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

Diagnosis: Colon cancer, septic shock, ventilator and dialysis
dependent
Treatment: Long Term Acute Care Facility Admission (LTACH), Pre-service
The insurer denied the Long Term Acute Care Facility Admission (LTACH), Pre-service
The denial is overturned.

This male patient with a history of colon cancer was admitted with a strangulated hernia, bowel obstruction, and septic shock.  He was found to have septic emboli and abdominal abscesses.  He underwent exploratory laparotomy with placement of  abdominal drains. His hospital course was complicated by respiratory and renal failure.  

Recent clinical notes show the patient is hemodynamically stable and afebrile.  He is ventilator and dialysis dependent.  He is on a trach collar during the day and ventilator during the night.  He is receiving duobnebs every six hours.  Intravenous (IV) antibiotics were recommended.  He is tolerating a regular diet.  Hyperglycemia is controlled.  Anemia is being monitored.  The patient's abdominal wound care includes wound packing and dressing changes twice daily.  He was found to have a medial collateral ligament (MCL) strain after complaining of leg pain and is recommended for physical therapy (PT).   Long Term Acute Care Facility Admission (LTACH) is recommended.

Yes, the proposed Long Term Acute Care Facility Admission (LTACH) is medically necessary.
Long Term Acute Care (LTAC) is indicated for patients needing treatment for a primary complex condition or illness as well as active management of active comorbidities.  In long term acute care, the patient requires services of on-site specialty services, skilled nursing services and daily intervention of a medical practitioner.  

This patient has multiple conditions.  He is ventilator dependent with plan for weaning.  He has a trach that needs management.  He is dialysis dependent.  He has an abdominal wound that requires complex care with wound packing and dressing changes twice daily.  He requires monitoring of anemia and transfusions as needed.  He requires skilled rehabilitation.  A long term acute care level of care is medically necessary for the intensity of services needed with medical necessity for daily intervention of a medical practitioner.  The proposed Long Term Acute Care Facility Admission (LTACH) is medically necessary.

No, the health plan did not reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: LDL-C (High Cholesterol)

Treatment Repatha

The insurer denied coverage for Repatha

The denial is overturned

This patient has hypercholesterolemia, refractory to atorvastatin therapy. Past medical history is relevant for atherosclerotic cardiovascular disease (significant carotid and coronary artery disease requiring intervention), diabetes mellitus, and hypertension. She is treated with atorvastatin 80mg (milligrams) daily and has a contraindication to taking Zetia. Serum blood testing revealed a low-density lipoprotein (LDL) of 61.6mg/dl (milligrams per deciliter) and high-density lipoprotein (HDL) of 28mg/dl.

The patient is already on maximal statin therapy and according to documentation provided, she has a contraindication to ezetimibe.  Thus, the formulary drug is likely to cause an adverse reaction.  This patient suffers from severe atherosclerotic coronary artery and bilateral carotid artery disease.  She is on high intensity statin treatment (atorvastatin 80mg daily) with an LDL cholesterol 61.6mg/dl. Addition of a non statin agent such Evolocumab in this setting has been associated with significant cardiovascular event rate reduction regardless of serum LDL level (Reference 1,2,3). Current American Heart Association and American College of Cardiology guidelines recommend addition of PCSK-9 (a protein that's made in the liver) inhibitor therapy to maximally tolerated statin therapy in patients at high risk for future Atherosclerotic cardiovascular disease (ASCVD) events including those with multivessel disease and diabetes (Reference 1,2).  According to the European Society of Cardiology guidelines this patient with documented ASCVD and diabetes mellitus (DM) is considered to have "very high risk" of cardiovascular event (Reference 3).  Such patients are given a class I indication for treatment with non-statin therapy such as evolocumab when LDL-C (high cholesterol) levels are greater than 55mg/dl (Reference 3). In conclusion, the proposed treatment is medically necessary and is more effective than the formulary medication as the patient has a contraindication to ezetimibe.

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

Based on the above, the medical necessity for the Repatha is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male who suffered blunt scrotal trauma. Following the injury, he presented to the emergency room (ER). Ultrasonography was consistent with testicular injury worrisome for rupture. He was taken to the operating room where a traumatic laceration was confirmed. Debridement and repair were performed uneventfully.
Following the procedure, he was afebrile, had managed post operative discomfort, and voided. Vital signs remained stable. Acute postoperative care and intervention was not needed. Under review is the inpatient level of care.

Inpatient hospital admission was not medically necessary. Based on the submitted documentation, the patient may have been safely and properly managed at a lower level of care. Advancement to inpatient status may have been deferred pending his post operative course.
Following the surgical procedure, the patient received routine and appropriate nursing care. He voided well, tolerated orals, and had proper pain control. He remained afebrile. Activity was appropriate for the next level of care. No additional interventions were needed. His treatment did not require an acute inpatient hospital admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neck pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a woman with SLE (systemic lupus erythematosus) and asthma. She was admitted after having neck pain for one to two months. Her neurologist had tried steroids and gabapentin during this time, but because the pain was getting worse and she had blurred vision, radiation of neck pain to extremities and headache that was rated as severe and leukocytosis, she was admitted for a lumbar puncture to rule out meningitis after a bedside LP (lumbar puncture) was unsuccessful. Neurology was consulted. She was ultimately diagnosed with bilateral occipital neuralgia.

The inpatient hospitalization was deemed by the plan as not medically necessary, as the patient did not ultimately have a condition that was considered severe and warranted inpatient hospitalization. This denial is being appealed.

No, the Inpatient admission was not medically necessary.
The inpatient admission is not considered medically necessary because patient could have received the same care at a lower level of care status. Although there was concern initially for meningitis, this was ultimately ruled out.  MCG (Milliman Care Guidelines) guidelines are applicable when a patient has a confirmed diagnosis of a severe condition that is causing the headaches including subarachnoid hemorrhage, cerebral hemorrhage, and meningitis to name a few. The patient did not have any of this so per the guidelines, admission would not be warranted. Furthermore, IV (intravenous) steroids were given, however this could have been done at a lower level of care status.

Yes, the health plan acted reasonably, with sound medical judgement and in the best interest of the patient, as the hospital stay could have been done at a lower level of care status with equivalent level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Endometriosis, Uterine Fibroids

Treatment: inpatient admission

The insurer denied coverage for inpatient admission,

The denial is upheld.

The patient had a history of endometriosis, uterine fibroids, perimenopausal menorrhagia, hydrosalpinx and obesity who was scheduled for a robotic assisted total vaginal hysterectomy, bilateral salpingectomy, lysis of adhesions, cystoscopy, and left ovarian cystectomy. The surgery was without complication. Blood loss was 75cc (cubic centimeters).  She was transferred from the post-anesthesia care unit (PACU) to an inpatient unit for post-operative recovery. She was later discharged.

There are many ways of doing a hysterectomy. The trend has been towards less invasive procedures. Conventional and robotic laparoscopy share similar advantages over laparotomy, including decreased morbidity, rapid recovery, and improved aesthetics of incisions.  Laparoscopic hysterectomies are outpatient procedures unless a complication arises. Admission becomes necessary if the patient is febrile, hypotensive, bleeding, has difficulty breathing or the severity of the pain is such that admission is necessary. According to Milliman Care Guidelines, Inpatient and Surgical Care 24 Edition, Laparoscopic hysterectomy, a laparoscopic hysterectomy is an ambulatory procedure. Inpatient stay may be needed for:

1)	Surgical complications (bladder ureter or bowel injury or hemorrhage)
2)	Conversion to abdominal hysterectomy
3)	Complex surgery (staging of endometrial cancer)
4)	Wound complications 
5)	Comorbidities.

This patient did not have any of these criteria. Her procedure was uncomplicated. There was no evidence of any injury to other organs. Post operatively, the patient was stable. Nothing in the operative report or the progress notes suggested any serious problem that warranted admission. Please note that laparoscopic hysterectomy is an outpatient procedure and includes appropriate postoperative monitoring and an overnight stay if required.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient. Based on the above, the inpatient admission was not medically necessary.

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: Gender Dysphoria. 
Treatment: Bilateral Mastectomy. 

The insurer denied Bilateral Mastectomy. 
The health plan's determination is overturned. 

This is a patient with gender dysphoria. Chest dysphoria began. The chest deformity results in debilitating anxiety, social avoidance and poor self-confidence. Gender affirming chest surgery (top surgery [Bilateral Mastectomy]) is planned and is under review. 

The bilateral mastectomy is medically necessary. 

Per the World Professional Association for Transgender Health (WPATH) "Standards of Care for the Health of Transsexual, Transgender, and Gender- Nonconforming People" 7th Edition guidelines: 
Criteria for Breast/Chest Surgery (One Referral) 
Criteria for mastectomy and creation of a male chest in FtM (female to male) patients: 
1) Persistent, well-documented gender dysphoria 
2) Capacity to make a fully informed decision and to consent for treatment 
3) Age of majority in a given country (if younger, follow the SOC(standards of care) for children and adolescents) 
4) If significant medical or mental health concerns are present, they must be reasonably well controlled. 
Hormone therapy is not a prerequisite. 
Regarding chest surgery for adolescents, WPATH guidelines are as follows: "Chest surgery in FtM patients could be carried out earlier, preferably after ample time of living in the desired gender role and after one year of testosterone treatment. The intent of this suggested sequence is to give adolescents sufficient opportunity to experience and socially adjust in a more masculine gender role, before undergoing irreversible surgery. However, different approaches may be more suitable, depending on an adolescent's specific clinical situation and goals for gender identity expression." 
The patient meets these guidelines. The patient has well documented gender dysphoria and has the capacity to make an informed decision. Mental health concerns are managed by the therapist. The patent's mental health professional has recommended the mastectomies. The standard of care for adolescent top surgery is met.
Appeal type: Medical necessity
Decision: Upheld

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

This patient is a previously healthy man who presented to the ED (emergency department) with left testicular/left groin pain. The pain was described as severe 9/10 and of 6-hours duration.

The patient was clinically and hemodynamically stable at the time of presentation. Labs and vital signs were normal. He was imaged with scrotal ultrasound and abdominal and pelvic CT (computed tomography) scan. There was no evidence for testicular torsion, rupture or mass. There was a small left varicocele. The CT (computed tomography) scan did not equivocal findings for early appendicitis.

Surgical and urology consultation was obtained and the patient was treated pain medication. The diet was advanced and pain medications were converted to oral. The submitted nursing, surgical, urology and ED (emergency department) records document hemodynamic stability during the period of monitoring. The pain was improved and he was discharged from the hospital.

The health plan denied coverage of inpatient admission for this patient on the basis of medical necessity. This is being appealed.

No, the Inpatient admission was not medically necessary.
This patient presented to the ED (emergency department) with a left testicular/left groin pain. He was evaluated and imaged in the ED (emergency department). Surgical and urology consultations were obtained, and the patient was monitored overnight.  The records support that inpatient care and treatment was not medically necessary. This patient required prompt evaluation for left testicular/left groin pain. However, the care and treatment provided could have reasonably been provided in the observation setting with monitoring.

This patient did not require inpatient admission, as provision of IV (intravenous) fluid, pain medications, antiemetics, and surgical assessment could have been appropriately provided in the observation setting. This level of care would have provided for regular clinical assessment, follow up monitoring, surgery and urology consultations, provision of the prescribed IV (intravenous) medications and fluid. The observation level of care would have also allowed for overnight observation.

Yes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient.
Inpatient care was not medically necessary, as the care provided could have reasonably been rendered with a lower level of care (observation).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin dysesthesia. 
Treatment: Ultraviolet Light System (code E06994). 

The insurer denied the Ultraviolet Light System (code E06994). 
The denial is upheld. 

The patient is a male with skin dysesthesia.  The provider is requesting a home phototherapy unit.  The prior denial reason was that this is considered investigational and not medically necessary for this diagnosis. 

No, the proposed treatment is not medically necessary. 

There is no evidence based medical literature to support use of phototherapy in this case.  Dysesthesia is a generic term for a cutaneous symptom--such as pruritus, burning, tingling, stinging, anesthesia, hypoesthesia, tickling, crawling, cold sensation, or even pain--without a primary cutaneous condition in a well-defined location that is often caused by nerve trauma, impingement, or irritation. There are multiple types of dysesthesias depending on the body location and the nerves involved. While location, exact symptoms, and etiologies might vary, the underlying theme is that these conditions are of neurologic origin and have dermatologic consequences. For many of these conditions, the symptoms are localized to the skin, and patients frequently present to the dermatologist. 

Treatment primarily involves treating the underlying condition. Gabapentin may reduce pain associated with polyneuropathy and is generally well tolerated. Tricyclic antidepressants have been utilized for many years for this condition and are generally considered effective.  Many other medications have also been tried in the treatment of painful polyneuropathy with varying success, including duloxetine, pregabalin, carbamazepine, phenytoin, topiramate, baclofen, mexiletine, and dextromethorphan. However, there are no well-executed studies comparing the effectiveness of these drugs for this condition, thereby limiting the ability of practitioners to make evidence-based decisions. 

Simultaneous treatment with drugs such as tramadol, nonsteroidal anti-inflammatory drugs (NSAIDs), or low-dose narcotics may be necessary in some patients for occasional "breakthrough pain." 

Physical therapy evaluation is important in patients with significant weakness. Appropriate use of ankle-foot orthoses, splints, and walking assistance devices can significantly improve lifestyle in the face of significant disability. 

Patients with distal polyneuropathy are at increased risk for developing foot ulcers; proper foot and nail care is especially important in this population. Regular visits to a podiatrist can also help prevent problems. 

No evidence based medical literature was found assessing the use of phototherapy for this condition.  Assessment of the underlying condition with referral to Neurology may be appropriate. 

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

Diagnosis: Prostate Cancer Gleeson Group 2

Treatment: Genetic testing of prostate tissue with Oncotype DX (likelihood of cancer spreading to other body areas) for prostate cancer (code 0047U)

The insurer denied coverage for genetic testing of prostate tissue with Oncotype DX for prostate cancer (code 0047U).

The denial is upheld.

This is a patient had prostate specific antigen (PSA) 4.78. The patient is diagnosed with prostate cancer Gleeson group 2. The patient was considering active surveillance for treatment, and Oncotype Dx Genomic Prostate Score (GPS) test was ordered. GPS score 26, indicating favorable risk.

The insurer has denied coverage for the Oncotype Dx as not medically necessary, as medical criteria for genetic testing was not met. The appeal on behalf of the patient by Genomic Health, Inc. is noted. 

While current National Comprehensive Cancer Network (NCCN). Guidelines state that men with low risk/favorable intermediate risk prostate cancer and at least a 10-15 year life expectancy may consider the usage of genomic biomarker tests like Oncotype Dx they also note the absence of randomized prospective trials. 

The American Urologic Association (AUA) guidelines are not so positive stating that "tissue based genomic biomarker (such as Oncotype Dx) have not shown a clear role in active surveillance for localized prostate cancer and are not necessary for follow up." 

There is currently no level I evidence supporting use of genomic biomarker in clinically localized prostate cancer. The most common result of a genomic biomarker test is no change in the clinical risk profile. The impact of genomic biomarker tests in clinical practice and long-term patient outcomes remains to be empirically demonstrated. Prospective studies of these types of tests addressing a true clinical benefit when implemented in clinical practice are still lacking.

The health care plan acted reasonably and with sound medical judgement and in the best interest of the patient. The genetic testing of prostate tissue with Oncotype Dx for prostate cancer (code 0047U) is not considered medically necessary for this patient.

The insurer's denial of coverage genetic testing of prostate tissue with Oncotype DX for prostate cancer (code 0047U) is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: upper gastrointestinal (GI) bleed

Treatment: inpatient hospital admission

The insurer is denied coverage for inpatient hospital admission

The denial is modified. 

This male patient has a history of hypertension, dyslipidemia, and participation in a methadone maintenance program (MMTP).

The inpatient hospital admission is partially medically necessary. Full length of stay was not. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. However, an admission for two days should have been sufficient. The patient could have been transfused on the same day as admission and have recovered earlier with outpatient PPI.      

This patient presented to the emergency room (ER) , with hemoglobin (Hgb) level dropped from 10.1 to 6.3, over a month. He reports taking 10-12 aspirins per day, over the past month. The patient was admitted with severe anemia, likely secondary to an upper gastrointestinal (GI) bleed. On admission, Hgb was 6.6 (normal 13.5-17.5), and hematocrit (Hct) was 21 (normal 38.3-48.6). Stool occult blood was positive. The patient was started on a proton pump inhibitor (PPI). One unit of packed red blood cells (PRBC) was transfused . The patient was discharged.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient. An admission for two days should have been sufficient.

The carrier's denial of coverage for inpatient hospital admission is modified.  The medical necessity is partially substantiated.