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

Diagnosis: Hypertension
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld
 

This patient presented to the hospital complaining of palpitations. Past medical history was relevant for hypertension and diabetes mellitus. Upon arrival to the hospital vital signs were blood pressure (BP) 213/139, pulse 73. Physical examination revealed no abnormality. A 12-lead electrocardiogram revealed normal sinus rhythm with left ventricular hypertrophy and no acute ischemia. Serum blood testing revealed an elevated high sensitivity troponin level (70.5ng (nanograms)/L (liter)). He was treated with intravenous labetalol and admitted to the hospital for hypertensive urgency and type II non-ST (interval on an ECG[electrocardiogram]) elevation myocardial infarction. The patient responded immediately to antihypertensive therapy and was discharged the following day with controlled blood pressure.

Hypertensive emergency is defined as BP>(greater than) 180/120 with target organ damage. In this patient the troponin levels were elevated. The goals of treatment of hypertensive emergency are to minimize progressive or additional target organ damage while preventing consequence of rapid BP (blood pressure) correction. This patient's BP immediately responded to therapy, and he did not require continuous intravenous therapy for blood pressure control. He also had a low risk for myocardial infarction. Utilizing the HEART (history, electrocardiography, age, risk factors, troponin) risk score this patient would have a low risk for major adverse cardiac events, ST-segment elevation myocardial infarction, non-ST-segment elevation myocardial infarction, unstable angina, percutaneous coronary intervention, coronary artery bypass grafting, significant stenosis (>50%[percent]) treated conservatively, or death due to any cause. In conclusion, this patient presented with poorly controlled hypertension and chest pain that was easily controlled with medical therapy. He could have been managed at a lower level of care.  Acute inpatient admission was not medically necessary. 

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

The insurer's denial of coverage for the inpatient admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Diagnostic Esophagogastroduodenoscopy (EGD)
The insurer denied Diagnostic Esophagogastroduodenoscopy (EGD).
The health plan's determination is upheld. 

The patient is a female. Esophagogastroduodenoscopy showed mild esophagitis at the gastroesophageal junction, antral gastritis, and normal duodenum. 

Diagnostic Esophagogastroduodenoscopy (EGD) is not medically necessary for this patient. Clinical guidelines (including the American College of Gastroenterology guidelines for the treatment of gastroesophageal reflux disease, and guidelines for dyspepsia) recommend endoscopy for investigation of upper gastrointestinal symptoms when those symptoms are refractory to proton pump inhibitor taken properly for 4-8 weeks without response. The most recent American Society for Gastrointestinal Endoscopy (ASGE) guidelines for appropriate use of endoscopy state that endoscopy is warranted if an appropriate empirical trial of therapy for a suspected benign digestive disorder has been unsuccessful. Current medical literature continues to support these recommendations. In this case, there is no documented proton pump inhibitor therapy for at least 4 weeks before the endoscopy. No other guideline-supported indication for esophagogastroduodenoscopy is documented. For these reasons, the EGD is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rectal Bleeding
Treatment: Inpatient Hospital Stay
The insurer denied: Inpatient Hospital Stay
The denial is: Upheld

The patient is a female with medical history of pregnancy at 16 weeks, miscarriage and cervical cerclage. She presented to the emergency department with cramping lower abdominal pain and rectal bleeding starting that day. Vital signs were unremarkable. Physical examination was notable for soft, nondistended abdomen with minor diffuse lower abdominal tenderness and normal bowel sounds. Labs showed low hemoglobin of 10.5 grams per deciliter (g/dL) and hematocrit of 32.0%, and unremarkable comprehensive metabolic panel. Obstetric ultrasound showed single live intrauterine gestation. She was treated with intravenous fluids and pantoprazole. She was made nothing by mouth (NPO). She was started on intravenous famotidine. Gastroenterology consultation noted signs and symptoms suggestive of hemorrhoidal bleeding secondary to current pregnancy, with no acute bleeding, and stable hemoglobin; the recommendation was to monitor the hemoglobin as inpatient and outpatient, monitor bowel movements for overt gastrointestinal bleeding, advance diet as tolerated, continue iron, and no endoscopic evaluation unless there was unstable gastrointestinal bleeding with hemodynamic instability. Gynecology consultation concluded that she had no obstetrical complaints, and recommended continued prenatal vitamin, progesterone, oral iron, initiate Miralax with Colace, and outpatient Gynecology follow-up. She was discharged on Miralax, with a plan for Gynecology and Gastroenterology follow-up. At issue is the medical necessity for an inpatient hospital stay.

The health plan's determination is upheld.

The inpatient hospital stay is not supported as medically necessary, and the care provided could have been provided at a lower level of care. In this case, the patient presented with rectal bleeding. However, there was no sustained tachycardia or hypotension. After initial equilibration, her hemoglobin remained stable, and there was no significant ongoing bleeding. The patient had close monitoring, which was warranted as bleeding can be severe and sudden in onset [1-6]. Colonoscopy was not deemed necessary [1-6]. Her bleeding was suspected to be secondary to hemorrhoids. There was no sepsis, toxic megacolon, or other reasons for the inpatient level of care. All of the measures that were undertaken, including monitoring, labs, and specialist consultations, could have been performed in sequence after presentation and without acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

This patient is an adult previously healthy man who presented to the ED (emergency department) with the complaint of abdominal pain, nausea and vomiting. The patient's examination revealed right lower abdominal tenderness. Vital signs identified a normal 
temperature and normal vital signs at the time of presentation. The WBC (white blood cell) count was elevated at 14.3 K (thousand). Surgical consultation was obtained. CT (computed tomography) scan was completed showing findings of acute appendicitis. The patient was started on IV (intravenous) antibiotics. The patient underwent laparoscopy with appendectomy for the condition of appendicitis that was performed the next day. The operative note describes findings of non-perforated appendicitis. Following surgery, the patient was treated with IV (intravenous) fluid and analgesia. Vital signs were consistently normal in the perioperative period. He was transitioned to oral medications and diet. He required a single catheterization the following day for post-operative urinary retention. He was able to void following this intervention. He was discharged from the hospital the next day.

The health plan rationale for denial of coverage of the inpatient stay is that there is no documentation of need for an inpatient level of care, and the care rendered could have been provided without admission to the hospital (observation status).

The Inpatient Hospital Admission was not medically necessary. 

Acute inpatient hospitalization was not medically necessary for this patient. The medical records support that this patient could have been reasonably and safely monitored with a lower level of care during this period of time. This patient presented with abdominal pain. The evaluation with examination, lab data, and CT (computed tomography) scan supported the diagnosis of acute appendicitis. He underwent uncomplicated appendectomy. He was admitted to an inpatient level of care was discharged from the hospital on the first post-surgical day. There is no clinical documentation to support need for inpatient admission on these dates. The patient remained hemodynamically stable throughout the perioperative period, and there was no documented complication of surgery. This patient's clinical needs could have been satisfied without need for an inpatient designation and could have been satisfied with a lower level of care. This lower level of care would have provided for pre-surgical assessment, surgical treatment and post-surgical recovery including overnight observation (if required). This lower level of care would have permitted straight catheterization for urinary retention.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Heart failure.
Treatment:  Life Vest.

The insurer denied coverage for Life Vest.  The denial is overturned .

This is an adult patient with a history of rheumatic heart disease, chronic atrial fibrillation, mechanical mitral valve, chronic heart failure with reduced ejection fraction and a single chamber implantable cardiac defibrillator. The patient underwent an Implantable Cardioverter Defibrillator (ICD) pulse generator change for battery depletion. The patient subsequently developed a pocket infection, and a system extraction was successfully performed, and the patient was discharged and treated with home IV (intravenous) antibiotics. A wearable Life Vest defibrillator was prescribed until it was deemed appropriate to reimplant an ICD. A right sided single chamber implantable was eventually implanted.

Wearable Life Vest defibrillator therapy was medically necessary. This patient had a history of chronic systolic heart failure and a previously implanted ICD. Following a pulse generator change the patient developed a pocket infection necessitating extraction. The patient was discharged on intravenous antibiotic therapy. The patient also has a history of rheumatic heart disease and a mechanical mitral valve necessitating careful following to ensure that infection was completely resolved prior to re-implantation. The Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) clearly demonstrated that such patients have a significant risk of sudden cardiac death and benefit from ICD therapy. The wearable Life Vest defibrillator is instrumental in protecting patients when implantable devices cannot be utilized. Guideline statements from the Heart Rhythm Society/American Heart Association and the American College of Cardiology specify that wearable Life Vest defibrillator therapy should be utilized during periods when patients are at risk of sudden cardiac death. In conclusion Wearable defibrillator therapy is medically necessary. 

The health plan did not act reasonably, with sound medical judgment or in the best interest of the patient. The insurer's denial of coverage for the Life Vest is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Palpitations
Treatment is an inpatient admission 
The insurer denied coverage for an inpatient admission 
The denial is upheld

This is the case of an adult female that presented to the hospital complaining of sudden onset palpitations. Her medical history was significant for being pregnant. Upon arrival to the hospital vital signs were stable with blood pressure (BP) 120/81 and heart rate 94. No abnormal findings were noted on physical examination. A 12-lead electrocardiogram (EKG) revealed sinus rhythm with no ST (interval on an EKG) or T (interval on a EKG) wave abnormalities. Serum blood testing revealed an elevated troponin 0.069 and .038 nanogram/ milliliter (ng/ml) and an elevated D-dimer of 2.66. A computed tomography (CT) angiogram was negative for a pulmonary embolism. She was admitted to the hospital for monitoring and treatment. Evaluation by obstetrics/maternal/fetal medicine revealed no fetal abnormalities. An echocardiogram revealed normal right ventricular and left ventricular function. The patient was ultimately discharged home the day after presentation. 

This patient presented with palpitations and a mildly elevated troponin level. Her pretest probability of coronary artery disease was low. Utilizing the HEART (History, EKG, Age, Risk factors, and troponin) score she was considered low risk. Utilizing the TIMI (Thrombolysis in Myocardial Infarction) risk score she also had a low risk of developing major adverse cardiac events in the subsequent 30 days. Risk assessment of patients presenting with chest pain and no significant ST changes on the EKG was reviewed by Hedayati et al. Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events [defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death] in the six weeks following presentation. Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation. In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary. This patient could have been treated at a lower level of care.

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

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

Diagnosis:  Syncope.
Treatment:  Inpatient Hospital Admission.

The insurer denied the Inpatient Hospital Admission.  The denial is overturned.

The patient is an adult female. She presented to hospital for multiple episodes of syncope. Intermittent palpitations were noted. There was a history of this within the prior year, but this was not formally evaluated by a cardiologist. Given the concern for cardiac versus neurological etiology for syncope, the patient was admitted for prolonged telemetry monitoring. It was later determined that the etiology of syncope was migraines.

The inpatient admission was denied coverage by the health plan, as it was determined not to be medically necessary. The denial is being appealed.

The Inpatient Hospital Admission was medically necessary.

Inpatient admission was medically necessary. According to the MCG (Milliman Care Guidelines) guidelines 25th edition for general admission, inpatient admission is indicated for cardiac monitoring beyond scope of observation care, which was the case with this patient.

Episodes of recurrent syncope could have both cardiac and neurological origin, including arrhythmia and seizures. If a diagnosis is missed, this could potentially lead to significant morbidity and/or mortality.

Diagnostic yield increases with duration of telemetry monitoring. The yield is much higher the longer one is on telemetry. According to Chen et al. (3), the far majority of people are noted to be on telemetry monitoring for more than 48 hours, well past the observation period.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gait abnormality
Treatment: Personal assistance services (PCS) w/o schedule-12 hours a day, 7 days a week, totaling 84 hours 
The insurer denied personal assistance services (PCS) w/o schedule-12 hours a day, 7 days a week, totaling 84 hours. 
The determination is upheld.

This is a patient with a medical history notable for coronary artery disease, weakness, and gait abnormality. The patient is currently approved for 6 hours per day, 7 days per week (42 hours per week) of personal care services. The patient and her care team requested an increase to 12 hours per day, 7 days per week (84 hours per week), and this request was denied by the health plan.
A letter of support for this appeal was provided by the treating physician. The letter states that the patient is unable to complete any activities of daily living (ADLs) independently. The physician requests an increase in personal care hours. It does not describe any further details or discuss any unmet personal care needs.
A Uniform Assessment System (UAS) was completed and was available for review. The patient was cognitively intact and able to call 911 in an emergency. From a functional standpoint, she requires maximal assistance for meal preparation, housework, and shopping. She requires extensive assistance for transportation. She requires setup help only for medications. For her ADLs, she requires extensive assistance for nearly all, including bathing, hygiene, dressing, walking, locomotion, toilet transfer, and toilet use. She is independent with bed mobility and eating. She is frequently incontinent of urine and continent of stool. She uses approximately 50 pull-ups per month to manage her incontinence. A task tool associated with the assessment recommended 38 hours per week to address her personal care needs. At issue is the medical necessity of personal assistance services (PCS) without (w/o) schedule-12 hours a day, 7 days a week, totaling 84 hours. 

The requested health service of personal assistance services (PCS) w/o schedule- 12 hours a day, 7 days a week, totaling 84 hours has not been demonstrated to be medically necessary for this patient.
There is no documentation of unmet personal care needs. The Uniform Assessment System (UAS) corroborates the physician's testimony that the patient needs assistance for nearly all ADLs. The task tool accounts for this with its recommendation for 38 hours per week (and the patient is currently granted slightly more at 42 hours per week). It has not been demonstrated that the patient requires additional hours to meet her functional needs.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mandibular crowding 
Treatment is D8080 braces, D8670 monthly visit x4 
The insurer denied coverage for D8080 braces, D8670 monthly visit x4.
The denial is overturned.

Upon review of the submitted documentation including lateral cephalometric radio graph, panoramic radio graph, montage of extraoral and intraoral clinical images, dental treatment noted as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified anterior impactions in addition to Class II malocclusion, maxillary and mandibular crowding and overbite. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index choosing the automatically qualifying condition of impacted permanent anterior where extraction is not indicated on the HLD index. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index. The patient's mother is appealing the decision on behalf of the patient. 

Upon review of the submitted documentation, it is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, an HLD index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 

In this case, the treating orthodontist completes the HLD index, choosing the impacted permanent anterior criterion to justify orthodontic care. The clinical circumstance meets this criterion for approval of care. 

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need. 

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

The insurer's denial of coverage for the D8080 braces, D8670 monthly visit, D8670 monthly visit, D8670 monthly visit, D8670 monthly visit is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gastroesophageal reflux disease. 
Treatment: Gastric procedure (procedure code 43239). 

The denial is overturned. 

The patient has had chronic gastroesophageal reflux disease (GERD). She had been on omeprazole 40 milligrams (mg) a day for 2 months. Her father had esophageal cancer. She had recently lost weight. She was referred for an upper gastrointestinal endoscopy. 

Milliman Care Guideline (MCG) clinical indications for admission for Upper Gastrointestinal Endoscopy (MCG ACG: A-0203) include having gastrointestinal reflux symptoms with failure of medical therapy. Failure of medical therapy is defined as a poor response to empiric proton pump inhibitor (PPI) therapy for 4-8 weeks. 

This patient has chronic reflux and had a trial of PPI therapy for 2 months. This met the MCG guideline for doing an endoscopy. In addition, the family history of esophageal cancer as well as the weight loss further supports the importance of doing the endoscopy. 

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 a gastric procedure (procedure code 43239) is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Low testosterone.
Treatment: Xyosted.
The insurer denied Xyosted. 
The health plan's determination is upheld.

The patient is a male with a history of low testosterone. He is symptomatic with low sex drive. Has been on hormone replacement therapy which has not been effective. The request is for Xyosted. 

A formulary exception is not indicated.
Formulary alternative(s) include: testosterone transdermal gel 25 milligrams (mg) /2.5 g (grams) (1%); testosterone transdermal gel; testosterone cypionate; testosterone enanthate.
There are no high-quality head to head studies examining differences between the various formulations noted on the formulary versus. the non-formulary request. As such, there can be no conclusion made that the formulary drugs will be or have been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.