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

Diagnosis: Back, hip and leg pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male with history of hypertension (HTN), diabetes mellitus type II (DM2), and schizoaffective disorder who presented with back and leg pain and was unable to walk to the emergency department (ED).

No, the inpatient admission was not medically necessary.  

There is insufficient evidence provided during the hospitalization to support the acute inpatient level of care. The patient does not have any focal deficit, no acute intervention required, or requirement for intravenous (IV) medications or other treatments that would support each of the dates for acute inpatient level of care. The notes indicate the patient refused surgery, was converted to oral steroids and did not have any other findings that would support acute level of care. Therefore, the entire acute inpatient stay was not medically necessary and the patient could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Epigastric abdominal pain; coffee ground emesis
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female with past medical history significant for hypertension, rheumatoid arthritis (RA), seizure disorder, deep vein thrombosis (DVT) for which she has been on Eliquis, and history of (h/o) hiatal hernia status post (s/p) fundoplication.  She was discharged two days prior to presentation with self-limited hematemesis. On her prior admission, she underwent esophagogastroduodenoscopy (EGD) which revealed mild esophagitis, atrophic gastritis, three-centimeter (cm) hiatal hernia, evidence of fundoplication, and a gastric nodule in the hiatal hernia pouch. There was no evidence of active bleeding. 

The patient presented this time with one day h/o epigastric abdominal pain, two episodes of vomiting with food contents, and two episodes of coffee ground emesis. In the emergency department (ED), the patient was hemodynamically stable, and afebrile. Her complete blood count (CBC) and Chem-panel were normal. In the ED, the patient was given intravenous (IV) Zofran, and Protonix after she felt better. She was admitted to the medical floor. During her hospitalization, she had no recurrence of vomiting. She was started on clear liquid diet and was started on IV Protonix and Zofran. Her hemoglobin/hematocrit (Hb/HCT) were closely monitored and she remained hemodynamically stable. She had no recurrence of hematemesis during her hospitalization. She was discharged home on Protonix 40 milligrams (MG) by mouth (PO) twice a day (BID) and advised to follow up with gastroenterology (GI) on an outpatient basis.

No, the health plan should not cover the proposed acute level inpatient care for the management of this patient's condition.

This patient was admitted with one-day h/o abdominal pain, vomiting and coffee ground emesis. On the prior admission a few days prior, she was admitted with similar symptoms and on EGD was found to have mild esophagitis (possible cause of hematemesis), three-cm hiatal hernia, and an evidence of fundoplication. During her current admission, she was hemodynamically stable and afebrile, and CBC and Chem-panel were essentially unremarkable. She was managed conservatively with IV Protonix and Zofran. After hospitalization, she had no recurrence of emesis/hematemesis, and Hb/HCT remained stable, and she did not require blood transfusion or repeat EGD. The patient was placed on clear liquid diet which she tolerated well, and her diet was advanced to regular diet which she tolerated very well. She was discharged home on Protonix 40 MG PO BID and was advised to follow up with GI on an outpatient basis.

No, the proposed acute level care was not medically necessary in whole or in part and was not expected to be health beneficial for the patient and withholding the treatment in whole or part was not expected to affect the patient's health adversely.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Hypertension, History of Bariatric Surgery.
Treatment: CAROSPIR 25 MG/5 ML ORAL SUSPENSION.
The insurer denied the CAROSPIR 25 MG/5 ML ORAL SUSPENSION.
The determination is overturned.

The patient has had bariatric surgery. She has fluid intake restrictions and is struggling to swallow her pills. Carospir 25 milligrams (mg)/5 millilters (mL) oral suspension for the treatment of hypertension was requested and was denied by the health plan. The formulary alternatives are generic spironolactone, amiloride, eplerenone, and triamterene. At issue is whether the formulary drug(s) will be or has been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.

The absorption of medications is altered after bariatric surgery [1,2]. Liquid formulations are better absorbed [3-5]. The use of liquid medication formulations is recommended for at least two months after bariatric surgery [6]. In this case, in which the patient is in the postoperative period after bariatric surgery, and the patient is unable to take her medications in pill form, the use of liquid Carospir for the treatment of hypertension is supported over the use of solid formulations of spironolactone, amiloride, eplerenone, and triamterene, as it would be better absorbed and therefore, would be more effective.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cervical Myelopathy

Treatment: Inpatient admission

The insurer denied the inpatient admission.

The denial was upheld.   

This is a male patient with history of cervical myelopathy, coronary artery disease (CAD), benign prostatic hyperplasia, bladder cancer, cystoscopy, appendectomy, diabetes mellitus, hypertension, and hyperlipidemia and underwent a scheduled, anterior cervical discectomy and fusion C3-C4. The patient's surgery was without complications and his preoperative neurological deficits returned to normal. The patient had episodes of high blood pressure that was controlled with intravenous (IV) medications and pain was controlled with a patient-controlled analgesia (PCA). The patient was seen by Cardiology and was noted to be in stable cardiovascular status. The patient was voiding, taking oral fluids and able to ambulate with walker. The patient's physical therapy (PT) suggested home discharge. The patient was discharged the following day in stable condition. 

According to Yuk et al (2017), "Patients with anterior surgery performed experienced a length of stay that was 2.07 days shorter on average. Higher [estimated blood loss (EBL)], longer incisions, more intervertebral levels, and longer operating time were significantly associated with the posterior approach." As per Tetreault et al (2016), "A longer operative duration (moderate evidence)...s predictive of perioperative complications and a 2-stage surgery is related to an increased risk of major complications (high evidence). In terms of surgical techniques, higher rates of neck pain were found in patients undergoing laminoplasty compared with anterior spinal fusion (moderate evidence)."

In this case, the patient had an uncomplicated anterior cervical discectomy and fusion C3-C4 procedure and postoperative recovery. The patient had no neurological deficit and was able to void, ambulate and tolerate oral intake. The patient could have been safely monitored and treated in observational level of care. The patient did not have complications that required inpatient level of care. 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 inpatient admission is not substantiated.  The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Removal of hardware of the left Knee.
Treatment:  Inpatient admission.

The insurer denied the inpatient admission.  The denial was upheld.

This is a female patient with history of left knee osteoarthritis, knee arthroscopy, hypertension, hyperlipidemia, prediabetes, and left tibial plateau fracture with open reduction internal fixation (ORIF), who presented to the hospital for scheduled removal of hardware (ROH) of the left knee and conversion to left total knee arthroplasty (LTKA).  The patient was admitted for post-operative monitoring of her left knee removal of hardware.  The patient complained of throbbing pain on the incision.  The hospital course of treatment and management included intravenous (IV) cefazolin, IV fluid, Percocet, oxycodone, morphine injection, zolpidem, Tylenol, pantoprazole, Lisinopril, amlodipine, Lovenox injection, and neurovascular check.  After treatment, the patient was cleared for discharge to subacute rehab. 
 
Based on the review of the medical record, this patient came to the hospital for a scheduled knee replacement, and she had a non-complicated total knee replacement procedure.  The patient's physician removed her previous hardware, which by itself was without problem.  The operation was straight-forward without excessive bleeding or technical issues.  The physician did not use a drain.  The patient's post-surgical course was also uncomplicated with a stable hematocrit.  The patient's vital signs were satisfactory.  There were no issues with this patient's surgical wound.  The patient was able to tolerate oral pain medication and received injection for anticoagulation.  The patient was able to tolerate physical therapy (PT) and use a walker for ambulation.  The patient required no treatment for an underlying medical condition.  The patient's preoperative evaluation report was also "low risk of perioperative complication". 
 
A full hospital admission may have been indicated if this patient had severe problems before or after surgery.  However, the medical records received for this review did not support this case.  The patient could have had treatment outside of a hospital setting for the services provided after the surgery.  These findings thus, do not substantiate the medical necessity for admission.  A lower level of care, such as observation status could have been provided 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 inpatient admission is not substantiated.  The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma Exacerbation

Treatment: Inpatient admission

The insurer denied the inpatient admission.

The denial was upheld.   

This is a male patient with a history of asthma and marijuana use who presented to the Emergency Department (ED) with complaints of cough and shortness of breath. The patient did not improve with use of inhalers at home so had come to the ED.
The patient denied history of fever. The patient was only on albuterol as needed (PRN) and Spiriva PRN. The patient's vital signs (V/S) at ED presentation were: Temperature 98, Heart Rate 100, Respiratory Rate 42, Blood Pressure 139/95, oxygen (O2) saturations 97 % Room Air. The patient was tachypneic. Bilateral (B/L) Rhonchi and Wheezing heard. The patient was treated with steroids, magnesium and bronchodilator. The patient was placed on BIPAP. The patient's bloodwork showed: white blood cell (WBC) count of 5.6K, hemoglobin 12.2, sodium 141, potassium 2.9, and BUN/Creatinine 6/0.7. The patient was treated with potassium supplement. The patient's chest x-ray revealed (CXR) no acute infiltrates. The patient clinically improved on treatment and BIPAP. Later that night the patient clinically improved saturating 100% on nasal cannula (NC). The patient had bilateral wheeze on lung exam with unremarkable cardiovascular and abdominal exams. The patient was treated with tapering steroids.

Based on the review of the medical record, this patient did not need acute inpatient hospitalization. The patient could have been placed on observation status while treatment and diagnostic testing were initiated. The patient had started improving with treatment, was taken off the BIPAP and switched to supplemental oxygen by nasal cannula. The patient remained stable after admission. As per H&P around midnight, the patient was described to be in not in acute distress (NAD). The patient remained stable and was cleared for discharge by later that morning.

This patient could have been placed in observation status. There was no evidence of pneumonia. The patient improved after a short period on BIPAP. The patient could have been discharged home on bronchodilator, tapering steroids and oxygen supplementation if needed after a period in observation status with close follow-up in the outpatient setting upon discharge.

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 inpatient admission is not substantiated.  The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Labial hypertrophy
Treatment: Vulvectomy (removal of part of the vulva)
The insurer denied the Vulvectomy (removal of part of the vulva).
The determination is upheld.

The patient has a diagnosis of labial hypertrophy. There is documentation that it bothers her and she feels she has to "adjust herself down there". She desired reduction. The physical exam indicated "redundant left labia minora tissue" at 3 centimeters (cm) in length and the right labia minora is 1 cm in length. She had a partial vulvectomy/labiaplasty. At issue is the medical necessity of the procedure.

The requested health service/treatment of vulvectomy (removal of part of the vulva) is not medically necessary for this patient.

The patient has self-documented discomfort with her labia minora and desired reduction. On exam the left labia minora was 3 cm and the right labia minora was 1 cm. The average length of the labia minora is 0.4 to 6.4 cm in length, and about 2 cm wide. This patient had a completely normal exam without any documentation of labial hypertrophy. Her labia minora are on the smaller side of normal. She does have a self-perceived problem, however, there is no medical necessity for the surgery as her labia minora are normal.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Cerebral Palsy. 
Treatment: Durable Medical Equipment (Transit Option, Canopy and Basket) (Pre-Service). 
The insurer denied the Durable Medical Equipment (Transit Option, Canopy and Basket) (Pre-Service). 
The denial is overturned, in part. 

This is a child with history of seizure disorder and developmental delays. The child has been diagnosed with microcephaly with hypotonia. The child has been receiving pediatric rehabilitation services at school and has been followed by the pediatric physiatrist and neurologist. The child has been recommended to use the Convaid adaptive stroller, gait trainer and activity chair. A detailed letter of medical necessity has been provided in support of the Convaid Cruiser with accessories. The health plan denied coverage for the following components/accessories: Cruiser Transit Option CX14, Deluxe Canopy with Side Windows CX14 and Underseat Storage Basket CL13/16T. 

Yes, in part, the proposed durable medical equipment is medically necessary. The transit option and canopy are medically necessary; the basket is not medically necessary. 

Accessory items including a transit option, canopy and basket were previously deemed not covered on the basis that they were not medically necessary for home use. However, the submitted medical records as well as substantiated clinical evidence identify important needs related to this child which should be taken into consideration such as transportation safety to and from the physician's office/school and environmental exposure related to seizure history/medication use at the time of transport. 

As detailed by the physical therapist, the proposed transit option is required for safe transportation when attending various doctor's appointments and community activities, as well as on the school bus when attending school. While this feature may not be required for daily use, it is essential to comply with safety standards. The canopy is being requested for protection from direct sunlight for extended periods of time; this is based on the child's history of seizures as well use of medication that can had adverse side effects if exposed for prolonged periods. This item is appropriate to prevent adverse health events. The last item, the basket, is being requested to carry the child's medications during transport. However, this item would not be medically necessary as it is more of a convenience item. Medications can be carried by other means; it is not a requirement to carry them in this storage basket. 

The transit option and canopy should be considered as essential items that have been specifically requested by qualified healthcare providers to ensure safety of this vulnerable child. The above-mentioned accessories should be viewed as sound and reasonable options for this very involved child with neurological impairment requiring a safe transportation option and prevention of adverse health events.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left below the Knee Amputation (BKA)

Treatment: Continued acute rehabilitation admission

The insurer denied the continued acute rehabilitation admission.

The denial was overturned.  

This is a female patient with a medical history of hypertension, diabetes and peripheral artery disease. The patient underwent a left below knee amputation. The patient was subsequently transferred to a facility for acute rehabilitation. The patient was discharged home.  

The clinical records support that the patient required the level of medical acuity and rehabilitation intensity that necessitated acute rehabilitation admission. According to the clinical records, successful discharge home was delayed due to the patient's increased pain and wound drainage from the residual limb. A vascular surgery specialist was consulted and documented that "It would be reasonable to observe the patient for several more days prior to discharge." The patient was re-evaluated by the vascular surgeon (while on the acute rehabilitation service). The patient also continued to received physical therapy (PT) and occupational therapy (OT) during this time. The patient's staples were removed and the patient was discharged home.  

Based on the review of the medical record, discharge to a lower level of care (during the 72 hours currently under review) while being consulted by the vascular surgeon and continuing rehabilitation would not have been practical or in the best interest of the patient. Continued stay at the acute rehabilitation facility afforded the patient the optimal setting for specialty consultation, wound care and continued rehabilitation; with overall excellent outcome. 

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 continued acute rehabilitation admission should be overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory problems/chest pain 
Treatment: Inpatient hospital 

The insurer denied the entire hospital stay. The denial is upheld in whole. 

This case involves a patient with a history of polysubstance abuse, who presented to the hospital with left-sided breast pain, and breast mass. For the past year, the patient has noted palpable bilateral breast masses, which have changed in size, getting both smaller and more prominent. The masses were relatively tender to palpation, but the patient denies nipple discharge or fevers. 

No, the requested health service/treatment of inpatient hospital stay is not medically necessary for this patient. The patient primarily presented to the hospital with left breast pain concerning for a mass. There was no evidence of cardiac etiology for the chest pain, and the patient ruled out for an acute coronary syndrome with serial cardiac enzymes by the time the admission was completed. 

The patient experienced mild hypokalemia, which was rapidly treated and resolved. There was no evidence of severe cardiac arrhythmias caused by this hypokalemia. There is no evidence of severe dehydration based on the vital signs, laboratory studies, and physical examination. The abdominal ultrasound did not reveal any acute gastrointestinal abnormalities. The endoscopic evaluation by gastroenterology showed some gastritis. Alcohol withdrawal prevention measures were employed, while the patient was undergoing gastroenterology workup, and as soon as it was completed, the patient was discharged home. 

This presentation can be accomplished under a lower level of care, with no clear indications for inpatient hospitalization. There is no evidence of bowel obstruction, bowel ischemia, ileus, or the need for surgical intervention. The documentation does not support an inability to maintain oral hydration.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain - s/p laparoscopic appendectomy 
Treatment: Inpatient admission 

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

No, the Inpatient admission was not medically necessary. 

The patient is a male that presented upon transfer from an outside facility. CT done at an outside hospital (transferring facility) was concerning for appendicitis. The patient was evaluated in the ED and it was determined the patient would undergo appendectomy.  Perforated appendicitis was never suspected. The patient was admitted preoperatively to acute inpatient level of care. 

The patient underwent single-site laparoscopic appendectomy, which was completed the same day as the arrival in transfer. The operative report describes a straightforward procedure less than one hour in duration. The findings were acute non-perforated appendicitis confirmed by subsequent pathology report. The patient was discharged from the PACU (post-anesthesia care area) home within hours of the procedure. 

The care the patient would have received at a lower level of care would have been identical to that which he received. The most appropriate level of care for treatment of non-perforated acute uncomplicated appendicitis is ambulatory. Generally accepted practice guidelines for treatment of acute appendicitis without perforation in pediatric population is the procedure is considered outpatient with a short period observation in some cases. The care does not require acute inpatient level of care.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Thyroid cancer
Treatment: Tirosint 150MG OR CAPS
The insurer denied the Tirosint 150MG OR CAPS.
The denial is overturned.

The health plan should cover the proposed Tirosint.

This patient is a male with hypothyroidism and a history of thyroid cancer status-post thyroidectomy currently on Tirosint. He has tried and failed levothyroxine and Synthroid. 

This patient has tried and failed levothyroxine and Synthroid. This patient is currently stable on Tirosint and the American Thyroid Association recommend continuing on the same formulation of levothyroxine due to the differences in strength between brands/generics even at the same doses. By switching to an alternative formulation, this patient is at significant risk of hypothyroidism, which can cause serious adverse effects, including myxedema coma, which can be life-threatening. In addition, this patient has a history of thyroid cancer and if he develops hypothyroidism, the elevated thyroid stimulating hormone (TSH) level can stimulate growth of thyroid cancer cells. Therefore, yes, the health plan should cover the proposed Tirosint.