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

Diagnosis: Chronic Obstructive Pulmonary Disease.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is an adult male with history of COPD (chronic obstructive pulmonary
disease) on home oxygen, CHF (congestive heart failure), pulmonary hypertension,
DVT (deep venous thrombosis) on anticoagulation, HTN (hypertension), and opioid
dependence. He presented to the emergency room with worsening
SOB (shortness of breath) that was ongoing for approximately one week.

The patient was noted to be hypoxic, with saturation of 83% on RA (room air). He
was started on home oxygen at 4L (liters) NC (nasal cannula). The patient was
admitted to the hospital for the management of COPD (chronic obstructive
pulmonary disease) exacerbation. The patient was started on IV (intravenous)
steroids, IV (intravenous) antibiotics and DuoNebs, as well as continued on
supplemental oxygen. The patient was seen by cardiology as well as
ophthalmology for blurry vision during the hospitalization.

The patient's IV (intravenous) steroids were reduced. The patient's oxygen levels were improving, and the supplemental oxygen was reduced to 2L (liters) NC (nasal cannula). The IV (intravenous) steroids were switched to oral prednisone.

For three admission days, the patient remained on home medications, as well
as 2L (liters) NC (nasal cannula) and oral prednisone.

No, the inpatient admission was not medically necessary.

The patient had mild COPD (chronic obstructive pulmonary disease) exacerbation.
The patient was started on IV (intravenous) steroids, IV (intravenous) antibiotics
and DuoNebs. The patient required more supplemental oxygen (4L [liters] NC
[nasal cannula]) compared to home dose (2L [liters] NC [nasal cannula]). The
patient's SOB/DOE (shortness of breath/dyspnea on exertion) improved within 24
hours of hospitalization. The patient was ambulating, tolerating oral diet, and
hemodynamically stable. The patient was not receiving any invasive drips. Based
on this patient's clinical scenario, the inpatient admission level of care was not medically necessary to manage this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute Cholecystitis and Cholangitis.

Treatment inpatient hospital.

The insurer denied coverage for inpatient hospital.

The denial is overturned.

The patient presented to the emergency department (ED) for evaluation of epigastric pain. The patient was diagnosed with acute cholecystitis and cholangitis and underwent sphincterotomy, balloon sweep and stent placement, followed by laparoscopic cholecystectomy the following day.

Acute cholecystitis and biliary complaints are a common inpatient diagnosis. Acute cholecystitis is also estimated to attribute to millions of ambulatory visits each year, and is a leading cause of hospital admissions. [1] Studies have shown that ambulatory laparoscopic cholecystectomy is safe and avoids an overnight hospital stay. [2, 4, 5] Factors that contribute to admission after laparoscopic cholecystectomy include drain placement, conversion to open surgery, persistent abdominal pain, nausea, and vomiting. [3] In patients without abnormalities of the bile duct or abnormal liver function tests, ambulatory laparoscopic cholecystectomy is safe and feasible. [5] Ambulatory and/or outpatient laparoscopic cholecystectomies reduce hospital costs without compromising patient outcomes. [6]

Per clinical documentation, this patient presented to the ED with upper abdominal pain. There was associated nausea. Vital signs in the ED were within normal limits. An ultrasound indicated cholelithiasis and mild common bile duct dilatation. A CT (computed tomography) scan also demonstrated mild common bile duct dilatation. The total bilirubin was elevated at 2.1. Alkaline phosphatase, alanine transaminase, and aspartate aminotransferase were all elevated at 320, 1018, and 954, respectively. White blood cell count was normal at 9.0. An magnetic resonance cholagiopancreatography (MRCP) was performed due to the elevated liver function tests and demonstrated choledocholithiasis and mild common bile duct dilatation to 7 mm (millimeter). The patient was taken to the operating room for an Endoscopic retrograde cholangiopancreatography (ERCP). A sphincterotomy and stent placement were also performed. The patient underwent a laparoscopic cholecystectomy. There were no reported complications. The patient was discharged. The discharge summary notes that the patient had mild acute pancreatitis after the ERCP. The patient was noted to have abnormalities of the bile duct with associated abnormal liver function tests. Per MCG (Milliman Care Guidelines) criteria, admission is indicated when common bile duct obstruction is indicated via imaging. [7] The patient was noted to have common bile duct obstruction on ultrasound, MRCP, and ERCP. Peer-reviewed literature and MCG criteria indicate that inpatient admission is necessary in these circumstances. Per provided clinical documentation, inpatient admission was medically necessary. 

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 the inpatient hospital stay is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Family history of abdominal aortic aneurysm.
Treatment: Ultrasound, abdominal aorta.
The insurer denied the ultrasound, abdominal aorta.
The denial is upheld.

The patient is an adult male with a family history of abdominal aortic aneurysm (AAA) in his father. The attending physician is requesting a screening ultrasound (US) of the aorta.

No, the ultrasound of the abdominal aorta is not medically necessary.

The Society for Vascular Surgery recommends one-time ultrasonography screening for abdominal aortic aneurysm (AAA) in all men and women aged 65 to 75 years with a history of tobacco use, men 55 years or older with a family history of abdominal aortic aneurysm (AAA), and women 65 years or older who have smoked or have a family history of abdominal aortic aneurysm (AAA).  The United States Preventative Services (USPS) Task Force does not recommend screening in patients age 50 with a family history of abdominal aortic aneurysm (AAA).  As such, the ultrasound of the abdominal aorta is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alopecia Areata

Treatment: Xeljanz

The insurer denied coverage for Xeljanz. 

The denial is upheld.

The patient is an adult male with a diagnosis of alopecia areata. The documentation provided shows that he is being treated with Jakafi, intralesional Kenalog injections (ILK), and minoxidil topical solution without the desired improvement. The requested medication is Xeljanz.  

Based on the clinical documentation provided, the patient has not failed or shown to have a contraindication to numerous non-systemic therapies known to possibly improve alopecia areata, including light therapy, squaric acid, calcipotriene, and anthralin (1-11). Although case reports have demonstrated possible efficacy of Xeljanz for alopecia areata, further studies are needed to demonstrate the long-term efficacy and safety of Xeljanz. It is noted that the Food and Drug Administration (FDA) released a statement finding increased risk of deep vein thrombosis (DVT) and pulmonary embolism (PE) in patients enrolled in a phase 4 clinical trial of Xeljanz at a dosing of 10mg (milligrams) twice per day (bid) (1) and later issued a more inclusive safety warning regarding use of Xeljanz and associated risk of heart attack, stroke, and blood clots (12). Xeljanz is not medically necessary for the patient's condition, alopecia areata.

The standard of care for treatment of alopecia areata would necessitate an attempt to use the above mentioned non-systemic options for the treatment of alopecia areata. The patient has not failed or shown to have a contraindication to numerous non-systemic therapies known to possibly improve alopecia areata, including light therapy, squaric acid, and anthralin (9-12).  

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

The insurer's denial of coverage for Xeljanz is upheld. Medical necessity is not substantiated.
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 with a past medical history significant for HTN (hypertension), end-stage renal disease on hemodialysis, and anemia. He presented to the ER (emergency room) for evaluation of intermittent non-exertional chest pain with no radiation.

The patient was hemodynamically stable. ECG (electrocardiogram) revealed normal sinus rhythm with LBBB (left bundle branch block), which was old. The cardiac troponin was mildly elevated. Of note, the patient had an admission for a similar complaint a few months prior, and cardiac catheterization was performed, revealing no significant coronary artery disease.

The patient underwent hemodialysis. A 2D (two dimensional) echocardiogram was performed, revealing normal LV (left ventricle) systolic function, and a small pericardial effusion. The patient was seen in consultation by cardiology. No ischemic work-up was recommended, given recent negative catheterization.  The patient was discharged home with a plan for outpatient follow-up.

No, the inpatient admission was not medically necessary.

This patient presented for evaluation of atypical chest pain. The patient had a prior admission for similar presentation, and a cardiac catheterization was negative for obstructive CAD (coronary artery disease), so no further ischemic workup was planned. There was no evidence of acute myocardial infarction, ACS (acute coronary syndrome), decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability. There was no evidence of hemodynamically significant effusion, tamponade, etc. The clinical information provided in the record submitted for review does not support medical necessity for this admission, and the care required could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: ascites

Treatment: inpatient level of care

The insurer is denied coverage for inpatient level of care.

The denial is upheld. 

This female patient has a history of diabetes mellitus, Hodgkin lymphoma, and hepatitis C virus (HCV) cirrhosis.

Clinical indications for admission for Liver Disease Complication (M-570) include moderate to severe hepatic encephalopathy, hemodynamic instability, infected ascites, international normalized ratio over 2, hepatorenal syndrome, severe vomiting, and acute liver necrosis. The patient did not have these conditions. 

This patient had fluid overload and poor compliance with her mediations. She required adjustments to her diuretic therapy. However, this could have been done with observation care. She had advanced cirrhosis and required a workup. This could have been done as an outpatient. She did not meet Milliman Care Guideline (MCG) criteria for admission for liver disease complications.

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

The carrier's denial of coverage for the inpatient level of care is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Weakness and altered speech
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned. 

The patient is a female with non-alcoholic steatohepatitis and related cirrhosis with ascites status post paracentesis, awaiting liver transplant. She presented to the hospital with weakness and altered speech.

The patient had SVT (supraventricular tachycardia) on arrival.  She was tachycardic to 130.  Her hemoglobin was 9.8 and creatinine was 5.75. She was admitted with encephalopathy and possible hepatorenal syndrome.

Day two, the patient's condition deteriorated.  She had tachypnea, hypotension, and was not following commands.  She was transferred to the ICU (intensive care unit) and intubated.  Her creatinine was 6.6 on day two.

Yes, the Inpatient admission was medically necessary.
The hospital admission was medically necessary due to management of acute kidney injury, which may have been secondary to the patient's liver disease / hepatorenal syndrome. The patient also had acute respiratory failure, which could not have been treated at a lower level of care.

The medical records do not support that a lower level of care was appropriate. The patient did not require services of such intensity that could have been safely and effectively provided at a lower level of care. The health, safety, and medical condition of the patient would have been threatened by providing the care given in a lower level of care setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Intentional overdose

Treatment: Inpatient hospitalization

The insurer is denied coverage for inpatient hospitalization.

The denial is overturned. 

This female with no known past medical history.

In this case this patient was considered a high-risk patient in need of 24-hour hospital treatment as she had a reported suicide attempt in which she ingested 5 Tylenol pills and a cup of bleach and had depressed mood. She also reported that it was an intentional overdose, so she was considered an imminent danger to self and in need of 24-hour hospital treatment. She was considered to have severe psychiatric symptoms putting her in imminent danger to self and requiring hospital treatment. There were also concerns for esophageal damage. Notes the next day reported continued suicidal thoughts and depression, and the need for 1:1 close observation so she was still considered a danger to self and in need of hospital treatment. The patient reportedly denied suicidal thoughts and was discharged with psychiatric follow up. 

This patient reportedly was considered a high suicide risk due to her suicide attempt with suicidal intent and major depressive symptoms and was on 1:1 close observation and suicide precautions throughout the hospitalization and was considered an imminent danger to self. As a result, the recommendation is to reverse the previous decision and approve coverage for inpatient hospital treatment.

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

The carrier's denial of coverage for the inpatient hospitalization is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Refractory Cutaneous Systemic Lupus Erythematosus (SLE).
Treatment: Revlimid.
The insurer denied the Revlimid.
The denial is upheld.

The patient is a female with systemic lupus erythematosus (SLE) and refractory discoid lupus.  Per the attached documentation, she has failed treatment with prednisone, Benlysta, mycophenolate mofetil, Myfortic acid, Rituxan and was due for Rituxan, but unclear if received, chloroquine, and multiple topicals.  At her office visit earlier in the year, she was treated with prednisone 5 milligrams daily, chloroquine 250 milligrams daily, and Myfortic 720 milligrams twice daily, and remained with active skin disease.  The attending rheumatologist and dermatologist wished to treat the patient with Revlimid for refractory cutaneous systemic lupus erythematosus (SLE)/discoid lupus.  The appeal is for Revlimid for the treatment of  refractory cutaneous systemic lupus erythematosus (SLE).

No, the proposed Revlimid is not medically necessary.
The attending physician wishes to prescribe Revlimid, which is not Food and Drug Administration (FDA)-approved for the treatment of SLE or refractory cutaneous lupus.  Although there very small open-label trials supporting the use of Revlimid for refractory cutaneous lupus, there is no documentation that this patient has tried or failed other standard of care disease-modifying antirheumatic drugs (DMARDs) for this indication, including methotrexate, systemic retinoids, dapsone or intravenous gamma globulin.  The use of Revlimid at this juncture, prior to failure of other appropriate disease-modifying antirheumatic drugs (DMARDs), is not clinically appropriate or in accordance with standard of care in the medical community.  Therefore, the proposed Revlimid for the treatment of refractory cutaneous lupus is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status post cervical spine surgery.
Treatment: Inpatient Hospital Admission.
The insurer denied the Inpatient Hospital Admission.
The denial is overturned.

Yes, the inpatient admission was medically necessary. 

The patient has multiple comorbidities including obesity, and severe cervical
stenosis with myeloradiculopathy. The patient underwent a major cervical spine
surgery, with three level fusion, and had expected major pain after the surgery that
limited mobility. The patient required close monitoring for any immediate
complications after surgery as well as for monitoring related to pain control.

The patient could not have been treated at a lower level of care as the patient had a
multilevel fusion, and has multiple comorbidities that put her at a higher risk for
complication in the immediate postoperative period. For these reasons, acute
inpatient care is more appropriate for this patient, considered standard of care and
medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ataxia, dementia, muscle weakness, and major depressive disorder.
Treatment: Home Care/Personal Care, Level 2 Personal Care Services (per 15 Minutes), increase to 56 hours per week.
The insurer denied the request for Home Care/Personal Care, Level 2 Personal Care Services (per 15 Minutes), increase to 56 hours per week. 
The insurer approved Personal Care Services (per 15 Minutes) at 28 hours per week.
The denial is overturned.

The patient is a senior with medical conditions including ataxia, dementia, muscle
weakness, and major depressive disorder. He lives in a three bedroom apartment.
Uniform Assessment System (UAS) evaluation completed shows minimally impaired cognition and functional status as follows: total dependence with meal preparation and housework; maximal assistance with shopping and bathing; extensive assistance with managing finances and medications, and lower body dressing; limited assistance with phone use, personal hygiene, upper body dressing, walking, locomotion, and toileting; and independence with bed mobility and eating. The patient has bowel and bladder incontinence. Per the son, the patient's wife assists with shopping, cleaning and meal preparation. The patient had a recent fall.

An appeal letter from the physician, notes that the patient's wife is ill and can no longer assist with the patient's care. This is an appeal of denial of an increase in Home Care/Personal Care - Level 2 Personal Care Services to 56 hours per week. The insurer approved Personal Care Services (per 15 Minutes) at 28 hours per week.

Yes, the requested increase in Home Care/Personal Care - Level 2 Personal Care
Services to 56 hours per week is medically necessary. The approved Personal
Care Services 28 hours per week is insufficient to meet this patient's needs.

Personal assistance services provide hands-on assistance to individuals to include:
assistance with activities of daily living (ADLs); health maintenance activities; and
routine support services. This patient has multiple chronic conditions including
dementia and ataxia. Uniform Assessment System (UAS) evaluation completed shows the patient requires assistance with all activities of daily living /instrumental activities of daily living (ADLs / IADLs) except bed mobility and eating.
The patient's wife assists with shopping, cleaning and meal preparation. The
patient is incontinent of bowel and bladder. The patient had a fall one month ago.
The appeal states that the request is for additional hours because the patient's wife
is no longer able to provide assistance with the patient's care.

This patient requires significant assistance with activities of daily living /
instrumental activities of daily living (ADLs / IADLs). He no longer receives informal
support from his wife as accounted for in the Uniform Assessment System
(UAS) evaluation. As a result, the approved Personal Care Services 28 hours per
week is insufficient to meet this patient's needs. The requested increase in
Personal Care Services to 56 hours per week is appropriate and medically
necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain

Treatment inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient presented with abdominal pain. He developed vomiting of coffee grounds. He was afebrile and the vital signs were stable. The abdominal exam was benign. The hemoglobin was 11.8. A computed tomography (CT) scan revealed a hydroureter and it was felt that he passed a stone. An endoscopy was performed, and ulcerative esophagitis and a gastric ulcer were found. He was advised to stop taking non-steroidal anti-inflammatory drugs (NSAID). Proton pump inhibitor (PPI) therapy was given.
Clinical indications for admission for Upper Gastrointestinal Bleeding (M-180) include hemodynamic instability, ongoing active bleeding, high risk endoscopic features, severe coagulopathy, severe anemia, severe pain, and gastric outlet obstruction. The patient did not have these conditions.

Clinical indications for admission for Undiagnosed Abdominal Pain (M-05) include hemodynamic instability, peritoneal signs, inability to maintain oral hydration after observation care, and the need for a procedure that cannot be performed on an ambulatory basis. The patient did not have these conditions.

This patient had abdominal pain which resolved, and he likely passed a kidney stone. He also vomited coffee grounds. However, the endoscopy was negative for active bleeding or high-risk endoscopic features. He was stable to have been treated with a PPI and have the endoscopy performed with observation status. He did not meet Milliman Care Guidelines (MCG) criteria for admission for either Upper Gl (gastroenterology) Bleeding or Undiagnosed Abdominal Pain. 

The health care plan acted reasonably and with sound medical judgement. An inpatient admission was not medically necessary.

The insurer's denial of coverage for the inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Compromised bone support
Treatment: Extraction of Tooth #10 and Retainer Crowns on Teeth #6 and #8
The insurer denied the Extraction of Tooth #10 and Retainer Crowns on Teeth #6 and #8.
The denial is upheld. 

The patient is a female. Tooth # (number) 10 has had a root canal procedure and a post and core done to it. The tooth does not have a lot of bone support around it. Tooth #6 has two composite restorations in it already. One is medium in size and one is small. Tooth #8 has a small composite restoration already in it.

No, the proposed treatment is not medically necessary.

The extraction of tooth #10 using code 7210 is not appropriate or medically necessary. The appropriate code for simple extraction is 7140. Tooth #10 is a short tooth with compromised bone support around the root. It only needs a simple extraction (code 7140) to remove it and surgical extraction is not warranted (code 7210).

The Retainer Crowns on Teeth #6 and #8 are also not medically necessary. Since tooth #7 only needs a single crown to restore it, and not a bridge, there is no need to have teeth #6 and #8 (the adjacent teeth) as retainers for a bridge. The bridge is not appropriate since a single crown is supported for tooth #7.