to normal caliber distal small bowel loops. These distal small bowel loops appear mildly thickened and demonstrate mild hyperenhancement of the mucosa. These findings are consistent with an acute enteritis which may be infectious or inflammatory."

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 enteritis; yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for nothing by mouth (NPO) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission.  

"Several different viruses including rotavirus, norovirus, adenovirus, and astroviruses account for most cases of acute viral gastroenteritis. Most are transmitted via the fecal-oral route, including contaminated food and water. Transmission has also been shown to occur via fomites, vomitus, and possibly airborne methods. Norovirus is more resistant to chlorine and ethanol inactivation than other viruses." (Stuempfig, ND. et al.).

"Medical therapy is not necessary in the majority of patients with non-severe viral gastroenteritis (GE). The most important aspect of treatment of acute viral GE is hydration and electrolyte repletion. Oral rehydration solution (ORS) is a balanced sodium-glucose solution which has dramatically reduced the mortality of infectious diarrhea in the developing world. Diarrhea can be slowed using antidiarrheal drugs. These can either slow secretion or motility. Recent studies suggest there may be benefit to use of ondansetron to reduce upper and lower gastrointestinal symptoms in children." (Orenstein, R.).

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 full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 


The patient is an adult who presented to the Emergency Department (ED) with  complaints of abdominal pain. The patient received an intravenous (IV) fluid bolus, IV Zofran, IV Pepcid, IV Toradol, Mylanta and Lidocaine. Imaging revealed gastroenteritis and the patient was admitted with the diagnoses of enteritis, acidosis, and hyperbilirubinemia. She had an elevated temperature at 100.1 degrees Fahrenheit and a low blood pressure at times with a systolic readding over 99. 

Per Milliman Care Guidelines 26th Edition regarding Gastroenteritis, Admission is indicated for 1 or more of the following(1)(2)(3)(4)(5):

Suspected severe infection (e.g., bloody diarrhea), Severe abdominal pain, Peritoneal signs, Toxic megacolon(5), Hemodynamic instability, Vomiting that is severe or persistent, Dehydration that is severe or persistent, Electrolyte or metabolic abnormality that is severe or persists despite observation care (e.g., acidosis, alkalosis, hyponatremia, hypernatremia), Hemolytic uremic syndrome[A](6), Inability to maintain oral hydration (e.g., needs IV fluid support) that persists after observation care.

The patient had an infection; yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for nothing by mouth (NPO) 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 safely been rendered at a lesser level.

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 emergent admission is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Diabetes
treatment: Januvia
The insurer denied Januvia. The health plan's determination is upheld. 

This is a female diagnosed with T2DM (type 2 diabetes mellitus). This request is for Januvia. As reported, she has been stabled on Januvia. Since switching to Tradjenta 5 milligrams (mg) daily her BGs (blood glucose) have been consistently above 250.

A formulary exception is not indicated in this case.
The requested medication is Food and Drug Administration (FDA) approved for type II diabetes. The DPP IV (Dipeptidyl peptidase IV) Inhibitors have similar efficacy. There are no trials showing superiority of one DPP IV inhibitor over another including linagliptin (tradjenta), saxagliptin (onglyza), vidagliptin (galvus), alogliptin (Nesina) or sitagliptin (Januvia). The American Association of clinical endocrinologists' consensus statement regarding treatment of patients with type two diabetes is as follows. It recommends the use of metformin followed by the use of a DPP IV ((Dipeptidyl peptidase IV)) inhibitor or a GLP 1 (glucagon like peptide 1) agonist. The patient's hemoglobin A1c, blood glucoses and other medications are not reported. The formulary alternative is expected to be as effective as the requested drug.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:   Legally blind, heart disease, hypertension and kidney disease

Treatment: Consumer directed personal assistance services (CDPAS) 7 days per week, 10 hours per day; 70 hours per week

The insurer denied coverage for consumer directed personal assistance services (CDPAS) 7 days per week, 10 hours per day; 70 hours per week

The denial is overturned

 
This is an elderly patient with chronic medical problems including heart disease, hypertension and kidney disease. She also has macular degeneration and is legally blind. The patient lives alone in a 2 bedroom apartment. The plan approved 42 consumer directed personal assistance services (CDPAS) hours/week and the request is for 70 CDPAS hours/week. 

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as modified independent. She is reportedly totally dependent to maximal assistance for completing much of her Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient reportedly requires maximal assistance for lower body dressing. Extensive assistance is reportedly needed for bathing, personal hygiene, upper body dressing, eating, toilet transfer/use, locomotion and ambulation. Limited assistance is reportedly needed for bed mobility. The patient is reportedly frequently incontinent of bladder and bowel. Her activity of daily living (ADL) status and self-sufficiency have reportedly declined and deteriorated, respectively over the prior 90 days. She has reportedly fallen over the prior 30 days. The prior UAS report also demonstrates a significant functional decline when compared to the most recent UAS report. The patient's condition and functional deficits have progressed to a level and unpredictable as to require the requested CDPAS 70 hours/week. Based on the enclosed documents reviewed, the patient's health and safety are more appropriately provided and maintained by increasing CDPAS to 70 hours/week.

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 consumer directed personal assistance services (CDPAS) 7 days per week, 10 hours per day; 70 hours per week is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nausea and vomiting. 
Treatment: Inpatient admission. 
The insurer denied the inpatient admission. 
The determination is upheld. 

This is a female patient with a medical history of diabetes mellitus, hypertension, chronic Hepatitis C, hyperlipidemia, cirrhosis, chronic kidney disease stage 2, and depression. She presented to the emergency department with nausea and vomiting. The physical examination was notable for epigastric tenderness, distention, shifting dullness, and guarding. A computed tomography scan of the abdomen and pelvis showed diffuse gastric wall thickening which is nonspecific secondary to under distention versus gastritis, cirrhosis, splenomegaly, hydropic gallbladder, and borderline gallbladder wall thickening. An ultrasound of the liver showed hepatic cirrhosis, mild pericholecystic fluid, lack of cholelithiasis or gallbladder wall thickening, and negative sonographic Murphy's sign; the appearance was stable compared with a prior study. She was treated with intravenous fluids, famotidine, ondansetron, and Ativan. She was placed on a clear liquid diet. She was feeling better and eating; her nausea, vomiting, and abdominal pain had subsided. At issue is the medical necessity for the inpatient level of care.

The inpatient level of care is not medically necessary. The patient presented with abdominal pain, nausea, and vomiting, assessed to be consistent with diabetic gastroparesis versus gastroenteritis. However, there was no small bowel obstruction, acute pancreatitis, active gastrointestinal bleeding, peritonitis, abscess, fistula, or sepsis, which would require the inpatient level of care [1-3]. Although the patient presented with nausea and vomiting, she did not have persistent hypotension, organ failure, or other stigmata of severe volume depletion. An endoscopy was not performed, and her symptoms improved (and she was tolerating a diet) by the next day, without other disease signs or symptoms [4-7]. The interventions performed, including labs, monitoring, and imaging, could have been performed without the inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld



Diagnosis: obesity
Treatment: Wegovy
The insurer denied Wegovy. The health plan's determination is upheld.

This is a case review for a female being prescribed Wegovy 1 milligrams (mg) injections for the diagnosis of overweight. Coverage for this medication was denied by the health plan, and this denial is the subject under review.

Wegovy 1 milligrams (mg) Injections are not medically necessary for this patient.
The patient's current BMI of 24.9 is normal. She had successfully lost weight with Ozempic (semaglutide). There is currently no evidence that starting Wegovy is medically necessary as she is currently at a normal weight profile. She is continuing to participate in a diet and exercise program. The request does not fall within the FDA prescribing parameters for the requested medication, Wegovy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholelithiasis. 
Treatment: Full hospital admission. 
The insurer denied coverage for the full hospital admission. 
The denial is upheld. 

This is the case of a patient who presented to the emergency department (ED). The patient was afebrile with stable vital signs. As per the ED provider note the patient has a past medical history of gastroesophageal reflux disease (GERD) and cholelithiasis and presented to the ED complaining of persistent 5/10 right upper quadrant (RUQ) abdominal pain. The patient stated she had an ultrasound which revealed multiple gallstones and was told that if the pain was persistent for more than a couple of hours to come to the ED. She had mild pain yesterday which was exacerbated by eating a hot dog. The pain was initially in the upper abdomen and now localized to the RUQ. She denied fevers, chills, nausea or vomiting. She was afebrile and exam revealed the abdomen to be soft with RUQ tenderness to palpation, non-distended with positive Murphy's sign. Labs were ordered. Amylase was normal. White blood cells (WBC) were 11.3. Liver function tests were normal. Ultrasound of the abdomen revealed findings concerning for acute cholecystitis. General surgery was consulted.  The patient was given intravenous (IV) Zosyn and made nothing by mouth (NPO).

The patient was taken to the operating room and underwent an uneventful lap cholecystectomy. As per the operative note the post op diagnosis was acute cholecystitis with purulence in the gall bladder. No drain was placed. Pathology revealed acute gangrenous cholecystitis with cholelithiasis and cholesterolosis.

Based upon the records, the inpatient admission was not justified as this patient could have been managed as noted by the insurer in an ambulatory/observation setting as she had an uneventful lap cholecystectomy for cholelithiasis/acute cholecystitis. She did not have acute cholangitis and did not come in septic. She did not have a significantly elevated WBC and she did not have a fever. She did not have elevated liver function tests. She did have a cholecystectomy but this could have been done in an ambulatory/observation setting without an acute inpatient admission. 

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 full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Dental
Dental/orthodontic

Diagnosis: impacted teeth
Treatment: Braces and Follow-Up Orthodontic Care 
The insurer denied Braces and Follow-Up Orthodontic Care. The health plan's determination is overturned. 

The patient in question is a young male with impacted teeth # (number) 4 and #13. These teeth are unable to erupt due to crowding. He presents with a Class III malocclusion and significant crowding. Both teeth #4 and #13 are completely blocked out of the arch. 

Braces and Follow-Up Orthodontic Care x 12 are medically necessary for this patient.
Approximately 10% of all impacted teeth are premolars. Studies have shown almost 65% of untreated impacted teeth will cause some kind of pathology. The two most common types of pathology causes are periodontal bone loss and root resorption of adjacent teeth. If left untreated, the damage that can occur to the patient's teeth will be more time consuming and costly to correct than the patient's existing orthodontic problem. For this reason, the requested treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hospital admission after lumbar laminectomy. 
Treatment: Full Hospital Admission. 
The insurer denied the the full hospital admission. 
The health plan's determination is upheld. 

The patient is a male who presented for an elective lumbar (L) decompression of L3-L5 for bilateral lower extremity pain associated with weakness and numbness down to his feet. Prior to surgical intervention, the patient participated with physical therapy, chiropractic care, and epidural injections with limited results. The patient underwent the lumbar decompression of L3-L5 surgery without any complications. His pain was well controlled postoperatively. He was discharged home with home health assistance.

At issue is the medical necessity of an inpatient hospital admission. 
I uphold the health plan's determination, in whole. 

The requested health service/treatment of inpatient level of care for Lumbar decompression L3 -L5 was not medically necessary for this patient. 

This patient presented for an elective lumbar (L) decompression of L3-L5 for bilateral lower extremity pain associated with weakness and numbness down to his feet. Prior to surgical intervention, the patient participated with physical therapy, chiropractic care, and epidural injections with limited results. The patient underwent the lumbar decompression of L3-L5 surgery without any complications. His pain was well controlled postoperatively. He was discharged home with home health assistance. He did not require any Intensive Care Unit (ICU) admission. His post operative care was uncomplicated, and the patient was discharged home within 48 hours from admission. His care could have been provided at an alternate level of care. (Sivaganesan 2019) [2]