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

Diagnosis:  Right flank pain, vomiting (kidney stones).
Treatment:  In patient Hospital Admission.
The insurer denied the Inpatient Hospital Admission.  
The denial is upheld.

The patient is an adult female, seven weeks post partum, seen initially in the emergency room with the complaint of right flank pain, nausea and vomiting. Radiologic evaluation demonstrated right ureterovesical junction stone, moderate right hydroureteronephrosis and stones in both kidneys. The patient requested discharge with trial of outpatient management. She was discharged to home on Zofran, but the patient was not aware of script for Zofran. 

The patient represented to the emergency room the next day with complaint of intermittent right flank pain, nine out of ten, and nausea/vomiting. The patient received two liters of intravenous fluids in the emergency department and Zofran with improvement in her pain from nine out of ten to three out of ten but had 300 cubic centimeters brown emesis in emergency department after the fluids and Zofran. The patient was noted to be afebrile in the emergency department with stable vital signs. Her white blood cell count was noted to be elevated at 17.1, and her urinalysis showed bacteria, three to five white blood cells (WBCs) and red blood cells. An inpatient admission order was placed with the patient placed nothing by mouth (NPO) after midnight, urology consult placed, and the patient was started on antibiotic therapy and pain control. 

Overnight, the patient's temperature maximum was 38.5 Celsius. Urology consult noted urinalysis results with question of contamination or obstruction - reviewed studies and recommended ureteroscopy, possible laser lithotripsy and stent. The patient underwent ureteroscopy, stone basket removal and stent placement and was discharged to home the next day. Urinalysis on discharge was negative for nitrites and leukocyte esterase and white blood cell count had improved to 11.7. 

Coverage of the inpatient admission was denied by the health plan as it was not medically necessary, as it did not meet Milliman Care Guideline criteria.

The proposed inpatient hospital admission was not medically necessary.

The patient was seen the day prior to admission and returned with complaints of recurrent flank pain, nausea and vomiting. She was afebrile and hemodynamically stable on presentation to the emergency department. The patient failed a trial of hydration and Zofran with recurrent emesis and was noted to have an elevation in her white blood cell count and creatinine and thus warranted further care.  However, as the patient was known to have two kidneys, only one of which was obstructed, was hemodynamically stable, pain had improved with Toradol, urinalysis was equivocal for urinary tract infection per the urology note, urinalysis was negative for nitrites and was negative for leukocyte esterase, and, as there was no history of urinary tract infections, the patient could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female who initially was directed from a clinic to the emergency department with concerns about hyperglycemia. Pertinent history included diabetes mellitus, hypertension, and chronic kidney disease stage 2. Initial vital signs revealed a temperature of 97.6oF, heart rate (HR) of 70, blood pressure (BP) of 95/61, respiratory rate (RR) of 18, and peripheral capillary oxygen saturation (SpO2) of 97% on room air. Initial examination documented the patient as alert and oriented without neurologic focal deficits. 

The inpatient hospital admission was not medically necessary. Evaluation and management could have been performed at a lower level of care. The patient had a history of diabetes mellitus type and hypertension and was directed to the emergency department for concerns of hyperglycemia and low blood pressure. The initial evaluation documented the patient as alert and oriented with a serum glucose of 442. There was no evidence of diabetic ketoacidosis or other significant pathology. Treatment included aggressive fluid resuscitation and subcutaneous insulin. Following emergency department care, serum glucose decreased to an appropriate level and hemodynamics were stable. No other acute issues or complications were documented.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Diabetic gastroparesis.
Treatment:  Inpatient Hospital Admission.

The insurer denied the Inpatient Hospital Admission.  The denial is upheld.

The patient is an adult male with diabetic gastroparesis, who presented with nausea and vomiting that started suddenly that morning. The patient was hemodynamically stable. His white blood cell (WBC) count was 17.8, and his glucose was 211. Ultrasound and x-ray were negative. The patient was hydrated and treated with pain medication. The next day there was no vomiting, and the patient was tolerating a clear liquid diet. The following day, the patient signed out against medical advice (AMA).

The proposed inpatient hospital admission was not medically necessary.

The patient had just started vomiting that morning and was hemodynamically stable.  He did not have persistent vomiting, hematemesis, dehydration, perforation or pneumonia.  In addition, there were no abnormal laboratory values. Ultrasound and x-ray were negative. Therefore, the requested acute inpatient hospital stay was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Moderate to Severe Ulcerative Colitis
Treatment: Rinvoq tab 45 mg (milligrams) ER (extended release)
The insurer denied coverage for Rinvoq tab 45 mg ER
The denial is overturned

The patient has moderate to severe ulcerative colitis and has already failed high dose infliximab, Stelara, and Entyvio. His physician is now advising him to take Rinvoq. 

The Lancet Volume 399, Issue 10341, Pages 2077-2078 has an article titled " Upadacitinib for ulcerative colitis". This drug is a selective inhibitor of the JAK1 (Janus Kinases 1) enzyme. Patients receiving Rinvoq were significantly more likely to obtain clinical remission and to maintain clinical remission as compared to placebo. Based on these results, Rinvoq was approved by the Food and Drug Administration (FDA) for the treatment of ulcerative colitis. 

The insurance company has denied Rinvoq because the patient did not receive Humira. However, the patient did receive a different tumor necrosis factor (TNF) blocker which was infliximab and failed this treatment. In addition, he has failed multiple other biologic agents. It would not be appropriate to try Humira on this patient given the history of already failing a TNF blocker. Furthermore, Sandborn et al in a study of Rinvoq wherein the majority of patients enrolled had shown an inadequate response to anti-TNF agents or other biologics, Rinvoq was found to be superior to placebo. The FDA has also approved Rinvoq. "Rinvoq is indicated for the treatment of adult patients with moderately to severely active ulcerative colitis who have had an inadequate response or intolerance to one or more TNF blockers." Therefore, giving Rinvoq is a medically necessary treatment. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for Rinvoq tab 45 milligrams (mg) ER is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia, heart failure, atrial fibrillation, and abnormal gait
Treatment: Increase in personal care aide (PCA) - 7 days for 12 hours for 2 shifts, a total of 168 hours/week
The insurer denied an increase in PCA - 7 days for 12 hours for 2 shifts, a total of 168 hours/week.
The denial is upheld.

This elderly male has conditions including dementia, heart failure, atrial fibrillation, and abnormal gait.  He lives with his daughter and son-in-law.  He is appealing denial of increase personal care aide (PCA) to seven days/week for two-12 hour shifts, a total of 168 hours/week.  The health plan approved 55 hours/week.  Uniform assessment system (UAS) evaluation completed shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, managing finances and medication, phone use, and shopping; maximal assistance with bathing and toilet use; extensive assistance with stairs, transportation, personal hygiene, and dressing; limited assistance with walking, locomotion, toilet transfer, and bed mobility; and supervision with eating.  A letter states the patient needs split shift home care due to dementia. The patient is forgetful and needs assistance with activities of daily living (ADLs) and personal needs.  Another letter states the patient needs assistance with toileting and ambulation.  He cannot sleep and wanders.  He is a fall risk.  A night log shows attendance for coughing, wandering, undressing and toileting.

The proposed treatment is not 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 PCA, 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 patient has dementia.  He is appealing denial of increase in PCA to seven days/week for two-12 hours shift, a total of 168 hours/week.  The health plan approved 55 hours/week.  Appeal statements are provided requesting split shift home care due to dementia, wandering, and for assistance with ADLs.  The night log shows the patient getting attendance for a variety of issues including redirecting.  The log does not show frequent care for toileting.  PCA is not indicated for supervision or when no tasks are being performed.  The patient does not have continuous needs for PCA services.  The proposed PCA 12 hours split shift times two is not medically necessary.  The approved PCA 55 hours/week is appropriate for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: GERD (Gastroesophageal Reflux Disease).
Treatment: transoral incisionless fundoplication (EsophyX).
The insurer denied transoral incisionless fundoplication (EsophyX).
The determination is overturned.

The patient has gastroesophageal reflux disease (GERD) and epigastric pain. An esophagogastroduodenoscopy showed irregular squamocolumnar junction, a small hiatal hernia, patchy gastric erythema, and normal duodenum. He has failed several proton pump inhibitors including Dexilant, histamine (H2) receptor antagonists twice daily, and sucralfate; in the past he failed omeprazole, pantoprazole, rabeprazole, lansoprazole, and esomeprazole. At issue is whether transoral incisionless fundoplication (EsophyX) is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The requested transoral incisionless fundoplication (EsophyX) is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.  The efficacy of transoral incisionless fundoplication (TIF) using the EsophyX device has been studied in a meta-analysis including 3 randomized controlled trials (including 233 patients at 3 years), with finding of improved esophageal pH, decreased proton pump inhibitor utilization, and improved quality of life compared with proton pump inhibitor therapy of sham treatment [1-4]. The American College of Gastroenterology (ACG) guidelines for the treatment of gastroesophageal reflux disease (GERD) state that "We suggest consideration of transoral incisionless fundoplication (TIF) for patients with troublesome regurgitation or heartburn who do not wish to undergo antireflux surgery and who do not have severe reflux esophagitis (Los Angeles (LA) grade C or D) or hiatal hernias greater than (>) 2 centimeters (cm)"; in this case, the patient does not have severe reflux esophagitis or hiatal hernia larger than 2 cm [5]. American Gastroenterological Association (AGA) guidelines also recommend TIF as an "effective endoscopic option in carefully selected patients" [6]. The patient has attempted therapy with multiple proton pump inhibitors, as recommended by ACG guidelines, without control of symptoms. For these reasons, the use of transoral incisionless fundoplication is supported as likely to be more beneficial than any standard treatment or treatments for the insured's gastroesophageal reflux disease (GERD).
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: GERD (Gastroesophageal Reflux Disease).
Treatment: Transoral incisionless fundoplication (EsophyX)
The insurer denied the transoral incisionless fundoplication (EsophyX).
The determination is upheld.

The patient is under evaluation and management for gastroesophageal reflux disease (GERD). The patient is not obese. He experiences heartburn, regurgitation and belching. The patient has been treated with numerous proton-pump inhibitor (PPI) medications, most recently in combination with sucralfate. An upper endoscopy did not show erosive esophagitis, and he has a 2 centimeter (cm) hiatal hernia.
The patient's provider has recommended treatment with the transoral incisionless fundoplication (TIF) procedure. At issue is whether transoral incisionless fundoplication (EsophyX) is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

Transoral incisionless fundoplication (EsophyX) is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The patient has symptoms of acid reflux; however, the patient has not responded to multiple medicines for treatment of this disorder. This raises the concern that the patient is not truly having pathologic acid reflux as the cause of symptoms. In order to fully investigate this patient prior to contemplating either endoscopic or surgical fundoplication, a high-resolution esophageal manometry followed by a 24-hour combined potential hydrogen (pH)/impedance study would be needed.  For example, this patient may have functional heartburn, whereby there is no pathologic acid reflux, and isolated brief reflux events do not correlate with the sensation of heartburn or regurgitation (a low symptom associated probability). This disorder is treated with neuromodulator therapy, not a procedure. Without full testing, no procedure is indicated to treat this patient's symptoms. Therefore, the transoral incisionless fundoplication (EsophyX) is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dehydration
Treatment: Inpatient Hospital Stay. 
The health plan denied the inpatient hospital stay as not medically necessary. 
The health plan's determination is upheld. 

The patient is a female with a past medical history (PMH) of autism, who presented to the emergency department (ED) with 1 day of non-bloody, non-bilious (NBNB) emesis consistent with hypoglycemic and hyponatremic dehydration. The initial labs were concerning for a glucose of 47, a sodium of 143, a carbon dioxide (CO2) of 19, and a lactate of 3.1. In the ED, the patient was given intravenous (IV) bolus fluids x 3 and started on maintenance fluids. The decision was made for inpatient admission to the hospital for ongoing monitoring and serial repeat labs. Overnight, the patient improved with no continued emesis, tolerated oral intake, and had normalization of labs (a glucose of 130, a sodium of 140, a CO2 of 24, and a lactate of 2), and therefore, she was able to be discharged home with out-patient primary care physician follow up. 
At issue is the medical necessity of the inpatient admission. 

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

The requested health service/treatment of inpatient admission was not medically necessary for this patient. This patient did meet criteria for an admission for the diagnosis of dehydration; however, treatment could have been provided at an alternate level of care. On admission, the patient was having ongoing symptoms of NBNB emesis. The initial lab values were consistent with mild dehydration, including her glucose of 47, her sodium of 143, her CO2 of 19, and her lactate of 3.1. With the ongoing symptoms, the patient would not have been able to tolerate oral rehydration alone and required IV treatment. Indications for ongoing IV therapy (and need for observation admission rather than discharge from the emergency room) include inability to tolerate oral intake and need for ongoing lab monitoring after initial bolus - both of which were met by this patient. While this patient did require overnight admission to the hospital for continued treatment (IV fluids) and ongoing repeat lab monitoring, she should have been admitted to an alternate level of care. Per the documentation, the patient did not meet standards for inpatient status. While admission was medically necessary for this patient, it should have been at an alternate level of care, not inpatient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: atrial fibrillation.
Treatment: coronary angiography.
The insurer denied the coronary angiography. 
The health plan's determination is overturned.

The patient is a man with hypertension, hyperlipidemia, and a history of atrial fibrillation with the previous ablation. He complains of dyspnea on exertion and chest pain occurring multiple times per day. The patient is on two antianginal agents, amlodipine and metoprolol, with continued symptoms. An Echocardiography showed normal left ventricular systolic function. A Nuclear stress test showed an inferior reversible defect compatible with myocardial ischemia.

Coronary angiography is medically necessary.
The patient has chest pain and dyspnea that may be cardiac in origin. The provider properly recommended an echocardiogram which showed normal left ventricular (LV) function. He then ordered a nuclear stress test which suggested inferior ischemia. The stress test results fall in the spectrum between "low" and "intermediate" risk. The patient is on 2 antianginal agents with persistent symptoms. It is appropriate to perform coronary angiography to determine if the patient has obstructive coronary artery disease.
By the American College of Cardiology (ACC) Appropriate Use Criteria (AUC), performing coronary angiography classified is as appropriate, Indication 16, score 7 if the stress test is classified as intermediate, and uncertain, Indication 15, score 4 if classified as low risk. In either case, coronary angiography is reasonable and considered within the standard of care for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope.
Treatment: Leadless Pacemaker.
The insurer denied: Leadless Pacemaker.
The denial is upheld.

The patient is a male with recurrent syncope that is thought to be neurocardiogenic in etiology. Ambulatory electrocardiographic monitoring revealed marked sinus pauses of 18 and 25 seconds in duration. Medical necessity for a leadless permanent cardiac pacemaker is at issue.

The health plan's determination is upheld.

Based on the documentation provided a leadless pacemaker is not medically necessary. The medical necessity for a leadless cardiac pacemaker for the management of this patient's neurocardiogenic syncope (NCS) is at issue. The primary advantage of a leadless pacemaker is the elimination of several complications associated with transvenous pacemakers and associated intra-cardiac leads. They have particular advantages for use in children and relatively young adults in that the need for lead extraction, or multiple lead implantations over time as previously implanted leads fail, is mitigated. However, at present, the available leadless pacemakers are capable of only pacing the right ventricle. Pacing in this particular case has been recommended for the treatment of syncope due to NCS. While, as in this case, NCS can be associated with marked bradycardia and significant sinus pauses, there is often a considerable vasodepressor response as well, and pacing alone does not necessarily prevent syncope. Nonetheless, in selected patients pacing can be effective in preventing frank syncope. Given the hemodynamic benefits of atrioventricular (AV) synchrony with dual chamber pacing, versus single chamber ventricular pacing, current guidelines endorse the use of dual-chamber devices when cardiac pacing is used in the treatment of NCS. Per the 2017 American College of Cardiology (ACC)/American Heart Association (AHA)/Heart Rhythm Society (HRS) Guideline for the Evaluation and Management of Patients With Syncope, "Dual-chamber pacing might be reasonable in a select population of patients 40 years of age or older with recurrent vasovagal syncope and prolonged spontaneous pauses." Since the leadless pacemaker cannot provide dual chamber pacing, current guidelines do not support its use in this instance.