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

Diagnosis: Uterine fibroids

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

The patient is an adult with a history of symptomatic uterine fibroids. The patient presented to the hospital and underwent an open abdominal myomectomy. The hospital course was uneventful. The patient was discharged after a period of medical stability.

This adult patient underwent a laparotomy. Laparoscopies are ambulatory procedures, laparotomies are not. The standard of care is for patients who undergo an open procedure to stay in the hospital for 48 hours. On postoperative day 1, the Foley catheter is removed, the patient is encouraged to get out of bed and ambulate, clear liquids are started. On postoperative day 2, if the patient is passing flatus, and tolerating regular diet, the patient is discharged home.

The standard of care was followed in this case. The admission was medically necessary and should be approved based on Milliman Care Guidelines (MCG) Laparotomy.

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

Diagnosis: Class I malocclusion
Treatment: braces/monthly visits
The insurer denied braces/monthly visits. The health plan's determination is overturned. 

The patient in question is a male with a Class I malocclusion. He has spacing in the upper arch and mild crowding in the lower arch. He is missing tooth 10. Tooth 7 is severely undersized and is in anterior crossbite with tooth 27. 

Braces and monthly visits are medically necessary. The patient has significant spacing with tooth #7 in crossbite. This tooth has a high risk for restorative problems in the future due to the traumatic occlusion with the mandibular teeth. It will be impossible for this tooth to have proper function without orthodontically moving it so a restoration can be done. Studies have shown that even the untreated dentition shows increased anterior irregularity with time, which will make treating this occlusion at a later time more difficult. Orthodontic treatment now will likely prevent the need for future expensive periodontal and restorative procedures. For these reasons, braces and monthly visits are medically necessary.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: obesity.
Treatment: Wegovy.
The insurer denied Wegovy. 
The health plan's determination is overturned. 

The patient is a female being prescribed Wegovy 0.25MG (milligrams)/0.5 Pen Injector for the diagnosis of obesity. Coverage for this medication was denied by the health plan.

Wegovy 0.25MG/0.5 Pen Injector is medically necessary for this patient.
The patient has obesity with a body mass index (BMI) greater than 30 and obesity-related comorbidity (hypertension). She has tried extensive dietary therapy, exercise programs, and weight loss programs as documented in her office visit notes with her provider. In patients who fail to achieve adequate weight loss using these measures alone, pharmacotherapy for obesity is recommended. Semagludide (Wegovy) is one of the preferred first-line treatments.  Single therapy treatment with a GLP-1 (glucagon-like peptide 1) agonist is the preferred approach by experts (Perreault et al). Therefore, Wegovy is medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Central Nervous System/Neuromuscular Disorder/Migraine
Pharmacy/Prescription Drugs/Diclofenac Oral Powder
The health plan denied the requested prescription medication Diclofenac Oral Powder as not medically necessary. The health plan's determination is upheld.

The patient is a female with migraines. The medical necessity for treatment with Diclofenac powder is the subject of this review. The drug was denied because the patient has not tried and failed 3 formulary alternatives: Diclofenac Sodium, Diflunisal, Etodolac, Ibuprofen, Meloxicam, Nabumetone, Naproxen, Oxaprozin, or Sulindac.

The health plan's determination is upheld, in whole.

The patient has only tried and failed one formulary alternative based on the letter of medical necessity: Diclofenac tablets. The patient has not tried and failed any other non-steroidal anti-inflammatory drugs (NSAID) per the letter of medical necessity. NSAIDs are considered potential first-line agents for acute migraine. There is no medical reason to believe that all of the NSAID on the formulary would not be effective for treatment of the patient's condition. If needed, some of the formulary alternatives can be crushed for ease of swallowing. The patient does not have a contraindication provided to the use of these medications.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Atopic Dermatitis
Treatment:/Cibinqo 200 mg (milligrams) tablet
The health plan denied the requested prescription medication, Cibinqo 200 mg tablet as not medically necessary.
The health plan's determination is upheld.

The patient is a female with moderate to severe atopic dermatitis since early childhood. The patient has been started on Cibinqo with vast improvement but not attaining full disease remission at the 100 milligrams (mg) dosage. The patient had eczematous plaques and papules, a few lichenified, on the trunk, upper and lower extremities (30% body surface area involvement, immunoglobin A (IGA) of 3. The patient previously tried and failed topical Triamcinolone, Mometasone, Hydrocortisone, and Eucrisa, as well as Prednisone and Xolair and numerous antihistamines. The patient was on Dupixent, but she remained in a severe disease flare, and so the patient was started on Cibinqo.
Health plan coverage of Cibinqo, dosed at 200 mg/day, is under review for medical necessity.

Health plan denial of Cibinqo coverage, either at the 100 mg/day or 200 mg/day dosage, is recommended to be upheld.

The patient has no documented treatment failure with, or true medical contraindication to, the formulary-favored Rinvoq [1] at either the 15 milligrams/day (mg/day) or 30 mg/day dosage. There is no literature-supported [2-6] difference safety risks or adverse effects between Rinvoq or Cibinqo. Cibinqo is not proven to be more effective, or with fewer adverse effects, than the health plan-preferred Rinvoq. Rinvoq is recommended to be initiated for treatment of this patient at this time.

Health plan denial of Cibinqo coverage, either at the 100 mg/day or 200 mg/day dosage, is recommended to be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial flutter.
Treatment: Inpatient admission.
The insurer denied: Inpatient admission.
The denial is upheld.

The patient is an adult male for which an inpatient hospitalization is under review. There was history of hypertension, aortic valve replacement, hyperlipidemia, and sleep apnea. He presented with a syncopal episode. He was also having palpitations. An outpatient MRI (magnetic resonance imaging) of the brain and EEG (electroencephalogram) were negative. The initial ECG (electrocardiogram) demonstrated an atrial tachycardia at 161 bpm (beats per minute). Other vital signs were essentially normal. Repeat ECG (electrocardiogram) demonstrated sinus rhythm. Electrolytes were essentially normal. Troponins were negative. A chest x-ray was suggestive of cardiomegaly. He was started on Multaq. He was with history of atrial flutter and SVT (supraventricular tachycardia) ablation. He also had history of hypertension and obesity. Prior echocardiogram demonstrated normal LVEF (left ventricular ejection fraction). The patient was offered discharge the next day as he was stable and improved. The patient preferred to wait in the hospital for an additional week for an EP (electrophysiology) consult. He underwent an EP (electrophysiology) evaluation, and outpatient follow-up was ultimately planned.

The Inpatient admission was not medically necessary.

This patient presented with atrial tachycardia and remained stable. There was no MI (myocardial infarction), acute coronary syndrome, CHF (congestive heart failure), hemodynamic instability, need for prolonged IV (intravenous) medication, CVA (cerebrovascular accident), altered mental status, respiratory distress, recent thromboemboli, severe underlying structural heart disease, need for acute anticoagulation, introduction of high-risk antiarrhythmic medication requiring in hospital monitoring, need for ongoing oxygen support, severe electrolyte abnormality, or a recurrent unstable arrhythmia. In the setting of this case, an acute inpatient level hospitalization, compared a lower level of care, has not been established as standard of care towards improved cardiac outcomes. Therefore, it is considered not medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Attention Deficit Hyperactivity Disorder. 
Treatment: Occupational Therapy Visits (Code 97168). 

The insurer denied: Occupational Therapy Visits (Code 97168). 
The denial is overturned. 

The patient is a school-aged male child with medical history significant for attention deficit hyperactivity disorder inattentive type. He attends a private school and does not have individualized education plan (IEP)/504 occupational therapy (OT) services provided; however, he does have a student support plan that includes classroom accommodations to maximize academic success. He has been receiving occupational therapy for 4 years to address executive function difficulties and fine motor deficits. He has demonstrated consistent progress toward goals, with increased independence at school and at home. His family has been actively implementing the home exercise plan. However, he continues to have difficulties with attention in group settings, has challenges with following multiple instructions, struggles to complete tasks at grade level, and has ongoing difficulty with self-regulation and social skills. 

The continued occupational therapy is medically necessary and appropriate. 

Attention-deficit disorder is thought to be the most common psychiatric disorder of school-age children, with an incidence of 3-7%. Although the cause is unknown, there are many theories under investigation involving brain anatomy and chemistry. Genetics and environmental factors may also play important roles. A person with attention deficit hyperactivity disorder may experience difficulties in many aspects of life including processing of sensory information, motor planning, executive functions, and fine motor coordination, and may also suffer from comorbid disorders such as autism, Tourette's, or other mental illnesses. This child has been provided with academic accommodations through his private school, but he does not receive occupational therapy services. He has been receiving occupational therapy services as both group and individual sessions. He has made consistent progress toward all goals and is compliant with his home program. However, he continues to lag behind same-age peers in executive functioning, social skills, self-regulation, sequencing, and attention. Continued occupational therapy services are medically necessary and appropriate to address these challenges.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Syncope; Acute Coronary Syndrome.
Treatment:  Inpatient stay.

The insurer denied the inpatient stay.  The health plan's determination is upheld. 

The patient is a male who presented to the emergency department (ED) after an episode of syncope precipitated by laughing and coughing. His medical history was remarkable for obesity, obstructive sleep apnea and left ventricular hypertrophy diagnosed on a prior echocardiogram. In the ED, his blood pressure was 133/61 with a heart rate of 89 beats/minute. His room air oxygen saturation was 99%. An electrocardiogram showed sinus rhythm with an intraventricular conduction delay and possible old posterior infarction. 

Based on the documentation provided, an inpatient hospital admission was not medically necessary.

This patient presented with syncope after laughing and coughing. His electrocardiogram was abnormal, but showed no acute changes. His cardiac troponin levels were minimally elevated without a significant delta troponin. Based on his Canadian Syncope Arrhythmia Risk score, his 30-day risk for major adverse cardiac events was low. The literature does not adequately describe which patients will benefit from inpatient hospital admission or observation nor has it demonstrated the value of admission in preventing future adverse outcomes. However, certain features have been identified as signifying high risk. These include exertional syncope, known structural heart disease, age > (greater than) 60 years and a family history of sudden cardiac death. This patient had none of these features.

Per the 2017 American College of Cardiology (ACC) / American Heart Association (AHA) / Heart Rhythm Society (HRS) Guideline for the Evaluation and Management of Patients With Syncope, inpatient admission is recommended for patients presenting with syncope, who have a serious medical condition potentially relevant to the cause of syncope identified during initial evaluation. This patient had no such condition identified. The document further states, "In intermediate-risk patients with an unclear cause of syncope, use of a structured ED observation protocol can be effective in reducing hospital admission. Two small randomized controlled trials suggest that structured ED-based protocols, consisting of time-limited observation and expedited access to cardiac testing/consultation, result in reduced health service use without adverse impact on clinical outcomes when compared with unstructured hospital admission."
Thus, based on the information provided about this patient, an inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abnormal vaginal bleeding.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient who had a Cesarean section delivery. She presented to the obstetrics (OB) triage unit approximately 1 week later with abnormal vaginal bleeding. A suction, dilation and curettage was performed and the estimated blood loss was 2 liters (L). She also received Methergine and Cytotec. Her hemoglobin was 8.8 and then 8 and rose to 8.4. She had 1 unit of PRBCs (packed red blood cells). She was admitted as an inpatient. She was discharged home the same day. At issue is the medical necessity of inpatient admission.

The requested health service/treatment of full hospital admission is not medically necessary for this patient.

The patient was a healthy female without significant comorbidities. She had vaginal bleeding, and a minimally invasive treatment was performed. Her vital signs were normal, and she had no hemodynamic instability. Her procedure was without complications, and her bleeding resolved. She had no pulmonary complications. She could have been observed after surgery in the post-anesthesia care unit (PACU) or under observation status, as she was discharged less than 24 hours later. There was no need for acute, inpatient monitoring as there was no complications after surgery. She had no continuing hemorrhage, infection nor poor wound healing.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain.
Treatment: Inpatient Hospital Admission.

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

The patient is an adult female. She had no significant past medical history when she presented to the emergency department (ED) for evaluation of chest pain. On arrival to the ED, the patient was afebrile, her blood pressure was 120/83, her heart rate was 78 bpm (beats per minute), respiratory rate was 16, and SPO2 (pulse oximetry) was 100% (percent) on room air. Twelve-lead EKG (electrocardiogram) showed normal sinus rhythm with nonspecific T-wave (interval on EKG) changes. Chest x-ray did not demonstrate any acute cardiopulmonary abnormalities. Initial labs showed a WBC (white blood cell) count of 8, hemoglobin of 13.6, sodium of 135, potassium of 3.6, and creatinine of 0.65. Troponins, however, were within normal limits.

The patient was admitted to the inpatient unit and was evaluated by cardiology. A transthoracic cardiogram was obtained, which did not demonstrate any acute findings. She also had a stress test, which did not demonstrate any evidence of ischemia. She was ultimately discharged with outpatient follow-up.

The inpatient hospital admission was not medically necessary.

The patient was hemodynamically stable and was not hypoxic. There was no evidence of sepsis, no mental status changes and no end organ malperfusion. There was no evidence of acute coronary syndrome. Transthoracic echocardiogram did not demonstrate any structural cardiac abnormalities. Stress test did not demonstrate any evidence of significant ischemia. Consequently, based on the provided documentation, there is insufficient clinical data to support medical necessity for inpatient level of care. Observation level of care would have been appropriate in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Blocked teeth.
Treatment: D8080 Braces and D8670 Monthly Visits.
The insurer denied the D8080 braces and D8670 monthly visits.
The denial is overturned.

The patient is a teenaged female requesting orthodontic benefits including monthly visits. The patient has a class I malocclusion with moderate maxillary and mandibular crowding. The prior denial was due to a handicapping score of 18.

The proposed treatment is medically necessary.

The patient has both upper permanent canines out of position. They are "blocked" out of the dental arch, meaning that there is not enough room for them to be in their proper positions. Because of this, the upper canines [teeth # (number) 6 and #11] do not touch the lower canines like they are supposed to. Without this connection, there can be no "canine guidance", which is when the lower canines glide along the backs of the upper canines during the chewing cycle. When there is no canine guidance, the rest of the teeth do not mesh together harmoniously. Rather, they grind and bang together traumatically. Without canine guidance, over time there will be teeth that are traumatized, fractured and/or loosened. There can also be temporomandibular joint (TMJ) problems developing. Orthodontic treatment is medically needed for this patient to correct the malocclusion. The monthly visits are also needed to make sure the treatment is progressing properly. The prior denial of the teeth not being out of position is incorrect.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Pain. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the Inpatient Hospital Stay. 
The determination is overturned. 

This is a female patient who presented to the emergency department (ED) complaining of two months of intermittent chest pain. She had a history of alcohol use disorder and had recently begun drinking heavily after a period of abstinence. In the emergency department (ED), she had an episode of vomiting. An electrocardiogram showed sinus tachycardia without acute changes. Her liver enzymes were mildly elevated. Her serum bicarbonate level was 10 milliequivalents per liter (mEq/L) with an anion gap of 30. A chest x-ray showed no acute pathology. Her troponin T level was 20 nanograms per liter (ng/L). Her blood alcohol level was 326 milligrams per deciliter (mg/dl). The patient was treated with aspirin, ondansetron, intravenous fluid and thiamine for alcoholic ketoacidosis and was admitted to the hospital. Phenobarbital and lorazepam were prescribed to prevent alcohol withdrawal. She continued to complain of chest pain, as well as nausea, abdominal pain and anxiety. Her troponin level increased to a peak of 107 ng/L. She was profoundly hypophosphatemic with a serum phosphorus level of 0.4 mg/dl and required intravenous and oral replacement therapy. A cardiac catheterization showed normal coronary arteries. The patient's serum phosphorus levels remained low at 0.9 mg/dl. Replacement therapy was continued. She was discharged. At issue is the medical necessity of an inpatient admission. 

Based on the documentation provided, an inpatient level of care was medically necessary. 

This patient presented with chest pain and had more than a five-fold increase in her serum troponin level. While acute coronary syndrome (ACS) was eventually ruled out, the marked troponin increase was suggestive of an acute non-ST segment elevation myocardial infarction. Upon presentation she was tachycardic and significantly acidotic due to alcoholic ketoacidosis. She was at risk for hypovolemic shock and required vigorous fluid resuscitation. She was found to be profoundly hypophosphatemic and at risk for respiratory failure, heart failure, rhabdomyolysis and neurologic deterioration. She required careful and continuous monitoring with the ability to intervene emergently, if needed. This warranted an inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: foot pain
Treatment: custom molded orthotics
The insurer denied custom molded orthotics. The health plan's determination is upheld. 

The patient is a male who was seen for sore feet. The patient had previous custom molded orthotics that feel weak and are falling apart. On exam, the patient shows hyperpronation of his feet b/l (bilateral). Pain in heels and arch is noted. The patient was diagnosed with plantar fasciitis, calcaneovalgus deformity, and pronation of his feet. He was recommended for custom molded orthotics.

The requested custom shoe inserts are not medically necessary for this patient. There is no documentation of any conservative measures tried such as adjustment of activities, anti-inflammatory meds, stretching tried before recommending custom molded orthotics. Thus, the custom shoe inserts are not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pregnancy
Treatment: Genetic testing
The insurer denied Genetic Carrier Testing.
The health plan's determination is overturned. 

The patient is a pregnant female. She underwent expanded carrier screening as part of her prenatal care. At issue is the medical necessity for Genetic Carrier Testing.

Genetic carrier testing is medically necessary for this patient. The American College of Obstetricians and Gynecologists (ACOG) recommends "If a patient requests carrier screening for a particular condition for which testing is readily available and which reasonably would be considered in another screening strategy, the requested test should be offered to her (regardless of ethnicity and family history) after counseling on the risks, benefits, and limitations of screening." This is independent of any family history or personal history.