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

Diagnosis: Cellulitis.
Treatment: Inpatient hospital admission.
The insurer denied the inpatient hospital admission.
The denial was upheld.

This is a female patient with a medical history of hypertension, gastroesophageal reflux disease (GERD), and hypothyroidism. She presented to the Emergency Department (ED) with complaints of left leg pain and swelling after insect bites. The patient's vital signs on ED presentation included: Temperature 98 F, Blood Pressure 137/100, Pulse 64, Respiratory Rate 18, Oxygen (O2) saturation 100% on Room Air. The patient's laboratory values were notable for the following: white blood cell count (WBC) 6.42, hemoglobin (Hgb) 12.7, hematocrit (Hct) 40.7, creatinine 0.6, glucose-82, lactate 0.9, and C-reactive protein (CRP) 1.7. The patient's chest x-ray (CXR) was unremarkable. The patient was admitted for cellulitis of the left lower leg following an insect bite. The patient received antibiotics (i.e., vancomycin and Zosyn. Infectious Diseases was consulted and they recommended switching the antibiotics to intravenous Ancef. The patient remained febrile, hemodynamically stable, and clinically improved. The patient was discharged with instructions to continue on oral antibiotic (i.e. Keflex) as an outpatient.

Based on the review of the medical record and literature, inpatient admission was not medically necessary for this patient. The patient was admitted with worsening lower extremity cellulitis. Although the patient had taken Augmentin as an outpatient, the patient was afebrile, hemodynamically stable with unremarkable laboratory results including normal leukocyte and lactate levels. There was no evidence of a disseminated infection. The patient was able to tolerate oral intake, and required no surgical intervention that warranted inpatient level of care.  Based on these clinical findings, the patient did not meet inpatient criteria for acute level of care and hospitalization. The patient's care could have been safely and sufficiently provided at the observational level of care. 

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

Based on the above, the medical necessity for the acute inpatient stay is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Obstructive Pulmonary Disease, End Stage Renal Disease.

Treatment: Skilled nursing facility for sub-acute rehabilitation admission.

The insurer denied the skilled nursing facility for sub-acute rehabilitation admission.

The denial was upheld.

This is a female patient with a history of chronic obstructive pulmonary disease (COPD), end stage renal disease (ESRD), diabetes, and hypertension. The patient was transferred from an acute hospital status post COPD exacerbation to a skilled nursing facility (SNF) for subacute rehabilitation. It was reported that the patient had achieved a functional level that was appropriate for discharge to a lower of care (e.g., home with therapy services or outpatient therapy services) on the denied dates of service.  According to the occupational therapy Discharge Summary the patient was at the set-up to modified independence level for activities of daily living, which included dressing, bathing and toileting.  A similar high level of function was documented by the physical therapist in the report.  The patient was modified independent for bed mobility, transfer activities and ambulating with a rolling walker.  In addition, there were no complex nursing issues or acute medical problems that required skilled nursing or physician services.  

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

Based on the above, the medical necessity for admission to a skilled nursing facility for sub-acute rehabilitation is not substantiated.  The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic migraine.

Treatment: Emgality.

The insurer denied coverage for Emgality. 

The denial is overturned.

This patient is a female who has a chronic headache history with suspicion of chronic migraine. The patient was seen for a follow-up.  The documentation indicates that the patient had a motor vehicle accident causing posttraumatic cervical and lumbosacral radiculopathy.  The patient also had a separate history of headaches developing in childhood and into early adulthood.  The patient described her headache as throbbing or pressure-like pain triggered by light and sometimes weather changes, and was associated with light and sound sensitivity and nausea; symptoms consistent with migraines.  In the last several years, the physician noted that the patient's headaches have increased and have recurred more than half of the month.  The patient's headaches would last for several days in a row and at times, the patient experienced temporary relief with over-the-counter analgesic medications.  The patient has been prescribed topiramate and has used Emgality with excellent results and no significant headache symptoms in the last few months.  The patient still experienced mild headaches but have been more self-limited since her use of Emgality.  The patient also has comorbid conditions of fibromyalgia and Raynaud's phenomenon.  The patient was also being treated for temporomandibular joint (TMJ) dysfunction with mouth guards.  On exam, the patient had mild tenderness at the TMJ. 
Based on the review of the medical record, the patient has failed monotherapy on Topamax as well as Pamelor. The patient had chronic migraine refractory to treatment. The patient also had comorbidities that limited her choice of treatment options. Amitriptyline/antidepressant medications were not indicated as this patient's use of nortriptyline had caused issues with gastric motility and caused increased symptoms of depression. Aimovig use was also not indicated as this patient suffered from gastroparesis. Lastly, beta-blocker medications were not indicated as this patient had self-reported hypotension. The patient's treating physician documented this patient's solid clinical response to Emgality with reduction in intensity and frequency with current Emgality injections. Literature supports the use of Emgality, for which Emgality has been shown in clinical trials to reduce the frequency and intensity of migraine headaches. This was the case for this patient. Therefore, based on the review of the medical record and literature, Emgality is considered medically necessary for this patient.

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

Based on the above, the medical necessity for Emgality for migraines is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned

Cardiac
Inpatient hospital

Diagnosis: Chest pain
Treatment: Inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is overturned. 

The patient is an old man with nonischemic cardiomyopathy, ejection fraction (EF) 15%, s/p implantable cardioverter defibrillator (ICD), diabetes, hypertension, hyperlipidemia, atrial fibrillation and flutter who presented to the emergency room (ER) with complaints of left sided chest pain and dyspnea for one week. He had been taking ibuprofen 4 time a day recently. He was compliant with medications and diet. He was in moderate respiratory distress. Blood pressure (BP) was 125/83 mm HG , pulse 81 beats per minute (bpm), and respiratory rate 23. Oxygen saturation was 97%. A chest x-ray (CXR) showed pulmonary congestion. An electrocardiogram (EKG) showed atrial fibrillation with a ventricular rate of 107 bpm with no ischemic ST segment changes. ProBNP was elevated at 5881. Troponin was 0.031. He was admitted to telemetry step down unit with a diagnosis of decompensated heart failure.

The inpatient hospitalization is medically necessary. Per Milliman Guidelines, for patients presenting with congestive heart failure, inpatient admission is indicated for dyspnea and tachypnea over baseline that persists despite emergency and observation care. That is the situation for this patient. Per Milliman Guidelines, the usual length of stay is 2 days.
The patient, with multiple comorbidities and congestive heart failure (CHF) with an EF of 15%, presented with decompensated heart failure. She was in moderate respiratory distress, had pulmonary congestion on XR and elevated brain (or B-type) natriuretic peptide (BNP). She required intravenous diuretic therapy. The Inpatient admission is indicated and within the standard of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Altered mental status and dyspnea.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female with a past medical history pertinent for asthma and schizophrenia who presented to the emergency room (ER) for further evaluation/management of altered mental status and dyspnea. Intake vitals were notable for significantly elevated blood pressure of 201/91 mmHg. Physical examination was non-focal with no significant abnormalities noted. Laboratory and electrocardiogram (ECG) testing were also within normal limits. The medical records indicate that this patient was admitted to the inpatient medical service in stable condition where she received supportive care with intravenous (IV) fluids and continued cardiac monitoring. She responded well to the prescribed therapies and was subsequently discharged in stable condition. 

No, the proposed treatment of inpatient admission is not deemed medically necessary. 

The patient responded well to the prescribed therapies and was subsequently discharged in stable condition. There is no evidence of intensification of services throughout the course of this patient's hospital stay. Hence, patient's care could have been safely furnished in a less intensive setting without adversely affecting patient's safety or outcome.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcohol dependence
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

This patient is a male with a history of alcohol dependence and withdrawal who presented to the emergency department (ED) for evaluation of alcohol withdrawal.  The patient complained of tremors, nausea, tactile hallucinations and being anxious.  Also, he had intermittent left-sided chest pain.  

Vital signs (VS) were as follows: 97.4, 76, 20, 112/96, and 99%.  Exam was remarkable for diaphoresis.  Labs revealed the following: complete blood count (CBC) and basic metabolic panel (BMP) were within normal limits (WNL), troponin was less than (<) .015, and alcohol (EtOH) was 260.  Electrocardiogram (EKG) showed sinus rhythm, lateral infarct.  The patient was admitted.  Plan of care included Clinical Institute Withdrawal Assessment (CIWA) protocol.  

The patient's vital signs were stable (VSS); there was no acute distress (NAD).  There were no hallucinations.  Troponins were negative three times (x3).  Disposition after CIWA protocol.  CIWA was 5. Disposition after CIWA completed. 

No, the proposed inpatient admission was not medically necessary.

This patient was admitted after presenting with possible alcohol withdrawal.  The patient was hemodynamically stable and afebrile.  He did not have tachycardia or arrhythmia.  He did not have persistent vomiting, delirium, seizures, or gross tremor. The patient also complained of chest pain.  Troponin was negative.  Labs were remarkable for elevated alcohol level.  The patient was admitted with plan for CIWA protocol.  The patient remained hemodynamically stable without signs of alcohol withdrawal.  The patient was not scoring high on CIWA protocol.  The patient was clinically stable and did not have findings of severe alcohol withdrawal.  He did not have symptoms that required an acute inpatient level of care.  He had not failed management in a lesser level of care.  The requested inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:Growth Hormone Deficiency
Treatment: NORDITROPIN FLEXPRO 30MG/ML PEN INJCTR
The insurer denied the NORDITROPIN FLEXPRO 30MG/ML PEN INJCTR.
The determination is upheld.

The patient's height was 145.5 centimeters (cm) (23rd percentile) and weight 38.2 kilograms (kg) (31st percentile). He was noted to have Tanner 2 pubic hair and testes measured 12-15 cubic centimeters (cc) bilaterally. 
His insulin like growth factor-1 (IGF-1) level was 224 nanograms per milliliter (ng/mL). Insulin-like growth factor binding protein-3 (IGFBP-3) was 4,016 micrograms per liter (ug/L).
Provocative growth hormone (GH) testing was performed. GH peak was 14.7 ng/mL.
Magnetic resonance imaging (MRI) of the brain showed a cystic lesion in the pituitary such as pars intermedia cyst or Rathke's cleft cyst.
The patient's height was 149.2 cm and weight 42 kg. GH therapy as well as treatment with Arimidex were proposed. At issue is the medical necessity of Norditropin FlexPro.
GH therapy is not medically necessary. The patient has a normal height at the 23rd percentile for age. He has a normal bone age, normal growth factors and normal GH level of 14.7 ng/mL during provocative testing. The patient exhibited an accelerated growth velocity of 7.1 cm/year, based on measurements; this is an appropriate growth velocity for pubertal stage.
Based on the patient's bone age, radiograph and the height measurement at that time, the estimated final adult height prediction is just over 66 inches, using the Bayley-Pinneau method; this is a normal height for a United States (US) adult male and not short enough to qualify for GH treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right sided neck mass 
Treatment: Inpatient admission 

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

The patient is a male with autism who presented to an outside facility with a four week history of right sided neck swelling. A computed tomography (CT) was performed which reported a right sided neck mass noted to be abscess versus infected branchial cleft cyst and the patient was transferred to the facility for the stay in question. 

The patient's white blood cell (WBC) count was 10.3. The vital signs were stable,
and the patient was afebrile on admission. The patient was seen by otolaryngology
(ENT) and infectious disease (ID) and the neck mass drained pus spontaneously. 
Medical treatment included intravenous (IV) antibiotics and fluids. 

No, the proposed inpatient admission was not medically necessary. All records were reviewed. The patient is a male with autism who presented to an outside facility with a four-week history of right sided neck swelling. A CT was performed which reported a right sided neck mass noted to be abscess versus infected branchial cleft cyst and the patient was transferred to the facility for the stay in question. The patient's WBC 10.3. The vital signs were stable, and the patient was afebrile on admission. The patient was seen by ENT and ID and the neck abscess drained pus spontaneously. Medical treatment included IV antibiotics and fluids. 

There were no airway problems and no eating difficulty. The patient's symptoms 
did not deteriorate while in the hospital. There was no hemodynamic instability. 
There was no CT of the neck report provided documenting a deep neck abscess. The 
abscess below the angle of the mandible was soft and mobile. Therefore, based on the information provided, the medical necessity of the inpatient admission cannot be confirmed as the patient's care could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis 
Treatment: Inpatient Admission 

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

No, the Inpatient admission was not medically necessary. 

The patient is a female. Her medical and surgical histories were negative. She presented to an emergency room with a one-day history of right lower quadrant abdominal pain and tenderness. 

The patient's vitals were temperature 98.1, pulse 93, blood pressure 124/73, respirations 20, and oxygenation 100%. Physical examination demonstrated tenderness to palpation in the right lower quadrant of the abdomen. Serum laboratories demonstrated leukocytosis to 15.79. Computed tomography demonstrated acute, non-perforated appendicitis. 

The patient was admitted at an acute inpatient level of care with a diagnosis of acute appendicitis. She was made nil per os [NPO]; and provided with intravenous fluids, antibiotics, analgesics, and anti-emetics. She underwent laparoscopic appendicitis. 

The patient's surgery and recovery were uncomplicated. Having returned to her baseline health and function, the patient was discharged home in good and stable condition with outpatient surgical follow-up. 

According to several studies, the majority of patients with uncomplicated appendicitis who undergo laparoscopic appendectomy can be treated effectively and safely at a lower level of care [Gilliam et al; Cross et al; Cosse et al]. In fact, most patients can be discharged from the post-anesthesia care unit -- the recovery room --, precluding the need for inpatient admission, even on observational status [Mitchell et al; Dubois et al; Cash et al]. Therefore, for this patient, there was no need for admission at an acute inpatient level of care. 

Patients with uncomplicated appendicitis who undergo laparoscopic appendectomy, as in this patient, can be treated effectively and safely at a lower level of care; most patients can be discharged from the recovery room. The inpatient admission was not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Diabetes insipidus.
Treatment:  Consumer Directed Personal Assistant Services: Total of 168 Hours Weekly (24 Hours per Day/7 Days per Week). 

The insurer denied Consumer Directed Personal Assistant Services: Total of 168 Hours Weekly (24 Hours per Day/7 Days per Week).  The health plan's determination is upheld. 

The patient is a female with past medical history significant for diabetes insipidus secondary to resected astrocytoma.  She was previously living in Virginia and had received 12 hours per day of home health care services plus respite care.  Recently, she moved to New York.  She is requesting CDAP (Consumer Directed Personal Assistant Services) services 168 hours weekly, 24 hours a day 7 days a week.  Currently, she is approved for 26 hours a week.

The Consumer Directed Personal Assistant Services: Total of 168 Hours Weekly (24 Hours per Day/7 Days per Week) is not medically necessary for this patient.  26 hours per week of CDPAP services are sufficient to meet the patient's medical needs.  The number of hours noted are sufficient to meet the patient's ADLs and Instrumental activities of daily living (IADL), as outlined through the UAS State of New York.  The question is whether the patient should have an aid to monitor the patient to maintain the patient's hydration status based on the patient's medical history of diabetes insipidus.  The patient cannot maintain hydration status adequately on her own secondary to her cognitive function disability.  However, having an aid present to prompt the patient to drink and maintain hydration status would be considered supervision.  In order for the patient have more hours, there must be a documented need of medical necessity for additional ADLs or IADLs.  There is no evidence noted in the documentation provided of this.  Therefore, the 26 hours per week are sufficient to meet the patient's documented needs.
Appeal type: Medical necessity
Decision: Overturned

Skin Disorders
Pharmacy/Prescription Drugs

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

The patient is a male with atopic dermatitis, treated with topicals including steroids, Eucrisa and topical calcineurin inhibitors, phototherapy and cyclosporine. The provider requesting Dupixent.

Dupixent is medically necessary for this patient.
Dupixent is United States Food and Drug Administration indicated for treatment of recalcitrant atopic dermatitis and can potentially make a significant impact of this patient's life. Dupixent is a novel interleukin-4 and interleukin-13 blocker, which inhibits the arm of the immune system responsible for atopic dermatitis. In clinical trials, after 12 weeks of monotherapy with Dupixent, 85% of patients had a greater than 50% reduction in eczema severity and pruritus scores decreased by 57.1%. In phase III clinical trials, Dupixent led to a 75% improvement in eczema severity, when compared to placebo, and decreased symptoms of anxiety and depression. It also led to a significantly decreased use of topical corticosteroids. The safety and efficacy were supported in a recent meta-analysis of all published Dupixent paper.
This patient has tried and failed all other appropriate therapies for atopic dermatitis. The patient has already tried cyclosporine and phototherapy. Methotrexate and azathioprine should be avoided in males of childbearing potential. Dupixent is FDA approved for this condition and is the next logical therapeutic option for this patient.