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

Diagnosis: Hyperemesis due to cannabinoid use

Treatment: Inpatient Admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient presented with vomiting and abdominal pain. She had a history of alcohol abuse. She tested positive for cannabinoids; she was hemodynamically stable but had hypertension. The abdominal exam was benign. An abdominal computed axial tomography (CAT) scan showed a corpus luteum cyst but no acute cause for her symptoms. She was diagnosed with hyperemesis due to cannabinoid use. Intravenous (IV) hydration and antiemetics were given. Her symptoms improved and then she left against medical advice (AMA). 

Clinical indications for admission for Vomiting (Milliman Care Guidelines (MCG) include having a severe metabolic derangement such as ketoacidosis, severe vomiting that is not responsive to antiemetic therapy, severe pain, severe electrolyte abnormalities, bacteremia, acute renal failure, and an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

Clinical indications for admission for Undiagnosed Abdominal Pain include hemodynamic instability, peritoneal signs, inability to maintain oral hydration after observation care, and the need for a procedure that cannot be performed on an ambulatory basis. The patient did not have these conditions.

This patient had vomiting that was fell to be related to cannabinoid use. IV hydration, Pepcid, and antiemetics could have been given with observation care. She responded to the treatment and improved, she did not meet MCG criteria for admission for either Vomiting or Undiagnosed Abdominal Pain. 

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 inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dysautonomic Syndrome. 
Treatment: Inpatient Admission. 

The insurer denied coverage for an inpatient admission. 
 
The denial is overturned. 

The patient has a dysautonomic syndrome and goes into crisis twice per year. She presented with intractable vomiting with signs of hypovolemia. The patient was started on a Precedex drip and was admitted to the ICU (intensive care unit). The admission to the ICU for monitoring while on the drip is medically necessary. The patient has a history of respiratory failure on other sedatives. The patient's care could not have been managed in less acute setting. 

Reel, B., Maani, C.V. (2022), "The FDA (food and drug administration)-approved indications for dexmedetomidine are sedation of intubated and mechanically ventilated patients in the intensive care unit (ICU) and peri-procedural (or peri-operative) sedation of non-intubated patients. Over time, usage has expanded to off-label uses, including treatment and prevention of delirium, adjunctive analgesia, therapy for insomnia in the ICU, and treatment of alcohol withdrawal. Dexmedetomidine has also been used in peripheral nerve blocks to prolong the duration of analgesia. This activity will highlight the mechanism of action, adverse event profile, pharmacology, monitoring, and relevant interactions of dexmedetomidine, pertinent for members of the interprofessional team in treating patients where anesthesia is appropriate." 

Taghavi, S., Nassar, A.K., and Askari, R. (2022), "Patients with hypovolemic shock have severe hypovolemia with decreased peripheral perfusion. If left untreated, these patients can develop ischemic injury of vital organs, leading to multi-system organ failure. The first factor to be considered is whether the hypovolemic shock has resulted from hemorrhage or fluid losses, as this will dictate treatment. When etiology of hypovolemic shock has been determined, replacement of blood or fluid loss should be carried out as soon as possible to minimize tissue ischemia. Factors to consider when replacing fluid loss include the rate of fluid replacement and type of fluid to be used." 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shoulder, Knee, and Left Sided Pain.
Treatment: Inpatient admission.
The insurer denied: Inpatient admission.
The denial is upheld.

The patient is an adult male with a past medical history of non-ischemic cardiomyopathy status post ICD (implantable cardioverter defibrillator), paroxysmal atrial fibrillation, DVT (deep venous thrombosis), antiphospholipid syndrome, pulmonary embolism, chronic interstitial lung disease, COPD (chronic obstructive pulmonary disease), and hyperlipidemia. He presented to the emergency department for evaluation of flank pain.

On arrival at the ED (emergency department), the patient was afebrile and hemodynamically stable. Abdominal CT (computed tomography) demonstrated mild bladder wall thickening with mild surrounding fat stranding. Findings within the lung bases most compatible with organizing pneumonia/NSIP (nonspecific interstitial pneumonia). CT (computed tomography) scan of the chest demonstrated a right lower lobe segmental chronic pulmonary embolus. Diffuse ground glass and micro reticulations of bilateral lungs likely sequela of prior lung injury including diffuse alveolar hemorrhage with interval decrease in overall density and increased subpleural clearance.

The patient was admitted to the inpatient unit. During his hospitalization, he had a 12-lead EKG (electrocardiogram) and complained of arthropathy in his shoulders and knees, which raised suspicion of an underlying rheumatologic disorder. X-rays were unremarkable, and outpatient rheumatology follow-up was recommended. The patient was ultimately discharged with outpatient follow-up.

The inpatient 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 ischemia or acute coronary syndrome. Consequently, based on the provided documentation, there is insufficient clinical data to support the medical necessity for an inpatient level of care. An observation level of care would have been appropriate in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fractured tooth.
Treatment: Crown (tooth #5).
The insurer denied: Crown (tooth #5).
The denial is upheld.

The patient is an adult female. The request is for benefits for a dental crown on tooth #5. The tooth has an amalgam filling in it now. The health plan's denial of coverage was due to there being at least 8 back teeth to chew on, and therefore the crown was not needed. The denial is being appealed.

The requested Crown (tooth #5) is not medically necessary.
Tooth #5 does not exhibit any fracturing or decay, based on the records presented (x-rays). The patient states the crown is wanted because tooth #5 is "dark." However, no evidence of the need for the crown is presented. Therefore, given the above, medical necessity has not been established for a crown for tooth #5.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: CPP (central precocious puberty). 
Treatment: Triptodur. 

The insurer denied coverage for Triptodur. 

The denial is overturned. 

This is a patient diagnosed with CPP (central precocious puberty). This request is for Triptodur. As reported; her past medical history is significant for congenital adrenal hyperplasia; had corrective genitalia surgery and excessive height growth. Her current height is 143.2 cm (centimeter) and is experiencing clitromegaly and labial fusion after her corrective surgery. Her MRI (magnetic resonance image) showed there is a 5 mm (millimeter) focus of hypo-enhancement in the left central posterior pituitary gland which is suspicious for microadenoma or Cyst; there is also a questionable smaller focus of hypo- enhancement in the right posterior pituitary gland. 

The definition of precocious puberty is children who have the onset of secondary sexual characteristics in younger boys and girls [1-3]. Central precocious puberty (CPP) is diagnosed using a basal LH (luteinizing hormone) of >0.3 or stimulation testing with a GnRH analog such as luprolide showing a pubertal response defined as an LH >5 or estradiol greater than 40 [4]. CPP is treated with GnRH agonists [5-10] such as Lupron [11] Triptodur, and supprelin[12]. The FDA (Food and Drug Administration) indication for GnRH agonists is for use in central precocious puberty (CPP). In addition when used for CPP the FDA recommends discontinuation of GnRH agonists before teenage years for females males [11]. This is consistent with accepted recommendations for discontinuation of GnRH agonist therapy at a bone age. [2, 4-7]. 

The patient has onset of secondary sexual characteristics at an early age. The patient has a pubertal LH greater than 0.3. The necessity of an MRI is determined based on the clinical situation. The patient has a cause for her central precocious puberty namely congenital adrenal hyperplasia causing advancement of bone age. An MRI is not necessary to approve this medication. 

The request is consistent with generally accepted standards of medical practice and is therefore medically necessary. 

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

The insurer's denial of coverage for the Triptodur is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Congestive heart failure, prostate cancer and pleural effusion.

Treatment is an increase in personal care services (PCS) to 12 hours 7 days a week (total 84 hours/week).

The insurer denied coverage for an increase in personal care services (PCS) to 12 hours 7 days a week (total 84 hours/week).
 
The denial is modified.

This is a patient with chronic medical problems including congestive heart failure, prostate cancer and pleural effusion. He lives with his spouse in a 2 bedroom apartment and is receiving hospice services. An increase in personal care services (PCS) from 10 hours 5 days a week and 3 hours 2 days a week (total of 56 hours) to 12 hours 7 days a week (total 84 hours/week) is requested and currently under review.  

The Uniform Assessment System (UAS) report was reviewed. The patient is alert, oriented, self-directing and able to make his needs known. He is able to call 911 or activate PERS (personal emergency response system) in an emergency situation. The patient requires maximal assistance for bathing, personal hygiene, dressing and toilet transfers/use. Extensive assistance is required for bed mobility and eating. He is frequently incontinent of bladder and continent of bowel. He is non-ambulatory and wheelchair dependent. The patient's significant functional impairments support the medical necessity of consistent personal care services. However, his condition and functional needs are not at a level or as unpredictable to require the requested PCS 12 hours 7 days/week (total 84 hours/week). However, the patient's health and safety can be appropriately provided and maintained by increasing PCS services to a more consistent 10 hours/day, 7 days/week (total 70 hours). 

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

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, the requested Personal Care Services (PCS) 12 hours 7 days a week totaling 84 hours is not medically necessary.  However increasing PCS to a more consistent 10 hours/day 7 days/week (70 hours) is medically necessary.  

The insurer's denial of coverage for personal care services, 12 hours 7 days a week totaling 84 hours is modified. Medical Necessity is partially substantiated
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prostate Cancer
Treatment: Nubeqa
The insurer denied the  Nubeqa
The denial is upheld

The patient is a male with metastatic castrate sensitive prostate cancer.  The attending physician (AP) has requested Nubeqa.  There are no details provided.

No, the proposed treatment is not medically necessary.
Nubeqa is not approved or supported at this time to treat metastatic castrate sensitive prostate cancer.  There is literature to support its use with docetaxel in this setting, however the attending physician has offered no evidence that this is being given with docetaxel. The National Comprehensive Cancer Network (NCCN) does not recognize the use of Nubeqa to treat metastatic castrate sensitive prostate cancer.


Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cholelithiasis. 
Treatment: Inpatient Stay. 

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

The patient is a male who presents to the emergency department with 1 day history of right upper quadrant pain. The pain was associated with nausea and vomiting and after meals. Physical exam shows right upper quadrant tenderness. Laboratory studies showed normal white count, but elevated liver function tests (alanine aminotransferase (ALT) 241, aspartate aminotransferase (AST) 172, and Total Bilirubin 2.6). Imaging studies show ultrasound with cholelithiasis and sludge without evidence of cholecystitis. The patient was evaluated by Gastroenterology. A magnetic resonance cholangiopancreatography (MRCP) showed choledocholithiasis. He underwent an endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy per gastroenterology. The patient then underwent laparoscopic cholecystectomy without any complications and was discharged. 

The requested Inpatient Hospital Admission is medically necessary for this patient. 
According to Milliman Care Guidelines (MCG) health Guidelines 26th edition Gallbladder or bile duct inflammation or stone, an Inpatient admission is indicated for Common bile duct obstruction diagnosed and vomiting that is severe or persistent (Criteria met).
The patient presented to the hospital for evaluation of right upper quadrant pain. He was found to have elevated liver function tests with a total bilirubin of 2.6 on presentation. Imaging studies showed cholelithiasis on ultrasound and choledocholithiasis on MRCP. Gastroenterology consultation and intervention via an ERCP with sphincterotomy was indicated to removed common bile duct stones. His total bilirubin and liver function tests normalized. The patient then underwent a laparoscopic cholecystectomy prior to discharge to prevent further episodes of choledocholithiasis.
The patient's hospital stay meets inpatient criteria for the above-mentioned procedures (ERCP and laparoscopic cholecystectomy). Observation status does not qualify in this case as both procedures were medically necessary and exceed the 24-48 hour observations status. The standard of care is for inpatient evaluation of choledocholithiasis either with a 2 stage procedure during same admission or combined procedure during the same admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Stay
The insurer denied: Inpatient Stay
The denial is: Upheld

The patient is a female with medical history of hypertension, chronic obstructive pulmonary disease, depression, anxiety, and intravenous drug use with methadone dependence. She presented to the emergency department with severe progressive worsening nausea, vomiting, and abdominal pain. She had been hospitalized for similar symptoms previously, with finding of esophagitis and small hiatal hernia on esophagogastroduodenoscopy, and incomplete colonoscopy due to limited bowel preparation.
Vital signs were notable for elevated blood pressure of 157/82 millimeters of mercury (mmHg). Physical examination was notable for diffusely tender abdomen. Labs showed unremarkable blood count and low sodium of 133 millimoles per liter (mmol/L). Computed tomography scan of the abdomen and pelvis showed a sliding hiatal hernia and otherwise normal examination. She was treated with intravenous fluids and pantoprazole.  Gastroenterology consultation concluded that symptoms were due to gastritis, peptic ulcer disease, neoplasia, or esophagitis, with no evidence of gastrointestinal bleeding or pancreatitis; the recommendation was to continue pantoprazole, advance diet as tolerated, hyoscyamine for bowel cramps, lifestyle modification, and outpatient colonoscopy. She had abdominal pain without nausea or vomiting. She was discharged with a plan for Primary Care follow-up. At issue is medical necessity for the inpatient stay.

The health plan's determination is upheld.

The inpatient stay is not medically necessary, and the care could have been provided at a lower level of care status. In this case, the patient presented with abdominal pain, nausea, and vomiting. This was consistent with inflammation (esophagitis, gastritis, duodenitis, peptic ulcer disease) or gastroenteritis; however, there was no sustained tachycardia or hypotension, gastrointestinal bleeding, acute pancreatitis, gastrointestinal perforation, abscess, fistula, peritonitis, sepsis, or bowel obstruction; appropriate therapy was provided with intravenous fluids and proton pump inhibitor. [1-5] Endoscopy during the hospital stay was not deemed necessary. The patient had improvement and was discharged with outpatient follow-up. All of the measures that were undertaken, such as monitoring, labs, Gastroenterology consultation, and proton pump inhibitor therapy, could have been performed without the acute inpatient level of care, at a lower level of care status. [2-5]
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: dental issues
Treatment: Crowns on Teeth Numbers 24 and 25
The insurer denied Crowns on Teeth Numbers 24 and 25. The health plan's determination is upheld. 

The patient is a female who presents to the office for evaluation and treatment of teeth #24 and 25. 

Crowns on Teeth Numbers 24 and 25 are not medically necessary for this patient. From the provided documentation, there is not support for full coverage restorations. Radiographic documentation does not support the statements made regarding cervical loss nor decay for the teeth in question nor does it support the need for indirect restorations let alone Crowns on Teeth Numbers 24 and 25.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay.
The health plan's determination is upheld.

The patient is a female who initially presented to the emergency department with concerns of left foot pain following an injury. Pertinent history included diabetes mellitus. Initial vital signs revealed a temperature of 97.9 degrees Fahrenheit, heart rate (HR) 111, blood pressure (BP) 150/84, respiratory rate (RR) 20, and peripheral capillary oxygen saturation (SpO2) 97% (percent) on room air. Initial examination documented the patient as alert, oriented, non-toxic appearing, and with tenderness of the left foot metatarsals. Initial laboratory testing revealed a white blood cell (WBC) count 7.1, Hemoglobin (HGB) 9.7, platelets (Plt) 705, blood urea nitrogen (BUN) 8, Creatinine 0.9, potassium (K) 4.3, carbon dioxide (CO2) 26, Glucose 565, and sodium (Na) 129. Venous blood gas potential hydrogen (pH) was 7.40 and beta hydroxybutyrate negative. Urinalysis revealed glucosuria and proteinuria. Initial electrocardiogram (EKG) revealed normal sinus rhythm without acute ischemic changes. Radiographs of bilateral ankles were unremarkable. Intravenous (IV) fluids and subcutaneous (SC) insulin were provided. The patient was placed in the hospital thereafter with hyperglycemia secondary to uncontrolled diabetes mellitus type 2. 

The inpatient hospital services were not medically necessary. The patient had a history of diabetes mellitus type 2 who presented with left foot pain after a traumatic event. The initial evaluation did not reveal an acute foot pathology, but did note a serum glucose of 565. There was no evidence of significant acute pathology related to such, such as diabetic ketoacidosis, and treatment was essentially IV fluids and SC insulin. After monitoring glucose levels overnight, the patient was deemed medically stable for discharge. No other issues or complications were documented. Moreover, clinical indications for admission to inpatient care were not met. The patient did not have diabetic ketoacidosis, hemodynamic instability, hyperglycemic hyperosmolar state, mental status changes, severe or persistent dehydration, significant electrolyte abnormality not responsive to observation care, or severe or persistent vomiting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cleft palate. 
Treatment is an inpatient admission.
The insurer denied coverage for an inpatient admission. 
 The denial is overturned.

A female infant was delivered via repeat cesarean section with failed vacuum times two, in the breech position. APGAR (appearance, pulse, grimace, activity and respiration) scores were 8 and 9 at one and five minutes, respectively. Initially, the infant was admitted to the well newborn nursery. Her physical examination was significant for a posterior cleft palate. There were mild intermittent nasal flaring, substernal retractions, and grunting. Secondary to grunting, poor feeding and pitting, the infant was transferred to the neonatal intensive care unit (NICU) where she was placed on continuous monitoring. A NICU Attending Progress Note documented there was "regurgitation through nostrils after feeds with desaturations". The infant required feeding with a Haberman nipple. She had jaundice attributed to an ABO (blood types) set-up. This was treated with phototherapy. The infant was feeding well with her mother working on feeding using the Haberman nipple. She was discharged with a referral and follow-up planned with her primary MD (medical doctor) in 24 hours.  

The insurer denied coverage of an in-patient admission citing MCG (Milliman Care Guidelines) 25th Edition, Newborn Care, Term, with Severe Illness or Abnormality.  However, according to this guideline, Higher-level neonatal care (i.e., other than Level I nursery) for neonate whose gestational age is 37 0/7 weeks or greater is indicated by 1 or more of the following: Congenital anomaly or structural disorder requiring care or monitoring. Thus, the transfer and admission for feeding difficulty associated with the cleft palate was in accord with this guideline and met the standard of care for a newborn symptomatic with a cleft palate. 

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

The insurer's denial of coverage for the inpatient hospital admission is overturned. Medical Necessity is substantiated.