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

Diagnosis: High blood sugar 
Treatment: Inpatient admission
The health plan has denied the requested inpatient admission as not medically necessary.
The health plan's determination is upheld. 

The patient is a female who initially presented to the emergency department with concerns of fatigue, increased urinary frequency, headache, and dry mouth. Her pertinent history included insulin dependent diabetes mellitus and hypertension. The patient's initial vital signs revealed a temperature of 98.4o (degrees) Fahrenheit, a heart rate (HR) of 92 beats per minute (bpm), a blood pressure (BP) of 157/95 millimeters of mercury (mmHg), a respiratory rate (RR) of 18 breaths per minute, and a peripheral capillary oxygen saturation (SpO2) of 95% (percent) on room air. The review of systems was negative for chest pain, shortness of breath, nausea, or abdominal pain. The initial examination documented the patient as alert, oriented, and without focal neurologic deficits. An electrocardiogram (EKG) revealed T wave inversions in the anterolateral leads with no comparison. Initial laboratory testing revealed a white blood cell (WBC) count of 8.6, a hemoglobin of 14.0, a glucose of 312, a carbon dioxide (CO2) of 19, an anion gap of 12, a blood urea nitrogen (BUN) of 35, a creatinine of 1.7, a potential hydrogen (pH) of 7.35, and a negative troponin. The patient's urinalysis was unremarkable. The patient was placed in the hospital with an impression of acute coronary syndrome rule out and uncontrolled diabetes mellitus. The treatment plan included serial cardiac enzymes, telemetry, an echocardiogram (ECG), intravenous fluids, and subcutaneous insulin. Serial cardiac enzymes remained negative. Serum creatinine improved to 1.3. The ECG revealed a preserved left ventricular ejection fraction (LVEF) without significant findings. A stress test was planned. The patient was discharged with plans to undergo an outpatient cardiac stress test. 

At issue is the medical necessity of an inpatient admission. 

The health plan's determination is upheld in whole.

The requested inpatient admission was not medically necessary. 

Based on the clinical documentation provided, evidence-based literature, and standards of care, acute inpatient level of care was not indicated as medically necessary for the entire admission. Evaluation and management could have been performed at a lower level of care, such as Observation with transition to outpatient services. 

The patient had a history of insulin dependent diabetes mellitus and presented with fatigue, lightheadedness, increased urinary frequency, and dry mouth for several months due to an inability to treat her diabetes mellitus. The initial evaluation revealed hyperglycemia without significant complications as well as an EKG with T wave inversions. There was no documented chest pain. The patient was then placed in the hospital to rule out acute coronary syndrome. Serial cardiac enzymes were negative, and an ECG was relatively unremarkable. Acute coronary syndrome was ruled out, and an outpatient cardiac stress test was recommended. No other issues or complications were documented.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient admission
The health plan denied inpatient admission. The denial is upheld.

The patient is an adult previously-healthy man. He presented to the ED (emergency department) complaining of abdominal pain.

The patient's vital signs in the ED (emergency department) identified a normal temperature, a heart rate of 108/minute, and normal blood pressure. Oxygen saturation was 96%. The WBC (white blood cell) count was 10 K (thousand). Serum electrolytes and renal parameters were normal. Imaging with CT (computed tomography) scan identified findings that suggested enterocolitis and partial small bowel obstruction. He was admitted to the hospital and was treated with antibiotics.

The next day, the patient's diagnosis was considered to be acute enteritis (rather than bowel obstruction). There was no small bowel obstruction per the consulting surgical service. The patient was started on a liquid diet. Vital signs were normal. The patient remained hemodynamically stable throughout the period of monitoring. The WBC (white blood cell) count and the basic metabolic panel were normal. He was considered to be stable for discharge home with continued oral antibiotics.

The health plan rationale for denial of coverage per the letter is that the documentation does not show that the requirements for an inpatient level of care have been met. Per this letter there is no documentation of severe fluid or blood loss or severe infection. The health plan states that this service could have been performed with a lower level of care. This letter references MCG (Milliman Care Guidelines), Gastroenteritis.

Acute inpatient hospitalization was not medically necessary for this patient. The medical records support that this patient could have been reasonably and safely treated with a lower level of care during this time, with subsequent care provided in the outpatient setting.

This patient had abdominal pain and presented to the hospital. He was clinically stable at the time of presentation. The patient was provided IV fluid and antibiotics for enteritis and was able to tolerate oral intake as of the next day. He had consistently normal vital signs following the initial presentation when the heart rate was elevated at 108/minute.

The records support that as of the day after admission, the patient was tolerating diet, oral medications, and demonstrated normal vital signs. Acute inpatient admission was not medically necessary, as the care provided could have been rendered with a lower level of care such as observation. The health plan rationale for denial of inpatient care is appropriate and consistent with medical standards.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back Pain. 
Treatment: Injection in spine. 

The health plan denied: Injection in spine. 
The determination is overturned. 

The patient is a female who is requesting treatment with an epidural spinal injection for back pain. The procedure was originally denied because there was not adequate documentation that the member had tried and failed conservative therapy including measures like physical therapy, physician directed exercise, or medication. The provider appealed this determination. 

At issue is the medical necessity of the pain management injections.
The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of epidural spinal injection is medically necessary for this patient. There is ample documentation that the member has tried and failed conservative measures for treatment of back pain. There is documentation from a physical therapist that the member has participated in biweekly physical therapy for approximately 4 months. The physician also documented that the patient has tried and failed multiple analgesics in the past without any improvement in the right leg pain. The patient's medication list shows that she is using gabapentin. As such, there is ample documentation to show that the member has tried and failed conservative measures prior to request for the epidural spinal injection for the treatment of lumbar radiculopathy. Given failure to these conservative modalities, the requested service, an epidural spinal injection, is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status asthmaticus

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned
 

This is a toddler with a history of wheezing who had been treated in an emergency room (ER) 2 months before this admission for wheezing. He was unvaccinated because his father did not agree with the need for childhood vaccinations. He had been sick with a cough and fever for 4 days. When he developed increased difficulty breathing, he was brought to the ER for treatment.

In the ER he was noted to be in moderate respiratory distress with rapid breathing, retractions and bilateral wheezing upon examination of the lungs. He was treated with two intravenous (IV) normal saline fluid boluses, steroids, three doses of DuoNeb, oxygen supplementation and IV magnesium sulfate. He continued to have wheezing after treatment in the ER. Blood testing showed acidosis. When the child's respiratory distress did not improve with treatment in the ER and his oxygen saturation remained low at 92% (percent) the decision was made to admit him with a diagnosis of status asthmaticus and acidosis for ongoing treatment with IV fluids, oxygen and albuterol.  

The insurer has denied the admission as not medically necessary and indicated that there was no documentation in the medical record to support the need for inpatient treatment.

The patient was treated appropriately in the ER for a cough, wheezing and respiratory distress. He has a history of wheezing in the past and he has not been vaccinated with recommended childhood vaccinations. When there was ongoing respiratory distress with wheezing and increased work of breathing, and he was documented to have acidosis despite 2 bolus treatments with IV normal saline it was appropriate and consistent with the standard of care to admit him to the hospital for ongoing treatment with IV fluids, oxygen and albuterol. He was not stable enough to be sent home in view of the failure to respond to appropriate treatment in the ER. 

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

Diagnosis: Shortness of Breath. 
Treatment: Inpatient Hospital Admission. 

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

The patient is an adult female who presented to the emergency room with shortness of breath and wheezing. The patient was seen by her primary physician (PMD) and was treated with antibiotics without any improvement. In the emergency room, the patient received intravenous steroids and duonebs and was found to have viral infection. The patient was admitted to hospital for further management. The hospitalization was denied due to lack of medical necessity. This denial is being appealed. 

The proposed treatment was not medically necessary. 

The patient was being treated for viral bronchitis. The patient's symptoms improved with emergency room treatment. At the time of admission, the patient was hemodynamically stable. The patient's oxygen levels were above 92 percent on minimal oxygen. The patient's symptoms had resolved with emergency room treatment. The patient did not receive any treatment that could not have been provided safely and effectively at a lower level of care. The proposed hospitalization was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This elderly female was hospitalized for chest pain. She presented to the emergency department for evaluation of non-exertional, sharp and stabbing midsternal chest pain of two days. Outpatient stress test showed moderate inferior and inferolateral ischemia. However, cardiac catheterization showed only nonobstructive coronary artery disease (CAD) and no intervention was warranted. There were no procedural complications, she was treated medically and discharged to home. The requested coverage for inpatient hospitalization was denied, based on her policy and the patient is appealing the 
decision.

The proposed inpatient hospital admission was not medically necessary.

Based on the peer reviewed medical literature, there was not a medical need for the requested acute inpatient hospital stay, because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. Per the Milliman Care Guidelines (MCG) criteria for Chest Pain, #M-89, criteria for inpatient admission are not met, including hemodynamic instability, respiratory distress, pulmonary edema, angina with acute coronary syndrome, chest pain that is indicative of a serious cardiac condition like pulmonary embolism or aortic dissection, acute myocardial infarction, pneumonia, hypertension requiring inpatient hospitalization or any other medical condition, symptom or finding for which inpatient hospitalization is considered appropriate. In this particular case, there was no clinical decline or inadequate response to treatment which required inpatient hospital stay. The care the patient received, including urgent, uncomplicated cardiac catheterization like in this case, is routinely provided safely and effectively at a lower level of care. Therefore, based on the submitted information and the current published medical literature, the proposed treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Central nervous system.
Home health care.

Diagnosis: dementia.
Treatment: Personal Care Aide (PCA) Level 2 Services: 1 Day x 7 Days per Week (Live-In) per Diem.
The insurer denied Personal Care Aide (PCA) Level 2 Services: 1 Day x 7 Days per Week (Live-In) per Diem. 
The health plan's determination is overturned. 

The patient is a male with past medical history of dementia, anxiety, foot drop, osteoarthritis, diabetes mellitus type 2, urinary incontinence, glaucoma, hyperlipidemia, and benign prostatic hyperplasia (BPH) who had been assigned PCA (personal care aide) services based on an assessment performed that assessed the patient at total assistance with task of ordinary housework while maximum assistance with tasks of meal preparation, managing medication, stairs, shopping, and transportation. 

Personal Care Aide (PCA) Level 2 Services: 1 Day x 7 Days per Week (Live-In) per Diem are medically necessary for this patient.
The patient has documented 24-hour care needs with required assistance with walking, locomotion, transfer toilet, and toilet use. The patient's medical condition of dementia is a progressive illness, and the patient has been experiencing some hallucinations and requires assistance with walking and locomotion when he is walking around during the day and at night. The patient requires at least maximum assistance with walking, locomotion, transfer toilet, and toilet use and therefore has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The requested increase in PCA services is not solely for safety supervision but to assist the patient with safe completion of activities of daily living (ADL) and Instrumental activities of daily living (IADL). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The plan assumes the patient has informal help outside of the currently assigned hours which is not the case as his daughter is unable to provide informal support outside of those hours due to her own job and the fact that she does not live close to the patient. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, the requested services 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 his own home.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Chronic Obstructive Pulmonary Disease. 
Treatment: Formulary exception for Ventolin HFA. 

The insurer denied: Formulary exception for Ventolin HFA. 
The denial is overturned. 

The patient is an adult male with COPD (chronic obstructive pulmonary disease). He is prescribed Ventolin HFA (hydrofluoroalkane-134a). The health plan denied coverage of the request, as there is no clinical documentation of trial and failure or contraindication to formulary alternatives, Proair HFA (hydrofluoroalkane-134a), generic Proair HFA hydrofluoroalkane-134a) or Proair Respiclick. This denial is being appealed, since the patient has tried and failed Proair HFA (hydrofluoroalkane-134a) and generic albuterol inhaler. 

The health plan should cover the Formulary exception for Ventolin HFA (hydrofluoroalkane-134a). 

This patient with COPD (chronic obstructive pulmonary disease) is prescribed Ventolin HFA (hydrofluoroalkane-134a). It was denied coverage by the health plan, as there is no clinical documentation of trial and failure or contraindication to formulary alternatives, Proair HFA (hydrofluoroalkane-134a), generic Proair HFA (hydrofluoroalkane-134a) or Proair Respiclick. However, the patient has tried and failed formulary alternatives, Proair HFA (hydrofluoroalkane-134a) and generic Proair HFA hydrofluoroalkane-134a). The Proair Respiclick would be contraindicated, since the patient has tried and failed Proair HFA (hydrofluoroalkane-134a). The use of Ventolin HFA (hydrofluoroalkane-134a) is medically appropriate in this case. 

The formulary drug would be ineffective for this patient. The formulary drug would not be as effective as the requested non-formulary drug. The formulary drug would have adverse effects for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alopecia Areata.
Treatment: Olumiant 4mg (milligram) Tablets.

The insurer denied: Olumiant 4mg (milligram) Tablets.  The denial is overturned.

The patient is an adult female with alopecia areata. She has been treated with intralesional steroids. The patient has 60% (percent) scalp hair loss. The provider is requesting Olumiant. The health plan denied coverage of the request, as alopecia areata is considered cosmetic. The denial is being appealed. 

The requested Olumiant is medically necessary. 

This is an adult female with alopecia areata. She has been treated with intralesional steroids. The patient has 60% scalp hair loss. The provider is requesting Olumiant. The health plan denied coverage of the request, as alopecia areata is considered cosmetic. According to the meta-analysis by Phan et al. regarding JAK (janus kinase) inhibitors in general, in 30 studies and 289 cases, there were 72.4% responders, good responders 45.7% and partial responders 21.4%. Mean time to initial hair growth was 2.2  6.7 months, and time to complete hair regrowth was 6.7  2.2 months. In the randomized controlled trial (King et al.), a total of 110 patients were randomized (placebo, 28; baricitinib 1-milligram, 28; 2-milligrams, 27; 4-milligrams, 27). The baricitinib 1-milligram dose was dropped after the first interim analysis based on lower SALT (Severity of Alopecia Tool score) of 30 response rate. At week 36, the proportion of patients achieving a SALT (Severity of Alopecia Tool) score of 20 was significantly greater in baricitinib 2-milligrams (33.3%, P = .016) and 4-milligrams (51.9%, P = .001) groups versus placebo (3.6%). Baricitinib was well tolerated with no new safety findings. The patient has 60% of scalp hair loss, and the studies demonstrate that this treatment is well tolerated. The requested service is not cosmetic and is considered medically necessary to treat this patient's condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

According to the documentation submitted, this is the case of a patient with a history of diabetes mellitus and hypertension. The patient presented to the Emergency Department (ED) due to chest pain, and headache. The patient was admitted to inpatient telemetry level for continued evaluation, monitoring, and treatment. The patient had a cardiology consult, X-ray, intravenous (IV) Toradol, cardiac monitoring, and continuous pulse oximetry.

The insurer has denied coverage for inpatient hospital admission. In their Final Adverse Determination letter, they write that a review of the records shows that the patient could have been placed in observation under monitoring. The patient could have had an evaluation by professional(s), had testing and been treated symptomatically while awaiting test results. The admission does not meet clinical criteria.

This is a patient with a past medical history of diabetes mellitus and hypertension that presented to the hospital with chest pain.  On arrival to the hospital, vital signs were stable: blood pressure (BP) 126/84, pulse 82.  Physical examination revealed no major abnormality.  12 lead electrocardiogram (ECG) revealed sinus rhythm with no evidence of ischemic ST or T wave abnormalities.  Serum blood testing revealed no major abnormality.  Computed tomography (CT) chest revealed coronary artery calcium.  The patient was treated with Toradol and discharged with cardiology follow up.

This patient presented with atypical chest pain and a past medical history of hypertension. The patient's pretest probability of coronary artery disease was low (1).  Utilizing the HEART (identifies cardiac risk) score the patient was considered low risk (2).  Utilizing the Thrombolysis in Myocardial Infarction (TIMI) risk score, the patient also had a low risk of developing major adverse cardiac events in the subsequent 30 days (3). Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed (3).  Using the HEART  score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation.  Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all-cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation.  In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary. This patient could have been treated 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 inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: sleep apnea
Treatment: Diaphragm Pacemaker supplies
The insurer denied Diaphragm Pacemaker supplies. 
The health plan's determination is overturned. 

The patient is a female who is seeking approval for a equipment for a diaphragm pacemaker. She has a history of obstructive sleep apnea (OSA) and CSA (central sleep apnea). It appears the patient was in need of new transmitter and antennas. The patient has a history of ROHHAD (Rapid-onset obesity with hypothalamic dysregulation, hypoventilation, and autonomic dysregulation). The diaphragm pacemaker was implanted 12 years ago. The patient also uses bi-level positive airway pressure (BiPAP) every night.

The requested health services are medically necessary for the patient.
According to Hill et al., (2019), McDermott et al., (2012), and Le Pimpec-Barthes et al., (2011), the patient had a diaphragm pacemaker previously implanted in 2011 and required new supplies for this. With any durable medical equipment such as a diaphragm stimulator, the patient will need supplies for the normal function and operation of the equipment. As this stimulator is vital to the patient's normal function, the materials requested are medically necessary.