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

Diagnosis: Sleep Apnea. 
Treatment: Polysomnography; Sleep Study (codes 95810, 95811). 
The insurer denied coverage for Polysomnography; Sleep Study (codes 95810, 95811). 
The denial is upheld. 

The patient is an adult male with a history of obesity, with sleep related symptoms including restless sleep, nocturia, witnessed apneas, and excessive daytime sleepiness.  His Epworth Sleepiness Scale (ESS) is a 10 and his body mass index (BMI) is 38.4. He has undergone a home sleep apnea test (HSAT) that showed an apnea hypopnea index (AHI) of 22 and central apnea index (CAI of 6) consistent with moderate mixed sleep apnea (MSA). His provider is requesting an in-laboratory continuous positive airway pressure (CPAP) titration sleep study. 

The medical records indicate that his member has had a previous home sleep apnea test (HSAT) diagnostic for moderate sleep apnea (MSA); however, the medical records do not show that this member has failed or is not a candidate for a continuous positive airway pressure (CPAP) trial. 

The member already has a diagnosis of moderate sleep apnea (MSA), thus does not need an attended sleep study for diagnostic purposes. The medical records provided do not document any contraindications to a home trial of auto-PAP (Positive Airway Pressure) therapy, nor that he has had surgery for sleep apnea treatment. There is also no documentation for concern of obesity related hypoventilation syndrome, nor any patient comorbidities that would preclude a trial of an auto-titrating device at home. Thus, the requested service is not medically necessary for this member. 

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 Polysomnography; Sleep Study (codes 95810, 95811) services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cavity
Treatment: White glass with high gold content crown for teeth 7 and 8 (D2750)
The insurer denied the white glass with high gold content crown for teeth 7 and 8.
The denial is upheld.

This is an adult female patient requesting crowns on teeth numbers 7 and 8. Tooth number (#) 7 has two existing two-surface composite restorations on the mesial and distal surfaces and tooth #8 has an existing two-surface composite restoration on the distal surface. Tooth #8 also has a cavity on the mesial surface requiring a new two-surface composite restoration. The prior denial was due to not enough tooth structure being missing in either tooth for a crown to be needed.

The proposed treatment is not medically necessary.

Based upon the documentation presented (x-rays), there is not enough destruction of either tooth presented to warrant crowns. The two fillings on tooth #7 look fine and the only treatment indicated on tooth #8 is a 2-surface composite restoration. There is no documentation presented that would indicate treatment otherwise.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Diabetes
Treatment: Metformin ER (extended release)
The insurer denied: Metformin ER (extended release)
The denial is upheld.

This is an adult male with type 2 diabetes, hyperlipidemia, hypertension, and obesity. Request for Metformin ER (generic Glumetza) is under review. The prior request was denied as the patient has not tried and failed or had intolerance to or contraindication to metformin, metformin extended release (except generics for Fortamet and Glumetza). The provider is appealing this determination. The patient was intolerant to metformin. Glycated hemoglobin (A1C) was 8.3%. 

The health plan should not cover the proposed treatment. 

This request is for metformin tab ER 1000milligram (generic of Glumetza) for the treatment of type 2 diabetes. The American Diabetes Association does not recommend metformin ER (generic of Glumetza) over the preferred formulary alternative extended-release metformin. Metformin extended release is expected to be equally safe and effective as the requested metformin ER (generic of Glumetza) in this clinical situation. Therefore, no, the health plan should not cover the proposed metformin ER (generic of Glumetza).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nausea, vomiting, fatigue, dizziness. 
Treatment: Inpatient Hospital Admission. 
The insurer denied the inpatient hospital admission. 
The health plan's determination is upheld. 

The patient is a female who was admitted to the hospital for abdominal pain and diarrhea in addition to nausea and vomiting. She was evaluated and underwent an upper endoscopy which was negative for acute process. She was treated with intravenous (IV) fluid, pain medication, and antiemetics and was discharged in stable condition. 

At issue is the medical necessity of an inpatient hospital admission. 

I uphold the health plan's determination, in whole. 

An inpatient hospital admission was not medically necessary. 

The patient was hemodynamically stable. She had normal oxygenation, negative cultures, did not have significant electrolyte disturbances or change in kidney function, did not have cardiac arrhythmias, altered mental status, or persistent nausea and vomiting with dehydration. She was able to tolerate an oral diet, did not require total parenteral nutrition, and her work up was negative for acute process. 

An analysis of a database including 6,710 adults [69 percent (%) female, 80% age 18 to 55 years] evaluated in emergency departments for acute abdominal pain found that 85% did not require inpatient admission. [1] A retrospective analysis of 6,633 consecutive adults evaluated in an urban academic medical center emergency department for acute abdominal pain found that 64% did not require admission. [2] Analysis of 327 patients admitted to an observation unit for abdominal pain found that 91% were discharged within 24 hours. [3] Analysis of national hospital discharge data shows 33% of hospitalized adult patients with the various principal diagnoses for abdominal pain were discharged in 1 day. [4] Therefore, the inpatient level of care was not medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Rheumatoid Arthritis.
Treatment: Orencia SQ (subcutaneous) 125mg (milligrams).

The insurer denied: Orencia SQ (subcutaneous) 125mg (milligrams).  The denial is upheld.

This patient is an adult female with history of systemic lupus erythematosus (SLE) and rheumatoid arthritis. She has previously tried and failed conventional disease modifying anti-rheumatic drug (DMARD) methotrexate, hydroxychloroquine and azathioprine along with biologic DMARD (disease modifying anti-rheumatic drug) Benlysta. The request for Orencia was initially denied due to the patient not having tried and failed formulary alternatives Enbrel, Humira, Rinvoq and Xeljanz. Also, the patient has not tried and failed secondary preferred product Kevzara. The reason the provider is appealing the determination is because the provider indicates that the patient is unable to do tumor necrosis factor (TNF) inhibitor such as Enbrel and Humira, given patient's underlying lupus. 

The health plan should not cover the proposed treatment. 

The patient does have history of rheumatoid arthritis and lupus. Given the patient's underlying lupus, the use of a TNF (tumor necrosis factor) inhibitor such as Humira or Enbrel would be contraindicated in this patient as studies have shown they can cause drug-induced lupus. That being said, other formulary alternatives including Rinvoq, Xeljanz and Kevzara would not be contraindicated for this patient. There are clinical studies showing efficacy in the treatment of lupus with JAK kinase inhibitors such as Rinvoq and Xeljanz. These would also treat the patient's rheumatoid arthritis. There are no clinical studies showing that the requested medication Orencia would be more efficacious or safer than the preferred formulary alternatives.  Therefore, the health plan should not cover the proposed treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Depression/anxiety.
Treatment: Social Day Care (SDC) Services: Total of 2 Days per Week.

The insurer denied Social Day Care (SDC) Services: Total of 2 Days per Week.  The health plan's determination is overturned.

This is a case review for a female with medical history notable for depression and anxiety. 

The patient's physician provided a letter of support for this appeal. The letter states that the patient is elderly and suffers from multiple medical and mental health conditions. Her mental health has declined recently, and the physician recommends increased socialization as part of her treatment. Therefore, they request additional time in social day care.

The requested Social Day Care (SDC) Services: Total of 2 Days per Week is medically necessary for this patient.

The patient has had a recent worsening of her depression and cognition. Her physician is recommending an increase in social day care to help as part of her treatment plan. The requested service will have medical benefit for the patient if it improves her cognitive function, as suggested by the physician support letter. Therefore, the requested Social Day Care (SDC) Services: Total of 2 Days per Week is medically necessary for the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Infertility
Treatment: Artificial Insemination (IUI)
The insurer denied: Artificial Insemination (IUI)
The denial is overturned.

The patient is an adult female with a diagnosis of infertility of 2 years duration. Hysterosalpingogram showed a normal cavity and a patent left fallopian tube. However, the right fallopian tube showed a mid-ampullary block.

The requested Artificial Insemination (IUI) is medically necessary.

The patient has a diagnosis of infertility. She has a patent left fallopian tube. She has 2 options for treatment: either proceeding with in vitro fertilization or with intrauterine insemination with left-sided ovulation. In other words, the patient will be given a medication to stimulate her ovaries. An ultrasound will be performed and if she has a mature follicle on the left side, she will undergo an intrauterine insemination. Patients who had one of their tubes removed are able to conceive routinely.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: COVID-19. 
Treatment: Inpatient Hospital Stay. 

The health plan denied the Inpatient Hospital Stay. 
The determination is upheld. 

This is a male patient who presented for chest pain, lightheadedness and syncope. He tested positive for coronavirus 2019 (COVID-19) at the emergency room. He was then admitted for further management. He remained stable and did not have any further episodes of syncope. He was then discharged home in a stable medical condition.
At issue is the medical necessity of an inpatient admission. 

The admission to an acute level of care was not medically necessary. 

The patient presented to the hospital for one episode of syncope and chest pain. He was diagnosed with COVID-19. However, he was hemodynamically stable and did not have respiratory distress. He did not require supplemental oxygen or mechanical ventilation and did not require any invasive procedures or complex treatment regimens. The provided care included monitoring and evaluation by cardiology. The care was possible at a lower level of care. 
Therefore, an acute level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned in Part

Trauma
Inpatient hospital

Diagnosis: Traumatic brain injury and a left ventriculoperitoneal shunt.
Treatment: Inpatient stay.
The insurer denied the inpatient stay. The health plan's determination is overturned in part. 

The patient is a female with a history of traumatic brain injury and a left ventriculoperitoneal shunt who had undergone a wound revision with mesh cranioplasty performed by the plastic surgery team. Subsequently, a baclofen trial was conducted with neurosurgery service. She presented to the hospital with a right-sided scalp wound associated with delayed healing. Specifically, the suture line from the previous plastic surgery closure performed was affected.

Two of the days in question were medically necessary at the inpatient level of care. During this time period, this patient remained severely confused and oriented only times one. It was reported that the patient had increased sleepiness and was unable to answer simple questions. The patient was not withdrawing to noxious stimuli. The patient was still receiving intravenous antibiotics per infectious disease service recommendations. The plastic surgery team was still monitoring closely the scalp flap. Due to the complexity of care during this period of time, an acute inpatient level of care was indicated.

For the remainder of the stay, this patient remained in relatively stable clinical condition. This patient remained afebrile and hemodynamically stable and was not undergoing any kind of treatment that would require admission at the acute inpatient level of care. The patient was able to open her eyes spontaneously and was able to track objects. During this period of time, the patient was waiting for a craniotomy. Based on the clinical condition, a lower level of care was most appropriate.
Appeal type: Medical necessity
Decision: Upheld

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

This is a female patient with no past medical history (PMH) who was admitted with complaints of (c/o) a sore throat associated with a fever. Imaging studies included a chest x-ray (CXR) which showed possible right lower lobe (RLL) community acquired pneumonia (CAP), a computed tomography (CT) scan of the abdomen/pelvis (A/P) showed no acute pathology, a CT scan of the chest showed no pneumonia. The patient was diagnosed with CAP and treated with intravenous (IV) antibiotics and intravenous fluids (IVF), but was eventually diagnosed with viral pharyngitis and antibiotics were discontinued. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with complaints of (c/o) a sore throat associated with fever. The patient was initially diagnosed with CAP and treated with antibiotics. The patient was hemodynamically stable, did not require intubation, non-invasive positive pressure intubation, did not have any severe respiratory distress, tachypnea, use of accessory muscles in neck, severe intercostal retractions, cyanosis, new altered mental status (AMS), hypoxia, and the CURB-65 [confusion, uremia, respiratory rate, blood pressure (BP), age greater than or equal to (>=) 65 years) score was 0, indicating a low-risk patient. The pneumonia severity index was risk class I, indicating that outpatient therapy was reasonable. The patient was ultimately diagnosed with viral pharyngitis and treated with IV fluids and antibiotics were discontinued, and overall care could have been safely provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Slurred speech and weakness
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.


This is a female patient who was admitted to the hospital for the diagnosis of slurred speech and weakness. She has a medical history significant for thyroid cancer status post partial thyroid resection and chronic anemia. She presented to the emergency department after an episode of acute onset left-sided weakness. She was teaching a high school class and was feeling well when she suddenly developed lightheadedness, left arm numbness, right arm numbness, blurred vision, a headache, chest pain, and slurred speech. She later developed left leg numbness. Others noticed a left-sided facial droop. She had an episode of urinary incontinence while in the computed tomography (CT) scanner in the emergency department. She was confused for several hours before returning to baseline. At the time of the admission history and physical, the patient was hemodynamically stable and feeling better. She denied any acute concerns or neurologic symptoms at the time. She was admitted for further care.
The patient was admitted with the concern of transient ischemic attack, cerebrovascular accident, or hypoglycemic seizure. She underwent imaging of the head. Her stroke scale was zero on admission. She was started on aspirin and atorvastatin. Regular neuro checks were ordered. An magnetic resonance imaging (MRI) and an electroencephalogram (EEG) were ordered and a neurologist was consulted for input. The patient's MRI and EEG were negative. Blood work was notable for mild peripheral eosinophilia, and hematology recommended follow up testing. She was back to her baseline and discharged home and stable condition. The discharge diagnosis was complex migraine. At issue is the medical necessity of an inpatient stay.

The requested health service of inpatient stay has not been demonstrated to be medically necessary for this patient.
The patient presented as a stroke alert after an acute onset of neurologic symptoms including weakness and facial droop. She underwent an expedited work up in the hospital which was negative for a seizure or cerebrovascular disease. Her symptoms were ultimately attributed to a complex migraine. The Milliman Care Guidelines (MCG) 26th edition would recommend observation level of care for this type of presentation. The patient did not have any evidence of infection of the central nervous system, altered mental status that was severe or persistent, aneurysm, neurologic findings that were severe or persistent, ataxia, or alternative diagnosis such as multiple sclerosis or Parkinson's disease. The patient underwent the appropriate diagnostic testing which was normal and she was deemed safe for discharge. The unrelated finding of mild peripheral eosinophilia does not increase the patient's medical complexity to warrant inpatient level of care. A lower level of care was appropriate for the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Myocarditis. 
Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is overturned. 
 
This patient presented to the hospital complaining of chest pain.  Past medical history was significant for learning impairment due to anoxic brain injury at birth.  Pain was accompanied by palpitations, nausea and vomiting. On arrival to the emergency department vital signs were stable (Blood Pressure 133/87, Pulse 84).  Physical examination revealed no significant abnormality. 12 lead electrocardiogram (ECG) demonstrated sinus rhythm with incomplete bundle branch block and no significant segment (ST) or T wave changes.  Serum blood tests were markedly abnormal with troponin 25 and creatinine kinase 1274.  He was admitted to the hospital for observation and testing.  Echocardiogram demonstrated a normal left ventricular ejection fraction.  Cardiac catheterization demonstrated no evidence of coronary artery disease.  He was diagnosed with myocarditis and treated with colchicine and non steroidal anti inflammatory medications.  He was ultimately discharged home with plans for an outpatient cardiac magnetic resonance imaging (MRI). 

Positive troponin levels were noted and he was admitted for further work up. His pretest probability of coronary artery disease was low. (Reference 1)  Utilizing the HEART (evaluates cardiac risk) score he was considered low risk for major adverse cardiac events in the setting of non-ST elevation myocardial infarction (NSTEMI). (Reference 2) Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation. 

However, the patient had a high serum troponin level and was diagnosed with myocarditis. Additional observation and management of myocarditis was necessary. Up to 9% of patients presenting with myocarditis can develop fulminant myocarditis resulting in lethal ventricular arrhythmia and cardiogenic shock. (Reference 3). These findings are concerning and warrant management and evaluation at a higher level of care. Serial troponin measurement, echocardiography and ischemia work up were warranted prior to discharge. 

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 inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Respiratory System/Other/Acute respiratory failure with hypercapnia, COPD with exacerbation, other lack of coordination
Skilled Nursing Facility
The health plan has denied the requested treatment, skilled nursing facility, as not medically necessary. The health plan's determination is upheld.
 
This is a male with chronic obstructive pulmonary disease (COPD) and respiratory failure who was admitted to a Skilled Nursing Facility (SNF) for rehabilitation. Initially, he was dependent/maxA functionally and is currently supervision level.

At issue is the medical necessity of a skilled nursing facility.
The health plan's determination is upheld, in whole.

The skilled nursing facility is not medically necessary.
The patient is supervision level of care with his activities of daily living (ADL's) and is supervision level of care for transfers and ambulation. He can be discharged with home therapies.
Appeal type: Medical necessity
Decision: Upheld


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

The patient is a female with a migraine disorder who presented to the hospital with double vision. The double vision was present for approximately 2 weeks. The patient also complained of an intense headache. The patient was admitted to the hospital and underwent an magnetic resonance imaging (MRI) / MRV (magnetic resonance venography) of the brain. A lumbar puncture was also requested by the physicians, but the patient declined. 

An acute inpatient hospitalization was not medically necessary for evaluation of an isolated cranial nerve palsy. The patient has a long history of migraine and complained of double vision. A provider was concerned about a left cranial nerve palsy. The patient was sent to the hospital for emergent workup. Generally, an isolated cranial nerve palsy does not require urgent hospitalization for evaluation and treatment. In the hospital, the patient underwent an MRI of the brain and an MRV of the brain that was normal. A lumbar puncture was suggested but declined. The patient was subsequently discharged home with outpatient follow-up. An acute inpatient admission is not medically necessary to perform an MRI or MRV of the brain.