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

Diagnosis: Status asthmaticus

Treatment: Inpatient admission 

The insurer denied coverage for the inpatient admission

The denial is overturned

This is a female child with a history of asthma who had worsening cough and wheezing with a viral illness for one day. There is a history of 2 recent hospitalizations for asthma. The child had been seen by the pediatrician and started on Pulmicort and albuterol at home. The mother administered the medication but when the child had worsening cough and increased work of breathing the mother contacted emergency medical services (EMS) who brought her to the emergency room (ER) by ambulance for further treatment.
 
In the ER, she was noted to have respiratory distress with grunting, retractions, and evidence of increased work of breathing, on physical exam she was noted to have tachypnea, coarse breath sounds and subcostal retractions. There was evidence of increased work of breathing.  She was treated with intravenous (IV) fluids, dexamethasone, and multiple inhalation treatments with albuterol. Blood testing and chest x-ray were unremarkable. A respiratory viral panel was positive for rhinovirus. When she did not improve with treatment in the ER, the decision was made to admit to the hospital with a diagnosis of status asthmaticus for ongoing treatment with albuterol every 3 hours.  

The patient was treated appropriately in the ER for a cough, wheezing and respiratory distress. She has a history of 2 recent previous admissions to the hospital for asthma. Despite appropriate treatment in the ER there was clinical evidence of persistent wheezing and increased work of breathing. It was appropriate and consistent with the standard of care to admit her to the hospital for ongoing treatment with albuterol every 3 hours. She was not stable enough to be sent home. 

The inpatient is medically necessary. The patient does meet InterQual Acute Pediatric, Asthma criteria.

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

The insurer's denial of coverage for inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male who presented with one week of epigastric pain and nausea. There were no fever or chills. He had dark stools, but had taken Pepto-Bismol. He was hemodynamically stable. He had a normal white blood cell (WBC) count, normal hemoglobin (Hgb), normal liver function tests (LFTs) and a mild lipase elevation. Imaging did not reveal acute pancreatitis. The patient was given Pepcid with improvement in his pain. The next day, the patient's pain was improved, his diet was advanced, and he was discharged.

No, the proposed treatment is not medically necessary.

The patient had abdominal pain, but was hemodynamically stable, without vomiting, dehydration, electrolyte abnormalities, biliary obstruction, gastrointestinal (GI) bleeding, or need for urgent intervention. A lower level of care was medically indicated up until when the patient was tolerating a diet without ongoing pain, he was medically stable for discharge. Acute inpatient hospital stay was not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.

As it is not medically necessary, the health plan acted reasonably, with sound medical judgment, and in the best interest of the patient by denying it.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: G43.719 Chronic Migraine. 
Treatment: Brain MRI. 

The insurer denied the Brain MRI. 
The denial is overturned. 

The patient is a female with chronic migraines. Given that her headache characteristics have changed including interval development of hearing loss, a MRI (magnetic resonance imaging) brain is being requested by her provider to rule out an intracranial process. 

Yes, the requested brain MRI (magnetic resonance imaging) is medically necessary. 
According to multiple guidelines, when a headache characteristic is different or is accompanied by a focal neurologic change such as loss of hearing in this case, imaging including MRI (magnetic resonance imaging) is medically necessary. MRI (magnetic resonance imaging) is more sensitive than a CT (computed tomography) scan to rule out intracranial process. 

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient. 

MRI (magnetic resonance imaging) was indicated and was within the guidelines in this specific patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hiatal Hernia. 
Treatment: Inpatient Admission. 

The insurer denied coverage for the inpatient admission. 

The denial is upheld. 

According to the documentation submitted, this is the case of a patient with a history of asthma, gastroesophageal reflux disease (GERD) and hypertension (HTN). The patient presented to the hospital for an elective hiatal hernia. The patient underwent hiatal hernia repair with robotic Nissen fundoplication and was admitted for further monitoring. The patient was discharged home 4 days later. 

The health plan acted reasonably and with sound medical judgment. The inpatient admission was not medically necessary. 

According to Milliman Care Guidelines (MCG) General Admission Criteria: "General Criteria: Observation Care. Observation is not a location within the hospital, but rather a short period when the same active diagnostic and therapeutic services used during an inpatient hospitalization are provided to gather more information and assess the response of the patient. Typically, it is 48-hours or less, but can be up to 72-hours in certain situations."  This patient was medically stable and needed only additional analgesic medication. She could have been safely managed at an observation level of care. The records document that the patient's pain was well controlled. Per the progress notes, she remained in the hospital primarily because she was slow to tolerate a diet. Her oral intake was poor following surgery, and she was treated with intravenous (IV) fluids, Zofran and Decadron. She received both oral and IV pain medications. She was physiologically stable and was ambulating. She could have been managed at an observation level of care while awaiting her ability to tolerate a post-fundoplication diet. 

Based on the above, the medical necessity for the inpatient admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic Dermatitis (AD). 
Treatment: Dupixent once weekly. 

The insurer denied Dupixent once weekly. 
The health plan's determination is overturned. 

The patient is a female with atopic dermatitis (AD). Her face, neck, chest, and extremities are affected. She has severe atopic dermatitis flaring on Dupixent every two weeks of treatment. She has also failed Protopic and Eucrisa. 

The requested Dupixent once weekly is medically necessary for this patient. 
Based on the current peer-reviewed literature, Dupixent weekly is medically necessary. The patient has tried and failed biweekly Dupixent. There are limited other systemic therapies approved for use in atopic dermatitis. Thibodeaux et al published "A review of dupilumab in the treatment of atopic diseases." in which they demonstrated that weekly dosing of Dupixent had significant efficacy. Beck et al also have reported on the efficacy of weekly Dupixent in "Dupilumab Provides Favorable Safety and Sustained Efficacy for up to 3 Years in an Open-Label Study of Adults with Moderate-to-Severe Atopic Dermatitis". 

Deleuran et al writes "This first-step analysis of a long-term, open-label study of dupilumab 300 mg weekly in patients who previously participated in randomized, double-blinded, placebo-controlled clinical trials of dupilumab is, to our knowledge, the longest published study with a systemic drug in adults with AD to date and the first report of dupilumab safety and efficacy beyond 52 weeks of treatment...he safety and efficacy profile from this study supports the role of dupilumab as continuous long-term treatment for patients with moderate to severe AD". 

Therefore, based on the patient's clinical findings and refractory disease, weekly Dupixent is medically necessary in this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Relapsed Or Refractory Acute Myeloid Leukemia. 
Treatment: Xospata, Pre-service. 

The insurer denied the Xospata, Pre-service. 
The denial is upheld. 

The patient in this case is a male. The patient has a prior history of Burkitt lymphoma. He was treated with combination chemotherapy and autologous transplantation.  He now has FLT3+ (fms-like tyrosine kinase 3 positive) AML (acute myelogenous leukemia).  He was treated with Vyxeos plus midostaurin.  He had residual disease and was changed to azacitidine plus venetoclax. His physician has recommended addition of Xospata. 

No, the requested Xospata is not medically necessary. 

Xospata is FDA (United States Food and Drug Administration)-approved for treatment of AML (acute myelogenous leukemia) with a FLT3 (fms-like tyrosine kinase 3) mutation. However, it has not been shown to be safe and effective when used in combination with venetoclax and azacitidine. This use of Xospata is not endorsed by NCCN (National Comprehensive Cancer Network) guidelines and has not been shown to be effective in any published study. Given that there is no evidence supporting the ability of Xospata to improve health outcomes when combined with venetoclax and azacitidine, this treatment cannot be considered to be medically necessary. 

Yes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pouchitis
Treatment: Vancomycin
The insurer denied the Vancomycin
The denial is upheld

The patient is a male with ulcerative colitis status post colectomy, with pouchitis. He has failed conventional therapy. His provider is requesting treatment with vancomycin.

No, the requested Vancomycin  is not medically necessary
Other than small case reports of a few patients, there is no medical literature to support the use of vancomycin for the treatment of ulcerative colitis or pouchitis. Therefore, the requested vancomycin in this patient is not clinically appropriate, accepted standard of care or medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
As it is not medically necessary, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient by denying it.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems/Injury/Trauma to the Mouth.
Treatment: Inpatient Hospital.
The health plan denied the requested inpatient stay as not medically necessary.
The health plan's determination is upheld.

The patient is a male with current medical history of bipolar disorder, with bilateral mandibular subcondylar fractures and open symphysis fracture secondary to a fall due to a syncopal episode. He was taken to the operating room on the same day and was treated with open (open reduction internal fixation (ORIF)) and closed (CR) techniques for the three fractures The patient recovered overnight as an inpatient and was discharged the next day. The patient did not require any intravenous (IV) pain medications pre- or post-surgery and the surgery ended at an appropriate time for discharge.

At issue is the medical necessity of the inpatient stay.

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

No, the treatment provided to the patient was appropriate for a lower level of care. The patient did not need inpatient care and never received intravenous (IV) pain medications post-operatively. A lower level of  care also can be changed to inpatient if the patient requires inpatient care such as IV pain medication, blood products, supplemental oxygen, or other interventions. This patient had none of those. IV antibiotics can be provided prior to surgery as is protocol for open mandibular fractures with through mouth (per orem), by mouth, or oral nutrition (po) antibiotics post-operatively, if needed. 
There is no evidence that a patient must be inpatient for having his "mouth wired shut"  i.e., closed reduction and tooth extractions.  This is routinely done in the office and patients are sent home.  The open reduction was performed as well, and the patient was stable. There is no evidence he was given IV pain medications post-op.  The note in the PACU (post anesthesia care unit) stated "To PACU and likely home."  This patient could have been discharged to home.  
Multiple studies show very good treatment outcomes with lower level of care treatment of mandibular fractures with a window of 1-3 days from the injury with minimal post-op infection risk.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Musculoskeletal/Orthopedic. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient stay. 
The denial is upheld. 

The patient is a female with a complaint of right knee pain. She had documented advanced osteoarthritis of the right knee and failed conservative treatments including injections, oral medications, and therapy. She elected to undergo right total knee replacement. The surgery was successful with no documented complications. She progressed well with physical therapy and was deemed stable for discharge home. The patient's health plan denied the inpatient hospital admission. At issue in this case is the medical necessity of the inpatient hospital stay for this patient. 

The health plan's determination is upheld. 

The requested inpatient hospital stay was not medically necessary for this patient. This determination is based upon the provided medical records which document that this patient underwent primary right total knee replacement surgery. The records document that this surgery was successful with no documented complications. The patient had normal lab values and vital signs after surgery and there was no documentation of post-operative bleeding complications or infection. The physical therapy notes also documented that the patient ambulated after surgery and met her therapy goals after surgery. Therefore, the medical necessity of the inpatient hospital stay is not established based upon the documentation in the medical records.
Appeal type: Medical necessity
Decision: Overturned

Cancer
Cancer Screening

Diagnosis: breast cancer
Treatment: Oncotype DX Breast Recurrence Score Gene Test 
The insurer denied Oncotype DX Breast Recurrence Score Gene Test. The health plan's determination is overturned. 

This is a female with a history of a resected invasive lobular 3.0 centimeter (cm) estrogen receptor (ER)+, progesterone receptor (PR)+, HER2 (human epidermal growth factor receptor 2)- breast cancer. One sentinel lymph node was involved with 1.5 cm of disease. 

The Oncotype DX Breast Recurrence Score Gene Test is medically necessary for this patient.
Two studies have evaluated the role of the Oncotype DX assay in this clinical population (post-menopausal, hormone receptor positive, HER2-, < (less than) 3 lymph nodes positive) - The RxPonder trial and the PlanB study. In both of these studies, patients where low recurrence scores did not benefit from chemotherapy. For these reasons, American Society of Clinical Oncology (ASCO), the authors of UpToDate and the National Comprehensive Cancer Network (NCCN) Guidelines consider the proposed approach to be a data-driven option as the results may prevent the patient from experiencing needless toxicity of therapy if she would not derive an outcomes benefit. This is not the subject of ongoing investigation and is an established standard of care. Therefore, the OncotypeDx test is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastrointestinal/Digestive System. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.

The patient is a female with medical history of alcohol use disorder, opiate use disorder, methadone, decompensated alcoholic cirrhosis, and portal hypertension; she was on palliative care.

She presented to the emergency department with worsening abdominal pain and distention, and dyspnea, for several days. Her last paracentesis was several months prior. She has been admitted with spontaneous bacterial peritonitis, bacteremia, and hepatic abscess in recent months. Vital signs were notable for elevated blood pressure of 130/74 millimeters of mercury (mmHg), rapid pulse 120/minute, and rapid respiration of 22/minute. Physical examination was notable for jaundice, dyspnea, soft and nontender but distended and protuberant abdomen, and pedal edema. Electrocardiogram showed sinus tachycardia. Labs showed a blood cell count of 3.7 thousand per microliter (K/uL), low hemoglobin of 8.3 grams per deciliter (g/dL) and hematocrit of 25.8%, low platelet count of 51 K/uL, low back intake and history sodium of 126 milliequivalents per liter (mEq/L), elevated alkaline phosphatase of 190 units per liter (U/L), elevated bilirubin of 11.5 milligrams per deciliter (mg/dL), and low albumin of 2.4 g/dL. Chest x-ray showed clear lungs. Computed tomography scan of the abdomen and pelvis showed an ill-defined liver lesion with surrounding hyperenhancement with differential including hepatic abscess or malignancy, cirrhotic liver, splenomegaly, distended gallbladder with mural hyperenhancement, distended fluid-filled cecum and ascending colon, non-dilated small bowel loops, mural thickening of the distal esophagus and stomach, and moderate abdominal pelvic ascites.  Paracentesis was performed with minimal fluid removal. She reported some abdominal pain the prior night; she denied abdominal pain and was tolerating a diet. Ultrasound showed moderate right upper quadrant ascites and mild scattered pelvic ascites, and chronic liver disease. She was discharged on hospice, with a plan for Primary Care follow-up. At issue is medical necessity for the inpatient stay.

The health plan's determination is upheld.

The inpatient stay is not supported as medically necessary. In this case, the patient presented with increased ascites and abdominal pain in the setting of decompensated cirrhosis. She had a successful low-volume paracentesis after presentation. [2-6]. The patient remained stable, and no intervention was performed which required the inpatient level of care. The monitoring, specialist consultation, and paracentesis performed could have been performed at a lower level of care status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Melanoma differentiation-associated protein 5 (MDA5) dermatomyositis with associated Raynaud's.
Treatment:  Botox.

The insurer denied coverage for Botox.  The denial is overturned.

The patient is a female with a diagnosis of melanoma differentiation-associated protein 5 (MDA5) dermatomyositis with associated Raynaud's. She has failed therapy with prednisone, intravenous immunoglobulin (IVIG), mycophenolate mofetil, hydroxychloroquine, sildenafil, and pentoxifylline. The requested medication is Botox for the fingers for treatment of Raynaud's.  

Based on the review of the submitted documentation Botox injections of the digits are medically necessary for the treatment of the patient's Raynaud's associated with her dermatomyositis diagnosis. The patient has failed multiple systemic therapies, including vasodilators, as well as systemic immunosuppressive and anti-inflammatory medications. The control of the Raynaud's of her digits requires a localized therapy. There is sufficient peer reviewed evidence in the medical literature that Botox injections can improve symptoms of digital Raynaud's. 

Fregene et al. conclude, "Botulinum toxin type A (BTX-A) significantly improves pain and improves healing in Raynaud's patients with few complications. BTX-A was found to be a safe and useful treatment option for vasospastic digital ischemia." (2)  

Given the unique nature of the patient's condition and the failure of multiple systemic therapies, the use of Botox injections to the digits is medically necessary under the medical management of the treating physician.  

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.
 
The insurer's denial of coverage for Botox is overturned.  Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  End Stage Renal Disease (ESRD).
Treatment:  Hospital admission.

The insurer denied coverage for hospital admission.  The denial is upheld.

The patient has end stage renal disease (ESRD) on hemodialysis (HD) and was admitted for hemodialysis; he was evaluated by nephrology and underwent dialysis therapy, which was tolerated well.

The patient was admitted for ESRD; he was treated with hemodialysis and blood pressure medication on admission.  His condition responded to treatment; he did not have persistent severe hyperkalemia; he had no signs of severe volume overload or hypoxia and no documentation of severe uremia, such as encephalopathy or uremic bleeding.  He had established dialysis access and did not require emergent vascular intervention.  His condition could have been treated safely under lower level of care.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. The inpatient hospital admission is not considered 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: Orthopedic/Musculoskeletal/Osteoarthritis
Treatment: Surgical Services (All)
The health plan denied the requested inpatient hospital stay as not medically necessary. 
The health plan's determination is overturned.

This is a female with a retrospective review regarding an inpatient hospitalization.

An operative report indicates a right total knee arthroplasty was performed. The knee pain was significantly worse after falling on the knee. It was rated at 9/10. The pain limited the patient's desired activities, and it interfered with her sleep. The patient was admitted with a diagnosis of surface of the right knee and acute pain of the right knee. 

An orthopedic daily progress note indicates the patient is resting comfortably in bed without any new complaints. Pain is well controlled. The vital signs are stable. The physical examination indicates the incision is clean, dry, and intact, and the lower extremity is neurovascularly intact. There is a plan for discharge home on the day of the encounter.

A discharge summary indicates the patient was discharged home with skilled nursing and physical therapy home care services. It is noted that the postoperative findings included asymptomatic hypotension and a leukocytosis that was reactive in nature.

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

The patient underwent right total knee arthroplasty, with postoperative complications that included nausea, vomiting, and lightheadedness precluding the ability to effectively participate in physical therapy. The patient was not cleared by physical therapy from a mobility standpoint until post op (postoperative) day 2, and she was not cleared by orthopedics from a surgical standpoint until post op day 2. The patient was discharged from inpatient physical therapy post op day 2, and the orthopedic service recommended discharge on post op day 2. Based on this information, the continued inpatient stay through and including post op day 2, was medically necessary.