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

Diagnosis: Osteoporosis. 
Treatment: Tymlos (abaloparatide) to treat osteoporosis. 

The insurer denied coverage for Tymlos (abaloparatide) to treat osteoporosis. 

The denial is upheld. 

The patient is a female with a diagnosis of osteopenia (according to bone density scan performed). The provider requested coverage for 80 micrograms (mcg) of Tymlos at bedtime to treat her osteoporosis. The insurer has denied coverage for Tymlos (abaloparatide) to treat osteoporosis, as not medically necessary. In a Final Adverse Determination letter, they stated that the patient has not taken and had a poor response to the medication on the preferred drug list. There must be documentation that the patient has tried Prolia. 

The patient has osteopenia and treatment is medically necessary. The treatment of osteopenia is as follows: 

- Bisphosphonates are preferred as initial therapy because of their efficacy, favorable cost, and the availability of long-term safety data. (Up to Date) 
- For patients who cannot receive or are intolerant of oral and IV [intravenous] bisphosphonates, the choice of agent depends on risk of fracture. 
- For patients at very high risk of fracture, an anabolic agent (like Tymlos) or Prolia is suggested. 

Tymlos is a human parathyroid hormone analog indicated for the treatment of postmenopausal women with osteoporosis at high risk for fracture. In addition, "Cumulative lifetime duration of abaloparatide (and/or teriparatide) therapy should not exceed 2 years." (Lexicomp: abaloparatide- drug information). 

Prolia is indicated for the treatment of postmenopausal women with osteoporosis at high risk for fracture, defined as a history of osteoporotic fracture, or multiple risk factors for fracture; or patients who have failed or are intolerant to other available osteoporosis therapy.  With regard to duration of treatment, treatment can extend to 10 yrs. (Lexicomp; denosumab: drug information) 

Based on the above, this patient could use either the Bisphosphonates, or Prolia. Note that Prolia is a subcutaneous injection given every 6 months. In other words, it is much easier than the administration of Tymlos which is a daily subcutaneous injection. 

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. Tymlos (abaloparatide) to treat osteoporosis is not considered medically necessary for this patient. 

The insurer's denial of coverage for Tymlos (abaloparatide) to treat osteoporosis is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Uterine fibroids.
Treatment: Inpatient admission.

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

The patient is a female with a history of symptomatic uterine fibroids, with a reported uterine size of 16 weeks. She was admitted to the hospital for an abdominal myomectomy. The procedure was performed without complications with a 1500 cubic centimeters (cc) blood loss. Cell saver treatment delivered 500 cubic centimeters back to the patient. The patient was admitted as an inpatient for the diagnosis of acute blood loss anemia. She recovered uneventfully and was discharged. 

The Health Plan has denied coverage of the admission due to lack of significant co-morbidities or complications. The provider has appealed on the basis of acute blood loss anemia.

No, the proposed inpatient admission was not medically necessary.

The medical records and medical literature were thoroughly reviewed. The patient underwent an uncomplicated abdominal myomectomy. The procedure time was not longer than expected. According to the medical records the patient was afebrile in the post-anesthesia care unit (PACU). Her vital signs were normal and stable during the post-anesthesia care unit (PACU) stay. The post-op hemoglobin and hematocrit (H&H) were 12.6/36.6. The patient required intravenous (IV) pain medications for a short period of time, and her pain was satisfactorily controlled with oral non-narcotic pain medications on the first postoperative day. According to the inpatient records the patient had progressed to a normal diet, was ambulating without difficulty, had normal bowel sounds and a nontender abdomen by the first postoperative day. She was voiding normally. The post-operative period in the post-anesthesia care unit (PACU) was not significantly complicated and the patient's condition was stable, with normal vital signs on discharge to the inpatient service. The patient did not have serious co-morbidities to be a complicating factor in her preoperative and postoperative care plans. The patient was likewise stable on admission from the post-anesthesia care unit (PACU). Stable postoperative patients who have undergone uncomplicated procedures such as abdominal myomectomy do not necessarily require acute inpatient admission after their discharge from the post-anesthesia care unit (PACU). They may be reliably observed, by the standard of care, in a lesser level of care prior to their eventual discharge. Therefore, the patient could have been reliably discharged from the post-anesthesia care unit (PACU) to a lesser level of care rather than the acute inpatient service. Therefore, the treatment did not have to be provided in an acute inpatient setting and was not medically necessary.

The patient could have been reliably discharged from the post-anesthesia care unit (PACU) to a lesser level of care rather than the acute inpatient service. Therefore, the treatment did not have to be provided in an acute inpatient setting and was not medically necessary. Therefore, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Concern for small bowel lymphoma.
Treatment: Wireless Capsule Endoscopy.
The insurer denied the Wireless Capsule Endoscopy.
The denial is upheld. 

The patient is a female who is being evaluated for small bowel lymphoma. The patient had undergone a colonoscopy, an endoscopy, and an upper GI (gastrointestinal) series with small bowel follow through. The patient has been on chronic immunosuppressive therapy.

No, the Wireless Capsule Endoscopy is not medically necessary.
The standard accepted indications for a capsule endoscopy are as follows:
1) Chronic Occult GI (gastrointestinal) Bleeding
2) Significant Intermittent GI (gastrointestinal) Bleeding
3) Crohn's disease
4) Lynch syndrome
5) Suspected Small Bowel Neoplasm

The test is indicated for the detection of neoplasms of the small bowel, when the diagnosis has not been previously confirmed by other studies. The patient must be symptomatic for a neoplasm (e.g., GI [gastrointestinal] bleeding), or have a documented polyposis syndrome that is associated with small bowel neoplasia, or there is other history suggesting the presence of small bowel neoplasia and other diagnostic testing to assess these symptoms must have been performed. WCE (wireless capsule endoscopy) may be indicated for the detection of small bowel neoplasm in those patients with documented intussusception of the small bowel, without established etiology. In such instances, the requirement for prior examination by upper and lower endoscopies may be waived. This was not met, as while the provider was concerned for a small bowel lymphoma, there was no basis for this concern provided in the records.

The indications that are the standard of care were not met, because while the provider was concerned for a small bowel lymphoma there was no basis for this concern provided in the records.

The patient was not in the pediatric age range. There was no notation of anemia or bleeding. Significant intermittent gastrointestinal bleeding was not noted as an indication or concern. Crohn's disease was not noted as an indication or concern. Lynch syndrome was not noted as a concern.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental caries
Treatment: Extraction of Impacted Tooth with Some Bone, Tooth #32 (Pre-service)
The insurer denied the Extraction of Impacted Tooth with Some Bone, Tooth #32 (Pre-service)
The denial is overturned. 

The patient is a female requesting dental benefits for the extraction of tooth #32 (partial boney impaction).  X-rays reveal caries on the mesial aspect of the tooth. The roots of tooth #32 curved distally and the position of the bone rises sharply as you go distally to encompass the coronal aspect of the tooth.

Yes, the proposed treatment of extraction of the partially boney impacted tooth #32 is medically necessary.

As seen on the x-ray, tooth #32 has caries on the mesial.  The recommendation to remove this tooth is the best option as the position of the tooth does not lend itself to easy hygiene care.  The x-ray shows the sharp rise of the bone around the coronal aspect of the tooth as you go towards the distal aspect of the tooth. The roots are also curved distally with this morphology; typically this type of extraction can be challenging and is considered partially boney because of the anatomy on the distal of the tooth.

In addition, tooth #32 needs to be extracted as the opposing tooth #1 is not present in the mouth; therefore, tooth #32 is not functional and it has decay present.  The indication is to have the tooth extracted.  It will not be a routine extraction because of the morphology of the tooth and the position of the tooth in the arch as the bone level on the distal aspect of the tooth is considered.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bladder Cancer.
Treatment inpatient hospital admission.
The insurer denied coverage for inpatient hospital admission.
The denial is upheld.

This patient has a history of bladder Cancer. The patient presented to the hospital for a planned elective resection of a large multi-focal bladder tumor. The patient had his scheduled procedure and appeared to tolerate procedure well. The patient was given 1 unit packed red blood cells (PRBC) post-operatively (post-op).  Foley was draining pinkish urine. The patient was noted to be tolerating a regular diet and ambulating well. He was deemed stable for discharge home with foley in place and outpatient Urology follow up. The insurer has denied coverage for the inpatient hospital admission as not medically necessary. They noted the patient's presentation and hospital course and stated that guidelines for admission were not met. 

Per Milliman Care Guidelines (MCG):

1)	Bladder: Transurethral Destruction of Lesion, patient meets the discharge parameter within 24 hours post-op. The patient did not need post-op control of bleeding.

2)	Urologic Surgery or Procedure:  The patient meets the general recovery guideline (GRG) discharge parameter within 24 hours post-op. Some hematuria is expected after transurethral resection of bladder tumor (TURBT) of large multifocal bladder tumors. The patient had no post-op complication, and recovery was uneventful after TURBT.

The healthcare plan acted reasonably and with sound medical judgement and in the best interest of the patient. The inpatient hospital admission was not medically necessary for this patient.

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skin Disorders
Treatment: Inpatient Hospital
The health plan denied the inpatient stay as not medically necessary. The health plan's determination is overturned.

The patient is a male with a history of obesity, diabetes, hypertension, coronary artery disease and stroke who initially stepped on a toothpick  and subsequently developed an abscess, requiring evaluation in the emergency department (ED). At that time, he underwent wound debridement by a podiatrist and was given a tetanus vaccine, as well as a 10-day course of oral Augmentin. Despite these interventions, at outpatient podiatry follow up, he required another wound debridement with return of purulent fluid, so his podiatrist recommended that he return to the ED for intravenous (IV) antibiotics and likely additional debridement under anesthesia. Evaluation at that time was notable for tachycardia (101 beats per minute (bpm)), hypertension (188/83 millimeters of mercury (mmHg)), hyperglycemia (glucose 226), elevated creatinine for his age (1.1) and a 1 x 1 centimeter (cm) plantar ulcer over the right foot with associated erythema and purulent drainage. Blood cultures were collected, and he was started on IV Vancomycin and Zosyn in the ED before being admitted for continued management.

Based on the findings above, I overturn the health plan's determination, in its entirety.

Yes, this inpatient stay was medically necessary. His treatment could not have been rendered safely at a lower level of care, since he required rapid initiation of IV antibiotics, surgical wound debridement, multiple specialist evaluations, intensive glycemic control and assessment of rehab needs. Inpatient treatment was necessary to mitigate risks of sepsis, bacteremia, wound breakdown, osteomyelitis, intractable pain, diabetic ketoacidosis (DKA) / hyperglycemic hyperosmolar syndrome (HHS), loss of function in the foot, potential limb loss, falls and failure to thrive, in his previous living environment. (Ramsay et al)
He presented with persistent purulent drainage from a right foot abscess and associated cellulitis despite attempts at outpatient management, including a previous ED visit, oral antibiotics, outpatient wound debridement and outpatient follow up in podiatry clinic. These features warranted admission for parenteral antibiotics (Eron et al; Raff and Kroshinsky). Furthermore, his weight (>100 kg) was a significant risk factor for cellulitis treatment failure (Halilovic et al), and parenteral antibiotics achieve therapeutic tissue concentrations faster than oral therapy. He met Milliman Care Guidelines (MCG) criteria for inpatient admission for cellulitis due to his urgent need for parenteral antibiotics, as well as urgent surgical intervention to address an infected wound that failed to improve with outpatient management.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Intra-abdominal Ewing sarcoma.

Treatment: Collecting and storing of stem cells.

The insurer denied coverage for the collecting and storing of stem cells.

The denial is overturned.

This is a male patient with a history of intra-abdominal Ewing sarcoma.  The patient had a Hematology-Oncology Telemedicine visit, and per the visit notes, the patient's treatment includes chemotherapy, surgery, and radiation.  The patient's Hematology-Oncology Specialist is requesting authorization for collecting and storing of stem cells for the patient.

Targeted radiation therapy is an effective cancer treatment.  However, it has the potential to cause significant damage to normal tissues surrounding the tumor.  Stems cells provide an option to restore functionality to the irradiated tissues.  Stems cells are able to promote recovery of normal tissues exposed to ionizing radiation and potentially ameliorate the side effects due to normal tissue damage.  They can also protect and restore endogenous cell functions and hasten recovery of patients subjected to irradiation.[1] Patients undergoing pelvic or abdominal radiotherapy are prone to developing complications of the intra-abdominal organs located close to cancers.  The most radiosensitive intra-abdominal organ is the small intestine. Mesenchymal stem cells have been shown to favor renewal of healthy intestinal tissue.[2, 5] The reduction of damage caused by radiotherapy will allow for a better quality of life and also allow for dose escalation to the tumor therefore improving tumor control.[3] Stem cells are also useful in promoting the regenerative process in colorectal tissue.[4, 5] The collection and storage of stem cells has the appropriate approval from the regulatory bodies.  As the patient is currently off chemotherapy, he would be a good candidate for the collection of stem cells.  He is also a good candidate due to the associated risks of whole abdomen radiation. 

Research has demonstrated that stem cell apheresis is beneficial in improving quality of life and promoting regeneration of cells and cellular tissues.  The requested service is likely to be more beneficial than any other standard treatments/procedures for this patient. 

The carrier's denial of coverage for collecting and storing of stem cells should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: seizure.

Treatment: inpatient hospital admission.

The insurer is denied coverage for inpatient hospital admission.

The denial is overturned. 

This male patient has a history of substance abuse.  He presented to the Emergency Room (ER) with complaints of a seizure.  The patient reported taking Xanax 4 times a day or more.  He was shopping with his wife and had a witnessed seizure that last for 2 minutes.  Labs were significant for hypophosphatemia.  The patient was admitted with a withdrawal seizure.  Xanax dosage was decreased to three times a day (TID).  Phosphorus supplementation was provided and phosphorus levels improved.  The patient's symptoms improved gradually during the admission.  He was discharged.

Cranial nerves 2 through 12 were normal with normal motor and sensory function.  His gait was steady.  The treatment plan included seizure with hypophosphatemia, intravenous (IV) Keppra, phosphorus supplementation, Clinical Decision Unit (CDU) observation and a hospitalist with a possible Neurology consult.  The patient was admitted with a withdrawal seizure.  His Xanax dosage was decreased to three times per day.  After supplemental phosphorus, his phosphorus levels improved.  The patient was discharged.

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

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

Diagnosis: Chronic Obstructive Pulmonary Disease

Treatment: Inpatient Admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

The patient is a female with history of asthma, chronic obstructive pulmonary disease (COPD), depression, seizures and immunocompromising illness. The patient did not get relief from her rescue inhalers and nebulizer so she presented to Emergency Department (ED) with complaints of shortness of breath, wheezing and some chest tightness. The patient's vital signs at presentation were: temperature 98.2 degrees Fahrenheit, blood pressure 121/67, heart rate 64, respiratory rate 20, and oxygen (O2) saturations 98% on room air. Lung exam revealed bilateral (B/L) wheezing. The patient was treated with intravenous (IV) steroids and bronchodilators via nebulizer. Initial labs: white blood cell (WBC) count was 8.8, hemoglobin (Hb) 14.7 and electrolytes within normal limits (WNL). Venous blood gases (VBG) were potential of hydrogen (pH) 7.26/ carbon dioxide (CO2) 66.

Chest X-rays revealed no infiltrates, hypoplastic left lung, no change from a few years ago. Troponin was normal. Electrocardiogram (EKG) was normal sinus rhythm (NSR), no acute changes. The patient's peak expiratory flow (PEF) was 150 (baseline of 250). The patient was admitted to the hospital. As per the history and physical, the patient was alert and oriented to person, place, and time. She was in no acute distress and was speaking full sentences. Wheezing had been described in lung exam. In assessment note, the medical doctor (MD) states the patient was saturating well on room air. Symptoms of dyspnea had improved. The patient refused arterial blood gases (ABG). The patient remained stable after admission. She was treated with bronchodilators and steroids.

Later, the patient was afebrile and hemodynamically stable. O2 saturation was 97% and PEF was 250. Labs were stable. The patient was discharged home the same day on oral steroids and bronchodilators. This patient did not need acute inpatient hospitalization. The patient could have been placed in observation status, which could have been up to 48 hours while diagnostic testing and treatment were initiated. The patient responded well to treatment. She remained stable after admission and was discharged the next day. The patient did not have hypoxia, was tolerating orally, no pneumonia or pneumothorax on chest x-ray.

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

The insurer's denial of coverage for the inpatient admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Aneurysm

Treatment: Inpatient Admission

The insurer denied coverage for inpatient admission.

The denial is overturned.

This case involves a female who presented to the hospital for retreatment of her left anterior temporal artery aneurysm recurrence. The submitted documentation does indicate she is initially admitted with the subarachnoid hemorrhage (SAH) secondary to a left anterior temporal artery aneurysm status post coil embolization. Hospitalization was complicated by a right common femoral artery deep vein thrombosis (DVT) status post inferior vena cava filter placement. The submitted documentation indicated she had a 6-month follow-up angiogram demonstrating recanalization of the neck and a small proximal part of the sac of the previously coil embolized left anterior temporal artery aneurysm. The documentation indicated she also underwent a 9-month angiogram that demonstrated a stable or mildly enlarged recanalization of the neck and small proximal part of the sac. The documentation indicated it was recommended to proceed with additional treatment and therefore the patient presented to undergo treatment pertaining to the above. The patient was admitted for retreatment of the left anterior temporal artery aneurysm recurrence. She underwent digital subtraction angiography and attempted balloon and stent assisted coiling, however, this was unsuccessful. She was recommended postoperatively to continue with neurologic monitoring. Post procedure, it was noted that the patient did initially have bleeding to the groin, however, this was controlled. She did continue with monitoring without any further significant adverse events. The documentation indicated given the period of stability, she was discharged the following day with instruction to follow-up.

A balloon and stent assisted coiling procedure, even though it was not successful, is a very invasive procedure and is an appropriate reason for 1-day hospitalization. The submitted documentation indicated the patient was initially admitted to undergo treatment pertaining to her ongoing condition. The documentation indicated this patient does have evidence of a complicated past medical history. The requested 1-day inpatient hospitalization is appropriate for this patient to continue with monitoring and intervene if necessary. As such, the denial is overturned.  

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

The insurer's denial of coverage for the inpatient admission is reversed. Medical necessity is substantiated.