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

Diagnosis: Respiratory System. 
Treatment: Pharmacy/Prescription Drugs. 

The insurer denied Breztri. 
The denial is upheld. 

The patient is a female who is seeking Breztri. The patient has a history of chronic obstructive pulmonary disease (COPD) with multiple exacerbations and has failed Anoro and Trelegy due to adverse reactions. Breztri was denied as the patient had not taken or had a poor response to other formulary inhalers. Formulary alternatives include Incruse Ellipta, Striverdi Respimat, Stiolto Respimat, Trelegy Ellipta, Fluticasone/salmeterol powder for inhalation or Wixela Inhub and generic Symbicort.
A pulmonary visit encouraged the patient not to smoke. Trelegy was given. A computed tomography angiography (CTA) of the chest noted emphysema. The pulmonary function test (PFT) noted emphysema. At the patient's visit, she was on Anoro and Proair.
At issue is the medical necessity of Breztri Aerosphere Sphere Inhaler.

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

The requested health service/treatment of Breztri Aerosphere Sphere Inhaler is not medically necessary for this patient.
According to The Global Initiative for Chronic Obstructive Lung Disease (GOLD) (2021), National Institute for Health and Care Excellence (NICE) et al., (2018), and Wedzicha et al., (2017), there are some who will benefit from triple therapy inhalers, but there are other medications/inhalers available which work and are just as effective. The patient will need to try and fail the formulary inhalers before switching to Breztri, as the health plan's formulary alternatives are considered just as effective.
Therefore, the requested health service/treatment of Breztri Aerosphere Sphere Inhaler is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Severe Alcohol Withdrawal.
Treatment: Continued Inpatient Hospital Admission.
The insurer denied the Continued Inpatient Hospital Admission.
The denial is upheld.

This male patient with a history including alcohol abuse, substance abuse, encephalopathy, and bipolar disorder was admitted with acute alcohol withdrawal.  He was intubated and admitted to the intensive care unit.  His hospital course was complicated by delirium tremens.  He was extubated.  He completed a course of antibiotics for pneumonia.  He had persistent confusion after completion of withdrawal therapy.  He was eventually cleared for discharge to home.  The following day, the patient's vital signs were stable.  Delirium tremens had resolved.  The withdrawal protocol was finished.  The patient was tolerating an oral diet.  His pneumonia had resolved.  Medications were established for congestive heart failure.  The patient was medically stable for discharge, but the family was unwilling to take patient home.  He remained medically stable through discharge.  Discharge was delayed pending placement.

No, the proposed inpatient admission was not medically necessary.
This patient was admitted with delirium tremens.  During the period in question, he was medically stable and cleared for discharge.  During this period, the patient was hemodynamically stable.  Alcohol withdrawal had resolved.  His respiratory status was stable.  He was no longer receiving intervention that required an acute ongoing inpatient level of care.  Discharge was delayed pending placement.  The proposed inpatient admission was not medically necessary because it was not in accordance with generally accepted standards of medical practice for the care provided.

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

Diagnosis: Bipolar, polysubstance abuse, alcohol intoxication.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female with bipolar disorder, polysubstance abuse with confusion and agitation in the setting of alcohol intoxication. The patient was noted with an elevated creatinine of 2.1 milligrams per deciliter (mg/dl). The patient was treated for alcohol intoxication due to ongoing agitation and was also treated with intravenous fluid hydration due to elevated renal function. With clinical stability, the patient was transferred to the psychiatric unit for further care of bipolar disorder.

The proposed inpatient admission was not medically necessary.
The patient could have safely and effectively been managed at a lower level of care.

Based on the Milliman Care Guidelines (MCG) criteria, inpatient level of care may be recommended for renal failure as indicated by one or more of the following: three-fold rise in serum creatinine from baseline, serum creatinine greater than four milligrams per deciliter (mg/dL) (354 micromoles per liter) with acute rise greater than 0.5 milligrams per deciliter (mg/dL) (44.2 micromoles per liter) , or reduction of more than 75% (percent) in estimated glomerular filtration rate or anuria indicated by adequate volume status.   

The patient was noted with an elevated creatinine of 2.1 milligrams per deciliter (mg/dl). Based on available data, these criteria are not met.

Inpatient admission may be indicated for renal failure if the patient cannot be managed in outpatient or observational care setting as indicated by one or more of the following: clinical status unstable, altered mental status that is severe or persistent, hemodynamic instability, severe hypertension, cardiac arrhythmias of immediate concern, or clinically significant electrolyte abnormality or metabolic abnormality that is severe or persists despite outpatient or observation care treatment, acute treatment of renal failure (eg, dialysis) not feasible or appropriate in observational care setting, other suspected etiology needing inpatient level of care. 

Based on available data, these criteria are not met and therefore, the inpatient level of care is not recommended.

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: Obstructive Sleep Apnea
Treatment: Hypoglossal Nerve Stimulator
The insurer denied the Hypoglossal Nerve Stimulator
The denial is overturned.

The patient is a male with a history of obstructive sleep apnea (OSA).  His apnea hypopnea index (AHI) on sleep study was 34.9 with a body mass index (BMI) of 26.5. The patient could not tolerate continuous positive airway pressure (CPAP) and underwent a sleep endoscopy where there was no complete concentric collapse at the velum.  There is also a history of a failed oral appliance trial and nasal turbinate surgery. The provider is requesting placement of an Inspire hypoglossal nerve stimulator system to treat the patient's obstructive sleep apnea.  The request was previously denied as not meeting Plan criteria and the provider is appealing the denial.

Yes, the proposed treatment is medically necessary.
All records were reviewed. The provider is requesting placement of a hypoglossal nerve stimulator to treat the patient's obstructive sleep apnea.  There is support in the literature for the efficacy of the Inspire hypoglossal nerve stimulator for the treatment of a subset of patients with obstructive sleep apnea (OSA) who have failed, or cannot tolerate, continuous positive airway pressure (CPAP) therapy.  A prospective multi center study documented a reduction of apnea hypopnea index (AHI) out to 12 months.  In addition, there was a randomized, controlled withdrawal arm of the study which reported apnea hypopnea index (AHI) reduction out to 18 months.  Therefore, based on current scientific literature, scientific evidence would support the efficacy of upper airway stimulation therapy with a hypoglossal nerve stimulator for a subset of patients with obstructive sleep apnea who meet Food and Drug Administration (FDA) criteria for the procedure.  

In this particular case, the patient would meet Food and Drug Administration (FDA) criteria for the device in terms of body mass index (BMI), age, apnea hypopnea index (AHI) and sleep endoscopy findings (there was no complete concentric collapse on sleep endoscopy).  The patient has had a previous turbinate surgery and oral appliance therapy which did not eliminate the symptoms.  There was also a reported failed continuous positive airway pressure (CPAP) trial.  There would be no contraindications to the procedure based on the information provided.  Therefore, based on the information provided, the medical necessity of the requested service would be confirmed.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
The health plan denied the requested procedure.  However, based on the information available currently, the patient had a more recent sleep study with a lower apnea hypopnea index (AHI).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Blood Disorder. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient stay. 
The denial is upheld in whole. 

The patient is a male with a history of a gastrectomy and tobacco abuse. He presented to the emergency room when outpatient testing revealed a low hemoglobin and a possible chest mass. He denied any bleeding symptoms. The vital signs were non-contributory. Physical exam revealed pale conjunctiva. Labs were remarkable for a hemoglobin of 4.2 grams per deciliter (g/dl), white blood cell (WBC) count 2300, and a platelet count 31000. A chest computed tomography (CT) scan revealed a right upper lung mass, multiple pulmonary nodules. An abdominal CT angiogram did not find a source of active bleeding. The electrocardiogram (EKG) was negative for acute ischemia or significant arrhythmia. Multiple red blood cell transfusions and intravenous fluids were administered. The patient was admitted for further treatment and evaluation.
Upon admission, the patient was treated with intravenous fluids, along with parenteral cyanocobalamin and folate. A multi-day hospitalization ensued. He received an additional red blood cell (RBC) transfusion, as well as a platelet transfusion. The remainder of the stay was clinically uneventful, and the patient was discharged. The subject under review is the medical necessity for the inpatient stay. 

The health plan's determination is upheld. 

The requested inpatient stay was not medically necessary for this patient. Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or EKG of an imminently life-threatening cause of the patient's complaints that required acute inpatient admission. The patient was hemodynamically stable, there were no mental status changes, there was no evidence of active or uncontrollable bleeding, there was no respiratory distress, or severe metabolic disarray. The services provided - red blood cell and platelet transfusions, cyanocobalamin and folate, and consultations - did not require acute inpatient care. Therefore, based on the standard of care, and the peer reviewed literature cited in the references, the acute inpatient level of care was not medically necessary, and the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tubo-ovarian Abscess. 
Treatment: Inpatient Hospital Admission. 

The insurer denied coverage for inpatient hospital admission. 

The denial is overturned. 

The patient has a history of asthma, COVID (coronavirus) 19, and endometrioma, possible tubo-ovarian abscess [TOA]. She presented to the emergency room (ER) with fever, chills, nausea vomiting and diarrhea of 2 weeks duration.  Her white blood cell was elevated.  The patient was admitted to the medical unit with intractable abdominal pain. She was managed with IV (intravenous) antibiotics. The patient's condition improved after treatment. She was discharged with instructions to continue Augmentin, Doxycycline, Omeprazole, and Senna. 

Most women with PID [pelvic inflammatory disease] can be safely treated in outpatient settings. Indications for hospitalization and parenteral antibiotics include: 

1) Severe clinical illness (high fever, nausea, vomiting, severe abdominal pain) 
2) Complicated PID with pelvic abscess (including tubo-ovarian abscess) 
3) Possible need for invasive diagnostic evaluation for alternate etiology (eg, appendicitis or ovarian torsion) or surgical intervention for suspected ruptured tubo-ovarian abscess 
4) Inability to take oral medications due to nausea and vomiting 
5) Pregnancy 
6) Lack of response or tolerance to oral medications 
7) Concern for nonadherence to therapy 

This patient had a suspected tubo-ovarian abscess. Tuboovarian abscess (TOA) is typically considered a complication of pelvic inflammatory disease (PID), and the classic presentation is the same as for PID alone, including acute lower abdominal pain, fever, and chills.  Experts agree that women with a TOA should be treated as an inpatient with intravenous antibiotics, at least initially. This is consistent with the recommendation by the United States Centers for Disease Control [CDC]. 
This patient presented with abdominal pain, elevated WBCs (white blood cells) and a diagnosis of TOA that did not respond to outpatient management. She was admitted according to the standard of care and the CDC recommendation. Once, the patient was deemed stable with an improvement of her symptoms she was discharged home. 

The inpatient hospital admission is considered medically necessary for this patient. 

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

Diagnosis: Ballistic Distal Femur Fracture. 
Treatment: Inpatient Hospital. 

The insurer denied coverage for inpatient hospital. 

The denial is upheld. 
 
This is the case of a patient with no past medical history. The patient presented to the emergency department (ED) via ambulance status post gunshot wound and fracture to his left leg requiring repair. Orthopedic Surgery and Trauma were consulted. The patient was admitted to trauma services and underwent irrigation and debridement of the left knee, removal of foreign body from the left knee and open reduction internal fixation (ORIF) of left medial femoral condyle fracture (code 27514). Postoperatively, the patient received intravenous (IV) antibiotics and physical therapy. He was discharged home. 

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

The medical record demonstrates the patient sustained an isolated gunshot wound of low velocity to his knee. His physician performed the irrigation, debridement, removal of bullet and provided fixation to the medial femoral condyle. (Screw fixation). The operation was of limited duration (approximately 1 1/2 hours). It was not complex nor extensive. Exposure and direct reduction were performed. 

There was no blood loss. His post-surgical course was non-complicated. He did not have fever nor signs of bleeding. He did not require additional imaging. His wound was satisfactory. He was able to tolerate oral pain medications. He received IV antibiotics.  He was independent with crutches and mobile. He did not require treatment for other associated medical conditions. These findings do not substantiate necessity of the inpatient admission. The level of service could have been provided at Observation. 

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated. The insurer's denial is upheld.
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 with a history of seizure disorder who presented to the emergency ward with seizure activity.  At presentation, the patient was noted to be awake and able to communicate appropriately with no neurological deficit. Her carbamazepine level was sub-therapeutic. She was admitted to the acute inpatient service and anticonvulsants were adjusted. The patient was subsequently discharged the following day.

No, the proposed treatment, inpatient admission, was not medically necessary.
The patient had a pre-existing history of seizure disorder, an established outpatient anticonvulsant regimen and a sub-therapeutic carbamazepine level, which explained her breakthrough event. At presentation, she was medically and neurologically stable. The clinical evaluation, diagnostic studies, medication adjustments and monitoring could have been safely and effectively provided at a lower level of care.

Yes, 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: Coronary artery disease.
Treatment: Personal Care Assistance Services: 70 Hours per Week.

The insurer denied Personal Care Assistance Services: 70 Hours per Week.  The health plan's determination is overturned.

The patient is a male with past medical history of coronary artery disease (CAD), congestive heart failure (CHF), aortic stenosis, diabetes mellitus (DM), hyperlipidemia, hypertension, chronic kidney disease stage 4, obesity, right sided lacunar infarcts, dementia, urinary incontinence, and chronic obstructive pulmonary disease (COPD) who had been assigned PCA (personal care assistant) services 35 hours/week based on assessment tool assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, and shopping while extensive assistance with tasks of managing finances, managing medication, stairs, transportation, bathing, dressing upper/lower body, transfer toilet, and toilet use. Tasking tool estimated hours at 20.81. The patient was hospitalized with fever and treated with intravenous (IV) antibiotics and transitioned to oral antibiotics. There was a request to increase PCA services and the patient underwent an assessment, but the full report was not available for review. The patient was assessed at maximum assistance with tasks of bathing and dressing lower body while extensive assistance with task of dressing upper body. Notes from the assessment stated the patient lived alone and had no informal support. 

Personal Care Assistance Services: 70 Hours per Week are medically necessary for this patient.

There is documentation of the patient's decline in physical and cognitive functioning by the patient's primary care physician (PCP) following recent hospitalizations. The patient developed a sacral ulcer following the second hospital admission. The patient required at least limited assistance with all activities of daily living (ADL) / Instrumental activities of daily living (IADL). The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 70 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in his own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vision. 
Treatment: Skilled Nursing Facility. 

The insurer denied Long-Term Custodial Care Services. 
The denial is upheld. 

The patient is a male with a past medical history significant for legal blindness, alcohol abuse, and glaucoma. The patient was admitted to the hospital secondary to a fall. After hospitalization, the patient required skilled services. The patient reached his maximum potential, and the patient was transferred to custodial care and has been in custodial services. 

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

The requested health service/treatment of Long-Term Custodial Care Services is not medically necessary for this patient. 

The patient is a male with a past medical history significant for legal blindness, alcohol abuse, glaucoma. To prove this service in full, documentation must be provided that the patient's needs cannot be met in a community setting. The medical necessity for continued stay was not supported. The patient is able to direct his own care, make transfers in and out of bed and toilet independently, and do his own activities of daily living (ADLs) with little or no support. The patient's main disability as noted in the medical record is his blindness. He was previously being taken care of by a family member who is no longer willing or able to take care of the patient. The patient is otherwise independent in self-care including ambulation, transfers, feeding, and toilet use. It does not appear from the medical record that the patient is able to provide for himself and manage his affairs independently. However, the confinement custodial setting is not medically necessary for the patient. Alternative living arrangements are appropriate as the patient is independent in most ADLs. 

Therefore, the requested health service/treatment of Long-Term Custodial Care Services is not medically necessary.