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

Diagnosis: Osteoarthritis

Treatment: Inpatient hospital admission

The insurer denied coverage for an inpatient hospital admission.

The denial is overturned.

This is the case of an adult female with a history of joint pain, osteoarthritis, scoliosis, chronic opioid use, and poor pain control. The patient was admitted to the hospital for a scheduled right total knee replacement. Postoperatively, the patient had asymptomatic acute blood loss and required intravenous (IV) patient-controlled analgesia (PCA). Pain Management was consulted, the patient was transitioned to oral pain medication, and she received physical therapy. The patient was discharged.

The medical record demonstrates the patient's clinical course was complicated by continued pain and delays in mobilization. She required Pain Management Consultation on a continual basis. Her PCA was discontinued several days after her operation. She required multiple doses of IV narcotic and oral medications. The records showed slow progress in PT (physical therapy) and no evidence of early independence. She also was noted to have drainage from the wound to require dressings. 

Social work records documented her husband being uncomfortable to manage her because of her high narcotic requirements. 

She would not be able to receive this level of care outside of the hospital. Admission and length of stay would thus be appropriate. 

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

The hospital admission is considered medically necessary for this patient.

The insurer's denial of coverage for the inpatient hospital admission is overturned. Medical necessity is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Paroxysmal Atrial Fibrillation.
Treatment: Formulary exception for Eliquis.

The insurer denied the Formulary exception for Eliquis.  The denial is upheld.

The patient is a male with history of paroxysmal atrial fibrillation. He presented with a recurrence. The plan was to cardiovert him after anticoagulant. He was started on Eliquis. He spontaneously reverted to sinus rhythm. It was elected to keep him on anticoagulation. Eliquis was continued, as he was already on it. He was placed on metoprolol by EP (electrophysiology), and Crestor was tried. He was Covid-negative.

The patient's Echocardiogram showed normal LV (left ventricle) function and normal size left atrium.

It was determined by the treating doctor that patient had a CHA2DS2-VASc (congestive heart failure, hypertension, age 75, diabetes mellitus, prior stroke or TIA or thromboembolism, vascular disease, age 65-74, sex category) score of 0, and Eliquis was continued.

No, the health plan should not cover the Formulary exception for Eliquis.
Per guidelines, no anti-coagulation is indicated in patients with a CHA2DS2-VASc (congestive heart failure, hypertension, age 75, diabetes mellitus, prior stroke or TIA or thromboembolism, vascular disease, age 65-74, sex category) score of 0.

If it were decided to anticoagulate, either of the health plan's preferred formulary alternatives, Xarelto or Warfarin, would be as effective as Eliquis in this clinical situation. Both can be used for atrial fibrillation, and neither had been tried in this case.

Therefore, given the above. The health plan should not cover the formulary exception for Eliquis.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male who was transported to the emergency department (ED) via Emergency Medical Services (EMS) after he developed dyspnea and hives and had an episode of syncope after taking Protonix. His blood pressure when EMS first evaluated him was 68/30 millimeters of mercury (mmHg). He was treated with steroids, epinephrine, Benadryl and intravenous fluid en route to the hospital. His blood pressure increased to 120/90 millimeters of mercury (mmHg). Upon arrival to the ED, he was shaky and anxious but denied dyspnea. His blood pressure was 145/128 mmHg with a heart rate of 116 beats/minute. His respiratory rate was 25/minute with a room air oxygen saturation of 99%. An electrocardiogram showed sinus tachycardia without acute changes. His troponin I level was .10 nanograms/milliliter (ng/ml) and rose to a peak of .44 ng/ml. Chest x-ray showed no acute pathology. His white blood cell count was 18,600/cubic millimeters (cumm). His lactate level was 6.8 millimoles per liter (mmol/L) and fell to 4.8 mmol/L when remeasured. His D-dimer was elevated. He was admitted to the hospital and seen by a cardiologist who recommended intravenous heparin and an echocardiogram, which showed a normal left ventricular ejection fraction with normal wall motion. His troponin I level was .09 ng/ml. Computed tomography (CT) angiography showed normal coronary arteries and no evidence of pulmonary embolism. The patient was discharged. 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 after an anaphylactic reaction to a medication. While he was initially hypotensive, his blood pressure stabilized with treatment by EMS. Due to elevated troponin levels, there was concern for acute coronary syndrome and he was admitted to the hospital. While admission until evaluation for possible non-ST segment elevation myocardial infarction could be completed was appropriate, troponin elevation alone is not sufficient for the diagnosis of acute myocardial infarction. Per the fourth universal definition, an acute myocardial infarction is defined as acute myocardial injury with: troponin rise and fall, or fall of already elevated troponin value (with one value above the 99th percentile upper reference limit [URL]) (MET); and at least one of the following: symptoms of myocardial ischemia; new ischemic changes; development of pathologic Q waves; imaging evidence of new loss of viable myocardium or new regional wall motion abnormality in a pattern consistent with an ischemic etiology; identification of a coronary thrombus by angiography or autopsy) (NOT MET). Thus, this patient did not meet accepted criteria for a diagnosis of acute myocardial infarction (AMI), he remained hemodynamically stable and no intervention for AMI was deemed necessary. The patient could have been managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Immunologic Disorders. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital services. 
The denial is upheld.

The patient is a female with no significant past medical history who presented to the hospital with a presumable allergic reaction.
The patient stated that a couple of days before the presentation she went to an Italian restaurant and a few hours later developed lip swelling and diffuse itching.
The next morning the patient went to see her primary care physician who gave her a shot of steroid with a resolution of symptoms. Subsequently, her symptoms returned and consisted of skin rash that was itching around the abdomen and upper thighs.
The next day, the patient went to see an allergist who told the patient that she had an allergic reaction, hives. The allergist specialist prescribed Claritin. The patient tried to take Claritin but developed nausea and vomited. She also had one episode of diarrhea.
On the day of admission, the patient still complained of itching and swelling sensation in her throat, which was associated with difficulty swallowing. At the same time, the patient denied shortness of breath, chest pain, and wheezing.
The patient stated that she had the COVID-19 vaccine 10 days before the initial episode. The subject under review is the medical necessity for the inpatient services.

The health plan's determination is upheld.

The inpatient hospital services were not medically necessary.  The patient presented to the hospital with a possible allergic reaction and urticaria. However, this patient was afebrile and had no signs of active infection. There was no evidence of respiratory distress, bronchospasm, or stridor. There was no evidence of hemodynamic instability. There was no mention that the patient did not tolerate oral intake. The leukocytosis that was present on admission was most likely related to the use of corticosteroids.
Overall, this patient remained in a stable clinical condition and did not require any diagnostic studies or interventions that would necessitate admission at the acute inpatient level of care.
According to the progress notes, on the next day after admission, the patient complained of generalized weakness and chills, but no shortness of breath. It was specifically mentioned that the patient had no stridor, and the air movement was fair without wheezing.
Furthermore, the patient's laboratory results were unremarkable except for the leukocytosis already mentioned above.
Taking into consideration all these facts, there is no overwhelming evidence that either the severity of the patient's condition or the complexity of the services provided rose to the acute inpatient level of care. Admission for monitoring was reasonable. This patient could have been managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alpha-1-antitrypsin (AAT) deficiency (PiMZ) 
Treatment: Prolastin
The insurer denied Prolastin.
The health plan's determination is upheld. 

The patient is a male former smoker with a history of alpha-1-antitrypsin (AAT) deficiency (PiMZ) with the most recent AAT serum concentration level of 100. He has an FEV1 (forced expiratory volume in 1 second) 52% (percent) of predicted.

Prolastin is not medically necessary for this patient.

Per the clinical information, the patient has PiMZ genotype AAT deficiency, a baseline AAT concentration of 100 mg/dL (milligrams per deciliter), is a former smoker and has an FEV1 of 52% of predicted.

The current American Thoracic Society (ATS) and European Respiratory Society (ERS) statement on the diagnosis and management of AAT deficiency does not recommend augmentation therapy for patients with heterozygous phenotypes whose plasma AAT level exceeds 11 (corresponds to 80 measured by radial immunodiffusion), such as in this patient. Therefore, it would not be considered medically necessary, as it is not reasonably expected to prevent an illness or expected to reduce/improve developmental effects of an illness and is not considered generally accepted standard of medical practice per the literature/national guidelines.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Speech Therapy. 

The insurer denied Speech Therapy. 
The denial is upheld. 

This patient is a male with a diagnosis of mixed receptive-expressive language disorder. The patient initially received speech therapy services which were interrupted due to the coronavirus 2019 (COVID-19) pandemic. During this time the patient showed regression of learned skills; thus, resumption of speech therapy was requested. 
Comprehensive evaluation was provided. Standardized scales were used to evaluate receptive and expressive language skills. Receptive language index standard score was 14% indicating a mild delay in receptive language skills. Expressive language index standard score was 23% indicating an average score and skills that are within functional limits. Overall, the patient's communication ability was deemed a mild receptive-expressive language delay and once weekly speech therapy was recommended to address receptive language skills and executive functioning skills. 

Academic records show struggling grades in reading comprehension, correlating with evaluation findings. A letter indicated the patient had received outpatient speech therapy for 30 minutes/session once weekly. 
At issue is Speech Therapy for medical necessity. 

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

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

According to the medical documentation provided, there is no documentation to support the medical necessity of ongoing speech therapy services for this patient. This male presented with speech and language concerns. Results of a comprehensive evaluation, now a year out of date, indicate composite receptive language score of mild delay at the 14th percentile and expressive language or normal functioning at the 23rd percentile. Although the speech and language provider provided a written summary of goals, they did not include individual session notes showing interval progress towards stated goals. Additionally, it is unclear whether specific speech and language services would be most beneficial to this child, versus academic supports and services. 
Therefore, the requested health service/treatment of Speech Therapy is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer. 
Treatment: Stem Cell Transplant. 
The insurer denied Autologous Stem Cell Transplant. 
The denial is overturned. 

This is a female patient with the diagnosis of multiple myeloma. She has had 13 cycles of Revlimid/velcade/Cytoxan/dexamethasone. She has responded but still has residual disease. Her treating provider would like to proceed to an autologous stem cell transplant.
At issue is the medical necessity of Autologous Stem Cell Transplant.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of Autologous Stem Cell Transplant is medically necessary for this patient.
The relationship between survival and the degree of response (complete versus partial) to initial therapy is controversial. While some studies have suggested a survival benefit from attaining a deeper response, it is unknown whether this just reflects underlying disease biology (i.e., a prognostic marker) or specific treatment effect. The heterogeneity of initial therapy and of salvage therapy available over the time period studied limit the extrapolation of these data to determine goal of therapy. One must be careful when interpreting studies that show improved outcome in responders versus nonresponders since such comparisons have inherent methodologic flaws that cannot be overcome by increasing the sample size. In general, whether a treatment works or not, "responders" will typically appear to do better than "nonresponders." In this case, for this disease, use of autologous stem cell transplant is the standard of care even in those who did not achieve a response from initial therapy.
Therefore, the requested health service/treatment of Autologous Stem Cell Transplant is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Colon mass
Treatment: Outpatient Surgery (Endoscopic Submucosa Dissection)
The insurer denied Outpatient Surgery (Endoscopic Submucosa Dissection). 
The health plan's determination is overturned.

The patient is a male with a colonic mass. A colonoscopy showed a 3.2 centimeter (cm) centrally depressed distal sigmoid colon lesion which was biopsied and found to be at least high-grade dysplasia on superficial biopsy; given the small, superficial biopsy, a more advanced lesion could not be ruled out.

Outpatient Surgery (Endoscopic Submucosa Dissection) is medically necessary. The patient has a large colonic polyp with at least high-grade dysplasia not amenable to conventional colonoscopic resection given size and central depression, and a colectomy is one method for removal. However, the lesion (which may be benign or malignant) can be removed non-surgically using endoscopic submucosal dissection (ESD). The American Society for Gastrointestinal Endoscopy guidelines for ESD state that ESD is a well-established technique of endoscopic resection that allows for en bloc removal of lesions, both benign and malignant. The principal use for ESD is an early, invasive lesion in the mucosa or superficial submucosa measuring greater than 20 millimeter (mm) in diameter, consistent with the lesion in question in this case. The American Gastroenterological Association states that "ESD should be recognized as a mature endoscopic technique that enables complete removal of lesions that are too large for en bloc endoscopic mucosal resection or are at increased risk of containing cancer" and "All colorectal lesions should be evaluated for suitability for endoscopic resection. Accumulating evidence has shown that the majority of colorectal neoplasms without signs of deep submucosal invasion or advanced cancer can be treated by advanced endoscopic resection techniques". In this case, ESD is likely to allow avoidance of a colectomy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back pain

Treatment: Radiology service(s)/magnetic resonance imaging (MRI) of the lumbar spine (code 72148)

The insurer denied coverage for radiology service(s)/ MRI of the lumbar spine (code 72148)

The denial is upheld 

This is a female with chronic back pain. She was seen by the treating physician 1 day after low back/buttock pain exacerbation and morning stiffness. The patient complained of low back and buttock tenderness as well as decreased range of motion. The provider performed trigger point injections and instructed her to obtain a lumbar spine MRI scan.  

Based on the enclosed clinical information, lumbar spine MRI scan was not medically necessary. According to the provider's note, the patient complained of an exacerbation of chronic back pain the prior day. The provider is unclear whether or not the mentioned treatments "prescribed medications (prednisone, Mobic), sent to physical therapy and advised about home exercises and activity modifications to improve pain" were actually provided during the 6 weeks prior to the date of provider note. Without the prior notes documenting appropriate treatment prior to ordering the lumbar spine MRI scan, the requested diagnostic study is not supported as medically necessary.  

From a physical medicine and rehabilitation perspective, MRI of the lumbar spine (code 72148) was not medically necessary.

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

The insurer's denial of coverage for radiology service(s)/magnetic resonance imaging (MRI) of the lumbar spine (code 72148) is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skin Infection.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a woman with breast cancer and DM (diabetes mellitus) on oral chemotherapy. She presented to the hospital with swelling and pain of the pinna of the left ear after piercing the ear three weeks prior. She had been prescribed oral cephalexin by her primary physician, and when there was lack of resolution of infection, doxycycline was prescribed for MRSA (methicillin-resistant Staphylococcus aureus). The patient took Doxycycline for 5 days but failure of improvement of infection led the patient's primary physician to recommend inpatient admission and IV (intravenous) antibiotics.

On presentation, the patient reported chills. She had pain, swelling and redness of the left pinna. Her white cell count was elevated to 12,000. She received IV (intravenous) Vancomycin and Unasyn, which was later switched to Zosyn and this led to improvement in redness, swelling and pain of the ear as well as resolution of the white cell count. She was discharged the following day.

The health plan denied coverage of the inpatient admission. The reason for denial was based on MCG (Milliman Care Guidelines) criteria / guidelines pertaining to cellulitis - MCG 70. There was no severe problem and no hemodynamic compromise or severe underlying condition or rapidly progressing infection.

The appeal noted that the patient had immune compromise due to chemotherapy, DM (diabetes mellitus), and failure of outpatient treatment, which indicated that inpatient medical care was medically necessary.

Yes, the Inpatient admission was medically necessary.
According to the IDSA (Infectious Diseases Society of America) guideline, referenced below, this patient had a moderate infection with failure of outpatient treatment. She had a piercing related infection which involved chills and elevation in white cell count. She had failed outpatient treatment with 7 days of antibiotics which are considered appropriate and first line for cellulitis, including cephalexin and doxycycline. This condition of moderate infection with failure of outpatient treatment should be treated with IV (intravenous) antibiotics in the hospital, according to the guidelines cited.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
See response to question 2. After failure of outpatient treatment, and in the context of diabetes mellitus, older age and chemotherapy, the patient required inpatient treatment with IV (intravenous) antibiotics. Outpatient treatment would not have been safe and efficacious. It would not have been in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease.
Treatment: Personal Care Services: 24 Hours per Day, 7 Days per Week (Split Shift).

The insurer denied the Personal Care Services: 24 Hours per Day, 7 Days per Week (Split Shift).  The health plan's determination is overturned.

This is a case review for a woman who lives alone in her apartment and has a medical history notable for Alzheimer's dementia, incontinence, gait instability, seizure disorder, recurrent urinary tract infections, and depression. The health plan approved her for 84 hours per week, 12 hours per day of personal care assistance level 2 in home health care aid. The patient and her daughter are requesting an increase to 24 hours split shift.

The personal care services 24 hours per day, 7 days per week split shift is medically necessary for this patient. This service was originally denied by the insurance company under the grounds that it was primarily for safety and support, and it is true that these are not indications for increased number of hours for personal care services. This was also the first reasoning listed by the hospice physician. However, the patient has significant ongoing needs involving activities of daily living, including needs for toileting around the clock with prompt incontinence care and frequent position changes to avoid skin breakdown. If the patient is left by herself for 12 hours every day, it would take only a very short period of time for her condition to dramatically deteriorate, resulting in hospitalization or irreversible decline in her health. Her ongoing fungal skin infection, immobility within bed, and incontinence issues would all be severely exacerbated if not tended to throughout the day and night. Therefore, the Personal Care Services: 24 Hours per Day, 7 Days per Week (Split Shift) are medically necessary for this patient.