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

Diagnosis:  Syncope.
Treatment:  Inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.  The denial is upheld.

This is a female patient, who presented to the hospital due to syncope and a presumed fall.  The documentation indicated that the patient has a past medical history that includes diabetes.  The documentation detailed in the Emergency Department (ED) noted that the patient was mildly amnestic, recalling waking up at 6 a.m., having a cup of coffee, and walking to the gym, but she did not remember what happened after that.  The patient was found on side of street.  The patient had a laceration to the forehead that required sutures.  The patient's glucose was 180, and she was able to move all extremities.  She was oriented X3.  She was conversing normally, only complaining of sternal chest pain.  The patient's examination revealed an abrasion to the lateral left knee with full range of motion.  Neurological exam showed no deficits.

As per the documentation, the patient underwent laceration repair while in the ED.  The patient's chest x-ray revealed no acute cardiopulmonary process.  There was no fracture noted to the pelvis, and the physician detailed that they would likely admit for syncope work-up.  A computed tomography (CT) scan of the head revealed no intracranial lesion.  There was no skull fracture.  There was right frontal and left parietal subcutaneous soft tissue swelling.  The patient's CT scan of the spine did not reveal any acute findings.  The patient's laboratory studies revealed sodium of 141 with potassium of 4.2.  The patient's BUN was 13, and creatinine was 0.8.  The patient had a negative troponin.  The patient was admitted and given medications.  The patient underwent an echocardiogram, which was remarkable for a left ventricular ejection fraction of 65%.  The patient's white blood cell (WBC) count on admission was notable at 14.2, which decreased the following day.  The patient continued with treatment and monitoring, as well as daily dressing changes.  The patient did not have any other significant adverse events during the hospital stay.  The patient was discharged with instructions to follow-up given the continued stability. 

Based on the review of the medical record, this case involves a patient that presented with probable syncope.  There was no evidence of an acute neurologic or cardiac event.  Extensive testing and imaging did not reveal any acute pathology that required inpatient admission.  The patient could have been observed, and when no acute issues found, discharged to be followed as an outpatient. 

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

The carrier's denial of coverage for a full hospital admission should be upheld.  The medical necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Chronic migraine
Treatment: Formulary exception for Nurtec 75MG OR TBDP
The insurer denied the Formulary exception for Nurtec 75MG OR TBDP.
The denial is upheld.

The health plan should not cover the Formulary exception for Nurtec 75MG OR TBDP.

The patient is a female with migraine headache disorder. She had tried and failed sumatriptan for migraine abortive therapy. 

There is no documented reason as to why the patient cannot be treated with the preferred formulary agents for her condition. She has only tried and failed one preferred agent.  All of the preferred agents are FDA-approved for the treatment of her condition and are considered first-line, standard of care migraine abortive therapies. There are no high-quality clinical trials or standard of care guidelines supporting the preferential use or superiority of Nurtec relative to the preferred oral agents.
Appeal type: Medical necessity
Decision: Upheld

Trauma/injuries
Inpatient hospital

Diagnosis: Back Pain
Treatment: Inpatient stay. The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a female with no significant past medical history who has had intermittent low back pain, however, the patient started with acute severe low back pain. She had been doing some work at home and felt a pop in her back and was unable to move without severe pain that she rated at 10/10. Emergency Medical Services (EMS) was summoned and the patient was taken to the emergency department receiving intravenous (IV) fentanyl en route to the emergency department.

The inpatient stay was not medically necessary. The patient presented with intractable back pain, following administration of fentanyl in ambulance. The patient had stable vital signs in the ED, with nonfocal neurological exam. Laboratory studies did not indicate a serious electrolyte abnormality or infection. The patient's initial CT imaging did not show a condition requiring urgent surgical procedure. The patient was not having persistent vomiting or dehydration. The patient was treated with IV morphine and IV Toradol in the ED and it was ordered at the time of admission but was able to be transitioned to oral medication. The patient did not have altered mental status, trouble breathing or other serious cardiovascular symptoms. The patient's severity of illness at the time of admission was not at inpatient level of care, nor was the intensity of service at inpatient level of care at the time of admission. At the time of admission, the patient's hospital stay was not anticipated to be greater than a 2 midnight stay. A lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Overturned

DX: Digestive System/Gastrointestinal
Tx: Inpatient Hospital
Denied: Inpatient Stay
Denial: OVERTURNED in whole

The patient is a male who presented to the emergency room (ER) with worsening abdominal pain. The pain was initially diffuse but then localize to the right lower quadrant. He was found to have a white blood cell count of 11.3, 85% neutrophils, and a lactic acidosis of 1.7. He was afebrile with appropriate vital signs. Computed tomography (CT) scan demonstrated "appendix dilated and fluid-filled consistent with acute appendicitis. There is thickening of the base of cecum" with the impression of "acute appendicitis." The patient was seen by general surgery and setup for laparoscopic appendectomy later that day. During the course of the operation the patient was found to have acute suppurative appendicitis. No mention of perforation in the operative report. The patient was seen by the surgery team and found to be doing well, but the decision was made to keep him overnight. The patient was seen and kept another night due to elevation of white blood cell count. The patient was discharged home. Pathology demonstrated "severely acute appendicitis with focal area of perforation" and "severely acute serositis/peritonitis." The subject under review is the medical necessity of the inpatient stay.

The health plan's determination is overturned.

The requested service of inpatient stay is medically necessary for this patient. The severity of illness at presentation, and the ultimate finding of perforation on final pathology justify the continued monitoring close for evidence of complications at inpatient level of care.
This patient had white blood cell count elevation with a left shift (increased neutrophils), and lactic acidosis on presentation. The patient was found to have suppurative appendicitis with significant mucopurulent fluid at the time of the operation. The patient was monitored closely for complications associated with these findings for two nights postoperatively prior to discharge. The final pathology did demonstrate a focal perforation which demonstrates good reason for the surgical team's concern for and monitoring of this patient.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male with a past medical history significant for a seizure disorder, hyperlipidemia, and alcoholism who presented to the emergency department because of three episodes of seizures. When the patient was seen by the admitting physician he was awake, alert, and oriented times 3. On the physical exam, he was afebrile, the blood pressure was 101/61, pulse rate 91, respiratory rate 18, and oxygen saturation 95% on room air. The patient was in no acute distress. Head, eyes, ears, neck, throat (HEENT) exam was within normal limits. 

The inpatient stay was not medically necessary for this patient.

The patient presented to the hospital with breakthrough seizures. He had already been diagnosed with a seizure disorder in the past. At the time of the admission, the patient was afebrile and hemodynamically stable. On the physical exam, the patient had no neurologic abnormalities. Laboratory evaluation did not show any clinically significant abnormalities, including abnormal electrolytes. The imaging studies did not reveal any acute abnormalities including stroke, the EEG was normal. Taking into consideration all these facts, neither the severity of the patient's condition nor the complexity of the services provided rose to the level of acute inpatient care.

Observation was definitely appropriate to ensure adequate response to treatment with Keppra. This could have been done at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prostate cancer

Treatment: Genetic testing

The insurer denied coverage for Genetic testing. The denial is upheld. 

This patient is a male on active surveillance of prostate cancer. The patient was initially diagnosed with prostate cancer. The patient's prostate specific antigen (PSA) was 5.298 at that time, biopsy revealed Gleason grade 6 prostate cancer in 1/12 core biopsies. The patient's PSA later increased to 8.096, and the patient's magnetic resonance imaging (MRI) noted suspicious area. A decipher test was performed.

While National Comprehensive Cancer Network (NCCN) guidelines states that men with low risk or favorable intermediate risk prostate cancer (NCCN risk groups) consider the usage of Gene expression tests (such as Decipher), they also note the absence of randomized prospective trials. Current American Urological Association (AUA) guidelines are more grounded about the usage of Gene expression test, stating in guidelines statement: "tissue based genomic biomarkers have not shown a clear role in active surveillance for localized prostate cancer, and are not necessary for follow up." The impact of tissue based Gene expression tests, such as Decipher, on clinical practice and long term patient outcomes remains to be empirically demonstrated. Prospective studies of these tests yielding a true clinical benefit when implemented in clinical practice are still lacking. Although being studied at different institutions, it is not yet clear where this test fits into the algorithm of diagnosis or management of prostate cancer. 

Thus, the Genetic testing of prostate tissue with Decipher test was not medically necessary for this patient. The health care plan acted reasonable with sound medical judgement, and in the best interest of the patient.

The carrier's denial of coverage for Genetic testing of prostate tissue with Decipher test performed is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath (SOB)

Treatment: Inpatient hospital services

The insurer denied coverage for inpatient hospital services.  The denial is upheld. 

This patient is a female with history of systemic lupus erythematosus (SLE), pulmonary fibrosis and hypertension (HTN).  The patient presented to the Emergency Department (ED) with complaint of exertional dyspnea.  The patient had seen her pulmonologist for the same symptom recently and the patient's computed tomography (CT) of the chest was reported normal.  The patient complained of some dyspnea at rest and chest pain of 3 out of 10 in severity that worsened with coughing.  The patient's vital signs in the ED were: temperature 98.2 F, heart rate (HR) 76, blood pressure (BP) 122/63 mm Hg, respiratory rate (RR) 18 and oxygen (O2) saturations 100% on nasal cannula (NC).  In the ED, the patient was in no acute distress (NAD).  On the patient's exam, there was no respiratory distress; lung exam revealed some basal crackles; cardiac exam was normal; abdomen was soft and nontender (NT); there was a non-focal neuro exam.  The patient's bloodwork showed: white blood cell (WBC) count 4.3K, Lactate 1.4, Troponin 0, BNP 20; the patient's hemoglobin (Hb) was stable and electrolytes, BUN/ Creatinine were within normal limits.  The patient's electrocardiogram (EKG) showed no acute changes.  The patient's chest x-ray showed stable chronic changes.  The patient was admitted for shortness of breath (SOB), and was evaluated by Pulmonology and Rheumatology.  The patient was given intravenous (IV) steroids.

Based on the review of the medical record and literature, this patient did not need acute inpatient hospitalization.  The patient could have been placed on Observation status while diagnostic testing and treatment were initiated.  The patient was described to be in no acute distress.  The patient was afebrile and hemodynamically (HD) stable.  The patient's lungs were clear, and the patient denied shortness of breath or chest pain (CP).  The patient was on maintenance medications and tolerating oral intake.  Myocardial infarction (MI) had been ruled out, and congestive heart failure (CHF) was not present.  The patient's lung exam and pulmonary condition did not appear to be any worse.  This patient was stable to be discharged home on oral steroids and other maintenance medications with close follow-up in an outpatient setting. 

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

The carrier's denial of coverage for the inpatient hospital services is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.
The Inpatient admission was not medically necessary and appropriate for the management of this patient's condition. 

The patient is a male. He presented to the ED with a two-day h/o (history of) abdominal pain, nausea, vomiting and diarrhea. He had no h/o hematemesis, melena or bright red blood per rectum (BRBPR). 

In the ED, the patient was hemodynamically stable and afebrile. His CBC (complete blood count) was normal, with normal Hb/HCT (hemoglobin/hematocrit). Chemistry panel revealed normal lytes. BUN (blood urea nitrogen) was 16, and Cr (creatinine) was 1.6. 

The patient underwent CT scan of the abdomen without contrast, which revealed terminal ileitis, and mildly dilated mid and distal small bowel, consistent with small bowel ileus or partial small bowel obstruction, and fluid filled colon. 

The patient was admitted to the hospital. The differential diagnosis was infectious enteritis vs Crohn's enteritis. The GI (gastroenterology) consult was obtained, and the patient was made NPO (nothing by mouth). He was started on IV fluids, IV Solumedrol, and IV Cipro and Flagyl for empirical treatment of Crohn's ileitis. His abdominal pain was managed with IV morphine and Percocet. The nausea and vomiting were managed with IV Zofran Prn (as needed). He was started on IV Pepcid for GI prophylaxis.

Later, the patient's abdominal pain was better, and he was able to tolerate clear liquid diet. Then, his chem panel revealed improvement in his renal function with decrease in Crt to 1.2. 

Then, the patient was able to tolerate regular diet, and he had no abdominal pain, nausea and vomiting. His repeat labs revealed normal renal function and normal lytes, normal Hb/HCT, and normal WBC (white blood count). He was discharged home in a fair and stable condition. 

The patient presented with two-day h/o abdominal pain, nausea and vomiting, and diarrhea, with no associated symptoms of fever and chills. In the ED, he was hemodynamically stable and afebrile. He had mild renal insufficiency (prerenal azotemia) due to dehydration. The CT scan of the abdomen revealed terminal ileitis, and ileus. He was treated with IV fluids and IV antibiotics and steroids, as per GI recommendation for empiric treatment of Crohn's disease. His abdominal pain and diarrhea were much better, and he was able to tolerate clear liquids, and his renal function had improved. Later, he tolerated regular diet without recurrence of abdominal pain, vomiting and diarrhea and his renal function normalized, and he was discharged home in a fair and stable condition. Given this clinical course, he could have been safely and appropriately managed under the lower level of care.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a diagnosis of chronic obstructive pulmonary disease. The denied treatment is an inpatient level of care.

The patient has a history of chronic obstructive pulmonary disease, chronic respiratory failure on 2 liters (L) of oxygen at home, obesity, congestive heart failure, obstructive sleep apnea, and hypertension, who presented to the emergency department with shortness of breath, chest tightness, wheezing, and an episode of pre-syncope.
On presentation, the patient was afebrile with a blood pressure 106/72, heart rate 80, respiratory rate 18, and oxygen saturation 96% on an unknown amount of oxygen. The exam otherwise noted the patient to be using accessory muscles without wheezing, crackles or rhonchi noted. Labs resulted with white blood cell count (WBC) 7.1, Hemoglobin (HGB) 13.9, Platelets 178, sodium (NA) 144, potassium (K) 4.2, blood urea nitrogen (BUN) 10.5, creatinine 1.17, and arterial blood gas (ABG) with potential of hydrogen (pH) 7.37/ partial pressure of carbon dioxide (pCO2) 42.8 /partial pressure of oxygen (pO2) 67 on an unclear amount of oxygen. A urinalysis did not show evidence of an acute infection. A chest x-ray showed no clear evidence of cardiopulmonary disease. An electrocardiogram (EKG) revealed no acute ischemia or arrhythmia. A computed tomography (CT) scan of the cervical spine showed reversal of the normal lordotic curvature with degenerative change with mild canal stenosis at the level of cervical (C) 4-C5 and no evidence of an acute fracture. The patient was brought into the hospital with concerns for pre-syncope with chest pain and associated shortness of breath with her noted to look comfortable and with no concern for acute chronic obstructive pulmonary disease (COPD) exacerbation. The plan was for serial troponins, telemetry, echocardiogram, carotid ultrasound, neurology consultation, and continuing nebulizers and home medications.
The patient remained hemodynamically stable. She signed out against medical advice with her carotid doppler and echocardiogram results pending.

The health plan's determination is upheld.
This is a patient with chronic respiratory failure on home oxygen who presented with dizziness and near syncope. She was afebrile with hypotension or tachycardia on presentation and remained hemodynamically stable throughout her course. She furthermore had no arrhythmia on presentation, no recurrent syncope, and there was no concern for acute coronary syndrome contributing to near syncope, with the patient otherwise also having normal labs. She was otherwise noted to have a history of COPD without evidence of acute exacerbation. It is unclear why, in the face of presenting with near syncope and dizziness, with hemodynamic stability throughout her course and unremarkable labs with no ongoing pre-syncope or syncope after presentation, this patient was not safe to care for at a lower level of care. Pre-syncope/syncope is almost always cared for as an outpatient diagnosis. Inpatient care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Inability to walk
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male with a history of diabetes and obesity who presented with inability to walk. He reported he has had progressive difficulty walking for five years. The neurological examination documented he has full strength in his legs with decreased sensation. He was admitted and had inpatient electromyography (EMG)/nerve conduction study (NCS), magnetic resonance image (MRI) and computed tomography (CT) of the lumbar spine. He refused surgical evaluation and was discharged to a rehabilitation facility.  

No, the proposed inpatient admission was not medically necessary.

The patient presented with a protracted course of progressive gait impairment over five years. There were no signs or symptoms of cord compression or any other neurological condition that required inpatient level of care. The diagnostic studies, treatments, evaluations and monitoring could have been safely and effectively completed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Impacted canines
Treatment: Comprehensive Orthodontic Treatment of the Adolescent Dentition (D8080)
The insurer denied the Comprehensive Orthodontic Treatment of the Adolescent Dentition (D8080). 
The denial is overturned. 

The patient is a female.  The request is for orthodontic benefits.

Yes, the proposed treatment, comprehensive orthodontic treatment of the adolescent dentition (D8080), is medically necessary. 

The patient has impacted maxillary (upper) permanent canines. When there are impacted permanent anterior teeth that are not to be extracted, as in this case, this is an automatic qualifier according to the handicapping index scale. This case needs orthodontic treatment to correct this problem.