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

Diagnosis: Knee Pain
Treatment: Hyaluronan Orthovisc injections
The insurer denied Hyaluronan Orthovisc injections.
The determination is upheld.

This is a female patient with a complaint of bilateral knee pain. An office note documented that the patient had prior left knee arthroscopic surgery many years prior for a partial medial meniscectomy. She had used topical Voltaren gel and used oral Aleve to control her pain. She also had cortisone injections which provided approximately 6 weeks of pain relief. The provider proposed a course of bilateral Orthovisc injections for this patient, despite a radiology report of both knees which reported no fractures and no significant arthropathy. The report stated that the joint spaces were preserved. The health plan denied coverage for the requested Hyaluronan Orthovisc injections. At issue in this case is the medical necessity for the requested Hyaluronan Othovisc injections for both knees.

The requested health service/treatment of Hyaluronan Othovisc injection is not medically necessary for this patient.
The medical records do not clearly establish the diagnosis of bilateral knee osteoarthritis for this patient. The progress note indicates that the patient had moderate medial and patello-femoral compartment arthritis in both knees but this is not corroborated by the official radiology report which states that the knee joint spaces are preserved. The current, peer-reviewed literature does not support the use of viscosupplementation injections for the treatment of knee osteoarthritis. A peer-reviewed study by Tammachote and colleagues in the Journal of Bone and Joint Surgery was a randomized, double blind study which compared a Hylan injection to a corticosteroid injection for patients with pain from knee osteoarthritis. The authors found that "Triamcinolone acetonide provided similar improvement in knee pain, function, and range of motion compared with Hylan G-F 20 at the 6-month follow-up, with better pain control in the first week and better knee functional improvement in the second week." Also, the use of viscosupplementation injections is not supported by the current American Academy of Orthopedic Surgeons guideline on the management of knee osteoarthritis published by Brophy and colleagues in 2022. Therefore, the requested Orthovisc injections for this patient are not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

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

This is a patient with a past history of bronchiolitis who presented with rapid breathing. She was well until 2 days prior to presentation when she developed rhinorrhea, fever, and a cough. Her mother had been suctioning her nose, but she then developed rapid breathing and therefore, was brought in for care. She was seen in the emergency department and was diagnosed with bronchiolitis, and was discharged to home. However, her symptoms persisted so she returned for care. Her past history was significant for a prior admission to the intensive care unit for pneumonia.
In the emergency department, she was found to have bilateral transmitted airway noises and persistent tachypnea. A chest x-ray was obtained which revealed perihilar peribronchial thickening bilaterally and laboratory studies were drawn. She was also not feeding well and therefore, the decision was made to admit her to the hospital for care.
At the time of admission, she was described as being in acute distress. She had retractions and tachypnea with a prolonged expiratory phase. She was treated with saline nebulizers every 3 hours along with continuous cardiopulmonary monitoring. She also continued to have a fever and received acetaminophen. She did improve, and was felt to be stable for discharge with follow-up as an outpatient.
At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient admission was medically necessary for this patient.
This is a young infant who presented twice to the emergency department with tachypnea. She had a prior history of an intensive care unit admission, increasing her risk for poor outcomes. She continued to have tachypnea, she had poor feeding, and upon arrival in the hospital was noted to be in respiratory distress. She, therefore, required hospital admission for continued treatment, initially with saline nebulizer treatments every 3 hours, along with continuous monitoring with additional treatments as needed.
The decision making at the time of admission for this patient was consistent with her young age, the presence of persistent tachypnea and respiratory distress, and the need for intensive treatment in an inpatient setting along with close monitoring for potential deterioration of clinical status.
Indications for hospitalization for bronchiolitis include poor feeding and respiratory distress with retractions. This patient had persistent tachypnea and respiratory distress, and also had poor feeding with a prior intensive care unit (ICU) admission. Therefore, hospital admission was appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain 

Treatment: Inpatient admission 

The insurer denied coverage for inpatient admission 

The denial is upheld  

The patient is an adult with a history of asthma, gastroesophageal reflux disease (GERD), and right bundle branch block. The patient presented to the emergency department (ED) after complaining of chest pain and shortness of breath (SOB) after visiting a cafeteria. 

Vital signs at presentation to ED: Temperature 37.1 degrees Celsius, heart rate 120, Respirations 16 and Blood Pressure 134/99, Oxygen (O2) saturation 99%. The patient was in no acute distress. 

The patient was noted to have some wheezing on lung exam. Heart sounds were normal.  The patient was alert and oriented x 3. Non focal neuro exam. White Blood Cell (WBC) count was  normal.  Electrocardiogram (EKG) was normal sinus rhythm (NSR) with no acute ST changes. 
Troponin level was negative. 

Chest x-ray (CXR) showed haziness at the left heart border, possible pneumonia (PNA) or atelectasis. 

Patient was admitted for treatment of Asthma Exacerbation rule out (R/O) PNA. 

The patient was treated with intravenous (IV) Steroids, Magnesium, bronchodilators (BD) Via Nebulizer and antibiotics (Abx). A computed tomography angiogram (CTA) of the chest was done - no pulmonary emboli (PE), no PNA or pleural effusion. 

The patient improved with treatment. By the next day the patient remained afebrile and hemodynamically (HD) stable. Lungs were clear. WBC was 7. The patient was feeling better. The patient was discharged home on oral (PO) medications with outpatient follow-up. 

This patient did not need acute inpatient hospitalization. The patient could have been placed in Observation status while diagnostic testing and treatment were initiated. Observation period could be for up to 48 hours. The patient improved after treatment in ED. The patient did not have a PNA or PE on CTA. The patient did not have a myocardial infarction (MI). The patient may have had some reactive airways which rapidly improved with steroids, Magnesium and BD. This patient could have been discharged home on PO medications after a period under observation. The patient was discharged the next day after admission. The patient could have been easily observed in observation status and then discharged. 

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 the full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: leg pain/swelling
Treatment: inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

This case involves a man with peripheral vascular disease and chronic bilateral lower extremity ulcers who was admitted to the hospital with worsening swelling and pain. He currently resides in the homeless shelter. He is not taking any medications and has had chronic wounds for approximately 20 years. The patient reported seeing a wound care doctor and a vascular surgeon in the past but not recently. He complained of burning pain in both lower extremities. While in the emergency department, he received pain medications in the form of intravenous (IV) morphine, oxycodone, and tramadol. He then expressed suicidal ideation, resulting in a psychiatry consultation and 1:1 sitter.

The inpatient admission was not medically necessary for this patient. The patient was admitted for suicidal ideation, elevated blood pressure, and neuropathic leg pain. Suicidality was ruled out, and the patient was no longer in danger after the initial hours of the admission. Psychiatry prescribed Remeron, and he was not considered a suicide risk. The blood pressure improved after the initiation of blood pressure medications. The neuropathic pain was treated with gabapentin, tramadol, and oxycodone. The documentation repeatedly states there is no evidence of infection. Deep vein thrombosis (DVT) was ruled out with a duplex scan. Therefore, there were no clinical indications for inpatient admission. A lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stroke and residual right upper extremity weakness.
Treatment: Implantation (Placement) of the Vagus Nerve Stimulation (VNS) Device.
The insurer denied the implantation (Placement) of the Vagus Nerve Stimulation (VNS) Device
The denial is upheld.

The patient is an adult male with a history of stroke and residual right upper extremity weakness. The provider has requested the implantation of a vagal nerve stimulator.

The requested health service is not medically necessary.

The patient has a history of stroke with residual right upper extremity weakness. There are no data derived from high-quality clinical trials to support that vagal nerve stimulator improves outcomes for persons with residual upper extremity weakness from stroke (1, 2). Standard of care guidelines do not support the use of a vagal nerve stimulator for this patient's condition.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Crossbite.
Treatment:  D8080 Comprehensive Orthodontics.

The insurer denied: D8080 Comprehensive Orthodontics.  The denial is overturned.

The patient is an adult male requesting orthodontic benefits. The patient has a Class I malocclusion with moderate upper and lower arch crowding. Patient also has a deep bite. Prior denial was due to handicapping index score of 20.

The requested service is medically necessary. 

The patient has a crossbite of an anterior tooth (#27) with clinical attachment loss and gingival recession. He also has a deep bite with trauma to the gum tissue behind the upper front teeth. Both of these conditions are automatic qualifiers for treatment according to the handicapping index scale. Orthodontic treatment is needed to correct these problems. This case is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Pain, Dyspnea
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a female patient who presented to the emergency department (ED) via Emergency Medical Services (EMS) for a 40 minute episode of chest pain and dyspnea. EMS found the patient to be in atrial fibrillation (AF) with a rapid ventricular rate. Her medical history was remarkable for hypertension. She admitted to noncompliance with her prescribed antihypertensive regimen. An electrocardiogram showed atrial fibrillation with a rapid ventricular rate. Her initial high sensitivity troponin and brain (or B-type) natriuretic peptide (BNP) levels were normal. The patient was sedated and electrically cardioverted to sinus rhythm. Her chest pain resolved. Her post-cardioversion electrocardiogram showed no acute ischemic changes. Her serum troponin level rose from 5 nanograms per liter (ng/L) pre-cardioversion to 2840 ng/L post-cardioversion. The patient was admitted to the hospital. She remained asymptomatic and in sinus rhythm. Computed tomography (CT) angiography showed no obstructive coronary artery disease. There was a left subsegmental pulmonary embolism. An echocardiogram was unremarkable. The patient was anticoagulated. She remained stable and was discharged. The medical necessity of an inpatient admission is at issue.
Based on the documentation provided, an inpatient level of care was medically necessary.
This patient presented with chest pain and acute atrial fibrillation with a rapid ventricular rate. She was successfully cardioverted to sinus rhythm in the emergency department. Her chest pain resolved with restoration of sinus rhythm. However, chest imaging revealed a subsegmental pulmonary embolism. Her serum troponin level increased more than 500-fold to 2840 ng/L. While minor elevations are common with atrial fibrillation and, to some extent, after electrical cardioversion, elevations to this degree are very unusual with AF and with cardioversion. Patients with pulmonary embolism levels greater than 16 ng/L are associated with an increased risk of in-hospital adverse outcomes (odds ratio 6.5) and all cause mortality (odds ratio 3.7). Given this patient's risk for major adverse events, she required careful and continuous monitoring with the ability to intervene emergently, if needed. This warranted an inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bilateral Leg Swelling

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

The patient has a past medical history significant for hypertension, brain aneurysm, multiple pulmonary embolism, depression, seizures, migraines, and opioid dependence who presented to the emergency department with complaints of leg swelling and shortness of breath.

Vitals on presentation included: Temperature 96.8 Fahrenheit, Blood Pressure (BP) 141/98, Pulse 110, Respiratory Rate 16, oxygen (O2) saturation 98% on Room Air. Laboratory results included the following: white blood cell count (WBC) 13.9, hemoglobin (HGB) 7.9, creatinine 0.59, and glucose 127.

The patient was given Lasix x 1. An echocardiogram showed normal findings. A chest X-ray (CXR) was negative. Leg swelling was suspected to be secondary to "chronic venous stasis versus due to mild liver disease."  The patient remained afebrile, hemodynamically stable, and clinically improved. The patient was discharged to continue outpatient management.

According to documentation, this patient with chronic leg swelling responded to diuresis.  The patient was afebrile, hemodynamically stable. Although initially tachycardic, heart rate normalized with diuresis while still in the emergency department. Laboratory results showed an elevated WBC, their clinical impression was "chronic" warranting "outpatient work-up." Patient had no evidence of an infection, and no antibiotics were deemed necessary. Based on the above findings, the patient met criteria for observation level of management. 

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 the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

This case involves a man with a history of intravenous (IV) drug use, a history of abscesses and methicillin-resistant staphylococcus aureus (MRSA) bacteremia, spinal epidural abscess, and developed diffuse wounds to the bilateral upper and lower extremities. The patient is supposed to be on antibiotics, based on an admission ten days before this presentation; however, the patient has been injecting heroin three times daily. The medical team documents a diffuse red and tender rash at the injection sites. The patient also had pain and swelling at the left wrist and left foot. 

The inpatient hospital admission was not medically necessary.
During the 4-hour hospital stay, the patient was noted to have inflamed skin lesions where he was injecting heroin. He received an intravenous (IV) in the emergency department and subsequently eloped. The medical team documents no signs of systemic inflammatory response syndrome. White blood cell count was normal, renal function was normal, and there was no clear evidence of a systemic infection. There is no documentation of subcutaneous abscess formation that would require drainage. There is no documentation stating the patient has a life-threatening or limb-threatening infection. The patient did not fail outpatient therapy with antibiotics. Instead, he was not compliant with therapy. There is no documentation of severe dehydration. The patient has chronic non-exertional chest and back pain, with negative cardiac enzymes and negative computed tomography angiography (CTA) of the chest, ruling out pulmonary embolism (PE) and dissection. As a result, there are no clinical indications for inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urticaria

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient presented to the emergency department (ED) with body rash which had spread despite Medrol treatment. The patient's past medical history is significant for recent cesarian section, hypothyroidism, obesity and endometriosis. The vital signs (heat rate (HR), blood pressure (BP), temperature, and oxygen saturation) were normal. The ED physical examination was positive for urticaria on entire body. An initial complete blood count (CBC) showed a white blood cell count (WBC) of 13.0 with 9.9% eosinophils. A comprehensive metabolic panel (CMP) was normal, and triplex viral panel negative. The patient was admitted with plans to give Solumedrol, Pepcid and Benadryl. Inpatient orders for Lovenox, Nexium, Solumedrol, betamethasone cream, hydroxyzine and loratadine were entered. A progress note from the following day noted normal vital signs and continued rash. Epstein-Barr Virus (EBV) Polymerase Chain Reaction (PCR), anti-nuclear antibodies (ANA) and cardiolipin antibodies were negative. An allergy immunology consultant saw the patient who noted palpable eruption of the trunk and upper extremities that blanched. The impression was diffuse urticaria and delayed hypersensitivity disorder with a narrative impression of possible vasculitis with rash improvement over the last 12 hours. The plan was to continue steroids.

The patient did not have any indication of liver, kidney, gastrointestinal, cardiopulmonary or neurologic abnormalities. Furthermore, the skin disease was not desquamating. There were no signs of vital sign instability. The patient does not fulfill the systemic or infectious condition (allergic reaction subsection) GRG (MG-SIC) of the Milliman Care Guidelines (MCG) criteria for admission. Also, the vasculitis section of Musculoskeletal Disease GRG: MG-MD (ISC GRG) was not fulfilled. There was therefore inadequate evidence for a level of severity that warranted hospital admission.

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 the full hospital admission is not substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Obesity.
Treatment: Wegovy.

The insurer denied the request for Wegovy.  The health plan's determination is overturned in whole. 

The patient is a female who is diagnosed with obesity and hyperlipidemia. Despite lifestyle modifications (a diet program and diet, exercise) she failed to lose weight. As per the visit note, she has impaired glucose intolerance. Her hemoglobin A1C (A1C) was 5.6 percent (%).

There is no formulary alternative provided for the patient to try. The requested Wegovy (Semaglutide) is a glucagon-like peptide-1 receptor (GLP1R) agonist (1) that is Food and Drug Administration (FDA) approved in the treatment of type II diabetes and obesity (2-4). Recent studies published in major peer reviewed medical journals have shown safety and efficacy of Semaglutide for the treatment of obesity (5-7). This medication is now available for the treatment of obesity in the form of Wegovy.

The standard of care requires that the patient is participating in lifestyle modification. It also requires that the patient has a BMI (body mass index) of 30 or greater or a BMI of 27 or greater with comorbidities such as hypertension or hyperlipidemia. The patient is participating in lifestyle modification and has failed to achieve a normal BMI. Given the fact that the patient has glucose intolerance, the requested medication a GLP1R agonist is superior to medications and other classes to treat obesity. 

The health plan's determination is overturned in whole.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Migraine
Treatment: Qulipta 30 Milligram Tablet
The insurer denied: Qulipta 30 Milligram Tablet
The denial is upheld.

The patient is an adult female with migraines. She has tried and failed Topamax. There is no documentation of any of the medications tried for migraine preventative. The provider wishes to prescribe Qulipta. The request was previously denied as the patient has not tried and failed all formulary alternatives.

The health plan should not cover the proposed treatment.

Qulipta should not be covered as the patient has not tried and failed at least two different preventative migraine medications. The patient has only tried Topamax. According to the American Headache Society anti-calcitonin gene-related peptide (CGRP) guidelines, anti-calcitonin gene-related peptide medications, which Qulipta is, are indicated when one has tried and failed at least two different preventative medications for migraines. Other anti-calcitonin gene-related peptides on the formulary include Ajovy and Emgality which also require prior trial and failure of at least two different preventive migraine medications.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ulcerative colitis
Treatment: Zeposia 0.9 MG (milligrams) OR (oral) CAPS (capsules)
The insurer denied Zeposia 0.9 MG (milligrams) OR (oral) CAPS (capsules).
The denial is overturned.

The patient is an adult male with moderate to severe ulcerative colitis, with active disease to the descending colon. He has failed oral mesalamine and steroid enemas, with hematochezia and diarrhea requiring prednisone. He started Zeposia (ozanimod) earlier this year and has done well. The doctor is requesting continuation of Zeposia.

The requested Zeposia is medically necessary.

Zeposia is a United States Food and Drug Administration (FDA)-approved conventional "small molecule" drug that belongs to the class of medicines called sphingosine 1-phosphate (S1P) receptor modulators. It has been classified as a pre-biologic and is safe and effective for the treatment of ulcerative colitis that is refractory to mesalamines. As this patient has failed mesalamines and required steroids, and has done well on Zeposia, continuation of Zeposia is clinically appropriate, accepted standard of care, and medically necessary.