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

Diagnosis: Hypoxemia
Treatment: Inpatient hospital admission
The insurer denied coverage for inpatient hospital admission.
The denial is upheld.

The patient is a male who was having a persistent cough and congestion for one month. The parents brought the child to the ER (emergency room) previously during this illness and they also indicated that they had seen the pediatrician. The treatments that had been prescribed included Tylenol and saline for administration via a nebulizer. The child was having diarrhea for 3 days and the parents indicated that the cough was getting worse and there was thick mucus from the nose when the child was coughing. The parents indicated that the symptoms had not improved and when the child was noted to have a decrease in oral intake and urine output, they brought the child to the ER for further treatment.

Upon arrival in the ER, he was noted to be breathing comfortably. On physical exam, there was some evidence of dehydration and there was wheezing audible in both left and right upper lobes. A pulse oximeter reading was low at 85% (percent). The child was administered a nebulization treatment with normal saline and the pulse oximeter only improved to 89%. The child was then started on 5 liters of oxygen supplementation. Blood testing and a chest x-ray were unremarkable. A treatment with albuterol was administered and the pulse oximeter improved to 97%. Because of the mild dehydration and hypoxemia, the decision was made to admit the child to the hospital for observation with a diagnosis of hypoxemia. 

The insurer has denied this admission and stated that there was no documentation in the medical record to establish the medical necessity of an acute inpatient hospital stay.

The medical record documents that the patient had viral gastroenteritis with 3 days of diarrhea and post tussive vomiting. Blood testing and physical examination did not demonstrate evidence of dehydration or acidosis and the white blood count was not elevated. The hypoxemia did improve when the child was administered albuterol via a nebulizer. This child did not receive a bolus of normal saline in the ER which is the standard of care for the treatment of acute dehydration. In addition, the child did not receive additional treatment with albuterol following the improvement in his hypoxemia after one treatment. When a child has hypoxemia and wheezing it is the standard of care to treat with multiple treatments in the ER to assess whether the child's symptoms improve and to determine if the child was stable enough to be discharged home with continued treatment with albuterol if the cough recurred. 

The documentation of the medical care administered in the ER does not support the need for hospitalization. 

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

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia. 
Treatment: Inpatient Hospital Admission. 

The insurer denied: Inpatient Hospital Admission. 
The denial is upheld. 

The patient is an adult female with a history of asthma who presented to the emergency room (ER) with shortness of breath (SOB), wheezing, and fevers. The patient was found to have moderate respiratory distress, leukocytosis and pneumonia. The patient was treated in the emergency room with supplemental oxygen, duonebs, intravenous (IV) steroids, and intravenous antibiotics. 

The patient was admitted to acute in hospital level of care for further management. The patient received duonebs, oxygen and antibiotics in the hospital. The patient was in hospital for 4 days. This request was denied due to lack of medical necessity. This denial is being appealed. 

The proposed inpatient hospital admission was not medically necessary. 

The patient was admitted to acute in-hospital level of care for pneumonia and asthma exacerbation.  She had shortness of breath, wheezing and fevers.  The patient received duonebs, oxygen and antibiotics in the hospital.  The patient's signs and symptoms improved with emergency room care. The patient was stable. The patient was ready to be discharged within 48 hours of admission. 

Given that the patient's signs and symptoms due to pneumonia and asthma exacerbation improved significantly with emergency room care, and that the patient was stable, the patient's treatment course would have been expected to be safe and effective at a lower level of care. The treatment for this patient was reasonably expected to be provided but does not require an acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld.

This is a gentleman with a history of hypertension, diabetes and coronary artery disease that presented to the emergency (ED) complaining of intermittent sharp chest pain lasting for minutes, not related to exertion. Physical examination upon arrival was benign and no abnormalities were reported.  Blood pressure (BP) was 137/86 and pulse was 58 bpm (beats per minute).  Electrocardiogram (ECG) revealed left ventricular hypertrophy with associated T (interval on ECG) wave abnormalities. Serial high sensitivity troponin studies were negative (less than 50 ng/L [nanogram per liter]) Echocardiogram revealed normal left ventricular function without wall motion abnormalities and a left ventricular ejection fraction (LVEF) of 66% (percent).  Chest pain was deemed to be atypical, and the patient was discharged home with follow up. 

His pretest probability of coronary artery disease is high (Reference 1).  Utilizing the HEART (history, ECG, age, risk factors and troponin), he was considered intermediate risk (Reference 2). Risk assessment of patients presenting with chest pain and no significant ST (interval on ECG) changes on ECG was reviewed by Hedayati et al. (Reference 3).  Using the HEART score risk stratification schema, this patient would have an intermediate risk of major adverse cardiac events (myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation. These findings are concerning and warrant management and evaluation that includes serial troponin measurement, echocardiography and ischemia work up prior to discharge. However, numerous studies have demonstrated that work up can be performed in an observation unit without the need for hospital admission. Several investigators studied patients presenting to the hospital with chest pain and compared outcomes between those admitted to the hospital for short stay admissions and those that were placed in an observation unit at a lower level of care (References 4,5). They found no significant difference in outcome at 30 days between the two groups.  Fernando Bellolio et al. noted that patients presenting with chest pain, that were managed in an observation unit, had similar 30-day myocardial infarction rates as those admitted to the hospital (Reference 5). This patient could have been managed at a lower level of care.

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

The insurer's denial of coverage for the inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atrial flutter. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for an inpatient admission. 
 
The denial is overturned. 

The patient is an adult female who has history of (H/O) asthma, hypertension (HTN), congestive heart failure (CHF), atrial fib on anticoagulation and S/P (status post) mitral valve replacement (MVR). The patient presented to the emergency department (ED) after she had gone to an urgent care center with complaint of (C/O) shortness of breath (SOB) and Orthopnea. The patient was found to be in atrial flutter and a CXR (chest x-ray) revealed pulmonary congestion with left pleural effusion. 

In the emergency department (ED) vital signs were Temperature 97.3 degrees F (Fahrenheit), Respiratory Rate 18, and Blood Pressure 133/58 mm Hg (millimeters of mercury). Oxygen (O2) saturation was 95% on room air. The patient was in no acute distress (NAD). Lung exam revealed bilateral (B/L) rales. Cardiovascular system (CVS) S(sinus)1 S2 N (normal). The patient had LE (lower extremity) chronic venous stasis. 

White blood cell count (WBC) was 6.3 K (thousand), hemoglobin (Hb), 11.1 electrolytes within normal limits (WNL), BNP (B-type natriuretic peptide) elevated at 251. Troponin was normal. 

EKG (electrocardiogram) showed A flutter with variable A-V block. Chest x-rays revealed (CXR) Interstitial edema with L (left) pleural effusion. 

The patient was treated with intravenous (IV) Lasix for diuresis and was seen by Cardiology for decompensated CHF (congestive heart failure) and atrial flutter with variable block. The patient was treated with IV Metoprolol for rate control and continued on Amlodipine. 

The patient was admitted to Telemetry for decompensated diastolic Heart Failure and A (atrial) Fibrillation/ Flutter. 

The patient had initially improved but then developed worsening of shortness of breath (SOB). The patient went into A Flutter with rapid HR (heart rate) up to 133 and was given 1 dose of IV Lopressor and Metoprolol was increased to 75 mg (milligrams). The patient also had Lasix increased to 40 mg. The plan was to control the rate and if not achieved DC (direct current) cardioversion to be considered. 

The patient slowly responded to the above interventions. The patient was subsequently discharged home after her heart rate was under control and congestive heart failure (CHF) treated. This patient had multiple other co morbid conditions including hypothyroidism and status post (S/P) MVR. She was not stable to be treated in a lesser setting. 

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 the inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Parkinson's disease; status post fall. 
Treatment: Inpatient Hospital Admission. 

The insurer denied the Inpatient Hospital Admission. The denial is upheld. 

The patient is an adult female with a history of Parkinson's disease and dementia. She presented after a trip and fall after having felt weak and lightheaded. No loss of consciousness was reported. 

The patient's vital signs were as follows: Temperature 98.4, Pulse 78, Respiratory Rate 18, Blood Pressure 165/83, Oxygenation saturation 95%. The patient's exam was remarkable for abrasion of forehead, pain with knee range of motion, and ecchymosis on right knee. Head and cervical spine CT (computed tomography), and x-rays of knee, pelvis and tibia/fibula showed no acute disease. The patient's labs revealed White blood cells (WBC) 8.30, Hemoglobin 14.4, Platelet (Plt) 274, Sodium (Na) 142, Potassium (K) 4, Blood urea nitrogen/Creatinine (BUN/Cr) 13/.91, and pH 7.45. The EKG (electrocardiogram) was with no ischemia or arrhythmia. Urinalysis was positive for bacteria, WBC (white blood cells), RBC (red blood cells) and blood. 

The patient was admitted. Plan of care included monitoring. On the next day, the patient developed an episode of hypotension after initiating an antihypertensive. She was given IV (intravenous) fluids. On the following day, the plan was to continue to adjust medications for blood pressure. The patient required wheelchair to perform ADLs (activities of daily living). The patient was discharged the next day. 

The Inpatient Hospital Admission was not medically necessary. 

This patient with a history of Parkinson's and dementia was admitted after a fall. She was hemodynamically stable. Brain imaging and skeletal imaging was negative for an acute process. She did not have significant findings on labs. There were no acute findings. She was admitted for monitoring and did not receive intervention that require an acute inpatient level of care. She had not failed a lesser level of care. Inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Idiopathic Short Stature
Treatment: Nutropin
The insurer denied coverage for Nutropin.
The denial is upheld.

The patient is a male. This request is for Nutropin. His Growth Hormone (GH) stimulation test with clonidine and arginine peaked at 17.40. His testes were 2 cc (cubic centimeters) bilaterally and pubic hair was at tanner 1. His Insulin-like Growth Factor Binding Protein (IGFBP) 3 was 2.39; Insulin Growth Factor (IGF) 1 was 81. His IGF1 was 82; IGFBP3 was 3280. 

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 above referenced guidelines are the latest available guidelines from these respective societies. The diagnosis is based on height, height velocity, biochemical and sometimes radiological findings. The height and height velocity criteria based on consensus guidelines upon which a biochemical evaluation is to be initiated are 1) severe short stature, defined as a height more than 3 SD (standard deviation) below the mean; 2) height more than 1.5 SD below the mid parental height SD; 3) height more than 2 SD below the mean and a height velocity over 1 yr (year) more than 1 SD below the mean for chronological age, or a decrease in height SD of more than 0.5 over 1 yr in children over 2 yr of age; 4) in the absence of short stature, a height velocity more than 2 SD below the mean over 1 yr or more than 1.5 SD sustained over 2 yr. The biochemical criteria include low IGF1 or IGFBP3 or GH stimulation testing with a peak GH less than 10 ng/ml (nanograms per milliliter). The patient did not meet biochemical criteria. GH stimulation testing peaked at greater than 10. 

GH in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines [4-9]. Food and Drug Administration (FDA) approval for this indication is for "non-growth hormone-deficient short stature, defined by height SDS (standard deviation score) less than or equal to -2.25 SD, 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" [10-13]. The patient does not have a pretreatment height less than or equal to -2.25 SD. The patient therefore does not meet ISS criteria. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient. The medical necessity for Nutropin services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The denial is upheld.

The patient is a previously healthy female who presented to the hospital with a history of progressively worsening abdominal pain of 1-day duration. Evaluation included physical exam, labs, and computed tomography (CT) scan. She was without fever at the time of presentation. The heart rate was 81/minute in the emergency department (ED). Lab data identified white blood cell (WBC) count of 7.0 K (thousand). CT scan yielded the diagnosis of appendicitis. Treatment was initiated with intravenous (IV) fluid and antibiotics.

Surgery consultation was obtained with the recommendation for appendectomy. The patient underwent laparoscopic appendectomy. The clinical notes and the anesthetic record indicate an uncomplicated appendectomy. She was provided IV fluid and perioperative antibiotics. Vital signs remained normal throughout the hospitalization without fever. Diet was advanced and pain management was converted to oral medications. She was discharged home.

The subject under review is the medical necessity for the inpatient hospital stay.

The health plan's determination is upheld.

An inpatient stay was not medically necessary for this patient.

This patient presented to the ED with abdominal pain. The evaluation with examination, lab data, and CT scan established the diagnosis of appendicitis. The initial treatment appropriately included nothing by mouth (NPO) status, IV fluid, and appendectomy performed promptly. The early post-surgical course was uncomplicated, and the patient was clinically stable for discharge from the hospital.

The submitted clinical documentation does not support the need for inpatient hospital admission for this patient. Generally accepted criteria indicate that in the absence of hemodynamic instability, sepsis or toxicity, significant electrolyte imbalance, bleeding, gastrointestinal (GI) obstruction or surgical complications, the procedure may be performed without inpatient hospital admission. In this case, the patient tolerated oral hydration, diet and medication and pain was well controlled. The patient presented with abdominal pain and underwent uncomplicated appendectomy. A lower level of care would have satisfactorily provided for the care provided and would have been consistent with the accepted standard of medical care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic Dermatitis
Treatment: Dupixent
The insurer denied Dupixent.
The health plan's determination is upheld.

The patient is a male with moderate to severe atopic dermatitis (more than 50% body surface area involvement) that affects the arms, trunk, and legs. The patient has tried and failed topical fluocinonide, mometasone, and tacrolimus.

Dupixent is not medically necessary.

The patient has no documented treatment failure with, or true medical contraindication to, either of the standard, first-line oral medications used for moderate to severe atopic dermatitis (such as Methotrexate, or Azathioprine) and/or phototherapy. These therapies are time-tested, effective, and safe for long-term use, and recommended as standards of good medical care for moderate to severe atopic dermatitis, based on current medical literature to date. Dupixent is not proven to be superior to all other formulary alternatives as per comparative, controlled studies. Therefore, consistent with current medical literature, the requested Dupixent is not medically necessary.
Appeal type: Step Therapy
Decision: Upheld

Diagnosis: Polycythemia vera 
Treatment: Basremi
The insurer denied Basremi.
The health plan's determination is upheld. 

This is a female with polycythemia vera (PV) and a monoclonal B cell lymphocytosis. The patient has been treated with interferon in the first line setting because of safety concerns with hydroxyurea. Besremi has been recommended and is under review.

Besremi is not medically necessary for this patient.

Interferon (IFN) alpha is a naturally occurring biologic response modifier that has anti-angiogenic, anti-proliferative, pro-apoptotic, immunomodulatory, and differentiating properties. IFN achieves control of erythrocytosis, reduction of spleen size, and relief from intractable pruritus in approximately 80 percent of patients with PV. Pegylated interferon alfa-2a provides a more favorable toxicity profile than conventional IFN alfa, and its prolonged activity is compatible with once weekly dosing. Both Basremi and Pegasys are pegylated interferons. While these have not been compared head-to-head, the authors of UpToDate have provided guidance on the dosing of Pegasys. The National Comprehensive Cancer Network (NCCN) does not prefer one formulation over another and considers both to be "preferred".

Lacking data indicating that Basremi is a superior initial therapy, medical necessity for this agent cannot be established in this clinical scenario.

The required prescription drug is not contraindicated. The required prescription drug (on formulary) is not expected to be ineffective based on the known clinical history and conditions of the patient and the patient's prescription drug regimen.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hearing Loss
Treatment: Increase in hearing aids and dispensing fees

The insurer denied increase in hearing aids and dispensing fees.  The denial is overturned.

The patient is a female with a history of multiple medical problems including glaucoma, tinnitus, thoracic aortic ectasia, mitral valve insufficiency, chronic pain, osteoarthritis, bronchiectasis, and hearing loss for at least 5 years. Audiogram performed demonstrated severe sensorineural hearing loss. She had been previously been wearing hearing aid amplification. She underwent an evaluation with an Audiologist who recommended binaural hearing aid amplification. The health plan has denied coverage for an additional hearing aid. The subject under review is the medical necessity for increase in hearing aid and associated dispensing fees.

The health plan's determination is overturned.

The requested increase in hearing aid and dispensing fees is medically necessary for this patient. Binaural hearing aid amplification is necessary for this patient.

Based on the available records, for patients with bilateral sensorineural hearing loss, it is always in the best interest of the patient to use binaural hearing aid amplification for optimal benefit to improve hearing. There is improved speech intelligibility, improved perceived sound quality, and decreased effort for understanding speech with using binaural versus monaural hearing aid amplification.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hyperbilirubinemia
Treatment: Inpatient admission 
The insurer denied coverage for an inpatient admission 
 The denial is overturned

An infant female presented from her pediatrician's office with hyperbilirubinemia. Total bilirubin was 19.3 mg (milligrams) /dL (deciliter). The infant had not regained birth weight (2.965 kg (kilograms)) and only weighed 2.52 kg. She was being exclusively breast-fed. The Hyperbilirubinemia was treated with phototherapy. Fluids and nutrition were provided with breast milk and formula supplementation. Her weight increased to 2.59 kg on HD1 (hospital day 1) and to 2.63 kg on admission day 2. Hyperbilirubinemia adequately responded to phototherapy treatment.

According to MCG (Milliman Care Guidelines), 26th Edition (2022), Neonatal Jaundice P-265, Admission is indicated for total serum bilirubin greater than 17mg/dL at 96 hours or more in a medium-risk infant. According to the American Academy Guidelines (2004), the infant's bilirubin was in a high-risk zone. At 38 weeks gestation or greater, with hyperbilirubinemia risk factors (exclusive breastfeeding, especially with poor feeding or weight loss), the risk level was medium. The AAP (American Academy of Pediatrics) set a threshold for initiating phototherapy at 18 mg/dL with the option to start at 2-3 mg/dL below.  

The infant's admission was in accordance with the standard of care for hyperbilirubinemia and failure to thrive in a breast fed infant. 

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 the inpatient admission is substantiated.