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

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

The patient was transferred to the emergency department (ED) from her physician's office. The patient was being seen for palpitations, lightheadedness and chest tightness and was found to be in rapid atrial fibrillation with preexcitation. The shortest preexcited RR interval [the interval from the onset of one R wave to the onset of the next one] was 230 milliseconds (msec). Her average ventricular rate was greater than 200 beats/minute. She was transferred to the ED via Emergency Medical Services (EMS). She was treated with intravenous amiodarone which terminated the tachycardia. A sinus rhythm electrocardiogram showed evidence of a left-sided atrioventricular accessory pathway. Her serum troponin level was elevated. She was then transferred to another facility  for catheter ablation. This was performed and the patient was discharged the next day. The medical necessity for an inpatient admission is at issue.
The inpatient stay was medically necessary.
This patient presented with rapid preexcited atrial fibrillation due to Wolff Parkinson White syndrome (WPW). While the majority of symptomatic patients with WPW do not have malignant arrhythmias, a small percentage do present with ventricular fibrillation and sudden cardiac death. Symptomatic arrhythmias, atrial fibrillation (AF) and shortest preexcited RR interval (SPERRI) of 250 msec or less during AF are risk factors for sudden death in WPW. This patient met these three criteria; her SPERRI was 230 msec. Given her risk for malignant arrhythmias, admission and continuous monitoring until catheter ablation could be performed was necessary. If she were to have had recurrent AF during this period, immediate intervention with pharmacologic or electrical cardioversion would have been necessary. Given the need for careful and continuous monitoring along with the ability to intervene emergently, if needed, an inpatient level of care was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Pregnancy/Childbirth/Premature Birth.
Treatment:  Inpatient Hospital.

The health plan denied the requested inpatient hospital stay. The health plan's determination is upheld.

This female infant was born by spontaneous vaginal delivery. The one- and five-minute Apgar scores were 9 and 9, respectively. The mother's pregnancy was complicated by known Group B Streptococcus status, pre-gestational Type 2 diabetes mellitus and preeclampsia. The mother had rupture of membranes three hours prior to delivery, and she received 6 does of antibiotics prior to delivery.
The infant was admitted to the Neonatal Intensive-Care Unit (NICU) for prematurity and received phototherapy. Neonate's blood type was O+ (+ = positive) with a negative Direct Coombs. Mother was blood type A+. The infant was able to be transitioned to the well-baby nursery and was discharged to home. 

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

No, the requested health service/treatment of Inpatient Hospital Admission: Neonatal Intensive Care Unit was not medically necessary for this patient.
The neonate was hemodynamically stable, breathing unassisted room air, able to maintain her temperature in an open crib and able to orally feed adequate volumes to maintain her blood glucose within reference ranges.[1,2] The neonate was hemodynamically stable, breathing unassisted room air, able to maintain her temperature in an open crib and able to orally feed. [1-4] This level of care can be provided at a level of care lower than Neonatal Intensive Care. Monitoring of feeding ability, glucose concentrations, and temperature can be performed in the well-newborn nursery. [1,2] While late preterm infants require close monitoring compared to their term counterparts, that monitoring does not need to be in the Neonatal Intensive Care Unit. Monitoring can be provided outside of the Neonatal Intensive Care Unit level of care. The infant was being monitored for feeding ability, temperature stability and jaundice.[1-7] Monitoring of a hemodynamically stable neonate born at > 35 weeks gestation and weighing >2000 grams does not require care in the Neonatal Intensive Care Unit.[1-4] None of the care provided required care in the NICU, including the provision of phototherapy. [5-7]
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Genitourinary/Kidney Disorder-UTI/Vaginal Infection.
Treatment: Inpatient stay.

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

This patient presented with fever, abdominal pain, and vaginal discharge.  She was in her usual state of health until 2 days prior to admission when she started having chills as well as a sore throat. She noted her temperature was 101F.  She went to the urgent care center. COVID and rapid strep tests were negative. However the next day she continued to have fevers, and developed abdominal pain, dysuria, and vaginal discharge. She also described arthralgias of her right knee. She returned to the urgent care center and a urinalysis and urine culture were obtained. She was prescribed nitrofurantoin and sent home. The next day, her symptoms were still not improving so she presented to the emergency department for care. Her past history was significant for having 5 previous male sexual partners with inconsistent condom use. On physical examination in the emergency department she was noted to be ill-appearing, with posterior oropharyngeal erythema as well as suprapubic tenderness and both left and right costovertebral angle (CVA) tenderness. She was admitted for pyelonephritis with failed outpatient management, and possible pelvic inflammatory disease. She was treated with ceftriaxone and azithromycin, and the obstetrician/gynecologist (OB /GYN) team was consulted. The OB/GYN recommended further testing for sexually transmitted infections, contraceptive counseling, and additional treatment with Diflucan. 

The requested inpatient hospital admission was medically necessary for this patient.
This patient presented with fever, abdominal pain, and vaginal discharge and was felt to have pyelonephritis that was not responding to outpatient management. She had been treated appropriately with oral antibiotics, but continued to have worsening symptoms as well as fever. She also had vaginal discharge and required full evaluation for possible pelvic inflammatory disease. At the time of presentation she had continued abdominal tenderness, CVA tenderness, and low-grade fever. Her laboratory values were significant for inflammation with an elevated C-Reactive protein (CRP). She required inpatient admission for prompt initiation of parenteral treatments, specialist evaluation, and close monitoring with additional treatments as needed. Patients receiving treatment for pyelonephritis should have clear signs of improvement within 24-48 hours. Patients with the lack of response to treatment require inpatient admission for parenteral treatments.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Obstructive Pulmonary Disease.
Treatment: Pharmacy/Prescription Drugs/Synagis.
The health plan denied the request for Synagis. 
The health plan's determination is overturned.

This is a baby with chronic lung disease, a history of intrauterine growth restriction (IUGR), dependent on tracheostomy, a history of apnea of prematurity, excessive secretions, and of a gastrostomy tube (G tube) placement. Prenatal history of maternal drug use, and maternal Hepatitis B. He was weaned to a tracheostomy collar. The request is for Synagis injection.

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

Yes, the requested health treatment of Synagis is medically necessary for this patient.

This patient is on a gastrostomy tube and tracheostomy collar and has severe secretions. As per the 2014 guidelines of American Academy of Pediatrics (AAP), patients with pulmonary complications with secretions may benefit from Synagis. Also, in a study it was conclusively shown that patients with tracheostomy will benefit from Synagis and can prevent severe respiratory syncytial virus (RSV) related morbidity.

This patient also has a G tube and possibly gastroesophageal reflux disease (GERD), as well as a small atrial septal defect (ASD). Given all the complexities of this patient and the evidence that RSV can be prevented if used in medically complex children like this, the medication would be medically necessary.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: History of deep venous thrombosis (DVT) and pulmonary embolism (PE). 
Treatment: Savaysa (edoxaban). 

The insurer denied the Savaysa (edoxaban). 
The denial is overturned. 

The patient in this case is a man with history of deep venous thrombosis (DVT) and pulmonary embolism (PE). Initial testing revealed the presence of a lupus inhibitor, but subsequent testing was negative, failing to confirm the lupus inhibitor.  He was treated in the past with Lovenox.  This caused persistent pruritus at injection sites.  Given that, he was changed to Xarelto but also had side effects so was changed to Pradaxa.  An appeal letter states that the patient had treatment failure with Pradaxa and at that time, he was started on edoxaban.  That medicine was started several years ago and he has done well since that time, without side effects documented and also without recurrent venous thrombosis. The request in this case is for continued treatment with edoxaban. 

Yes, the health plan should cover the proposed treatment with Savaysa (edoxaban). 

This patient has been treated with Pradaxa, Xarelto and also Lovenox.  Two of these medicines caused side effects and one (Pradaxa) was ineffective.  He has had recurrent venous thrombosis but has done well for several years.  Edoxaban is clearly effective and also tolerated by him.  This medicine is Food and Drug Administration (FDA) approved for treatment of venous thromboembolism (VTE) and is associated with lower risk of bleeding than warfarin.  Changing to a different medicine at this point exposes him to risk of treatment failure as well as risk of side effects.  As he has experienced both in the past, and as he has continued to do well on edoxaban, there is no medical justification for changing therapy at this point.  Continued treatment with edoxaban should be covered in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Adjustment disorder.
Treatment:  Inpatient admission.
The insurer denied coverage for inpatient admission.  The denial is upheld.

This patient is a female who presented to the Emergency Department (ED) with complaints of nausea and vomiting.  The patient presented via the Emergency Medical Services (EMS) and was noted to have been seen in the ED the prior night and was discharged.  The patient reported that her symptoms worsened, which prompted her to return to the ED.  Prior to arriving to the ED, the patient received intramuscular (IM) Zofran.  The patient's past history included gastroesophageal reflux disease (GERD), pericarditis, a prior hysterectomy and pericardial window.  The patient's physical examination revealed normal vital signs.  The patient had diffuse tenderness to palpation of the abdomen but had no rebound or guarding.  The patient had a negative Romberg sign and had a normal gait.  The patient's treatment included morphine, Zofran and intravenous (IV) fluids.  The patient's laboratory studies did not reveal any significant abnormalities.

The patient remained hemodynamically stable throughout the ED stay and was admitted to the floor in stable condition.  The recommendation was made for a GI consult, and  esophagogastroduodenoscopy(EGD) with a biopsy was recommended.  The patient continued to remain stable throughout the inpatient stay.  Additional consultations took place as well as additional testing.  A surgery consultation was recommended.  Additional laboratory studies and a follow-up magnetic resonance imaging (MRI) did not reveal any metastases.  The patient continued treatment with fluids, Zofran, morphine, and pantoprazole.  There were no further significant adverse events, and the patient was seen by Psychiatry, who ultimately diagnosed the patient with adjustment disorder. It was noted that the patient was stable and, therefore, was discharged with instruction to follow-up.

Based on the review of the literature, inpatient admission was not medically necessary to treat this patient's medical condition.  The patient presented to the Emergency Department (ED) with nausea and vomiting.  The patient had a history of gastroesophageal reflux disease, and had heartburn symptoms.  Though this patient was found to have abdominal tenderness on exam, the patient had neither abdominal rebound tenderness nor guarding.  The patient did not present with clinical signs nor was at high-risk for a surgical abdomen.  There was no hemodynamic instability.  Extensive work up in the ED revealed no etiology or severity of the illness that required urgent, inpatient intervention.  The management of vomiting could have been provided at an outpatient level of care or under observation.  There was no indication for inpatient admission.

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

Based on the above, the medical necessity for the inpatient admission is not substantiated.  The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Lower extremity cellulitis.
Treatment:  Inpatient admission. 

The insurer is denied coverage for inpatient admission.  The denial is reversed. 

The patient was a female with a past medical history significant for hypertension and status post appendectomy.  The patient presented to the Emergency Department (ED) with complaints of fever and left leg swelling.  The patient's vitals on presentation included: Temperature 103 F, Blood Pressure 139/76, and Heart Rate 109, Respiratory Rate 18, and Oxygen (O2) saturation 96% on room air.  The patient's laboratory results included the following: white blood cell (WBC) count-19.8, hemoglobin (HGB)-12.8, hematocrit (HCT)-38.7, creatinine-1.08, and glucose-89.  The patient was started empirically on intravenous (IV) fluids and IV antibiotics (i.e., vancomycin and ceftriaxone) for lower extremity infection.  The patient's venous Doppler was negative for deep vein thrombosis (DVT).  The patient's blood cultures were negative.  Infectious Diseases was consulted, and the patient's antibiotics were adjusted accordingly.  The patient remained hemodynamically stable.  The patient was discharged with instructions to continue oral antibiotics as outpatient. 

Based on the review of the medical record and the literature, inpatient admission was medically necessary.  This case involved a patient of elderly age who presented with left lower extremity cellulitis and hemodynamic instability concerning for sepsis.  The patient had a fever of 103 F, tachycardia of 109 beats per minute, and leukocytosis of 19.8.  The patient's pain was noted to be 10 out of 10 in severity.  This patient's elderly age with comorbid condition, including hypertension, indicated that inpatient admission was medically necessary to safely treat this patient's medical condition. 

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

The carrier's denial of coverage for the inpatient admission should be reversed.  The medical necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Reviewer #3

Diagnosis: Small patent foramen ovale (PFO).

Treatment: Heart surgery (transcatheter closure of patent foramen ovale; procedure code 93580).  The insurer is denied coverage for heart surgery (transcatheter closure of patent foramen ovale; procedure code 93580).  The denial is upheld.

This was then a man with a history of diabetes mellitus, hypertension, hyperlipidemia, and two transient ischemic attacks (TIA).  The first TIA was presenting as transient right arm numbness, and the second TIA was presenting as transient aphasia.  Evaluation revealed evidence of a small infarct in the left frontal region by computed tomography (CT) scan, magnetic resonance imaging (MRI), and CT angiogram (CTA), which also revealed 30% left internal carotid stenosis with mixed plaque.  Records indicated that that the patient underwent left carotid endarterectomy at that time and there was no report of recurrent symptoms.  The patient's home medications included irbesartan, amlodipine, aspirin, atorvastatin, fenofibrate, Trulicity, Humalog, multiple vitamins, Toujeo, metformin, and CoQ10.  The patient's transcranial Doppler performed indicated findings possibly consistent with a small patent foramen ovale (PFO).  The patient's echocardiography did not reveal intracardiac shunting and echocardiogram on was reported as normal ejection fraction, with no other details available.  The patient's electrocardiogram (EKG) showed normal sinus rhythm with premature ventricular contractions (PVC) and left axis deviation.  Records seem to indicate that the decision to perform transcatheter PFO closure was based on the transcranial Doppler results.

Based on the review of the literature, there is no evidence that the PFO closure is more likely to be beneficial to this patient, compared to usual treatment with antiplatelet agents and secondary prevention of vascular disease.  Thus, the PFO closure is not likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of coverage for heart surgery (transcatheter closure of patent foramen ovale; procedure code 93580) should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Reviewer #1

Diagnosis: Patent foramen ovale (PFO)

Treatment:  Heart surgery (transcatheter closure of patent foramen ovale; procedure code 93580)

The insurer denied coverage for heart surgery (transcatheter closure of patent foramen ovale; procedure code 93580).  The denial is upheld.

The patient was a male with a history of cerebrovascular accident (CVA), transient ischemic attacks (TIA's) x2, carotid artery stenosis (status post left carotid endarterectomy [CEA]), hypertension, hyperlipidemia, diabetes, and an atrial septal defect (ASD) (small grade 1 patent foramen ovale [PFO]).  The patient was evaluated for possible PFO closure, given the patient's two TIA events/cryptogenic stroke in the setting of grade 1 suspected PFO.  The patient had TIA's where he had transient right arm numbness and had transient aphasia that resolved.  The patient was found to have significant carotid stenosis and subsequently underwent left carotid endarterectomy (CEA).  The patient's echocardiograms were normal at the time with no intra-cardiac shunts as a possible cause.  There have been no underlying arrhythmias diagnosed as likely caused his stroke events.  The patient elected to have a Noble heart stitch PFO closure.

Based on the review of the literature, the use of patent foramen ovale (PFO) closure is not medically necessary.  This procedure is FDA approved for patients with cryptogenic strokes attributable to the PFO or atrial septal defect (ASD).  The patient had prior cryptogenic stroke or TIAs, which occurred before left CEA was performed.  There had been no echocardiographic or other evidence of significant intra-cardiac shunting.  Furthermore, there had been no documentation of recurrent cerebrovascular accident or transient ischemic attack while the patient was taking antiplatelet therapy, dual antiplatelet therapy, or full anticoagulation with or without an antiplatelet agent. The patient had no contraindications to these variations of medical therapy.  Based on these factors, the use of PFO closure is not likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of coverage for heart surgery (transcatheter closure of patent foramen ovale; procedure code 93580) should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fibroid Uterus

Treatment: Inpatient Admission

The insurer denied the inpatient admission. The denial was upheld.   

This is a female patient with a diagnosis of uterine fibroids and polycystic ovarian syndrome.  She was admitted to the hospital for a scheduled uterine artery embolization.  She underwent a uterine artery embolization. The procedure was completed without complications. It was reported that the patient was admitted to the hospital for management of her postoperative pain. She was managed with intravenous (IV) morphine and acetaminophen; she was transitioned to oral analgesics with positive results. After a period of medical stability the patient was discharged home.

Uterine artery embolization (UAE) is a non-surgical treatment option for premenopausal women with bothersome fibroid-related symptoms who wish to retain their uterus, avoid the side-effects associated with prolonged medical therapy, and avoid surgery (e.g. myomectomy). UAE is typically performed as an outpatient procedure. One study showed that with defined telephone follow-up, staff availability, and a protocol designed to alleviate the post-procedure constitutional symptoms, uterine artery embolization is both safe and effective when performed as an outpatient procedure (See ref.). Patient-controlled analgesia, oral or parenteral opiates, nonsteroidal anti-inflammatory drugs, antipyretics, and anti-emetics can be started preemptively in the recovery room.
According to literature review, virtually all women experience post-procedure pain from the UAE, which is believed to be due to the ischemia of the fibroids and the uterus. However, the degree of pain ranges from mild to severe cramping, and the options for pain control depend on the severity of the pain. These options include patient-controlled analgesia, oral or parenteral opiates, and nonsteroidal anti-inflammatory drugs. Intravenous conscious sedation during the procedure followed by a patient-controlled anesthesia (PCA) suffices for post-procedural pain management. Following the procedure, most women also experience post-embolization syndrome, which consists of pelvic pain and cramping, nausea, vomiting, fever, fatigue, myalgia, malaise, and leukocytosis. These symptoms occur within the first 48 hours of the procedure and gradually improve over seven days. Patients who do not gradually improve should be evaluated for other conditions, such as sepsis.

Literature supports that UAE is usually performed as an outpatient setting, and would include appropriate postoperative monitoring and an overnight stay if required. Though the patient had post-operative pain, this was expected, and the patient was otherwise clinically stable. The patient could have been discharged home after appropriate postoperative monitoring and an overnight stay. 
The health care plan acted reasonably with sound medical judgment and in the best interest of the patient. 

The carrier denial of coverage for the inpatient admission is upheld.  The medical necessity is not substantiated.