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

Diagnosis: Decompensated heart failure

Treatment: Inpatient hospital admission

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld.

This is a male patient with a medical history of congestive heart failure (CHF), diabetes mellitus, implantable cardioverter-defibrillator (ICD) and permanent pacemaker who presented to the Emergency Department (ED) with complaints of shortness of breath over a 2-day period. The patient also complained of some orthopnea. The patient denied a fever, cough, chest pain, nausea/vomiting or diarrhea. 

The patient's vital signs were abnormal in the ED but improved after an administration of intravenous (IV) Lasix. As per physical examination, the patient was noted to be comfortable and in no acute distress. The patient was speaking in full sentences and was alert and oriented. The patient had coarse breath sounds but clear lungs and unremarkable cardiovascular and abdominal examinations. The patient had no clinical findings of cyanosis or edema of extremities. The patient was admitted for decompensated heart failure, and was continued on maintenance cardiac medications and IV Lasix. The patient was evaluated by an electrophysiologist (EP) who interrogated the patient's pacemaker and ICD, and made adjustments; as per EP evaluation, the patient's device was pacing and sensing normally. EP recommended that the patient follow-up as outpatient in 2 weeks. This patient remained stable after admission. 

Based on the review of the medical record and literature, this patient did not need acute inpatient hospitalization. The patient could have been placed in observation status while diagnostic testing and treatment were being done. This patient did not have an acute coronary syndrome (ACS), and remained hemodynamically stable. The patient tolerated oral intake. The patient reported reducing his Lasix dose, which could have precipitated his symptoms. The patient could have been discharged after a period of observation and IV Lasix treatment in the observation level of care. The patient was cleared by EP cardiology for outpatient follow-up. The patient's permanent pacemaker and ICD were working normally. The patient remained afebrile, hemodynamically stable with normal oxygen saturations on room air, and no symptoms of cardiac ischemia (i.e. chest pain). The patient was stable for outpatient management after a period in observation. Thus, inpatient admission was not medically necessary for this patient.

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

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

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 
The insurer denied: crown on tooth 3. 
The denial is overturned in whole. 

The patient is a female who presented to the office of her dental provider for evaluation and treatment of tooth #3. Included for review are previous letters of appeal and denial, a narrative from the provider explaining the need for the porcelain crown on tooth #3, full mouth radiographic images, one page of American Dental Association (ADA) claim forms, periodontal indices, a narrative from the patient, and multiple journal articles in support of the provider's position.
In question is the medical necessity of the planned treatment of porcelain crown for #3. Previous denials have been on the basis that health plan language states that when there are remaining four maxillary and four remaining mandibular teeth in the posterior dentition in occlusion without the tooth in question, those crowns are not covered.

Based on the provided documentation, the patient had recurrent decay and cracked tooth structure and that when the decay and previous restoration were removed, over half of the crown of the tooth was missing, eliminating the ability to place a direct restoration and necessitating a buildup and crown. This treatment is common and standard in the practice of dentistry and the maintenance of the dentition for structure and function. Teeth that do not maintain their interocclusal and interdental contacts will shift, and teeth cannot be restored with fillings in the event that the filling itself is not supported by the tooth structure, as is the case with this tooth. As such, the entire treatment of the porcelain crown for #3 is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity
Treatment: Saxenda Injection 
The health plan denied the Saxenda Injection. 
The denial is overturned.
The proposed Saxenda Injection 18mg/3ml is medically necessary.


The patient is a male diagnosed with obesity. This request is for Saxenda. As reported, he has prediabetes, hyperlipidemia (HLD), and hypogonadism. He has engaged in lifestyle interventions, including diet modifications with reduced caloric intake and exercise without success. Orlistat and anorexiants would by contraindicated per the provider. The patient's weight was 255 pounds, height was 167.64 centimeters, and body mass index (BMI) was 41.16. 

Saxenda is a glucagon-like peptide-1 (GLP-1) agonist that is used in the treatment of obesity [1-3]. The Food and Drug Administration (FDA) label is below [4].

Indications and Usage: 
Saxenda is a glucagon-like peptide-1 (GLP-1) receptor agonist indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index (BMI) of: 
- 30 kg/m2 or greater (obese) (1); or
- 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbid condition (e.g. hypertension, type 2 diabetes mellitus, or dyslipidemia) (1).

Limitations of Use: 
- Saxenda is not indicated for the treatment of type 2 diabetes (1). 
- Saxenda should not be used in combination with any other GLP-1 receptor agonist (1).
- Saxenda should not be used with insulin (1, 5.4).
- The effects of Saxenda on cardiovascular morbidity and mortality have not been established (1).
- The safety and efficacy of coadministration with other products for weight loss have not been established (1).
- Saxenda has not been studied in patients with a history of pancreatitis (1, 2). 

The standard of care with respect to the treatment of obesity is that patients are treated with the most appropriate medication taking into consideration their comorbidities and other disorders and contraindications and which medication is likely to be most effective.

This patient is participating in lifestyle modification. The request is consistent with the FDA label and generally accepted standards of medical practice. In this case, the patient has prediabetes and obesity. The requested medication is a GLP-1 receptor agonist, which is expected to be beneficial in reducing the patient's hemoglobin A1c and preventing diabetes. It would be superior to the health plan's alternatives (orlistat, Xenical, Qsymia, and Contrave), which are not expected to improve the patient's prediabetes directly.

The request is expected to be effective for this patient and is therefore medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Mesenteric adenitis; Asthma exacerbation.
Treatment:  Inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.  The denial is upheld.

The patient is a female child with a past medical history of asthma, who presented to emergency department (ED) with complaints of suprapubic and right lower quadrant abdominal pain, vomiting for 2 days and asthma exacerbation.  There were no fevers.  The patient's mother reported 5 episodes of vomiting the prior day and 2 on the day of arrival.  The patient had been given Albuterol nebulizer treatments at home for wheezing.  In the ED, physical exam was remarkable for an alert, active child in no distress with normal vital signs.  Physical examination was positive for prolonged expiration, wheezing and for initial mild generalized abdominal tenderness.  Subsequently on follow up exams suprapubic and right lower quadrant abdominal tenderness was noted on deep palpation.  There was no vomiting noted while in the ED or hospital.  There was questionable McBurney's sign and positive Rovsings.  Lab studies were unremarkable, and a chest x-ray and abdominal x-ray were normal.  An ultrasound of abdomen noted some mesenteric nodes, and the appendix was not visualized.  In the ED she received 1 treatment with Duoneb and intravenous normal saline fluid infusion.   The patient was admitted to the pediatric unit for observation for symptoms of appendicitis.  The patient was placed on clear liquid diet and albuterol every 3 hours initially then every 4.  She was started on oral prednisone daily for 5 days.  Her lungs were noted with intermittent wheezing.  Serial examination of the abdomen remained with tenderness and parental report of pain, so a computerized tomography (CT) scan was done and showed mesenteric adenitis with a cystic mass on the right suspicious for ovarian cyst.  A repeat ultrasound after the CT scan showed normal ovaries.  There was no surgical consult obtained.  The pediatric attending physician note clearly stated no surgical co-morbidities.  Serial exams done noted the patient as in no distress, smiling and having intermittent pain on deep palpation.  Discharge diagnosis was listed as mesenteric adenitis and mild persistent asthma. 

Based on MCG 24th Edition, both for Pediatric Abdominal Pain and Asthma, this inpatient hospital stay was not medically necessary.  The health plan acted reasonably and with sound medical judgement in its decision; based on MCG 24th edition, this inpatient admission was not medically necessary. 

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congestive heart failure, Shortness of breath

Treatment: Inpatient hospital admission

The insurer denied coverage for the inpatient hospital admission.

The denial is overturned. 

This is a male patient whose past medical history included diabetes mellitus, alcohol abuse, hypertension, fatty liver, chronic obstructive pulmonary disease (COPD) and recent onset atrial fibrillation status post pacemaker placement, who came to the Emergency Department (ED) because of shortness of breath. At the time, the patient was recently discharged from the same hospital after being treated with the same symptoms. 

On this admission, the patient reported that his symptom of shortness of breath started at 2 a.m. and awoke him from his sleep. With the shortness of breath, the patient also reported epigastric discomfort. He had a permanent pacemaker implanted a week prior to admission because of tachycardia-bradycardia syndrome. On physical examination, the patient was described as being in no apparent distress; rales were heard at both lung bases, and the patient had ascites and significant pitting edema. The physician's assessment of the patient was shortness of breath secondary to congestive heart failure (CHF) exacerbation. The patient's electrocardiogram (EKG) showed normal sinus rhythm with first-degree atrioventricular block; there was left axis deviation and an incomplete left bundle-branch block. The patient was discharged home on day 5 of admission with arrangements made for out-patient follow-up.

Studies have been done to identify patients admitted with CHF who are candidates for early discharge. A study by Diercks et al (2006) attempted to identify factors that could find a low risk group of patients with acute decompensated heart failure who were suitable for management in a 23-hour observation unit. They concluded that initial blood pressure and troponin can identify patients with CHF with lower risk for adverse events and could be managed in the hospital for less than 24 hours. As per Neal et al (2010), factors which identify CHF patients as being at high risk include elevated blood urea nitrogen (BUN) and creatinine, hyponatremia, ischemic changes on EKG, very elevated brain natriuretic peptide levels, elevated troponins and low systolic blood pressure.

In this case, this patient presented to the hospital with an episode of CHF exacerbation. The patient's blood pressure was high, and his lab was significant for elevated BUN of 48 and creatinine of 2.6. The patient also had rales, ascites and peripheral edema confirmed on chest imaging. The patient required intravenous diuretics and supplemental oxygen. Based on the literature review, this patient presented with clinical findings that characterized him as a high-risk patient and in need of acute level of care. Thus, inpatient admission was medically necessary for this patient. 

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

The carrier's denial of coverage for the inpatient hospital admission should be overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Suicidal ideation, Paranoia, Depression

Treatment: Behavioral health inpatient hospital admission

The insurer denied coverage for continued behavioral health inpatient hospital admission.

The denial is upheld.

This is a female patient with a history of anxiety disorder, trauma and paranoid schizophrenia who was admitted for inpatient mental health treatment due to suicidal thoughts to end life without a plan, depressive symptoms, increased paranoid thoughts, and anxiety including trauma issues. The patient reportedly was the victim of sexual trauma. The patient was in outpatient psychiatric treatment with a psychiatrist and therapist. The patient lived with her mother and siblings. The patient had no reports of past suicide attempts or illicit substance use. During this inpatient stay, treatment included sertraline and risperidone. The patient reportedly improved and was discharged on day 8 of admission.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Schizophrenia reports that patients with hallucinations, delusional thinking, disorganized behavior, suicidal or homicidal plan or intent, agitation, or aggressive behavior are candidates for inpatient treatment. In this case, as of day 7 of admission, there were no reports of further serious psychotic symptoms such as paranoid delusions, and there were no reports of hallucinations or disorganized behavior, suicidal or homicidal ideation, intent, or plan, manic symptoms, aggressive, threatening, self-injurious, or agitated behavior, withdrawal symptoms or acute medical instability. Notes reported that the patient was feeling fine, was pleasant, interacting and participating well, and her paranoia resolved. There were no reports of suicidal thoughts or severe depressive symptoms then. 

Based on the review of the medical record, as of day 7 of admission, there were no reports of acute or severe mental health or behavioral symptoms that required 24-hour acute hospital treatment. There was also no specific evidence that the patient was considered an imminent danger to self or others, and there were no reports of specific identifiable or quantifiable treatment goals or objectives that could only be achieved in a 24-hour acute psychiatric hospital treatment setting or that could not be achieved in a less restrictive level of care as of then. Thus, continued inpatient psychiatric treatment from day 7 to day 8 of admission was not medically necessary for this patient.

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

The carrier's denial of coverage for the continued behavioral health inpatient hospital admission from day 7 to day 8 of admission should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned


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

The patient is a woman with a history of pseudotumor cerebri who was admitted to the hospital with complaints of diplopia of the left eye for the past three days and lower back pain for the past two weeks. She reported blurry vision and eye pain. She had been seen in an outside hospital for similar symptoms in the recent past. She stated that her back pain was sharp and non-radiating. Vital signs showed temperature 97.8 Fahrenheit, blood pressure 138/72, heart rate 91, and respiratory rate 16. In the emergency department, she underwent head computed tomography (CT) and was referred for lumbar puncture with a goal of reducing pressure to less than 20 mmHg. She was also seen by ophthalmology. On physical examination, the intraocular pressure was 16 mm, with no optic disc swelling bilaterally. A cranial nerve deficit with left lateral visual field deficit was present. Labs showed a white blood cell (WBC) 5.59, hemoglobin 11.6, platelets 262, sodium 141, potassium 4.4, glucose 144, and creatinine 0.7. X-rays of the lumbar and thoracic spine showed no acute fracture. The patient was admitted for diplopia. The plan of care included head CT, intravenous (IV) steroids due to contrast allergy, Benadryl, continue Topamax, neurology consult, neurosurgery consult, ophthalmology consult, and monitor electrolytes. Neurosurgery saw the patient and agreed with the plan of repeating imaging and therapeutic lumbar puncture. Neurology agreed with the plan to perform a therapeutic lumbar puncture, and she was scheduled with interventional radiology after multiple failed attempts on the medical floor. When she underwent a lumbar puncture, the opening pressure was 17, and 17 ml of fluid was aspirated. She was then referred for brain magnetic resonance imaging (MRI) and psychiatry consult to further evaluate anxiety. She later declined the brain MRI and communicated to the treating team that she wanted to leave the hospital to celebrate with her family. She subsequently signed out against medical advice.

The inpatient hospital admission was medically necessary. The patient presented with pseudotumor cerebri and concerns for visual complications. She required consultation with neurology, neurosurgery, and ophthalmology, and she required this care promptly after her presentation. Given the possibility of long-term visual injury and the need for multiple consultants for acute recommendations, it was reasonable to treat her at the inpatient level of care. The patient was complex and presented with diplopia of the left eye that was thought to be related to her pseudotumor cerebri. She required multiple specialist consultants and was also underwent lumbar puncture with interventional radiology. Given the acuity of her signs/symptoms, and the significance of her concerns, and the possibility of long-term visual loss, an inpatient level of care was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prostate adenocarcinoma

Treatment: Genetic Test Oncotype DX

The insurer denied coverage for the Genetic Test Oncotype DX.

The denial is upheld.

This is a male patient with a prostate specific antigen (PSA) of 7.2. The patient's prostate biopsy revealed 2 biopsy scores of Gleason 3+3 prostate adenocarcinoma; clinical stage T1c. The Oncotype DX prostate cancer (PCA) test was ordered for further evaluation. This revealed a Genomic Prostate Score (GPS) score of 16, which falls into the "very low risk" category. 

While it is true that National Comprehensive Cancer Network (NCCN) guidelines state that molecular testing, including the Oncotype DX PCA test be considered for men with NCCN low or favorable intermediate risk prostate cancer and at least a 10-year life expectancy, they also note the absence of randomized prospective trials. The American Urological Association (AUA) guidelines are not as enthusiastic regarding the usage of Oncotype DX PCA or other similar tests, stating that "tissue based genomic biomarkers have not shown a clear role in active surveillance for localized prostate cancer and are not necessary for follow-up". The impact of tissue based gene expression tests such as Oncotype DX PCA on clinical practice and long term patient outcomes remains to be empirically demonstrated. Prospective studies of these molecular tests yielding a true clinical benefit when implemented in clinical practice are still lacking. It is not yet clear where this test fits into the algorithm of the management of prostate cancer. Not every case of low risk or favorable intermediate risk prostate cancer requires additional confirmation by the usage genomic biomarker testing. There is no medical evidence at this time that usage of this type of test improves health outcomes in patients with prostate cancer or is more likely to be more beneficial to the patient than any other available standard health service or treatment.
	
Genetic Test Oncotype DX for prostate cancer performed for this patient is not considered medically necessary. As stated above, further studies are needed to evaluate the efficacy of these genomic biomarker assays. Prospective studies of Oncotype DX PCA and other similar tests yielding a true clinical benefit when implemented in clinical practice are still lacking in peer-reviewed literature. 

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

Based on the above, the medical necessity for the Genetic Test Oncotype DX for prostate cancer, performed for this patient is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Excess abdominal skin

Treatment: Panniculectomy

The insurer denied coverage for a panniculectomy

The denial is upheld.

This is a female patient with a medical history of obesity, chronic bilateral headaches, esophageal reflux heartburn and hyperlipidemia.  The patient was seen in her general surgeon's office for a follow up after laparoscopic gastric sleeve surgery; the patient had lost 80 pounds since surgery.  The patient was noted to have an abdominal panus and was associated with skin inflammation, rash, back pain and psychosocial and somatic problems. The patient was also advised to further lose weight by her general surgeon due to a co-morbid mastoid cerebral spinal fluid (CSF) leak. The patient was recommended panniculectomy in order to assist with the patient's mobility and exercise needed to further loss weight. 

Based on the review of the medical record, the panniculectomy is not medically necessary for this patient.  The medical records do not provide any documentation in the form of primary care physician (PCP) or dermatology progress notes that describe ongoing clinically significant dermatologic problems that have either 1) never responded to physician directed topical therapy or 2) despite initial response, have recurred and caused significant functional impairment.  Supervised medical management for this patient's rashes is not documented in any of the progress notes submitted for this review.  The photographs submitted do not show rashes.  A study by Staaleson, et al (2012) found that panniculectomy surgery following weight loss has a complication rate of nearly 50%.  Medical treatment is a simpler and safer solution to manage this patient's rashes.  Surgical lipectomy should be reserved for patients that have failed optimal medical management for intertrigo that has been supervised by a physician, which is not documented to be the case for this patient.  Summary treatment letters and member appeal testimonies in the absence of physician office note documentation of specific dates of treatments and medications prescribed do not provide sufficient documentation to confirm the failure of medically supervised care. Thus, panniculectomy is not considered medically necessary for this patient.

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

The carrier's denial of coverage for Panniculectomy should be upheld.  The medical necessity is not substantiated.