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

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

This is a female patient who presented to the emergency department for right sided abdominal pain for several days. The patient had associated nausea, vomiting and abdominal pain. She had a medical history of type 2 diabetes, anxiety, depression, hypertension, hyperlipidemia, and obesity. The patient had previous Cesarean (C)-sections and a cholecystectomy. A computed tomography (CT) scan demonstrated a dilated cecum and ascending colon with a ventral hernia containing transverse colon. The ventral hernia demonstrated transition to normal size of the colon. The hernia was felt to be reducible but due to the size, this was unclear. The patient was hospitalized overnight. The next day the patient was doing well. She was tolerating a diet without nausea and vomiting. She was passing gas. The patient was discharged home. At issue is the medical necessity of an inpatient stay.
An inpatient stay was not medically necessary. The patient could have been safely managed at a lower level of care.
The patient had rapidly improved vital signs and symptoms in the overnight stay in the hospital. The bowel obstruction quickly resolved as evidenced by tolerating food and passing gas. The patient did not have a suspected acute intra-abdominal process that was ongoing, The patient did not have acute appendicitis with planned non-operative management, she did not have ascites requiring acute treatment, severe diarrhea, severe dysphagia, gastroparesis, encopresis or severe fecal impaction, complication of a feeding tube, complications of a transplanted organ, or abdominal compartment syndrome. She did not have clinically active comorbidities that required high level management. She did not experience complications or conditions such as anemia, arrhythmia, electrolyte disorder, fever, gastrointestinal (GI) bleed, hyperglycemia or complicated diabetes control, mental status change, psychiatric disorders, respiratory insufficiency, urinary complications, thrombotic complications or wound and skin care complications. There is no documentation that the treating team identified conditions or problems specific to the patient that would have required inpatient care. The patient did not have significant dehydration, hemodynamic instability (after decision to admit), severe pain requiring frequent or high doses of narcotics, peritonitis, or bacteremia. The provided documentation does not support the medical necessity of an inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: History of drug abuse, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD)
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

The patient is an adult male with history of drug abuse, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD). He had a syncopal episode at home. In the emergency room, the patient was found to be in respiratory distress due to congestive heart failure exacerbation as well as hypoglycemia. The patient received treatment in the emergency room with Lasix, oxygen, and dextrose but continued to have respiratory distress. The patient was admitted to acute hospitalization for further management of hypoglycemia and congestive heart failure exacerbation as well as pneumonia. From the length of stay, the patient was treated for congestive heart failure exacerbation and pneumonia as well as encephalopathy due to hypoglycemia. The acute hospitalization was denied due to lack of medical necessity. This denial is being appealed.

The requested health service was medically necessary.

The patient presented to the emergency room with syncope in the setting of acute congestive heart failure exacerbation and pneumonia as well as hypoglycemia. The patient was hemodynamically unstable with tachycardia, tachypnea, and hypertension that persisted despite emergency room treatment. The patient needed to be monitored for acute myocardial infarctions, needed intravenous antibiotics and intravenous diuretics as well as close monitoring of the kidney function. The treatment provided to the patient could not have been safely and effectively be provided at a lower level of care other than acute in-hospital level of care. The requested admission was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Elective cardiac catheterization
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This is an adult male patient that was hospitalized for elective cardiac catheterization. His past medical history was remarkable for hypertension, hyperlipidemia, known nonobstructive coronary artery disease (CAD), diabetes, and end-stage renal disease requiring hemodialysis. His scheduled procedure showed 70-80 percent in mid left anterior descending artery (LAD) stenosis, and he underwent successful percutaneous coronary intervention (PCI) with stenting on the same day. There were no procedural complications, and the patient was discharged following overnight observation. The requested coverage for inpatient hospitalization was denied, based on the policy and the patient is appealing the decision.

The requested health service 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 the inpatient hospital stay. In this particular case, the patient underwent planned left heart catheterization (LHC) followed by successful and uncomplicated percutaneous coronary intervention (PCI) with stenting of the left anterior descending artery (LAD) on the same day. The information provided does not support the medical necessity for admission after the patient's successful and uncomplicated coronary intervention. Percutaneous coronary intervention procedures are routinely performed in the ambulatory setting with observation. 
There is no documentation of unstable medical conditions like acute coronary syndrome/acute myocardial infarction (ACS/AMI), cerebrovascular accident (CVA), contrast nephropathy, 
acutely decompensated congestive heart failure (CHF), life-threatening cardiac arrhythmia, procedural complications like acute coronary perforation or vascular access complication 
requiring surgery, or other medical instability or acute care needs that would require acute inpatient management. Therefore, based on the submitted information and the current published medical literature, the requested health service is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male with a past medical history (PMH) of generalized anxiety disorder (GAD), major depressive disorder (MDD), gastroesophageal reflux disease (GERD), melanoma, prostate cancer, and post-traumatic stress disorder (PTSD) who was admitted with complaints of (c/o) a one-day history of nausea, vomiting, and diarrhea. The vital signs were unremarkable. The physical exam was notable for ill-appearing, abdomen with diffuse, mild tenderness to palpation (TTP). Lab work was notable for leukocytosis. The patient was diagnosed with acute viral gastroenteritis and dehydration and treated with intravenous fluids (IVF), pain control, an anti-diarrheal, and anti-emetics, and patient was noted to be improved on admission documentation and tolerated a diet the day after admission. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.
This patient presented to the emergency department (ED) with complaints of (c/o) a one-day history of nausea, vomiting, and diarrhea. The patient did not have associated high-risk features, such as severe acute renal failure, congestive heart failure, or liver failure, nor did the patient have any hemodynamic instability, bowel obstruction, diabetic ketoacidosis, appendicitis, pyelonephritis, ascending infection, unstable vital signs, or immunosuppression. The patient presented with acute viral gastroenteritis with dehydration, was treated and responded to IVF, pain control, anti-diarrheal, and anti-emetics, and was noted to have clinical improvement on admission history and physical (H&P) while the patient tolerated a diet advance the day after admission and was discharged. Overall, these interventions could have been safely and appropriately provided at a lower level of care for this stable and quickly improving patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse.
Treatment: Detox admission.
The insurer denied Detox admission.
The determination is overturned.

This is a male patient who self-referred and was admitted, following the medical screening, to acute inpatient-level services for detoxification and withdrawal management of severe alcohol and stimulant (cocaine) use disorders. The patient was using up to one liter of liquor daily together with $500 worth of cocaine up to three days per week.
The patient presented with withdrawal symptoms that included tremors, sweats, muscle aches, nausea, insomnia, irritability, restlessness, motor agitation, and anxiety with a Clinical Institute Withdrawal Assessment (CIWA) scale score of 13. He had an extensive history of substance-related treatment episodes including a recent detoxification with discharge.
The patient was admitted to acute inpatient-level care and placed on a detoxification regimen with a Librium taper, vitamin and nicotine replacement therapy, and medical monitoring. Following his first day of treatment, the patient began to participate in counseling and educational sessions. Psychiatric consultation was provided with the use of sertraline, quetiapine, and melatonin with as-needed (prn) Vistaril. The patient was discharged with plans/referral to start a rehabilitation treatment and with recommendations for involvement in 12-step recovery meetings, as well as continued mental health services. The CIWA had diminished to a score of 6 at the time of discharge.
This review is a New York State-mandated review with the application of NY State OASAS LOCADTR 3.0 Criteria/Guidelines.
At issue is the medical necessity of detoxification admission.

The requested health service/treatment is medically necessary for this patient. The patient in this case presented with a diagnosis of severe alcohol and stimulant use disorder. The presenting clinical features and history and risk for withdrawal seizures and other psychosocial complications of alcohol and stimulant use disorders did warrant the admission and continued inpatient level services with medical monitoring in this case scenario. 
The adult inpatient treatment of this patient's substance disorders did require admission and the continued structure of an inpatient level setting and 24-hour monitoring given the severity of the alcohol use disorder, and the presentation with continued use of substances despite recent substance-related treatment. Withdrawal symptoms were managed with tapering dosages of benzodiazepine/Librium requiring monitoring, as well as comfort medications and vitamin and nicotine replacement therapy, and the co-occurring psychiatric disorders were managed with psychiatric consultation. Thus, the patient did require safe and effective detoxification with withdrawal management during the time frame under review, as it was reasonable that the patient would have been unable to abstain from the substances of abuse if detoxification and treatment were to be attempted at a lower level of care.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Unilateral primary osteoarthritis, right hip. 
Treatment: Oxycontin [oxycodone ER (extended release)]. 
The insurer denied Oxycontin (oxycodone ER). 
The health plan's determination is upheld. 

The patient's diagnoses include lumbar spondylosis without myelopathy and unilateral primary osteoarthritis of the right hip. The provider is requesting OxyContin 15 milligrams (mg) every 12 hours. Prior medications trialed include Xtampza. 

At issue whether the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects. 
I uphold the health plan's determination, in whole. 

The alternative formulary drugs are opioids and will likely be just as effective and have a similar adverse effect profile. There is no rationale provided as to why the patient cannot trial the plan alternatives. There are no allergies or contraindications noted. Additionally, there are insufficient large-scale, randomized, controlled studies showing the superiority of Oxycontin over the formulary alternatives in this patient's clinical situation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Edentulous tooth #18

Treatment: Procedure code D6010, dental implant on tooth 18

The insurer denied coverage for procedure code D6010, dental implant on tooth 18

The denial is upheld

 
Based on review of the submitted documentation which includes copy of panoramic radiograph, pre and post implant placement periapical radiographs, treatment/progress notes, narrative letter from the dentist, in addition to insurer correspondence, it appears that this patient presented for dental evaluation and treatment regarding prosthetic rehabilitation for the mandible in the area of edentulous #18. The dentist recommended endosteal implant in the area for occlusal stability. The insurer has denied the aforementioned services stating that in their estimation endosteal implants are not the only appropriate treatment, and implant services are only covered when there is a documented functional deficit that will be alleviated by the implant. The insurer states that the medical. records received do not demonstrate such a condition and therefore the endosteal implants and related services are considered not medically necessary, considered elective and therefore no benefit is available. Further as per the medical policy implants are not considered medically necessary in the second molar area if there is a functional first molar occlusion. The patient is appealing the decision.

Upon review of the objective documentation which primarily consists of the panoramic and periapical radiographs and treatment notes, the patient exhibits oligodontia and carious retained root tip #18. As regards endosteal implant placement, although implants are an acceptable treatment to restore edentulous spaces after extractions as planned and performed in the # 18 area, an accepted standard of care in dentistry is not exclusively endosteal implants. Alternative appropriate treatment would include conventional removable denture to treat all edentulous areas or no treatment as the patient exhibits a stable and functional first molar occlusion. Peer reviewed literature (references below) support that a stable first molar occlusion is adequate for proper occlusal function. Further as per the Excellus Medical Policy, policy statement II implants to replace a second molar (such as# I 8) "are considered not medically necessary if used to extend an arch with functional first molar occlusion" as in this patient.

Uphold denial of coverage for dental implant as not medically necessary, as the patient exhibits a stable first molar occlusion.

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 procedure code D6010, dental implant on tooth 18 is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Idiopathic Short Stature (ISS),
Treatment: Omnitrope
The insurer denied coverage for Omnitrope.
The denial is upheld. 

This is an adolescent male diagnosed with Idiopathic Short Stature (ISS). This request is for Omnitrope 2.4mg (milligrams) daily. 

The patient's bone age was 16 years. His height velocity is reported to be 1.719 cm/yr (centimeters/year).  His testes were 20 ml (milliliters) bilaterally and pubic hair was at Tanner 4 (scale used to assess level of puberty). The patient's weight was 57 kg (kilograms).

The patient's height eight months ago was 157.7 cm (centimeters) (+0.08 SDS [Standard Deviations]) and two months ago was 158.5 cm (centimeters) (-0.31 SDS) with height velocity over 6 months of 1.6 cm/yr (centimeters/year).

His mother's height is 152.4 cm (centimeters), and father's height is 162.6 cm (centimeters) with mid parental height at 164 cm (centimeters) (-1.64 SDS).

The peer reviewed literature including consensus clinical guidelines are summarized below:

Classic GH deficiency:

Classic GH deficiency criteria are outlined in the consensus guidelines for the diagnosis and treatment of GH deficiency published by the GH research society(1), the Lawson Wilkins Pediatric Endocrinology Society(2,3), and the medical guidelines for GH use provided by the American Association of Clinical Endocrinologists(4). 

The patient did not meet biochemical criteria. Growth hormone stimulation testing is not reported.

Idiopathic Short stature:

Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines (4-9). FDA (Food and Drug Administration) approval for this indication is for "non-growth hormone-deficient short stature, defined by height SDS (Standard Deviations) less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means."

The patient does not have a pretreatment height less than or equal to -2.25 SD (Standard Deviations). The patient therefore does not meet idiopathic short stature criteria. 

The request does not meet any nationally accepted criteria for use of growth hormone. 

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 Omnitrope services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Pulmonary embolism
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is an adult female. She presented to the emergency room with back pain. The patient had recent knee surgery six weeks prior. The patient was diagnosed with pulmonary embolism. The patient was admitted to the hospital for further management. The patient was started on subcutaneous Lovenox. The patient was discharged home the next day on Eliquis. The acute hospitalization was denied coverage by the health plan as not medically necessary. This denial is being appealed.

The Inpatient admission was not medically necessary.

The patient was diagnosed with a pulmonary embolism. The patient was hemodynamically stable. The patient's oxygen levels were above 90% with minimal oxygen support. The patient was able to ambulate and tolerate an oral diet.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fall/rib injury
Treatment: Inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld. 

The patient is a woman who presented to the emergency department (ED) four days following a trip and fall. She had been seen previously at another hospital but presented with worsening pain. She complained of right rib pain. Comorbid health conditions included no chronic health conditions. She was initially evaluated in the ED. She was without fever, and heart rate was 80/minute. Blood pressure was 153/91 and the oxygen saturation was 96% on room air. At the time of presentation, she was awake and alert with a Glasgow coma score of 15/15. Imaging with computed tomography (CT) scan showed fractures of right ribs 8, 9, and 10 with no associated pneumothorax.

The inpatient level of care was not medically necessary for this patient as the care and treatment provided could have been rendered with a lower level of care.
This patient presented to the ED following a fall at home several days earlier. She sustained right sided rib fractures 8, 9, and 10. She was clinically stable at the time of presentation with normal heart rate, oxygen saturation, and labs. Her pain was appropriately treated with oral medications and a transdermal lidocaine patch. She remained stable during the period of monitoring. Based on her presenting condition with 3 acute rib fractures, her lack of comorbid health conditions, and her favorable response to the treatment provided, it was reasonably anticipated that she would not require at least two midnights in the hospital. A lower level of care would have provided for the care and treatment necessary for this patient that spanned a period of 1-day.
Generally accepted guidelines state that inpatient admission may be indicated in the setting of rib fractures for hemodynamic instability, 3 or more rib fractures, flail chest, acute respiratory failure, pain management, associated injury, infection, hypoxemia, tachypnea, immediate surgery needed or other condition. This patient did have 3 left rib fractures, but vital signs were normal and her pain was appropriately treated with oral and transdermal analgesia. She was considered stable for discharge from the hospital on the first day following her ED presentation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity
Treatment: Mounjaro
The insurer denied Mounjaro.
The determination is upheld.

This is a female patient with a history of obesity, polycystic ovarian syndrome, insulin resistance, migraine, and fatty liver disease. She is requesting coverage for Mounjaro. It was noted that her weight was 159 pounds, and her body mass index (BMI) was 27.3. At issue is the medical necessity of Mounjaro.
The requested health service/treatment of Mounjaro was not medically necessary for this patient.
There is no evidence that the patient has type 2 diabetes or the failure of formulary-approved alternatives. At this time Mounjaro only has Food and Drug Administration (FDA) approval for the treatment of type 2 diabetes. At this time there is no clear evidence that Mounjaro is safer and/or more effective than other similar medications that are approved for the treatment of obesity. Therefore, based on the standard of care, as well as the peer reviewed literature and Plan's drug criteria cited in the references, the Mounjaro was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity
Treatment: Wegovy
The insurer denied Wegovy
The health plan's determination is overturned. 

This is a female diagnosed with obesity. As documented, she is currently on a reduced calorie diet and exercise program. Recently, her weight was 226 lbs (pounds); body mass index (BMI) was 35.40.

Wegovy is medically necessary.
Semaglutide is a GLP1R (glucagon-like peptide-1 receptor) agonist that is Food and Drug Administration (FDA) approved in the treatment of type II diabetes and obesity. Recent studies published in major peer reviewed medical journals have shown safety and efficacy of semaglutide for the treatment of obesity. This medication is now available for the treatment of obesity in the form of Wegovy.
The standard of care requires that the patient participate in lifestyle modification. It also requires that the patient has a body mass index (BMI) of 30 or greater or a BMI of 27 or greater with comorbidities such as hypertension and hyperlipidemia. The patient has a BMI of 35.40 and participates in lifestyle modifications such as diet and exercise programs. The request meets the standard of care and is, therefore, medically necessary.