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

Diagnosis: Intra-abdominal abscess
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The health plan's determination is overturned.

The patient is a man who presented to the hospital emergency department (ED) with abdominal pain and a known large right scrotal hernia and prior perforated diverticulitis. He has a past medical history of hypertension, arthritis, and prior laparotomy for a gunshot wound. He had been treated in the outpatient setting with antibiotics for a diverticular abscess. At the time of presentation, vital signs were normal. The white blood cell (WBC) count was 7.1. A computed tomography (CT) scan showed findings of severe wall thickening of the sigmoid colon with an adjacent multiloculated abscess containing feculent debris and air. There was also a very large right inguinoscrotal hernia containing the colon and small bowel. He was admitted to the hospital.

The inpatient hospital admission was medically necessary for this patient. The intensity of patient monitoring, the potential for rapid clinical deterioration given his diagnostic test results and diagnosis of diverticular abscess, daily labs, and the need for interventional radiology drain placement were consistent with an inpatient level of care. Additionally, this patient had had a failure of outpatient therapy with persistence/progression / no improvement after an adequate trial of an outpatient treatment regimen.
In this case, the necessary care provided for this patient was anticipated to last greater than 48 hours and there were indications for an inpatient admission as detailed above. The care and treatment for this patient were most appropriate for an inpatient level of care.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Chronic idiopathic constipation
Treatment: Motegrity (prucalopride)
The insurer denied Motegrity (prucalopride).
The denial is overturned. 

This is a male patient with chronic idiopathic constipation (CIC), who has tried and failed multiple medications for his constipation including Amitiza, Linzess, and Miralax. Therefore, the attending provider would like to use Motegrity (prucalopride) to treat his CIC.

At issue is whether the formulary drugs will be or have been ineffective, as compared to the non-formulary drug Motegrity (prucalopride).

The health plan's determination is overturned in whole.

The formulary drugs (lubiprostone [generic Amitiza] and Linzess) have not been effective.

The medical records provided indicate that the patient has tried and failed both Amitiza and Linzess. Constipation is a common symptom that may be primary (idiopathic or functional) or associated with a number of disorders or medications. CIC can be defined as bowel movements (BMs) that are difficult to pass, are not occurring frequently, or have incomplete evacuation during defecation. High-fiber diet and laxatives are the commonly used treatments, however in many cases, they do not produce satisfactory results. The first line of treatment is osmotic laxatives. If there is no improvement, the second line is guanylate cyclase-C (GCC) agonists like linaclotide or prokinetic agents such as prucalopride. Mu-opiate antagonists are effective for managing opioid-induced constipation. Constipation that is refractory to available laxatives should be evaluated for defecatory disorders and slow-transit constipation using studies of anorectal function and colonic transit.

Motegrity (prucalopride), a selective serotonin-4 (5-HT4) receptor agonist, provides a different class of treatment for CIC that works by enhancing colonic peristalsis to increase bowel motility. The efficacy of once-daily treatment with Motegrity (prucalopride) was evaluated in six double-blind, placebo-controlled, randomized, multicenter clinical studies lasting 12 weeks or 24 weeks. Of the 2,484 patients, most were female (76 percent [%]) and Caucasian (76%), with an average age of 47. During studies, significantly more patients taking Motegrity (prucalopride) achieved the primary endpoint (an average of greater than or equal to 3 complete spontaneous bowel movements [CSBMs] per week over 12 weeks, considered normalization of BM frequency) than those in the placebo group (19-38% Motegrity less than or equal to 2 milligrams (mg) versus (vs) 10-20% placebo) across five of six trials. A rapid response was seen with Motegrity (prucalopride) as early as week 1, with improvements maintained throughout 12 weeks of treatment.

Since this patient has tried and failed other formulary alternatives, lubiprostone and linaclotide, it is medically necessary to use Motegrity (prucalopride) to treat this patient's chronic idiopathic constipation.

Therefore, the formulary drugs (lubiprostone [generic Amitiza] and Linzess) have not been effective, as compared to the non-formulary drug Motegrity (prucalopride).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fever
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay.
The health plan's determination is overturned. 

The patient is a female with a complex medical history who presented with recurrent fevers for 4 weeks. She was seen in the emergency department 3 weeks prior to her presentation due to fevers with no associated symptoms, and subsequently received 2 courses of antibiotics with no improvement. She continued to have fevers about once a week for a month. The fevers went up to 102 degrees Fahrenheit at home. She also had poor weight gain. Her work up as an outpatient revealed an elevated white blood cell count of 21.5. She also had a chest-x-ray and urine studies, which were normal.

Inpatient hospital admission was medically necessary for this patient.

This is a young girl with a complex medical history who presented with recurrent fevers without a clear source. She had received 2 courses of antibiotics, but continued to have fevers. At the time of presentation, she was tachycardic and hypoxemic, and had an elevated white blood cell count and high urine specific gravity. She required hospital admission for expert consultation and ongoing monitoring and evaluation.

The decision making at the time of admission for this patient was consistent with her young age, the presence of persistent fevers with no clear source, poor weight gain, abnormal laboratory values, and the need for ongoing care in an inpatient setting with additional extensive evaluation and close monitoring for potential deterioration of clinical status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic dermatitis. 
Treatment: Dupixent 300 mg (milligrams) weekly. 
The insurer denied coverage for Dupixent 300 mg weekly. 
 The denial is overturned. 

This is a patient with atopic dermatitis who was being treated with Dupixent. Due to breakthrough atopic dermatitis, the Dupixent dose was changed from Q (every) 2 weeks to Q 7-10 days. The request is for continuation of weekly Dupixent dosing. 

Based on the current peer-reviewed literature, Dupixent weekly is medically necessary. The patient has tried and failed biweekly Dupixent. In 2019, Thibodeaux et al published "A review of dupilumab in the treatment of atopic diseases" in which they demonstrated that weekly dosing of Dupixent had significant efficacy (1).  Beck et al also have reported on the efficacy of weekly Dupixent in "Dupilumab Provides Favorable Safety and Sustained Efficacy for up to 3 Years in an Open-Label Study of Adults with Moderate-to-Severe Atopic Dermatitis" (2). Therefore, it is appropriate, based on the patient's clinical findings and refractory disease, to approve weekly Dupixent in this patient. 

The insurer's denial of coverage for Dupixent 300 mg weekly is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fever/abdominal pain
Treatment: Inpatient stay

The insurer denied the inpatient stay. The health plan's determination is overturned.

The patient is a female with past medical history (PMHx) significant for Desmond tumor, abdominal mesh erosion into bladder, and recent SBO (small bowel obstruction). She presents to the emergency department (ED) with recurrent fevers (101 to 103 F), and malaise for 2 weeks. Temperature was 103 and persisted all day. She denies abdominal pain, nausea, vomiting, and burning with urination, hematuria. Pulse was 103. Assessment included a concern for an intraabdominal infection. The patient was admitted and started on intravenous (IV) antibiotics (cefepime per infectious disease (ID)). 

The inpatient hospital admission was medically necessary for this patient. The patient meets Milliman Care Guidelines (MCG) as she has a ureteral obstruction (left hydronephrosis on CT scan). In addition, the patient had fevers, tachycardia, as well as an elevated white blood cell (WBC) count.

Also, the patient has met criteria for SIRS [Systemic inflammatory response syndrome]. She has an acute upper urinary tract infection in the setting of hydronephrosis. She has an elevated white blood cell count (WBC), tachycardia, and high fevers at home. Management of this should include admission for intravenous (IV) antibiotics and urological consultation to assess for need for drainage (nephrostomy tube or ureteral stent). Per these recommendations, the patient was admitted and IV antibiotics, and her clinical picture of sepsis resolved.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: New onset diabetes

Treatment: Inpatient hospital admission

The insurer denied coverage for the inpatient hospital admission.

The denial is overturned.

According to the documentation submitted, this is a female with a history of new onset diabetes. She presented to the emergency room (ER) with complaints of a one month history of increased thirst, increased urination, and increased appetite. Urine dipstick was 500 and glycated hemoglobin (HbA1c) level was greater than 14. The patient was given an intravenous (IV) fluid bolus. She was admitted for care. The patient was started on an insulin regimen with basal and short acting insulin. Diabetes education was provided. The patient was placed on a carbohydrate counting regimen. She was discharged.

Diabetes education consists of several components, nutritional counseling, self-monitoring of blood glucose, and treatment of hyper and hypoglycemia. The standard of care is that all patients with diabetes should receive all these components. [1, 2]

Practice patterns differ depending on the availability of educators and so forth. Whether a patient gets hospitalized for intensive insulin therapy initiation depends on the available program where the patient is seen.

The majority (75% [percent]) of medical centers in the United States that treat new onset type 1 diabetes admit their patients. [3] According to the American Diabetes Association (ADA) statement on treatment of type 1 diabetes, hospitalization is necessary regardless of severity if, "the center is not experienced in the outpatient management of newly diagnosed children with diabetes or is not adequately staffed to provide outpatient care because regional health care reimbursement is inadequate for initial outpatient care and education." [4] In type 1 diabetes, the initial hospitalization is to educate the patient and the family in self-injection, drawing up and mixing of insulins, checking blood sugar, recognizing and responding to hyper and hypoglycemia, and evaluating ketosis, as well as nutrition education on carbohydrate counting because there is only one treatment option (insulin). Learning these skills is an overwhelming task for most patients and families and is the reason that this is done with a 2-3-day admission to the hospital. 

The patient was admitted appropriately for initiation of a basal bolus insulin regimen as well as diabetes education on all the tasks required of the patient and family. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.

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 the inpatient hospital admission is overturned. Medical necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic vertebrogenic pain.
Treatment: Procedure codes 64628 & 64629 to treat low back pain.

The insurer denied coverage for procedure codes 64628 & 64629 to treat low back pain.  The denial is upheld.

The patient is a male with a diagnosis of low back pain. The patient was seen for low back pain and recommendations included trigger point injections, possible Intracept procedure, and continue medication.

The patient was seen by pain management for low back pain. Has tried acupuncture, chiropractor, and massage therapy. Medications include Oxycodone-acetaminophen, Meloxicam, Cyclobenzaprine. On exam normal spine curvature. 5/5 strength in all extremities. Steady gait.  Magnetic resonance imaging (MRI) lumbar spine shows Modic changes, degenerative disc disease, foraminal narrowing, disc herniation lumbar (L) 2-3 and L4-5. Recommends medial branch radiofrequency ablation.

Procedure codes 64628 & 64629 to treat low back pain is not considered more beneficial for this patient's diagnosis, as there has not been documented failure of steroid injections to the lumbar or documentation to support the patient has done physical therapy (PT). Intracept can be beneficial, and literature shows it can improve pain, and sustain pain relief up to 24 months. However, failure of conservative measures prior to Intracept should be noted. Further, the patient has already had previous radiofrequency ablation (RFA) to the lumbar spine.       

Intracept is not the best available treatment for the patient at this time. Further options need to be assessed for this patient that would provide a more long-term pain relief, as the patient has already had previous RFA to lumbar spine. 

This procedure is not likely to be more beneficial than any other procedure. There is not a significant adverse risk to this treatment verses standard treatments.     

Finally, the Spine Society in their guideline for treatment of low back pain make no mention of basivertebral nerve radiofrequency ablation.

The carrier's denial of procedure codes 64628 & 64629 to treat low back pain should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: COVD-19 pneumonitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This is a patient with past medical history significant for hypertension and diabetes mellitus who presented to the emergency department (ED) with complaints of myalgias and dyspnea on exertion. Patient tested Coronavirus disease (COVID) positive; she was unvaccinated. 

Vitals on presentation included: Temperature 97.8 Fahrenheit, Blood Pressure 122/61, Pulse 89, Respiratory Rate 18, oxygen (O2) saturation 92% on Room Air. Laboratory values were notable for the following: white blood cell (WBC) count 5.8, hemoglobin (Hgb)- 12.9, hematocrit (Hct)- 39.4, creatinine- 0.75, glucose- 409, d-dimer 1.35.

Patient was admitted to the hospital for COVD-19 pneumonitis. Chest x-ray (CXR) was negative. Computed tomography (CT) angiogram showed bilateral lower lobe ground-glass opacification.  Patient required supplemental O2 and was started on intravenous (IV) steroids. Patient remained afebrile and hemodynamically stable. She left hospital against medical advice (AMA).

Although COVID treatment and management guidelines continue to evolve. The decision to hospitalize patients with COVID infection is typically based on presence of severe dyspnea (dyspnea at rest and interfering with the ability to speak in complete sentences), O2 saturation on room air <= 90% (regardless of severity of dyspnea), alternations in mentation (i.e., confusion, change in behavior), and other signs of hypoperfusion or hypoxia. Similarly, the National Institutes of Health (NIH) COVID-19 Treatment Guidelines Panel suggests hospitalization for patients with any of the following: an oxygen saturation of <94 percent on room air, respiratory rate of >30 breaths/minute, arterial oxygen partial pressure (PaO2)/ fractional inspired oxygen (FiO2) <300 millimeters of mercury (mmHg), or lung infiltrates >50 percent. According to medical records, patient had dyspnea on exertion, initial O2 saturation <94%, abnormal laboratory findings (elevated glucose, elevated d-dimers) and ground-glass findings on CT scan. Based on above findings in a high-risk patient with co-morbidities, hospital admission was medically necessary.

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

Diagnosis:  Nausea.
Treatment:  Esophagogastroduodenoscopy (EGD).

The insurer denied EGD.  The denial is upheld.

The patient is a male. The patient endorsed that he experienced nausea and fatigue once in a while. He was infected with helicobacter (H.) pylori in the past and treated. His physical exam was normal. The patient underwent an esophagogastroduodenoscopy (EGD). The exam was normal except for mild gastritis. Pathology results did not reveal any serious findings. The H. pylori staining was negative. The patient's EGD was denied by the health plan as not medically necessary.

At issue is the medical necessity of EGD.

The health plan's determination of medical necessity is upheld as a whole.

The requested health service/treatment of EGD is not medically necessary for this patient.

Based on the history and documentation provided, there is no justification for the EGD.  For a patient below the age of 60, an EGD would be justified if there were "red flag" symptoms. These include vomiting, weight loss, dysphagia, or evidence of gastrointestinal (GI) bleeding either clinically or on lab testing. None of this is listed in the documentation. The standard of care is to assess for H. pylori eradication via a non-invasive method. An EGD is not the standard of care in this case.

Therefore, the requested health service/treatment of EGD is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer.
Treatment: Subacute Rehabilitation Admission.
The insurer denied Subacute Rehabilitation Admission. 
The health plan's determination is upheld. 

The patient is a male with a history of generalized weakness, polysubstance abuse, chronic obstructive pulmonary disease (COPD), Stage III squamous cell carcinoma of the anus, and human immunodeficiency virus (HIV) / acquired immunodeficiency syndrome (AIDS). He completed chemotherapy and concomitant radiation. Treatment was complicated by colostomy loop prolapse that did not require surgical intervention.

Subacute Rehabilitation Admission is not medically necessary for this patient.
As of the date in question, the physical therapy note stated that the patient's strength was within functional limits with the exception of bilateral hip flexor weakness. He required contact guard assistance for standing balance. Bed mobility was sit to supine with supervision. Transfers sit to stand were with supervision without an assistive device. He ambulated 150 feet with supervision contact guard without an assistive device. The occupational therapy note stated that he was independent with activities of daily living (ADL) . He performed oral care and hair care with setup and performed bed mobility with supervision. His strength was within functional limits. Concerning wound care, the perianal area required irrigation with normal saline and application of Aquacel Ag and Mepilex border foam with changing every 24 hours if moderately saturated.

The patient could participate in a home or outpatient program to include strengthening, range of motion, and endurance exercises and wound care. Subacute Rehabilitation Admission is not medically necessary as there is minimal to no weakness and independence with bed mobility, transfers, and ambulation 150 feet without an assistive device with contact guard supervision.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol withdrawal.
Treatment: Inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is overturned. 

The patient is a male who initially presented to the emergency department with concerns of mild tremor. Pertinent history included alcohol abuse, depression, and human immunodeficiency virus (HIV) on highly active antiretroviral therapy (HAART). The patient was placed in the hospital thereafter with an impression of alcohol withdrawal and suspected liver cirrhosis. Treatment plan included benzodiazepines as needed and liver imaging. 

The inpatient hospital admission was medically necessary. In this particular situation, the patient had a history of excessive, daily alcohol use and presented with tremors believed to be due to alcohol withdrawal. Treatment plan included Clinical Institute Withdrawal Assessment (CIWA) with as needed benzodiazepines while investigating liver disease and thromboembolic disease. Despite observation care with multiple doses of benzodiazepines, the patient continued to score via CIWA with anxiety, tremor, and tachycardia which was treated with diazepam.
Moreover, clinical indications for admission to inpatient care were met. The patient had marked signs of withdrawal as indicated by a heart rate greater than 120 beats per minute and grossly visible tremor. These signs and symptoms persisted despite adequate pharmacotherapy delivered via emergency department care as well as observation care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental issues. 
Treatment: Coronectomy tooth 17 and tooth 32. 
The insurer denied Coronectomy tooth 17 and tooth 32. 
The health plan's determination is overturned. 

This is a female patient with impacted wisdom teeth #1, #16, #17 and #32. The provider plans to remove #1 and #16 and perform coronectomies on teeth #17 and #32 due to the close position of the tooth roots to the inferior alveolar nerves. 

Coronectomy tooth 17 and tooth 32 is medically necessary for this patient. A Coronectomy is a safe and effective treatment and greatly reduces the risk of nerve injury in patients in whom there is clear contact between the root of an impacted third molar and the inferior alveolar nerve. 

Patients requiring third molar removal with high-risk findings for proximity of the tooth to the inferior alveolar nerve were re-examined with computed tomography (CT) scans; 216 teeth in 124 patients were evaluated by CT. Patients then were divided into 2 groups. Those who had no bone between their alveolar canal and the tooth root were placed in the coronectomy group. Those in whom there was bone between the root and the nerve were in the extraction group. The surgery was then accomplished either by extracting the tooth or by performing a coronectomy under local anesthesia. Patients were followed up at 1 week, 1 month, 3 months, 6 months, and then each year thereafter. Any complication including injury to the inferior alveolar nerve was reported, and the incidence of complications was compared between the 2 groups. No nerve injuries occurred in the coronectomy group. There were 2 nerve injuries in the extraction group even though there was a clear indication of bone between the tooth root and the nerve on the CT scan. 

A Coronectomy is a safe and effective treatment and greatly reduces the risk of nerve injury in patients in whom there is clear contact between the root of an impacted third molar and the inferior alveolar nerve.