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

Diagnosis: Coronary artery disease

Treatment: Inpatient admission

The insurer denied coverage for an inpatient admission

The denial is overturned.

This is a man with a history of coronary artery disease, hyperlipidemia, hypertension, fatigue, shortness of breath, exertional chest pain, hemorrhoids, and multiple myeloma. 

He presented to the hospital for cardiac catheterization with likely percutaneous coronary intervention (PCI). 

That catheterization revealed 3-vessel coronary artery disease (CAD), involving the right coronary artery, the left anterior descending artery, and the circumflex artery. His doctor recommended an inpatient admission based on the expectation that the patient was at high risk for short-term adverse events, and that acute level close monitoring was required to allow for rapid evaluation and treatment as needed. A severe anemia was noted, and while PCI was being planned, he remained inpatient for optimization, and the "need to ensure bleeding stabilized prior to CABG [coronary artery bypass grafting]"; "Will require CABG but need to stabilize bleed".

The health plan did not act reasonably and with sound medical judgment and in the best interest of the patient. He was identified as having symptomatic 3-vessel CAD, and intervention was warranted; however, that intervention could not be performed with his severe, new, and poorly characterized anemia. The barrier posed by this anemia (compounded by his history of multiple myeloma) complicated the decision to proceed with revascularization and required additional workup and management. That workup and management were performed quickly, thoroughly, and appropriately. Avoidance of unnecessary delays in elective CABG is advantageous, as such delays are associated with increased mortality. 

The patient risk for bleeding with DAPT (dual anti-platelet therapy) was high, with a major risk factor of Hgb (hemoglobin) less than 11.0 mg (milligrams)/dL(deciliter), and potentially complicated by the history of malignancy. The anemia also significantly increased his perioperative risk for CABG. This risk represented by pre-operative anemia is by more than three-fold, in one study, and by two-fold in another. 
A standard part of a pre-operative evaluation for CABG should include workup for anemia, defined as Hgb < (less than) 14 for men by the Society of Cardiovascular Anesthesiologists.  Their guidelines indicate that "it is often appropriate to postpone elective cardiac surgery to diagnose causes and ensure correction of preoperative anemia." 

Intervention was appropriate in this case as the patient was symptomatic on guideline-directed medical therapy with three-vessel CAD. His pre-operative medical regimen included aspirin, metoprolol, high-intensity statin (atorvastatin 40 milligrams daily), losartan, and clopidogrel. 

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

The insurer's denial of coverage for an inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: abdominal pain
Treatment; Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a man who presented with abdominal pain, nausea. At the time of presentation, the patient was without fever and vital signs showed elevated blood pressure and normal heart rate. He was tender in the abdomen diffusely. The white blood cell (WBC) count was slightly elevated at 10.5. The complete metabolic panel identified normal alkaline phosphatase, aspartate aminotransferase (AST) and alanine aminotransferase (ALT), and bilirubin. A computed tomography (CT) scan and abdominal ultrasound showed gallstones and findings of cholecystitis (thickened gallbladder wall).
He was admitted to the hospital and initially treated with intravenous (IV) fluid, antibiotics, and antiemetics. 

An inpatient level of care was not medically necessary in this case. This patient  presented to the hospital with abdominal pain, nausea. He was determined to have cholelithiasis/cholecystitis. There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care. Additionally, there is no documentation of failure to achieve discharge criteria, conversion to open surgery, care for comorbidities, procedural complications, or any other condition requiring inpatient admission. The indication for cholecystectomy was established and surgery was performed 3 days later.  Acute inpatient care was not medically necessary for this patient as the care and treatment provided could have been rendered at a lower level which would have provided for ED (emergency department) assessment, perioperative care and monitoring, provision of IV antibiotics and fluid, and overnight care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.

The patient is a male who presented to the hospital for scheduled cardiac catheterization after outpatient noninvasive testing suggested obstructive disease. His medical history was remarkable for coronary artery disease with coronary artery stent placement, hypertension, hyperlipidemia, obesity, and chronic kidney disease. At the time of presentation, the patient denied chest pain. His electrocardiogram showed sinus bradycardia and was otherwise normal. Coronary angiography showed multi-vessel obstructive disease. Stents were placed in the proximal and distal right coronary artery and the left anterior descending coronary artery. The procedure was uncomplicated. The patient was discharged with plans to return in five to six weeks for staged intervention on the left circumflex artery. Medical necessity for an inpatient admission is at issue.

The health plan's determination is upheld.

Based on the documentation provided an inpatient level of care was not medically necessary.
This patient presented for elective coronary angiography and underwent implantation of several coronary artery stents. The procedure was uncomplicated. While some period of observation immediately following percutaneous coronary intervention (PCI) is needed to ensure hemodynamic and access site stability, as well as recovery from sedation, inpatient admission is not generally required for most patients. Per the 2018 expert consensus document update from the society for cardiovascular angiography and interventions, with the exception of patients with acute segment elevation, most patients who undergo uncomplicated PCI can be discharged home the same day, once they have recovered from sedation, their vascular access site is stable, and their comorbidities are at baseline. In this instance, given the patient's chronic kidney disease, overnight hospitalization for hydration was reasonable. However, this did not require an inpatient stay.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems 
Treatment: Dental/Orthodontic Procedure 
The insurer denied comprehensive orthodontic treatment. 
The denial is upheld. 

The patient is a female with a Class I occlusion. She is currently in orthodontic treatment. She originally presented with appropriate overbite and overjet. She had maxillary and mandibular spacing. She started orthodontic treatment with extraction of four first premolars to correct her malocclusion. The subject under review is the medical necessity for the comprehensive orthodontic treatment.

The health plan's denial is upheld.

There is no medical reason to correct her malocclusion with braces. Comprehensive orthodontic treatment is not medically necessary.

The patient has some very minor spacing. Her overbite is appropriate and there is no indication of damage to the incisors in the photographs. Her cephalometric radiograph shows she does not have a traumatic deep bite. There is no indication from the photographs there is severe soft tissue damage (or any soft tissue damage) on this patient.

While the patient has minor spacing, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. [1] This patient presents with none of those conditions. This patient has a Class I occlusion and masticatory efficiency is highest in patients with a Class I occlusion. [2] If her spaces were closed it would provide an esthetic improvement, but it would not create a medically significant improvement to the patient's health. For these reasons treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic Dermatitis

Treatment: Prescription drug Dupixent

The insurer denied coverage for the prescription drug Dupixent.

The denial is overturned. 

The patient is a female with a diagnosis of atopic dermatitis. The condition is severe, affecting 18% (percent) total body surface area (TBSA). The patient has failed therapy with tacrolimus ointment, triamcinolone, and mometasone. The requested medication is Dupixent.  

The patient has severe atopic dermatitis (AD) that involves a large surface area. As such, the patient requires systemic therapy given the extent of involvement, and the use of Dupixent would appear to be reasonable given that it is Food & Drug Administration (FDA) approved for the treatment of atopic dermatitis. The request for Dupixent is supported by the medical literature and specialty society guidelines. Dupixent is the only systemic therapy approved by the FDA for the management of atopic dermatitis. The FDA approved Dupixent for adults with moderate-to-severe AD who are inadequately controlled with topical treatments (1-3). According to consensus guidelines "Dupilumab has shown strong efficacy and safety for treatment of moderate-to-severe AD... Considering the safety profiles of conventional systemic therapies, which are not FDA-approved for AD treatment, it is recommended that dupilumab be used as a first-line systemic treatment... with moderate-to-severe AD who are uncontrolled with topical therapies". (1) As such, the decision is reversed and Dupixent is approved at the medical discretion of the physician based on the standard of care and the provided medical documentation.   

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

The insurer's denial of coverage for prescription drug Dupixent should be overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

The patient is a female. She was admitted for acute appendicitis. Her medical history was significant for hypercholesterolemia, diabetes, and hypertension. The patient was seen in the ED (emergency department) for two days of dull abdominal pain that progressed. Documentation showed that she had TTP (tender to palpitation) in the RLQ (right lower quadrant), WBC (white blood count) 11, and CT (computed tomography) scan findings of acute appendicitis without evidence of perforation.

The health plan denied coverage of the inpatient admission due to patient not meeting criteria for inpatient admission. This denial was appealed.

No, the Inpatient admission was not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
The patient was seen in the ED (emergency department), and found to have acute appendicitis. She was evaluated by cardiology and medicine regarding her HTN (hypertension) and diabetes. She was medically optimized. The operative report did not demonstrate any evidence of abscess, perforation , or inflammation that hindered removal of the appendix. The patient was discharged with no documentation regarding pain, diet, and plan for discharge.

The patient could have had a lower level of care (i.e., observation status) rather than inpatient stay. Although the patient has medical co-morbidities, there was no documentation regarding the need for inpatient admission for her acute appendicitis. Health plan acted appropriately to deny the inpatient admission given lack of medical necessity.
Appeal type: Medical necessity
Decision: Overturned

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

The patient has a past medical history (PMH) of migraines and attention deficit hyperactivity disorder (ADHD) who was admitted with complaints of (c/o) a migraine, chest pain, and epigastric pain. Vital signs were remarkable for hypertension (HTN). The physical exam was notable for abdominal tenderness. Lab work was significant for transaminitis. A chest x-ray (CXR) showed no acute pulmonary disease, a right upper quadrant (RUQ) ultrasound (US) showed cholelithiasis and biliary sludge with a dilated common bile duct (CBD). The patient was diagnosed with cholelithiasis and biliary sludge, possible choledocholithiasis, and treated with an endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy. She was offered a surgical cholecystectomy, but declined. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.
The hospital stay was medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with complaints of (c/o) abdominal and chest pain and was found to have significantly elevated transaminases. The patient's imaging studies were consistent with choledocholithiasis, for which the patient underwent an invasive procedure of ERCP with sphincterotomy and required observation for potential complications, such as acute pancreatitis, cholangitis, cholecystitis, infection, and perforation. In addition, the patient was recommended to have an additional invasive procedure, a cholecystectomy, which the patient declined, but was still medically indicated. Overall, this complex patient required invasive interventions and close clinical monitoring for safe treatment, and this could not have been safely provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Seizure and Alcohol Use.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a woman. She presented to the emergency room with episodes of vomiting and shakiness following a few glasses of wine (quantity unknown). She usually drinks three to four drinks per night. The first episode occurred in the morning after waking up hung over, which began with vomiting, followed by shaking. In the evening, she had another episode in the afternoon with vomiting followed by shaking. An hour later, she was witnessed to be shaking with elbows bent towards body and foaming at the mouth and was found with left lateral tongue laceration.

The patient was noted to be tachycardic, with a BP (blood pressure) of 113, and febrile to 100.6. She was noted to have low sodium level (31) and elevated lactate as well as low O2 (oxygen) saturation of 90.8 and with ketones in urine.

The patient's CT (computed tomography) head was negative, and she was given IV (intravenous) fluids, IV (intravenous) Ativan, IV (intravenous) Keppra, Librium and neurology was consulted. She was also noted to be postictal on neurology.

The patient's mental status improved the following morning. MRI (magnetic resonance imaging) brain was unremarkable. There was no further evidence of alcohol withdrawal. Nephrology was consulted for proteinuria. The patient was discharged.

Yes, the Inpatient admission was medically necessary.
The inpatient hospitalization was necessary, as the patient was noted to be shaking, and then an hour later, she was noted to be shaking and unresponsiveness. The episode likely lasted longer than an hour, which meets the definition for status epilepticus. This was supported by fever (shaking induced), multiple laboratory abnormalities as well as postictal state. Per the MCG (Milliman Care Guidelines) guidelines, status epilepticus as well as persistent altered metal status are part of the guidelines for MCG (Milliman Care Guidelines) that warrants inpatient admission, and patient clearly had both.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
It was clear that the patient had status epilepticus, as well as persistent altered mental status, which are part of the MCG (Milliman Care Guidelines) guidelines for inpatient hospitalization. Given status epilepticus and risk for further seizures as well as risk for alcohol withdrawal, she needed to be admitted for close monitoring.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute Pancreatitis.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a male who presented with epigastric abdominal pain. The patient's lipase was elevated at over 2000 (normal 60), and computed tomography (CT) scan of the abdomen and pelvis revealed interstitial pancreatitis. The patient was kept 'nothing by mouth' (NPO) and was treated with analgesics. On day two, the patient started a clear liquid diet.  On day three, the patient was advanced to solids and required less pain medication. He was discharged.

Yes, the proposed treatment, inpatient hospital admission, was medically necessary.
As the patient had abdominal pain consistent with acute pancreatitis, a lipase of greater than three times the normal and computed tomography (CT) findings of acute pancreatitis, criteria for acute inpatient hospital stay for pancreatitis was met.

No, he health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
As the patient met criteria for inpatient admission for pancreatitis, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient by denying it.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Uterovaginal prolapse.
Treatment: Inpatient admission.

The insurer denied coverage of an inpatient admission.
The denial is upheld.

According to the documentation submitted, this is the case of a female with a history of uterovaginal prolapse. She presented to the hospital for a supracervical laparoscopic hysterectomy, bilateral salpingectomy, sacrocolpopexy, and perineorrhaphy. 

As per the postoperative note an intraoperative consult to GYN (gynecological) Oncology was obtained for retroperitoneal hematoma due to incidental injury to retroperitoneum near sacrum with robotic tenaculum and small expanding hematoma. The retroperitoneum was explored using the robotic platform and bleeding from small peritoneal vessels was noted. No injury was seen to iliac vessels with no further retroperitoneal bleeding. The estimated blood loss (EBL) was 100 cc (cubic centimeters). Pathology revealed leiomyoma and left and right fallopian tube, minute fragment of urothelial mucosa with mild chronic inflammation

The patient could have been discharged after a 23-hour observation stay as the procedures that she underwent are ambulatory procedures and she was kept overnight for observation. This patient had a laparoscopic hysterectomy, Sacro colpopexy, and cystoscopy all of which could have been performed in a 23-hour observation/ambulatory status. She did have a retroperitoneal hematoma which was explored laparoscopically and there was no major injury to the iliac vessels. The procedure was never converted to an Open procedure. Thus, only observation was needed. The surgery was otherwise uneventful, and the patient improved and was discharged the following day. Post-surgery the patient was afebrile, and stable. The patient had her pain controlled and was advanced on her diet. The patient did not have any evidence of altered gastrointestinal (GI) tract that required continued hospitalization nor any comorbidities or complications from the surgery that required acute inpatient care. 

According to MCG (Milliman Care Guidelines) Health Inpatient and surgical care 26th Edition, Urethral suspension procedures the goal length of stay is ambulatory. Extended stay may be required with Minimal (a few hours to 1 day), Brief (1 to 3 days), Moderate (4 to 7 days), and Prolonged (more than 7 days). Inpatient stay may be needed for: Complications of procedure (e.g., vascular, rectal, or urinary tract injury): complications which may require surgical repair..." Thus again, ambulatory status is all that was required.

The patient did not warrant inpatient status but ambulatory for this procedure as she did not warrant inpatient care but just observation for the bleeding at the time of the surgery. 

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

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

Diagnosis: Psoriasis
Treatment: Stelara SQ 45MG
The insurer denied the Stelara SQ 45MG.
The denial is upheld.

The patient is a female with psoriasis and psoriatic arthritis, treated successfully with Stelara and Otezla combination. The provider is requesting continuation of combination therapy. The health plan denied the request as Otezla is not covered when combined with a biologic agent.

No, the proposed treatment with Stelara is not medically necessary.

Otezla has been combined safely with biologics based mostly on case reports. However, it is standard of to care to switch to a different biologic and attempt monotherapy. Stelara is not one of the most effective medications for psoriatic arthritis, and therefore switching to a different agent to control the arthritis would also be appropriate. Therefore, the combination therapy is not medically necessary.

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