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

Diagnosis: auditory processing disorder, attention/concentration deficit, cognitive communication disorder and mild cognitive deficit due to concussion
Treatment: Speech Therapy Services
The insurer denied the Speech Therapy Services
The denial is overturned.

The patient is a female with history of and concerns for auditory processing disorder, attention/concentration deficit, cognitive communication disorder and mild cognitive deficit due to concussion. She has problems with working memory, delayed recall, serial subtraction, attention, concentration, calculation, and reasoning.

The patient has a relevant past medical history of concussion several years ago while ice-skating.

The request is for cognitive rehabilitation towards attention, increased working memory, delayed recall for auditory and divided attention, etc.

The health plan denied coverage because it thinks it is experimental and investigational.

Yes, the health plan should cover the requested health service.
In this case, the patient had concussion several years ago after a fall while ice-skating. She has had attention, memory and cognitive issues since then. Because of her current age, and when she sustained the injury, early cognitive rehabilitation will be the best option for her.

Stephens et al noted that it is clear that extending the use of remediation strategies may be advantageous in some recovery domains. Clinicians have found that attention process training, providing tactile feedback, and training divided attention can successfully ameliorate attention deficits.

Yes, the requested cognitive rehabilitation is more beneficial than any standard treatment for the attention, memory and cognitive issues that started after confusion about several years ago.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse/Addiction. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient stay. 
The denial is overturned. 

The patient is a male who presented to the emergency department with restlessness and anxiety. The patient reported daily binge drinking for over two weeks and abruptly stopped about 8 hours before presentation. He felt nauseated and vomited three times. He expressed feeling unhappy and guilty but denied hopelessness or suicidal ideation. He denied using drugs. The patient was admitted to the hospital under telemetry for alcohol withdrawal. He was placed on Clinical Institute Withdrawal Assessment (CIWA) protocol, intravenous (IV) fluid hydration, vitamin cocktail, and nocturnal clonidine. The next day, the patient was resting, having received 2 milligrams (mg) of IV Ativan. His temperature was normal. Scheduled Librium was noted on the Medication Administration Record (MAR). Repeat labs showed normalization of the white blood cell count. Electrolytes and renal function appeared stable; magnesium level was normal as well. The medical team documents a plan to taper down Ativan. It was also noted that the patient had received Ativan intramuscular (IM) for agitation. The patient was reporting mild tremors. His heart rate was 117. Sinus tachycardia was documented per telemetry. The medical team lowered the dose of Ativan and continued with concurrent Librium taper. The following day, the patient was deemed stable for discharge home. He was set up for a follow-up with his primary care doctor in one week. The subject under review is the medical necessity for the inpatient stay. 

The health plan's determination is overturned. 

The inpatient stay was medically necessary for this patient. 

The patient was experiencing clear signs of alcohol withdrawal, tachycardia, tremulousness, diaphoresis, nausea and vomiting, and psychological guilt symptoms. The symptoms did not abate adequately within the observation time frame. After two weeks of binge drinking, the patient presented to the hospital with abrupt cessation of alcohol, with visible signs of alcohol withdrawal. Despite appropriate treatment with benzodiazepines, both scheduled and as needed, the patient still exhibited signs of tremulousness, agitation, and tachycardia. The patient was at risk of developing seizure activity and severe delirium tremens. As a result, clinical indications for admission to inpatient care are satisfied.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pregnancy. 
Treatment: Inpatient Stay. 

The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

In this case, the patient is a pregnant female who presented to labor and delivery. She reported no recent international travel and had complaints of feeling not well, weak and dizzy. She had gestational diabetes and chest pain and heartburn. The fetal heart rate of 145 which was normal. Her blood pressure was 120/72 with a heart rate of 96 and respiratory rate of 18. She was afebrile at 98.2F. She reported no pain at presentation. The patient was at 32-5/7 weeks' gestation with a pregnancy from In-vitro fertilization (IVF). The patient denied contractions, vaginal bleeding or leakage of fluid. 

The inpatient hospital admission was not medically necessary. Per the Milliman Care Guidelines (MCG) Health General Recovery Guideline entitled "Systemic or Infectious Condition GRG" (MCG Health  General Recovery Guidelines 25th Edition), this patient did not meet criteria for an inpatient level of care. 

There was no hemodynamic instability, and the patient was always stable at admission and throughout the admission There was no severe adverse drug or systemic toxin reaction. The patient was noted to have a rash and pruritus that preceded her pregnancy. There was no airway edema, stridor, respiratory distress, bronchospasm, or hemodynamic instability. There was also no acute psychiatric disease per tele-consultation to indicate inpatient care. 
Therefore, the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Genital itching. 
Treatment: Inpatient stay. 

The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a male who presented for genital itching and discharge. Review of system was positive for weight loss, increased thirst, and frequent urination. The patient was admitted for penile itching and drainage. He was suspected to have untreated candida with characteristics of balanitis with phimosis. The patient was treated with oral Diflucan and Miconazole topical cream. The patient was also found to have new onset diabetes with blood sugar > (greater than) 500. The patient was evaluated by an endocrinologist for Type 1 diabetes and was treated with metformin. 

The requested inpatient hospital admission was not medically necessary. The care could have been safely rendered a lower level of care for initiation of diabetes treatment and treatment of genital infection. 

The patient was admitted for balanitis and genital candida that requires oral and topical medication. This is typically treated on the outpatient basis. The indication for admission was related to the findings of new onset diabetes and hyperglycemia. The documentation supports a lower level of care for initiation of anti-hyperglycemic and monitoring of blood sugar for improvement. Inpatient level of care was not warranted since the patient did not have hyperosmolarity, electrolyte derangements, or diabetic ketoacidosis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Endocrine/Metabolic/Nutritional 
Treatment: Pharmacy/Prescription Drugs -  Androgel pump actuation (ACT)
The insurer denied Androgel pump actuation (ACT). 
The denial is upheld.

The patient is a male with history of hypogonadism. Per provider note, the patient's glycated hemoglobin (A1c) is 5.8 and he is on suboxone for alcohol detoxification. The provider recommends trying to get Androgel testosterone cypionate because of rash at injection site. Per provider note, the patient has testicular hypofunction and tried and failed testosterone transdermal gel 25 milligram (mg)/2.5mg (1% [percent]) which was discontinued due to ineffectiveness and symptom recurrence. The subject under review is the medical necessity for the requested Androgel pump actuation (ACT).

The health plan's determination is upheld.

Androgel ACT pump is not medically necessary. Plan alternatives include testosterone transdermal gel, testosterone cypionate, testosterone enanthate. Hypogonadism treatment in symptomatic men is recommended by the Endocrine Society 2018 guidelines, and the society does not differentiate between different types of testosterone preparations in terms of efficacy in treating hypogonadism and its symptoms. Similarly, the 2018 American Urological Association (AUA) guidelines on the topic also do not differentiate between different types of testosterone preparations in terms of treatment efficacy. Additionally, there are no high-quality clinical studies showing one preparation results in improved patient outcomes versus another testosterone preparation.

The provider stated that the testosterone transdermal gel was ineffective and testosterone cypionate caused injection site rash. The patient has not tried testosterone enanthate, and there is no medical reason why the patient could not try a plan preferred drug. The patient does not meet medical literature guidelines for Androgel ACT pump.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Myotonic Dystrophy

Treatment: Inpatient hospital admission

The insurer denied coverage for an inpatient hospital admission.

The denial is upheld. 

This patient presented to the hospital for elective implantable cardiac defibrillator insertion. Past medical history was significant for myotonic dystrophy. Prophylactic ICD (implantable cardioverter defibrillator) was recommended. The patient underwent uncomplicated dual chamber ICD implantation and was discharged the following day.

The health plan acted reasonably, with sound medical judgement, and in the best interest in the patient. This patient underwent prophylactic ICD implantation without complication. He was discharged the following day. Several studies have demonstrated that following uncomplicated ICD implantation, same day discharge is safe and feasible. (Reference 1-3). Inpatient hospital admission was not medically necessary.

The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient.

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute portal vein thrombosis

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is overturned. 

The patient is a female with a history of gastric bypass, migraines, and an ovarian cyst who was admitted to the hospital for right abdominal pain. On exam, she "appears comfortable" and tender in the right lower quadrant (RLQ). Computed tomography (CT) was negative. The magnetic resonance imaging (MRI) was done to rule out the distal right (R) portal vein, which was occluded on MRI. Heparin was started for portal vein thrombosis. She received an intravenous heparin drip, oral medications, a hematology consultation, and laboratory work. 

An acute new portal vein thrombosis requires assessment and treatment as inpatient.      

Acute portal vein thrombosis requires a prompt diagnosis and initiation of anticoagulation, certainly when symptomatic. Meta analyses suggest that anticoagulation therapy significantly increases the rate of portal vein recanalization and complete portal vein recanalization, and reduces the rate of thrombus progression, while the risk of bleeding did not significantly differ between patients who received anticoagulation therapy and those who did not.

"Direct oral anticoagulants (DOACs), including direct thrombin inhibitor (dabigatran) and factor Xa inhibitors (rivaroxaban, apixaban, edoxaban), are attractive oral alternatives to vitamin K administration (VKA) in many clinical settings. However, their role in cirrhotic patients is still unknown, since patients with remarkable liver disease have been excluded from most of the randomized clinical trials on DOACs. Indeed, in this setting potential hepatotoxicity and unpredictable pharmacokinetics related to various degree of hepatic elimination (apixaban 75% [percent], rivaroxaban 65%, edoxaban 50%, dabigatran 20%), cytochrome... plasma protein binding levels alterations, overcame the advantages of no need of laboratory monitoring, rapid onset of action and oral formulation." (Faccia, M., et al 2019).

The insurer's denial of coverage for inpatient hospital admission is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension.
Treatment: Loop recorder implant.
The insurer denied coverage for loop recorder implant.
The denial is overturned.

The patient is a female with a history of hypertension whose chief complaints are lightheadedness, dyspnea, and sense of dizziness. Patient complained most recently of worsening shortness of breath, dizziness and pre-syncopal episodes. The frequency of the pre-syncopal episodes was not described by the provider. Echocardiogram described normal LV (left ventricle) systolic function with ejection fraction of 60-65% (percent) and mild tricuspid regurgitation. The patient wore a Zio patch ambulatory monitor for 7 days and 10 hours without any conclusive events or arrhythmias noted. A loop recorder was implanted.  

Consider the clinical standards of the plan, the information provided concerning the patient, the attending physician's recommendation, and applicable generally accepted practice guidelines developed by the federal government, national or professional medical societies, boards and associations. 

Based on the documentation submitted by the provider, the health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.  The provider was attempting to determine the cause of the patient's spells considered to be possibly arrhythmic in nature and did perform a 7-day Zio patch ambulatory monitoring without conclusive findings. It was reasonable to consider a very long-term monitoring approach with the ILR (implanted loop recorder). As such, it is considered medically appropriate and necessary to use the ILR in this patient. As such, the denial is considered not in the best interest of the patient.

The patient had been tried on a 7-day ambulatory monitory that was inconclusive. As such a very long-term monitoring approach with an ILR is considered medically necessary.

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

The insurer's denial of coverage for the Loop Recorder Implantation is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Deep vein thrombosis (DVT)
Treatment: Inpatient admission
The insurer denied coverage for an inpatient admission
The denial is upheld 

The patient is a pregnant female with a history of anemia. She presented to the emergency room (ER) with complaints of a one-week history of worsening left lower extremity pain. The patient was admitted to the floor with a deep vein thrombosis (DVT) of the left common and superficial femoral veins. She was placed on a heparin drip and later changed to Lovenox. 

Deep venous thrombosis (DVT) during pregnancy is associated with high mortality, morbidity, and costs. Pulmonary embolism (PE), its most feared complication, is the leading cause of maternal death in the developed world. DVT can also result in long-term complications that include post thrombotic syndrome (PTS) adding to its morbidity. Women are up to 5 times more likely to develop DVT when pregnant. The current standard of care for this condition is anticoagulation. LMWH (low molecular weight heparin) is the drug of choice for therapy.

According to ACOG (American college of obstetrics and gynecologists), hospitalization for the initiation of anticoagulation therapy may be indicated in cases of hemodynamic instability, large clots, or maternal comorbidities. This patient did not have any of the above. She could have been started on Lovenox, observed for 24 hours to make sure that there was no concern about respiratory issues and sent home to be followed as an outpatient.

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

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure. 
Treatment: Inpatient admission. 

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

The patient is a female. She presented to the emergency ward after an apparent seizure while sleeping. 

At presentation, the patient's neurological examination, vital signs, laboratory work-up and neuro-imaging was normal. She was admitted to the acute inpatient service for neurological evaluation and monitoring. EEG (electroencephalogram) and MRI (magnetic resonance imaging) were completed, and she was discharged to home. 

No, the Inpatient admission was not medically necessary. 

The patient had a single spell during sleep suggestive of possible seizure. At presentation her neurological examination and neuro-imaging were normal. There were no recurrent events. There were no active co-morbid conditions or neurological complications. The diagnostic studies, monitoring, neurological consultation and treatment could have been safely and effectively provided at a lower level of care (Franco et al.). 

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Recurrent Pregnancy Loss.
Treatment:  Pharmacy/Prescription Drugs (S0122 INJECTION MENOTROPINS 75 IU and S0128 INJECTION FOLLITROPIN BETA 75 IU).

The health plan denied the requested prescription drugs (S0122 INJECTION MENOTROPINS 75 IU and S0128 INJECTION FOLLITROPIN BETA 75 IU).  The health plan's determination is upheld.

The patient is a female gravida (G) 3 para (P) 3 with a history of recurrent pregnancy loss. Genetic testing was not performed for her first pregnancy loss. Her second pregnancy loss was confirmed as Trisomy 16.  Microarray testing of her third pregnancy loss resulted in a lack of deoxyribonucleic acid (DNA) available for testing.  She consulted a reproductive endocrinologist who has recommended in vitro fertilization (IVF)) with preimplantation genetic testing for aneuploidy (PGT-A) as a treatment.  At issue is the medical necessity of drugs used in IVF cycle.

The health plan's determination of medical necessity is upheld.

The medical literature and health plan documentation were thoroughly reviewed.  The American Society of Reproductive Medicine (ASRM), in its Practice Committee Opinion, states: "Since 24-chromosome techniques have become available, there have been few well-designed studies providing Level-I evidence regarding IVF pregnancy outcomes in select populations with these techniques.  Several opinion pieces have discussed advantages and disadvantages of PGT-A.  Other potential advantages and disadvantages exist with PGT-A, though there are limited data to support or refute these.  For example, PGT-A testing may lower the risk of aneuploidy detected during pregnancy or after birth.

PGT-A is an assisted reproductive technology that requires the performance of in vitro fertilization (IVF). IVF treatment consists of ovarian stimulation with the use of injectable gonadotropins, which results in production of multiple oocytes which after retrieval are eventually fertilized with sperm and yield the required embryos for sampling. Therefore, the codes: S0122 INJECTION MENOTROPINS 75 IU and S0128 INJECTION FOLLITROPIN BETA 75 IU are associated with PGT-A and as such are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: s/p (status post) Fall
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient is a female who presented after a fall. She reported right hip pain. She reported dizziness. She had a past history of arthritis. Imaging studies revealed a dysplastic hip with dislocation. The condition was not acute. She was admitted to a hospital and then transferred to another hospital for definitive management.

No, the Inpatient admission was not medically necessary.
The records show a diagnosis of a chronic condition (i.e., hip dysplasia in the presence of chronic anemia). The facts were that the reported fall occurred days prior, and the patient was ambulatory. Her anemia was chronic. There was no evidence of fracture. There was no hip fracture as reported.

The patient was evaluated the following day, and documentation was made of need to transfer to another facility. The services provided - diagnostic testing and arrangements for transfer - could have been completed at lower level of care. Her vital signs were stable, there were no open wounds, there was no acute fracture. Her pain was managed by oral medications. Her transfusion was not an emergent procedure.

There were no extenuating circumstances to substantiate the admission.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.