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

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital admission for medical necessity. 
The denial was overturned in whole.

This patient is a female with a history of heart failure and preserved ejection fraction, stroke, diabetes mellitus type 2, essential hypertension, prior opiate abuse on methadone, chronic obstructive pulmonary disease (COPD) with chronic hypoxic respiratory failure on oxygen by nasal cannula, and oropharyngeal cancer status post percutaneous endoscopic gastrostomy (PEG) tube. She presented to the emergency room (ER) with worsening shortness of breath and leg swelling. The signs and symptoms were consistent with acute heart failure exacerbation with volume overload.
The patient was admitted to inpatient telemetry service for aggressive intravenous (IV) diuresis, and telemetry monitoring under the guidance of Cardiology consultation. Transthoracic echocardiogram showed normal cardiac function and mild aortic stenosis. The lower extremity Doppler ultrasound was negative for deep vein thrombosis (DVT). She required a PEG tube replacement because it became dislodged during her hospitalization.
Records show that the patient experienced a rapid response evaluation for a syncopal event attributed to acute upper gastrointestinal (GI) bleeding.  The esophagogastroduodenoscopy (EGD) demonstrated a bleeding papule located in the gastric fundus which was clipped. She was eventually discharged home in stable condition.
At issue is the medical necessity of the Inpatient Stay.

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

The requested health service/treatment of Inpatient Stay was medically necessary for this patient.
This medically complex patient with a history of heart failure and multiple other comorbid conditions presented with worsening signs and symptoms of volume overload due to acute on chronic heart failure exacerbation. She required aggressive IV diuresis for persistent symptomatic heart failure while monitored on telemetry along with daily labs and management guided by Cardiology. She experienced a syncopal event requiring a rapid response evaluation due to an upper GI bleed. Given the patient's complicated hospital course, the inpatient level of care was medically appropriate, necessary, and in the best interest for the safety of this patient for urgent intervention. The Inpatient level of care for management of her acute heart failure exacerbation in the context of her other acute medical conditions is supported by peer-reviewed medical literature and expert consensus guideline statements on acute heart failure management. [1-3]
Therefore, the Inpatient stay was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory System. 
Treatment: Inpatient Hospital. 
The insurer denied emergent hospital admission. 
The denial is overturned. 

The patient is a male who presented to the emergency department (ED) complaining of 3 weeks of worsening exertional dyspnea and orthopnea. His medical history was remarkable for hypertension, hyperlipidemia, obesity, and coronary artery disease. He had coronary artery bypass graft surgery. In the ED, his blood pressure was 151/74 millimeters of mercury (mmHg) with a heart rate of 59 beats/minute. His respiratory rate was 20/minute. His physical exam was remarkable for jugular venous distension and pulmonary rales. An electrocardiogram showed sinus rhythm with right bundle branch block and inferior and anterior ST segment and T wave changes. His brain natriuretic peptide (BNP) level was 2232 picograms per milliliter (pg/ml); his serum troponin I level was 0.3 ng/ml. Chest x-ray showed probable pulmonary vascular congestion. The patient was treated with intravenous furosemide and admitted to the hospital. His dyspnea was improved. His troponin I level was mildly elevated at .05 nanograms/milliliter (ng/ml). An echocardiogram showed a normal left ventricular ejection fraction; there were new regional wall motion abnormalities in the area supplied by the left anterior descending coronary artery (LAD). Cardiac catheterization showed stenosis of the internal mammary artery graft to the LAD. Two drug eluting stents were placed in the LAD. The patient's troponin I level rose to .26 ng/ml; it rose further to 2.69 ng/ml. The patient denied chest pain and there were no acute electrocardiographic changes. He was discharged. Medical necessity for an inpatient admission is at issue.


The health plan's determination is overturned in whole.

This patient presented with worsening exertional dyspnea, heart failure, new left ventricular wall motion abnormalities and a mildly increased troponin level. His symptoms were precipitated by acute ischemia due to occlusion of his recent internal mammary artery bypass graft. He was at high risk for major adverse events, including myocardial infarction, shock, malignant arrhythmias and death. He required careful and continuous monitoring with the ability to intervene emergently, if needed. This warranted an inpatient level of care. After his revascularization the patient developed a significant and progressive increase in his troponin level. This degree of troponin elevation suggests new irreversible myocardial injury, the magnitude of which correlates directly with the extent of troponin elevation, which in this case was substantial. Thus, continued close monitoring in an inpatient setting to ensure that the patient remained clinically stable was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems/Chest Pain. 
Treatment: Inpatient Hospital. 

The health plan denied the requested inpatient hospital stay as not medically necessary. 
The health plan's determination is upheld. 

This case involves a female with a history of essential hypertension, cholecystectomy, mechanical mitral valve replacement, tricuspid valve repair, and prior subdural hematoma who presented to the emergency room (ER) with worsening shortness of breath and pleuritic stabbing chest pain for 2 days. The patient was mildly hypertensive on admission with otherwise had stable vital signs. She was admitted to inpatient telemetry service for evaluation of atypical chest pain and shortness of breath. She ruled out for acute coronary syndrome (ACS). A transthoracic echocardiogram was performed showing normal mitral valve prosthesis and normal cardiac function. She underwent a treadmill stress test which was nondiagnostic due to inadequate heart rate increase. No ischemia reported. The patient was recommended for transfer to another hospital for further evaluation of shortness of breath with a right heart catheterization. The patient was transferred to another hospital. The patient's health plan has denied coverage for inpatient level of care due to the lack of medical necessity. 

I recommend that the health plan's determination of medical necessity be upheld, in whole. 

This patient presented with atypical chest pain and shortness of breath. There was no evidence of decompensated heart failure on admission and the patient ruled out for ACS. The patient's calculated Heart Score was low, 1, indicative of low risk for major adverse cardiac event. According to the well validated Heart Score pathway, this patient did not require inpatient admission [1]. Furthermore, given the patient's negative cardiac troponins, lack of ischemic changes on electrocardiogram (ECG), observation level of care would be medically appropriate for evaluation and monitoring in this case as recommended by the 2014 American College of Cardiology (ACC) / American Heart Association (AHA) guideline for the management of patients with non-ST-elevation acute coronary syndromes [2]. In addition, given patient's lack of decompensated heart failure on admission and stable echocardiogram findings, outpatient right heart catheterization would not have been appropriate in this case. 

Given the patient's atypical symptoms for ACS, stable cardiac examination, normal echocardiogram findings, and negative cardiac troponins, inpatient level of care was not medically necessary. Rather, observation level of care in this case would have been medically appropriate and safe for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic Sinusitis.
Treatment: Endoscopic Sinus Surgery.
The insurer denied the Endoscopic Sinus Surgery. The denial is upheld.

The patient is a male with a history of reported chronic sinusitis and nasal obstruction. There was also a history of mild OSA (obstructive sleep apnea). Exam reported a deviated septum with congested inferior turbinates. Medical treatment included Flonase. Sinus CT (computed tomography) reported mild mucosal thickening. The patient underwent ESS (endoscopic sinus surgery), including anterior ethmoidectomies and middle meatal antrostomies.

No, the health plan should not cover the Endoscopic Sinus Surgery.

All records were reviewed. The patient underwent multiple nasal and sinus procedures, including anterior ethmoidectomies and middle meatal antrostomies. However, while it is reported that the patient had been treated with antibiotics prior to sinus surgery, there is no detailed documentation of the failure of maximal medical therapy with antibiotics, including names of medications and length of therapy. Therefore, based on the information provided, the medical appropriateness of the ESS (endoscopic sinus surgery) procedures performed cannot be confirmed.

No, the endoscopic sinus surgery is not likely to be more beneficial.

There was no detailed documentation of the failure of maximal medical therapy with antibiotics, so the requested therapy cannot be stated to be more likely to be more beneficial for the enrollee than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic Sinusitis.
Treatment: Endoscopic Sinus Surgery.
The insurer denied the Endoscopic Sinus Surgery. The denial is overturned.

The patient is a male. The patient describes nasal obstruction and decreased sense of smell. He has used nasal steroid pray and Breathe Rite strips. The patient also has a family history of nasal polyps.

The patient's examination demonstrates a severely deviated nasal septum. Turbinate hypertrophy was evident on nasal endoscopy. The patient had polysomnogram with AHI (apnea hypopnea index) of 5. On CT (computed tomography) of the paranasal sinuses, minimal mucosal thickening was seen in the alveolar recess without obstruction of the osteomeatal complex. There was also minimal sphenoid mucosal thickening and anterior and posterior ethmoid disease. The patient is reported to have had multiple courses of antibiotic therapy (multiple times prior and has had courses of at least three weeks).

Yes, the health plan should cover the Endoscopic Sinus Surgery.

Clinical management meets the standard of care. The plan had suggested that treatment was experimental or investigational, and no evidence of such categorization is seen. The patient has had prior episodes of chronic sinusitis and has been treated appropriately with antibiotic and adjacent therapies. CT demonstrated evidence of chronic sinusitis yielding appropriate clinical indicators for endoscopic sinus surgery.

The patient has had appropriate medical therapies prior to the completed endoscopic sinus surgery. There are no other therapies recommended. The surgical procedures completed are standard therapies and not experimental or investigational.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic Sinusitis.
Treatment: Endoscopic Sinus Surgery.
The insurer denied the Endoscopic Sinus Surgery. The denial is overturned.

The patient is a male with a long history of nasal airway obstruction, smell disturbances, and sleep disorders with evidence of chronic sinusitis on the exam.

CT (computed tomography) done shows only minor mucosal thickening in paranasal sinus with some polypoid thickening, a narrow nasal passage, and deviated septum. The patient failed medical therapy for a year.

Patient underwent operation that consisted of bilateral endoscopic anterior ethmoidectomy, bilateral endoscopic middle meatal antrostomy, endoscopic adenoidectomy, submucous resection of septum, and bilateral submucous resection of inferior turbinates. The patient seeks coverage for ESS (endoscopic sinus surgery).

Yes, the health plan should cover the endoscopic sinus surgery.

This patient has chronic rhinosinusitis that did not responded to medical therapy and had CT (computed tomography) findings of sinus disease.

The value of endoscopic sinus surgery for these types of patients is well-established. The literature, including consensus statements and Cochrane reviews, shows the value of this approach. (1-3)
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shoulder Pain.
Treatment: Shoulder surgery.
The insurer denied the shoulder surgery. The denial is upheld.

The patient is a female with left greater than right shoulder pain. The patient's BMI (body mass index) was 50. She was evaluated. She reportedly had undergone arthroscopic surgery to both her shoulders on two occasions. Her pain level was eight and did not improve with Ibuprofen. Her physical examination was significant for decreased range of motion and weakness. She had positive speed, drill and Ferguson test. She was diagnosed with tendinopathy and referred for left shoulder MRI (magnetic resonance imaging).

The patient returned with MRI (magnetic resonance imaging) report of partial tear to cuff, SLAP (Superior Labrum Anterior and Posterior) tear and biceps tendinopathy.

Surgery was recommended. The patient was reported to have received conservative treatment, which did not provide relief. The surgery was performed. Her physician performed several procedures.

The patient then reported pains to the right shoulder. PT (physical therapy) and MRI (magnetic resonance imaging) were recommended for the right.

The patient returned and felt worse on the left side. Additional MRI (magnetic resonance imaging) was recommended for the left. Her BMI (body mass index) was now 52.

No, the shoulder surgery was not medically necessary.

The records show this patient had undergone two previous shoulder surgeries. The type and result were not known. She had pain which was the "indication for the operation." There were reports she had completed conservative treatments, but they were not documented.

The physician reported multiple conditions and performed several reconstructive procedures.

The facts were there was no documentation to functional loss. The patient had pain but no reported problems with activities of daily living. There were no records showing the course of conservative management. There were no PT (physical therapy) records or documented injection. There were no reports of rest. The only treatment provided was Ibuprofen.

Three months of conservative management prior to the operation was not documented. The surgery would thus not have been medically necessary.

Additional records were submitted. The records show an initial consultation. Magnetic resonance image (MRI) was recommended. No course of physical therapy (PT) nor other conservative treatment was provided. These findings do not change the previous opinion. Criteria have not been fulfilled. Note - the additional physical therapy records were those submitted after the operation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity. 
Treatment: Saxenda. 

The insurer denied Saxenda. The health plan's determination is upheld. 

The patient is a female who requests prescription coverage for Saxenda for management of weight loss. She was previously on this medicine for several months; however, coverage was stopped secondary to not meeting criteria for continued coverage. 

Saxenda (liraglutide) is not medically necessary for this patient. 

SAXENDA is a glucagon like peptide 1 (GLP-1) receptor agonist indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in: 
Adult patients with an initial body mass index (BMI) of
 30 or greater (obese), or 
27 or greater (overweight) in the presence of at least one weight-related comorbid condition (e.g. hypertension, type 2 diabetes mellitus, or dyslipidemia) 
There is one medical progress note available for review. The progress note states that the patient's weight today is 182 pounds. She started on medication 3-4 months prior, and her weight was 185 pounds. She decreased to 177 pounds for a total of 8 pounds of weight loss. Her BMI (body mass index) is 37. She regained several pounds after stopping the medication. 

There is conflicting data submitted. The prior authorization request states the patient did not lose at least 4% of body weight. Another progress note states that the patient did lose 4% of body weight. 
Data missing from this review is a progress note prior to initiation therapy and also one on or around when the prior authorization was completed. Without this data to review, there is insufficient information available to satisfy medical necessity. Most studies use a loss of 5% of body weight as measure for effective therapy. The patient in this case did not appear lose 5% of body weight according to the information provided. Therefore, it would be considered a medication failure and Saxenda would not be medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Seizures
Treatment Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient has a history of attention deficit hyperactivity disorder (ADHD) and global developmental delay of unknown etiology. She was in her usual state of health until she had a generalized tonic-clonic seizure, which stopped spontaneously. For evaluation of this seizure, she was taken to the emergency room, where she had a second documented generalized tonic-clonic seizure and for which she was treated with Ativan. In the emergency room, she was noted to have a fever of 101.5 degrees Fahrenheit (F). Because of the combination of recurrent seizures and fever, she was admitted at an acute level of care to the pediatric intensive care unit, where she was treated with antibiotics and an anticonvulsant. She also underwent continuous electroencephalogram (EEG) monitoring, which showed diffuse slowing, but no epileptiform activity. She was discharged from the hospital on Keppra and a 10-day course of antibiotics. At issue is the medical necessity of an inpatient stay.
The inpatient stay was medically necessary. She had complex febrile seizures. The febrile seizures were considered complex because they were recurrent.
The patient had recurrent seizures and a documented fever. Whenever a child has a new onset of seizures in the context of a fever, they may have a serious neurological infection or they may have complex febrile seizures. In either case, admission to the hospital at an acute level of care is appropriate. It would not be appropriate to send a child home under these circumstances. To discharge a child to home under these circumstances would expose the child to the risk of having an untreated serious neurological infection, such as meningitis, or to having further, untreated recurrent febrile seizures. Instead, children with recurrent seizures in the presence of fever should be admitted and treated with anticonvulsants and antibiotics, as this patient was. According to the Milliman Care Guidelines for Pediatrics, inpatient admission to the hospital is indicated for complex febrile seizures, including recurrent febrile seizures.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a woman with a history of ulcerative colitis who presented to the hospital with a chief complaint of coughing and difficulty breathing. She reported having three weeks of coughing and was previously seen in the emergency department at that time. She tested negative for COVID-19 and her chest x-ray was negative for pneumonia. She was treated with bronchodilators and steroids. She presented again with persistent symptoms and improved with nebulizers. In addition, she described pleuritic chest pain and back pain. Review of systems was negative for fevers and chills. Vital signs showed blood pressure 122/85, heart rate 129, temperature 98 Fahrenheit, and respiratory rate 24. On physical exam, she had diffuse expiratory wheezes, no crackles, trachea was midline, heart was regular, and the abdomen was soft and nontender. Influenza testing was negative. COVID-19 testing was negative. Other labs showed sodium 139, potassium 4.1, creatinine 0.83, calcium 9.6, white blood cell (WBC) 15.8, hemoglobin 12.3, and troponin negative. Chest x-ray was negative for pneumonia. Breathing improved in the emergency department with an albuterol nebulizer. The patient was admitted with suspected asthma exacerbation. 

The inpatient hospital admission was not medically necessary. The patient presented with suspected acute asthma exacerbation despite not having a prior diagnosis of asthma and she did require further management. However, the emergency department notes indicate that her symptoms had already improved with an albuterol nebulizer, and there was no evidence of other signs or symptoms that would typically be associated with the acuity needed for inpatient level of care. Specifically, the patient had no sepsis, no evidence of acute pneumonia, no acute coronary embolus, no hemodynamic instability, no significant hypoxia, and no evidence of acute coronary syndrome. Overall, she could have been safely and effectively managed at a lower level of care.