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

Diagnosis: Drug Overdose
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

This patient is an adult female with a history that includes schizophrenia and polysubstance abuse. She presented complaining of body aches and asking to see a psychiatrist. She reported auditory hallucinations. She was found to have a blood pressure of 155/112 in the emergency department. Blood pressure was 126/70 after monitoring in the emergency department. While in the emergency department, the patient took pills Biktarvy, metronidazole, Lipitor, and another unknown bottle. 
The patient's vital signs were stable, and she was afebrile. Her heart rate was 93. Her respiratory rate was 20 and oxygen saturation was 97 percent. The patient's exam was remarkable for appearance of intoxication on cocaine. Pertinent labs included white blood cell count 3.3, hemoglobin 10.6, and platelet 125. Urine toxicology was positive for cocaine and cannabinoids. Chest x-ray revealed no acute disease. Electrocardiogram (EKG) shows normal sinus rhythm. 
The patient was admitted with suicide attempt with drug overdose. On day # (number) 4, psychiatry consult recommended initiation of risperidone. On day #5, the patient was recommended for inpatient psychiatric admission.

The proposed treatment was not medically necessary.

This patient has a history of polysubstance use and was admitted after a suicide attempt with drug overdose in the emergency room using Biktarvy, metronidazole, and Lipitor. 
She did not ingest medications with potential for dangerous arrhythmia. The patient was hemodynamically stable and afebrile. She did not have hypoxemia. She did not have an 
arrhythmia on electrocardiogram. She did not have severe electrolyte abnormalities. Labs were remarkable for positive urine toxicology. The patient did not have active comorbid conditions. 
The patient was admitted with planned psychiatry consultation. Psychotropic medications were started. The patient remained clinically stable during the hospital stay and was recommended for inpatient psychiatry on day #5. The patient did not have symptoms that required an acute inpatient level of care. The requested inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld



Diagnosis: Migraine.
Treatment: Butalbital/Acetaminophen/Caffeine.
The insurer denied Butalbital/Acetaminophen/Caffeine.
The health plan's determination is upheld. 

The patient is a male with chronic migraines. Treatment with Butalbital/Acetaminophen/Caffeine is the subject of this review. The drug was denied as off-label for treatment of migraine. The provider appealed the determination. The member is prescribed nadolol for the prevention of migraine and the treatment of anxiety. The patient is having near-daily headaches. 

Butalbital/Acetaminophen/Caffeine is not medically necessary. 
Butalbital/Acetaminophen/Caffeine is not Food and Drug Administration (FDA) approved or compendia supported for the treatment of acute migraine. Although butalbital-containing products commonly are prescribed for migraine, no evidence in the literature demonstrates their benefit over other triptans, gepants, or placebos. When used in the treatment of migraine butalbital may result in frequent adverse consequences of butalbital-containing products for migraineurs, such as poor migraine control, disability, drug-induced headaches, and withdrawal symptoms.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This adult female patient was hospitalized for chest pain and shortness of breath. Her past medical history was significant for hypertension and family history of premature coronary artery disease (CAD). Her brother had coronary stents in his 40s. The patient's vitals revealed an initially elevated blood pressure of 184/90. Exam revealed mid sternum and epigastric tenderness to palpation. Electrocardiogram (EKG) was remarkable for a 
nonspecific T-wave abnormality. Labs showed creatinine of 1.38 and blood urea nitrogen (BUN) of 24. Treatment included Tylenol, aspirin, intravenous Pepcid, and Maalox and the patient had a good response. Her acute kidney injury (AKI) improved, and she was started on losartan for her hypertension. 
By day #3, the patient had undergone an echocardiogram and left heart catheterization. The latter revealed multi-vessel nonobstructive coronary artery disease and the patient was treated medically. Metoprolol was added for transient tachycardia that occurred during the heart catheterization. She remained medically stable and was discharged the following day. The requested coverage for inpatient hospital admission was denied based on the patient's policy, and the patient is appealing the decision.

The proposed treatment was not medically necessary.

Based on the peer-reviewed medical literature, including the provided Milliman Care Guidelines (MCG) guideline, criteria for inpatient admission are not met, including hemodynamic 
instability, respiratory distress, pulmonary edema, angina with acute coronary syndrome, chest pain that is indicative of a serious cardiac condition like pulmonary embolism or aortic dissection, acute myocardial infarction, pneumonia, hypertension requiring inpatient hospitalization, or any other medical condition, symptom or finding for which inpatient hospitalization is considered appropriate. In this particular case, there was no clinical decline or inadequate response to treatment that required inpatient hospital stay. The care the patient received, including urgent cardiac catheterization with transient tachycardia responding to beta-blocker, is routinely provided safely and effectively at a lower level of care. Also, there was a delay in progression of care due to delay in performing the heart catheterization or discharging the patient and considering performing the service on an ambulatory basis. There was no medical condition documented to explain why there was a delay, other than the hospital's weekend schedule. Therefore, based on the submitted information and the current published medical literature, the proposed treatment was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

This is a case of a female admitted for diagnosis of acute asthma exacerbation. The patient presented with chief complaint of shortness of breath and cough. She had past medical history of asthma. Vital signs demonstrated temperature 98.3F (degrees Fahrenheit), pulse 90, respiratory rate 20, blood pressure 122/69 and O2 saturation 94% (percent). Physical exam showed no altered mental status or acute distress. White blood cell count was 10.6 with hemoglobin 15.4. Creatinine was 0.61. Chest x-ray was normal. Symptoms were thought to be related to acute exacerbation of asthma possibly triggered by viral upper respiratory infection or allergies in the setting of noncompliance with asthma medications. 

The inpatient hospital admission was not medically necessary for this patient. The patient in this case was treated for asthma exacerbation but did not have tachypnea, use of accessory muscles, diaphoresis, inability to speak in full sentences or pulseless paradoxes. She had developed tachycardia during the hospital stay but thought this was related to albuterol treatments. She did not require workup for additional causes. Chest x-ray did not show evidence of pneumonia and there was no leukocytosis. There was no progression of deterioration despite intensive therapy. There was no depressed consciousness, bradycardia or myoclonus to suggest hypercapnia. She was treated and improved with standard therapies including bronchodilator therapy and systemic steroids.
Although the patient required services in the hospital setting the monitoring, diagnostics testing and therapeutic interventions prescribed could have been rendered at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary tract infection. 
Treatment: Inpatient admission. 
The insurer denied coverage for inpatient admission. 
The denial is upheld. 
 
The patient was admitted for dysuria and flank pain. The patient was diagnosed with urinary tract infection and was started on intravenous (IV) fluid and antibiotics. Computed tomography (CT) Abdomen/Pelvis showed hepatic cyst and enlarged mildly heterogenous postpartum uterus. Her condition improved and was discharged in stable condition. 

Observation level of care is appropriate. 

The patient was admitted for urinary tract infection (UTI). During this hospital stay, the patient was hemodynamically stable. She did not have severely abnormal vital signs or severe sepsis which required inpatient level of care. 

Patients with an uncomplicated UTI (e.g., no fever, no flank pain) are treated as outpatients (if no other indication for admission is present). [1,2]  Some patients with an uncomplicated upper UTI (e.g., hemodynamically stable, able to maintain hydration orally) do not require inpatient admission. [3] Database analysis including 572,479 adult visits to an emergency department for UTI found an inpatient admission rate of 17%.[4] Another analysis of a national database found that out of more than 1.5 million visits to the emergency department for pyelonephritis, 27% were admitted to inpatient care.[5] 

Therefore, per standard of care and evidence-based literature, inpatient admission was not medically necessary and a lower level of care was more appropriate. 

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 hospital stay is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

This is a female patient with a history of chronic migraines who presented to the emergency room (ER) with complaints of headaches for 1 month not relieved with usual abortive medications. She also had associated nausea and vomiting and came to the emergency room (ER) for abortive therapy.  A computed tomography (CT) scan of the head showed no acute findings and was unchanged from prior CT scans. A magnetic resonance imaging (MRI) scan of the brain showed no acute infarction or intra parenchymal enhancement to suggest metastasis. MRI of the neck and head showed no significant stenosis. She had a sodium of 126. 
She was admitted with a diagnosis of hyponatremia, acute on chronic and it was thought that she had Syndrome of Inappropriate Antidiuretic Hormone (Secretion) (SIADH). Labs were drawn and intravenous (IV) fluids were held. For chronic migraine, Topamax was continued and she was being monitored. Neurosurgery was consulted and she was seen by neurosurgery. It was felt that her meningioma was stable and no acute neurosurgical intervention was required. She was seen by neurology who stated that her headache severity had reduced from more than 10 to 3 after 2 rounds of migraine cocktail and dexamethasone. 
By morning, the patient stated that her headache was about 4 out of 10 and she was feeling better. Her blood pressure was controlled, and she had a normal physical exam. The sodium had improved to 132 after fluids were held. She had received intravenous (IV) iron repletion and was to continue on oral medications. The rest of her exam was unremarkable. She was doing much better and did not have any additional headaches. She was evaluated by physical therapy and recommended for discharge home with outpatient physical therapy (PT). She was discharged in stable condition. At issue is the medical necessity of an inpatient stay.

Admission at an inpatient level of care was not medically necessary.
The patient presented with an intractable migraine and though she had stable neurological signs and no acute findings on imaging, she was noted to have hyponatremia. She was reviewed by neurosurgery and there was no need for any acute neurosurgical intervention. By the following morning, her headache and sodium had improved. She had no migraine related complications nor any seizures or complications related to hyponatremia. She was also reviewed by neurology and advised to continue Topamax and to arrange outpatient long term follow-up of her headaches. The remainder of her stay was uneventful.
Records show that the headaches improved within the observation period; she did not have persistent vomiting, she had no acute findings on computed tomography (CT) or magnetic resonance imaging (MRI) of the brain, and a normal neurologic examination and no seizures. As a result, the care could have been provided at a lower level.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: breast cancer.
Treatment: chemotherapy. New Century Health Regimen: Tratzsumab Products: Pertuzumab and Phesgo.
The insurer denied New Century Health Regimen: Tratzsumab Products: Pertuzumab and Phesgo.
The health plan's determination is overturned. 

This is a female with right breast cancer. The cancer was estrogen receptor (ER) +/ progesterone receptor (PR) +/ human epidermal growth factor receptor 2 (HER2) 2+ (ISH (in situ hybridization) negative) at diagnosis. The patient underwent neoadjuvant cytotoxic therapy and underwent mastectomy. The surgical pathology demonstrated cancer with 7/8 lymph nodes involved.

The New Century Health Regimen: Tratzsumab Products: Pertuzumab and Phesgo is medically necessary for this patient.
In this patient with high risk disease and suboptimal response to neoadjvuant systemic therapy without HER2 targeting therapy, the use of adjuvant therapy with pertuzumab+trastuzumab (Phesgo) is a category 1, preferred therapy. The guidelines state "...Considering the unprecedented improvement in overall survival (OS) in the metastatic setting and the significant improvement in pathological complete response rate (pCR) seen in the neoadjuvant setting, the National Comprehensive Cancer Network (NCCN) Panel considers it reasonable to incorporate pertuzumab into the above adjuvant regimens, if the patient did not receive pertuzumab as a part of neoadjuvant therapy...".
This is echoed by the authors of UpToDate, who state "...The APHINITY trial... suggests that in these higher-risk tumors, the addition of pertuzumab reduces the risk of tumor recurrence. We also extrapolate from the neoadjuvant setting, in which the addition of pertuzumab in high-risk disease improves the rates of complete pathologic response. ..".
In the phase III APHINITY trial, over 4800 patients with node-positive or high-risk, node-negative, HER2-positive, operable breast cancer were randomly assigned to chemotherapy and trastuzumab with either pertuzumab or placebo. Preplanned subgroup analysis showed that pertuzumab improved the three-year disease-free survival (DFS) among those with node-positive disease. These results were particularly strong in patients such as this one with hormone receptor positive disease.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Other - Palpitations
Treatment: Inpatient Admission

The health plan denied: Inpatient Admission
The determination is: Upheld

The patient is a female with a past medical history significant for coronary artery disease (CAD), atrioventricular (AV) block status/post pacemaker, meningioma status/post resection, obstructive sleep apnea (OSA), hypertension, and hyperlipidemia who presented to the emergency department (ED) for evaluation of dizziness and palpitations occurring for 1 day. Her vital signs in the ED were stable, and her chest x-ray was clear. Her permanent pacemaker (PPM) was interrogated in the ED and showed no events. The patient was administered intravenous (IV) fluids in the ED and admitted overnight for monitoring on telemetry. She was then discharged home the following day. At issue is the medical necessity of the inpatient admission.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of inpatient admission is not medically necessary for this patient.

The patient was hemodynamically stable, the permanent pacemaker interrogation was normal, and there was no evidence of acute coronary syndrome (ACS). Furthermore, the patient clinically improved after administration of IV fluids in the ED. An alternate level of care would have been medically appropriate and safe in the management of this patient's symptoms as supported by the 2017 American College of Cardiology (ACC)/American Heart Association (AHA)/Heart Rhythm Society (HRS) guideline for the evaluation and management of patients with syncope[1].
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute colitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission 

The denial is upheld.

The patient had a history of cardiac disease, diabetes, and celiac disease. The patient presented with abdominal pain and diarrhea. The patient was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. There was no leukocytosis. A Computerized Tomography (CT) scan showed acute colitis. Stool testing was ordered, and pain medications were given. The patient's symptoms improved and the patient was able to tolerate a diet.

Medical necessity was determined using Milliman Care Guidelines (MCG) M-170 for Gastroenteritis. Clinical indications for admission include having a severe infection such as bloody diarrhea, peritoneal signs, hemodynamic instability, severe dehydration, severe electrolyte abnormalities, or an inability to maintain oral hydration after observation care. The patient did not have these conditions.

This patient had evidence of colitis on the CT scan. The patient could have been treated for the gastroenteritis with intravenous (IV) hydration and pain medications in the Emergency Room (ER) as an outpatient. If antibiotics were felt to be necessary, the patient could have been treated with a course of oral antibiotics as an outpatient. The patient did not meet MCG criteria for admission for Gastroenteritis. The health care plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary. 

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

The medical necessity for the inpatient admission from is not substantiated.
Appeal type: Medical necessity
Decision: Upheld



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

This is a male patient with a history of alcohol abuse, hypertension, gastrointestinal bleeding, atrial fibrillation (AF) (not anticoagulated) and congestive heart failure who presented to the emergency room with an episode of syncope. He was standing at the mall when he suddenly felt hot and then fell to the ground. A head computed tomography (CT) scan was performed which showed a small hypodensity in the left basal ganglia, possible age indeterminate infarction. He was admitted and seen by neurology who recommended magnetic resonance imaging (MRI). An MRI was performed with findings consistent with chronic rather than an acute cerebrovascular accident (CVA). An echocardiogram (ECHO) showed normal left ventricular size and function with mild concentric left ventricular hypertrophy. There was no significant valve regurgitation or stenosis. He complained of hip pain. X-rays were negative for a fracture. The patient remained stable hemodynamically. His syncope was felt to be vasovagal. Anticoagulation was recommended, but declined by the patient. He was discharged. Ziopatch was recommended, to assess the AF burden. At issue is the medical necessity of an inpatient admission.

An inpatient admission is not medically necessary. The patient presented following a syncopal fall but was hemodynamically stable throughout his course and had no acute cardiac findings. He had completed an evaluation which ruled out a serious injury or cerebrovascular accident (CVA) within the first 24 hours of hospitalization. Hospitalization could have been handled at a lower level of care.
Per Milliman Guidelines, inpatient admission is indicated for patients with syncope who have "hemodynamic instability, altered mental status that is severe or persistent, cardiac disease or finding that indicates necessity of immediate intervention (eg, automatic implantable cardioverter defibrillator (AICD) placement, electrophysiologic study, surgery, prolonged telemetry monitoring), dehydration that is severe or persistent, or syncope causing injury requiring hospitalization." In this case, the patient had syncope with a fall. However, he underwent testing including a head computed tomography (CT) scan, magnetic resonance imaging (MRI), and hip x-rays which did not show significant injury. He did not have any cardiac or other clinical findings to indicate the need for an inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Family history of breast cancer
Treatment: Gene Test (BRCA)
The insurer denied: Gene Test (BRCA)
The denial is upheld.

The patient in this case is an adult female with no personal history of cancer. The patient's family history is notable for a paternal aunt diagnosed with breast cancer. The aunt's age at 
diagnosis is not provided. There is no other family history of cancer. Multi-gene genetic testing was performed. At issue is BRCA testing.

The proposed gene test was not medically necessary.

The provided records do not indicate that this patient met standard criteria for BRCA testing. While her aunt, who is a close blood relative, was diagnosed with breast cancer, her age at 
diagnosis is not provided. Therefore, it cannot be concluded that this patient has a close blood relative who met criteria for BRCA testing. Given that and her lack of a personal history of cancer, the BRCA testing done in this case was not medically necessary.