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

Diagnosis: Chest pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld.
 

This is the case of an adult that presented to the hospital complaining of intermittent chest pain for several days. The patient also noted that she had tested positive for Coronavirus disease (COVID) 19 virus 12 days prior to presentation. Past medical history was significant for hypertension, diabetes mellitus, and peripheral vascular disease. Past surgical history was significant for gastric bypass surgery. Upon arrival to the hospital vital signs were stable (BP 120/80, Pulse 92). Physical examination revealed no abnormality. 12 lead electrocardiogram (ECG) demonstrated normal sinus rhythm with no ST or T wave abnormalities. Laboratory testing demonstrated an elevated high sensitivity troponin (27.8) and a positive COVID antigen test. The patient was admitted to the hospital for further testing and treatment. Serum troponin levels were trending downward, and the patient was discharged on medical therapy with cardiology follow up.

This patient presented with atypical chest pain and a past medical history of hypertension, diabetes and peripheral vascular disease. Her pretest probability of coronary artery disease was intermediate. (Reference 1) Utilizing the HEART (History, ECG, Age, Risk factors, and troponin) score she was considered low risk. (Reference 2) Utilizing the Thrombolysis in Myocardial Infarction (TIMI) risk score she also had a low risk of developing major adverse cardiac events in the subsequent 30 days. (Reference 3) Risk assessment of patients presenting with chest pain and no significant ST changes on EKG was reviewed by Hedayati et al. (Reference 3) Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events [(defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death] in the six weeks following presentation. Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation. Although this patient had a positive COVID antigen test, she was asymptomatic, afebrile and did not have findings consistent with COVID myocarditis. In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary.

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

Diagnosis: Right lower quadrant trauma
Treatment: Hospital admission
The insurer denied coverage for hospital admission
The denial is upheld

This is a teenager with a past medical history of asthma, patient referred to emergency room from urgent care after being struck in the right lower quadrant (RLQ) by a baseball. Patient developed abdominal pain, hematuria, and a right upper quadrant (RUQ) contusion. Computed tomography (CT) scan was unremarkable, trauma service was consulted and recommended admission. Computed tomography cystogram was negative for bladder injury, but there was purulent, yellow green discharge from penile meatus, with penile redness-pain. Patient given oxycodone/ciprofloxacin. The patient stabilized, was discharged home with outpatient follow up. The insurer has denied coverage for the full hospital admission as not medically necessary. They noted imaging did not show any injury to the bladder or kidney. 

Per Milliman Care Guidelines (MCG) Health (26th) Urologic Disease GRG, patient fails to meet clinical indications for admission to inpatient care under subsection "gross hematuria requiring inpatient care", and also subsection "trauma to the genitourinary (GU) system requiring inpatient care." Patient was hemodynamically stable during his hospital course: no injury was visualized on any imaging study. 

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

Diagnosis: Class II malocclusion
Treatment: Braces
The insurer denied: Braces
The denial is upheld

The patient is a teenage female with reported Class II malocclusion. There is moderate crowding on the upper and lower arches. The reason for the prior denial was a handicapping index scale of 14.

The proposed treatment is not medically necessary.

This is a patient with reported Class II malocclusion. There is moderate crowding on the upper and lower arches. However, the patient does not have any chewing, eating or speech difficulties related to her dentition. She also did not meet the cutoff score on the handicapping index scale for benefits.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Fever, increased heart rate, and increased respiratory rate with cough
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a known school aged child with cystic fibrosis. The patient is followed by a pediatric pulmonologist. The patient presented with fever, increased heart rate, and increased respiratory rate with cough. The patient was not in any distress, there was no vomiting, and no decrease in feeding or oral intake (PO). The patient did not require oxygen, nor did they demonstrate any signs of respiratory distress. The patient was negative for COVID (coronavirus disease) but positive for influenza A. While inpatient, the patient never required oxygen and only received one dose of Tylenol. The patient was sent home on antiviral medication.

The proposed inpatient hospital admission was not medically necessary.

Based on the clinical course of the patient, the inpatient admission was not medically necessary. The patient did not demonstrate any respiratory distress, nor did the patient demonstrate any symptoms of dehydration. The patient did not require oxygen. The patient was discharged on an antiviral medication and no other treatments. Nothing was done inpatient that could not have been provided at a lower level of care. The denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Skin
Pharmacy/prescription drug

Diagnosis: atopic dermatitis
Treatment: Dupilumab (Dupixent)
The insurer denied Dupilumab (Dupixent). The health plan's determination is overturned. 

The patient is a young female with atopic dermatitis, treated with hydrocortisone, mometasone, cetirizine, systemic steroids and Eucrisa. The Provider is requesting Dupixent. The patient has erythematous, scaly and lichenified plaques to the extremities and trunk, 40% body surface area (BSA).

Dupilumab (Dupixent) is medically necessary for this patient.
In May 2020, the Food and Drug Administration (FDA) also approved dupilumab for the treatment of patients aged 6 years and older with moderate to severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable. This approval followed a phase 3, randomized, double blinded placebo controlled trial that enrolled 367 patients to evaluate the safety and efficacy of dupilumab in children (ages 6-11 years) for treatment of atopic dermatitis (Paller et al). Significantly and clinically meaningful improvements in patients signs and symptoms of atopic dermatitis as well as quality of life were reported. As seen in adults, treatment in pediatric population was reportedly well tolerated with the most commonly reported side effects including injection site reactions and conjunctivitis. Dupixent is now approved for ages 6 months and up. This patient has had an adequate trial of topical therapy and has severe disease. Therefore, Dupixent is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alopecia universalis
Treatment: Olumiant 4mg
The insurer denied Olumiant 4mg.
The determination is upheld.

The patient has alopecia universalis. She has failed topical and intralesional steroids. She has had a partial response to Xeljanz. The prescriber is a dermatologist. The medication under review is Olumiant 4 milligrams (mg) tablet.

The requested health service/treatment of Olumiant 4 mg tablet is not medically necessary for this patient. There are no medical and scientific literature and/or evidence based clinical practice guidelines that strongly support the administration of Olumiant for this patient's condition as an accepted standard of practice in the United Stated (U.S.) prior to the standard alternatives. There is no documentation the patient has exhausted all standard options, and that it would therefore be medically necessary to start systemic treatment with Olumiant, which would carry a higher side effect profile. Within the peer-reviewed literature, there are other effective first-line treatment for the management of severe alopecia. (4)
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Deep Vein Thrombosis (DVT) prophylaxis.
Treatment: Eliquis.
The insurer denied: Eliquis.
The denial is: Upheld.

The patient is a male who is status post hip replacement. There is request for Eliquis. Prior authorization information documents that the patient can be switched to a formulary medication. An operative report documents that the patient underwent a right total hip arthroplasty. The subject under review is whether the formulary choices, warfarin and Xarelto would be ineffective or have more adverse effects than the non-formulary choice Eliquis.

There is no documentation indicating the patient has tried and failed warfarin or Xarelto. Additionally, there is no documentation that the patient has a contraindication to the use of warfarin or Xarelto. There is no indication in the medical literature that warfarin and Xarelto are inferior to Eliquis. Warfarin, Xarelto, and Eliquis have the same side effect profile. The American College of Chest Physicians recommend do not recommend one over the other following arthroplasty for deep vein thrombosis (DVT) prophylaxis. Given that the patient does not have a documented trial and failure of or contraindication to available formulary alternatives, these would be appropriate options for this patient.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Transient ischemic attack
Treatment: Eliquis (apixaban)
The insurer denied Eliquis (apixaban). 
The health plan's determination is overturned. 

The patient is a woman with a history of two embolic strokes and a transient ischemic attack, presumed due to occult paroxysmal atrial fibrillation. Her medical history is otherwise remarkable for hypertension, hyperlipidemia, diabetes and obesity. 

A formulary exception is indicated for this patient. Apixaban has been prescribed for thromboprophylaxis in this woman with a history of embolic strokes and transient ischemic attack presumed to be due to atrial fibrillation. The formulary alternatives include warfarin and rivaroxaban (Xarelto).
Warfarin would be expected to be less safe and less effective in this instance as compared to apixaban, which is a direct oral anticoagulant (DOAC). Data from multiple randomized controlled trials have shown that use of DOACs, as compared to warfarin, for thromboprophylaxis in atrial fibrillation has been associated with fewer ischemic events and fewer severe bleeding episodes.
Rivaroxaban, like apixaban, is a DOAC. While retrospective studies have suggested that apixaban is superior to rivaroxaban when used for thromboprophylaxis in patients with atrial fibrillation, there have been no randomized controlled trial and direct comparison is confounded by differences in enrollment criteria in the different studies. Thus, to date, it is not clear that rivaroxaban would be less safe or less effective in most instances.
However, this patient has a history of intermittent deterioration in her renal function. Elimination of apixaban occurs via multiple pathways including metabolism, biliary excretion, and direct intestinal excretion, with approximately 27% (percent) of total apixaban clearance occurring via renal excretion. In contrast, 66% of rivaroxaban is renally excreted, 36% as unchanged drug. While dosage adjustment of apixaban on the basis of changes in renal function alone is not required, it is recommended that the dosage of rivaroxaban, when used for thromboprophylaxis in atrial fibrillation, be reduced if the eGFR (estimated glomerular filtration rate) falls below 50. ml (milliliter) /minute. Higher doses are associated with an increased risk for bleeding, Thus, given the possibility that acute changes in this woman's eGFR, if undetected, would potentially result in significant bleeding, apixaban would be preferred in this particular situation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's disease
Treatment Stelara 90 mg every 4 weeks
The insurer denied the Stelara 90 mg every 4 weeks.
The determination is overturned.

The patient has a history of Crohn's disease (CD). She previously tried and failed infliximab. She was started on Stelara, however, she continued to have active disease and her drug level was low. The requested service is Stelara at 90 milligrams (mg) every 4 weeks is under review for medical necessity.

Stelara is Food and Drug Administration (FDA) approved for Crohn's disease. The safety and efficacy of Stelara are well established. However, some patients do not respond adequately to the standard dose. Dose escalation is often required in biologics in order to achieve therapeutic levels. There are many peer reviewed literature reports showing that low Stelara levels were associated with poor clinical response. The requested dose of 90 milligrams (mg) every 4 weeks is proven to be effective in patients who fail the standard dose.
Per Ollech, Jacob E., et al.: "Shortening the ustekinumab 90 mg dose interval to 4 weeks for patients with CD who did not respond to doses every 8 weeks improved clinical and biological indices of disease activity. Patients who lose response to the standard dose of ustekinumab might benefit from dose interval shortening, which was effective and safe."
Per Cohen, Erica et al.: "A majority of patients with moderate to severe CD benefited from ustekinumab (UST) dose escalation suggesting the clinical utility of optimizing dosing in the treatment course. "
This patient has a history of refractory Crohn's disease which failed anti-tumor necrosis factor alpha (infliximab). The patient also failed to respond to Stelara standard dose (90 mg every 8 weeks) and continued to have an active disease. Therefore, dose escalation is appropriate and medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mandibular fracture
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.


The patient fell off a bike at a park and was seen at the hospital. He had a workup including a computed tomography (CT) scan which demonstrated a mandibular fracture. He was wearing a helmet and did not have loss of consciousness. There were no other injuries noted. He was transferred to for oral maxillofacial (OMFS) and dental services. He was admitted to the pediatric intensive care unit (ICU) and taken to the operating room (OR). At issue is the medical necessity of an inpatient stay.

An inpatient stay was not medically necessary. The patient received Tylenol and Toradol and had good pain control. An external reduction was attempted in the emergency department (ED) but was unsuccessful. He was taken to the operating room (OR) and discharged that day. He had one episode of hypotension in the recovery room.
A study states that cost of care for mandibular fractures can be controlled with the following suggestions: (ref 1) Conclusions: Our results led to specific cost-efficiency recommendations: 1) perform closed reduction whenever possible; 2) encourage performing procedures with patients under local anesthesia (closed reductions and arch bar removals); 3) provide improved and shared training among the services treating craniofacial trauma; 4) encourage arrival by privately owned vehicle; 5) provide outpatient treatment, when applicable; 6) offer provider incentives to take trauma call; and 7) offer hospital incentives to treat patients and not transfer them. Another study found that outpatient management of mandibular fractures was feasible if the fracture was not complicated (ref 2); the study excluded pediatric patients. A National Surgical Quality Improvement Program (NSQIP) study showed that outpatient management had no adverse effects (in regard to inflammatory complications) (ref 3)
Appeal type: Medical necessity
Decision: Upheld

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

This is a patient with a past medical history significant for asthma, diabetes mellitus, and hypertension who presented to the emergency department with complaints of dizziness. She reported a loss of consciousness after a fall in the shower several days before her presentation. The patient stated that she did not recall if she lost consciousness and did not remember having seizure activity but was told by her friend that she had a seizure. When seen by the admitting physician, the patient complained of right-sided chest pain related to her fall. She also complained of right upper extremity weakness and mild right foot weakness.
In the emergency department, she underwent a computed tomography (CT) scan of the head that was interpreted as a negative study. A CT scan of the chest was also negative.
She was evaluated by a neurologist and was recommended magnetic resonance imaging (MRI) of the brain to rule out an acute stroke.
Per the neurologist, the differential diagnosis included syncope versus the new onset of a seizure. The neurologist also recommended a routine electroencephalogram (EEG), although no antiepileptic medications were started. An electrocardiogram (EKG) demonstrated sinus tachycardia. There were no EKG changes to suggest that acute ischemia was seen.
The patient underwent a transthoracic echocardiogram that revealed hyperdynamic left ventricular function but no regional wall motion abnormalities. The electroencephalogram (EEG) was normal. MRI of the brain did not demonstrate any significant abnormalities. A Holter monitor was ordered. The patient decided to leave the hospital against medical advice. At issue is the medical necessity of an inpatient stay.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care. There were no signs of hemodynamic instability or severe or persistent altered mental status. The imaging studies did not reveal evidence of an acute stroke, brain mass, or hydrocephalus.
There was no indication that the syncopal episode was related to pulmonary embolism, arterial dissection, acute congestive heart failure (CHF) exacerbation, acute blood loss anemia, or acute coronary syndrome. There were no indications for an immediate electrophysiological study or other interventions such as automatic implantable cardioverter defibrillator (AICD) placement.
Based on the telemetry monitoring, there was no evidence that the patient had a high degree of atrioventricular block, bradycardia with sinus pauses, and bursts of supraventricular tachycardia. There was no evidence that the patient was severely dehydrated. The EEG was normal and the patient did not need initiation of antiepileptic medications.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left arm edema and swelling, cellulitis
Treatment: Inpatient Hospital
The insurer denied the inpatient Hospital Stay.
The determination is upheld.


This is a female patient with a past medical history (PMH) of diabetes mellitus (DM) type 1, major depressive disorder (MDD), and bulimia nervosa who was admitted with complaints of (c/o) a low blood sugar after excess insulin administration and left-hand swelling after intravenous (IV) infiltration the day prior. Her vital signs were unremarkable. The physical exam was notable for non-toxic appearing, left hand with diffuse swelling, cold to touch, tenderness to palpation (TTP), and decreased range of motion (ROM). Lab work was notable for glucose of 38 and 46. A left upper extremity (LUE) radiograph showed soft tissue swelling. The patient was diagnosed with cellulitis and was treated with antibiotics. Surgery evaluated the patient and recommended no acute surgical intervention and documented low clinical suspicion for compartment syndrome. 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. The patient presented to the emergency department (ED) with c/o left arm pain and swelling. The patient was afebrile, did not appear toxic, had no unstable comorbidities, did not have a limb-threatening infection, there was no septicemia, life-threatening infection, necrotizing fasciitis, leukocytosis, features of systemic inflammatory response syndrome (SIRS), animal or human bite with extensive damage, high risk location (face, neck, genitals), pain out of proportion to clinical findings, crepitus, neutropenia, immune-suppression, marked systemic toxicity or worsening symptoms, or inability to take oral medications. This patient was treated with antibiotics and surgical consultation, who recommended no acute surgical intervention, and this could have been safely provided at a lower level of care. Overall, this patient could have been safely treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atypical Chest Pain
Treatment: inpatient admission
The insurer denied coverage for the inpatient admission.
The denial is upheld.

This patient presented to the hospital complaining of intermittent mid-sternal chest pain. Past medical history includes hypertension and coronary artery disease with previous stent to the right coronary artery.  Upon arrival to the hospital, vital signs were stable (Blood Pressure 154/88 mmHg (millimeters of mercury), Pulse 72 bpm (beats per minute)) Physical examination was unremarkable.  A 12-lead EKG (electrocardiogram) revealed inferior Q (interval on EKG) waves and T (interval on EKG) wave inversions.  Serum blood testing revealed no elevation in troponin (<0.01ng/ml [nanogram per millimeter]). Cardiac catheterization revealed patent stents in the right coronary artery and right posterolateral artery. Ejection fraction was 50-55% (percent). There were no perioperative complications, and the patient was discharged home the same day with cardiology follow up. 

This patient presented with atypical chest pain and a past medical history of hypertension. Utilizing the HEART (history, EKG, age, risk factors, troponin) score, he was considered low risk (Reference 1). He underwent an uncomplicated procedure and stents were placed in the mid LAD (left anterior descending) and Ramus arteries.  Several investigators have studied the safety surrounding same day discharge following percutaneous intervention and demonstrated no difference between patients that are discharged on the same day as compared to patients admitted to the hospital (Reference2-5). Current expert consensus from the Society of Cardiovascular Angiography and Interventions support treatment at a lower level of care (Reference 4). The patient could have been managed at a lower level of care.

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 admission is not substantiated.