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

Diagnosis: Atopic Dermatitis
Treatment: Adbry
The insurer denied the request for Adbry.
The health plan's determination is upheld.

The patient is a female with moderate to severe atopic dermatitis of the neck, back, chest, upper extremities, and digits. The patient is reported by her dermatologist as having tried and failed topical Augmented Betamethasone, Calcipotriene, Fluocinonide, Mometasone, Triamcinolone, Desocimetasone, Protopic, Eucrisa, and Opzelura. She has also tried and failed oral Prednisone and Hydroxyzine, as well as Dupixent. Traditional/oral systemic medications (such as Methotrexate, Cyclosporine, or Azathioprine) have been avoided because they are off label for atopic dermatitis. The patient was briefly treated with Rinvoq but she is reported to have developed an allergy (hives a week after starting this medication) so this was discontinued.

The patient has significant atopic dermatitis that is insufficiently controlled on Dupixent, and it is not controlled on Rinvoq. For any patient to require Adbry as medically necessary, then all other reasonable alternatives would have had to be tried and failed. Such is not the case at this time, because other standard and time-tested oral/alternative options to Rinvoq have not yet been tried. The health plan acted reasonably in its determination of medical necessity, and with both sound medical judgment and in the best interest of the patient.

The requested health service/treatment of Adbry is not medically necessary for the patient. 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, Azathioprine, or Mycophenolate Mofetil). These agents are time-tested and literature/specialty consensus-approved [2-6] as first-line systemic therapy for moderate to severe atopic dermatitis. Adbry is not proven to be superior to all other formulary alternatives according to comparative, controlled studies.
According to the patient's health plan policy language [1], and to be consistent with current standards of care [2-6], the request for Adbry is not medically necessary and is not more effective than all formulary alternatives, and therefore does not meet the health plan coverage requirements.

The health plan's determination of medical necessity if upheld in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: appendicitis.
Treatment: inpatient stay.
The insurer denied an inpatient stay. 
The health plan's determination is upheld. 

The patient is a man who presented to the emergency department (ED) with a history of progressively worsening abdominal pain and fever of 3-days duration. Comorbid health conditions included diabetes and hyperlipidemia. His evaluation included physical exam, labs, and computed tomography (CT) scan. He was without fever at the time of presentation. The heart rate was elevated at 104/minute. He was tender in the right lower quadrant. Lab data identified a white blood cell (WBC) count of 10.6. A computed tomography (CT) scan yielded the diagnosis of acute appendicitis with microperforation and a small peri-appendiceal phlegmon. Treatment was initiated with intravenous (IV) fluid, nothing by mouth (NPO) status, and antibiotics. Surgical consultation was obtained.

Inpatient Hospital Admission medically was not necessary for this patient.
This patient presented with abdominal pain. His evaluation with examination, lab data, and CT scan confirmed the diagnosis of appendicitis. The treatment plan per the surgical consultation was for non-operative management that included NPO status, IV fluid, and IV antibiotics. He was maintained on IV antibiotics until his discharge from the hospital when oral antibiotics were continued. The WBC count was normal at the time of presentation and remained normal throughout the period of monitoring. Vital signs were consistently normal throughout the period of monitoring. He was tolerating a regular diet.
The submitted clinical documentation does not support the need for inpatient admission for this patient. 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. There was no documentation of hemodynamic instability, complications of his condition, severe pain, or unstable comorbidities. The member tolerated oral hydration, diet and medication. Pain was well controlled.
He responded appropriately to the prescribed nonoperative therapy without complication. Observation would have provided for surgical assessment, provision of antibiotics, and serial monitoring as provided.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient who presented to the emergency department with a fever and abdominal pain. The pain was located in the right lower quadrant (RLQ). The patient had a temperature in the emergency room (ER) that registered at 103 degrees. The patient was tender in the right lower quadrant. A computed tomography (CT) scan demonstrated a 1-centimeter (cm) appendix with mild wall thickening and surrounding inflammatory changes. General surgery was contacted and evaluated the patient. The patient was made nothing by mouth (NPO) and started on intravenous (IV) fluids and IV antibiotics. The patient was added on for a laparoscopic appendectomy later that day. The patient underwent a laparoscopic appendectomy without complications; no perforation was noted. The patient remained hospitalized and did well overnight. He was continued on IV antibiotics but was discharged later that day. The pathology demonstrated acute necrotizing appendicitis with abscess formation and marked serositis. At issue is the medical necessity of an inpatient stay.

Inpatient stay was not medically necessary for this patient.
The patient had acute appendicitis, but did not have evidence of other complications. The patient did very well after surgery and was able to be discharged home early the next morning. The patient achieved discharge criteria in a reasonable amount of time. He did not have any evidence of complicated appendicitis. He did not have any evidence of active comorbidities requiring inpatient management. There were no complications such as a wound infection, wound dehiscence, enterocutaneous fistula or continued ileus. There is no evidence that additional complex testing or therapy other than the surgery was performed. There is no evidence that a complicating event occurred before, during, or after the procedure that required a higher level of care. There is no documentation that the treating team identified conditions or problems specific to the patient that would have required inpatient care. The patient did not have significant dehydration, hemodynamic instability, severe pain requiring frequent or high doses of narcotics, signs of intestinal obstruction, peritonitis, or bacteremia. The patient did not utilize complex testing or therapy other than surgery that would have required an inpatient level of care. The provided documentation does not support the medical necessity of an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Brain tumor, right hemiplegia.
Treatment: Continued Stay in Skilled Nursing Facility (SNF).
The insurer denied: Continued Stay in Skilled Nursing Facility (SNF).
The denial is upheld.

The patient is an adult female with history of brain tumor (astrocytoma) resected years ago and recently diagnosed with left fronto-parietal meningioma with craniotomy and development of right hemiplegia.  Relevant medical history includes resected astrocytoma, left parietal mass cavernous resection, hypothyroidism, deep vein thrombosis (DVT) status post inferior vena cava (IVC) filter, seizure, and multiple falls.  Prior to admission, the patient lived alone independently with basic activities of daily living (ADLs) using a rolling walker and in an apartment at the 18th floor with an elevator and no steps to enter.

The patient was admitted to skilled nursing facility (SNF) with cognitive defects and had shown no tangible progress in rehabilitation that included occupational therapy and physical therapy - she was dependent with some activities and was requiring moderate to maximum assistance with most activities of daily living.

The proposed continued stay in skilled nursing facility (SNF) is not medically necessary.

The patient was admitted to skilled nursing facility (SNF) with cognitive defects.  The patient had shown no tangible progress in rehabilitation that included occupational therapy and physical therapy.  She was dependent with some activities and was requiring moderate to maximum assistance with most activities of daily living.  The continued stay in skilled nursing facility (SNF) is not medically necessary.  The patient may benefit more from custodial care.

The above aligns with the health plan's rationale for denial of coverage.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status Post Fall
Treatment: Inpatient Admission 
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient is an adult female for which an inpatient level hospitalization is under review. The patient had a history of substance abuse, alcohol abuse, hypertension, and schizophrenia. She presented after having fallen in the bathroom.

The patient was admitted with chest pain. The patient's CT (computed tomography) scan was negative for a PE (pulmonary embolism). A trauma evaluation was negative. Troponins were negative. Echocardiography was reported as normal. She had no arrhythmias. There was a left bundle branch block on ECG (electrocardiogram). Cardiology recommended outpatient follow-up. She was diagnosed with vagal syncope. Electrolytes and the creatinine were normal.

The Inpatient Admission was not medically necessary.

This patient presented with vagal syncope and remained stable. There was no recurrent syncope, imminently dangerous cause (i.e. PE [pulmonary embolism]), respiratory distress, MI (myocardial infarction)/acute coronary syndrome, hemodynamic instability, cardiac disorder such as aortic stenosis/IHSS (idiopathic hypertrophic subaortic stenosis), unstable arrhythmia, syncope-related serious injury, severe electrolyte abnormalities, need for prolonged IV (intravenous) medications, introduction of high risk medications requiring in-hospital monitoring, dehydration, need for a temporary pacemaker, need for invasive monitoring, need for emergent cardioversion, or an unstable neurologic syndrome (i.e. CVA [cerebrovascular accident]). In this setting, an acute inpatient level hospitalization, compared to for example observation, has not been established as standard of care towards improved cardiac outcomes. Therefore, it is considered not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Paroxysmal Atrial Fibrillation (AF) and Atrial Flutter
Treatment: Inpatient Admission
The insurer denied coverage for the inpatient admission.
The denial is upheld.

This is an adult male that presented for elective catheter ablation of paroxysmal atrial fibrillation and atrial flutter.  Relevant past medical history includes hypertension, diabetes mellitus, hypertrophic cardiomyopathy, implantable cardioverter-defibrillator (ICD) in situ, and obstructive sleep apnea. Left atrial catheter ablation with pulmonary vein isolation and cavotricuspid isthmus ablation was performed.  Electrical isolation of the right superior pulmonary vein was not isolated despite utilization of both radiofrequency energy and cryo energy.  There were no perioperative complications, and the patient was discharged the following day following observation.

This patient presented to the hospital for an elective electrophysiologic (EP) study and ablation. According to hospital records, the ablation was successfully performed without complication. Observation following ablation was unremarkable and no post-operative issues were noted. The patient was discharged home the following day. In this case, there were no clinical reasons for hospital admission and the patient could safely be managed at a lower level of care. In two multicenter registry studies looking at healthcare utilization after EP study catheter ablation, more than 80% (percent) of patients undergoing ablation were hospitalized for a single day, regardless of age or co-morbidity (Reference 1). Bartoletti demonstrated that patients undergoing atrial fibrillation ablation procedures could be safely discharged on the same day (Reference 2). In a report involving over 6000 patients, same day discharge following catheter ablation of AF was found to be safe and comparable to outcomes in patients that were observed overnight (Reference 3). 

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 is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertrophic obstructive cardiomyopathy
Treatment: Inpatient admission
The insurer denied coverage for the inpatient admission.
The denial is overturned.

This patient has a past medical history of hypertrophic cardiomyopathy, implantable cardiac defibrillator (ICD) in situ, and endocarditis status post biological mitral valve replacement. The patient presented to the hospital after taking 100mg (milligrams) of Zoloft (sertraline) instead of 100mg of metoprolol. He presented to the hospital and reported symptoms of shaking chills that had resolved on arrival. He was transferred to another hospital for management and treatment. On arrival, vital signs were stable (Blood Pressure 124/80 mmHg (millimeters of mercury), Pulse 80 beats per minute).  Physical examination revealed no major abnormality. A 12-lead ECG (electrocardiogram) revealed sinus rhythm with right bundle branch block and deep/wide T (interval on ECG) wave inversions across the precordial leads.  Significant prolongation of the QT (interval on ECG) interval was noted (QTc [interval on ECG) 546 msec [milliseconds)) High sensitivity serum troponin levels were elevated (49 ng/L [nanogram per liter]) Echocardiogram demonstrated concentric left ventricular hypertrophy. The patient was admitted to the telemetry unit for monitoring and treatment. 

This patient presented with an accidental drug overdose with sertraline, a medication that prolongs the QT interval on electrocardiogram (Reference 1). In a study of more than 1600 patients with hypertrophic cardiomyopathy, prolongation of the QT interval was a risk factor for sudden cardiac death even when controlling for typical risk factors.  This patient had a prolonged QT interval after accidentally taking sertraline and required inpatient telemetry monitoring. 

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

Diagnosis: Crohn's disease.
Treatment: Rinvoq 45 MG (milligrams) OR (oral) TB24 (24-hour tab).
The insurer denied the Rinvoq 45MG OR TB24.
The denial is upheld.

The patient is an adult female with moderate to severe Crohn's. She has failed Lialda, asacol, steroids, mercaptopurine (6-MP), methotrexate, Humira, Remicade and Entyvio. The physician (MD) is requesting treatment with Rinvoq. Rinvoq was denied, as it was felt that the patient had ulcerative colitis and had not failed the plan preferred Xeljanz.

The proposed treatment with Rinvoq is not medically necessary.

While the request states the patient has ulcerative colitis, per the documentation, including the colonoscopy report and the gastrointestinal progress note from the provider, the patient has Crohn's disease. Rinvoq is not Food and Drug Administration (FDA) approved for treatment of Crohn's disease. Therefore, the requested Rinvoq is not clinically appropriate, accepted standard of care or medically necessary.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: seizure.
Treatment: inpatient stay.
The insurer denied the inpatient stay. 

The health plan's determination is upheld. 

This case involves a man admitted to the hospital with breakthrough seizures. The patient has a history of cerebrovascular accident (CVA) and was undergoing acute rehab, where he was found to be altered flaccid with tonic-clonic movements of his right arm. The stroke was located in the right anterior cerebral artery (ACA) territory but had bilateral subcortical infarcts. He was discharged on Keppra 1000 milligrams (mg) twice daily to the rehab due to 5 seizures witnessed during the prior admission. Head computed tomography (CT) showed chronic infarcts and no intracranial hemorrhage.
He was reloaded with Keppra in the emergency department; neurology was consulted, and repeat magnetic resonance imaging (MRI), neuro-checks, and labs, including creatinine kinase and lactate dehydrogenase (LDH) were ordered.

An inpatient hospital admission was not medically necessary.
The patient has a known seizure etiology and experienced a breakthrough seizure. He was treated with an increased dose of Keppra and suffered no further seizure events. There were significant delays in obtaining appropriate imaging as well as cardiovascular testing, which prolonged the patient's hospitalization. Typically, a breakthrough seizure evaluation can be completed within 24 hours with a brain magnetic resonance imaging (MRI), electroencephalogram (EEG), and interrogation of the loop recorder. The patient had no further recurrences of the seizure disorder and was slated to return to rehab to complete his therapies. There was no clinical indication for prolonged inpatient monitoring. Labs were stable. Hemodynamics were unaffected. There were no new focal neurologic deficits to suggest stroke. There was no new intracranial bleeding.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia. 
Treatment: Home Health Care. 

The insurer denied Personal Care Aide Service Hours: 7 Days per Week, 2 x 12 Hour Split Shifts (168 Hours per Week). 

The health plan's determination is overturned. 

The patient is a female with past medical history of hypertension, congestive heart failure (CHF), dementia, peripheral vascular disease, colon cancer, bladder cancer and urinary incontinence who had been assigned PCA (personal care aide) services. 

Personal Care Aide Service Hours: 7 Days per Week, 2 x 12 Hour Split Shifts (168 Hours per Week) are medically necessary for this patient. 

There is documentation in the universal assessment of increased assistance needs with tasks of managing finances and shopping. The patient's medical provider had documented worsening physical and mental functioning and therefore the assessment via video incorrectly noted the patient had improved with tasks of phone use, walking, and locomotion. The patient's medical provider also documented medical necessity of turning and repositioning every 2 hours at night as well as assistance with activities of daily living (ADL) in the overnight hours as the patient had insomnia related to dementia. The patient's care needs would not allow a PCA 5 hours of uninterrupted sleep. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and Instrumental activities of daily living (IADL). The requested increase in PCA services cannot be met solely with adaptive equipment and medical supplies. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 7 Days per Week, 2 x 12 Hour Split Shifts (168 Hours per Week) are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe Anemia
Treatment: Inpatient admission
The insurer denied coverage for the inpatient admission.
The denial is overturned.

The patient has been seen and treated in the emergency room (ER) with complaints of (c/o) chronic fatigue for six weeks. The patient's laboratory value(s) show the Hemoglobin (Hgb) level was 4.4 and Hematocrit (Hct) was 13.2. The patient also was thrombocytopenic. The patient was given two units of packed red blood cells (PRBCs) and the patient's White Blood Cell (WBC) count was elevated. The patient was admitted for care. There was a concern for acute myelogenous leukemia. Additional units of blood were transfused. The patient was discharged after a period of hemodynamic stability. 

The initial admission was appropriate, because of severe anemia, increased white count, and thrombocytopenia. Admission to transfuse multiple units of red blood cells (RBC) and establish the diagnosis was appropriate. A blood smear showed blasts and Hematology was called. The patient was seen by Hematology. The bone marrow was done. Myelodysplastic syndromes (MDS) versus acute myeloid leukemia (AML) were being considered and chemotherapy was scheduled. The patient was discharged. 

"In patients with myelogenous leukemia, skin infiltration usually occurs after, but occasionally before, the appearance of hemogram and myelogram abnormalities, and the presence of skin infiltration is often associated with a poor prognosis and short survival time. myeloid leukemia cutis often presents as generalized or localized nodules or masses with characteristic pathological and histochemical findings." (Li, et al., 2018).  

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.