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

Diagnosis: Sickle Cell Anemia
Treatment Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a history of homozygous sickle anemia who was admitted to the hospital due to a pain crisis and urinary tract infection (UTI). The patient reported bilateral knee pain. Vital signs revealed a temperature of 98.1 degrees Fahrenheit, heart rate (HR) 108, respiratory rate (RR) 18, blood pressure (BP) 128/86, and oxygen saturation (O2 sat) of 100%. The white blood cell count (WBC) was 33.1. She had an electrocardiogram (ECG), 3 units of packed red blood cells (PRBCs) for a hemoglobin of 5.5, a chest x-ray (CXR), plain film x-rays of the left and right knee, Fentanyl, Dilaudid and Rocephin. X-rays were negative and the ECG was unrevealing. The urine grew Escherichia (E) coli and blood cultures were negative.
The medical necessity of an inpatient hospitalization is under review.

The requested health service/treatment of inpatient stay was not medically necessary for this patient. The patient was admitted to receive intravenous (IV) opiates, packed red blood cell (PRBC) transfusions, Rocephin and intravenous fluids (IVF).  Cardiology evaluated her due to a slightly abnormal ECG and no further intervention was recommended regarding this issue and she was subsequently cleared.  Her pain did resolve with all of the aforementioned measures and she was stable for discharge to be sent home on by mouth (PO) Bactrim for 6 days, folic acid and Hydrea.  The interventions were all appropriate for the care of this patient but they could have been provided at a lower level of care and did not require inpatient hospitalization.   According to the Milliman Care Guidelines (MCG) inpatient criteria for sickle cell anemia, admission is indicated when 1 or more of the following are seen: stroke, seizure, posterior reversible encephalopathy, or other serious central nervous system (CNS) event, acute chest syndrome, hypoxemia, emergent surgery, acute ischemia manifested by metabolic acidosis, cyanotic extremities or ischemic bowel. Other indications are aplastic crisis, acute renal failure, traumatic hyphema, infection requiring inpatient treatment such as bacteremia, altered mental status, pain insufficiently responsive to observation care that requires treatment in the inpatient setting, inability to maintain hydrations orally despite observation care, exchange transfusion or osteomyelitis or septic joint.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asymptomatic thrombocytopenia.

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld. 

This is a female patient with multiple medical problems including anemia, nerve sheath tumor, and traumatic brain injury. She was sent by her doctor to the Emergency Room for a bone marrow biopsy and platelet transfusion for a platelet count of 17,000. She had a similar episode two weeks prior. This was an ongoing established issue in this patient. On arrival she was noted to be stable with stable vital signs, otherwise normal labs and no documented bleeding. She was admitted, received a platelet transfusion and then left against medical advice (AMA).

At the time of hospitalization she had asymptomatic thrombocytopenia. A simple outpatient platelet transfusion was all that was necessary. Acute level hospitalization for a platelet transfusion is not warranted. As this was an established issue there was no emergent need to perform bone marrow biopsy. Bone marrow biopsy is an outpatient procedure that can be performed in a physician office and does not require an acute level care. Therefore, the acute level hospitalization was not medically necessary.

Per Khan, A. M., Mydra, H., & Nevarez, A. (2017), "Immune thrombocytopenia (ITP), previously called idiopathic thrombocytopenia purpura, is an autoimmune disorder characterized by a severe reduction in peripheral blood platelet count.  In healthy individuals, normal platelet count ranges from 150450  109/L [liter], while in thrombocytopenia counts fall to less than 100  109/L.1 In adults, the incidence of ITP is approximately two to four per 100,000.2,3 Bleeding risks, specifically hemorrhage and intracranial hemorrhage, represent the most serious complications for patients with ITP."

Per Jinna, S., and Khandhar, P.B. (2020), "Thrombocytopenic emergencies that require immediate action includes conditions of suspected HIT [heparin-induced thrombocytopenia], TTP [thrombotic thrombocytopenic purpura], HUS [hemolytic uremic syndrome], drug-induced ITP, pregnancy with severe thrombocytopenia, bleeding with severe thrombocytopenia, urgently needed an invasive procedure in the presence of severe thrombocytopenia, leukopenia, and aplastic anemia."                                                         

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:  Hyperglycemia.
Treatment:  Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

The patient was admitted to the hospital due to hyperglycemia. He has a history metastatic melanoma and had been receiving Vedolizumab. He presented to the clinic with a blood sugar of 470 in addition to dizziness, increased thirst and continued diarrhea. He had a normal heart rate and blood pressure, was afebrile and had a normal oxygen saturation (O2 sat) on room air. A complete blood count (CBC) was normal except for mild anemia. The creatinine was normal and there as no indication of acidosis. Vitamin D was low and therapy was started.

He was admitted and given insulin, loperamide, intravenous fluids (IVF), and he received an esophagogastroduodenoscopy (EGD) and colonoscopy, which were normal except for a polyp. Pancreatic enzymes were initiated, and he was discharged to home with a glucose of 161.

The medical necessity of an inpatient hospitalization is under review.

The requested health service/treatment of inpatient hospital stay was not medically necessary for this patient. This patient had symptoms of hyperglycemia that could have been treated at a lower level of care.  He had dizziness and increased thirst as a result of dehydration.  These do not require admission under inpatient status. The diarrhea was chronic and not acute.  He had been on various agents for control of that symptom complex.  None of the interventions required inpatient status.  All of the procedures, interventions, medications could have been delivered in the outpatient or observation status.  The signs and symptoms of this patient's hyperglycemia were the typical symptoms seen in such patients and did not require inpatient hospitalization.
According to the Milliman Care Guidelines (MCG) inpatient admission for diabetes is indicated by 1 or more of the following: Diabetic ketoacidosis or hyperglycemic hyperosmolar state., hyperglycemia requiring inpatient care requires hemodynamic instability, altered mental status, dehydration that is severe of persistent, vomiting that is severe or persistent, significant electrolyte abnormality, glucose persistently too high that presents concern for redevelopment of dehydration or electrolyte abnormality or not sufficiently stable despite observation of care. Also included in this would be the inability to maintain oral hydration or tolerate diet despite observation care treatment and glucose management regimen suitable for outpatient setting not able to be arranged in observation care, needed supplies or medication not available and/or ability to adhere to treatment regimen or outpatient follow up is unclear. Lastly, if there was inpatient treatment needed of the underlying etiology of the hyperglycemia, none of those parameters were documented in this instance. Care could have been provided at a lower level than inpatient. Therefore, the inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Migraine Headaches.

Treatment: Procedure code J3032 - Vyepti (eptinezumab).

The insurer denied coverage for procedure code J3032 - Vyepti (eptinezumab).

The denial is overturned.  

This female patient has a diagnosis of chronic migraines without aura and intractable migraines. She is under the treatment with a neurologist. She was previously treated with Emgality, Ajovy or Aimovig for her condition. The patient is currently being treated with Botox every 10 weeks. She is also on topiramate and amitriptyline. The patient reports an increase in headaches, and the treatment plan is to also start Vyepti to treat her chronic migraines.

Vyepti is approved by the Food and Drug Administration (FDA) for migraine. (1) The patient suffers severe and frequent migraines which have been refractory to other medications including other calcitonin gene-related peptide (CGRP) inhibitors. She continues to have migraines despite taking several preventative medications including Botox. FDA prescribing information does not mention any concomitant medication such as Botox as being a contraindication for Vyepti, and current clinical practice is to add a CGRP drug such as Vyepti to a migraine patient's current anti-migraine regimen. (1,2,3) At least one study specifically addresses the safety and effectiveness of the combination of Botox and a CGRP inhibitor. (4) Vyepti for treatment of migraine headache is medically necessary.

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

The medical necessity for procedure code J3032 - Vyepti (eptinezumab) is substantiated. The carrier's denial of coverage is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Advanced dementia.
Treatment: Increase Personal Care Services, Level II, To 24 Hours Per Day, 7 Days Per Week (split-shift) Total of 168 Hours Per Week.
The insurer denied the Increase Personal Care Services, Level II, To 24 Hours Per Day, 7 Days Per Week (split-shift) Total of 168 Hours Per Week.
The denial is overturned. 

The patient is a male with a history of dementia. Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs). An appeal review was requested for potential approval of 168 hours per week Personal Assistance Services to offer increased ADL (activities of daily living) support.

Yes, the Increase Personal Care Services, Level II To 24 Hours Per Day, 7 Days Per Week (split-shift) Total of 168 Hours Per Week is medically necessary.

This is a male with a history of dementia. Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs). Recent documentation from the patient's medical provider indicates that due to worsening cognitive decline, urinary/fecal incontinence and gait ataxia/fall risk; the currently approved plan of 43 hours per week Personal Assistance Services is insufficient to meet the patient's current needs. For these reasons, the proposed treatment 168 hours per week Personal Assistance Services is deemed medically necessary.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Hypertension.

Treatment: Edarbyclor 40/12.5mg Tablet (azlisartan-chlorthal).

The insurer is denied coverage of a Formulary Exception for Edarbyclor 40/12.5mg Tablet (azlisartan-chlorthal).

The denial is overturned. 

This male patient has been diagnosed with hypertension. At issue is the request for Edarbyclor 40-12.5mg to control hypertension. The prescribing physician notes that patient has been intolerant to two other medications on the formulary including valsartan-hydrochlorothiazide (HCTZ) and irbesartan-HCTZ. He had experienced dizziness and headache. The patient has been taking Edarbyclor chronically and his blood pressure (BP) is well controlled.  The insurer requires a failure of three formulary alternatives unless there is compelling reason not to attempt additional formulary medications. Alternative angiotensin receptor blockers include losartan- HCTZ, candesartan, olmesartan-HCTZ and telmisartan-HCTZ.  

Alternative agents on the formulary do not contain chlorthalidone. Chlorthalidone is listed as a primary hypertensive agent that is preferred on the basis of prolonged half-life and proven trial reduction of cardiovascular disease. (1) Although there does not appear to be appreciable differences in efficacy or side effects between the different angiotensin receptor blockers (2), a trial of a third agent that contains the same diuretic (HCTZ) may be responsible for previous side effects and inefficacy.  

This patient has been treated chronically on Edarbcyclor and efficacy has been documented. The fact that HCTZ in the other formulary combinations will likely cause the same adverse reactions noted previously along with inefficacy, it would not be reasonable to subject this otherwise stable patient to another medication trial that is likely to cause headaches, dizziness and poorly controlled hypertension. On this basis the non-formulary drug would be more effective.

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

The medical necessity is substantiated. The carrier's denial of coverage for Edarbyclor 40/12.5mg Tablet (azlisartan-chlorthal) is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems - Chest pain
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The denial is upheld in whole.

This patient presented to the emergency department complaining of a 30 minute episode of chest pain that occurred at rest and radiated to his right abdomen. The pain resolved with one aspirin administered by Emergency Medical Services (EMS). His medical history was remarkable for morbid obesity, coronary artery disease, asthma, sleep apnea and hyperlipidemia, and schizophrenia. An electrocardiogram showed sinus rhythm without acute changes. A serum troponin level was normal. Chest X-ray showed a left basilar opacity suggesting atelectasis versus pneumonia, cardiomegaly versus poor inspiratory effort, and prominent reticular markings. Chest computed tomography (CT) scan showed a small right pleural effusion, mild cardiomegaly, and a small pericardial effusion. The patient was treated with aspirin and admitted to the hospital to rule out acute coronary syndrome. A repeat troponin level was normal. Cardiac telemetry monitoring showed episodes of AV (atrioventricular) block with pauses of up to approximately three seconds. These apparently occurred during sleep. The next day, the attending physician consult note indicated that the patient's chest pain was not thought to be due to ischemia and that no further ischemic workup was warranted. The psychiatrist's note stated that the patient was not cleared for discharge from a psychiatric standpoint. A cardiac electrophysiologist was consulted regarding the patient's AV block and opined that it could be attributed to increased vagal tone and sleep disordered breathing. No specific treatment other than compliance with continuous positive airway pressure (CPAP) was recommended. 

An inpatient level of care was not medically necessary for management of this patient's chest pain. This patient presented with chest pain that was thought to possibly represent acute coronary syndrome (ACS). Accordingly, a lower level of care until ACS could be ruled out was a reasonable approach. However, he was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. He did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received for his chest pain did not require an inpatient admission and could have been provided under a lower level of care status. This approach has been shown to be both safe and cost-effective and is in accordance with the 2014 American Heart Association (AHA)/American College of Cardiology (ACC) Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes. While the patient had episodes of heart block with brief pauses, these were attributed to increased vagal tone and obstructive sleep apnea. No treatment other than compliance with CPAP was recommended. This did not require an inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is overturned.

The patient is a male with a history of non-ischemic cardiomyopathy, atrial fibrillation, chronic kidney disease and morbid obesity presented to the emergency department complaining of dyspnea, edema and a 50 pound weight gain over the prior two weeks. He had a left ventricular ejection fraction of 20% and an implanted left ventricular assist device (LVAD). He was on chronic antibiotics for a driveline infection. 

In the emergency department, his mean arterial blood pressure (MAP) was 80 millimeters of mercury (mmHg). His heart rate was 70 beats/minute. His respiratory rate was 22/minute with a room air oxygen saturation of 98%. His physical exam was remarkable for abdominal distension and lower extremity edema. The cardiology consultant later noted bibasilar pulmonary rales. Chest x-ray showed mild vascular congestion. The patient was admitted to the hospital with decompensated heart failure. He noted persistent dyspnea. His physical exam showed bibasilar rales and edema. He was treated with high dose intravenous furosemide twice daily. The next day, his dyspnea had improved but he had persistent rales, jugular venous distension and peripheral edema. High dose twice daily intravenous furosemide was continued until it was held after hypotension the night prior; the patient's MAP had fallen to 40 mmHg. His blood pressure was improved and oral diuretics were started. He was discharged. His discharge weight was 50 pounds less than his admission weight. Medical necessity for an inpatient admission is the subject under review.

An inpatient stay was medically necessary for this patient. This patient, with severe left ventricular systolic dysfunction and a left ventricular assist device, presented to the hospital with massive volume overload due to acute decompensated heart failure. He remained volume overloaded despite six days of aggressive intravenous diuresis, which was then complicated by hypotension. He required careful and continuous monitoring of his clinical status, LVAD parameters and laboratory values, along with adjustment of his pharmacologic regimen. This warranted an inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse/Addiction. 
Treatment: Substance Abuse Inpatient. 
The insurer denied inpatient stay. 
The denial is overturned in whole. 

The patient is a male who presented to the emergency department and was evaluated, treated and subsequently admitted to acute inpatient level services for detoxification and withdrawal management of opioid, stimulant, sedative-hypnotic-anxiolytic and alcohol use disorders. The patient was using up to 5 bags of heroin daily with intravenous (IV) administration and had stopped methadone that he had been receiving in a methadone maintenance treatment program. He presented with mild or light withdrawal symptoms at the time of admission with chills, nausea and diarrhea, as well as anxiety, irritability and restlessness with a Clinical Opiate Withdrawal Scale (COWS) and Clinical Institute Withdrawal Assessment (CIWA) scale score of 2/2, respectively.

The patient was admitted to acute inpatient level care and placed on a detoxification regimen. He was treated with comfort medications and antibiotics. The patient began to participate in counseling and educational sessions, as his withdrawal symptoms diminished, and he was feeling better. His mental status examination included persistent symptoms of anxiety and irritability with associated symptoms of insomnia. He demonstrated no severe symptoms such as mania, psychosis, perceptual disturbance or severe cognitive impairment. He did continue with detoxification treatment briefly and was provided education and counseling during the inpatient stay. The patient was discharged with referral for clinically appropriate aftercare. The subject under review is the medical necessity for the inpatient stay.

Inpatient stay was medically necessary for this patient. The presenting clinical features and history and risk for withdrawal seizures and other complications of alcohol/anxiolytic and opioid and stimulant use disorders did warrant the admission and continued inpatient level services with medical monitoring in this case in view of the severity of the substance use disorders with multiple substances of abuse, and the associated psychosocial stressors and impairment of functioning.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Impacted upper canine. 
Treatment: D8080 Braces and D8670 Monthly Visit. 

The insurer denied the D8080 Braces and D8670 Monthly Visit. 
The denial is overturned. 

The patient is a female. The request is for orthodontic benefits. 

Yes, the proposed treatment is medically necessary. 

The patient has an impacted upper canine, which is an anterior tooth. When there is an impacted permanent anterior tooth where extraction is not indicated, as is this case, this is considered an "automatic qualifier" according to the handicapping index scale. This case has medical necessity and needs correction with orthodontic treatment. 

As stated above, the case is automatically qualified for treatment benefits due to the impacted anterior canine.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer. 
Treatment: Advanced Imaging Services. 
The insurer denied the health service/treatment of a Positron Emission Tomography and Computed Tomography (PET-CT) - a Special Picture of Your Body from Your Head to Your Thighs. The denial was upheld.

The patient is a female with recurrent ovarian cancer and known breast cancer antigen (BRCA) mutation. She has most recently been treated with Zejula and stopped secondary to concern that it would interfere with her highly active antiretroviral therapy (HAART) regimen. The patient had an allergic reaction to intravenous (IV) contrast and has been recommended to undergo surveillance imaging by positron emission tomography (PET)/computed tomography (CT) scan. The patient had an IV contrast allergic reaction in the past despite use of steroids.

At issue is the medical necessity of the health service/treatment of Positron Emission Tomography and Computed Tomography (PET-CT) - a Special Picture of Your Body from Your Head to Your Thighs.

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

The requested health service/treatment of Positron Emission Tomography and Computed Tomography (PET-CT) - a Special Picture of Your Body from Your Head to Your Thighs, is not medically necessary for this patient.

There is no data that a PET/CT scan, is better than a non-contrast CT or other imaging in evaluation of disease recurrence in a patient who is not able to receive IV contrast. In this case the PET/CT scan would have to be done without IV contrast for the CT component of the study because of the patient's known IV contrast allergy. The use of PET/CT scan imaging prior to performing a non-contrast CT scan is not supported by peer reviewed literature, is not a standard of care or supported by professional organizations.

Therefore, the PET-CT scan is not medically necessary.