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

Diagnosis: Sepsis. 
Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is overturned. 

This patient is an adult with past medical history significant for stage IV (4) lung cancer with metastasis on chemotherapy, hypertension, alcohol use, anxiety, and fatty liver who presented to the emergency department with complaints of chills, dysuria, and urinary urgency. 

Vitals on presentation included: Temperature - 97.9 degrees F (Fahrenheit), Blood Pressure - 130/83, Pulse -107, Respirations -18, and oxygen saturation-98%. Laboratory results included the following: White blood cells (WBC)-2.9, Hemoglobin (Hgb)-10.3, Hematocrit (Hct) -30.3, creatinine-0.64, and glucose-111. 

The patient was started on intravenous (IV) fluids and empiric antibiotics (vancomycin and cefepime) for possible pneumonia and urinary tract infection. A chest x-ray showed minimal hazy opacities peripherally and left base infiltrate versus atelectasis. The urinalysis showed negative nitrite and leukocyte esterase positive. She was also started on stress dose steroids. The patient improved clinically and remains afebrile and hemodynamically stable. 

According to documentation the patient presented with complaints of chills and dysuria. Vital signs showed tachycardia (Heart Rate -107), and laboratory results were notable for leukopenia (WBC-2.9) and elevated C Reactive Protein (CRP). Based on above findings, in an immunocompromised patient with metastatic lungs cancer the hospital admission was medically necessary for intravenous antibiotics and other 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 an inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholecystitis
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is upheld.
 
Acute cholecystitis is a common inpatient diagnosis. Acute cholecystitis is also estimated to attribute to millions of ambulatory visits each year and is a leading cause of hospital admissions. Studies have shown that ambulatory laparoscopic cholecystectomy is safe and avoids an overnight hospital stay. Factors that contribute to admission after laparoscopic cholecystectomy include drain placement, conversion to open surgery, persistent abdominal pain, nausea, and vomiting. In patients without abnormalities of the bile duct or abnormal liver function tests, ambulatory laparoscopic cholecystectomy is safe and feasible. Ambulatory and/or outpatient laparoscopic cholecystectomies reduce hospital costs without compromising patient outcomes.

Per clinical documentation, this patient presented to the emergency department (ED) with a three-day history of acute right upper quadrant abdominal pain. There was associated nausea and vomiting. Vital signs in the ED (emergency department) were significant for an elevated blood pressure of 166/99. The patient had an ultrasound that demonstrated findings consistent with acute cholecystitis. The white blood cell count was 12.3. The total bilirubin was elevated to 2.1. The remaining liver function tests were within normal limits. The patient was taken to the operating room for a laparoscopic cholecystectomy. There were no reported complications. The patient was discharged. Per Milliman Care Guidelines (MCG) criteria, admission is indicated for calculus or obstruction of gallbladder or bile duct and either hemodynamic instability, common bile duct obstruction, severe or persistent vomiting or dehydration, severe pain, or bacteremia. According to clinical documentation, the patient did not meet criteria for inpatient admission. Peer-reviewed literature indicates that laparoscopic cholecystectomy can successfully be performed as an outpatient procedure. Therefore, the requested hospital stay should be observation status. An inpatient admission is not medically necessary, and the health plan acted reasonably. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission at Montefiore Medical Center is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Hepatitis B.
Treatment: Vemlidy.
The insurer denied the Vemlidy.
The determination is overturned.

This is a female patient with chronic hepatitis B. She had a headache and dizziness after starting entecavir. Hepatitis B deoxyribonucleic acid (DNA) was undetectable. The coverage is requested for Vemlidy 25 milligrams (mg) daily for the treatment of chronic Hepatitis B. The request was not approved as the formulary alternative (generic tenofovir disoproxil fumarate) has not been documented as attempted or contraindicated.

At issue is the medical necessity of the Vemlidy. The request for Vemlidy is supported as medically necessary in this case

Guidelines for the treatment of Hepatitis B from the American Association for the Study of Liver Disease (AASLD) recommend entecavir and tenofovir compared with alternatives for the treatment of chronic Hepatitis B [1]. In comparison with tenofovir disoproxil fumarate (Viread), the Vemlidy formulation of tenofovir is effective for Hepatitis B, but is associated with a lower incidence of side effects such as osteopenia and renal disease [2-4]. Viread can be associated with slow but progressive renal dysfunction, thus supporting Vemlidy as more appropriate; a meta-analysis including 26 studies and thousands of patients confirmed this [5-7]. For these reasons, the request for Vemlidy is supported as medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left hip fracture and surgery, diabetes mellitus, hypertension, heart failure (pacemaker), chronic kidney disease, fall.
Treatment: Level 2 Personal Care Services, per 15 minutes increase to 84 hours per week.
The insurer denied coverage for Level 2 Personal Care Services, per 15 minutes increase to 84 hours per week.
The denial is overturned.

This is a geriatric patient who fell, fractured the left hip, underwent surgical repair, and received rehabilitation in a skilled nursing facility (SNF). The patient lives with the son's family and the daughter-in-law is the paid caregiver. The insurer increased Level 2 Personal Care Services (PCS) from 56 to 63 hours per week and the request is for 84 hours per week.

The Uniform Assessment System (UAS) report was reviewed. The patient's cognition is described as minimally impaired. The patient is totally dependent to maximal assistance for Instrument Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework, and shopping. The patient is totally dependent for bathing, lower body dressing and toilet use. The patient requires maximal assistance for personal hygiene, upper body dressing, and toilet transfer. The patient is frequently incontinent of bladder and occasionally incontinent of bowel. Extensive assistance is needed for bed mobility, locomotion, and ambulation. The functional ability is much the same when compared to the previous UAS report. 

This physician disagrees with the insurer. The patient's clinical condition, cognition and functional deficits are at a level and unpredictable as to require the requested PCS 84 hours/week. The patient is totally dependent for most Activities of Daily Living (ADLs), is incontinent and limited in bed mobility and locomotion. Based on the records reviewed, the patient's health and safety are best provided by increasing the hours to 84/wk (week). 

From a physical medicine and rehabilitation perspective, the requested Level 2 Personal Care Services, per 15 minutes increase to 84 hours per week is 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 Level 2 Personal Care Services, per 15 minutes increase to 84 hours per week is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Reflux (with laryngospasm, not unexplained)
Treatment: Hospital Admission
The insurer denied the hospital admission.
The health plan's determination is overturned.

The patient is a male with Down Syndrome, congenital heart disease, and hydronephrosis. At the time of presentation, he had an episode of color change and stiffness at home. He was well until the evening of presentation when he was crying at home. His mother went to check on him and found him struggling to breathe with purple coloring and stiffness of his arms and legs. His mother also noted some foamy discharge from his mouth. She repositioned him and burped him, and he had watery stools. His color then returned to normal. He had been fed 2 hours prior to the event. He had been born at 39 weeks gestation and was admitted to the neonatal intensive care unit for hypoglycemia and respiratory distress. He was found to have a small perimembranous ventricular septal defect (VSD), small patent ductus arteriosus (PDA), and fenestrated atrial septal defect (ASD). An ultrasound showed grade 1 hydronephrosis.

He was found to have a heart rate of 171 beats per minute (bpm). His laboratory values were drawn and an electrocardiogram (ECG) was obtained. He was subsequently admitted to the hospital for evaluation and monitoring after a brief, resolved, unexplained event (BRUE). He did not meet low risk criteria, due to his age and the event lasting greater than (>) 1 minute.

He was admitted to the intensive care unit and was monitored with neurology checks every 2 hours, continuous cardiorespiratory monitoring, and vital signs checks every 2 hours. He was stable during the hospitalization and didn't have any further events. After evaluation, he was felt to have laryngospasm with reflux. His mother was educated on reflux precautions, he was felt to be ready for discharge to home with follow up as an outpatient.

The health plan, in its determination of medical necessity, has not acted reasonably, with sound medical judgment and in the best interest of the patient.

The requested health service/treatment of a hospital admission was medically necessary for this patient. When an infant does not have the low-risk characteristics for BRUE, further evaluation is warranted. In-hospital care with cardiorespiratory monitoring is indicated for infants with warning signs prompting additional evaluation and perceived need to monitor and observe feedings. This infant was very young and had Down Syndrome, cardiac abnormalities and hydronephrosis. He therefore required a hospital admission after the event to provide necessary evaluation and monitoring with prompt administration of additional treatments as needed.

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

Diagnosis: Atrial Fibrillation.
Treatment: Inpatient Stay.
The insurer denied the inpatient stay.
The health plan's determination is upheld.

The patient is a male who was referred to the emergency department (ED) from his primary care physician's office. He had presented there for a routine physical exam and was found to be in atrial fibrillation (AF). He denied any symptoms related to the AF. His medical history was remarkable for irritable bowel syndrome. In the ED, the patient reported feeling well. His blood pressure was 104/68 with a heart rate of 91 beats/minute. His room air oxygen saturation was 98%. His physical exam showed an irregular heart rhythm and was otherwise unremarkable. An electrocardiogram showed AF with a ventricular rate of 85 beats/minute. 

Based on the documentation provided a full hospital admission was not medically necessary. 

This patient was found to be in atrial fibrillation (AF) during a routine office visit. He was asymptomatic and it was unclear how long he had been in AF. He was hemodynamically stable, with a controlled ventricular rate. There was no evidence of acute ischemia or decompensated heart failure. He did not require any acute intervention. While electrical cardioversion was a reasonable approach, based on the documentation provided this could have been scheduled and performed at a lower level of care.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Tinea Unguium. 
Treatment: Jublia. 

The insurer denied: Formulary exception for Jublia. 
The denial is upheld. 

The patient is an adult female with tinea unguium for whom Jublia 10% topical solution is requested. She has failed topical ciclopirox. Due to high cholesterol, she takes lipid-lowering medications and cannot take oral antifungals. Her PCP (primary care provider) will not allow cessation of the lipid-lowering agents for any period of time. She takes rosuvastatin. 

The health plan should not cover the Formulary exception for Jublia. 

Oral antifungals have superior efficacy to topical antifungals for the treatment of tinea unguium. Rosuvastatin has no interaction with terbinafine, one of the health plan's formulary alternatives, so there is no documented reason to avoid use of terbinafine. On the other hand, itraconazole and rosuvastatin have a possible interaction (combo may increase rosuvastatin levels, risk of myopathy, rhabdomyolysis, and other adverse effects) and should not be combined. Per the CDC (Centers for Disease Control and Prevention), oral antifungal therapy (terbinafine) is considered first-line treatment for confirmed onychomycosis. According to a Cochrane review, medication taken orally is evidenced to cure the condition more quickly and effectively than topical treatment. There was high-quality evidence that oral azole (itraconazole) and terbinafine treatments were more effective for achieving mycological cure and clinical cure for onychomycosis compared to placebo, and when compared directly, terbinafine was probably more effective than azoles and likely not associated with excess adverse events (griseofulvin was associated with more adverse reactions than azoles and terbinafine). Oral treatment of onychomycosis is the standard of care however, drug interactions and risk of acute liver injury can limit their use. Difficulties in formulating topical treatment to penetrate the nail and reach the site of infection in the nail bed has hampered the development and the use of topical agents Jublia (efinaconazole) is the first triazole antifungal developed for the treatment of onychomycosis. In 2 randomized trials, complete cure rate, defined as no evidence of fungal infection at week 52, was demonstrated in 15.2% to 17.8% of patients receiving efinaconazole (N=1236) compared with 3.3% to 5.5% receiving placebo (N=415) for the treatment of onychomycosis of the toenail. The odds of mycological cure with continuous terbinafine 250 mg (milligrams) are significantly greater than topical treatments. Therefore, given the above, the health plan should not cover the formula exception for Jublia.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Obstructive Pulmonary Disease.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a male patient with a history of chronic obstructive pulmonary disease (COPD) on 3 liters (L) of oxygen via nasal cannula oxygen at baseline, with obstructive sleep apnea (OSA), and pulmonary hypertension. His presenting complaint was dyspnea, he was told to report to the emergency department (ED) by his pulmonologist and he was requiring 6L of oxygen at the clinic. He was also experiencing blurry vision and a headache. The physical exam was notable for wheezing and pursed lip breathing. Lab results were notable for partial pressure of carbon dioxide (pCO2) of 65. Radiology was notable for a chest x-ray with bibasilar densities and cardiomegaly. The patient was admitted to an inpatient level of care for treatment and monitoring of a COPD exacerbation.
The inpatient admission was medically necessary.
The patient presented with a moderate COPD exacerbation evidenced by pursed lip breathing, hypoxia beyond baseline, and hypercapnia. There was a high likelihood of further clinical decompensation, and so careful monitoring was required in addition to aggressive treatment to improve the patient's symptoms and resolve the COPD exacerbation. Therefore, the inpatient stay was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Expressive Aphasia.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.


This is a male patient with a past medical history (PMH) of benign prostatic hyperplasia (BPH) status/post (s/p) prostatectomy, cerebrovascular accident (CVA) and Parkinson's disease who was admitted with complaints of (c/o) expressive aphasia that resolved within 5-10 minutes associated with chest pain (CP). The vital signs were unremarkable. The physical exam was notable for no apparent distress (NAD), no focal deficits, awake, alert, and oriented times 3 (AAOx3). Lab work was unremarkable. Imaging studies included a computed tomography (CT) scan of the head which showed no acute intracranial process, magnetic resonance imaging (MRI) / magnetic resonance angiography (MRA) of the brain which showed no acute pathology, a transthoracic echocardiogram (TTE) was within normal limits (WNL). An electrocardiogram (EKG) showed normal sinus rhythm (NSR) without ST-T changes. The patient was diagnosed with transient aphasia and a possible transient ischemic attack (TIA) and was treated with anti-platelets, statins, radiological work-up, and neurology consultation. The patient was discharged against medical advice (AMA). At issue is the medical necessity of an inpatient level of care.
The hospital stay was not medically necessary at an acute inpatient level of care.
This patient presented to the emergency department (ED) with complaints of (c/o) expressive aphasia not associated with any focal neurologic findings. The patient's ABCD2  (age, blood pressure, clinical features, duration of transient ischemic attack (TIA), and presence of diabetes); score was 2, indicating a low-risk for recurrent risk of stroke (approximately (~) 1 percent (%) at 7 days), suggesting that a lower level of care was appropriate for this patient. Further suggestion that this patient was appropriate for observation care is that the patient did not have a crescendo TIA, a head computed tomography (CT)scan and magnetic resonance imaging (MRI) were negative, there was no known extracranial embolic source such as atrial fibrillation or artificial heart valve, known carotid stenosis, or hypertensive encephalopathy. This patient was treated with anti-platelets, statins, radiological work-up, which was negative, and neurology consultation, and these interventions could have been safely provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizures
Treatment: Inpatient Hospital Stay

The health plan denied: Inpatient Hospital Stay
The determination is: Upheld

The patient is a female with a medical history of seizure. The patient presented to the emergency department after a seizure associated with a head injury. The patient was admitted to the medical floor for further care. The patient eloped and was then discharged against medical advice. In the emergency room, the patient was continued on her home medications of Keppra, Depakote, and Dilantin. The patient did not have any further seizures in the emergency department or hospital setting.
At issue is the medical necessity of the inpatient stay.
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of impatient medical stay is not medically necessary for this patient. The patient presented to the emergency department after a cluster of seizures. The patient had no further seizures in the emergency department and was stable. In the emergency department, the patient did not have any abnormal vital signs, imaging, or laboratory studies. Nonetheless, the patient was admitted to the medical floor. The patient then left against medical advice without being seen by any further healthcare providers. The patient was stable. It is noted that the patient did not have any further seizures in the emergency room or hospital. The patient was treated with the doses of her home medications. The care provided once admitted to the hospital is not consistent with an inpatient level of care. There were no abnormal diagnostic studies or laboratory tests that required further treatment during an inpatient stay.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shoulder/back pain
Treatment: Pain Injection (62321 x 1 - Epidural Steroid Injection)
The insurer denied Pain Injection (62321 x 1 - Epidural Steroid Injection).
The health plan's determination is upheld.

This is a female patient diagnosed with left shoulder pain and back pain. Records indicate the patient was recommended to undergo a cervical epidural steroid injection, which was denied by the health plan.

The Pain Injection (Epidural Steroid Injection) is not medically necessary for this patient. Records indicate the patient has a history of chronic cervical and thoracic pain and has previously undergone multiple epidural steroid injections at C (cervical) 7 - T (thoracic) 1. Continuation of injections beyond 12 months or more the 4 therapeutic injections is not medically necessary because effectiveness and safety have not been established. The patient has been receiving these injections at the same level for 4 years and has clearly gone beyond 12 months of injections. Medical necessity is not established.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: bilateral plantar foot lacerations.
Treatment: inpatient hospital.
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

The patient is a female who initially presented to the emergency department with concerns for bilateral plantar foot lacerations. Pertinent history included initial evaluation at outside hospital where TdaP (tetanus, diphtheria, and pertussis) booster and clindamycin was administered. Initial vital signs found the patient to be afebrile and hemodynamically stable. Initial examination documented an exposed tendon of the right plantar foot. 

The inpatient hospital admission was not medically necessary. Evaluation and management could have been performed at a lower level of care. The patient had no significant co-morbidities and presented with bilateral foot lacerations. Initial examination documented the patient as alert, oriented, and with an exposed right plantar foot tendon. Initial laboratory testing was relatively unremarkable. Initial radiography did not reveal a foreign object, fracture, or gas. Podiatry consulted and performed a bedside washout and suture. Later in the day, operative management with washout and tendon repair was performed without issue or complication. The following day after presentation, the patient was discharged.