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

Diagnosis: Congestive Heart Failure. 
Treatment: Entresto 49 milligrams (mg)-51 mg tablet. 

The insurer denied Entresto 49 mg-51 mg tablet. 
The health plan's determination is upheld. 

The patient is a male with a history of mitral valve prolapse, mitral regurgitation and left ventricular systolic dysfunction. He underwent mitral valve repair. Postoperatively his left ventricular ejection fraction (LVEF) was 51 percent (%). It fell to 35-40%. It then was 45%. He has been treated with Entresto. 

The health plan, in its determination of medical necessity, did act reasonably, with sound medical judgment and in the best interest of the patient. Based on the limited information provided it cannot be determined that Entresto is medically necessary. 

The requested health service/treatment of Entresto 49 mg-51 mg tablet is not medically necessary. The patient has a history of mitral valve prolapse, mitral regurgitation, left ventricular systolic dysfunction and mitral valve repair. His most recent left ventricular ejection fraction was 45%. Other than several echocardiogram reports and a medication history, no medical records were provided for review. 

Entresto (Sacubitril/Valsartan) has been shown to be of benefit in patients with heart failure and reduced left ventricular ejection fraction, mid-range ejection fraction and ejection fractions below the median (45-57%). It is Food and Drug Administration (FDA) approved and endorsed by current guidelines for use in patients with symptomatic chronic heart failure across the range of left ventricular ejection fractions. 

The limited information provided regarding this patient does not include any mention of heart failure or heart failure symptoms. Thus, based on this limited information, it cannot be determined that Entresto is medically necessary in this instance. 

The health plan's determination is upheld in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Fever, nasal congestion, rhinorrhea, and intermittent diarrhea. 
Treatment: Inpatient admission. 
The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a preschool aged male child with medical history significant for birth small for gestational age and several episodes of acute otitis media that presented to the emergency department with five-day history of subjective fever to 101 at urgent care, nasal congestion, rhinorrhea, and intermittent diarrhea. The patient was complaining of some abdominal pain, with poor oral intake and mildly decreased urine output. One of his siblings was also ill. The patient had started evaluation for a firm lymph node in the right posterior chain, but the imaging and labs were not done. Vital signs included temperature 39.8, heart rate 149, respiratory rate 37, and blood pressure 96/58. Examination was significant for alert, active, well-appearance, bulging erythematous right tympanic membrane, congestion, dry lips, two by two centimeter hard mobile lymph node in the right posterior chain, clear lungs, benign abdomen, non-focal neurologic exam, and no other palpable lymph nodes. Laboratory evaluation was significant for white blood cell (WBC) count of 8.8 thousand (K), hemoglobin 8.7, sodium 131, carbon dioxide (CO2) 20, C-reactive protein (CRP) 3.0, erythrocyte sedimentation rate (ESR) 100, and rapid viral screen negative. Respiratory viral panel eventually returned positive for adenovirus and rhinovirus/enterovirus. The patient was treated with two normal saline boluses, antipyretics, and ceftriaxone to treat the otitis media. He was not taking adequate fluids in the emergency department, remaining tired with chills due to fever, and producing a large diarrhea stool. He was admitted for further management of dehydration and fevers. Admission orders included maintenance intravenous fluids, regular diet for age, repeat metabolic labs, antipyretics, follow-up cultures, and follow-up ferritin. Following admission, the patient's oral intake improved. He continued to have fevers, but they responded to antipyretics. He was deemed stable for discharge on day #2 to follow-up with his primary care practitioner. 

Acute inpatient admission was not medically necessary. 

This young male child with history of otitis media and a single palpable cervical lymph node presented with five-day history of fever, congestion, diarrhea, poor intake. He was noted to have right otitis media and elevated inflammatory mediators. Viral panel returned positive for adenovirus and rhinovirus, consistent with his clinical presentation. While it was reasonable to monitor the patient in the hospital for improved and adequate oral intake, he was overall hemodynamically stable with no evidence of sepsis, severe dehydration, or severe metabolic abnormality. He did not require acute inpatient admission and could have been safely managed at lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Type 1 diabetes
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is overturned.
 
Diabetes education consists of several components, nutritional counseling, self-monitoring of blood glucose and treatment of hyper and hypoglycemia. The standard of care is that all patients with diabetes should receive all these components (1,2). 

Practice patterns differ depending on the availability of educators, etc. Whether a patient gets hospitalized for intensive insulin therapy initiation depends on the available program where the patient is seen.

The majority (75% [percent]) of medical centers in the US (United Staes) (3) that treat new onset type 1 diabetes admit their patients. According to the American Diabetes Association (ADA) statement on treatment of type 1 diabetes (4-7), hospitalization is necessary regardless of severity if, "the center is not experienced in the outpatient management of newly diagnosed children with diabetes or is not adequately staffed to provide outpatient care because regional health care reimbursement is inadequate for initial outpatient care and education."  That is not the case for type 2 diabetes. Indications for admission for new onset type 2 diabetes are more stringent and dependent upon the presence of symptoms such as ketosis, dehydration, hyperosmolarity, vomiting and inability to maintain hydration or severe metabolic/electrolyte abnormalities.  In type 1 diabetes, the initial hospitalization is to educate the patient and the family in self-injection, drawing up and mixing of insulins, checking blood sugar, recognizing and responding to hyper and hypoglycemia, and evaluating ketosis, as well as nutrition education on carbohydrate counting because there is only one treatment option (insulin). Learning these skills is an overwhelming task for most patients and families and is the reason that this is done with a 2-3-day admission to the hospital. 

The patient presented with new onset diabetes, consistent with type I diabetes and required inpatient admission for new onset diabetes education and clearing ketones. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.

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 the hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fever, chills, and buttocks pain
Treatment: Inpatient Hospital Admission
The insurer denied coverage for Inpatient Hospital Admission.
The denial is overturned.

Patient is an adult female with past medical history significant for morbid obesity, status post bypass surgery, and recent adipose tissue transplant of her buttocks who presented to the emergency department with complaints of fever, chills, and buttocks pain. 

Vitals on presentation included: Temperature 100.8 degrees Fahrenheit, Blood Pressure 132/99, Pulse 160, Respiratory Rate 23, oxygen (O2) saturation 98% (percent) on Room Air. Laboratory results included the following: white blood cell (WBC) count 9.3, hemoglobin 5.9, hematocrit 19.1, creatinine 0.6, glucose 94. Chest x-ray (CXR) showed extensive areas of subcutaneous emphysema within the chest wall bilaterally, concerning for necrotizing fasciitis.

Patient was started empirically on intravenous antibiotics (vancomycin, Zosyn, and clindamycin) for possible post-operative necrotizing fasciitis. Urinalysis was suggestive of a urinary tract infection (UTI). Patient was transfused 2 units of packed red blood cells (PRBC). Surgery recommended continuation of antibiotics; no surgical intervention was deemed necessary. Patient remained afebrile, clinically, and hemodynamically stable. She was discharged to continue outpatient management. 

According to documentation, patient presented with multiple medical issues. Patient was febrile (100.8 F (Fahrenheit)), tachycardic (heart rate 160), and tachypneic (respiratory rate 23). Laboratory results were notable for several abnormalities including severe anemia (hemoglobin 5.9). Imaging studies, also abnormalities suggestive of infection. Based on above findings, in a high-risk patient who underwent a recent surgical procedure, hospital admission was medically necessary for administration of intravenous antibiotics and additional diagnostic evaluation.       

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

Diagnosis: Nausea, vomiting, diarrhea. 
Treatment: Inpatient admission. 
The health plan denied the requested inpatient admission as not medically necessary. 
The health plan's determination is upheld. 

The patient is a male with a medical history of cannabinoid hyperemesis syndrome, asthma, hypertension, hyperlipidemia, and migraine. He presented to the emergency department with nausea, vomiting, and diarrhea since the prior afternoon, with nausea worse after marijuana use the prior day. His vital signs were unremarkable. A physical examination was notable for appearance of acute distress, soft abdomen with epigastric tenderness, and normal bowel sounds. An electrocardiogram showed T-wave inversions in leads V5-6. Laboratory studies showed an elevated white blood cell count of 13.8 kilos per microliter (K/uL), a low potassium of 3.2 millimoles per liter (mmol/L), an elevated blood urea nitrogen of 28 milligrams per deciliter (mg/dL), an elevated creatinine of 1.4 mg/dL, and normal troponin. A chest x-ray showed a patchy infiltrate in the left lung suggestive of pneumonia. A computed tomography scan of the head showed no evidence of hemorrhage, mass, or acute infarct. He was treated with intravenous haloperidol, ondansetron, and fluids, and oral potassium and famotidine. He felt much better; he denied further diarrhea or nausea and vomiting, and denied melena; he was ambulating without difficulty. Laboratory studies showed a normalized white blood cell count, a low hemoglobin of 12.1 g/dL (grams per deciliter), a low hematocrit of 35.9%, and a normalized potassium. He was started on intravenous azithromycin and ceftriaxone. He was discharged on cefpodoxime and azithromycin, with a plan for Primary Care follow-up. 

At issue is the medical necessity of an inpatient hospitalization. 

I uphold, in whole, the health plan's determination. 

As the inpatient level of care was not supported in this case, the care provided could have been provided an alternate level of care. 

Although the patient presented with nausea, vomiting, and diarrhea, he did not have persistent hypotension or organ failure. The presenting gastrointestinal symptoms were assessed as consistent with cannabinoid hyperemesis syndrome. [1-6] However, the patient did not have evidence of bowel obstruction, peritonitis, abscess, fistula, sepsis, gastrointestinal bleeding, or other complications warranting inpatient level of care. [1-6] He had an acute kidney injury likely due to volume depletion, but he was treated with intravenous fluids and did not require hemodialysis. [7,8] There was suspected pneumonia, but he did not have any associated complications, such as sepsis or hypoxemia, and was appropriately treated with antibiotics. [9,10] During his brief stay, all of the measures that were undertaken, including observation, monitoring, laboratory studies, imaging, and antibiotic therapy, could have been performed in sequence after presentation and without the inpatient level of care, at an alternate level of care. [1-8]
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer (of the bile system). 
Treatment: FoundationOne Liquid CDx. 

The insurer denied: FoundationOne Liquid CDx. 
The denial is upheld. 

The patient is an adult male with a history of ulcerative colitis. Last year scans revealed a mass in the left lobe of the liver and abdominal lymphadenopathy. A biopsy confirmed adenocarcinoma consistent with intrahepatic cholangiocarcinoma. Treatment began with cisplatin (DDP)/ Gemzar the next month. Disease progression was documented two months later. A FoundationOne CDx liquid biopsy was reported at that time. 
The FoundationOne CDx was denied as unproven and not medically necessary. The health plan policy on Molecular Oncology Testing for Cancer Diagnosis, Prognosis and 
Treatment Decisions notes that multigene panels greater than 50 genes are unproven and not medically necessary. 

The proposed treatment was not medically necessary. 

The National Comprehensive Cancer Network (NCCN) guidelines recommend molecular profiling for metastatic biliary tract cancer and lists eight potential targets. Other potential molecular alterations may be found by next-generation sequencing (NGS) testing (five are listed) which could help to determine eligibility for clinical trials. At this time, there is insufficient evidence to recommend universal assessment (1). Okawa identified 21 actionable genes (2). There has not been established evidence that testing more than 50 genes is beneficial. The National Comprehensive Cancer Network guidelines also noted that circulating tumor deoxyribonucleic acid (ctDNA) may be considered but the technique may not reliably identify gene fusions or rearrangement depending on the panel used and specific partner gene. 
Per DiPeri T et al, the prospective collection of genomic data will allow for further understanding of the prognostic value of specific alterations and determinate of sensitivity/resistance of molecularly targeted agents (3). Jain (4) also noted the need for prospective evaluation of mutational findings. The effective standardization of the pre-analytic and analytical assay parameters used for each clinical scenario is needed to fully implement next-generation sequencing into routine practice (5). 

In summary, the National Comprehensive Cancer Network guidelines do not present any evidence that testing for more than 50 genes improves clinical outcome. No endorsement was made in the guidelines. Therefore, the proposed FoundationOne CDx liquid biopsy was not medically indicated or necessary.
Appeal type: Medical necessity
Decision: Overturned

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

This case involves a man with a history of anoxic brain injury, wheelchair-bound, and polysubstance abuse. He was admitted to the hospital with abdominal pain, right-sided chest pain, and emesis. The symptoms began the previous night, with the pain in the right upper quadrant radiating towards the epigastrium, unrelated to eating. Evaluation in the emergency room (ER) showed stable vital signs, including normal temperature, pulse rate, and blood pressure. Laboratory studies showed sodium of 137, normal potassium, and hemoglobin of 16. The white blood cell count was elevated to 23; the creatinine was 0.99. Lactic acid was elevated to 3.1, and troponin was normal. A computed tomography (CT) abdomen was completed showing gallbladder sludge and fatty liver infiltration. 

The inpatient hospital admission was medically necessary. The patient presented with vomiting and abdominal pain. The CT abdomen and the right upper quadrant ultrasound showed some gallbladder sludge, and magnetic resonance cholangiopancreatography (MRCP) was negative. He also had an initial significant leukocytosis concerning for an infectious source, with concurrent lactic acidosis, which did not improve after initiating IV fluids. Procalcitonin was elevated, suggestive of bacterial infection, and CRP (C-Reactive Protein) levels were also elevated, confirming an inflammatory/infectious process. By definition, this patient had sepsis, which improved with the administration of very broad-spectrum IV antibiotics. He was discharged on oral antibiotics to complete therapy at home after 48-hour hospital treatment and improvement in his general condition. Based on the laboratory studies' severity and concern for severe sepsis with lactic acidosis, an inpatient admission is indicated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension. 
Treatment: Inpatient Stay. 

The insurer denied the inpatient stay. 

The health plan's determination is upheld. 

This case involves a man admitted to the hospital with a headache. The patient had a concurrent elevation in his blood pressure secondary to noncompliance with medications.  He denied any other associated symptoms. His blood pressure was 205/116 at admission, with the rest of the vitals stable. Examination showed an alert and oriented individual, with a bradycardic cardiac exam. Respiratory sounds were normal. He was neurologically intact. 

The inpatient hospital admission was not medically necessary. A lower level of care is appropriate for managing this patient's condition. The patient did not have a hypertensive emergency, as there was no evidence of end-organ damage. The nephrologist clearly documented the patient's baseline creatinine as 1.54, consistent with chronic kidney disease stage IIIa. The admission creatinine was 1.5 and decreased to 1.4 by the time of discharge. Head computed tomography (CT) was negative for stroke or bleeding. After re-initiation of antihypertensive therapy, the patient's blood pressure stabilized. There was no indication for continuous antihypertensive infusion therapy for resistant hypertension. The blood pressure was elevated due to non-compliance with medications. There is no documentation that supports secondary resistant causes of hypertension. This was hypertensive urgency due to non-compliance. The symptoms resolved within 24 hours of hospitalization. From a febrile state standpoint, there is no evidence of sepsis. No clear source of infection other than nonspecific sinusitis was noted on the CT scan. Not every fever requires hospitalization or inpatient admission. The patient had no evidence of severe pneumonia, urinary tract infection, or intra-abdominal process, requiring prolonged hospitalization and refractory to IV antibiotics.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic obstructive pulmonary disease
Treatment: Continuation of the monthly rental of a home ventilator, code E0466, any type, used with noninvasive interface, (e.g., mask, chest shell)
The insurer denied coverage for continuation of the monthly rental of a home ventilator, code E0466 
The denial is overturned

This patient is an adult with severe chronic obstructive pulmonary disease (COPD) on home oxygen (O2) and steroid dependent. The patient also has multiple other co morbidities including right heart failure, pulmonary hypertension, obesity, and obstructive sleep apnea (OSA) amongst others.

Patient's medications include bronchodilators, inhaled corticosteroids, Daliresp, and oral steroids. In addition, she is on continuous O2 due to hypoxia. Patient was on continuous positive airway pressure (CPAP) and despite that she was getting progressively more dyspneic and also hypoxic. She was unable to move around or do Pulmonary Rehabilitation.

The patient had multiple exacerbations and progressive hypoxia and reduced exercise tolerance despite being on maximal therapy. Patient was placed on non-invasive ventilation (NIV) with Life 2000 and was able to ambulate with it during the day. It also made her feel less dyspneic during the day and also helped her with being mobile which improved her quality of life significantly.

This patient with severe COPD and daytime hypercarbia was a good candidate for NIV.

Life 2000 is an appropriate choice for her as it would let her maintain an active lifestyle and be able to ambulate during the daytime. Patient is already using it and is feeling better with it.

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 the continuation of the monthly rental of a home ventilator, code E0466 home ventilator, any type, used with noninvasive interface, (e.g., mask, chest shell) is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumonia

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

 
This is a toddler with viral and possibly bacterial pneumonia with a high fever of 104.6 degrees F (Fahrenheit), who needed broad spectrum antibiotics. The patient's venous blood gas was concerning as the respiratory rate was close to 40 and still the carbon dioxide (CO2) was 44; in tachypnea, the CO2 should be less than 30. This was a clear sign that the patient was tiring and retaining CO2. With parainfluenza virus propensity to infect upper airway and lower airway with already deficient ventilation with superimposed pneumonia, the patient was clearly at the risk of severe hypoxemia. Moreover, the lactate was 1.6. Although it was less than 2.2, this was indicative of tissue hypo perfusion. Also, the combined infection of Respiratory syncytial virus (RSV), Rhinovirus, and Parainfluenza can be very rapid and epidemiologically it predisposes the patient to complicated super imposed pneumonia and necrotizing pneumonia. The patient was at risk of severe sepsis as the 3 viruses can cause sepsis. Hence it was appropriate that the patient was admitted to an acute inpatient level care. 

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 hospital admission is substantiated.