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

Diagnosis: Endocrine/Metabolic/Nutritional-Other/hyperparathyroid. 
Treatment: Pharmacy/Prescription Drugs-Cinacalcet. 

The health plan denied the prescription Cinacalcet as not medically necessary. 
The reviewer has overturned in whole the health plan's determination. 

The patient has chronic kidney disease (CKD). He has a history of Acne, anemia, CKD stage 4, Gout, hyperglycemia, hyperkalemia, hyperparathyroidism, secondary, hyperphosphatemia, iron deficiency, metabolic acidosis, pruritus, renotubular dysgenesis, strabismus, and vitamin D deficiency. The patient has tertiary hyperparathyroidism. The request is for Cinacalcet. 

The request should be approved and is medically necessary for this patient. 

The patient has tertiary hyperparathyroidism. His most recent labs showed a creatinine of 4.66 consistent with very advanced chronic kidney disease and PTH (parathyroid hormone) level of 101 down from 1012 with the use of Cinacalcet. He is already on the requested medication and needs to continue it as it's helping him tremendously. 
Severe hyperparathyroidism that is refractory to medical therapy suggests tertiary hyperparathyroidism, in which there is autonomous secretion of PTH that is not responsive to the plasma calcium concentration (1). Most clinical manifestations of hyperparathyroidism generally occur at a parathyroid hormone (PTH) level of over 1000 picograms per milliliter (pg/mL). In the studies reporting on tendon rupture, patients had PTH levels of 1400 to 2000 pg/mL.  

Studies have shown that Cinacalcet reduces the risk of parathyroidectomy. This was demonstrated in the Evaluation of Cinacalcet Hydrochloride Therapy to Lower Cardiovascular Events (EVOLVE) randomized trial, in which patients were assigned to receive cinacalcet or placebo in addition to conventional therapy including phosphate binders and/or active vitamin D or synthetic analogs. The rate of parathyroidectomy was lower in cinacalcet-treated patients compared with placebo (relative hazard ratio [HR] 0.44, 95% confidence interval (CI) 0.36-0.54) (2).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 

The insurer denied the Inpatient Stay. 
The denial is upheld.

The patient is a male with a history of alcohol abuse, elevated transaminases, pancreatitis, and tobacco abuse. He presented to the emergency room with abdominal pain associated with heavy alcohol consumption. His vital signs were notable for a blood pressure of 145/97 and a pulse of 105. He looked uncomfortable due to pain but was not toxic in appearance. His physical exam revealed abdominal tenderness without rebound or guarding.
His labs were remarkable for a mildly elevated aspartate aminotransferase (AST), alanine aminotransferase (ALT), lipase, and lactic acid. A right upper quadrant (RUQ) ultrasound in the emergency room was unremarkable. The electrocardiogram (EKG) was negative for acute ischemia or significant arrhythmia. The patient was admitted for further treatment and evaluation.
Upon admission, the patient was treated with intravenous hydration, proton pump inhibitors, analgesics as needed, and a soft diet to be advanced as tolerated. Some symptoms of possible alcohol withdrawal were noted and lorazepam on a as needed (prn) basis was added. The remainder of the stay was clinically uneventful, and the patient was discharged.
At issue is the medical necessity of the Inpatient Stay.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Inpatient Stay was not medically necessary for this patient.
Based on review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or EKG of an imminently life-threatening cause of the patient's complaints that required acute inpatient admission. He was afebrile, hemodynamically stable, and was able to tolerate a diet. In the emergency department, he was noted to be intoxicated, but this cleared quickly and there were no significant mental status changes. There was no evidence of severe metabolic disarray or significant hematologic changes. Based on the standard of care, and the peer reviewed literature, the acute inpatient level of care was not medically necessary.
Therefore, the requested health service of Inpatient Stay was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal-Gastrointestinal Bleeding.
Treatment: Inpatient hospital stay.
The health plan denied the inpatient stay as not medically necessary. 
The reviewer has overturned in whole the health plan's determination.

This is a patient who presented with a history of (h/o) of black stools and lower urinary tract symptoms (LUTS) associated with weakness, shortness of breath, and dyspnea on exertion (DOE). Labs obtained on admission revealed positive Fecal Occult Blood Test (FOBT)and acute blood anemia with a Hemoglobin of 5.8. He received two units of packed red blood cells (PRBC) in the emergency room (ER). The patient was admitted to the Intensive Care Unit (ICU) for acute gastrointestinal (GI) bleeding secondary to acute blood loss anemia secondary to GI bleeding. History of current alcohol use. Because of his alcohol abuse history, he was placed on Clinical Institute Withdrawal Assessment (CIWA) protocol (intravenous (IV) fluid, thiamine, and folate supplementation). GI consultation recommended IV proton pump inhibitor (PPI) drip and urgent diagnostic esophagogastroduodenoscopy (EGD) to evaluate variceal and nonvariceal GI bleeding causes. Diagnostic EGD revealed nonbleeding gastric and duodenal ulcers with no stigmata of bleeding. The patient was discharged home after he tolerated oral intake.

The inpatient stay was medically necessary for this patient.
This is a patient who presented with a history of (h/o) overt GI bleeding (melena) associated with symptomatic acute blood anemia (shortness of breath (SOB), DOE) concerning for upper GI bleed. This patient is at risk for variceal (h/o alcohol abuse) and non-variceal causes of upper GI bleed (peptic ulcer disease). He required 2 Units of PRBC to correct his symptomatic anemia. Furthermore, clinical assessment with the Blatchford score identified the patient as a high-risk patient needing treatment (transfusion or endoscopic intervention).
This patient's clinical presentation was concerning for acute blood anemia secondary to variceal and nonvariceal bleed etiology. He was admitted  for intravenous (IV) acid suppression, serial labs, and urgent GI consultation. These detailed inpatient care (IV fluids, IV acid suppression, red blood cell (RBC) transfusion, serial labs, CIWA protocol, and GI consultation) are critically important for prompt evaluation and management of potential high-risk upper GI bleed. His comorbidities include the risk for both variceal and nonvariceal bleeding etiologies (peptic ulcer disease (PUD) versus (vs.) esophageal variceal bleed secondary to presumed alcoholic liver disease.)
Additionally, endoscopy is indicated to evaluate his upper GI bleed. He was started on IV acid suppression therapy and started on CIWA protocol to prevent alcohol withdrawal syndrome. He is at risk for alcohol withdrawal syndrome, and it is clinically prudent to place the patient on CIWA protocol. The above inpatient care can't be provided under a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient stay. 
The denial is upheld.

The patient is a female with a history of inflammatory bowel disease, COVID, hypothyroidism, anxiety, and depression. She presented to the emergency room with complaints of a one-month history of weakness and diarrhea. She was afebrile, the vital signs were normal, and she was well appearing. Physical exam revealed abdominal tenderness, but the bowel sounds were normal, and there was no rigidity, distention, rebound, or guarding. Labs were notable for a white blood cell (WBC) count of 12,200. An abdominal computed tomography (CT) scan revealed gallstones and the previously known sub-total colectomy. There was no evidence of active disease on the chest x-ray. The electrocardiogram (EKG) was negative for acute ischemia or significant arrhythmia. The patient was admitted for further treatment and evaluation.
Upon admission, the patient was treated with intravenous fluids, intravenous antibiotics, parenteral analgesics, multiple oral medications, and a clear liquid diet. The following day, the WBC count was down to 10,700. The surgeon evaluated the patient and concluded that she might be suffering from post-COVID enteritis. Continued medical management was recommended, and the diet was advanced as tolerated. The remainder of the stay was clinically uneventful, and the patient was discharged. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld in whole. 

The requested health service/treatment of inpatient stay was not medically necessary for this patient. Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or EKG of an imminently life-threatening cause of the patient's complaints that required acute inpatient admission. There was no hemodynamic instability; peritoneal signs; evidence of bowel ischemia, perforation, or obstruction; suspected toxic megacolon, or a persistent inability to maintain oral hydration. Therefore, based on the standard of care, and the peer reviewed literature and Milliman Care Guidelines (MCG) Health Recovery Guidelines cited in the references, the acute inpatient level of care was not medically necessary, and the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Infertility

Treatment: In vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI), cryopreservation, and biopsy

The insurer denied coverage for program eligibility/enrollment for in vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI), cryopreservation, and biopsy.

The denial is overturned.

According to the documentation submitted, this patient is of advanced maternal age and is pursuing services of in vitro fertilization with donor sperm. The medical record documents waning ovarian reserve. She denied past fertility treatments. Her history evidently met the insurer's eligibility criteria for infertility based upon her sexual history when she did attempt to conceive naturally in the past.  Furthermore, at this time she is now single and desires to attempt IVF using donor sperm.  

The literature clearly supports the use of IVF treatment as opposed to intrauterine insemination (IUI) in women with a compromised ovarian reserve inherent to being in this age group.  

In addition, the use of preimplantation genetic testing for aneuploidies (PGT-A) has also been demonstrated to be helpful to fertility treatment by improving the live birth rate per embryo transfer in such individuals due to their higher incidence of having aneuploid embryos.  Since upwards of 90 percent of blastocyst embryos have aneuploidy in women patients, both cryopreservation and biopsy have been shown to be beneficial.  The literature has demonstrated a clear benefit of PGT-A (biopsy of blastocysts) in women related to their increased aneuploidy rates.   It has been demonstrated that up to 50 percent of the embryos may have aneuploidy, 90 percent in a later age group, and up to 95 percent in the advance maternal age group.   For reasons related to increased age, higher aneuploidy rates, and lower spontaneous pregnancy rates with a higher miscarriage rate due to aneuploidy, all these treatments have been demonstrated to be appropriate and within the standard of care.  

For reasons cited above, 1) the health plan did not act reasonably and with sound medical judgment and in the best interest of this patient and 2) IVF, ICSI, cryopreservation, and biopsy should be considered medically necessary and reasonable for this patient.

Based on the above, the medical necessity for the program eligibility/enrollment, in vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI), cryopreservation, and biopsy is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient stay for medical necessity. 
The denial is overturned in whole. 

The patient is a male. He has a past medical history of alcohol induced pancreatitis, hypertension, hyperlipidemia, alcohol abuse/dependence and opioid abuse. He presented with abdominal pain, nausea, and vomiting. His vital signs showed a blood pressure of 123/88, pulse was 94, respiratory rate was 18, temperature was 99, and oxygen saturation was 98%. A computed tomography (CT) scan of the abdomen showed necrotizing pancreatitis along with loculated peripancreatic fluid collections.
The patient's labs showed a white blood cell count at 5.54, hemoglobin was 15.2, sodium was 141, potassium was 4, creatinine was 0.7, blood urea nitrogen (BUN) was 12 and lipase was 66. He was made nothing by mouth, started on intravenous (IV) fluids and admitted for further management and evaluation. 
During the course of the hospital stay, he was seen by gastroenterology. He was continued on intravenous fluids and pain medications. He was also seen by an infectious disease consultant who recommended continued intravenous antibiotics. Blood cultures were obtained. A right upper quadrant ultrasound revealed hepatic steatosis. His symptoms slowly improved. 

At issue is the medical necessity of the inpatient stay. 

The health plan's determination of medical necessity is overturned in whole. 

The requested health service/treatment of inpatient stay is medically necessary for this patient. 

The patient has a history of alcoholic pancreatitis who presented with abdominal pain, nausea, and vomiting. Imaging showed necrotizing pancreatitis along with loculated peripancreatic fluid collections. He was made nothing by mouth and treated with fluids, antibiotics, and pain medications. He failed observation care and continued to be symptomatic with pain and vomiting. The requested inpatient stay is medically necessary given the severity of illness at presentation. 
Necrotizing pancreatitis most commonly manifests as necrosis involving both the pancreas and peripancreatic tissues. Necrosis may result in an acute necrotic collection (ANC) that contains a variable amount of fluid and necrosis. The occurrence of pancreatic infection is a leading cause of morbidity and mortality in acute necrotizing pancreatitis. Approximately one-third of patients with pancreatic necrosis develop infected necrosis. (1) There is no correlation between the extent of necrosis and the risk of infection. Although infection can occur early in the course of necrotizing pancreatitis, it is more often seen late in the clinical course (after 10 days). (2) Clinical signs of infection and abdominal imaging demonstrating the presence of gas within the necrosis are reasonably suggestive of infection and antibiotic therapy can be initiated without aspiration and culture. (3) 

Therefore, the requested health service/treatment of inpatient stay is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Total hip arthroplasty
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned.

This appeal is for the hospital admission for Special Surgery. The request was for a full admission to the hospital after a total hip arthroplasty (THA). This surgery can be safely done without a full hospital admission and may include an overnight stay for managing pain and other problems that can occur after surgery.  Hospital admission can be medically necessary if there are severe problems. 

This patient is a female.  The patient underwent an uncomplicated left total hip arthroplasty (THA) performed.  The initial plan was an overnight stay only; however, the patient experienced nausea, dizziness and inability to progress with physical therapy. The patient's nausea and dizziness resolved and she was able to participate with physical therapy and was discharged.

Yes, admission to the hospital is supported as medically necessary.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient as hospitalization should be covered and is in the best interest of the patient.

After a review of all available medical records, hospital admission for the dates of was medically necessary.  While the patient was initially admitted for overnight stay only, her postoperative course with complicated by nausea, dizziness and inability to safely return home.  In a review of all rehabilitation notes, the patient required assistance for transfers and was unable to ambulate until day three and continued to require assistance.  On the day of discharge, the patient was able to perform transfers and ambulate safely enough to return home. Also, nausea and dizziness had resolved. While the plan was for an overnight stay only, due to inability to participate in physical therapy, nausea, dizziness and low blood pressure, the patient was unable to safely be discharged.

Per Bristol (1), average length of stay after a total hip arthroplasty (THA) was five days if unable to ambulate within eight hours of surgery.  This patient was unable to ambulate for two days postoperative.  "From the analyzed research the average length of stay for all 92 total hip replacement patients was 4.23 days. For those total hip replacement patients who were ambulated within eight hours of surgery completion the average length of stay was 2.83 days. For the total hip replacement patients who were ambulated after eight hours of surgery completion the average length of stay was 5.14 days."
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal 
Treatment: Stelara 
The insurer denied Stelara. 
The denial is overturned.

The patient is a male with ileocolonic and perianal Crohn's disease (CD), complicated by sigmoid colon stricture. He has failed 6-mercaptopurine, Remicade, and Humira. Colonoscopy (while on Humira with adequate drug level) showed active disease. The issue under review is the medical necessity Stelara for the treatment of Crohn's disease. The request was not approved as Entyvio has not been attempted.

The health plan's determination is overturned.

The medical necessity of Stelara is supported over the use of Entyvio for the treatment of Crohn's disease in this case. Stelara and Entyvio are recommended by American College of Gastroenterology guidelines for the treatment of Crohn's disease [1]. American Gastroenterological Association (AGA) guidelines for the treatment of Crohn's disease support the use of Stelara and Entyvio, and specifically do support the use of Stelara and Entyvio in patients with perianal Crohn's disease, including fistulizing perianal Crohn's disease [2]. However, the guidelines recommend Stelara rather than Entyvio in Crohn's disease patients who have primary non-response to an anti-tumor necrosis factor (such as Remicade and Humira, both attempted by the patient), stating "In adult outpatients with moderate to severe CD who never responded to anti-tumor necrosis factor (TNF)-alpha (primary nonresponse), the AGA recommends the use of ustekinumab (Stelara) and suggests the use of vedolizumab (Entyvio) over no treatment for the induction of remission." [2]. The mechanism of Stelara (ustekinumab) is entirely different than that of immunosuppressants and anti-TNF medications, which the patient has failed [3]. A recent study demonstrated that a significant majority of patients who have failed an anti-TNF medication achieve and maintain response with Stelara [4].
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal/ Back Pain
Treatment: Surgical Services (All)
The health plan denied the requested spinal surgery as experimental/investigational. 
The health plan's determination is upheld.

The patient is a female with complaints of low back pain. Most of her pain is axial, which radiates into the buttocks. The patient has had an epidural injection, and physical therapy. She has trialed anti-inflammatory medications. A magnetic resonance imaging (MRI) of the lumbar spine reported multilevel degenerative changes; there is multilevel degenerative disc disease. (lumbar-sacral) L5-S1 disc bulge with central disc protrusion, L4-L5 disc bulge with facet arthropathy, L3 for disc bulge with right foraminal disc protrusion. There is a request for intraosseous basivertebral nerve ablation.
The issue is whether the INTRACEPT procedure is an appropriate and medically necessary intervention for this patient.

I uphold the health plan's determination, in whole.

The proposed health service or treatment spine surgery is not likely to be more beneficial than any standard treatment or treatments for the patient's life threatening or disabling condition or disease. The patient has complaints of low back pain. There is a request for intraosseous basivertebral nerve ablation. This procedure is not recommended. Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. A Food and Drug Administration (FDA) investigational device exemption trial examined 225 chronic low back pain patients with type I or II Modic changes who were randomized to the requested procedure or sham treatment, resulting in decreased Oswestry Disability Index (ODI) of 20.5 and 15.2 points, respectively. The authors noted that these marginally clinically meaningful improvements suggested some potential as a minimally invasive treatment, however, there is lack of data to recommend this procedure as a treatment modality. In general, there is lack of substantial support for this procedure, and it is currently not considered standard of care. Given the above, the proposed health service or treatment spine surgery is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal/ Back Pain
Treatment: Surgical Services (All)
The health plan denied the requested spinal surgery as experimental/investigational. 
The health plan's determination is upheld.

This is a female patient. The patient is diagnosed with low back pain. She is noted to have complaints of back pain that radiates into the buttock.
A magnetic resonance imaging (MRI) of lumbar spine per record shows that at (lumbar-sacral) L5 - S1 there is a disc bulge and central disc protrusion resulting in mild subarticular stenosis contacting the descending S1 nerve roots increased in extent.
The issue is whether the INTRACEPT procedure is an appropriate and medically necessary intervention for this patient.

I uphold in whole, the health plan's determination.

No, there is no evidence that the proposed health service or treatment of spine surgery is likely to be more beneficial than any standard treatment or treatments for the patient's life threatening or disabling condition or disease. This patient is noted to have a history of chronic back pain that has not responded to conventional conservative treatment. It is noted that the patient's MRI reportedly shows L5 - S1 disc protrusion resulting in mild subarticular stenosis contacting the descending S1 nerve root. The provider feels that the patient's pain is coming from Modic changes and was recommended to undergo the INTRACEPT System (intra-osseous basivertebral nerve ablation). However, this procedure remains experimental and investigational as there is a lack of high-quality studies evaluating the long-term risks and benefits of this procedure.