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

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

The patient is a male with type 2 diabetes mellitus (T2DM) on metformin and glipizide. He was referred to the emergency department (ED) for evaluation of a right (R) second toe infection that developed after cutting himself a few weeks prior while cutting his toenails. He was seen by his primary care physician (PCP) and prescribed an antibiotic. He was referred to a podiatrist who prescribed by mouth (PO) Keflex 6 days prior to going to the ED. An outpatient x-ray raised concern for osteomyelitis and he was advised to go to the ED.
Photos of his foot from that visit showed R second toe swelling with a wound and darkening of the tip of the second toe and distal medial third toe. Magnetic resonance imaging (MRI) showed osteomyelitis of the R 1st-3rd toes. 
He was started on Zosyn and Vancomycin. Surgery was consulted and took a deep wound culture. An infectious disease (ID) consult advised change Zosyn to Ceftriaxone and continue Vancomycin.
Podiatry was consulted. They noted a wound at the tip of the second toe. There was no fluctuance or purulence, no malodor. He performed sharp debridement of the wound to healthy tissue and advised vascular evaluation for weakly palpable pedal pulses and ischemic changes versus (vs) deep tissue injury (DTI) second and third toes. His blood sugars were high and he was treated with insulin and determined to need ongoing insulin for blood glucose control outpatient, with endocrine follow-up.
A peripherally inserted central catheter (PICC) line was placed and the patient was discharged home.
At issue is the medical necessity of an inpatient stay.
Inpatient admission was not medically necessary for this patient.
The patient had no acute medical issues. He had a workup for osteomyelitis, he had wound debridement and cultures taken, and he had imaging as part of a vascular evaluation. His lab results revealed elevated inflammatory markers and poorly controlled diabetes mellitus (DM) on oral medication. He was afebrile and without signs/symptoms of systemic infection. His foot wound was noted by podiatry as not purulent, not fluctuant, and not malodorous, and a bedside debridement was performed to healthy tissue. He was worked up for osteomyelitis of the R foot, including vascular evaluation.
He had a PICC line placed prior to discharge on IV (intravenous) antibiotics. His poorly controlled diabetes was addressed in the hospital and he was discharged on an insulin regimen.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: History of H Pylori and Gastric Intestinal Metaplasia
Treatment: Esophagogastroduodenoscopy 
The insurer denied: Esophagogastroduodenoscopy 
The denial is upheld.

The patient is an adult female with a history of Helicobacter pylori (H. pylori) and gastrointestinal metaplasia. There is no documentation of a family history of gastric cancer. The doctor is requesting surveillance esophagogastroduodenoscopy (EGD).

The Esophagogastroduodenoscopy (EGD (43239) was not medically necessary.

Medical literature supports Helicobacter pylori breath testing as a safe and effective test for the documentation of eradication of Helicobacter pylori. In patients without ongoing upper gastrointestinal (GI) symptoms refractory to proton pump inhibitors, weight loss, dysphagia, vomiting or gastrointestinal bleeding, or without a family history of gastric cancer, surveillance endoscopy is not medically necessary to ensure Helicobacter pylori eradication. Medical literature does not support surveillance endoscopy in patients with gastric intestinal metaplasia, unless there is a family history of gastric cancer, or if there is extensive incomplete metaplasia. As this patient does not have ongoing upper gastrointestinal symptoms refractory to proton pump inhibitors, weight loss, dysphagia, vomiting or gastrointestinal bleeding, a family history of gastric cancer, or extensive incomplete metaplasia, the requested esophagogastroduodenoscopy was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

According to the medical record the patient presented to the emergency department (ED) complaining of pain in the abdomen for 8 hours. The patient denied nausea and vomiting. As per the ED provider note, the patient has a past medical history of hypertension (HTN) and hyperlipidemia (HLD) who presents for abdominal pain since earlier this evening. It was periumbilical but now has moved to the lower abdomen and prominently in the lower abdomen. The patient denied fever or chills. The patient was afebrile with stable vital signs. The abdomen was soft with right lower quadrant (RLQ) tenderness. There was no guarding. The patient's white blood cell (WBC) count was 15.5. A computed tomography (CT) of the abdomen showed an inflamed appendix with appendicolith at base and surrounding inflammatory changes. Intravenous (IV) antibiotics were given and the patient was admitted for surgery.

The patient was taken to the operating room and underwent an appendectomy with findings of an inflamed and partially gangrenous appendix with no purulence or free fluid in the abdomen. Surgery was uneventful.  The patient was discharged from the post-anesthesia care unit (PACU) in stable condition. The patient did well and was discharged to home the same day.

Based upon the records provided, it is agreed with that the patient did not require acute inpatient admission since they should have been managed in an ambulatory/observation status. The patient did not require an acute inpatient admission but rather observation status as they did not have any complications from the surgery that warranted inpatient care. The lap appendectomy was uneventful and there was no perforation. There was no evidence of a complicated post op course requiring hospitalization and the patient was discharged within 23 hours (on the same day of surgery). Thus, the patient should have had the appendectomy performed under an ambulatory/observation status without acute inpatient admission. 

To summarize, the reviewer agrees that the inpatient admission was not medically necessary at the acute inpatient level and denial for hospital admission should be upheld. The patient was admitted and underwent an uneventful lap (laparoscopic) appendectomy - all of which should have been done in an observation status. The reviewer does agree that based upon these findings the health care plan did act reasonably and with sound medical judgment.  

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: Tremors and Parkinson's disease
Treatment: magnetic resonance image guided high intensity focused ultrasound and unlisted magnetic resonance procedure.
The insurer denied magnetic resonance image guided high intensity focused ultrasound and unlisted magnetic resonance procedure.
The determination is upheld.

This is a female patient with a history of tremors and Parkinson's disease. She has had medications without relief. She is a non-smoker. The neurologic exam shows rigidity and bradykinesia. The provider has recommended right-sided magnetic resonance-guided focused ultrasound. At issue is the medical necessity of magnetic resonance image guided high intensity focused ultrasound and unlisted magnetic resonance procedure.

The requested procedure is not medically necessary. While this is a promising technology for the treatment of essential tremor, further research and studies have been recommended in the literature. Giordano and others (et al) cite, "The current gold standard surgical treatment for medication-resistant essential tremor (ET) is deep brain stimulation (DBS). While bilateral DBS proves superior to unilateral magnetic resonance imaging and high intensity focused ultrasound (MRgFUS) thalamotomy in the treatment of ET, a subgroup analysis suggests that treatment laterality is the most significant determinant of tremor improvement, thus highlighting the importance of future investigations on bilateral staged MRgFUS thalamotomy". Zaaroor et al cite, "MRgFUS ventral intermediate nucleus (VIM) thalamotomy to relieve medication-resistant tremor was safe and effective in patients with essential tremor (ET), Parkinson's Disease (PD), and ET-PD. Current results emphasize the superior adverse events profile of MRgFUS over other surgical approaches for treating tremor with similar efficacy. Large randomized studies are needed to assess prolonged efficacy and safety". Kapadia et al cite, "magnetic resonance imaging (MRI)-guided focused ultrasound (MRgFUS) thalamotomy is a promising non-invasive treatment option for medication-resistant essential tremor. However, it has been associated with variable efficacy and a relatively high incidence of adverse effects". Tian et al cite, "MRgFUS is a potential option for the treatment of drug-resistant PD-related tremor with satisfactory efficacy and safety. Speech disorders, ataxia and sensory abnormalities are the most common postoperative side effects, but the symptoms are mild and usually transient. However, because MRgFUS is a relatively new technique, follow-up data and randomized clinical trials are quite limited. More rigorous study designs, larger sample sizes, and longer follow-up times are needed in the future to further investigate the efficacy, safety, and durability of MRgFUS in the treatment of drug-resistant PD-related tremor in order to determine its long-term benefits in the management of drug-resistant PD-related tremor".
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alopecia areata

Treatment: Xeljanz

The insurer denied coverage for Xeljanz

The denial is overturned

The patient has a diagnosis of alopecia areata.  The patient had previously lost >30 percent (%) of their scalp hair after failing treatments with topical, intra-lesional, and oral steroids. The patient has had excellent response to Xeljanz.  The request is for continuation of Xeljanz therapy.  

Based on the standard of care and the provided documentation, the use of Xeljanz is clinically indicated for treatment of the patient's severe alopecia areata.  The patient has failed medications traditionally used to treat alopecia areata, including topical and intralesional steroids. The patient requires systemic therapy and the use of Xeljanz, a Janus Kinase (JAK) inhibitor has been reported to be beneficial with limited side effect profile compared to previously used alternatives.  A similar drug, Olumiant is a Food and Drug Administration (FDA) approved drug for treatment of alopecia areata and would be expected to have a similar clinical result.  In this case, the patient has been successfully treated with Xeljanz and thus the continued use is within the standard of care.  The criteria used by the health plan for this particular patient does not appear to be flexible enough to adjust on a case-by-case basis.  The criteria used to reach this decision is the standard of medical care for the treatment of alopecia areata and the medical literature cited.  

Of note, Xeljanz is an FDA approved oral medication available for multiple indications in the United States.  Significant clinical data is available in the medical literature documenting the safety and use of Xeljanz in the treatment of alopecia areata.  Only one FDA approved medication is available for the treatment of alopecia areata, Olumiant which was only approved in 2022.  Xeljanz has a similar mechanism of action to Olumiant and has been used more commonly in the treatment of alopecia areata prior to the approval of Olumiant.  In this particular case, the patient has been successfully treated with Xeljanz for a significant amount of time with excellent clinical response and no reported adverse side effects.  The criteria used by the health plan for this particular patient does not appear to be flexible enough to adjust on a case-by-case basis, particularly in a case where the continuation of a medication is being considered.  The criteria used to reach this decision is the standard of medical care for the treatment of alopecia areata and the medical literature cited.  

Based on the above, the insurer's denial must be reversed. 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 Xeljanz is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary Tract Infection
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This is an adult female patient with hypertension who presented to the hospital with abdominal pain and chills with vomiting. She was diagnosed with urinary tract infection. The patient was noted to have an elevated white count and creatinine of 1.6 milligrams per deciliter (mg/dl). A computed tomography (CT) scan showed perinephric stranding and intravenous fluids and intravenous antibiotics were administered. The patient was tolerating oral intake. She was converted to oral antibiotics and subsequently discharged.

The requested health service was not medically necessary.

The requested inpatient level of care was not medically necessary as supported by current medical literature. The request would be considered provided primarily for the convenience of the patient or the practitioner and was not the least intensive and/or most appropriate alternative among diagnostic and treatment options. It was also not provided in the most effective setting as other treatments such as a lower level of care would provide a clinically appropriate benefit. Therefore, the requested health service was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anorexia Nervosa, Bulemia
Treatment: Air ambulance
The insurer denied air ambulance.
The determination is overturned.

This is an adult female diagnosed with an eating disorder with severe anorexia nervosa, bulimia, and comorbid symptoms of anxiety and depressive disorders, and general medical complications. The patient has a history of treatment with eating disorder programs without remission of symptoms with worsening over two years complicated by a coronavirus 2019 (COVID-19) infection. The patient has had general medical complications in the context of worsening symptoms of the eating disorder and mood instability. Medical complications include glucose fluctuations, slow-transit constipation and gastroparesis, malnutrition with electrolyte and electrocardiogram (EKG) abnormalities, as well as suspected osteoporosis, and iron deficient anemia, as well as colonic polyps.  
At issue is the medical necessity of air ambulance transport.
The requested health service/treatment of air ambulance medical transport was medically necessary for this patient.
The patient is diagnosed with severe symptoms of anorexia nervosa including comorbid symptoms with anxiety and depression, as well as life-threatening general medical complications of malnutrition. The patient had failed to benefit from treatment with deterioration in her general medical status. The treatment facility was the most appropriate treatment facility to address the multiple general medical complications associated with the eating disorder and to provide the general medical services and comprehensive behavioral health and psychiatric services that were medically necessary and clinically appropriate for this patient. The transport by air ambulance was also medically necessary in view of the need for monitoring and support during the transport, as outlined in the clinical summary. The receiving treatment facility is the closest treatment facility that could address the medical needs of the patient, and the air ambulance transport was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain With High Blood Sugar
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is an adult male with a past medical history of type 2 diabetes, chronic pancreatitis due to alcohol abuse, hypertension, and non-compliance with medications. He 
presented to the emergency room complaining about abdominal pain, shoulder pain, and elevated blood sugars. He admitted that he was assaulted the day before. The patient's blood sugar was over 500 milligrams/deciliter. His bloodwork showed hyponatremia and acute kidney injury. Electrolyte abnormalities were corrected after intravenous fluids and insulin. Computed tomography (CT) scan of the abdomen was consistent with chronic pancreatitis, but no acute process was discovered. The patient was admitted for inpatient stay. The inpatient admission was denied coverage by the health plan as not medically necessary. The denial is being appealed.

The inpatient admission was not medically necessary.

The patient had hyperglycemia however, he did not have a diabetic ketoacidosis or any signs of hemodynamic instability, intractable nausea or vomiting, fever or infection, or severe electrolyte abnormality. The patient had hyponatremia and acute kidney injury. However, they resolved with intravenous hydration and insulin treatment by the next day. The patient could have been treated at a lower level of care, and an inpatient hospital admission was not justified.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Amaurosis fugax

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

The patient presented to the emergency department complaining of temporary vision loss. The patient's symptoms lasted for a couple seconds and then completely resolved. There were no left-sided vision changes, and the patient denied any associated numbness, weakness, or tingling. A Neurology consultation was done; the patient reported a transient episode of blurred vision in the right eye while driving to work that lasted under a minute. The patient described it like a veil pulled down and then a cecocentral scotoma lasted a little longer before resolving. No associated headache was reported. During the consultation, the patient stated that they felt well and had no visual complaints, weakness, numbness, headache nor vomiting. 

Computed tomography angiography (CTA) of the carotid showed unremarkable angioarchitecture and no severe, flow-limiting cerebral vasculopathy. 

Computed tomography of the head (CTH) and CTA were reviewed and no acute intracranial (IC) pathologies, large vessel occlusion (LVO), evidence of dissection or flow-limiting stenosis. Magnetic resonance imaging (MRI) was also reviewed and there were no acute IC pathologies. 

An echocardiogram with bubble study was done; left ventricular ejection fraction (LVEF) was 59%, no defects or clots were noted, symptoms were all resolved and imaging and labs were not concerning for cerebrovascular accident (CVA). The patient was deemed safe for discharge.

This is an adult who presented to the emergency department for evaluation of blurred vision in the right eye that occurred while driving to work and that lasted under a minute. During the Neurology consultation, the patient stated that they felt well and had no visual complaints, weakness, numbness, headache or vomiting.

The patient was admitted for amaurosis fugax (temporary loss of vision) and to rule out stroke. Diagnostic workup was all normal and did not show any signs of infarct or hemorrhage. Computed tomography angiography (CTA) showed minimal plaques bilaterally but no significant stenosis. The patient's symptoms had all resolved, and imaging and labs were not concerning for stroke. The patient was deemed safe for discharge.

Based on the review of the medical records submitted, the care rendered for the patient was more appropriate in a lower level of care such as outpatient evaluation and treatment in emergency department, rapid treatment site, urgent care center, medical office, or in an observation setting. As such, the acute inpatient admission 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 the acute inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

This patient is a previously healthy male who presented to the emergency department (ED) with the diagnosis of appendicitis. An outpatient computed tomography (CT) scan had identified appendicitis that persisted following a course of oral antibiotics.
The patient underwent laparoscopy with appendectomy for the condition of acute appendicitis. The operative dictation is not included with the review material, but the records indicate that the operation was completed without complication.
Following surgery, the patient was advanced to a diet. His vital signs were normal. The pain was controlled and he was discharged from the hospital.
At issue is the medical necessity of an inpatient stay.
Acute inpatient hospitalization was not medically necessary for this patient. The medical records support that this patient could have been reasonably and safely monitored and treated at a lower level of care without the need for a full inpatient admission.
This patient presented with the established diagnosis of appendicitis. The diagnosis and indication for surgery was established. He underwent an uncomplicated appendectomy. He was clinically stable and was started on a diet following surgery. Pain medications were transitioned to oral medications. He was considered stable for discharge from the hospital.
The patient was clinically stable at the time of presentation and remained so during the course of care.  A lower level of care would have provided for presurgical assessment, operative treatment and post-surgical monitoring and antibiotics. This lower level of care would have also allowed for overnight monitoring.
Milliman Care Guidelines (MCG), Appendectomy with Abscess or Peritonitis by Laparoscopy, 27th edition state that the procedure of appendectomy can be performed in the ambulatory setting for most otherwise healthy nonelderly (less than (<) 65 years) patients and some elderly patients without severe signs of infection (hemodynamic instability, severe peritonitis, bacteremia) who have appropriate discharge planning, follow up and home care support. Inpatient status may be required for most older patients (greater than (>) 65 years) or patients with severe signs of infection, active comorbidities, or inability to arrange adequate outpatient support. These Milliman Care Guidelines (MCG) list wound infection and post-surgical ileus with the inability to tolerate oral intake as indicators for continued hospital stay.
In this case, the patient did not manifest severe signs of infection, he did not have active comorbidities, nor was he unable to tolerate oral intake within one day of the procedure. The patient remained clinically stable and responded appropriately to the prescribed therapy. There were no complications or other clinical issues that mandated inpatient admission.