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

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a history of coronary artery disease, previous percutaneous coronary intervention (PCI) / stent placement to the left anterior descending coronary artery (2009), hypertension, hyperlipidemia, and gastroesophageal reflux disease and presented to the emergency room with chest pain. He experienced left-sided chest pressure with exertion that day. There was no radiation of the pain, nausea, vomiting, diaphoresis or dyspnea. The symptoms lasted minutes and resolved with rest. He took aspirin without improvement in symptoms.
In the emergency room (ER), his blood pressure (BP) was 143/100 millimeters of mercury [mmHg] (decreased to 129/79 mmHg by the time of admission), pulse 71 beats per minute (bpm) and respiratory rate 20/ min. He was afebrile. EKG showed normal sinus rhythm, normal axis and intervals. There were no ST segment or T wave changes. Troponin levels were negative. D dimer was negative.
He was admitted and seen in cardiology consultation. His second set of cardiac enzymes were also negative. He was asymptomatic after ambulating. He was discharged home with plans to follow up as an outpatient with his private cardiologist within one week. At issue is the medical necessity of an inpatient stay.
The requested health service of inpatient hospital stay was not medically necessary.
The patient has coronary artery disease, with previous percutaneous coronary revascularization, and presented with chest pain. However, he was hemodynamically stable and had no evidence for acute coronary syndrome based on cardiac enzymes or EKGs. He had no evidence for pulmonary embolus, pneumonia, aortic dissection or other critical cardiac or pulmonary diagnosis requiring inpatient admission. Care could have been provided at a lower level than inpatient. Per the Milliman Guidelines for inpatient admission for Chest Pain, indications for admission include: hemodynamic instability, respiratory distress, angina or myocardial infarction (which requires abnormal cardiac enzymes and/or EKGs), or chest pain indicative of a serious diagnosis requiring inpatient treatment, such as aortic dissection. None of these conditions were present in this case. Inpatient admission was not medically necessary for this stable patient with no objective evidence for an acute coronary syndrome.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal-Cholecystitis/Inflammation of the Gallbladder
Treatment: Inpatient hospital stay
The health plan denied the inpatient stay as not medically necessary. 
The reviewer has upheld the health plan determination in whole.

The patient presented to the hospital emergency department (ED)with right upper abdominal pain, nausea, vomiting, and bloating. The patient had a past medical history of morbid obesity status post gastric sleeve, anxiety and depression. The patient was tender in the right upper abdomen. At the time of presentation the patient was without fever and vital signs were normal. The white blood cell count (WBC) was elevated at 12.3 K. The complete metabolic panel identified normal transaminases and bilirubin. Ultrasound showed gallstones. A computed tomography (CT) scan and magnetic resonance cholangiopancreatography (MRCP) were subsequently performed confirming the diagnosis of cholelithiasis.

The patient was initially treated with intravenous (IV) fluid and IV antibiotics. The patient underwent cholecystectomy. A cholangiogram was not able to be performed due to inability to advance the cholangiocatheter. The operative dictation describes an otherwise uncomplicated cholecystectomy procedure. The patient was started on a clear liquid diet. The following day the patient was considered to be stable for discharge home with arrangements for outpatient follow up.

An inpatient level of care was not medically necessary in this case. This patient presented to the hospital with acute cholecystitis. Imaging with ultrasound, in addition to lab data support the diagnosis of acute cholecystitis with a leukocytosis of 12.3 K. The patient underwent an uncomplicated cholecystectomy procedure. The post-surgical course was uncomplicated. Diet was advanced. Vital signs remained normal. Pain was controlled with oral medication.
An inpatient designation was not consistent with professional guidelines. Inpatient care is needed when there is Failure to achieve discharge status criteria, Conversion to open surgery, Severe systemic infection, Care for active comorbidities, of Complications of the procedure. [5] In this case, the submitted documentation does not support that any of these clinical conditions existed to warrant an inpatient level of care. A lower level of care would have appropriately provided for a pre-surgical assessment, operative treatment and post-surgical care and monitoring including overnight care.
Appeal type: Medical necessity
Decision: Upheld

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

The patient presented to the hospital emergency department (ED) with upper abdominal pain, nausea, and vomiting. She had a past medical history of morbid obesity status post gastric bypass (current body mass index (BMI) 26.5 kilograms per square meter (kg/m2)). She had tenderness in the right upper abdomen. At the time of presentation, the patient was without a fever and her vital signs were normal. The white blood cell count (WBC) count was elevated at 12.3 thousand (K). The complete metabolic panel identified elevated transaminases and a normal total bilirubin. An ultrasound showed gallstones.
She was initially treated with intravenous (IV) fluid and IV antibiotics. The patient underwent a cholecystectomy. The operative dictation describes an uncomplicated cholecystectomy procedure. She was started on a clear liquid diet, the patient was considered to be stable for discharge home with arrangements for outpatient follow up.
At issue is the medical necessity of an inpatient stay.

The patient presented to the hospital with acute cholecystitis. Imaging with ultrasound, in addition to lab data, support the diagnosis of acute cholecystitis with a leukocytosis of 12.3 K. The patient underwent an uncomplicated cholecystectomy procedure. Her post-surgical course was uncomplicated. Her diet was advanced. Her vital signs remained normal. Her pain was controlled with oral medication.
An inpatient stay was not consistent with standard guidelines during this time. Inpatient care may be needed when there is:

   Failure to achieve discharge status criteria,
    Conversion to open surgery,
    Severe systemic infection,
    Care for active comorbidities,
    Complications of the procedure.

In this case, the submitted documentation does not support that any of these clinical conditions existed to warrant an inpatient level of care.
A lower level of care would have appropriately provided for pre-surgical assessment, operative treatment and post-surgical care and monitoring including overnight care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Moderate teeth crowding and traumatic deep bite with soft tissue damage.
Treatment:  Braces.

The insurer denied the braces.  The denial is upheld. 

The patient is a male.  The request is for dental benefits for orthodontic treatment.  Clinical analysis indicates that the patient has moderate teeth crowding and traumatic deep bite with soft tissue damage.

No, the proposed treatment is not medically necessary.

As stated in the summary of the clinical exam and analysis, the patient has a deep bite with trauma / damage to the gums.  This summary also details several normal conditions, such as a Class I normal occlusion, normal jaw size and all adult teeth being present in the mouth.  Typically, a deep bite with trauma to gums would be an automatic qualifier for orthodontic treatment; however, this is not evident on the intra-oral photos submitted for this case.  The gums of the anterior maxilla show no evidence of trauma, redness, swelling, or ulceration of the soft tissue (gums). The photos do not support the degree of severity of dental malocclusion to warrant orthodontic treatment.

Yes, the health plan acted in the best interest of the patient and with sound medical judgement because the clinical summary and photos do not support the degree of severity of dental malocclusion to warrant orthodontic treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Psoriasis.
Treatment:  Otezla.

The insurer denied the Otezla.  The denial is overturned. 

The patient is a man with severe generalized psoriasis for whom Otezla is requested.  He has tried and failed topical steroids.  He was on Otezla in the past with good results.  He has diabetes.

Yes, the treatment with Otezla is medically necessary.

The current treatment guidelines, which are in accordance with nationally accepted standards of medical practice for moderate to severe plaque psoriasis, recommend typical first-line treatments such as topical corticosteroids and calcipotriene, followed by typical second-line treatments such as ultraviolet phototherapy, oral systemic treatments (methotrexate, cyclosporine) and biologics. 

The patient has psoriasis of the head - therefore, phototherapy is not an appropriate option for treatment.  Cyclosporine is not a reasonable long-term option for the patient because of the side effect profile.  Methotrexate has life-threatening side effects and a much more severe side-effect profile than Otezla, which he has taken in the past and had a good response to. 

Otezla, an inhibitor of phosphodiesterase 4 (PDE4), is indicated for the treatment of adult patients with active psoriatic arthritis and patients with moderate to severe plaque psoriasis, who are candidates for phototherapy or systemic therapy (Celgene).  Otezla is an oral small molecule inhibitor of phosphodiesterase 4 (PDE4) specific for cyclic adenosine monophosphate (cAMP) and is indicated for the treatment of adult patients with active psoriatic arthritis (PsA) as well as the treatment of patients with moderate to severe plaque psoriasis (Celgene).

The patient has moderate to severe psoriasis, for which therapy with Otezla is appropriate and medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

This is a female patient with a diagnosis of fibroid uterus and menorrhagia who was referred by her provider to the Hospital for evaluation and management of anemia. Her hemoglobin was 4.3. The patient was also tachycardic. She received 3 units of Packed Red Blood Cells (PRBC) in the Emergency Department (ED). A progress note on day 2 of admission documented that the patient was stable and tachycardia has resolved. Her hematocrit was stable and the patient was discharged on day 3 of admission.

This patient had significant tachycardia; she was symptomatic for anemia. This patient also fulfills the transfusion guidelines for use of blood components: her hemoglobin was less than 8 and she was symptomatic, so transfusion was necessary. However, transfusions are done routinely in outpatient settings (oncology clinics, infusion centers, even at home). So the need for transfusion is not a reason for admission.

This patient was admitted and transfused. Except for receiving 3 units of PRBC, no other acute services were provided in the hospital. Ideally this patient could have been transfused in the ED, monitored for a few hours, her Complete Blood Count (CBC) repeated and then discharged home with a follow up within 24 hours with her Gynecologist. The treatment provided in the hospital could have been provided as an outpatient.

Milliman Care Guidelines (MCG) lists the clinical indication for inpatient care for patients with anemia. These include: active massive hemorrhage, active hemolysis, cognitive impairment, tachycardia, orthostatic changes, heart failure, chest pain, syncope. This patient did not have any of these. The patient could have been transfused in the observation area and discharged after finishing her transfusion.

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 carrier's denial of coverage for the inpatient hospital admission is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Cancer.
Treatment:  Proton Beam Therapy.

The insurer denied proton beam therapy.  The health plan's determination is upheld. 

This patient is a man with a history of an oral cavity squamous cell carcinoma post resection and radiation therapy.  He then had two recurrences with close margins and positive cervical lymph nodes for metastases in the most recent surgery.  Re-irradiation with concurrent chemotherapy are recommended, and the proton beam approach is being requested.

The recommended proton beam radiation for this patient is not considered medically necessary based on review of the clinical information.  There is a lack of any comparison radiation plans between photon beam and proton beam approach in this re-irradiation scenario.  There are published data supporting the use of proton beam radiation in the re-irradiation setting where protons have proven to protect previously irradiated critical vital structures in the treatment field. 

In this patient's case, no comparison radiation treatment plans were provided to show the benefit of protons over photons.  Without comparison plans provided for this patent, the requested proton beam radiation therapy is considered not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorder. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied a Dupilumab (Dupixent) 300MG/2ML SC SOPN as not medically necessary. 
The denial was upheld in whole.

The patient is a male with moderate atopic dermatitis of the trunk and extremities. The patient has tried and failed topical steroids such as triamcinolone and clobetasol and mometasone, calcineurin inhibitors, and phototherapy. The patient was previously on Dupixent with excellent disease control. Methotrexate was avoided because of acid reflux, fatty liver disease, and a positive Hepatitis B Core Antibody. The patient discontinued Dupixent because of the COVID-19 pandemic. Health plan coverage of renew of Dupixent treatment is under review for medical necessity. Health plan denial of Dupixent coverage is upheld. No, the requested health service/treatment of Dupilumab (Dupixent) 300MG/2ML SC SOPN is not medically necessary for this patient.
The patient has no documented treatment failure with, or true medical contraindication to, either topical calcineurin inhibitors, or standard, first-line oral medications such as Methotrexate, or Azathioprine, and/or a resumption of light therapy. With monitoring through blood work and a gastrointestinal (GI) consult if needed, Methotrexate would be an appropriate alternative given this patients situation. Additionally, cyclosporine in addition to azathioprine is also acceptable with monitoring. Appropriate alternative treatments have not been exhausted to date, and therefore Dupixent is not medically necessary. Alternative topical, light, and/or oral therapies are appropriate for this patient, and even during the current pandemic. Dupixent is not proven to be superior to all other preferred alternatives as per comparative, controlled studies. Therefore, consistent with current medical literature [1-4], the requested Dupixent is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse/Addiction. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient admission. 
The denial is upheld in uphold.

The patient is a male with past medical history of alcohol abuse without history of alcohol withdrawal seizures or delirium tremens, hypertension, hyperlipidemia, asthma, and glaucoma, who presented to the emergency department with tremors, anxiety, and request for undergoing alcohol detoxification.

On presentation, he was afebrile with blood pressure 143/85, heart rate 108, respiratory rate 18, and oxygen saturation 98% on room air. Exam otherwise noted visible tremor and tongue fasciculations in addition to tachycardia. Clinical Institute Withdrawal Assessment (CIWA) score was noted to be 9. He was given Librium in the emergency department and subsequently brought into the hospital with plans for alcohol detoxification.

On the patient was hemodynamically stable without persistent tachycardia, severe uncontrolled hypertension or hypotension. He was alert and oriented and tremors nearly subsided. CIWA score was noted to be 3 at highest. Labs noted aspartate aminotransferase (AST) 182 and alanine aminotransferase (ALT) 129. Discussions continued about potentially starting disulfiram and pursuing rehabilitation treatment.
The patient was ultimately discharged home with referral for outpatient substance use counseling. The issue in question is the medical necessity for the inpatient hospital stay.

The health plan's determination is upheld in whole.

The requested health service/treatment of inpatient hospital admission was not medically necessary for this patient. This is a patient who presented with mild alcohol withdrawal with CIWA score of 9 without other symptoms and in the setting of no history of alcohol withdrawal seizures of delirium. He remained hemodynamically stable throughout his course with CIWA documented at 3-4 after admission, no nausea, vomiting, or altered mental status, and without need for frequent IV Ativan. Inpatient level of care was not necessary  in the setting of mild withdrawal and no history of alcohol-withdrawal seizures or other acute issues requiring hospitalization. The patient could have been treated at a lower level of care status. Inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriatic Arthritis.
Treatment: Simponi Aria.
The health plan denied the requested dosage of Simponi Aria. 
The health plan's determination is upheld.

The patient is a male with very refractory psoriatic arthritis. The issue in this case is Simponi Aria every 6 weeks. Prior treatment includes: Arava, Otezla Cosentyx, Humira, Siliq, Stelara, Taltz, Tremfya, Remicade and Skyrizi. He is currently on oral methotrexate (MTX) and Simponi Aria 2mg/kg every 8 weeks consistent with Food and Drug Administration (FDA) approved dosing.
At issue is the medical necessity of the requested dosage of Simponi Aria.

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

No, the requested health service/treatment of Simponi Aria is not medically necessary for this patient. There is no data supporting its use every 6 weeks. The approved dose for psoriatic arthritis is 2 mg/kg at weeks 0, 4, and then every 8 weeks thereafter.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain. 

Treatment: Inpatient admission at the acute inpatient level of care. 

The insurer denied coverage for the inpatient admission at the acute inpatient level of care. 

The denial is upheld. 

This is a pregnant female patient at 25.3 weeks gestation who presented to the hospital as a transfer from another hospital with complaints of 10 out of 10, right lower quadrant abdominal pain. An ultrasound was done at the prior facility. The patient's fetal heart rate was 148 beats per minute and there was fetal movement. The patient had right-sided hydronephrosis. An abdominal ultrasound and Magnetic Resonance Imaging (MRI) of the abdomen were done. The patient's appendix was not visualized. The patient's labs were within normal limits and the urinalysis was unremarkable. In the Emergency Room (ER), the patient's vital signs were stable, and her white blood cell (WBC) count was 16. The patient was admitted with abdominal pain. Surgery and urology services consulted over the case. It was unlikely that the patient had appendicitis. The physician recommended treating the patient for a hydroureter, possible kidney stones, or a urinary tract infection (UTI). Surgical intervention was not needed. Recommendations included observing the patient and administering antibiotics. The care plan was implemented and the patient's condition improved. The patient was discharged on day 2 of admission. 

Based on the review of the medical record, this patient had complaints of severe abdominal pain. However evaluation did not reveal any anomaly. There was no evidence of appendicitis, kidney stone or other anomalies. The patient's fetus was doing well and the patient was not in labor, bleeding or febrile. There was no evidence of ruptured membranes. 

As per Milliman Care Guidelines (MCG), antepartum admission is considered medically necessary for the following conditions: (1) Condition requiring premature delivery; (2) Delivery; (3) Fetal distress or demise; (4) Preterm labor and positive fetal fibronectin test; (5) Significant maternal disease, infection or comorbidity as cause; (6) Significant vaginal bleeding or any vaginal bleeding with known placenta previa, vasa previa or placenta accreta; (7) Tocolytic therapy that requires inpatient care; (8) Complications of tocolytic treatment. In this case, this patient did not have any of the above indications. After observation for a few hours and ascertaining there was no serious cause for the pain, the patient could have been sent home on oral analgesics. Note that neither surgical nor urology consult required inpatient admission. 

Based on the review of the medical literature, inpatient admission at the acute inpatient level of care is not considered medically necessary for this patient. 

The health plan acted reasonably with sound medical judgment and in the best interest of the patient. 

Based on the above, the medical necessity for the inpatient admission at the acute inpatient level of care is not substantiated. The insurer's denial should be upheld.