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

Diagnosis: Sickle Cell Disease

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is overturned

This case involves a child who presented to the Emergency department with sickle cell pain crisis. Patient has a history of sickle cell with pain to the chest. The patient had partial relief with ibuprofen. It was noted the mother had upper respiratory infection. Past medical history was significant for acute chest syndrome as well as sickle cell anemia. It was also noted that the patient had abdominal pain that has been ongoing since prior emergency room visit for similar presentation. However, the patient now had complaints of non-radiating left-sided chest pain as well as trouble breathing that began shortly prior to the current visit. Physical examination noted tenderness to palpation over the left third to fourth rib and no abdominal tenderness. The patient was afebrile and clinically well-appearing. The patient was noted to have presentation consistent with vaso-occlusive crisis. Treatment plan was for labs, chest x-ray, and medication management. Chest x-ray was unchanged from previous study with viral pneumonia versus reactive airway disease. The patient continued to have complaints of 10/10 chest and abdominal pain despite medical management. The patient was recommended for admission for pain crisis in the setting of sickle cell disease. The patient was discharged once medically stable. 

The inpatient hospital admission is considered medically necessary for this patient. Milliman Care Guidelines (MCG) recommends inpatient admission for sickle cell disease when there is acute chest syndrome and/or pain insufficiently controlled. The patient presented to the emergency department with new onset of chest pain and trouble breathing. The patient had been recently seen in the emergency department for abdominal pain several days prior. The patient has a history of sickle cell disease and acute chest syndrome. The patient's presentation and history was consistent with vaso-occlusive crisis. The patient's pain remained 10/10 despite medication management. Inpatient admission was supported for pain insufficiently responsive to treatment as well as new onset of pulmonary symptoms. 

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 inpatient hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse/Addiction
Treatment: Substance Abuse: Inpatient
The insurer denied Substance Abuse: Inpatient
The determination is upheld.

This patient reported problems with addiction. The patient has a past medical history (PMH) that includes depression, anxiety, and post-traumatic stress disorder (PTSD). The patient was admitted into an inpatient rehabilitation center due to substance abuse issues. The patient reported having very little time sober from substances. The patient's substance use disorder diagnoses were cannabis dependence, nicotine dependence, and cigarettes dependence. The patient reported smoking six marijuana blunts per day. The patient denied any history of overdoses, blackouts, or seizures.

The patient's last attempt at rehabilitation for substance use had been prior to gender affirming surgery, however the patient left against medical advice due to disagreement with staff. The patient's clinical history included a suicide attempt by intentional overdose but no recent suicidal or homicidal ideation or behaviors were noted. The patient denied auditory or visual hallucinations or other psychotic symptoms. There were no medical issues requiring active clinical attention. At issue is the medical necessity of the inpatient stay at the rehabilitation level of care.

The requested health service/treatment of inpatient stay was not medically necessary for this patient. The patient did not require immediate hospitalization for a life-threatening medical condition or severe psychiatric crisis. The patient met criteria for cannabis use disorder. The patient was not in full remission from a substance use disorder. There were no medical complications from withdrawal. The patient had no serious medical symptoms or serious psychiatric symptoms that needed to be managed in an inpatient rehabilitation treatment facility to be effective.

There was no indication that the patient was using substances in hazardous situations and amounts for frequencies likely to imminently cause severe physical or emotional harm to others. The patient did have multiple interpersonal deficits as indicated by inability to maintain appointments and inability to maintain stable relationships. There was no evidence of predatory behavior. The patient did not have significant emotional instability or strong cravings that were unmanageable. The patient appeared capable of managing triggers for substance use at lower levels of care than inpatient rehabilitation. Based on your responses, the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Level of Care is: Rehabilitative Services in a Residential Setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity
Treatment: Wegovy
The insurer denied: Wegovy
The denial is overturned

This is an adult female with obesity, fatty liver, and polycystic ovarian syndrome. The request for continuation of Wegovy is under review. The prior request was denied because the patient's body mass index is below 25 kilograms per meter squared (kg/m2). The provider is appealing this determination. The patient had a previous approval for medication with a patient body mass index of 54 kilograms per meter squared (kg/m2). Chart notes submitted note that the patient has achieved goal weight and is doing well with a body mass index of 24.4 kilograms per meter squared (kg/m2).

The proposed Wegovy is medically necessary.

This request is for the continuation of Wegovy for the treatment of obesity. The prior request was denied as the patient's body mass index has decreased to 24.4 kilograms per meter squared. 
Her pretreatment body mass index was 54 kilograms per meter squared. The Endocrine Society guidelines on the management of obesity recommend the continuation of weight loss medications when patients lose at least five percent of their body weight, which this patient has done on Wegovy. Her body mass index has normalized, which is a significant success. Her body 
mass index is not in the underweight category. Without Wegovy this patient will be at high-risk of regaining weight and will be at increased risk of the complications of untreated obesity, including type 2 diabetes. Therefore, yes, the requested Wegovy is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Transient Ischemic Attack
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is upheld.

This is a male patient who presented to the hospital for evaluation of transient dizziness. The dizziness lasted between three and five minutes. The dizziness then subsided. The patient went to the emergency room (ER) for evaluation. His past medical history includes hypertension, hyperlipidemia, and obstructive sleep apnea. The patient was evaluated by magnetic resonance imaging (MRI) of the brain, which was negative for an acute ischemic stroke. The patient was also evaluated by computed tomography angiography (CTA) of the head and neck, which was unremarkable for flow limiting stenosis. The patient was treated with dual antiplatelet therapy and atorvastatin. The patient was discharged with outpatient follow up.

The acute inpatient level of care is not medically necessary for evaluation and treatment of a transient ischemic attack (TIA). Admission to the hospital for a TIA is not the standard of care in the United States. The patient presented to the hospital with transient and non-localizing neurologic symptoms. The patient had dizziness. On presentation to the ER, the patient was asymptomatic with a normal neurologic examination. The patient was admitted to the hospital for further imaging. All imaging, including MRI of the brain and CTA of the head and neck, did not show any acute findings. The patient was then treated with oral antiplatelet therapy and a statin. The patient did not have any significant neurologic deficit. The patient did not have significant vital sign or laboratory abnormalities. The patient did not require complex nursing care or an inpatient rehabilitation evaluation and stay. Together, none of these facts support an acute inpatient admission. The care could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Peripheral Arterial Disease
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The health plan's determination is overturned.

The patient is a male with a medical history of hypertension, hyperlipidemia, insulin dependent type 2 diabetes, and peripheral arterial disease. He was seen for a follow up of his claudication symptoms. He complained of right leg pain that began 4 weeks ago and describes no longer being able to climb stairs at work and having to stop halfway due to severe right leg pains.

The patient was admitted to the hospital and underwent a right lower extremity angiogram with angioplasty of right superficial femoral artery (SFA) with drug coated balloon. The patient recovered well after the procedure and was subsequently discharged to home the next day.

The health plan, in its determination of medical necessity, did not act reasonably, with sound medical judgement, or in the best interest of the patient.

The requested health service/treatment of an inpatient hospital stay was medically necessary for this patient. The patient was a complex patient with multiple medical problems and peripheral arterial disease requiring treatment. The lower extremity arterial duplex ultrasound performed demonstrated complete occlusion of the right common femoral artery, right superficial femoral artery stents, reconstitution of flow noted in the right popliteal via profunda collaterals. The patient has undergone prior treatments for right SFA revascularizations in the past. The patient was diagnosed with claudication and was scheduled for a peripheral angiogram with intervention. He underwent a successful right lower extremity angiogram and angioplasty of the right SFA.

The patient required admission for post procedure recovery and continued treatment of his medical conditions including diabetes, hypertension, and hyperlipidemia.

The health plan's determination of medical necessity is overturned in whole.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tooth Decay
Treatment: Crown 
The insurer denied: Crown
The denial is Overturned

The patient is a male requesting benefits for a new crown. The prior denial was due to no evidence of decay and/or fracturing of the tooth.

Yes, the proposed treatment is medically necessary.
The photo submitted shows multiple holes have developed in the crown. It is very probable that saliva will enter these holes and cause new decay in the underlying tooth structure. The only way to correct this problem is to have a new crown fabricated. The new crown is definitely medically indicated as there is no other way to treat this problem.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fractured humerus.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

This case involves a child who presented to the emergency department with left elbow pain after falling.  The pediatric triage note stated the patient had fallen directly onto the left elbow.  His blood pressure was 115/78 with a heart rate of 102, respirations 21, temperature 98.4 degrees F, and oxygen saturation 99% on room air.  The patient had no notable swelling the day of the incident but reported some pain.  He awoke with swelling and the inability to move the elbow due to pain.  His presenting symptoms were joint pain and swelling.  X-rays showed supracondylar fracture with possible type II requiring surgical intervention.  On examination, the patient had tenderness to palpation over the elbow.  The patient was admitted undergoing closed reduction and pinning of the left type II supracondylar humerus fracture.  The patient tolerated the procedure well with adequate pain control postoperatively.  A well-padded, well-molded splint was applied.  He was prescribed postoperative pain medications to take home and was discharged in stable condition. 

According to the Milliman Care Guidelines (MCG), closed reduction of a humerus fracture is considered an ambulatory procedure.  Extended stay in the hospital may be indicated when there is associated vascular or other injuries noted, complications related to the reduction, radial and ulnar nerve palsy, compartment syndrome, pathologic or combined fractures, open fractures, or multiple comorbidities.  

The information provided for the review did not support that the patient satisfied these criteria.  The surgical procedure was completed without complication and the patient had adequate pain control postoperatively.  While he received intravenous antibiotic therapy and underwent postoperative monitoring of labs, this could have all been completed on an observational or outpatient basis.  

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

Diagnosis: Fever; cancer.
Treatment: Inpatient Hospital Admission.
The insurer denied the inpatient hospital admission.  
The denial has been upheld. 
The proposed treatment was not medically necessary.

The patient is a male with stage IV gastric cancer with a history of a gastrectomy.  Currently, the patient is receiving treatment with Xeloda and Keytruda.  The patient presented to the emergency department with a history of fever (maximum temperature [Tmax] 103) following a dental procedure the day before and ongoing diarrhea.  The patient was admitted for continued medical care.

Inpatient admission was denied due to lack of meeting health plan criteria for inpatient admission and care.

This patient was receiving ongoing treatment which can result in reduction of neutrophil function as well as blunt the neutrophil response to infection.  The patient was below ideal weight and physically weakened due to his prior surgery and treatments.  He was moderately dehydrated with an elevated lactate level at the time of initial evaluation.  The patient did not meet the criteria for inpatient admission based upon the initial clinical findings.  The patient was a candidate for a lower level of care with formal admission if his condition worsened.  However, the patient's condition did not worsen.  Therefore, acute inpatient admission was not medically necessary.

This patient was afebrile, normotensive, and did not have tachypnea or tachycardia when evaluated.  The lactate level did normalize after fluids.  The chest x-ray (CXR) and computed tomography (CT) of the abdomen were unremarkable.  The patient was relatively stable when initially evaluated and an initial lower level of care would have been appropriate management.       

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

Diagnosis: Peritonsillar Abscess. 
Treatment: Inpatient Hospital Stay. 
The insurer denied the Inpatient Hospital Stay. 
The determination is overturned. 

This is a female patient with a history of several days of odynophagia/dysphagia who was diagnosed with a left peritonsillar abscess with a computed tomography (CT) scan of the neck showing a complex collection and leukocytosis on laboratory studies. She initially underwent needle aspiration and later incision and drainage by otolaryngology, but no purulence was extracted. Due to significant symptoms of trismus, dysphagia, odynophagia, with a known left sided peritonsillar abscess that was unable to be drained successfully at the bedside, the patient was admitted for intravenous antibiotics and was given Unasyn. When she was able to tolerate medication via oral challenge, she was then prescribed Augmentin and discharged. At issue is the medical necessity of an inpatient stay. 

The requested health service/treatment of inpatient admission was medically necessary for this patient. The patient required inpatient admission to treat a serious, potentially life-threatening condition, with intravenous antibiotics since attempted incision and drainage and needle aspiration of a known abscess were unsuccessful. 

The patient had significant trismus/dysphagia/odynophagia and would not be able to tolerate oral antibiotics. A peritonsillar abscess is a potentially life-threatening condition that requires prompt recognition and treatment. The patient required intravenous antibiotics in this situation until such time as the patient's trismus/dysphagia/odynophagia was sufficiently improved to safely tolerate oral antibiotics. The patient was discharged after 48 hours of intravenous antibiotics when the patient was deemed medically stable for discharge and thus could be managed on an outpatient regimen. The patient was evaluated daily to determine the continued need for hospital admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pyelonephritis
Treatment: Inpatient Hospital Admission
The insurer denied Inpatient Hospital Admission.
The denial is upheld.

The patient is an adult female with a history of obesity status post gastric bypass who presented to the emergency department with low back pain, fever and chills. The patient underwent evaluation with blood work, blood cultures, and urine culture. Her vitals revealed temperature 99.9 (degrees Fahrenheit), blood pressure 100/50, and heart rate 115. Her white blood cell count was 12.5. Computed tomography scan revealed pyelonephritis and a malpositioned intrauterine device (IUD). The patient was given intravenous fluids, intravenous ceftriaxone, Tylenol, and intravenous morphine. She had a pelvic ultrasound confirming malposition and would follow up with gynecology (GYN) as an outpatient. The patient continued with pain despite antibiotics and pain medication, so she was admitted. Urine culture did reveal Escherichia coli. The patient was afebrile. On day # (number) 3, the patient's pain improved so she was discharged home with oral antibiotics and follow up. This inpatient admission was denied as not medically necessary. This is being appealed.

The proposed treatment was not medically necessary.

According to Gupta, "The decision to admit patients with acute complicated urinary tract infection/pyelonephritis should be individualized. The decision to admit is usually clear when patients are septic or otherwise critically ill. Otherwise, general indications for inpatient management include persistently high fever (e.g., greater than (>) 38.4 C (centigrade)/ greater than (>) 101 Fahrenheit (F)) or pain, marked debility, or inability to maintain oral hydration or take oral medications. Additionally, inpatient management is warranted when urinary tract obstruction is suspected or there are concerns regarding patient adherence."
Outpatient management is acceptable for patients with acute complicated urinary tract infection/pyelonephritis of mild to moderate severity who can be stabilized, if necessary, with rehydration and antimicrobials in an outpatient facility or the emergency department and discharged on oral antimicrobials with close follow-up. Many patients can be managed in the outpatient setting. As an example, in a study of 44 patients with pyelonephritis but no major comorbidities, a 12-hour observation period with parenteral antimicrobial therapy in the emergency department followed by completion of outpatient oral antimicrobials was effective management for 97 percent of patients (Ward et al). In review of the medical record the patient presented with pain and was found to have pyelonephritis. She did not have a fever. She did not have signs of sepsis. There was no obstruction on imaging. She continued with pain but not severe. She was tolerating diet, ambulating, voiding. The information provided does not follow the literature recommendations for inpatient care. The patient did not require inpatient hospitalization.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Admission:
The insurer denied: Inpatient Hospital Admission.
The denial is upheld

This is an adult male who presented via ambulance to the emergency room with complaints of chest pain. The patient used sublingual (SL) nitroglycerine without relief. He was given aspirin by emergency medical services. He was using non-steroidal anti-inflammatory drugs (NSAIDs) and Excedrin for a sinus infection and reported melena for a few days. The patient's hemoglobin was 7.1 in the emergency room, and creatinine was 1.7. The patient was treated with intravenous magnesium, intravenous insulin, and intravenous Protonix. The patient was admitted to the telemetry step down unit with chest pain, acute kidney injury, and anemia. The patient was treated with intravenous Protonix twice daily; he was nothing by mouth (NPO). His lab work showed fecal occult blood positive stool. He was transfused with two units of packed red blood cells (RBCs). 
On hospital day #2, the patient underwent transthoracic echocardiogram and esophagogastroduodenoscopy (EGD). Esophagogastroduodenoscopy showed an irregularity of the mucosa, diffuse continuous erythema of the mucosa compatible with non-erosive gastritis and diffuse continuous erosions, congestion, and erythema of the mucosa with no bleeding in the posterior bulb / first part of the duodenum. The patient left against medical advice on day #2.

The proposed treatment was not medically necessary.

An in-patient level of stay was not medically necessary since the patient did not require any surgical intervention, did not have active and ongoing gastrointestinal bleeding, and did not require to be nothing by mouth for a prolonged duration of time. In addition. the patient did not require prolonged treatment with intravenous hydration or intravenous medications and did not have any complications such as intra-abdominal abscess or a surgical abdomen.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Type 2 Diabetes
Treatment: Freestyle Libre supplies
The insurer denied Freestyle Libre supplies.
The determination is upheld.

This is a male patient with type 2 diabetes with neuropathy treated with metformin and Ozempic. The patient's A1C is 5.8 percent (%). Freestyle Libre supplies were denied by the health plan and are under review for medical necessity.

The requested Freestyle Libre supplies are not medically necessary for this patient. The requested service is for the management of type 2 diabetes for a patient who is not on insulin therapy. Long-term continuous glucose monitoring has been shown to be safe and effective for people with type 2 diabetes on multiple daily insulin injections and basal insulin therapy. The safety and efficacy of continuous glucose monitoring has not been sufficiently studied in people with type 2 diabetes in the absence of insulin therapy to determine safety and efficacy in this clinical situation. The use of continuous glucose monitoring in this clinical situation is not supported by the Endocrine Society guidelines [1] or the American Diabetes Association clinical guidelines [2]. Therefore, the requested Freestyle Libre supplies are not medically necessary for this patient.