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

Diagnosis: Orthopedic/Musculoskeletal
Treatment: Inpatient hospital stay

Diagnosis: Orthopedic/Musculoskeletal-Hip problem/Pain.
Treatment: Inpatient hospital stay.
The health plan denied the entire inpatient hospital stay as not medically necessary.
The reviewer has overturned in part the health plan's determination. 

This is a patient who was diagnosed with right hip arthritis. The patient is noted have comorbidities of morbid obesity status post gastric bypass,  lymphedema of both lower extremities, asthma, chronic obstructive pulmonary disease (COPD), gastroesophageal reflux disease (GERD), hypertension, sleep apnea, and a history of deep vein thrombosis (DVT). A preoperative medical evaluation documents that the patient has had 8 years of pain and requires hip arthroplasty. The patient has a history of DVT and utilized Xarelto for 3 years in the past. An operative note documents that the patient underwent a right total hip replacement computer assisted navigation. A wound vacuum was placed. A progress note on the second Post operative day documented surgical site pain necessitating subcutaneous Dilaudid. The provider recommended ongoing discharge planning, DVT prophylaxis, and pain management. An orthopedic note the next day documented that pain was controlled overnight and the provider recommended discharge planning, pain control, DVT prophylaxis. Transfer to acute rehabilitation was denied. The patient refused subacute rehabilitation. The patient continued skilled physical therapy (PT) to increase stability and endurance with stair negotiation, and continued to decline subacute. The patient was eventually discharged home with home health. 

The requested inpatient stay would be medically necessary in part. The documentation provided indicates that the patient underwent right total hip arthroplasty and has significant comorbidities. The patient had an uneventful postoperative course and participated with physical therapy and was stable for discharge to rehabilitation 2 days later, which was denied. The patient remained inpatient for ongoing physical therapy services and discharged home with home health several days later. Given the significant comorbidities inpatient care would be medically necessary until the patient was ready for discharge to a lower level of service such as the recommended rehabilitation.
The Milliman Care Guidelines(MCG) criteria state that most patients are inpatient status after hip arthroplasty. The MCG criteria indicate outpatient arthroplasty is supported when there are no comorbidities that increase risk or require more than 24 hours of postoperative monitoring. A goal length of stay is 2 days. The documentation provided indicates that the patient has significant comorbidities of sleep apnea, morbid obesity, lymphedema, COPD, hypertension, and history of DVT. This would preclude outpatient arthroplasty and given the history of sleep apnea and need for opioid medication to control pain for more than 24 hours, postoperative monitoring would be indicated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Migraine Headache
Treatment: Trokendi XR 50mg OR CP24
The insurer denied the Trokendi XR 50mg OR CP24
The denial is upheld.

The patient is a female with migraine headache disorder. She has tried and failed topiramate IR (immediate release) and has an allergy to the use of topiramate ER (extended release). She has been treated with Trokendi (topiramate) XR (extended release), and the provider is requesting continuation of coverage. This was denied coverage as she has not tried and failed topiramate ER (extended release).

No, the requested Trokendi XR is not medically necessary.
There is no documented reason the patient cannot be treated the preferred topiramate ER (extended release). There is no documentation regarding the type of allergic response to red dye the patient has, and it cannot be confirmed that topiramate ER (extended release) generic has red dye in it. Red dye allergy is not listed as a contraindication to the use of topiramate ER (extended release). There are no high quality clinical trials or standard of care guidelines supporting the preferential use or superiority of the requested Trokendi relative to the preferred agents.

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

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

The patient is a male with low back pain and right buttock pain of a couple of days with right leg weakness. He presented to the ER (emergency room). He had a history of chronic low back pain, for which he had seen a pain management specialist and had an epidural a few months prior. He had tried Advil.

X-rays were obtained. The patient had difficulty ambulating. He was started on IV (intravenous) steroids. MRI (magnetic resonance imaging) of the lumbar spine revealed a right L4-5 (fourth lumbar spine vertebra-fifth lumbar spine vertebra) disc herniation. Physical examination revealed + (plus) straight leg raise. Orthopedic surgery evaluated the patient and found 4/5 strength in the right dorsiflexors and EHL (extensor halluces longus). The patient was seen by Neurosurgery with complaints of right leg pain/weakness and numbness. Physical exam revealed 4/5 strength in right knee flexion/extension, dorsiflexion and EHL (extensor halluces longus). The patient was taken to surgery for L4-5 (fourth lumbar spine vertebra-fifth lumbar spine vertebra) discectomy. The patient was discharged.

No, the Inpatient admission was not medically necessary.
This patient did not require urgent admission. Surgery was not performed for several days. The patient could have been made comfortable and discharged home. Pain medications and oral steroids would have been adequate. The patient could have followed up with a spine surgeon as an outpatient. The patient did not have cauda equina syndrome and did not have progressive weakness that required urgent surgery. Surgery was not performed urgently in any case.

The prolonged hospital stay was not medically necessary, as this surgery could have been done as an outpatient.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
This patient was admitted, and no treatment was rendered for several days. This patient could have been treated at a lower level of care. Surgery could have been done as an outpatient instead of waiting several days in the hospital.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory Problems. Treatment: DME. The insurer denied InCourage Airway Clearance Therapy. The denial is upheld.

The patient is a male patient who suffers from chronic obstructive pulmonary disease (COPD) and chronic bronchitis. The patient is on inhalers. The treating provider is requesting the coverage of the InCourage Airway Clearance Therapy (VEST). The medical necessity for the therapy is the subject under review.

The requested health service/treatment of InCourage Airway Clearance Therapy is not medically necessary for this patient. The VEST has been studied mainly in patients with cystic fibrosis (CF) with bronchiectasis. Various physical methods have also been suggested to facilitate clearance of airway secretions in patients with stable COPD, but there is little information documenting their efficacy and safety. In general, for non-cystic fibrosis patients requiring assisted clearance of secretions, information on high frequency chest compression is very limited.
This patient has history of COPD. He has difficulty getting rid of his sputum. Clearing the airways from the retained secretion should be of help (at least in theory) to improve the patient's clinical condition and decrease the risk of recurrent pneumonia and COPD exacerbation. However, there is no clear evidence to prove that the VEST can achieve such outcome in this patient. There are no long-term trials on the safety and efficacy of the VEST in patient with COPD and difficulty to clear the airway from retained secretion. There is no evidence that the VEST improves the overall outcome in such patients.
The VEST role in the management of various respiratory diseases continues to be uncertain. For COPD, evidence is insufficient, conflicting, or poor and additional research is recommended.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Endocrine/Metabolic/Nutritional. 
Treatment: Pharmacy/Prescription Drugs. 

The insurer denied testosterone gel. 
The denial is upheld.

The patient is a male with a history of low testosterone, sleep apnea, depression, post-traumatic stress disorder (PTSD), and anxiety. He is requesting coverage for brand name Testim transdermal testosterone gel 50 milligram (mg)/5 gram (gm) (1%). In an appeal letter, the attending physician wrote that the patient previously tried and failed Androgel (1%) 25 mg and Testosterone 30 mg gel but is doing well on the Testim. However, there are no medical records which document these previous trials. The subject under review is whether the requested formulary drug would be more effective than the plan alternative.

The health plan's determination is upheld.

There is no medical record documentation provided to substantiate that generic Androgel 1.62% or Androderm testosterone solution will be or has been ineffective or would not be as effective as the requested non-formulary drug. Likewise, there is no evidence that the formulary products would have more adverse effects than the requested non-formulary medication.
Other than a statement in an appeal letter, there are no medical records submitted which document the effectiveness, failure, or worsening adverse effects of the formulary drugs. Therefore, it cannot be substantiated that these formulary choices would be less effective, have been less effective, or will create more adverse effects. For the most part, all of these therapies are interchangeable.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left knee osteoarthritis
Treatment: Inpatient hospital admission

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

This is the case of a male patient with a history of left knee osteoarthritis, transient ischemic attack, bipolar disorder, gastroesophageal reflux disease and hyperlipidemia.  The patient presented to the emergency department with progressively worsening left knee pain. An Orthopedist was consulted. The patient was admitted for surgery. The patient was discharged to a short-term rehabilitation facility.

The medical record demonstrates a non-complicated left total knee arthroplasty was performed. There was limited blood loss. The discharge summary makes no report of problems. 

The patient did not have fever nor evidence of infection. His vital signs remained stable. He did not have wound problems. He was able to be mobilized by PT (physical therapy) with reported satisfactory motion. He was able to tolerate oral pain medication. He did not require treatment for an underlying medical condition. He did not require additional testing nor imaging. 

The records do not substantiate necessity of admission at the level provided. Care would be at a lower level.  There were no extenuating circumstances documented. 

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: Unspecified Injury, hand and fingers
Treatment: durable medical equipment (bio-mechanical prosthetic thumb and finger- L7499 x 4)

The insurer denied coverage for durable medical equipment (bio-mechanical prosthetic thumb and finger- L7499 x 4).
The denial is overturned.

This patient sustained left thumb and ring finger amputations due to a table saw accident.   His provider requested durable medical equipment (DME) bio-mechanical prosthetic thumb and finger which is currently under review.  

From a physical medicine & rehabilitation/pain management perspective, this physician agrees with the providers; the criteria utilized by the insurer are outdated and should be revised (1).  The patient tried the recommended passive prosthetics which "failed to meet the patient's fine motor needs."  The passive prostheses were unable to accommodate various sized objects or perform fine motor activities.  This physician also agrees that a passive device would impose unnecessary limitations when a body-powered biomechanical device is available.  There have been significant advancements in prosthetic devices for individuals with partial hand amputations (2,3).  The requested body powered biomechanically operated thumb driver and MCP [metacarpophalangeal joint] Driver provide natural finger biomechanics, articulation and grasp which is clinically appropriate for this patient. 

The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient.  (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations.  All decisions are evidence-based).

From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, the requested durable medical equipment (bio-mechanical prosthetic thumb and finger- L7499 x 4) is medically necessary for this patient.  

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 durable medical equipment (bio-mechanical prosthetic thumb and finger- L7499 x 4) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obstructive Sleep Apnea

Treatment: Hypoglossal nerve stimulation, procedure codes L8680 and L8688

The insurer denied coverage for hypoglossal nerve stimulation, procedure codes L8680 and L8688.

The denial is overturned.

The patient has diabetes mellitus, hypertension, and obstructive sleep apnea (OSA). Her OSA was confirmed by a sleep study, which indicated an apnea hypopnea index (AHI) in the severe range measuring 45.6. Her body mass index (BMI) is 33.6. She has tried and failed continuous positive airway pressure (CPAP) and is intolerant to numerous types of masks and machines. A drug induced sleep endoscopy (DISE) showed anterior posterior airway collapse. Her provider requests approval of a hypoglossal nerve stimulator (HNS) to treat her OSA.

Hypoglossal nerve stimulation therapy (HNS) is a non-anatomical modifying surgery to treat OSA. Although this patient has a BMI of greater than 32, she underwent a DISE showing no evidence for complete concentric collapse (CCC) of her airway. "Complete concentric collapse at the level of the velum, probably the strongest contraindication to HNS" (Baptista, et al 2020). Her DISE showed evidence for anterior-posterior base of tongue collapse. She also meets all other standard indications for HNS treatment including CPAP intolerant, and AHI of less than 50. Thus, she is a good candidate for HNS despite a BMI of greater than 32 based on medical evidence.

By analyzing studies, Baptista, et al (1) states "Although HNS is currently performed in highly selected patients, several baseline parameters seem to be not related to the post-operative outcome. According to existing data, the patients' age, BMI, pre-implantation AHI, and previous surgeries are not directly involved in HNS success and could not be considered as useful predictors during the selection process. At this moment, the strongest contraindication to HNS is the complete concentric collapse of the soft palate detected during DISE, which is an essential assessment tool for pre-operative patient selection."                                                         

The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. Medical evidence is in support of using HNS to treat moderate to severe OSA in patients with a BMI of greater than 32.      

The HNS is considered medically necessary for this patient. The insurer's denial of coverage for hypoglossal nerve stimulation, procedure codes L8680 and L8688, is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abscess.
Treatment: Inpatient admission.

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

The patient is a male whose inpatient Hospital Admission is under review. The patient originally presented to urgent care after two days of symptoms associated with a forehead infection and was placed on Doxycycline and Bactrim. The next day, he was seen by Dermatology who switched to Rifampin + cefazolin. With worsening symptoms he presented to the ER (emergency room) with facial erythema and tenderness. He had no fever, nausea, vomiting. He had a headache and a history of similar facial cellulitis and abscess approximately four years prior with MRSA (methicillin-resistant Staphylococcus aureus).

In the ER (emergency room), the patient's vitals were as follows:  T (temperature) 100.0, P (pulse) 104, RR (respiration rate) 19, and BP (blood pressure) 137/87. On general examination, the patient was noted to be NAD (no acute distress). Examination of the patient's Head revealed quarter-sized abscess between eyebrows. Examination of the patient's chest, CVS (cardiovascular system), and abdomen were normal.

The patient was thought to have MRSA (methicillin-resistant Staphylococcus aureus) facial cellulitis/abscess that had failed outpatient therapy. He was treated with IV (intravenous) ceftriaxone and PO (oral) bactrim. After he was seen by Infectious Diseases consultant he was placed on IV (intravenous) Daptomycin. The abscess spontaneously drained. The patient improved and he was sent home on PO (oral) antibiotics.

Yes, the Inpatient admission was medically necessary.

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

The inpatient admission was medically necessary, because the patient had failed outpatient therapy. This is an indication for inpatient admission and IV (intravenous) therapy (1). The patient also had evidence of systemic infection (elevated pulse and WBC [white blood cell] count). This is an indication for inpatient admission and IV (intravenous) therapy (1).

The patient had a facial cellulitis and abscess that failed outpatient therapy. He had systemic symptoms, and he had an infection in a critical area (face, near eyes and brain). The guidelines and standard of care would clearly admit and treat such a patient because there was danger of extension of the infection systemically and locally (brain).  Failure to admit and treat this patient could lead to death, blindness, or permanent disability.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status asthmaticus.
Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.  The denial is overturned.

This is the case of a young child with a family history of asthma. He had been sick with a COVID-19 (2019 Novel Coronavirus) infection a few months prior to the current illness. He had a runny nose and sneezing for several days. He developed a cough the evening prior to the admission and then developed difficulty breathing when playing outside. He was brought to the Emergency Room (ER) via ambulance and received 2 doses of DuoNeb enroute for respiratory distress.

In the ER, he was in significant respiratory distress with a respiratory rate of 41 breaths per minute. He exhibited nasal flaring, abdominal breathing, subcostal and intercostal retractions. He had a fever of 101 degrees. There was wheezing heard on examination of the chest. Blood gas results indicated a pH (potential of hydrogen) of 7.33 with a partial pressure of carbon dioxide (pCO2) of 43 which indicated concern for respiratory failure. He was treated with solumedrol, an intravenous bolus of normal saline, continuous albuterol via nebulizer and high flow oxygen. When his respiratory distress did not improve, he was admitted for treatment of status asthmaticus with continued steroids, oxygen, and albuterol every 2 hours. 

The patient was treated appropriately in the ER for an acute episode of wheezing and difficulty breathing. The child has a family history of asthma. He was experiencing acute onset of respiratory distress and wheezing which did not respond to treatment in the ER. His blood gas indicated an elevated pCO2, which is a risk for respiratory failure when tachypnea persists. It was appropriate and consistent with the standard of care during a first episode of asthma for a young child to be admitted to the hospital with a diagnosis of status asthmaticus. He was not stable enough to be safely discharged since he required albuterol every 2 hours.

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

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

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


The patient was admitted with complaints of left-sided jaw and neck pain after a dental procedure. His vital signs were unremarkable. The physical exam was notable for no apparent distress (NAD), no signs of lockjaw. Lab work was unremarkable. A computed tomography (CT) scan of the neck showed left cervical lymphadenopathy (LAD), and left-sided mastoiditis and otitis media, and suspected infiltrating neoplasm, a chest x-ray (CXR) showed no active chest disease. The patient was diagnosed with a nasopharyngeal mass and treated with intravenous (IV) antibiotics and pain control. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient stay.
The hospital stay was medically necessary at an acute inpatient level of care.
This patient presented to the ED with left-sided jaw and neck pain after a dental procedure. The patient was subsequently found to have a nasopharyngeal mass, for which antibiotics were initiated and ear, nose, and throat (ENT) was consulted. The patient did not respond to a course of outpatient antibiotics, which is considered a failure, and it was recommended the patient receive IV antibiotics for the mastoiditis and otitis media. In addition, the nasopharyngeal mass is documented to have displaced the patient's airway to the right, which increases the clinical concern for acute respiratory failure, and the patient required close clinical monitoring for airway compromise and/or need for intubation, sepsis, and adequate oral intake, and this could not have been safely provided at an observation level of care. Overall, this patient's presentation and potential for decompensation meant that an inpatient level of care was medically necessary.