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

Diagnosis: Hyperlipidemia.
Treatment: Repatha.
The insurer denied Repatha.
The determination is upheld.

The patient is a female with hyperlipidemia and a history of premature atherosclerotic cardiovascular disease. Her coronary artery calcium score is 91, placing her in the 90th-100th percentile based on her age, race and sex. Her baseline low density lipoprotein (LDL) cholesterol level is 211 milligrams per deciliter (mg/dl). She developed myalgias and elevated liver function tests with atorvastatin (dose not documented). The medical necessity for Repatha is at issue.

Based on the documentation provided, Repatha is not medically necessary for this patient.
This patient has a markedly elevated low-density lipoprotein (LDL) cholesterol level and a family history of premature atherosclerotic cardiovascular disease (ASCVD). Her baseline LDL cholesterol level (LDL-C) of 211 mg/dl is consistent with a diagnosis of phenotypic heterozygous familial hypercholesterolemia (HeFH). Published studies have indicated that the long-term atherosclerotic cardiovascular disease risks for United States (US) adults with a baseline LDL-C greater than or equal to 190 mg/dL are increased approximately 5-fold compared to those with average levels of LDL-C, even after adjustment for other cardiovascular risk factors. Current guidelines, including the 2017 National Lipid Association Update on the use of proprotein convertase subtilisin/kexin type 9 (PCSK9) Inhibitors in Adults and the 2022 American College of Cardiology (ACC) Expert Consensus Decision Pathway on the Role of Nonstatin Therapies for LDL-Cholesterol Lowering in the Management of Atherosclerotic Cardiovascular Disease Risk, endorse the use of PCSK9 inhibitors, such as Repatha, in patients with phenotypic heterozygous familial hypercholesterolemia (HeFH) whose LDL cholesterol levels remain above goal despite maximally tolerated statin therapy. However, based on the documentation provided it is not clear that this patient has complete statin intolerance and that her maximally tolerated statin therapy is no statin. By report, she had myalgias and transaminase elevations with atorvastatin. The dose of atorvastatin was not documented nor was the degree of transaminase elevation. Mild transaminase elevations occur commonly with statin therapy and elevations up three times the upper limits of normal are not, in themselves, a contraindication to, or an indication for discontinuation of, statins.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertensive emergency, non-ST-segment elevation myocardial infarction
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a male patient, with a past medical history of end-stage renal disease on hemodialysis, was brought to the emergency department for evaluation of a syncopal episode that occurred while undergoing dialysis.
The patient reported experiencing abdominal pain during the scheduled hemodialysis session earlier that day. While in the dialysis center, he felt the need to use the bathroom and had two episodes of watery stool. Subsequently, he became weak and fainted while attempting to reach the bathroom. The patient denied experiencing lightheadedness, dizziness, headache, nausea, or vomiting before the fall. He denied chest pain, shortness of breath, orthopnea, fever, or chills.
The patient disclosed a history of diarrhea following the initiation of hemodialysis three years prior, for which he had been taking diphenoxylate as needed. He assumed that the diarrhea might be related to the administration of iron or vitamin D during hemodialysis.
Upon arrival at the emergency department, the patient was afebrile but had a blood pressure reading of 225/111. The oxygen saturation was 96 percent (%) on room air. The physical examination revealed a pulse rate of 68 beats per minute (bpm), respiratory rate of 18 breaths/minute, blood pressure of 182/93, and oxygen saturation of 94% on room air. The patient had an unremarkable physical exam, and a left upper extremity arteriovenous fistula was noted.

The patient was admitted to the hospital with a diagnosis of hypertensive emergency, non-ST-segment elevation myocardial infarction, syncope-like symptoms, and end-stage renal disease. Initial admission was to the critical care unit.
Treatment included a nicardipine drip for blood pressure control, later transitioning to oral antihypertensive medications once the blood pressure was better controlled. Subsequent assessments determined that the patient had Type II myocardial ischemia.
As the patient's clinical condition continued to improve, he was transitioned to outpatient care. At issue is the medical necessity of an inpatient stay.

Based on the current clinical standards of care, admission at the acute inpatient level of care is justified for patients with syncope and acute coronary syndrome as well as a hypertensive emergency which manifested in type II myocardial infarction.
This patient presented to the hospital after he had a syncopal episode at the dialysis center. Based on the patient's evaluation, he had acute coronary syndrome. His troponin levels were severely elevated, and in this clinical case, he was diagnosed with type II myocardial ischemia.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male with a previous history of alcohol abuse who was admitted for 5 days of epigastric pain. The pain is radiating to the back. The patient confirmed he is no longer abusing ethyl alcohol (ETOH). On admission, vitals were normal except for a significantly elevated blood pressure (BP). He was afebrile. On labs, the complete blood count (CBC) was normal. Lipase was 221. The LFT's (liver function tests) were normal. The patient underwent a computed tomography (CT) of the abdomen and pelvis which did not identify changes consistent with acute or chronic pancreatitis. An ultrasound (US) of the abdomen did not identify cholelithiasis. 

The inpatient hospital admission was not medically necessary. The patient perhaps met the criteria of acute pancreatitis - he had pain consistent with pancreatitis and a near 3-fold elevation of the serum lipase. However, the CT scan showed a normal pancreas. The patient was able to take by mouth (PO) and did require total parenteral nutrition (TPN) or enteral tube feeding. His vitals were stable including oxygenation (ie., there was no evidence of adult respiratory distress syndrome (ARDS)). There was no evidence of metabolic consequences of pancreatitis (e.g., hypocalcemia) or evidence of hemorrhagic or necrotic complications of pancreatitis. Based on all of these factors, the patient did not require an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Narcolepsy without cataplexy
Treatment: 60 Vyvanse capsules (CAP) 50 milligrams (MG) for one month
The insurer denied 60 Vyvanse capsules (CAP) 50 milligrams (MG) for one month.
The determination is upheld.

This is a patient who suffers from narcolepsy without cataplexy. The treating physician is requesting the coverage of Vyvanse at a dose of 50 milligram, two capsules daily. The patient has a history of hypertension, dyslipidemia and asthma. At issue is the medical necessity of 60 Vyvanse capsules (CAP) 50 milligrams (MG) for one month.

No, the requested health service/treatment of 60 Vyvanse CAP 50 MG for one month is not medically necessary for this patient.
The excessive daytime sleepiness (EDS) in patients with narcolepsy is primarily treated with stimulants or wake promoting agents. The central nervous system (CNS) stimulants increase alertness and assist the patient to remain awake.
Vyvanse has been approved by the Food and Drug Administration (FDA) for the treatment of attention deficit hyperactivity disorder (ADHD) in children. The medication has a long history of off-label use in clinical practice for the treatment of narcolepsy but has limited information available on the benefit-to-risk ratio.
This patient was given the diagnosis of narcolepsy. The provider is requesting the coverage of Vyvanse 50 mg, 2 capsules daily (total dose of 100 mg daily) to improve the patient daytime alertness. However, there are no adequate or well-conducted randomized controlled or cohort trials in the prevailing peer-reviewed published medical literature that established the long-term efficacy and safety of Vyvanse 100 mg daily over maximum approved dose of 70 mg daily in the treatment of narcolepsy. There is no high-quality literature showing an improvement in health outcomes with the use of this medication at the requested dose of 100 mg daily for this condition. There are no national guidelines that support the routine use of the Vyvanse at a dose of 100 mg daily for the treatment of narcolepsy as in this patient's case.
Therefore, the 60 Vyvanse CAP 50 MG for one month is not medically necessary for this patient diagnosis.
Appeal type: Medical necessity
Decision: Upheld

Dental Issues
Dental/orthodontic

Diagnosis: dental issues
Treatment: Nerve Treatment and Crown on Tooth 18 
The insurer denied Nerve Treatment and Crown on Tooth 18.
The health plan's determination is upheld. 

The patient is a male who presents for the Nerve Treatment and Crown on Tooth 18. Provided for review are previous letters of appeal and denial, health plan language and explanation of benefits, clinical notes, as well as multiple radiographic images.

The requested Nerve Treatment and Crown on Tooth 18 is not medically necessary for this patient.
From the documentation provided, there is no diagnosis of any pulpal pathology, there is no periodontal indices provided, and there is not evidence of decay on tooth #18 to necessitate a crown nor root canal therapy. Although there is radiographic evidence of bone loss, there has not been an investigation into the possibility of periodontal origin to the radiographic appearance and the presence of a fracture has not been determined. Without these multiple factors being investigated and determined, the requested treatment is not indicated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain. 
Treatment: Inpatient admission. 
The insurer denied inpatient admission. 
The determination is upheld in whole. 

This patient is a female with a past medical history significant for hypertension, type 2 diabetes mellitus, breast cancer treated with lumpectomy, Herceptin and currently on radiation, who presented to the emergency department (ED) for evaluation of chest pain and shortness of breath. She was recently hospitalized and treated for pneumonia. In the ED, vital signs (VS) were stable and normal range. A computed tomography (CT) scan of the chest was negative for a pulmonary embolism (PE). High-sensitivity (HS) cardiac troponins were negative, D-dimer was high at 336. Erythrocyte sedimentation rate (ESR) was 64. Brain (or B-type) natriuretic peptide (BNP) was normal. An electrocardiogram (ECG) demonstrated normal sinus rhythm with new T wave inversions in the precordial leads. Echocardiogram demonstrated normal cardiac function and no pericardial effusion. The patient was treated for presumed acute pericarditis with colchicine twice daily and nonsteroidal anti-inflammatory drug (NSAID)s which improved her symptoms. She remained stable and was discharged home. 
At issue is the medical necessity of the inpatient admission. 

The requested health service/treatment of inpatient admission was not medically necessary for this patient. 
The inpatient level of care was not medically necessary in this case for the following reasons. The patient presented to the ED for evaluation of pleuritic chest pain after a recent hospitalization for pneumonia. The patient symptoms were atypical for coronary artery disease (CAD) and HS cardiac troponin levels were negative. ECG demonstrated normal sinus rhythm with nonspecific anterior T wave inversions. Echocardiogram was normal. The patient's calculated HEART (history, ECG, Age, risk factors, troponin) score was 4, indicative of moderate risk for short term adverse cardiac events. Given the patient's chest pain was atypical, cardiac troponins were negative, and acute coronary syndrome (ACS) was ruled out, inpatient level of care was not medically necessary in this case. Rather, a lower level of care would have been medically appropriate and safe for this patient as supported by peer reviewed medical literature on the HEART pathway and the 2022 American College of Cardiology (ACC) expert consensus decision pathway on the evaluation and disposition of acute chest pain in the emergency department.(1-3)
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe hyperglycemia
Treatment: Inpatient admission

The insurer denied coverage for Inpatient admission.  The denial is overturned.

This is adult with a history of diabetes, polycystic ovary syndrome (PCOS), hypertension (HTN), and recent admission for acute renal failure. The request is for coverage of admission. The patient was admitted to the emergency room (ER) with generalized weakness for 4 days and hyperglycemia. Finger prick glucose was over 600. The patient is noncompliant with her treatment regimen. Vital signs were: Blood Pressure 117/64, Pulse 103, Temperature 96.8 degrees Fahrenheit, Respiratory rate 20, and oxygen saturation at 97% (percent). Examination: 3+ bilateral pitting edema. 

Labs on the 3rd: Elevated glucose at > 600, white blood cell count (WBC) 3.50k (thousand), hemoglobin (Hgb) 9.1, blood urea nitrogen (BUN) 87, creatinine 3.76, sodium 120, potassium 4.8, chloride 85, carbon dioxide (CO2) 21.1, albumin 2.6, alkaline phosphatase 178, lipase 167, venous pH 7.36, blood glucose greater than 500.

Labs on the 6th: Glucose 253, sodium 129, CO2 20.8, creatinine 3.88, Hgb 8.2, Chloride 94, BUN 93, Calcium 8.4, phosphates 5.4.

The patient does not have chest pain, abdominal pain, fever, headache or blurry vision.
The patient was treated for hyperglycemia with insulin and given traditional Chinese medicine (TCM) education. The patient was diagnosed with hyperglycemia and hypovolemia.

Acute inpatient admission for patients with symptomatic diabetes is necessary when the patient has evidence of ketoacidosis or a hyperosmolar state [1-6]. Observation is generally sufficient for patients with ketosis or vomiting that resolves after hydration [7-9].  This patient had symptomatic diabetes with severe hyperglycemia in addition to acute kidney injury with a creatinine of 3.88, which required complex medical management and consultations beyond treating the patient's hyperglycemia.  The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.

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 admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Near Syncope

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

This is the case of a patient that presented to the hospital with lightheadedness and near syncope several days prior to presentation along with chest pain and shortness of breath.  The patient describes an episode of lightheadedness that began while standing and resolved after sitting down.  The patient's past medical history was significant for anxiety and near syncope. An implantable loop recorder (ILR) was previously implanted. On arrival to the hospital vital signs were stable (blood pressure 130/87 and pulse 77). Physical exam revealed no significant abnormality. Serum blood tests revealed a blood urea nitrogen (BUN) of 14 and Creatinine of 0.5.  Cardiac enzymes were not elevated (high sensitivity troponin was 5). An electrocardiogram (ECG) revealed normal sinus rhythm with normal intervals and no evidence of ST
(Sinus tachycardia) or T wave abnormality. The patient was admitted to the hospital while awaiting interrogation of the ILR.  Telemetry monitoring revealed no sustained arrhythmia.  Cardiology evaluation was unrevealing, and the patient was discharged.

The health plan acted reasonably and with sound medical judgment and in the best interest of the patient. This patient presented with lightheadedness and near syncope. Physical examination and serum blood testing revealed no major abnormalities.  No rhythm abnormality was noted on ECG (Electrocardiogram) or telemetry. This patient falls into a low-risk group for syncope.  According to American Heart Association (AHA)/American College of Cardiology (ACC)/Heart Rhythm Society (HRS) guidelines such patients should be managed utilizing a structured emergency room (ER) observational protocol (Reference 1).  In a study of individuals presenting to the emergency room, patients that were low risk or intermediate risk for cardiac events had an excellent prognosis and did not require admission to the hospital for further testing (Reference 2).  Acute inpatient admission was not medically necessary for this patient.

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: Alcohol Disorder, Abdominal Pain
Treatment: Inpatient Hospital Stay

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

This is a female patient with a past medical history remarkable for alcohol disorder, and major depression, who presented to the emergency department (ED) for right lower quadrant abdominal pain. The review of systems was positive for nausea and back pain.
The physical examination was remarkable for right lower quadrant abdominal tenderness.

The patient was admitted for abdominal pain most likely due to uterovesical junction calculi. A computed tomography (CT) scan of the abdomen and pelvis showed ureterovesical junction calculi and a large amount of stool in the colon. The patient was treated with intravenous (IV) hydration and pain control with Tylenol. The patient was also noted to have alcohol withdrawal and was treated with Ativan. The hospital course was notable for constipation for 4 days and awaiting placement for a detoxification (detox) program.

At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient hospital admission was not medically necessary. The care could have been safely rendered at a lower level of care. The patient was admitted for alcohol intoxication and withdrawal. The documentation does not support an inpatient level of care since the patient was hemodynamically stable and had no evidence of instability or focal neurologic deficits. There were no objective clinical findings that were consistent with alcohol withdrawal or delirium tremens.

The Diagnostic and Statistical Manual of Mental Disorders defines alcohol withdrawal as 2 or more distinguishing symptoms which develop within several hours to days following a significant decrease in alcohol consumption after a prolonged period of heavy drinking. These symptoms include nausea or vomiting, autonomic hyperactivity, insomnia, increased anxiety and agitation, tremor, perceptual disturbances, and seizure. In this case, the patient had no objective signs of autonomic hyperactivity. A lower level of care would have been appropriate for clinical monitoring and intravenous (IV) fluids. The patient's Clinical Institute Withdrawal Assessment (CIWA) scores did not warrant treatment at the inpatient level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: abdominal pain
Treatment: inpatient stay
The insurer denied the inpatient stay
the health plan's determination is overturned. 

This case involves a man with alcoholic liver cirrhosis, portal hypertension, and esophageal varices who has undergone banding in the past. He presented to the hospital with abdominal pain and distention. He denied nausea vomiting or fevers. His last alcoholic beverage was 4 months prior to this presentation. Temperature was 98.6 F, pulse rate 100, respirations 18 and blood pressure 119/74. Examination showed a well-developed well-nourished man in mild distress, with stable cardiopulmonary exam. Abdominal exam showed mildly distended but soft abdomen with diffuse tenderness. Point-of-care ultrasound was completed, showing no significant ascites. A computed tomography (CT) scan of the abdomen showed cholelithiasis with nonspecific gallbladder wall thickening. The medical team placed a surgery consult to evaluate the cholelithiasis, added prophylactic ceftriaxone and repleted the hypokalemia and hypomagnesemia noted on labs.

The inpatient hospital admission was medically necessary. The patient was admitted to the hospital with abdominal pain. In the setting of liver disease and ascites per computed tomography (CT) scan, a clinical suspicion was raised for spontaneous bacterial peritonitis. Treatment of spontaneous bacterial peritonitis typically occurs in the hospital setting with intravenous antibiotics. Diagnosis is primarily made by paracentesis; however, there is sometimes inadequate fluid, or peritoneal window, to drain ascites safely without causing internal injury, as appears to be in this case. Therefore, empiric treatment is typically continued for seven days. It was reasonable to admit this patient under inpatient status while continuing to work up causes of persistent abdominal pain, as noted in the progress notes.