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

Diagnosis: Chest pain
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld. 

This is the case of a patient with a past medical history of coronary artery disease and previous stents, hypertension, diabetes mellitus, and chronic obstructive pulmonary disease (COPD) that presented to the hospital with left sided chest pain and right arm numbness. The patient noted that chest pain radiated to the back and began bothering her one month prior to admission. On the morning of presentation, the patient awoke with right arm numbness. On arrival to the hospital, vital signs were stable [Blood Pressure (BP) 167/77, Pulse 98]. Physical examination revealed no major abnormality. 12 lead electrocardiogram (ECG) revealed sinus rhythm with no evidence of ischemic ST or T wave (intervals on ECG) abnormalities. Serum blood testing revealed elevated creatinine and glucose (1.6 and 278 respectively). Troponin levels were not elevated [< (less than) 0.01]. The patient was admitted to the hospital for testing and treatment. Glucose was elevated as a result of treatment with intravenous Decadron therapy. The patient responded to insulin and underwent exercise stress testing. Left-ventricular ejection fraction (LVEF) was noted to be preserved [76% (percent)] and no evidence of myocardial ischemia was noted. The patient was discharged home with outpatient cardiology follow up.

This patient presented with atypical chest pain and a past medical history of coronary disease, hypertension, and COPD. The patient's pretest probability of coronary artery disease was high. [1] Utilizing the HEART (history, ECG, age, risk factors, initial troponin) score, the patient was considered low risk. [2] Utilizing the Thrombolysis in Myocardial Infarction (TIMI) risk score, the patient also had a low risk of developing major adverse cardiac events in the subsequent 30 days. [3] Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati, et al. [3] 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. Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all-cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation. In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary.

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

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

Diagnosis: End Stage Renal Disease

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

The patient was admitted for rising creatinine. She had history of end stage renal disease status post kidney transplant. She was treated with intravenous (IV) fluid and Prograf dose was adjusted, and creatinine improved and she was discharged in stable condition.

The gold standard for the distinction between prerenal disease secondary to volume depletion and post-ischemic and nephrotoxic acute tubular necrosis (ATN) is the response to fluid repletion per Kidney Disease: Improving Global Outcomes (KDIGO) and National Kidney Foundation guidelines. If sufficient fluid is given to reverse any signs of volume depletion (e.g., hypotension, cool extremities, low urine-sodium concentration), return of the serum creatinine to the previous baseline within 24 to 72 hours is considered to represent a correction of prerenal disease, whereas persistent acute kidney injury (AKI) is considered to represent ATN.  This member's kidney function improved back to baseline in 48 hours, which is not consistent with serious, irreversible acute tubular necrosis which may benefit from inpatient admission to monitor kidney function and the need for renal replacement therapy.

In addition, she was hemodynamically stable, with normal oxygenation and negative cultures, did not have significant electrolytes disturbance or change in kidney function. She did not have cardiac arrhythmias, no altered mental status or persistent nausea and vomiting with dehydration. There was no documentation of refractory pain, and she was able to tolerate oral diet and did not require total parenteral nutrition.

Her condition could have been treated safely under lower level of care.

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

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

Diagnosis: Short of breath

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

 
Patient is a child with respiratory symptoms of cough and fast breathing who presented to Brookdale emergency department (ED). Patient was not in distress (in the ED physician note, it was documented "no distress" , had no tachypnea (24 to 28), and mild wheeze.  The oxygen saturation was 90%.  No hemodynamic instability. Perfusion was adequate. Chest x-ray (CXR) showed possible left lobe (LL) pneumonia but the official reading was normal.  The patient was treated with nebulization and steroids, also magnesium sulfate. Patient was also given ceftriaxone.  The clinical status improved. Patient was discharged with scheduled nebulization and steroids and close pediatric follow up.

There was no persistent hypoxia and no need for continuous positive airway pressure (CPAP) or high flow nasal canula (HFNC) .  There was no need for pressors nor multiple boluses. Arterial blood gas (ABG) done in the ED  and reassuring. Also, there was no severe dehydration on clinical exam . The general exam was documented as " Not in acute distress". Patient was given magnesium sulfate. Also, there was no second line treatment such as continuous albuterol or epinephrine or terbutaline. If one were to take the Pediatric Respiratory Assessment Measure (PRAM) score to assess the severity of the  asthma, it would be in the category of mild asthma. If one were to take the Pediatric Early Warning Score (PEWS) score, it would have been desirable also, indicating an expectant stable course in hospital.  The patient was continuing in expected clinical trajectory while in the hospital . Due to above reasons, this child with mild to moderate asthma exacerbation  could have been treated in observational status.

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

The medical necessity for inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Foot wound.
Treatment: Inpatient Admission.
The insurer denied: Inpatient Admission.
The denial is overturned.

The patient is an adult female. She presented the emergency room with a wound to her foot. She had a past history significant for diabetes. She had no known drug allergies present for 6 weeks. The patient's initial blood work showed elevated CRP (C-reactive provider). Her white count was 16. She was found to have acute osteomyelitis of the third toe. Cultures were growing staph and strep. She was administered cefazolin and long-term IV (intravenous) antibiotics. A PICC (peripherally inserted central catheter) line is noted. Her arterial status was confirmed using ankle-brachial index. Infectious disease was consulted. Podiatry had seen her and recommended Betadine and dry sterile dressing. She had appropriate radiological workup as well. She was discharged with IV (intravenous) and wound care services.

The Inpatient Admission was medically necessary.

Diabetic foot infections with the sudden worsening are typically treated with hospital evaluation, admission, workup for sepsis, appropriate consultation, appropriate radiology, and IV (intravenous) antibiotics with determination for long-term versus short-term and IV (intravenous) versus oral. All of this took place in an appropriate time during this patient's hospital admission and therefore was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Varicose Veins
Treatment:  Endoluminal radiofrequency ablation or endoluminal laser ablation
The insurer denied Endoluminal radiofrequency ablation or endoluminal laser ablation.
The determination is overturned.

This is a female patient a history of varicose veins right greater than left with painful tired legs. She has worn compression stockings with no benefit. A venous duplex exam demonstrated venous insufficiency bilaterally, no evidence of deep vein thrombosis (DVT) bilaterally. There was incompetence of the bilateral great saphenous veins.
The patient was diagnosed with symptomatic varicose vein of both lower extremities and was offered right greater saphenous vein ablation. She was seen for follow up after the right greater saphenous vein (GSV) ablation. The patient was very happy with the results of her treatment. She continued to use her compression stockings. She was offered left GSV ablation. At issue is whether the left GSV ablation is medically necessary.

The requested health service/treatment of endoluminal radiofrequency ablation or endoluminal laser ablation is medically necessary for this patient.
The patient has symptomatic lower extremity varicose veins and venous insufficiency. GSV (greater saphenous vein) ablation is the standard of care for the treatment of symptomatic lower extremity varicose veins and venous insufficiency. The treatment is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Digestive System/Gastrointestinal
Inpatient Hospital

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

This is a female patient who presented to the emergency department (ED) with a complaint of right upper abdominal pain. Her past medical history is notable for hypertension and prior sleeve gastrectomy and abdominoplasty. The vital signs were normal at the time of presentation. She was tender in the upper quadrant. The surgical history and physical (H&P) documents a normal white blood cell count (WBC) count of 6.3 thousand (K) with elevated liver enzymes and bilirubin. An abdominal ultrasound showed gallstones and wall thickening consistent with early acute cholecystitis. A laparoscopic cholecystectomy was recommended and planned. The patient was started on intravenous (IV) antibiotics.
Surgery was performed and the operative notes describes a laparoscopic cholecystectomy that was performed without complication.
Following surgery, the diet was advanced and the pain was controlled with oral medications. The vital signs were normal. Lab data was normal. The patient reported surgical pain. The patient remained clinically stable and was discharged from the inpatient setting.
At issue is the medical necessity of an inpatient admission.

An inpatient level of care was not medically necessary in this case. The care provided could have been rendered with a lower level of care. This patient presented to the hospital with a complaint of abdominal pain. Imaging and surgical consultation established the diagnosis of cholecystitis for which a cholecystectomy was recommended. At the time of presentation and at the time of surgical assessment the patient had normal vital signs and was without a fever.
Surgery, a cholecystectomy, was performed. The perioperative and early post-surgical recovery were uncomplicated and the patient had normal vital signs and tolerated a diet following surgery. She was discharged from the inpatient setting following the initial recovery period. Acute inpatient care was not medically necessary for this patient as the care and treatment provided could have been rendered with a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: health care
The insurer denied Customer directed personal assistance service hours 7 days per week 212-hour split shift (168 hours per week). The health plan's determination is overturned. 

This is a case review for a female with medical history notable for dementia, stage 4 sacral decubitus ulcer, type 2 diabetes, and reduced mobility. The patient and her care team requested Customer directed personal assistance service hours 7 days per week 212-hour split shift (168 hours per week).

The requested Customer directed personal assistance service hours 7 days per week 212-hour split shift (168 hours per week) are medically necessary for this patient.
The patient was approved for live-in care, and the request is for split-shift personal care. Live-in personal care aides are expected to receive adequate rest each night, including at least one 5-hour window of uninterrupted rest. If the patient has care needs that would preclude the required rest periods, then split-shift care is deemed medically appropriate. Therefore, the question at hand is whether the patient's personal care needs are expected or known to occur with such frequency to preclude the required rest window for a live-in aide.
The patient has advanced dementia. She is reliant on others for all personal care needs. She is incontinent of stool and urine. She will require prompt changing after episodes of incontinence to prevent skin breakdown and/or infection. She will also require turning and repositioning in bed every 2 hours as requested by her physician to promote healing of her pressure ulcer. The patient's personal care needs are expected to be continuous and at times unscheduled and will occur throughout each day and night with such frequency to prevent adequate rest of a live-in aide. Therefore, the requested increase is medically necessary for the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Congestive Heart Failure.
Treatment:  Increase Personal Care Services To 24 Hours A Day, 7 Days per Week, (split shift) For a Total of 168 Hours.

The insurer denied Increase Personal Care Services To 24 Hours A Day, 7 Days per Week, (split shift) For a Total of 168 Hours.  The denial is overturned.

This elderly female has medical conditions that include cerebral atherosclerosis, congestive heart failure, chronic obstructive pulmonary disease, and dementia. Denial of increase personal care services from 84 hours per week to 24 hours a day, 7 days per week, (split shift) for a total of 168 hours is being appealed. 
Uniform Assessment System evaluation completed two months ago shows moderately impaired cognition and functional status: total dependence and maximal assistance with all ADLs (activities of daily living), except extensive assistance with upper body dressing, and limited assistance with bed mobility and eating. She has bowel and bladder incontinence. A letter from her Provider from hospice reports the member is able to transfer and requires total care with most ADLs (activities of daily living). She is incontinent of bowel and bladder. She requires care at night, needs turning every 2 hours, and adjustment of positioning at night for comfort. 

The proposed treatment is medically necessary. 

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Continuous or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning, or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. This member has multiple chronic conditions, including care. Denial of increase personal care services from 84 hours per week to 24 hours a day, 7 days per week, (split shift) for a total of 168 hours is being appealed. Uniform Assessment System evaluation completed two months ago shows the member requires assistance with all ADLs (activities of daily living). She is incontinent of bowel and bladder. The appeal statements support the member is dependent with all ADLs (activities of daily living) and requires frequent assistance with toileting, transfers, and turning/repositioning. She needs turning every 2-3 hours. This member has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The proposed increase personal care services from 84 hours per week to 24 hours a day, 7 days per week, (split shift) for a total of 168 hours is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Varicose Veins
Treatment: Ambulatory Surgery
The health plan denied: Ambulatory Surgery
The determination is: Overturned

The patient is a female with symptomatic right lower extremity varicose veins, who underwent right leg phlebectomy. The patient was seen for follow up, where she was noted to be doing well post procedure. The patient also had a telephone follow up a month later. A right lower extremity venous ultrasound performed demonstrated no deep vein thrombosis (DVT) with a small fluid collection in the right posterior calf. The patient was diagnosed with swelling and varicose veins of the right lower extremity with pain. She was offered sclerotherapy of her symptomatic right lower extremity varicose veins.
At issue is the medical necessity of the ambulatory sclerotherapy surgery.
The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of ambulatory surgery (sclerotherapy treatment) is medically necessary for this patient.
The patient has symptomatic right lower extremity varicose veins. Sclerotherapy is the standard of care for the treatment of symptomatic varicose veins. The patient will benefit from the treatment.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Asthma
Treatment: Ventolin HFA (Hydrofluoroalkane)
The insurer denied Ventolin HFA.
The determination is upheld.


This is a male patient with a diagnosis of asthma. The provider is requesting Ventolin HFA (Hydrofluoroalkane) for treatment. At issue is whether the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.

The formulary drug will be as effective as the non-formulary drug.
The denial was for not having tried and failed all formulary alternatives: albuterol sulfate 90 micrograms (mcg) HFA (generic to ProAir HFA), albuterol sulfate 90 mcg HFA (generic to Proventil HFA), albuterol sulfate 90 mcg HFA (generic to Ventolin HFA), and levalbuterol HFA. Per the clinical documentation, the patient has a diagnosis of asthma. The provider is requesting Ventolin HFA for treatment. However, there were no clinical notes provided documenting whether the patient has tried/failed all the formula alternatives or has a contraindication to their use. In addition, there were no references (Pubmed search) to support the requested Ventolin HFA as being more effective compared to the formulary alternatives.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Prediabetes, Abnormal Weight Gain, Impaired Glucose Regulation, Abnormal Glucose Measurement.
Treatment: Mounjaro (Trizepatide).

The insurer denied the Mounjaro (Trizepatide). The health plan's determination is upheld.

The patient is an overweight female diagnosed with Pre-diabetes. As per a doctor's visit note, she is on Metformin. Her highest weight was 162 pounds (lbs); and her lowest weight was 131 lbs. She has hyperlipidemia (HLD). Ozempic was added to the patient's medication regimen, during which her weight was 139 lbs.

At issue is whether the formulary exception, Mounjaro (Trizepatide), is medically necessary.

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

There is no available formulary alternative for the patient to try.

The patient does not have a Food and Drug Administration (FDA)-approved or compendial supported diagnosis for the requested medication.

The requested medication, Mounjaro (Trizepatide), is FDA approved for the treatment of adults with type 2 diabetes. It is a Glucagon-like peptide (GLP-1) and gastric inhibitory polypeptide (GIP) receptor agonist. It has been shown in clinical trials to lead to improvement in hemoglobin A1c as well as weight loss. [1-3] Although the medication is only FDA-approved for type II diabetes, it has been shown to be safe and effective in the treatment of obesity. [4,5]

However, the patient has not tried and failed medications that are FDA-approved for obesity. It is not appropriate to treat a patient with an off-label treatment, such as Mounjaro, without trying an FDA-approved treatment for obesity. Therefore, the request for Mounjaro is not consistent with generally accepted standards of medical practice and is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Breathing difficulty and RSV (respiratory syncytial virus).
Treatment:  Air Ambulance Transport (code: A0431), Rotary Wing Air Mileage (code: A0436).
The insurer denied Air Ambulance Transport (code: A0431), Rotary Wing Air Mileage (code: A0436).  The denial is upheld.

The patient is a preschool female. She was evaluated for breathing difficulty and RSV (respiratory syncytial virus) at the referring facility. She has a history of prematurity 24 weeks and frequent respiratory infections. The patient was transferred via air ambulance from the referring facility, where she was found to have tachypnea, retractions, wheezing and pulse oximetry readings of 90-92% (percent). At the time of transport, she was noted to have normal breath sounds with tachypnea present. Her air ambulance transfer time was 18 minutes; ground transport time was noted to be 75 minutes.

The Air Ambulance Transport (code: A0431), Rotary Wing Air Mileage (code: A0436) was not medically necessary.

The patient was transferred via air ambulance to the admitting facility. At the time of transport, the patient was hemodynamically stable and did not require respiratory support. Air ambulance transfers are typically required when the patient has a life-threatening condition for which delayed time of transfer results in a threat to life or limb. Based on the provided documentation, this child did not have an acuity of illness for which transfer via ground ambulance would have resulted in a deterioration of her condition. Therefore, the requested air ambulance was not medically necessary.