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

Diagnosis: Rheumatoid arthritis
Treatment: Rinvoq 15 mg OR TB24
The insurer denied the Rinvoq 15 mg OR TB24.
The denial is overturned.

The patient is a female with seronegative rheumatoid arthritis (RA). She failed treatment with methotrexate, Plaquenil, Enbrel, Humira, Actemra, Xeljanz, Remicade and Orencia.

At her office visit, the patient was treated with Orencia 750 mg (milligrams) IV (intravenous) monthly and sulfasalazine 1000 mg (milligrams) twice daily.  She had increased RA (rheumatoid arthritis) disease activity on this regimen.  The provider added Medrol 4 mg (milligrams) twice daily, and switched Orencia to Rinvoq 15 mg (milligrams) daily.

Per the attached provider appeal note, the patient now has low RA (rheumatoid arthritis) disease activity on Rinvoq. The patient did not try or fail the plan-preferred agent Kevzara.  The appeal is for Rinvoq for the continued treatment of RA (rheumatoid arthritis).

Yes, the treatment with Rinvoq is medically necessary.

This patient with seronegative RA (rheumatoid arthritis) failed prior treatment with methotrexate, Plaquenil, Enbrel, Humira, Actemra, Xeljanz, Remicade and Orencia. Orencia was switched to Rinvoq 15 mg (milligrams) daily.  Per the attached provider appeal note, the patient now has low RA (rheumatoid arthritis) disease activity on Rinvoq.

Rinvoq is FDA (Food and Drug Administration)-approved for the treatment of RA (rheumatoid arthritis).  Per  guidelines for the treatment of RA (rheumatoid arthritis), "for patients with moderate or high disease activity despite prior treatment with at least one TNF [tumor necrosis factor] inhibitor and at least one non-TNF [tumor necrosis factor]-biologic (sequentially, not combined), we conditionally recommend first treating with another non-TNF [tumor necrosis factor] biologic."

This patient has failed multiple TNF (tumor necrosis factor) inhibitor and non-TNF (tumor necrosis factor) inhibitor biologics, and is now responding well to Rinvoq.  Although she did not try or fail the Plan-preferred agent Kevzara, she would be put at unnecessary risk of disease flare if her therapy is now switched from Rinvoq to Kevzara.  Furthermore, Kevzara is an IL (interleukin)-6 inhibitor that is mechanistically similar to Actemra, which this patent has already failed.  Therefore, the proposed continuation of Rinvoq is medically necessary for the treatment of RA (rheumatoid arthritis) in this specific patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is upheld.

The patient presented to the hospital with a history of progressively worsening abdominal pain in the right lower quadrant. Her evaluation included a physical exam, labs, and a computed tomography (CT) scan. She did not have a fever at the time of presentation. Lab data identified a white blood cell count (WBC) count of 9.5 thousand (K). A CT scan yielded the diagnosis of appendicitis. Treatment was initiated with intravenous (IV) fluid and antibiotics. A surgical consultation was obtained.

The patient underwent a laparoscopic appendectomy. The clinical notes and the anesthesia record indicate an uncomplicated appendectomy with findings of acute appendicitis without an abscess. She was provided IV fluid and perioperative antibiotics. Her vital signs remained normal throughout the hospitalization without a fever. The diet was advanced and pain management was converted to oral medications. She was discharged home following the initial recovery period.

At issue is the medical necessity of an inpatient stay.

Inpatient stay was not medically necessary for this patient.

This patient presented with abdominal pain. The evaluation with the examination, lab data, and CT scan supported the diagnosis of appendicitis. The initial treatment appropriately included nothing by mouth (NPO) status, IV fluid, and an appendectomy. The early postsurgical course was uncomplicated and the patient was hemodynamically stable and tolerating a diet on the first postsurgical day. She was discharged from the hospital.

The submitted clinical documentation does not support the need for inpatient admission. The patient underwent an uncomplicated appendectomy. A lower level of care would have satisfactorily provided for the care and would have been consistent with the accepted standard of medical care. The patient was clinically stable at the time of presentation and remained so during the course of care. 

Generally accepted guidelines of care indicate that in the absence of hemodynamic instability, sepsis or toxicity, significant electrolyte imbalance, bleeding, gastrointestinal (GI) obstruction or surgical complications, the procedure may be performed with a lower level of care. In this case, the patient tolerated oral hydration, diet, and medication and pain was well controlled. A lower level of care would have appropriately provided for presurgical assessment, laparoscopic appendectomy and post-surgical monitoring. Inpatient care was not required or medically necessary in this case per generally accepted medical standards.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diverticulitis
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female. She had presented with diverticulitis to the facility filing the appeal. The patient had pain for three weeks prior to presentation. The patient had a CT (computed tomography) scan, which showed diverticulitis. The patient was started on outpatient Cipro antibiotic as treatment.

The patient then presented to the ED (emergency department), and a repeat CT (computed tomography) scan was done, which showed diverticulitis. The patient was started on IV (intravenous) antibiotics, which was changed to zosyn by the ID (infectious disease) consultant. The patient's diet was advanced, and she was discharged home the following day.

No, the Inpatient admission was not medically necessary.

The medical treatment as provided was medically appropriate, but not necessary at the level at which it was provided. The patient did not require a full acute hospitalization.

Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had an infection (diverticulitis); yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for NPO (nothing by mouth) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission.  As such, the care could have been rendered at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pressure. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a male. He presented with chest pressure. He had an abnormal EKG (electrocardiogram) with early repolarization, troponin positive. Bedside ultrasound showed minor wall motion abnormality. 

The patient was seen by cardiology and infectious consults. The diagnosis was pericarditis. He was admitted to telemetry for arrhythmias. Echocardiogram and Cardiac MRI (magnetic resonance imaging) were performed, and were consistent with pericarditis. He was started on Colchicine. 

The patient was hemodynamically stable. He had no ectopy, and he had no adverse events. He was discharged the next morning. The final diagnosis was pericarditis. 

No, the Inpatient admission was not medically necessary. 

Determination of level of care is primarily dependent on the actual care a patient receives, and whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results; and highlighted in the orders for care. 

In this case, the patient's symptoms were unlikely to be representative of acute coronary syndrome. EKG (electrocardiogram) was classic for pericarditis. The patient's exam and cardiac findings were normal. Biomarkers showed mild elevation of troponin, commonly seen. CXR (chest x-ray) was normal. Echocardiogram showed no pericardial fluid or tamponade. Cardiac MRI (magnetic resonance imaging) was consistent with pericarditis. There was no hemodynamic instability. The physicians' treatment was anti-inflammatory medication and pain control. Orders did not include medical therapy for ACS (acute coronary syndrome), such as IV (intravenous) heparin, dual antiplatelet inhibitors, high dose beta blockers or IV (intravenous) NTG (nitroglycerin). There was no significant ectopy. 

The letter of appeal was carefully considered, but it offered no evidence to support an inpatient level of care. The only cardiac care that was provided was telemetry, which is frequently performed in a lower level of care. The patient was admitted for monitoring, and the subsequent tests and therapy did not require an inpatient level of care. There was no complex care that required inpatient care. This patient had no evidence of CAD (coronary artery disease) or CHF (congestive heart failure).  While there was always a potential for an adverse event, and in this case a low probability, one did not happen, and no actual treatment was added. 

Milliman criteria requirements for inpatient care were not fulfilled. 

All of the testing and therapy that were provided would be appropriate, safe and guidelines-consistent in a lower level of care. Thus, inpatient level of care was not medically necessary. 

The denial explanation was consistent with guidelines and usual community care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: s/p (status post) Fall
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female. She presented after having sustained a fall. She reported pain to her right hip. Her past medical history was significant for several medical conditions and previous right THR (total hip replacement).

The patient underwent diagnostic testing and was found to have a pubic rami fracture. She was admitted to the hospital for pain medication and PT (physical therapy) services. Skilled nursing placement was offered. The patient and family declined, with the patient subsequently signing out AMA (against medical advice).

The patient has severe dementia. She had taken Tylenol previously, with some relief. She lives with her family.

No, the Inpatient admission was not medically necessary.

The records show that the patient sustained an isolated closed fracture to the pubic ramus. It was of low energy without other trauma. There were no open wounds. Her vital signs were stable. She did not require additional testing nor invasive procedures. She was able to tolerate oral pain medication. PT (physical therapy) could have been provided as outpatient or home PT (physical therapy). There were no extenuating circumstances to warrant the admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Severe Septal Deviation.
Treatment:  CPT code 31256 (nasal/sinus endoscopy with maxillary antrostomy).

The insurer denied the CPT code 31256 (nasal/sinus endoscopy with maxillary antrostomy).  The denial was reversed.

The is a female patient with a history of chronic Eustachian tube dysfunction with repeated bouts of otitis either requiring tubes or, most recently, she had bilateral ear perforations.  She presented to the physician's office for a follow appointment with complaints of nasal congestion, chronic sinusitis with infection, headaches, and pressure.  The patient had allergy testing.  Her medications included Cefdinir, Flonase, Mucinex, and vitamin D.  A computed tomography (CT) scan of the sinuses was performed that revealed severe septal deviation with total obstruction of the left side.  There was significant hypertrophy of the right middle and inferior turbinate along with significant narrowing of both maxillary ostia and both frontal recesses.  A septoplasty and bilateral maxillary and frontal balloon sinuplasty with reduction of the right middle and inferior turbinate under sedation with image guided technology was recommended.  The patient underwent a septoplasty, out-fracture of the right inferior turbinate, submucous resection of the right inferior turbinate, reduction of the right middle turbinate and bilateral image guided including bilateral maxillary antrostomies, bilateral frontal recess surgery and bilateral sphenoidotomies.  

CPT code 31256, nasal endoscopy with maxillary antrostomy is medically necessary for this patient.  She has had long-standing symptoms of nasal congestion, chronic sinusitis, headaches, and pressure.  The patient failed medical therapy with medications including Cefdinir, Flonase, and Mucinex.  The patient had both CT scanned evidence of disease and sinus disease noted on examination.  For these reasons, the requested treatment is considered medically necessary.  The insurer did not act reasonably or with sound medical judgement or in the patient's best interest.

The carrier's denial of coverage for CPT code 31256 (nasal/sinus endoscopy with maxillary antrostomy) is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Issue under review: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female with history of multiple allergies, osteoporosis, Hashimoto thyroiditis, generalized anxiety disorder, celiac disease, fibromyalgia, and Raynaud's phenomenon.  The patient presented to the ED with crampy abdominal pain, nausea and diarrhea with green colored stools for last three weeks.  There was no history of travel and no history of sick contacts. Her symptoms began about a month back when she was started on Alendronate. She is also on multiple other medications; diagnosis of alendronate-induced diarrhea, diarrhea to polypharmacy, irritable bowel syndrome, and viral gastroenteritis were considered in the differential diagnosis. 

In the ED, the patient was hemodynamically stable and afebrile. Her physical examination was unremarkable. Her complete blood count (CBC) and Chem-panel were normal, and stools for Clostridium (C) difficile were negative. The lipase was mildly elevated at 205. Gasroenterolgy (GI) was consulted and the patient underwent esophagogastroduodenoscopy (EGD) that was unremarkable. Her diarrhea and abdominal pain were attributed to alendronate.  The patient was managed with intravenous (IV) fluids, antiemetics (Zofran), pain control with Tramadol as needed (PRN), and Pepcid for abdominal pain and bloating. She was able to tolerate diet without any vomiting or worsening of abdominal pain. She was discharged home on Pepcid 40milligrams (mg) by mouth (PO) twice daily, and Zofran PRN for nausea, and was advised to follow up with GI for her GI issues, and follow up with endocrinology for recommendation of alendronate for the management of osteoporosis.

No, the proposed acute care level inpatient care was not appropriate for the management of this patient's condition. 

This patient was admitted with three week history of crampy abdominal pain, nausea and diarrhea which started after she started alendronate. Her GI symptoms were attributed to alendronate which was stopped on admission. She was hemodynamically stable and afebrile on presentation and remained stable throughout her hospital stay. Her physical examination was essentially unremarkable. Her stool studies were unremarkable with no evidence of any infection. The GI provider recommended EGD which was done and was essentially unremarkable. She was managed with IV hydration, antiemetics, acid reducers (Pepcid) and oral pain medications. She was able to tolerate PO diet without exacerbation of abdominal pain, vomiting or diarrhea. She was discharged home in a fair and stable condition with outpatient follow up with GI and endocrinology.
Appeal type: Medical necessity
Decision: Overturned

Skin Disorders 
Pharmacy/Prescription Drugs 

Diagnosis: Psoriatic arthritis 
Treatment: Taltz 

The insurer denied Taltz. The health plan's determination is overturned. 

The patient is a male with psoriasis and psoriatic arthritis, 35% body surface area (BSA), treated with topicals, phototherapy, Humira, methotrexate and successfully with Taltz. The provider requests continuation of Taltz. 

Taltz is medically necessary for this patient. This patient has achieved control of both psoriasis and psoriatic arthritis on Taltz. It is generally considered medically necessary to continue a patient on a therapy that they have responded favorably to, given the risk of flare of both psoriasis and psoriatic arthritis. There are now many therapies available for the treatment of these conditions and it can be quite difficult to find the appropriate therapy. Stelara is not the most effective medication for psoriatic arthritis, and can worsen arthritis. Skyrizi and Tremfya are not currently approved for psoriatic arthritis. This patient has already failed one anti- tumor necrosis factor (TNF) agent (Humira), which makes Cimzia less appropriate. Simponi is not approved for plaque psoriasis. Therefore, given the patient's extremely favorable response to Taltz, it is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status post vaginal hysterectomy

Treatment: Inpatient admission 

The insurer is denied coverage for inpatient admission. 

The denial is upheld. 

The patient was then a female with a diagnosis of uterine prolapse, relaxed genital hiatus, weak pubocervical fascia, mixed incontinence symptoms, and incomplete emptying and frequency who underwent vaginal hysterectomy, left salpingo-oophorectomy, and intraperitoneal vaginal vault suspension, anterior repair with Vicryl mesh augmentation, posterior colporrhaphy, perineorrhaphy, and cystoscopy.  The procedure was reported as uncomplicated. The estimated blood loss was 150 milliliters. Post-operative note documented that the patient was stable and comfortable. The patient was admitted after surgery and was discharged.

Literature review indicates that vaginal hysterectomy is an outpatient procedure. The safety of this approach has been documented in multiple studies. Admission is usually not necessary unless there is a possible complication, such as heavy bleeding, surgical complications (i.e., bladder ureter or bowel injury or hemorrhage), conversion to abdominal hysterectomy, wound complications, and/or comorbidities.

In this case, this patient's procedure was uncomplicated. There was no evidence of any injury to this patient's other organs. A vaginal hysterectomy is an outpatient procedure and includes appropriate postoperative monitoring and an overnight stay if required. In other words, the patient could have been monitored overnight without the need for an admission and once the provider ascertained that the patient was stable, the patient could have been sent home. Thus, the inpatient admission was not medically necessary for this patient care and management.

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 is not substantiated.  The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient stay. The denial is upheld in whole. 

The patient is a male with hypertension (HTN), coronary artery disease (CAD) post coronary artery bypass graft (CABG) times three, obesity and arthritis, who was initially seen for cardiac clearance for right hip replacement. 
The patient was complaining of burning sensation in his chest and shortness of breath after exertion, such as walking up the stairs or on incline. His symptoms were similar to his complaints prior to CABG. 

The patient underwent coronary angiography, it revealed: 1. "Severe 3 vessels coronary artery disease (CAD). 2. Patent left internal mammary artery (LIMA) to mid left anterior descending (LAD). 3. Patent radial graft to Diagonal artery, moderate ostial disease with vasospasm). 4. Occluded saphenous vein graft (SVG) to obtuse marginal one (OM1). 5. Successful coronary intervention with drug-eluting stent (DES) implantation of the distal left main into Cx. 6. Successful coronary intervention with DES placement of the ostial and proximal to mid OM1. Angioseal was applied to right femoral artery. 

The patient tolerated the procedure well. The patient's condition during and after procedure remained stable. 

The health plan's determination is upheld in whole. 

The requested health service/treatment of inpatient stay was not medically necessary for this patient. The patient was evaluated for hip surgery. The patient with history of CAD and post CABG, during preoperative evaluation, was found to have exertional angina. The patient was found ischemia on his stress nuclear scan. He was scheduled for coronary angiography on elective basis. That means, there were no urgency and his angina was stable, without evidence of acute coronary syndrome. During elective admission, coronary angiography and intervention was performed. The procedure and post hospital stay was uneventful. The patient could have been managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Surgical Services. 
The insurer denied: Intracept Procedure. 
The denial is overturned in whole.

The patient is a female who was involved in a motor vehicle accident and has since sustained chronic back pain.
The patient has tried conservative pain management with pharmacotherapy (muscle relaxants, non-steroidal anti-inflammatory drugs [NSAIDs], Tylenol), physical therapy, chiropractic treatment, and trigger point therapy.
A magnetic resonance imaging (MRI) of the lumbar spine revealed diffuse Modic 1 endplate changes at L3 and L4, bright on T2 and dark on T2 weighted images. At L4-L5, similar milder Modic I changes are present.
A progress note by her treating provider indicated that the patient had axial pain in her low back worsened with bending and prolonged standing. The patient denied numbness or tingling sensation. The patient was noted to have an Oswestry Disability Index score of 9/45 (mild to moderate disability). An Intracept procedure, basivertebral nerve ablation at L3-L4, and L4-L5 was recommended for local relief and pain control.
The subject under review is the medical necessity of the Intracept procedure.

The health plan's determination is overturned in whole. 

The requested treatment, Intracept procedure, is medically necessary for this patient. In this case, the patient has a history of chronic vertebrogenic pain who has failed to respond to at least 6 months of non-surgical management and MRI demonstrated diffuse Modic 1 endplate changes at L3 and L4. The patient's low back worsened with bending and prolonged standing and she was noted to have an Oswestry Disability Index score of 9/45 (mild to moderate disability).
Unlike spinal fusion, total disc replacement, and spinal cord stimulation, the Intracept Procedure is implant-free and preserves the natural structure of the spine. The recovery time is also relatively quick. Basivertebral nerve ablation is a durable, minimally invasive treatment for the relief of chronic low back pain. The procedure is medically necessary for this patient.