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

Diagnosis: Abdominal pain. 
Treatment: Inpatient hospital stay. 
The insurer denied coverage for the inpatient hospital stay. 
The denial is upheld. 
 
The patient presented with abdominal pain. She was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. The liver enzymes were normal. An abdominal ultrasound showed sludge in the gallbladder. Proton pump inhibitor (PPI) therapy was given and the pain improved. She was also treated with antibiotics. She was able to tolerate a diet. 

Medical necessity was determined based on Milliman Care Guidelines (MCG) M-05 for Undiagnosed Abdominal Pain. Clinical indications for admission include hemodynamic instability, peritoneal signs, inability to maintain oral hydration after observation care, and bacteremia. The patient did not have these conditions. 

This patient presented with abdominal pain. She had possible biliary colic but did not have acute cholecystitis. If antibiotics were felt to be necessary, she could have been treated with oral antibiotics as an outpatient. Intravenous (IV) hydration and PPI therapy could have been given in the emergency room (ER) as an outpatient. She rapidly improved without the need for any acute interventions. She could have been managed with observation status. She did not meet MCG criteria for admission for Undiagnosed Abdominal Pain. 

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 inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right foot wound.
Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is upheld.
 
This is a patient with a history of right foot amputation stump with fibro granular wound. He was admitted to the hospital due to right foot wound with hyperglycemia. During admission, urine toxicology was positive for cocaine. Vitals were stable during admission and did not display signs of sepsis, nor did the wound show signs of infection. Patient was non-compliant with diabetes medical management. Patient left hospital against medical advice (AMA).

Based on documentation provided for review the patient was stable. Patient did not display signs of sepsis, and there were negative signs of right foot infection where patient had a history of ulcer in amputation stump area. He demonstrated hyperglycemia and demonstrated non-compliance with controlling diabetes. Patient was stable upon admission.

Wang, X., Yuan, C. X., Xu, B., & Yu, Z. (2022), "Diabetic foot ulceration (DFU) is a devastating complication of diabetes that is associated with infection, amputation, and death, and is affecting increasing numbers of patients with diabetes mellitus. The pathogenesis of foot ulcers is complex, and different factors play major roles in different stages. The refractory nature of foot ulcer is reflected in that even after healing there is still a high recurrence rate and amputation rate, which means that management and nursing plans need to be considered carefully. The importance of establishment of measures for prevention and management of DFU has been emphasized. Therefore, a validated and appropriate DFU classification matching the progression is necessary for clinical diagnosis and management. In the first part of this review, we list several commonly used classification systems and describe their application conditions, scope, strengths, and limitations; in the second part, we briefly introduce the common risk factors for DFU, such as neuropathy, peripheral artery disease, foot deformities, diabetes complications, and obesity. Focusing on the relationship between the risk factors and DFU progression may facilitate prevention and timely management; in the last part, we emphasize the importance of preventive education, characterize several of the most frequently used management approaches, including glycemic control, exercise, offloading, and infection control, and call for taking into account and weighing the quality of life during the formulation of treatment plans. Multidisciplinary intervention and management of diabetic foot ulcers (DFUs) based on the effective and systematic combination of these three components will contribute to the prevention and treatment of DFUs and improve their prognosis."                                                         

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 hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fast Heart Rate.
Treatment: Inpatient Hospital Admission.

The insurer denied the inpatient hospital admission.  The denial has been upheld. 

The proposed treatment was not medically necessary.

The patient is an adult female with a past medical history of hypertension.  She presented to the emergency department for evaluation of elevated heart rates.  She had undergone robotic hysterectomy earlier on the day of presentation.  On arrival to the emergency department, the patient was afebrile, blood pressure was 163/88, heart rate was in the 120's, and she was saturating well on room air.  Initial labs were notable for white blood cell (WBC) count of 15.7, sodium of 134, and lactic acid of 2.3.  The patient's electrocardiogram (EKG) showed sinus tachycardia with a heart rate of 103 beats per minute (bpm).  The patient was started on antibiotics, antiemetics, and intravenous metoprolol and was admitted to the inpatient unit for further care.  The patient's heart rate was improved with supportive care, and she was ultimately discharged with outpatient follow-up.

The patient was hemodynamically stable and was not hypoxic. There was no evidence of sepsis, no mental status changes and no end organ malperfusion.  There was no evidence of acute coronary syndrome or acute heart failure.  Consequently, based on the provided documentation, there is insufficient clinical data to support medical necessity for inpatient level of care.       

Due to the reasons stated above, there is insufficient clinical data to support medical necessity for admission to inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Congestive heart failure, breast carcinoma and diabetes

Treatment: Consumer directed personal assistance services (CDPAS)

The insurer denied coverage for consumer directed personal assistance services (CDPAS)

The denial is upheld 


This is an adult female with chronic medical problems including congestive heart failure, breast carcinoma and diabetes.  She lives alone in a private residence.  The patient was denied by her insurer for requested consumer directed personal assistance services (CDPAS). 

The Uniform Assessment System (UAS) report shows the patient's cognitive skills are described as independent.  Her ability to complete much of her Instrumental Activities of Daily Living (IADL) tasks is also independent.  However, she reportedly requires extensive to maximal assistance for ordinary housework and shopping.  She reports being able to make a grocery list and her daughter "goes to the supermarket to select and pay at the register."  The patient is independent for activities of daily living tasks including bathing, personal hygiene, dressing, eating, bed mobility, locomotion, toilet transfer/use and ambulation.  The patient reports being infrequently incontinent of bladder and continent of bowel. There have been no reported falls over the prior 90 days.   

The patient's condition and functional deficits are not at a level or unpredictable as to require the requested consumer directed personal assistance services (CDPAS).  The letter from her treating physician was reviewed, which does not provide a description of the patient's functional deficits or any associated office visit notes.  This physician would agree the patient may benefit from monitoring for safety; particularly due to reported fatigue and shortness of breath.  However, consumer directed personal assistance services (CDPAS) for companion care or safety supervision without the direct provision of Activities of Daily Living (ADL) task assistance is not a covered service.  Based on the enclosed documents reviewed, the provision of consumer directed personal assistance services (CDPAS) for health and safety are not medically necessary at this time.  

From a physical medicine and rehabilitation perspective, the requested Consumer Directed Personal Assistance Services (CDPAS) are not medically necessary.   

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 consumer directed personal assistance services (CDPAS) services is not substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Migraine headache

Treatment: Qulipta 30 mg tablet

The insurer denied coverage for Qulipta 30 mg tablet 

The denial is overturned
 

The patient was seen by the nurse practitioner who noted that the patient reported that she had been having headache for the prior 2 months. She noted that the patient was tried on Topamax with no benefit. In the impression she noted the migraine and that the plan was to stop Topamax and use Qulipta.  There was a letter from the insurance which was final adverse determination for denial of coverage of Qulipta. It was noted that the formulary alternatives are Ajovy and Emgality. There was a letter by the nurse practitioner to appeal the denial of coverage of Qulipta. She noted that the patient suffers from daily migraines. She noted that the patient has phobia of needles and cannot use the formulary alternatives Ajovy and Emgality.

The patient failed Topamax and cannot be on the formulary alternatives due to needle phobia. Therefore, the request for Formulary Exception for Qulipta 30 milligram (mg) tablet should be approved for therapy.

Per Alsbrooks, K., et al., (2022), "Needle phobia is an overlooked condition that affects virtually all medical procedures. Our study aimed to identify how commonly needle phobia is experienced, its underlying reasons, impacts, and potential mitigation strategies. Needle phobia is an understudied condition, which is experienced by patients undergoing procedures such as venipunctures and blood donations as well as those with chronic conditions necessitating frequent injections. Needle fear exists on a continuum of severity, and can lead to delayed therapy, treatment avoidance, and vaccine hesitancy."

"Oral atogepant (Qulipta) once daily was effective in reducing the number of migraine days and headache days over a period of 12 weeks". (Ailani, J., et al., 2021).

"INDICATIONS AND USAGE: QULIPTA is a calcitonin gene-related peptide receptor antagonist indicated for the preventive treatment of episodic migraine in adults". (Qulipta Package Insert).

"Migraine is a leading cause of disability worldwide. Approximately 15% (percent) of Americans experience migraines. Most people who have migraines feel that people who do not have them often underestimate their condition. Migraines affect people's quality of life and ability to participate in work, family, and social events. A new class of medication, calcitonin gene-related peptide (CGRP) antagonists, has been approved for migraine prevention in adults" (Peters, G. L. 2019).                                                          

The formulary drugs are not expected to cause adverse effects.

The formulary drugs were not tried due to needle phobia, and the patient did not have an adverse reaction or contraindication.

The formulary drug is not expected to be ineffective.

The non- formulary drug is expected to be more effective than the formulary alternatives because the patient is willing to take a tablet orally.

The carrier's denial of a request for a Formulary Exception for Qulipta 30 milligram (mg) tablet is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: left type 2 supracondylar fracture

Treatment: inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.


This is a male child with a closed fracture of the left distal humerus. A closed reduction and pinning was performed. The medical record indicated the patient was operated on and discharged on the same day. 

The inpatient admission was not medically necessary. Evaluation and treatment could have been handled at a lower level of care, such as outpatient. There were no complicating factors that indicate the patient could not have been managed at a lower level of care. The patient underwent a relatively minor procedure, although technically difficult, and had no major swelling or neurological issues. The patient was discharged to home the day of the procedure.

Per Hope, N., & Varacallo, M., "Elbow fractures are more common in the pediatric population than in the adult population. Children often utilize an outstretched arm as a protective mechanism when falling, creating a high incidence of fractures about the elbow. Supracondylar fractures of the humerus account for up to 18% (percent) of pediatric fractures and 60% of elbow fractures. Despite evolutions in the evaluation and treatment over the years, these fractures still pose considerable challenges to orthopedic surgeons. This activity reviews the mechanism of injury, classification, and management of these injuries in the pediatric population and highlights the role of the interprofessional team in evaluating and improving the care of patients with this condition. Non-operative management is acceptable for nondisplaced Gartland I and minimally displaced Gartland IIA fractures. Management of Gartland II fractures has been controversial. Gartland II injuries can be managed non-operatively, provided that fracture alignment is satisfactory. Displacement and malunion can occur in the presence of medial column comminution. There is a risk of medial column collapse, leading to a cubitus varus deformity. A recurvatum deformity secondary to malunion can occur if the anterior humeral line does not intersect the capitellum on lateral radiographs. These three factors: medial comminution, posterior displacement, and excess swelling, are contraindications to non-operative management of Gartland II fractures."                                                         

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 inpatient hospital stay is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Motor vehicle accident.
Treatment:  Subacute rehabilitation services.

The insurer denied coverage for subacute rehabilitation services.  The denial is upheld.

This is a morbidly obese male, who was involved in a motor vehicle accident and sustained multiple fractures including rib, spinous process, left wrist, bilateral acetabular and right femur.   Weight bearing precautions included left upper extremity for approximately 6 weeks and bilateral lower extremities for approximately 6 months.  Under review is the medical necessity for subacute rehabilitation.

The patient was not an appropriate candidate for the subacute rehabilitation level of care (1, 2, 3) for the time period under review.   His functional impairments were not yet amenable to (subacute) rehabilitation therapy; primarily due to his weight bearing precautions and dependent functional status.  The care provided was primarily custodial.  The physical and occupational therapy notes also document his essentially total dependence for activities of daily living (ADL) tasks and functional mobility.  In addition, there are no physician or nursing notes documenting acute medical or complicated nursing issues to support continued subacute rehabilitation services.

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 subacute rehabilitation services is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Total hip replacement

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This is the case of a patient with a history of diabetes mellitus, dissecting AAA (abdominal aortic aneurysm), gout, DVT (deep vein thrombosis), kidney stone, osteoarthritis, peripheral vascular disease, reflux esophagitis. The patient had a replacement total hip computer assisted navigation procedure in The Hospital for Special Surgery. The patient received 24 hours of prophylactic antibiotics postoperatively and Aspirin then Eliquis for DVT prophylaxis. Patient's pain was managed on oral pain medication. Postoperative asymptomatic tachycardia was treated with intravenous (IV) hydration. 

The medical records demonstrate a person at high risk for complications. Several factors were taken into consideration. They were the Body Mass index (BMI) of greater than 35, the previous history of aneurysm, American Society of Anesthesiologists (ASA) score of 3 and peripheral vascular disease (PVD). A post-surgical event occurred where there was concern for a pulmonary embolus. There was evidence of tachycardia (one occasion 130 beats per minute) and reported pulse oxygen at 93 percent saturation on room air. There was high suspicion for a thrombotic event to require special imaging and change in treatment (bolus of IV fluid). Observation and monitoring would be mandatory. This type of service could not be provided at a lower level of care. A full hospital admission was subsequently required.

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 inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: High Blood Pressure
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult male with a chief complaint of dizziness. He was admitted for hypertension. His initial blood pressure was 238/122. The patient had multiple comorbidities including hypertension, transcatheter aortic valve replacement (TAVR), heart failure with preserved ejection fraction (HFpEF), and heavy alcohol use. He denied chest pain or dyspnea. His pulse was 100, and oxygen saturation was normal. His exam was normal without murmurs or gallops. He was treated with oral angiotensin converting enzyme (ACE) and intravenous benzodiazepine. Creatinine was elevated at 1.39 and troponin was 0.07. The patient received oral nifedipine and intravenous Lasix with good response. The echocardiogram showed transcatheter aortic valve replacement; it was otherwise normal. Electrocardiogram showed no acute changes. Chest x-ray was normal. The principal diagnosis for admission was listed as alcohol withdrawal. Inpatient level of care was denied as not medically necessary.

The proposed treatment was not medically necessary.

Determination of level of care is primarily dependent on the actual care a patient receives and, whether a higher level of acuity is needed to give this care. This is best reflected in the 
presentation, physical exam findings, and laboratory orders and their results; and highlighted in the orders for care. In this case, the symptoms were atypical and unlikely to be representative of acute coronary syndrome. There was no evidence of a hypertensive emergency, either with signs or symptoms. 
Exam and cardiac findings were normal. Biomarkers and electrocardiogram showed no evidence of acute ischemia. Chest x-ray was normal. Echocardiogram showed no wall motion abnormality. The physicians' treatment did not reflect any serious concern about the patient's cardiac condition. Orders did not include medical therapy for acute coronary syndrome such as 
intravenous heparin, dual antiplatelet inhibitors, high dose beta blockers, or intravenous nitroglycerin (NTG). The treating physicians felt it was satisfactory and safe to just treat this patient with his by mouth medications. The letter of appeal was carefully considered, but it offered no evidence to support inpatient level of care. The only cardiac care provided was telemetry, frequently performed in a lower level of care. The patient was admitted for monitoring and subsequent tests and therapy did not require an inpatient level of care. There was no complex care that required inpatient care. There are no examples of care requiring inpatient level of care. The Milliman criteria requirements for admission were not fulfilled as there was never any evidence of neurologic or cardiac instability present. All testing and therapy would be appropriate, safe and guideline consistent in a lower level of care. Therefore, an inpatient level of care was neither medically necessary nor provided. The denial explanation was consistent with guidelines and usual community care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back Pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

The patient is an adult female with multiple medical problems who presented to the emergency department with right sided pain. Labs showed elevated white count. The patient had bladder retention. During workup, the patient left against medical advice (AMA).

This was medically necessary.

The patient has multiple concerning findings including the unexplained pain and bladder incontinence which necessitated additional imaging and work-up with consultations such as neurosurgery and neurology. These were all performed within the dates in question and the need for acute inpatient hospitalization is met due to the advanced consultation, imaging and pain control required for this patient. This could not be performed at a lower level of care.