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

Diagnosis: Trauma - Stab wound left chest. 
Treatment: Inpatient Hospital stay. 

The insurer denied inpatient hospital stay.  The denial is upheld.

The patient is a male who presented as a transfer patient following an altercation in which he was stabbed in the left posterior chest. The patient had normal vital signs and normal oxygen saturation at the time of presentation. His emergency department (ED) evaluation with physical exam, computed tomography (CT) scan and lab data did not identify other injury. The 2.5-centimeter (cm) chest wound was covered with a dressing. He was admitted to the hospital for hemodynamic monitoring. He remained clinically stable with regard to vital signs/neurological status throughout the overnight hospitalization. He was discharged from the hospital. The subject under review is the medical necessity for the inpatient stay. 

The submitted records do not support the medical necessity of acute inpatient admission for this patient. The records support that this patient presented to the ED as a transfer patient from another facility having been stabbed in the left posterolateral chest. He sustained a 2.5-cm laceration his back. The records including imaging with CT scan do not support that the stab wound penetrated the chest cavity, and the wound was covered with a dressing. The patient was clinically stable at the time of presentation and remained so during the period of overnight monitoring. He had normal vital signs and was tolerating diet. He was discharged from the hospital. Inpatient status was not medically necessary for this patient.

The care and treatment provided could have reasonably and safely been provided with a lower level of care. An inpatient designation is not in accordance with generally accepted standards of medical practice for the patient's condition.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Viral Hepatitis C
Treatment: Epclusa
The insurer denied the Epclusa
The denial is overturned

The patient is a male with chronic hepatitis C. His viral load is > [greater than] 1 million. The genotype cannot be typed. The request is for Epclusa.

Yes, the requested Epclusa is medically necessary.

Epclusa is pan-genotypic. Epclusa works against all genotypes of chronic hepatitis C. Therefore, even though the patient's hepatitis C genotype is not known, the request is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.

Epclusa is medically necessary to avoid complications of chronic hepatitis C, including advanced fibrosis, cirrhosis, need for liver transplant.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a woman. She presented to the hospital due to loss of consciousness. In the preceding three weeks, she experienced multiple episodes of loss of consciousness. She also noted headaches, episodes of dizziness in which she felt like she was going to faint and leg weakness.

Labs, imaging including CT (computed tomography) head and MRI (magnetic resonance imaging) brain were ordered prior to admission, which did not indicate an acute intracranial process. EKG (electrocardiogram) did not show acute abnormalities Neurology was consulted. There were no focal neurological deficits on the neurological examination. MRI of lumbar spine was done, and did not show an acute process. It was thought that her syncope was due to vasovagal process.

The health plan denied coverage of the inpatient hospital admission as it was not deemed medically necessary. The denial is being appealed.

No, the inpatient hospital admission was not medically necessary.

The inpatient hospital admission was not indicated. The patient had vasovagal syncope. Neurological examination did not show any focal deficits that were moderate to severe, which would have met MCG (Milliman Care Guidelines) guidelines for inpatient admission. Furthermore, there were no seizure-like aspects to the syncope, and so seizure was not thought to be in the differential. Neurology saw her once and signed off.

Therefore, given then above, the inpatient admission was not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.

The patient's symptoms were subjective, and there was were no concerning vitals or findings on neurological examination that would have necessitated in admission prior to the studies being done. Workup could have been done on at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient is a male. He was hospitalized for Chest Pain. He presented to the
hospital ED (emergency department) for evaluation of continuous chest pain since
the prior evening. His past medical history is unremarkable.

The patient's vital signs were stable: BP (blood pressure) 108/75, HR (heart rate)
76, O2 sat (oxygen saturation) 96-97% on RA (room air). EKG (electrocardiogram)
showed SR (sinus rhythm) and no acute changes. There were no arrhythmias or
elevated troponin documented. Chest x-ray was normal. Echocardiogram with
Doppler showed LVEF (left ventricle ejection fraction) was 50-55%, and there were
no RWMAs (regional wall motion abnormalities). Treatment included asa (aspirin),
Lovenox and statin.

The clinical impression was costochondritis, and the patient was discharged home on ibuprofen and referral for an OP (outpatient) stress test.

No, the Inpatient admission was not medically necessary.
Based on the peer-reviewed medical literature, there was not a medical need for
the acute inpatient hospital stay. 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 for Chest Pain, #M-89, criteria for inpatient admission are not
met, including, hemodynamic instability, respiratory distress, pulmonary edema,
angina with acute coronary syndrome, AMI (acute myocardial infarction), chest pain
that is indicative of a serious cardiac condition like pulmonary embolism or aortic
dissection, pneumonia, hypertension requiring inpatient hospitalization or any other
medical condition, symptom or finding for which emergency and observation care
have failed or are not considered appropriate. The care the patient received is
routinely provided safely and effectively at a lower level of care, such as
Observation. Therefore, based on the submitted information and the current
published medical literature, acute inpatient hospitalization for this patient was not
medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the
best interest of the patient.
The care the patient received is routinely provided safely and effectively at a lower
level of care, such as Observation.

The clinical impression was costochondritis, and the patient was discharged home
on ibuprofen and referral for an OP (outpatient) stress test. This is an appeal of the
denied claim; the requested Acute Inpatient Hospital Stay was not medically necessary
for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shoulder mass

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

This is a male with a history of asthma and a left shoulder mass. He presented to the hospital for a scheduled biopsy of the mass on the left shoulder. He was admitted for care. The patient was kept on nothing by mouth (NPO) status and was given intravenous (IV) fluids. He underwent a left scapular open biopsy with Orthopedic Surgery. He remained hemodynamically stable and afebrile. The patient was discharged. 

The records show the young man was admitted to the hospital for an elective biopsy. No special procedures nor consultations were completed. The operation was limited and not complex. The post-surgical course was non-complicated. The estimated blood loss was 30 cubic centimeters (cc). His vital signs were normal. There was no evidence of bleeding nor wound problems. The young man was able to tolerate oral pain medications. He was ambulatory and independent. He did not require additional treatment for an underlying medical problem. There were no extenuating circumstances to substantiate admission and length of stay. 

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

The insurer's denial of coverage for inpatient hospital admission is upheld.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Rheumatoid Arthritis. 
Treatment: Humira. 

The insurer denied Humira. 
The determination is overturned. 

The patient hassevere erosive rheumatoid arthritis (RA). Humira was denied by the health plan as the patient had not tried or had an intolerance to the formulary drugs, methotrexate (MTX), leflunomide, hydroxychloroquine and Sulfasalazine (SSz). At issue is whether the formulary drugs will be or have been ineffective, would not be as effective as the non-formulary drug or would have adverse effects. 

The formulary drugs would not be as effective as Humira. The patient has erosive RA with severe damage. The formulary drugs would not be as effective as Humira. A tumor necrosis factor (TNF) inhibitor (such as Humira) would be more effective than a disease modifying anti-rheumatic drug (DMARD) for the treatment of this patient's advanced RA. BioDrugs published a paper in 2004 that concluded that Humira ' retards the progression of structural joint damage, improves health related quality of life (HR-QOL), and is generally well tolerated'. In addition, a study in Rheumatol Ther in 2017 found that 'real-world data demonstrate a sustained effectiveness of adalimumab in the treatment of RA for patients who remained on therapy for 10 years'.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neck pain; back pain
Treatment: Continued Chiropractic Treatment
The insurer denied the Continued Chiropractic Treatment
The denial is upheld.

The patient is a female who has been under care with the chiropractic provider for approximately five years for neck and upper back complaints. She was under intermittent care for a period of time for diagnoses of M54.12 and M99.11.  The records indicate that there were re-examinations on several occasions all for the same complaints of neck and upper back pain.

The provider submitted a letter of appeal with no date that described a new presentation of a chronic complaint, the same complaints that had been treated for more than a year on a schedule of approximately every 6 weeks. Services were denied by the carrier under the guideline that care rendered is maintenance care and maintenance care is not medically necessary.

No, the Continued Chiropractic Treatment was not medically necessary.
The reviewed documentation supports that the patient has reached the point of Maximum Therapeutic Benefit as evidenced by the same complaints presented with from visit to visit. Care rendered after MTB (maximum therapeutic benefit) is considered maintenance and not medically necessary.

Maintenance or custodial care is considered to be unproven and not medically necessary for the treatment of disorders typically managed by chiropractors, physical and occupational therapists.

The role of maintenance/custodial care has not been established in scientific literature. A beneficial impact on health outcomes, e.g., prevention of recurrences and/or the sustainability of optimal health status has not been established.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gastroesophageal Reflux Disease (GERD).
Treatment: LINX Procedure.
The insurer denied the LINX Procedure.
The determination is overturned.

The patient sought surgical evaluation for the condition of gastroesophageal reflux disease (GERD) of several years duration. His symptoms include heartburn. He has been treated with anti-acid medications (Aciphex, Nexium). A gastroenterology consultation has been completed that includes the evaluation detailed below. An esophagogastroduodenoscopy (EGD) showed a normal esophagus without mention of esophagitis. An esophagram was performed and showed gastroesophageal (GE) reflux with provocation. There was no hiatal hernia. Esophageal motility was normal.
Potential hydrogen (pH) testing was performed while off acid suppression and showed an elevated esophageal acid exposure with a DeMeester score of 33 (normal less than [<] 14.7).
Manometry testing showed adequately preserved motility. There was no manometrically-detected hiatal hernia.
The treating surgeon has proposed the LINX procedure as treatment of chronic GERD and this is under review for medical necessity.
At issue is the medical necessity of the LINX procedure.

Yes, considering the submitted documentation, the published literature, and the clinical details of this case, the requested LINX procedure is medically necessary for this patient. This therapy is  proven safe and effective.
This patient has GERD. While the symptoms are partially controlled with medicinal therapy, there are breakthrough symptoms and the patient would like to not be dependent on PPI(Proton pump inhibitors)therapy. There is pathologic esophageal acid exposure as documented by the objective pH study that confirmed an elevated DeMeester score. The patient has been appropriately evaluated with an endoscopy, contrast upper gastrointestinal (UGI) study, and motility studies that confirm the absence of a precluding hiatal hernia and no alternative diagnosis or motor abnormality of the esophagus. An antireflux procedure is warranted. There are not equally effective treatments for GERD. LINX offers improved esophageal acid reduction compared to ongoing medication usage. LINX also offers similar reduction in esophageal acid exposure compared to surgical fundoplication, but with an improved risk profile. The ability to belch and vomit are preserved with LINX compared to fundoplication.
There has been the completion of ongoing clinical trials National Clinical Trial (NCT) 00776997 and NCT01624506 that provide the necessary long term follow up regarding LINX. These studies, in conjunction with previously published data, support the long-term safety and efficacy of the LINX and reinforce that this procedure has withstood appropriate scrutiny and should be included in the armamentarium of proven-effective therapy for the treatment of GERD in selected patients as in this case.

This therapy is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Polycystic ovarian syndrome

Treatment: Basic infertility testing services

The insurer denied coverage for basic infertility testing services

The denial is overturned

The patient is a female with a history of amenorrhea and previously diagnosed with polycystic ovarian syndrome. She has been trying to conceive for 10 months. The provider recommended infertility treatments and laboratory work. 

According to ASRM (American society for reproductive medicine), Infertility is a disease historically defined by the failure to achieve a successful pregnancy after 12 months or more of regular, unprotected sexual intercourse or due to an impairment of a person's capacity to reproduce either as an individual or with her/ his partner. Infertility is a disease which generates disability as an impairment of function. Diagnostic testing for infertility should be initiated without delay upon presentation in any patient with a medical history, sexual or reproductive history, advanced age or physical findings that suggest the possibility of impaired reproductive function. It is obvious that this patient had impaired reproductive function based on her medical history. She did not see her menstrual cycle for at least 6 months prior to presentation. In addition, she is known to have polycystic ovarian syndrome. Waiting a whole year does not make any sense clinically as she has a diagnosis of anovulatory infertility. 

Basic infertility testing services is considered medically necessary for this patient.

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

The insurer's denial of coverage for basic infertility testing services is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bilateral Breast Asymmetry. 
Treatment:  Bilateral Breast Augmentation with Breast Implants. 

The insurer denied the  Bilateral Breast Augmentation with Breast Implants. 
The denial is upheld. 

This patient is a female with complaints of bilateral breast asymmetry. Her left breast was approximately 75 grams larger than her right breast. Her surgeon performed bilateral breast augmentation to treat her asymmetry. The submitted photos are dark. 

No, the proposed treatment was not medically necessary. 
Augmentation of the breasts is not medically necessary to treat a health problem. The patient had breast asymmetry and hypoplasia, but her breasts were not causing any health problems. She would not have suffered any adverse health consequences if plastic surgery on the breasts was not performed.  Breast augmentation puts the patient at risk for functional problems including difficulties with mammography, implant infection, implant exposure, anaplastic large cell lymphoma and capsular contracture. Moreover, because the size and position of her breasts will change with age and weight gain or loss, her breasts will likely become asymmetric again as she ages. 

According to a study by Murphy et al regarding the psychological benefits of breast augmentation, "Significant improvements in body image were found postoperatively and remained throughout the study. Improvements in health-related quality of life, however, were not observed." 

The proposed surgery will not improve health related quality of life and will increase the patient's risk for health problems in the future.  The treatment was cosmetic to improve appearance and is not medically necessary. 

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

Breast augmentation was a cosmetic procedure to improve breast appearance.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male. He presented with complaints of shortness of breath and cough.

In the ED (emergency department), the patient was not in distress. His respiration rate was in the 20s, which improved. His SpO2 (pulse oximetry) was 95 on RA (room air). There was bilateral wheezing. CXR (chest x-ray) was negative. Lab parameters were reassuring. The patient was treated with nebulization and steroids.

The patient was admitted to the floor, and the nebulization was weaned. The patient was then discharged.

The health plan denied coverage of the inpatient admission with the contention that the inpatient admission was not medically necessary. This denial is being appealed.

No, the Inpatient admission was not medically necessary.

The patient could have been treated in a lower level of care than inpatient status. The patient was not in distress. The patient had no significant hypoxia, with SpO2 (pulse oximetry) of 95 on RA (room air). There was no significant atelectasis. The pH (potential hydrogen) was not less than 7.2 in the VBG (venous blood gas). The PaCO2 (partial pressure of carbon dioxide) was not above 50 in the VBG (venous blood gas). There was no need for continuous nebulization nor need for CPAP (continuous positive airway pressure)/BiPAP (bi-level positive airway pressure)/HFNC (High-Flow Nasal Cannula). The patient's PEWS (Pediatric Early Warning Score) was desirable. If one were to take the patient's PRAM (Pediatric Respiratory Assessment Measure) score to assess the asthma severity, it would have been less than 8 at time of admission. Due to above factors, the patient could have been treated at a lower level of care.

Therefore, given the above, the Inpatient admission was not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
The medical necessity criteria do not justify inpatient level of care in this patient's case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left occipital skull fracture

Treatment: Inpatient admission 

The insurer denied coverage for an inpatient admission 
The denial is upheld.

This case involves a male with a history of Ehlers-Danlos syndrome and depression who presented to the emergency department after tripping and falling down 7 steps in his home. He reported pain to the cervical spine, thoracic spine, and lumbar spine along with bilateral upper extremity weakness and hearing loss in the left ear. A CT (computed tomography) of the head showed subarachnoid hemorrhage in the right frontal, parietal, and temporal lobes extending to the interpeduncular cistern and left occipital skull fracture. An MRI (magnetic resonance imaging) of the thoracic spine without contrast showed no evidence of vertebral body fracture or disc herniation, no cord compression or abnormal cord signal. The patient was found to have mild thoracolumbar levoscoliosis. There were no acute fractures or dislocations of the cervical spine, with only the left occipital skull fracture noted with osteoma arising from the left C (cervical) 3 facet superior articular processes. X-rays of the chest were unremarkable.  

The Milliman care guidelines state that the goal length of stay for someone who has sustained a traumatic brain injury is 2 days. Indications for admission to inpatient care for head injury includes patients who are hemodynamically unstable, have altered mental status that is severe or persistent, post resuscitation or a presenting Glasgow coma scale score of less than 13 using the Glasgow Coma Scale calculator. Also, when there is worsening of neurologic function post presentation, when there are new signs or symptoms that are severe, for persistent despite observation care, when there are no focal signs on neurologic examination, evidence of increased intracranial pressure, and new intracranial pathology on imaging that requires intervention or monitoring beyond the observation care timeframe. Lastly, when the patient has a cerebrospinal fluid leak, recurrent seizures, significant respiratory or cardiac abnormality secondary to brain injury, increased intracranial pressure or cerebral edema monitoring is required. The information provided for the review did not endorse that the patient met the criteria for inpatient admission. While it was noted that he had sustained head trauma after his fall down the stairs at home, the evidence did not present that his condition could not be monitored on a lower level of service to include observation. If he had shown signs of neurological complications, admission would have been supported at that time.  

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

The insurer's denial of coverage for an inpatient admission is upheld. Medical Necessity is not substantiated.