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

Diagnosis: Atrial fibrillation
Treatment is an inpatient admission
The insurer denied coverage for an inpatient admission
The denial is overturned.

This is a patient that presented to the hospital complaining of palpitations. Past medical history was significant for hypothyroidism and recently diagnosed atrial fibrillation. Upon arrival to the ED (emergency department) her blood pressure was 133/80mmHg (millimeters of mercury) and her pulse was 127 bpm (beats per minute). A physical examination revealed an irregularly irregular pulse. A 12-lead electrocardiogram revealed atrial fibrillation with rapid ventricular rates at 127bpm. Serum blood testing revealed no significant abnormalities. Myocardial perfusion testing revealed no evidence of ischemia. An echocardiogram revealed a moderately depressed LV (left ventricular) ejection fraction: 41-45%. The patient underwent a transesophageal echocardiogram and cardioversion to sinus rhythm. Post procedure she was noted to have recurrent atrial fibrillation. She was treated with amiodarone therapy and monitored on telemetry. Ultimately, she was discharged home with follow up.

Admission for monitoring and treatment was medically necessary. Patients presenting with atrial arrhythmia and ventricular rates up to 127 require acute therapy and further monitoring to ensure that medications control heart rate and rhythm without producing significant bradycardia. An analysis of 68 million Medicare patients admitted to the hospital for atrial fibrillation over a fifteen-year period demonstrated an average length of stay of 3 days. (Reference 1) This analysis also demonstrated decreased mortality and readmission rates following admission to the hospital. American Heart Association/American College of Cardiology Guidelines for the management of patients with atrial fibrillation recommend telemetry monitoring for patients treated with atrial fibrillation requiring treatment with rate control and antiarrhythmic therapies. The current standard of care is consistent with hospital admission when patients present with symptomatic rapidly conducted atrial fibrillation. In conclusion, inpatient admission was medically necessary in this case. 

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

Diagnosis: S/P (status post) kidney transplant, feeding difficulties
Treatment: Home Nursing Care, by registered nurse and Licensed Practical Nurse for eight hours per day, seven days a week.
The insurer denied: Home Nursing Care, by registered nurse and Licensed Practical Nurse for eight hours per day, seven days a week.
The denial is upheld.

The patient is a female with feeding difficulties who underwent a kidney transplant. She requires medication administration, bolus gastrostomy (G)-tube feeds, and reported nasal suction on occasions. The subject under review is the medical necessity for in home nursing care, by registered nurse and licensed practical nurse for eight hours per day, seven days per week.

The requested health service/treatment of in home nursing care is not medically necessary. There is nothing in the records provided to suggest that patient requires 8 hours a day 7 days a week of skilled nursing support. The child is dependent on technology with gastrostomy tube feeds, but this appears to be stable and should not require ongoing home health care needs with such high acuity care.
G-tube feedings and medication administration are common procedures parents/caregivers of medically complex children are taught to do prior to release of the child into the caregivers care. There is no documentation provided that reports insecurity of the patient's airway during the hours of home nursing care. As a toddler, the patient would be supervised during the hours of reported home nursing and a caregiver could intervene with nasal suctioning.
The skills needed for this patient can be performed by a trained caregiver and the in home nursing care is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cervical dysplasia
Treatment is an inpatient admission 
The insurer denied coverage for an inpatient admission
The denial is upheld.

This is a patient who was s/p (status post) supracervical hysterectomy and bilateral salpingo-oophorectomy (BSO). She underwent a trachelectomy and repair of cystocele with suspension of the anterior vaginal wall. The patient was admitted after failing the voiding trial post-operatively; however, she was able to void over-night. The patient voided 200 cubic centimeters (cc) and 150 cc, and a bladder scan revealed a residual volume of 500 cc's. The patient was medically stable and discharged home with a foley catheter in place with a leg bag. The patient was advised to follow-up as an outpatient for foley removal.

A trachelectomy with an anterior repair is an outpatient procedure. Note that a vaginal hysterectomy which is a much more involved procedure is an outpatient procedure. The safety of this approach has been documented in multiple studies.
Admission is usually not necessary unless there is a possible complication such as: heavy bleeding, surgical complications (bladder ureter or bowel injury or hemorrhage), conversion to abdominal hysterectomy, wound complications or comorbidities.

This patient's procedure was uncomplicated. There was no evidence of any injury to other organs. A trachelectomy is an outpatient procedure and includes appropriate postoperative monitoring and an overnight stay if required. In other words, the patient could have been monitored overnight without the need for an admission and once the provider ascertained that the patient was stable, the patient could have been sent home with a foley catheter.
Based on the above, the inpatient admission was not medically necessary for this patient care and management.

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

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

Diagnosis: Cervical dysplasia
Treatment is an inpatient admission 
The insurer denied coverage for an inpatient admission 
The denial is upheld.

This is a patient who was s/p supracervical hysterectomy and bilateral salpingo-oophorectomy (BSO). She underwent a trachelectomy and repair of cystocele with suspension of the anterior vaginal wall. The patient was admitted after failing the voiding trial post-operatively; however, she was able to void over-night. The patient voided 200 cubic centimeters (cc) and 150 cc, and a bladder scan revealed a residual volume of 500 cc's. The patient was medically stable and discharged home with a foley catheter in place with a leg bag. The patient was advised to follow-up as an outpatient for foley removal.

A trachelectomy with an anterior repair is an outpatient procedure. Note that a vaginal hysterectomy which is a much more involved procedure is an outpatient procedure. The safety of this approach has been documented in multiple studies.
Admission is usually not necessary unless there is a possible complication such as: heavy bleeding, surgical complications (bladder ureter or bowel injury or hemorrhage), conversion to abdominal hysterectomy, wound complications or comorbidities.

This patient's procedure was uncomplicated. There was no evidence of any injury to other organs. A trachelectomy is an outpatient procedure and includes appropriate postoperative monitoring and an overnight stay if required. In other words, the patient could have been monitored overnight without the need for an admission and once the provider ascertained that the patient was stable, the patient could have been sent home with a foley catheter.
Based on the above, the inpatient admission was not medically necessary for this patient care and management.

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

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

Diagnosis: Anterior Crossbite
Treatment: Braces and monthly visits
The insurer denied Braces and monthly visits
The denial is: Overturned

The requested treatment of braces and monthly visits is medically necessary for this patient.
It is a generally accepted practice guideline in orthodontics to treat anterior crossbites as soon as possible because of the damage that can occur to the patient's dentition if left untreated. This patient is already developing wear on teeth 8 and 9 due to the anterior crossbite.
Treatment for the patient's anterior crossbite in the mixed dentition is medically necessary. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects.1,2,3 These problems are much more time consuming to correct than the patient's existing orthodontic problem.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Altered mental status
Treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned.

The patient is a boy who presented with altered mental status, headache, and vomiting. He was well until the day prior to presentation when he developed a headache and abdominal pain. The next day, his mother was called by the school nurse because of continued headache and abdominal pain. He was given acetaminophen, and his mother picked him up and brought him to his primary doctor. He was diagnosed with a throat infection and prescribed a 10-day course of antibiotics. As they were driving home from the doctor's office, he became unresponsive and had 3 episodes of vomiting with upward rolling of his eyes. His mother pulled to the side of the road and called for emergency services. When emergency services arrived, he did not display any noted seizure activity, and was responsive to painful stimuli. He was subsequently brought to the emergency department for care.

The inpatient hospital admission was medically necessary. This is a young boy who presented to the emergency department for evaluation of possible seizure activity with unresponsiveness and altered mental status. This was in the setting of a recent headache, abdominal pain, and sore throat. There was concern for possible new onset seizure versus infectious etiologies. Given the uncertainty of the etiology of these symptoms and potential high risk for complications, he required inpatient admission with further evaluation and close monitoring. He also required an extensive workup including video EEG (electroencephalogram) monitoring, imaging, and expert consultation.
The decision-making time of admission for this patient was consistent with his young age, the occurrence of a significant event including loss of consciousness and altered mental status of unclear etiology, and the need for careful evaluation along with close monitoring for potential deterioration of clinical status.
Appeal type: Medical necessity
Decision: Overturned

Central nervous system
inpatient hospital

Diagnosis: Altered mental status
Treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned.

The patient is a boy who presented with altered mental status, headache, and vomiting. He was well until the day prior to presentation when he developed a headache and abdominal pain. The next day, his mother was called by the school nurse because of continued headache and abdominal pain. He was given acetaminophen, and his mother picked him up and brought him to his primary doctor. He was diagnosed with a throat infection and prescribed a 10-day course of antibiotics. As they were driving home from the doctor's office, he became unresponsive and had 3 episodes of vomiting with upward rolling of his eyes. His mother pulled to the side of the road and called for emergency services. When emergency services arrived, he did not display any noted seizure activity, and was responsive to painful stimuli. He was subsequently brought to the emergency department for care.

The inpatient hospital admission was medically necessary. This is a young boy who presented to the emergency department for evaluation of possible seizure activity with unresponsiveness and altered mental status. This was in the setting of a recent headache, abdominal pain, and sore throat. There was concern for possible new onset seizure versus infectious etiologies. Given the uncertainty of the etiology of these symptoms and potential high risk for complications, he required inpatient admission with further evaluation and close monitoring. He also required an extensive workup including video EEG monitoring, imaging, and expert consultation.
The decision-making time of admission for this patient was consistent with his young age, the occurrence of a significant event including loss of consciousness and altered mental status of unclear etiology, and the need for careful evaluation along with close monitoring for potential deterioration of clinical status.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Diabetes mellitus type 2.
Treatment is Bydureon (exenatide).
The insurer denied coverage for Bydureon (exenatide).
The denial is upheld.

The patient has the medical diagnosis of type two diabetes mellitus (DM2). The patient has been seen and treated with a past medical history (PMH) of type two diabetes mellitus (DM2). The request is for coverage of Bydureon (exenatide). The coverage was previously denied, this is an appeal initiated by the treating provider. The coverage was previously denied, because the patient did not meet medical necessity criteria under the health plan, specifically because there is not a reason why the alternative, preferred drugs (Trulicity, Ozempic, Victoza, or Rybelsus) could not be used. Per an office note the patient has nausea on Trulicity, but it is mild. The patient is willing to restart it. Per an office note the patient is on Bydureon (exenatide), glimepiride, Jardiance, and metformin. This is a continuation of therapy request. Trulicity has been used on and off, but the patient feels queasy for two days. The treating provider prescribed Bydureon (exenatide). The treating provider is requesting plan approval for treatment with Bydureon (exenatide).

The formulary drug(s) are not likely to cause the patient an adverse reaction.      

The formulary drugs have not been ineffective based on the patient's clinical history. The patient has not tried Ozempic, Victoza, and Rybelsus.     

The requested drug would not be more effective than the formulary drug.

The patient had nausea on Trulicity despite repeated trials. Nausea and vomiting are common adverse events in the GP1a (glycoprotein) class, other formulary drugs include Trulicity, Ozempic, Victoza, and Rybelsus would not be more likely to cause this adverse reaction than Bydureon, the requested. The formulary drugs have not been ineffective based on the patient's clinical history. The patient has not tried Ozempic, Victoza, and Rybelsus. Bydureon would not be more effective than formulary drugs. Therefore, the request is denied and not medically necessary for this patient. 

"There are few head-to-head quality randomized controlled trials comparing efficacy of different GLP1 [glucagon-like peptide 1] agonists, however, generally as a class they have similar efficacy in glycemic control, with monotherapy Victoza and Bydureon lowering A1c (glycated hemoglobin test) by about 1.2%, with dulaglutide and injectable semaglutide lowering up to 1.6-1.7% at the 1.5 and 1mg (milligram) weekly doses respectively, oral semaglutide lowering A1c up to 1.1%, and Byetta and Lixisenatide lowering A1c slightly less than 1%. " (Feingold, et al., 2019). 

"Ozempic at the recently approved 2mg weekly dose was able to lower A1c further by 2.1%." (Frias, et al., 2021).  

The insurer's denial of coverage for Formulary Exception for Bydureon is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left upper extremity (LUE) numbness.
Treatment is an inpatient admission.
The insurer denied coverage for an inpatient admission.

The denial is overturned.

This is a patient with a history of arthritis, cataracts, and high cholesterol. He presented to the emergency room (ER) with complaints of pain, weakness, and paresthesias in the left arm for the past 8 months. He was admitted with left upper extremity (LUE) numbness. He had an elective C (cervical) 5-7 anterior cervical discectomy and fusion (ACDF). He reported having a sore throat which was relieved by Decadron and pain medications. The patient was able to tolerate a regular diet and ambulate. 

The medical records show the patient was evaluated in the ER with intractable pain and worsening weakness. He required subspecialty consultations and imaging which confirmed the pathology. His physician opined the need for emergent cervical spine surgery. This was performed in the morning of the next day. His operation was complex and extensive. A two level ACDF was completed. His post-surgical course was complicated by dysphagia and pain. There was also drainage on the bandage. It would be important to monitor his condition at the very least overnight after this type of operation. Catastrophic complications can occur of bleeding and airway obstruction. It would not be prudent to discharge him the same day after the procedure. 

Based upon clinical presentation, pathology and type of surgery performed, the service could not have been provided at a lower level.

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 admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left upper and lower extremity weakness.
Treatment is an inpatient admission.
The insurer denied coverage for an inpatient admission.
The denial is overturned.

This patient was seen in the emergency room (ER) for sudden onset left upper and lower extremity weakness and numbness. It was noted that the patient's symptoms improved and then recurred prior to presenting to the ER. At the time of evaluation in the ER it was noted that the patient continued to complain of left hand and left foot numbness. In the past medical history, it was documented the patient had hyperlipidemia, hypertension, and daily cigar use. On examination the patient had left hand and foot numbness and a mild left facial droop. It was noted that the head Computed tomography (CT) scan was negative and that the plan was to admit the patient to the hospital.

The patient was seen for a possible stroke. She noted the chief complaint of left arm and leg numbness and weakness. She noted that the patient had sudden onset left arm and leg tingling and weakness. The patient's initial symptoms resolved after 40 minutes before returning again for one hour. He continued to have tingling of the left arm and leg at the time of her evaluation. She noted that the patient NIH (National Institute of Health) Stroke Scale (NIHSS) was zero. She noted that the plan was to admit the patient for telemetry and obtain an Magnetic resonance imaging (MRI) of the brain. She noted that the patient continued to complain of intermittent tingling of the left arm and leg, that the neurological exam was normal, that the MRI of the brain was still pending, and that the plan was to continue on aspirin and statin.

The health care plan did not act reasonably and with sound medical judgement and in the best interest of the patient. The patient presented with multiple strokes like events prior to arrival in the emergency department. The patient's presentation of recurrent transient ischemic attacks (TIAs) raises concerns for progression to full blown stroke. This presentation was similar to an acute coronary and a discharge home was not acceptable. As such, the inpatient admission was medically necessary. 

"Up to a 10% risk of recurrent stroke exists after a TIA, and up to 80% of this risk is preventable with urgent assessment and treatment. Imaging of the brain and intracranial and extracranial blood vessels using CT, CT angiography, carotid Doppler ultrasound, and MRI is an important part of the diagnostic assessment. Treatment options include anticoagulation for atrial fibrillation, carotid revascularization for symptomatic carotid artery stenosis, antiplatelet therapy, and vascular risk factor reduction strategies." (Coutts S. B. 2017).

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 admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acquired Epidermolysis Bullosa.
Treatment: Octagam.
The insurer denied Octagam.
The denial is overturned.

The patient is an adult female who has been diagnosed with acquired epidermolysis bullosa, systemic lupus erythematosus and an unspecified bullous disorder and carries a positive rheumatoid factor test. The patient has tried and failed or had an adverse reaction to treatment with steroids, methotrexate and Plaquenil. The treating provider is now requesting approval of intravenous immunoglobulin (IVIG). This request was denied by the health plan, so the provider is appealing the denial.

The proposed treatment is medically necessary.

The policy states that the requested medication, Octagam, is approved for certain conditions including "immunodeficient disorders-autoimmune diseases, where the body attacks its own tissues". In this case, the policy does state that for immunodeficient disorders such as in the case of this patient, the medication Octagam can be approved. This is precisely what the patient has on multiple fronts; the patient has been diagnosed with acquired epidermolysis bullosa, systemic lupus erythematosus and an unspecified bullous disorder and carries a positive rheumatoid factor test.

Furthermore, the treating provider has noted that several conventional treatments have been tried and the patient either had an inadequate response of had an adverse reaction.