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

Diagnosis: left stump infection/abscess 

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This is an adult male with past medical history significant for substance abuse disorder, compartment syndrome, status post left leg above knee amputation, and right leg fasciotomy who presented with complaints of right foot pain.

Vital signs on presentation included: Temperature 36.7 degrees Celsius, Blood Pressure 117/68 mmHg, Pulse 78 beats per minute, Respirations 16 breaths per minute, oxygen saturation 100% on room air. Laboratory results included the following: white blood cell (WBC) count 19.6, hemoglobin (Hgb) 12, hematocrit (Hct) 36.4, creatinine 0.98, glucose 91.

The patient was started empirically on intravenous antibiotics (vancomycin and cefepime) for left lower extremity stump site. Computed tomography (CT) angiogram showed abscess of the left stump site. Vascular surgery was consulted and performed a bedside incision and drainage of retained hematoma and purulent fluid. Wound cultures grew Enterobacter. The patient received pain management and wound care. He remained afebrile, hemodynamically stable, and clinically improved. The patient left hospital against medical advice (AMA). 

According to the documentation, the patient presented with left stump infection/abscess. He was afebrile, hemodynamically stable; however, laboratory results showed a significantly elevated white blood cell (WBC). Computed tomography (CT) angiogram of the stump confirmed an abscess requiring surgical incision and drainage (I&D). Cultures grew bacteria-Enterobacter. Based on above findings in a high-risk patient with significant co-morbidities, hospital admission was medically necessary for surgical intervention and intravenous antibiotics.  

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 inpatient hospital is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alopecia universalis. 
Treatment: Litfulo 50 mg (milligrams) capsule. 
The insurer denied coverage for Litfulo 50 mg capsule. 
The denial is overturned. 
 
The patient has a diagnosis of alopecia universalis. The patient has nearly complete hair, eyelash, and eyebrow hair loss due to an autoimmune etiology, alopecia universalis. The patient has failed therapy with Xeljanz and Olumiant. 

Based on the submitted documentation Litfulo is medically necessary. Litfulo is a systemic Food and Drug Administration (FDA) approved therapy for alopecia areata. The patient has failed multiple systemic agents which are FDA approved for alopecia areata. Only one remaining FDA approved systemic therapy approved for alopecia areata is available, Litfulo. Based on the clinical documentation and the standard of care, the use of Litfulo is medically necessary and is unlikely to have an increased side effect profile compared to tried and failed therapies. The decision is overturned based on the current standard of care for the treatment of alopecia areata and its variants. 

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 Litfulo 50 milligrams (mg) capsule is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dizziness
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

This patient is an adult male who presented to the emergency room with complaints of dizziness. He has a medical history significant for bilateral cavernous carotid artery stenosis (moderate on left and severe on the right). Dizziness had been going on for a few hours and was progressively getting worse. Given his history of carotid artery stenosis, diagnostic cerebral angiography was performed. Inpatient admission was denied due to not meeting level of care.

The requested health service was medically necessary.

Inpatient admission was medically necessary. The patient underwent diagnostic cerebral angiography, which is a procedure that can have complications. For this reason, frequent neurologic checks are necessary, and this cannot be done in the outpatient setting. Therefore, the requested health service is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Palpitations
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient is a male who presented to the emergency department (ED) complaining of palpitations. His medical history was remarkable for hypertension. An electrocardiogram showed a narrow complex tachycardia at 233 beats/minute. His chest x-ray was unremarkable. His serum troponin level was .024 nanograms/milliliter (ng/ml). His N terminal probrain (or B-type) natriuretic peptide (BNP) level was normal. His lactic acid level was 20 millimoles per liter (mmol/L). The patient was treated with intravenous adenosine and diltiazem which resulted in a pause followed by continuation or re-initiation of his tachycardia. Intravenous amiodarone and oral metoprolol were prescribed. The patient's rhythm converted to sinus and he was admitted to the hospital. A repeat troponin level was .096 ng/ml. The patient remained in sinus rhythm. His troponin level was .074 ng/ml. An echocardiogram was performed and was normal. The patient was discharged. The medical necessity of an inpatient admission is at issue.

No. Based on the documentation provided, an inpatient level of care was not medically necessary.
This patient presented with hemodynamically stable paroxysmal supraventricular tachycardia (PSVT). The rhythm was not terminated with adenosine or diltiazem; sinus rhythm was restored with intravenous amiodarone. While there are no established guidelines regarding disposition for patients presenting to the emergency department with PSVT, most authors suggest that, in the absence of serious comorbidities, syncope, or rapid preexcited atrial fibrillation or flutter, hospital admission is not necessary for adults whose PSVT is converted to sinus rhythm without complications. One single-center, retrospective study of patients presenting to emergency department with PSVT found that 71 percent (%) were discharged home after an average stay of four hours. The 24-hour recurrence rate in those patients was less than 5%. Likewise, data from the National Hospital Ambulatory Medical Care Survey 1993-2003 database revealed a 76% discharge rate for PSVT after evaluation in the emergency department. While this man's serum troponin level was mildly elevated, this is common in PSVT, even in the absence of coronary stenosis. It is not recommended that troponin levels be checked, based on PSVT alone, but only when there is reasonable suspicion of acute coronary insufficiency. In this case, based on the records provided for review, it does not appear as if there was significant concern for acute coronary syndrome (ACS) and no treatment for ACS was deemed necessary. In summary, this patient's hemodynamically stable PSVT that was terminated with intravenous amiodarone did not require an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left peripheral vision loss

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

This is an adult male who presented to the emergency room with sudden onset of complete loss of left peripheral vision of bilateral eyes which lasted 1-hour before completely resolving without recurrence. According to the triage notes, the patient was alert and oriented to person, place, time and event and was ambulatory with steady gait in the emergency room (ER). The patient experienced a similar episode before and was seen by an Ophthalmologist with no abnormal findings. He has a history of Hyperlipidemia, Benign Prostatic Hypertrophy (BPH), and a smoking history. A stroke code was called. Glascow Coma Score was 15. Vital signs upon arrival to the emergency room were Blood Pressure 140/82 mmHg, Temperature 36.2 degrees Celsius, Pulse 59 beats per minute, Respirations 20 breaths per minute, and pulse oximetry of 98% on room air. 

On examination, the patient was in mild distress. Laboratory results showed the following abnormalities: Blood urea nitrogen (BUN) 26, and Total Bilirubin 2.2. Chest X-ray showed no active pulmonary disease and electrocardiogram (EKG) showed sinus bradycardia. Computed tomography (CT) Head showed no acute hemorrhage, mass effect, or midline shift however, there is finding of Paranasal Sinus disease. Computed tomography angiography (CTA) Carotids/Circle of Willis showed no acute large vessel occlusion. Neurology was consulted and reported acute onset transient left homonymous hemianopsia. The National Institutes of Health Stroke Scale (NIHSS) was 0 with no neurological symptoms at all. The initial treatment plan included an admission to telemetry for continuous cardiac monitoring, magnetic resonance imaging (MRI) of the brain, neurological assessments, laboratory studies, and TIA (transient ischemic attack)/CVA (cerebrovascular accident) protocol. The patient denied any headache, change in hearing/coordination, weakness, sensory changes, or change in speech. MRI Brain was unremarkable, showing bilateral ethmoid mucosal thickening. 

On day 2 of admission, the patient reported complete resolution of presenting symptomatology and was instructed to follow-up with Ophthalmology as an outpatient after discharge. 

The medical records provided for review do not support inpatient admission. The evaluation of a trans-ischemic attack (TIA) patient (e.g., brain imaging, echocardiogram, telemetry monitoring, carotid artery imaging, serial neurologic examinations) can be performed in observation 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 an inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis
Treatment: Zilretta (injection J3304)
The insurer denied: Zilretta (injection J3304)
The denial is upheld.

This patient is an adult male with a history of unilateral primary osteoarthritis of the right knee. He has been receiving Zilretta injections (triamcinolone acetonide extended-release injectable suspension) with good clinical results. He is not a good surgical candidate. He has been treated with the non-steroidal anti-inflammatory drug (NSAID) meloxicam. He has previously tried and failed corticosteroid injections. The request for Zilretta was initially denied due to Zilretta is only authorized to be given once per knee as repeat administration has not been shown to be safe and effective. The reason the provider is appealing the determination is because the patient has had clinical benefit, and the provider is requesting repeat treatment.

The requested health service is not medically necessary.

The patient has severe osteoarthritis. The patient has previously been on corticosteroid injections. There is no documentation that the patient has had weight reduction. The patient is currently receiving a non-steroidal anti-inflammatory drug (NSAID). The patient has already received one injection of Zilretta. There are no clinical research studies indicating that repeat injections of this medication are safe or effective. Therefore, the requested health service is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Flank pain
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is an adult male. He presented with complaints of three-hour duration of flank pain, nausea, and vomiting, similar to prior episodes of renal colic and difficulty urinating. Emergency medical technician (EMT) administered ketorolac for pain. The patient had a history of diabetes mellitus, atrial fibrillation, hypertension, renal colic, and dyslipidemia. The patient denied fevers/chills. In the emergency room, the patient was noted to be afebrile, blood pressure was 180/112, oxygen saturation was 98%. Pain was noted to initially be 8/10. Labs obtained demonstrated urinalysis with negative nitrite and negative leukocyte esterase 4, white blood cells 117, and red blood cells, and 13.3 urine bacteria. White blood cell count was elevated at 19.8, basic metabolic panel reported as normal. Computed tomography (CT) scan demonstrated mild left hydronephrosis secondary to mid ureteral stone. At change of shift patient reported no pain or discomfort or nausea or vomiting. Urology was consulted and recommended monitoring and to start antibiotic therapy. The patient was admitted for pain control, antibiotics. Consult noted that the patient was in no acute distress, temperature 98.2, heart rate 104, respiratory rate 20, blood pressure 155/101, glucose 100, and serum creatinine 0.97. The pain noted to be controlled with Toradol and morphine. Urology recommended conservative treatment. Urine culture resulted in no growth. Antibiotics were discontinued. He was discharged to home on day #3 noted to be afebrile versus denied pain, fever/chills/nausea/vomiting. Creatinine was 0.82 and white blood cell count decreased to 16.6 on day #2. Acute inpatient admission was denied coverage by the health plan as not medically necessary, noting that the patient could have been placed in observation under monitoring. The denial is being appealed.

The inpatient admission was not medically necessary.

This patient was hemodynamically stable, afebrile, and pain was noted to be controlled in the emergency room with Toradol and morphine. He required intravenous fluid hydration due to the prior nausea and vomiting. The patient's renal function was reported to be normal. The patient had a normal contralateral kidney. The patient's blood pressure improved with pain medication. The records do not indicate that he required acute inpatient admission for management of his other medical problems (hypertension, atrial fibrillation, dyslipidemia). The patient's urinalysis showed negative nitrite, negative leukocyte esterase and only four white blood cells present. Antibiotics were instituted, and culture came back negative. The patient's blood sugar did not require acute inpatient management. The urology consult recommended continued monitoring but did not recommend acute surgical intervention. The patient could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Admission

The insurer denied inpatient admission.  The denial is upheld.

The patient is an adult female. She presented with acute onset of abdominal pain. Her white blood cell count was 10.3. She was febrile, and her vital signs were normal. Computed tomography (CT) scan showed acute appendicitis. The patient was taken to the operating room for a laparoscopic appendectomy and was discharged the next day.

The inpatient admission was not medically necessary.

The patient had an uncomplicated appendectomy and was discharged the next day. No documentation supports inpatient admission. The patient was hemodynamically stable, her white blood cell count was near normal, and she did not require intensive post-operative services. Therefore, the requested health service is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

This is a case of a female admitted for diagnosis of sepsis, asthma exacerbation and pneumonia in the right lung. The patient presented with chief complaint of cough and fever. She had a past medical history of hypertension and asthma. She did not have a history of intubation. Vital signs demonstrated temperature 97.7F, pulse 93, respiratory rate 19, blood pressure 116/74 and O2 (oxygen) saturation 96%. Physical exam showed no acute respiratory distress. She was able to speak in full sentences with intermittent cough. There was no altered mental status. White blood cell count was 23.7 with creatinine 0.98. Chest x-ray showed prominent right upper lobe airspace opacity which was compatible with pneumonia. 

The inpatient hospital admission was not medically necessary.

The patient in this case was admitted for pneumonia and asthma exacerbation. However, there was no inability to maintain oral intake, concern about adherence to therapy, mental illness, cognitive impairment, hypoxia, or multi-lobar infiltrates. She did not have leukopenia or hemodynamic instability. Her pneumonia severity index calculation is that of risk class II which carries a 0.6 to 0.9% mortality typically acceptable for outpatient treatment. She was noted to have asthma and did not have wheezing on exam.
Although the patient required services in the hospital setting the monitoring, diagnostics testing and therapeutic interventions prescribed could have been rendered at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart failure
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a female patient with a past medical history significant for chronic systolic heart failure due to nonischemic cardiomyopathy, status post (s/p) cardiac resynchronization therapy (CRT-D), atrial fibrillation (afib), obesity, hypertension, type 2 diabetes, obstructive sleep apnea (OSA) on continuous positive airway pressure (CPAP) who presented to the emergency department (ED) for evaluation of leg swelling, shortness of breath, orthopnea. In the ED, the patient was placed on bi-level positive airway pressure (BiPAP) due to respiratory distress. The patient was hypertensive, tachycardic and tachypneic (respiratory rate (RR) 30/minute). The physical examination was notable for pulmonary rales, wheezing, and leg edema. A chest x-ray (CXR) showed pulmonary edema. The patient was admitted to the telemetry service under an inpatient level of care for evaluation and treatment of acute on chronic heart failure with volume overload. She was aggressively diuresed with intravenous (IV) Lasix with uptitration of the dose during her hospitalization for additional diuresis. After adequate decongestion and symptom improvement, the patient was discharged home. At issue is the medical necessity of an inpatient stay.

An inpatient level of care was medically appropriate, necessary, and in the best interest for the safety of the patient. This patient with known advanced heart failure and multiple comorbidities presented to the ED in respiratory distress due to acute on chronic heart failure with volume overload. Notable high-risk features in this case included pulmonary edema, respiratory distress requiring initiation of BiPAP in the ED and elevated brain (or B-type) natriuretic peptide (BNP) indicative of increased risk for short-term adverse cardiac events. The patient required ongoing IV diuresis beyond the observation level of care time frame in addition to uptitration of her IV dose of Lasix to achieve adequate decongestion and symptom improvement prior to discharge. Based on the patient's high level of medical complexity and high-risk clinical features discussed above, an inpatient level of care would be recommended by the peer reviewed medical literature and expert consensus guidelines on acute heart failure management (1-5).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's
Treatment: home health care
The insurer denied Consumer Directed Personal Assistance Services (CDPAS), 48 Hours per Week 
The health plan's determination is overturned. 

This is a female patient with a history of Parkinson's disease, atherosclerotic heart disease, diabetes mellitus type 2 with diabetic neuropathy, obesity, osteoporosis, generalized muscle weakness, insomnia, generalized osteoarthritis, low back pain and lumbar radiculopathy, and urinary incontinence. She lives alone in a 2-bedroom apartment. She has a daughter who provides informal support and visits her 4-5 times a week. She receives personal care services. 

Consumer Directed Personal Assistance Services (CDPAS), 48 Hours per Week are medically necessary for this patient.
There is documentation in the Uniform Assessment System (UAS) shows that the patient is requiring at least extensive assistance with tasks of walking, locomotion, transfer toilet, and toilet use. Therefore, the patient 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. A tasking tool should not be used to calculate hours given the patient's level of assistance with unscheduled and unpredictable care needs. There is documentation from the patient's PCP (primary care provider) of medical necessity of the requested hours. The patient does not have informal support for the entire time outside of the previously assigned CDPAS hours. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in CDPAS is not solely for safety and supervision but to assist the patient with activities of daily living (ADL).
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Hypogonadism

Treatment: Testim (testosterone)

The insurer denied coverage for Testim (testosterone)

The denial is upheld

 
This is a patient with hypogonadism. The patient was treated with topical testosterone (TST) and went off of the medication. The patient was then prescribed Testim by their urologist. The insurer has denied coverage for Testim (topical TST gel). They stated that this prescription may be covered when the requested product has no formulary alternative. The alternative is TST gel (Androgel), which must be tried and failed before Testim is covered. The appeal on behalf of the patient is noted and read in detail.

The formulary drug has not been ineffective based on the patient's clinical history.

The requested drug is not likely to be more effective than the formulary drug. Both are topical TST gels, administered in a similar fashion. There are no head-to-head trials that confirm that one topical TST gel is clinically superior to the other gel.

Formulary exception for Testim is not medically necessary. The patient should achieve similar clinical results/efficacy with the formulary alternative. 

The formulary drugs are not expected to cause adverse effects. 

The formulary drugs were not tried, and the patient did not have an adverse reaction or contraindication.

The formulary drug is not expected to be ineffective.

The carrier's denial of a request for a Formulary Exception for Testim (testosterone) is upheld.