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

Diagnosis: Left diabetic foot infection. 
Treatment: Inpatient Hospital Admission. 

The insurer denied: Inpatient Hospital Admission. 
The denial is upheld. 

The patient is an adult male with type 2 diabetes, hypertension, sinus ventricular tachycardia, asthma, hyperlipidemia, coronary artery disease, and history of transient ischemic attack. He presented to the Emergency Department with foot pain. He had previously injured foot and was seen at outside hospital and left against medical advice.
The patient was afebrile, heart rate 108, BP (blood pressure) 160/114. Glucose was 276 mg/dL (milligrams per deciliter), CO2 (carbon dioxide) 32. He was diagnosed with left diabetic foot infection. The patient was treated with opioid medications, Zosyn, subcutaneous insulin, and Vancomycin. MRI (magnetic resonance imaging) of his foot showed focus in the third webspace, which may represent a fluid collection. Infectious disease and podiatry were consulted. Infectious disease recommended discontinue intravenous antibiotics and treat with oral clindamycin. Inpatient stay is under review. 

The Inpatient Hospital Admission was not medically necessary. 

This patient presented with hyperglycemia and left diabetic foot infection. He was mildly tachycardic but hemodynamically stable. He was started on intravenous antibiotics that were discontinued the following day by infectious disease and placed on oral antibiotics. There was no evidence of osteomyelitis on imaging. He had moderate hyperglycemia without diabetic ketoacidosis or hyperglycemic hyperosmolar state. His diabetes was managed with subcutaneous insulin. He was discharged home the day after discharge. The documentation does not support that he failed a lower level of care. Therefore, no, the requested inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atrial fibrillation

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
This adult patient presented to the hospital complaining of palpitations. He had a past medical history of multiple cardioversions for atrial fibrillation, hypertension, left bundle branch block, obstructive sleep apnea and heart failure with preserved ejection fraction. Upon arrival, the patient was tachycardic with a pulse of 154 and hypertensive with a blood pressure 183/108. No abnormal findings were recorded on physical examination except for an irregular pulse. A 12-lead electrocardiogram demonstrated atrial fibrillation and left bundle branch block. Serum blood testing demonstrated no elevation in serum troponin.  Previously performed echocardiogram demonstrated an ejection fraction of 45-50%. The patient was treated with intravenous diltiazem and admitted to the telemetry ward. He spontaneously converted to sinus rhythm overnight and was discharged on medical therapy the next day. 

This patient presented with symptomatic atrial fibrillation and was effectively treated with atrial - ventricular (AV) nodal blocking agents. Following evaluation and additional testing, the patient reverted to normal sinus rhythm and was released from the hospital. Bellew studied patients presenting to the hospital with rapidly conducted atrial fibrillation and compared outcomes between those admitted to the in-patient service and those that were observed in the emergency department. In this study of almost 600 patients, there was no difference in outcome. American Heart Association (AHA) guidelines note that admission to the hospital for management of atrial fibrillation in patients that achieve rate control do not require hospital admission. This patient reverted to normal sinus rhythm several hours after presentation and had an extensive previous work up for paroxysmal atrial fibrillation. In conclusion, inpatient admission was not medically necessary. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute hypoxic respiratory failure, Chronic Obstructive Pulmonary Disease, hypertension, and sacral region ulcer

Treatment: Continued stay in skilled nursing facility

The insurer denied coverage for continued stay in skilled nursing facility

The denial is overturned

This is an adult patient with Chronic Obstructive Pulmonary Disease (COPD), hypertension and sacral region ulcer. The patient was admitted to a Skilled Nursing Facility (SNF) with a primary diagnosis of acute hypoxic respiratory failure secondary to pneumonia with COPD exacerbation. The patient was discharged to the community once stable. Under review is the medical necessity for continued stay in a SNF.

The patient was an appropriate candidate for the SNF subacute rehabilitation level of care for the time period under review. The patient had functional impairments amenable to (subacute) rehabilitation therapy. The physical and occupational therapy notes document continued improvement during the length of stay. According to the physical therapy notes the patient's functional ability for bed mobility, transfers and ambulation significantly improved from maximal assistance, total dependence, and maximal assistance, respectively to contact guard/supervision. The occupational therapist documented a similar level of improvement. Activities of daily living (ADL) tasks such as hygiene/grooming, dressing and self-feeding improved from total dependence to supervision/set-up from admission. Based on the trajectory of the documented improvement, continued length of stay was supported through discharge. During this time, the patient was also receiving care for the sacral and abdominal wounds which were documented as resolved as of the date of discharge. Overall, the clinical records document an excellent clinical and functional outcome, further supporting the continued care in a SNF from admission to discharge.  

The healthcare plan did not act with sound medical judgment or in the best interest of the patient. From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, continued care in an SNF was medically necessary.   

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 continued stay in skilled nursing facility, is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Shortness of breath; wheezing
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned

The patient is an adult male with history of asthma who presented to the emergency room (ER) with shortness of breath and wheezing. The patient was treated in emergency room with nebulization treatments and intravenous steroids for asthma exacerbation. Despite emergency room treatment, the patient continued to have respiratory symptoms and was admitted to the acute in hospital level of care for asthma exacerbation. The patient was continued on intravenous steroids and intravenous antibiotics. On day #2, the patient continued to have shortness of breath and worsening chest tightness and his oxygen requirements were going up. The patient received additional intravenous medications for worsening asthma exacerbation. On day #3, the patient's asthma symptoms improved. The acute in hospital level of care was denied due to lack of medical necessity. This denial is being appealed.

The proposed treatment was medically necessary.

The patient had an asthma exacerbation that was difficult to treat in the emergency room. The patient had worsening symptoms of asthma and despite emergency room treatment, it did not improve. During hospitalization, the patient had worsening symptoms and required increasing amount of oxygen as well as intravenous medications. The admission was denied due to lack of medical necessity. However, the admission was medically necessary, as patient had difficult to treat asthma. Given the patient's signs and symptoms without improvement and past history of multiple respiratory failure with intubations due to asthma exacerbations, it would not have been reasonable to expect significant improvement within 24 hours, as is what happened with the patient. The patient's treatment course would have been expected to require treatments or interventions that could not have been provided at a lower level of care. The treatment provided or reasonably expected to be provided in this case required an acute inpatient level of care. The proposed treatment is medically necessary as it is the current standard of clinical practice.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis 
Treatment: Inpatient hospital admission 
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

The health plan acted reasonably. Based on clinical documentation, the patient had acute appendicitis. The patient presented to the emergency department. The patient underwent an uneventful laparoscopic appendectomy and was discharged on the day of the procedure. There were no reported complications and the patient was cleared for discharge by the surgical team. Outpatient appendectomy is as safe and effective, with complication rates, readmission rates, and satisfaction equivalent to those patients kept in observation.

The inpatient hospital stay was not medically necessary. Per clinical documentation, the patient presented to the emergency department with a one-day history of right-sided abdominal pain. There was associated nausea. Vital signs were within normal limits. The white blood cell count was normal at 4.9. A Computed Tomography scan was positive for acute appendicitis. The patient underwent an uneventful laparoscopic appendectomy and was discharged home on the same day. Admission may be necessary for patients with severe systemic illness (such as sepsis), poorly controlled comorbidities (such as Chronic Obstructive Pulmonary Disease, Chronic Heart Failure), or complications from the procedure (such as infection, bleeding) that require more than 24 hours of postoperative care. There were no immediate complications documented after the surgery. Peer-reviewed literature also indicates that outpatient laparoscopic appendectomy can successfully be performed in those with uncomplicated appendicitis. Suitable criteria for same-day discharge include hemodynamic stability, tolerating liquids, and pain controlled on oral medications. Surgical documentation notes that the patient was uncomplicated. Therefore, the requested inpatient hospital stay was not medically necessary. Observation care would be more appropriate.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient. 

The medical necessity for the inpatient hospital admission is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Hypertension
Treatment: Formulary exception for Edarbi 40mg (milligram) Tablet (azlisartan)
The insurer denied: Formulary exception for Edarbi 40mg Tablet (azlisartan)
The denial is upheld.

The patient is an adult male with a past medical history of hepatic adenoma and a longstanding history of hypertension. He had a transthoracic echocardiogram 3 months ago which demonstrated normal biventricular function without significant valvular abnormalities. He has been followed by a cardiologist and has been on losartan and Edarbi with adequate control of his blood pressure.

The health plan should not cover the Formulary exception for Edarbi.

Based on the provided documentation, there is no evidence that the patient has tried and failed the formulary alternatives (such as hydrochlorothiazide) without adequate response. There is also no evidence that he has had any contraindications to treatment with formulary alternatives. Consequently, there is insufficient clinical data to support the use of Edarbi in this patient.

Therefore, given the above, the health plan should not cover the formulary exception for Edarbi.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Glanzmann's thrombasthenia

Treatment: continued inpatient stay

The insurer denied coverage for continued inpatient stay

The denial is overturned

 
The patient is a male child with a history of Glanzmann's thrombasthenia (GT) who was admitted to the hospital as a direct admission from the outpatient Hematology/Oncology office. The patient was admitted with gross bleeding from bilateral nares and oozing from the posterior oropharynx for two days. The patient was given Amicar every 6 hours (Q6H). NovoSeven was originally given every two hours (Q2H) and then spaced out. Human leukocyte antigens (HLA) platelets were available. The patient did not have any significant episodes of bleeding during the hospitalization. NovoSeven was spaced to every day (QD).

Notes show that the patient was 'tolerating every 12 hour Factor 7 without any bleeding. Awaiting insurance approval prior to discharge.

The Factor Vlla that was administered was medically necessary. It has been determined that a safe discharge plan was not in place since the at-home administration of Factor VIIa was denied by the insurer.

If the bleeding is unresponsive or incompletely responds to local measures, or if the patient is undergoing surgery, platelets and/or recombinant activated clotting factor VII (rFVIIa) may be required. Platelet transfusion as surgical prophylaxis and as the treatment for moderate to severe bleeding is standard for GT. Recombinant Factor VII a (FVIIa) binds to activated platelets and creates a thrombin burst, helping fibrinogen conversion to fibrin and subsequent hemostasis. Recombinant Factor VII a is approved in the United States for patients with GT with platelet refractoriness." (Krause, K.A., Graham, B.C., 2022).

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 the continued hospital stay is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Other - Pancreatic cysts.
Treatment: Abdomen MRI.
The health plan denied: Abdomen MRI.
The determination is: Overturned.

The patient is a male who has a history of neuroendocrine tumors (NETs) of the appendix. The patient underwent a computed tomography (CT) scan of the abdomen previously and was found to have a newly dilated main pancreatic duct (PD). He underwent an endoscopic ultrasound (EUS) and a follow-up magnetic resonance cholangiopancreatography (MRCP) which showed stability in the size of the PD. There was some tapering of the duct in the head of the pancreas; this area was biopsied and was benign. There were a few small pancreatic cysts, which were stable in size. The patient's provider has requested a MRCP of the abdomen for surveillance of the pancreatic duct. The concern is that this could be a main duct intraductal papillary mucinous neoplasm (IPMN).
At issue is the medical necessity of the abdomen magnetic resonance imaging (MRI).
The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of abdomen MRI is medically necessary for this patient. The patient likely has a main duct IPMN. Main duct IPMNs involve the main pancreatic duct diffusely or segmentally. The majority arise within the head of the pancreas such as in this case and progress distally with or without involvement of the side branches (his small cysts are likely side branch cysts). They are histologically more aggressive than branch duct IPMNs and more likely to harbor a malignancy. The risk of carcinoma in situ or invasive carcinoma in main duct IPMN is approximately 70 percent, and there are no radiographic or clinical characteristics that reliably predict malignancy in main duct IPMN. Surveillance depends on the size of the main duct. In this case, it was 6 millimeters (mm). If the duct is 5 to 9 mm in diameter, EUS with fine-needle aspiration is recommended. Surgery is indicated if there is evidence of thickened walls, intraductal mucin, or mural nodules on EUS, or if cytology is suspicious or positive for malignancy. If there is no evidence of thickened walls, intraductal mucin, or mural nodules in a patient with main duct IPMN, the results of the EUS are considered to be inconclusive; that is the result in this case. After this, yearly MRCP is indicated for surveillance, which is the request in this case. Therefore, the abdomen MRI is medically necessary.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: multiple myeloma
Treatment: Home health care
The insurer denied Personal Care Worker (PCW) Hours: 7 Days per Week x 12 Hours per Day. The health plan's determination is overturned. 

The patient is a female with past medical history of multiple myeloma, depression, diabetes mellitus type 2, hyperlipidemia, hypertension, gastroesophageal reflux disease (GERD), asthma, and urinary incontinence who had been assigned PCW (personal care worker) services.

Personal Care Worker (PCW) Hours: 7 Days per Week x 12 Hours per Day are medically necessary for this patient.
There is documentation from the patient's primary care provider and social worker of worsening physical functioning related to terminal illness of multiple myeloma. There is documentation that the patient is on hospice services with anticipated continued decline in functional status. The patient requires at least extensive assistance with walking, locomotion, transfer toilet, and toilet use and therefore has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The plan assumed the patient had informal help outside of currently assigned PCW services which was not the case as her adult children are unable to provide informal support. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, Personal Care Worker (PCW) Hours: 7 Days per Week x 12 Hours per Day are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pancreatic Cancer
Treatment: Radiation Therapy
The insurer denied: Radiation Therapy
The denial is Overturned.

The patient is an adult female with a diagnosis of stage cT4N0M1 (Clinical stage Tumor stage four - Node stage zero - Metastasis stage one) pancreatic cancer with oligometastatic liver lesions status post a good response and stable disease. Definitive radiation therapy to the pancreatic lesion was recommended and stereotactic body radiation therapy (SBRT) was requested. The request was initially denied because it was not considered medically necessary per eviCore guidelines.

The proposed treatment is medically necessary.

There are studies showing that stereotactic body radiation therapy (SBRT) is a safe and effective treatment for pancreatic cancer. A 2009 Stanford University study evaluated 77 patients with unresectable pancreatic cancer treated with stereotactic body radiotherapy. They authors concluded that "SBRT for pancreatic adenocarcinoma was effective for local control". Another study by Koong et. al. also concluded that "Concurrent IMRT and 5-FU followed by SRS in patients with locally advanced pancreatic cancer results in excellent local control but does not improve overall survival". A more recent 2017 study performed a systemic review and pooled analysis of 19 trials regarding stereotactic body radiation therapy for pancreatic cancer. The pooled one-year overall survival (OS) was 51.6%, and the local control rate (LRC) rate at one year was 72.3%. Overall, the occurrence of severe adverse events did not exceed ten percent. The authors concluded that "The advantages of SBRT in terms of treatment time, satisfactory OS, and LRC indicate that it is an effective option for inoperable PC". Another 2017 study by Zhong et al. analyzed 8450 patients (7819 chemoradiation, 631 stereotactic body radiation therapy with pancreatic cancer. The multivariate analysis showed that the median survival was 13.9 months for stereotactic body radiation therapy compared to 11.6 months for chemoradiation.

In this case, the patient has no active disease outside of the pancreas. If the patient's pancreatic lesion can be adequately controlled with stereotactic body radiation therapy, she may have a prolonged survival. Stereotactic body radiation therapy has been shown to be safe and effective for the treatment of pancreatic cancer; therefore, it is a medically necessary treatment option for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Viral infection.
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 (PMH) of diabetes mellitus type 2 (DM2), breast cancer status/post (s/p) chemotherapy/radiation and mastectomy who was admitted with complaints of (c/o) weakness associated with body aches and chills. Her vital signs were unremarkable. The physical exam notable for awake, alert, and oriented times four (AAOx4), non-toxic appearing, with no respiratory distress. Lab work was notable for a creatinine of 1.4, lactate 3.5, carbon dioxide (CO2) 18, transaminitis, and glucose 89. Imaging studies included a right upper quadrant (RUQ) ultrasound (US) which showed no acute pathology and a chest x-ray (CXR) showed no acute disease. The patient was diagnosed with a viral infection and dehydration complicated by an acute kidney injury (AKI) and was treated with intravenous fluids (IVF), biochemical monitoring, and diabetic optimization. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

No, the hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with complaints of (c/o) weakness associated with body aches and chills. The patient did not have associated high-risk features, such as severe acute renal failure, congestive heart failure, or liver failure, nor did the patient have any hemodynamic instability, bowel obstruction, diabetic ketoacidosis, appendicitis, pyelonephritis, ascending infection, toxic appearance, unstable vital signs, or immunosuppression. The patient was found to have an acute kidney injury, for which intravenous fluids (IVF) were administered and the patient's creatinine responded. This patient did not have hypertension (HTN) requiring continuous vasoactive medication, she had no concomitant febrile illness, and there was no urgent indication for dialysis, marked electrolyte abnormalities, volume overload, severe hyponatremia, hyperkalemia, severe metabolic acidosis, or acute respiratory distress. This patient, without distress, was admitted for an acute kidney injury and dehydration secondary to a viral illness, received intravenous fluids (IVF), and was discharged home in stable condition, The care could have been provided safely at a lower level of care. The patient did not have pulmonary manifestation or hemodynamic instability, inability to maintain oral hydration, severe altered mental status (AMS), new coagulopathy, stage 3 acute renal failure (ARF), stage 2 acute kidney injury (AKI), cardiac arrhythmia, hypothermia, neuromuscular impairment, varicella zoster virus (VZV), or hemorrhagic fever.