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

Diagnosis: right great toe infection

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 


Patient is an adult male with past medical history significant for of peripheral arterial disease, hypertension, hyperlipidemia, coronary artery disease, obstructive sleep apnea, and benign prostatic hypertrophy who presented to the emergency department with complaints of right great toe infection and shortness of breath.

Vitals on presentation included: Temperature 97.5 Fahrenheit, Blood Pressure 139/70 mmHg, Pulse 86 beats per minute, Respiratory Rate 18 breaths per minute, oxygen (O2) saturation 93% on Room Air. Laboratory results included the following: white blood cell count (WBC) 9.2, hemoglobin (Hgb) 16.4, hematocrit (Hct) 50.5, Creatinine 1.9, glucose 162. 

Patient was started empirically on intravenous antibiotics (vancomycin and Zosyn) for right foot infection. X-ray of the foot showed soft tissue swelling. Podiatry consulted and recommended topical wound care including dressing changes. Magnetic resonance imaging (MRI) of the foot was negative for osteomyelitis. Infectious Diseases recommended continuation of antibiotics. Patient remained afebrile, clinically, and hemodynamically stable. He requested discharge from the hospital on oral antibiotics (Augmentin).

According to documentation, patient presented with an unroofed blister over right big toe. Otherwise, he was afebrile, hemodynamically stable with unremarkable laboratory results including a normal white blood cell (WBC) count. Magnetic resonance imaging (MRI) was negative for osteomyelitis. Patient had no evidence of a disseminated infection, and no surgical intervention was required. Based on above findings, he did not fulfill criteria for acute care hospitalization. 

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 is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ovarian cyst.
Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is upheld.
 
The patient is a female who presented to the emergency room with complaint of abdominal pain. She was diagnosed with a right ovarian cyst. She was admitted and underwent an uncomplicated laparoscopic right ovarian cystectomy. She was discharged later that day.

A laparoscopy is an ambulatory procedure.

According to Milliman Care Guidelines (MCG), Inpatient and Surgical Care, Laparoscopic Gynecologic surgery, including myomectomy, oophorectomy, and salpingectomy, laparoscopic procedures are ambulatory procedures. Inpatient stay may be needed for:

Older patients (> 65)
Conversion to abdominal procedures
Surgical complications
Comorbidities.

This patient did not have any of these criteria. Her procedure was uncomplicated. There was no evidence of any injury to other organs. She was tolerating oral intake and voiding adequately.  

Please note that a laparoscopic procedure is an outpatient procedure and includes appropriate postoperative monitoring and an overnight stay if required.

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: Formulary Exception
Decision: Overturned

Diagnosis: Dry eye syndrome
Treatment: Tyrvaya
The health plan denied Tyrvaya as it is not on its drug formulary.
The reviewer has overturned, in whole, the health plan's determination.

The patient has a history of dry eye syndrome. The patient has been treated with Xiidra but failed to improve her symptoms. The patient has been treated with a sample of Tyrvaya with improvement of her symptoms. The treating physician requests the approval of Tyrvaya for the patient.

The patient has been treated with the formulary drug Xiidra, but it was found ineffective. The non formulary drug, Tyrvaya, has been given as a sample and has been shown to be beneficial in treating her symptoms of dry eye. Therefore, the non-formulary drug, Tyrvaya, has been shown to be effective in the treatment of this patient's dry eye symptoms and would be considered more effective than the formulary medication Xiidra.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite
Treatment: Braces and monthly visits
The insurer denied braces and monthly visits.
The health plan's determination is overturned. 

The patient in question is a male with a unilateral posterior crossbite and a functional shift to the left. He is treatment planned for braces and monthly visits with rapid palatal expansion to correct his crossbite. 

Braces and monthly visits are medically necessary for this patient.

There is strong medical evidence that that early correction of unilateral posterior crossbites with a shift reduces the need for future treatment. This patient presents with a posterior crossbite, crowding, and constricted arches. He is an excellent candidate for orthopedic rapid maxillary expansion to assist with orthodontic correction. Such a procedure can only be performed before the patient reaches skeletal maturity, otherwise the ability to achieve orthopedic expansion is greatly reduced. Given that the patient is almost skeletally mature, he is almost at the end of the time that orthodontics alone can correct his crossbite. Therefore, the requested treatment is medically necessary at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: nausea/vomiting
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld.

The patient is a male who presented to the emergency department with concerns for vomiting, palpitations, and fatigue. Pertinent history included atrial fibrillation, gastroesophageal reflux disease and hypertension. Initial vital signs revealed a temperature of 98oF, heart rate (HR) 103, blood pressure (BP) 178/104, respiratory rate (RR) 20, and pulse oximetry 97% on room air. Initial examination documented the patient as alert and oriented in no acute distress. 

The inpatient hospital admission was not medically necessary. The patient presented with nausea, vomiting and fatigue of a few days duration. Initial examination documented the patient as afebrile, hemodynamically stable, without hypoxia, and without significant abdominal findings. Initial evaluation revealed a borderline acidosis with mild elevation of lactate and beta hydroxybutyrate. Treatment included intravenous fluids and supportive care. Following observation care, presenting symptoms were improved, diet was tolerated, and laboratory abnormalities were resolved or trending toward baseline. No other issues or complications were documented.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Palpitations.
Treatment: Inpatient Hospital Stay.

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

This is a female patient, who presented to the emergency department (ED) via Emergency Medical Services (EMS). The patient called EMS for an episode of chest pain and palpitations. Her symptoms resolved en route to the ED after being treated with aspirin. Her medical history was remarkable for diabetes, hypertension, hemorrhagic stroke, hyperlipidemia, obesity and nonobstructive coronary artery disease. In the ED, she had no complaints. A chest x-ray showed no acute pathology. The patient was admitted to the hospital to rule out acute coronary syndrome. She had no further chest pain. Her troponin level remained normal. She was discharged. At issue is the medical necessity of an inpatient admission.

Based on the documentation provided, an inpatient level of care was not medically necessary.

This patient presented with symptoms that were thought to be suspicious for acute coronary syndrome (ACS). Accordingly, observation until ACS could be ruled out was a reasonable approach. However, she was hemodynamically stable, with normal cardiac biomarkers, and no acute ischemic electrocardiographic changes. She did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received did not require an inpatient admission and could have been provided at a lower level of care. This approach has been shown to be safe and is in accordance with current guidelines including the 2021 American Heart Association (AHA)/American College of Cardiology (ACC)/American Society of Echocardiography (ASE) /American College of Chest Physicians (CHEST)/ Society for Academic Emergency Medicine (SAEM)/Society of Cardiovascular Computed Tomography (SCCT) / Society for Cardiovascular Magnetic Resonance (SCMR) Guideline for the Evaluation and Diagnosis of Chest Pain and the 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion. 
Treatment: D8080 Braces, D8670 monthly visits, D8680 Retainer. 
The insurer denied coverage for D8080 Braces, D8670 monthly visits, D8680 Retainer. 
The denial is overturned. 

This is a teenager under the care of an orthodontist for the treatment of his dental malocclusion. The patient has an anterior crossbite, a very narrow maxilla, impacted premolar, and generalized crowding. The impacted premolar is supernumerary. It is noted the patient was given a Handicapping Labio-Lingual Deviation (HLD) of 19 by the insurer, which doesn't qualify. The request is for D8080 Braces, D8670 monthly visits, D8680 Retainer, which is under review. 

The HLD includes an overjet of four millimeters (mm) and an overbite of three millimeters. The patient's teeth, 9 and 10 are ectopic in eruption, as they are in complete crossbite. There is crowding in both the maxillary and mandibular arches for a 10 and the labiolingual spread is five millimeters for a total HLD score of 28, which meets policy. 

Therefore, the request for D8080 Braces, D8670 monthly visits, D8680 Retainer is medically necessary and is approved. 

"Orthodontics seeks to achieve esthetic and functional improvement via mechanical therapy that moves teeth into a more ideal position. Determining the ideal dental position for each patient depends on several factors, such as the facial profile, facial balance, and aesthetic concerns..." 

It is important to note that surgical treatment of malocclusion is typically only recommended in severe cases, and other treatment options, such as braces, may be tried first. A thorough evaluation by an orthodontist or oral and maxillofacial surgeon is needed to determine the most appropriate treatment approach."(Ghodasra, R., et al) 

"In general, oral health-related quality of life of all subjects significantly improved after orthodontic treatment. Subjects with moderate malocclusion showed better improvement than severe malocclusion subjects."(Jamilian, A., et al) 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for D8080 Braces, D8670 monthly visits, D8680 Retainer services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: syncope
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld. 

The patient is a male with a history of hypertension, diabetes mellitus, and congestive heart failure who presented to the hospital with syncope. According to his family, the patient experienced a sudden episode of syncope while sitting down, lasting several minutes. Upon returning to baseline, he had no shaking episodes. During the syncope episode, his family measured his blood pressure, which was found to be in the 80s/40s range. The patient had been well the past week, having recently undergone adjustments to his diabetic medications, including the addition of Jardiance. He reported persistent high blood sugar levels, frequent urination, and increased thirst. Palpitations that came and went were also noted, starting on the day of the presentation. 

The acute inpatient level of care was not medically necessary, since there were no signs of hemodynamic instability that persisted after observation, or severe or persistent altered mental status. The imaging studies did not reveal evidence of acute stroke, brain mass, or hydrocephalus.
There was no indication that the syncopal episode was related to pulmonary embolism, arterial dissection, acute congestive heart failure (CHF) exacerbation, acute blood loss anemia, or acute coronary syndrome. There were no indications for immediate electrophysiological study or other interventions such as automatic implantable cardioverter defibrillator (AICD) placement.
Based on the telemetry monitoring, there was no evidence that the patient had a high degree of atrioventricular block, bradycardia with sinus pauses, or bursts of supraventricular tachycardia.
Furthermore, there was no evidence that the patient was severely dehydrated, and in fact, his hypertension and mild acute kidney injury resolved very quickly.
The review of the medical records revealed that the patient remained in stable clinical condition during the entire hospital stay, and did not require any treatment or testing that would justify admission at the acute inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity
Treatment: Wegovy
The insurer denied Wegovy.
The health plan's determination is overturned. 

This is a case review for a female being prescribed Wegovy for the diagnosis of obesity. The patient has been meeting with her PCP (primary care provider) every month for 3 months for weight loss counseling. She has a history of doing Weight Watchers for 3 months in the past. She currently participates in boot camps and monthly weigh-ins.

Wegovy is medically necessary for this patient.

The patient meets the criteria for prescribing the weight loss medication that was prescribed. She has a BMI (body mass index) over 30 and is actively engaged and participating in a comprehensive weight management plan. She meets the Food and Drug Administration (FDA) criteria for the medication. Therefore, it is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest pain.
Treatment:  Inpatient admission.

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

This is an adult female who was referred for elective cardiac catheterization.  She reported several months of chest pain that occurred at rest and with exertion. Symptoms began after percutaneous intervention in 3 months prior to the dates of service under review.  Past medical history was relevant for ischemic heart disease with Coronary Artery Bi-pass Graft (CABG)/bio aortic valve replacement (8 years ago) and subsequent percutaneous coronary interventions, stroke with bilateral upper extremity numbness and left lower extremity weakness, diabetes mellitus, hypothyroidism, and hypertension. No abnormal findings were noted on physical exam.  Cardiac catheterization was performed via right femoral arterial approach. Findings included a patent left internal mammary artery (LIMA) to left anterior descending (LAD) artery, 100% mid left anterior descending (LAD) lesion, 80% (percent) obtuse marginal artery (OM2) lesion, 100% right coronary artery (RCA).  A drug eluting stent was successfully placed in the second obtuse marginal artery.  No periprocedural complications were noted. The patient was monitored overnight and discharged the following day on dual antiplatelet therapy. 

This patient presented for elective percutaneous revascularization.  She underwent an uncomplicated procedure, and a stent was placed in the second obtuse marginal artery. She was discharged the following day.  Several investigators have studied the safety surrounding same day discharge following percutaneous intervention and demonstrated no difference between patients that are discharged on the same day as compared to patients admitted to the hospital. (Reference1-4) Current expert consensus from the society of cardiovascular angiography and interventions support treatment at a lower level of care. (Reference 4)  

Inpatient admission was not medically necessary.  The patient could have been managed at a lower level of care.

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: Chronic obstructive pulmonary disease (COPD)
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult male with chronic obstructive pulmonary disease (COPD) on home oxygen. He had chronic respiratory failure and presented to emergency room with shortness of 
breath (SOB) and wheezing. The patient was treated for chronic obstructive pulmonary disease exacerbation with intravenous steroids and Duonebs. The patient was admitted to the hospital for chronic obstructive pulmonary disease exacerbation. The patient was treated with intravenous steroids and Duonebs and continued with supplemental oxygen. The acute hospitalization was denied due to lack of medical necessity. This denial is being appealed.

The proposed treatment is not medically necessary.

The patient was admitted to hospital and was being treated for chronic obstructive pulmonary disease exacerbation. At the time of admission, the patient's vitals were stable, and he was not on high amounts of oxygen. The patient was tolerating oral diet. The patient was not in any distress. He was not on any invasive drips. The patient did not receive any treatment that could not have been provided at a lower level of care. The proposed hospitalization was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Respiratory Distress
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is a toddler female. She was admitted due to fever, breathing difficulty, and decreased oral intake. Her symptoms included one day of fever and URI (upper respiratory infection) symptoms. Upon presentation, the patient had a fever to 102 Fahrenheit, P (pulse) 156, R (respiration rate) 31, respiratory retractions, and abdominal breathing. Laboratory studies showed an unremarkable CBC (complete blood count), and bicarbonate level of 21.6. A chest x-ray showed a perihilar infiltrate. The patient was given ibuprofen, a Duoneb, dexamethasone, Tylenol, and ceftriaxone. She continued to have retractions, and so she was admitted. She was placed on normal saline nebulizers and a general diet. On the next day, the patient remained febrile but had improved respiratory distress. She was given a second dose of ceftiraxone. On day #3, the patient continued to tolerate oral intake, had improved respiratory distress and was discharged home.

The Inpatient admission was not medically necessary.

The patient was admitted for breathing difficulty and possible pneumonia. At the time of admission, she was hemodynamically stable, tolerating oral intake, and had mild breathing difficulty. She did not require close monitoring, respiratory support, intravenous fluids, frequent laboratory monitoring, frequent changes to her treatment plan, or any other service the required an acute inpatient level of care. Therefore, the acute inpatient hospital stay was not medically necessary. Her care could have been safely provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity

Treatment: Ozempic (semaglutide)

The insurer denied coverage for Ozempic (semaglutide).

The denial is upheld. 

The patient is diagnosed with obesity. This request is for Ozempic. As reported, the patient has dyslipidemia. The patient recorded a 23-pound weight loss since last visit. The patient missed last dose of Ozempic because pharmacy couldn't supply medication and has noticed an increase in appetite. 

The health plan acted with sound and reasonable judgment in their determination.

Semaglutide is a glucagon-like peptide-1 receptor (GLP1R) agonist (1) that is Food and Drug Administration (FDA) approved in the treatment of type II diabetes and obesity (2-4). Recent studies published in major peer reviewed medical journals have shown safety and efficacy of semaglutide for the treatment of obesity (5-7). This medication is now available for the treatment of obesity in the form of Wegovy. There are no studies showing safety or efficacy of the requested medication for patients who do not have diabetes such as this patient. There are no extenuating circumstances in this case. The request is, therefore, 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 Ozempic (semaglutide) is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Metapneumovirus pneumonia

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

 
The patient is a very young female with a history of fever and a cough for 4 days. She had been vomiting for 2 days with the mother indicating that she had fewer wet diapers, so she brought the child to the emergency room (ER) for evaluation.

In the ER the child was noted to have a fever of 102.5 degrees F. On physical examination there was evidence of moderate distress with mild dehydration. A chest x-ray showed a retrocardiac infiltrate. She was treated with an intravenous (IV) bolus of normal saline. She was also treated with oxygen and albuterol via a nebulizer. Following treatment in the ER the child continued to have hypoxemia with an oxygen saturation in the low 90's and the decision was made to admit the child to the hospital for continuation of treatment with IV fluid and oxygen for a metapneumovirus pneumonia.

The insurer has denied this admission and stated that there was no documentation in the medical record to establish the need for admission to the hospital.

The patient was treated appropriately for respiratory distress in the ER and when her oxygen saturation remained low and did not improve with bronchodilator treatments and IV fluid, she required continued treatment with oxygen. The clinical impression on admission was respiratory failure from a metapneumovirus infection. The admission to the hospital for continued treatment was medically necessary and the child could not have been safely discharged when still requiring oxygen supplementation.

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 the inpatient hospital admission is substantiated.