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

Diagnosis: Dizziness and Low Blood Pressure
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

He patient is an adult male who had a submitted diagnosis of Dizziness and Low Blood Pressure. He was hospitalized for 3 days. His past medical history includes treatment for known HFrEF (heart failure with reduced ejection fraction) with EF (ejection fraction) 10-15%, ICD (implantable cardioverter defibrillator) for VFib (ventricular fibrillation) arrest and schizoaffective disorder. He presented to the ED (emergency department) for evaluation of lightheadedness, dyspnea and hypotension. The patient was afebrile, blood pressure was 79/51, pulse 77 and O2 (oxygen) saturation 98% on nasal cannula. Breath sounds were noted to be diminished, and he had leg edema. BNP (brain natriuretic peptide) was 102. EKG (electrocardiogram) showed sinus rhythm with right axis deviation. Chest film showed clear lungs. Treatment included IV (intravenous) fluids and cardiology consultation. The patient left AMA (against medical advice). The requested coverage for inpatient hospitalization was denied coverage by the health plan as not medically necessary. The denial is being appealed.

The Inpatient Hospital Admission was not medically necessary.

Based on the peer reviewed medical literature, including the MCG (Milliman Care Guidelines) guidelines for dizziness and syncope, there was not a documented medical need for the acute inpatient hospital stay, because the criteria for inpatient stay are not met. The submitted documentation shows that the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. Per the MCG (Milliman Care Guidelines) guideline, there was no suspicion of imminently dangerous cause, like pericardial tamponade, pulmonary embolism, syncope causing injury requiring hospitalization, inpatient admission required rather than observation care because of a significant finding or clinical condition judged too severe or too persistent to be within scope of observation care, such as hemodynamic instability that is severe or persistent, cardiac arrhythmias of immediate concern, acute coronary syndrome or myocardial Infarction, structural cardiac disorder like severe aortic stenosis or suspected as cause that requires immediate correction, respiratory distress, stroke, seizures, altered mental status, severe electrolyte abnormalities requiring inpatient care or other significant finding, or clinical condition judged not to be within scope of observation care. In this particular case, there was no clinical decline or inadequate response to treatment which required continuation of the hospital stay past the observation period. The care he received for iatrogenic hypotension corrected by IVF (intravenous fluid) resuscitation like in this case, is routinely provided safely and effectively at a lower level of care. Therefore, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting and Abdominal Pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult female who presented to the emergency department with chest and abdominal pain, nausea and vomiting. Comorbid health conditions included hypertension, diabetes, and asthma. At the time of presentation, the patient was without fever and vital signs identified normal heart rate. The blood pressure was 160/82 millimeters of mercury (mmHg). She was tender in the right upper quadrant. The white blood cell (WBC) count was normal at 9.6 thousand. The complete metabolic panel identified normal liver enzymes and normal bilirubin. Ultrasound and computed tomography scan showed gallstones with equivocal gallbladder wall edema. The patient was admitted to the hospital and initially treated with intravenous fluid, antibiotics, and antiemetics. Surgery consultation was obtained. The surgical recommendation was that the patient follow up in the outpatient clinic. It was also recommended that the patient continue a course of oral antibiotics post discharge. The records indicate that the next day the patient felt better and wanted to eat. She was started on a liquid diet. The discharge note states that the patient wanted to leave the hospital against medical advice (AMA). The denial letter referenced InterQual 2022 Adult General Medical, Gastrointestinal Criteria and summarizes the health plan rationale for denial of inpatient level of care.

The inpatient level of care was not medically necessary in this case.

This patient presented to the emergency department with abdominal pain that was attributed to biliary disease. She had normal vital signs. She had a normal white blood cell count of 9.6 thousand and imaging confirmation of cholelithiasis per ultrasound and computed tomography scan. While lab data identified mild hyperglycemia and hypomagnesemia, these conditions did not require inpatient admission. The patient was appropriately provided intravenous fluid. The surgical consultation yielded the recommendation for surgical follow up in the outpatient setting with plans for interval cholecystectomy. On day #2 the patient felt better and was able to tolerate a liquid diet. She opted to leave the hospital against medical advice.
The submitted records do not support the medical necessity of inpatient admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe atopic dermatitis and alopecia areata

Treatment: Dupixent Syn 300

The insurer denied coverage for Dupixent Syn 300

The denial is overturned
 

The patient is an adult female with a diagnosis of severe atopic dermatitis involving the face, arms, and legs as well as alopecia areata of the eyebrows.  The patient has had excellent clinical response to Dupixent for atopic dermatitis and Opzelura topical cream to the eyebrows for alopecia areata as well as breakthrough eczema plaques.  The request is for the concomitant use of Dupixent with Opzelura.  

Based on the submitted documentation and the standard of care, the use of Dupixent and Opzelura is medically necessary.  The patient has had an excellent clinical response to Dupixent for treatment of her atopic dermatitis.  The patient also suffers from alopecia areata which has responded to topical Opzelura to the eyebrows and integrin-linked kinase (ILK) and clobetasol to the scalp lesions.  Limited options exist for topical treatment of alopecia areata of the eyebrows given the risks associated with steroid use.  Dupixent (an IL4-IL5 inhibitor) and Opzelura (a JAK inhibitor) work through varying mechanisms and there are no known contraindications or drug-drug reactions to the concomitant use of systemic Dupixent and topical Opzelura.  Opzelura can also be used to treat breakthrough eczema lesions.  Based on the provided documentation, the use of Opzelura with Dupixent is medically necessary and within the standard of care. 

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 Dupixent Syn 300 services is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Personal Care Aide (PCA) and Consumer Directed Personal Assistance Program (CDPAP) Services: Live-In - Per Diem, 1 Day x 7 Days per Week - Total of 7 Days per Week
The insurer denied Personal Care Aide (PCA) and Consumer Directed Personal Assistance Program (CDPAP) Services: Live-In - Per Diem, 1 Day x 7 Days per Week - Total of 7 Days per Week.
The health plan's determination is overturned. 

This is a case review for a male with medical history notable for dementia, incontinence, blindness, and mobility issues. The patient has dementia and gets dizzy spells when walking. His daughter works and no one is at home to care for the patient. The patient gets very confused at home and has called 911 for help multiple times. The physician reports that additional hours will be necessary for the patient.

The requested Personal Care Aide (PCA) and Consumer Directed Personal Assistance Program (CDPAP) Services: Live-In - Per Diem, 1 Day x 7 Days per Week - Total of 7 Days per Week is medically necessary for this patient.
The patient has advanced dementia. He is incontinent of urine and stool and unable to manage his own incontinence care products. He is unable to complete toileting, transfers, or ambulation without assistance. He is also legally blind which will result in challenges with performing all activities of daily living. His personal care needs are, by definition, continuous and unscheduled throughout the day at night. Therefore, the requested services are medically necessary and reasonable for the patient. Failure to address his personal care needs to result in injuries, skin breakdown, and/or infection.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Shoulder pain. 
Treatment: Pain Injection (20552 x 1). 

The insurer denied: Pain Injection (20552 x 1). 
The denial is overturned. 

The patient is an adult female. She has history of right trapezius and shoulder pain that goes into the right arm and hand for the prior five to six months. Past treatments include home physical therapy, stretching, home exercise, Mobic, and Aleve. Past intervention includes a trigger point injection with local anesthetic last year that "worked well" and helped until 6 months ago. The patient's physical examination of 4 months ago shows return of right paracervical and trapezius, which is the same as previous, and positive Spurling's test. The request for right trapezius trigger point injection was denied coverage by the health plan as not meeting clinical guideline criteria for repeat injection. The denial is being appealed. 

The requested injection is medically necessary. 

The patient had one trigger point injection last year. This was noted to have relieved pain and improved function until 6 months ago. The patient is participating in a comprehensive program consisting of physical therapy and non-steroidal anti-inflammatory drugs (NSAIDs). It has been more than 12 months since the previous trigger point injection. The patient had nearly a year of relief with a single local anesthetic injection. At this time, the same pain is reproduced on clinical exam. As such, it is clinically reasonable to repeat the injection at this time. Therefore, the requested health service is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: nasal obstruction
Treatment: VivAer Procedure: Repair of Nasal Valve Collapse with Temperature-Controlled Radiofrequency
The insurer denied VivAer Procedure: Repair of Nasal Valve Collapse with Temperature-Controlled Radiofrequency. The health plan's determination is overturned. 

The patient is a female who complains of longstanding nasal airway obstruction for at least the last 3 years. According to the letter from her provider, she has tried and failed nasal steroid sprays, antihistamines and oral antibiotics. The current diagnosis is nasal airway obstruction secondary to nasal valve collapse, inferior turbinate hypertrophy and enlargement of the septal swell body. The current treatment plan is for an in office Vivaer procedure which uses temperature controlled radiofrequency for soft tissue remodeling of the affected area intranasally. 

The proposed treatment is more likely to be beneficial than the standard treatment for this condition. The standard treatment would consist of continued medical management with nasal steroids which has not been effective up to this point.
More invasive surgical options would include open functional septorhinoplasty, which can be quite effective in treating this condition. However, the Vivaer procedure can accomplish much of the same effect in a much less invasive fashion without anesthesia.
Numerous studies (including RCTs (randomized controlled trials)) have shown that temperature controlled treatment of the nasal valve area, inferior turbinates and septal swell body is effective for treating this area when it is the source of nasal obstruction.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: nasal obstruction
Treatment: VivAer Procedure: Repair of Nasal Valve Collapse with Temperature-Controlled Radiofrequency
The insurer denied VivAer Procedure: Repair of Nasal Valve Collapse with Temperature-Controlled Radiofrequency. The health plan's determination is overturned. 

The patient is a woman with a history of nasal congestion/obstruction/snoring for over 3 years with symptoms improved with modified Cottle maneuver. Based on submitted medical records/treating physical statements, she has received multiple treatments including intranasal corticosteroids, oral antihistamines, and oral antibiotics in the past without sustained improvement in symptoms. Clinical exam/nasal endoscopy exam was consistent with severe turbinate hypertrophy, septal swell bodies, and stenosis of the nasal valve/nasal valve collapse.

The VivAer is likely to be more beneficial for this patient since she has received standard treatments to date without sufficient improvement in symptoms. The patient has received a thorough workup including physical examination and appropriate standard medical treatment for treatment of nasal congestion/obstruction. The patient has undergone maximal medical therapy including undergoing treatment with intranasal corticosteroids, oral antibiotics, and oral antihistamines without sufficient improvement in symptoms. Clinical examination confirmed the patient had nasal valve stenosis contributing to the patient's symptoms of nasal congestion. The ViVaer is used to coagulate soft tissue in the nasal airway to strategically treat nasal airway obstruction by shrinking submucosal tissue and is an appropriate next step in treatment for this patient. VivAer received Food and Drug Administration (FDA) approval for this indication in 2017. There is sufficient clinical trials and peer reviewed literature to support the benefits of the procedure in appropriate patients such as this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: nasal obstruction
Treatment: VivAer Procedure: Repair of Nasal Valve Collapse with Temperature-Controlled Radiofrequency
The insurer denied VivAer Procedure: Repair of Nasal Valve Collapse with Temperature-Controlled Radiofrequency. The health plan's determination is overturned. 

The patient is a female with a history of nasal obstruction and nasal valve collapse for 3+ years. She has symptoms of nasal congestion, fatigue, and snoring. Prior treatment had included nasal steroids, oral antihistamines, and oral antibiotics. When the patient performed a modified Cottle maneuver (pulling the side of the nose to the side), the congestion symptoms were improved.

VivAer Procedure: Repair of Nasal Valve Collapse with Temperature-Controlled Radiofrequency is likely to be more beneficial than standard treatment for this patient.  This procedure involves using radiofrequency to scar up the lateral nasal cartilage to prevent the medial collapse. The current literature shows that the VivAer device was able to perform some "remodeling of the nasal valve that may have a profound effect on perceived nasal obstruction, despite little effect on nasal resistance." The patient failed conservative treatment and therefore the requested procedure is indicated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Renal disease. 
Treatment: Inpatient hospital admission. 
The insurer denied the inpatient hospital admission. 
The health plan's determination is upheld. 

The patient is a female with a history of end stage renal disease (ESRD) on hemodialysis who presented for evaluation after undergoing a LUE (left upper extremity) atrioventricular (AV) graft creation/revision. She was complaining of a post-procedural hematoma. 
She was afebrile and hemodynamically stable. Her labs were remarkable for a potassium of 6.1. On repeat examination, distal ulnar, radial, palmar arched graft all had doppler pulses present. The patient did not complain of new onset weakness, numbness or tingling in the LUE. 
The inpatient admission was not medically necessary based on the documentation provided. The patient underwent a left upper extremity atrioventricular (AV) graft procedure which was complicated by a hematoma and initial concern for possible decreased distal pulses. She was hemodynamically stable. She was not complaining of limb pain, numbness or weakness. Repeat doppler evaluations confirmed good distal pulses without signs of limb ischemia. It was noted that the initial doppler reading may have been faulty. The patient did not have severe electrolyte or metabolic abnormalities. She did not have respiratory distress or cardiac arrhythmias. She did not have severe or persistent changes in mental status. She could have been safely and effectively managed at lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hearing loss
Treatment: Digital Binaural Hearing Aids (2 units)
The insurer denied: Digital Binaural Hearing Aids (2 units)
The denial is overturned.

The patient is an elderly patient with sloping severe to profound bilateral sensorineural hearing loss. The patient has six-year-old hearing aids which are not currently beneficial and cannot be repaired. The hearing aids are broken and cannot be tested.

The proposed treatment is medically necessary.

The patient has severe to profound hearing loss that can only be managed with hearing aids or cochlear implant. The patient is in need of hearing aids for basic functions of daily living with hearing at the current levels.
Appeal type: Medical necessity
Decision: Upheld

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

This is a male patient with a past medical history (PMH) of seizures, gastroesophageal reflux disease (GERD), and alcohol abuse who was admitted with complaints of (c/o) a seizure after medication non-adherence. The physical exam was notable for the patient being awake, alert, and oriented times three (AAOx3). Imaging studies included a computed tomography (CT) scan of the head which showed no acute pathology, a chest x-ray (CXR) showed no evidence of active pulmonary disease. The patient was diagnosed with a seizure and was treated with intravenous (IV) Keppra, folic acid, intravenous fluids (IVF), antibiotics, benzodiazepines (BZDs), and thiamine. The patient was discharged against medical advice (AMA). At issue is the medical necessity of an inpatient level of care.

The hospital stay was not medically necessary at an acute inpatient level of care. This patient without a significant psychiatric history presented to the emergency department (ED) with complaints of (c/o) a seizure after medication non-adherence. The patient's mental status was documented to recover on admission documentation. The patient was hemodynamically stable, there was no hypoxia, respiratory failure or distress, apnea, intentional overdose/exposure, disruptive/uncooperative behavior, other acute co-existing illness, fever, significant trauma, focal deficits or unstable vital signs. In addition, there was no status epilepticus, poorly controlled repetitive seizures, delirium tremens, need for immediate surgical intervention, acute/subacute stroke, intracranial bleed, encephalitis, or eclampsia. There was a question of alcohol withdrawal, but the patient's Clinical Institute Withdrawal Assessment (CIWA) was 2 on admission with a decrease to zero, while there was also a question of pneumonia in the ED based on a wet CXR read with the final read with no active pulmonary disease. The patient received clinical monitoring, Keppra, imaging work-up and BZDs as needed (PRN), and these interventions could have been safely provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastrointestinal Bleeding. 
Treatment: Air ambulance transportation/rotary wing, code: A0431 and A0436. 

The insurer denied coverage for air ambulance transportation/rotary wing, code: A0431 and A0436. 

The denial is upheld. 

The patient presented with weakness and passing bright red blood per rectum. The hemoglobin was 8. His vital signs were stable. There was no gastroenterologist available to care for the patient. He required a transfer to a distant hospital.  An air ambulance was requested. It is reported that the airtime would be 2.5 hours while the drive time is 3 hours. The patient was against the air transfer but his physician insisted. He was transferred with intravenous (IV) fluids but was not receiving a blood transfusion. 

The Centers for Medicare and Medicaid Services has issued guidelines for Rotary Wing Air Ambulance transport. An air ambulance is furnished when the patient's medical condition is such that ground transportation by ambulance is not appropriate. The air ambulance may be necessary when the patient requires rapid transport to a treatment facility at either great distances or other obstacles such as heavy traffic or if a land ambulance is not available. 

This patient had gastrointestinal bleeding but was reported to be hemodynamically stable. He required transportation to a facility that had a gastroenterologist available. However, he was able to be transferred by land ambulance. He did not have unstable vital signs and was not being transfused. The difference in travel time between air travel and land ambulance would not have been clinically significant. The health care plan acted reasonably and with sound medical judgment. A rotary wing air ambulance was 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 air ambulance transportation / rotary wing, code: A0431 and A0436, services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cystinuria and Nephrolithiasis
Treatment: Thiola 100mg Tablet, take 3 tablets daily for 1 year
The insurer denied: Thiola 100mg Tablet, take 3 tablets daily for 1 year
The denial is upheld.

The patient is a teenage male with chronic kidney disease and cystinuria. He is on Thiola (tiopronin), which has been denied coverage by the health plan. The health plan denied coverage of the request, as there is no documentation regarding trial, failure, or contraindication to generic alternative tiopronin. The denial is being appealed.

The requested health service is not medically necessary.

The requested medication would be considered for the convenience of the patient or the practitioner, and, therefore, not considered medically necessary. There is no documentation regarding trial, failure, or contraindication to the health plan's preferred alternative. There are no large randomized controlled studies showing superiority of the requested medication over the preferred alternative. Therefore, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient, as medical necessity cannot be established.