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

Diagnosis: High Blood Pressure
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is overturned.

The patient is an adult female G1P1 (one pregnancy, one delivery). She presented to the emergency room five days post Cesarean section. Her pregnancy had been complicated by
preeclampsia without severe features. She stated that she had been checking her blood pressures at home, and they were 157/87 to 147/97. She denied symptoms of severe preeclampsia with the exception of headache, but also complained of some shortness of breath. In triage, the patient's initial blood pressure was 137/96. Workup with preeclampsia lab panel was negative. With continued observation, the patient's blood pressure increased to 170/92 and then 176/96. The diagnosis of preeclampsia with severe features, postpartum was then made. The patient was admitted to the hospital and given magnesium sulfate for seizure prophylaxis. The patient's antihypertensive medication was increased to 300 milligrams labetalol twice daily.
The blood pressures resolved, and the patient was discharged home on hospital day 3. The health plan contends that the admission was not medically necessary, because the patient did not meet MCG (Milliman Care Guidelines) guidelines, 26th edition, for unstable vital signs; severely high blood pressure; low platelets; abnormal liver tests; worsening kidney function; hemolysis; pulmonary edema; brain, eye, or kidney injury; or seizures. The facility contends that the admission was medically necessary based on MCG (Milliman Care Guidelines) criteria, 27th edition, due to severe hypertension with systolic blood pressure higher than 160. 

The Inpatient admission was medically necessary.

The guidelines of the American College of Obstetricians and Gynecologists state hospitalization is appropriate for women with a diagnosis of preeclampsia with severe features. Based on the blood pressures documented in the hospital, the blood pressures were sufficiently elevated to meet the diagnostic criteria for preeclampsia with severe features. Therefore, the admission was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld.

This is a patient who presented to the hospital with chest pain and elevated blood pressure. The patient had no reported past medical history and was taking no medications at home at the time of the patient's initial emergency department (ED) evaluation.

The patient had an episode of chest pain lasting several minutes, associated with lightheadedness and cyanosis, which had also occurred about 3 months earlier. The patient was asymptomatic at the time of evaluation. Blood pressure at the time of that evaluation was 154/91. There was mention of cramping pain, numbness, and tingling in the leg; weakness was denied. 

In the ED, a recent history of left arm numbness and slurred speech was noted. Troponins were undetectable x (times) 2, and amlodipine started for hypertension. Transthoracic echocardiogram was planned. Computed tomography angiogram of the head and neck was planned, as were various labs including a hemoglobin A1c and a lipid profile. Aspirin, statin, and neurology evaluation were planned.

Computed tomography angiogram (CTA) of the head and neck had been reassuring. 

Additional history noted  presenting symptoms of bilateral leg weakness and paresthesia's, blurry vision, and elevated blood pressure (BP) x1 day were reported, as well as a past medical history of hypertension. Chest pain was reportedly not an issue, but bilateral upper extremity paresthesia and mouth numbness was. The patient had noted for 3 months that their speech was slurred when their blood pressure was higher. 200 systolic was reported as the patient's initial blood pressure in the ED. A subsequent CTA and computed tomography (CT) of the head were both normal, as was an echocardiogram. The patient's labs were normal. BP was well-controlled on amlodipine. The patient's 10-year atherosclerotic cardiovascular disease (ASCVD) risk was calculated at 10.4% (percent)

Regarding  hypertension, 154/91 was listed in the ED documentation, other sources suggest systolic over 200, with associated mental status/ neurologic change. No objective findings were present to support acute end-organ damage. Furthermore, the patient ultimately seemed to respond well to a typical dose of a single oral agent.

For these reasons, inpatient admission was not necessary for the patient. A period of observation was all that was needed. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroenteritis
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This patient is an adult male who presented with abdominal pain for two weeks. The patient reportedly had epigastric and left upper quadrant pain, that had progressed to a 10/10 (ten out ten) pain since the previous day. The patient was seen by gastroenterology and was treated with Ciprofloxacin and Flagyl. 
The patient had non-bloody stools over the previous two days. Computed tomography (CT) of the abdomen showed colonic diverticulosis without acute inflammatory changes. The patient had Escherichia coli (E. Coli) and norovirus in his stool. He was treated with intravenous fluids at 100cc/hour (cubic centimeters per hour), intravenous Protonix, clear liquids, intravenous Zofran every six hours, Simethicone, and intravenous Morphine. The patient reportedly improved on day #3, he was noted to tolerate a clear liquid diet, and was discharged. The request for the 
inpatient hospital admission is under review. 

The requested health service of an Inpatient Hospital Admission is not considered medically necessary. 

This patient did not have hemodynamic instability, severe pain requiring acute inpatient management, or peritoneal signs. The patient did not require identification of etiology, or finding, or an evaluation requiring the patient to not eat or drink for an extended period (e.g. (for example)., more than 24 hours). The patient did not have the inability to maintain oral hydration (e.g. (for example)., needs intravenous fluid support), that persists after observation care, and he did not have a suspected toxic megacolon. Additionally, the patient did not have bacteremia. 
Furthermore, the patient did not require a procedure that could not have been performed on an ambulatory basis. Therefore, the requested health service is not considered medically necessary. 
The medical records do not support that the acute inpatient admission was medically necessary. 
The patient did not require services of such intensity that could only be safely and effectively provided at an inpatient level of service. The health, safety, and medical condition of the patient 
would not have been threatened by providing the care given in a lower level of care setting. Therefore, based on review of the submitted medical records, the requested inpatient level of 
care was not medically necessary for the dates of service in question as it exceeded in scope, and the intensity of the level of care necessary to provide safe, adequate, and effective treatment for this patient's condition.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vitiligo. 
Treatment: Opzelura 1.5% EX CREA (external cream). 
The insurer denied coverage for Opzelura 1.5% EX CREA. 
The denial is overturned. 
 
The patient is an adult with vitiligo affecting the face, hands, extremities, and feet.  The patient has failed therapy with XTRAC excimer laser, clobetasol, and tacrolimus.  The request is for Opzelura cream.  

Based on the standard of care and the documentation provided, Opzelura topical is medically necessary for the treatment of the patient's vitiligo. The patient has failed topical therapy with potent topical steroids as well as tacrolimus ointment. The patient has also failed therapy with excimer laser. Opzelura is the only approved Food and Drug Administration (FDA) treatment for patients 12 years of age and older treated for vitiligo.  The patient has tried and failed standard therapies, including topical steroids and non-steroidal tacrolimus ointment. The use of Opzelura is medically necessary for the treatment of this patient's vitiligo. 

Based on the above, 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 Opzelura 1.5% external cream is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: peritonsillar abscess. 
Treatment: Inpatient admission. 
The insurer denied coverage for inpatient admission. 
The denial is overturned. 
 
This case involves an adult patient who presented to the emergency department with symptoms of fatigue, fever, sudden sore throat, trouble swallowing, and voice change. On exam, the patient had a pulse of 117, and oropharyngeal exudate with a left peritonsillar abscess. It was stated that Ear, Nose and Throat (ENT) doctor was consulted, and the physician recommended inpatient admission for at least 2 nights as the patient required intravenous (IV) antibiotics which can only be accomplished in an inpatient setting. An infectious disease consult note indicated the patient was assessed for sudden onset throat pain, difficulty swallowing, low grade fever and chills. On exam, the patient had left tonsillar exudate and swelling. The provider noted the left peritonsillar abscess was improving after incision and drainage, and planned to continue monitoring closely. A discharge summary indicated the patient was managed during her inpatient stay with abscess incision and drainage, intravenous (IV) Decadron, IV unasyn, IV doxycycline, and pain management. 

Following treatment, the patient was noted to be feeling better, had reduced pain upon swallowing, and no difficulty breathing. On exam, mild erythematous exudate was noted on the left tonsil with no uvula deviation. The patient was discharged home with clindamycin 300 milligrams (mg) three times daily (TID), Medrol dose pack, and Tylenol as needed. 

Inpatient admission is considered medically necessary for this patient. Evidence based literature states if a peritonsillar abscess is left untreated or inadequately treated, it can spread to adjacent deep neck spaces and result in life threatening conditions such as airway obstruction, parapharyngeal space infection, sepsis, carotid pseudoaneurysm, and even death. 

Based on the above, the insurer's denial must be reversed. 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 inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Ankle fracture.
Treatment:  Inpatient stay.

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

The patient is a female, who injured her right ankle while rollerblading. She twisted the ankle and felt immediate pain. The patient subsequently underwent open reduction and internal fixation of this fracture. The surgery was successful with no documented complications. The patient was admitted to the hospital and discharged the following day. 

Inpatient Hospital Care was not medically necessary for this patient.

The records document that this healthy patient underwent elective ankle fixation surgery. The surgery was successful with no documented complications. The patient was discharged the following day; however, the records do not provide any evidence to support the overnight hospital admission. The patient had no signs of infection or excessive bleeding and there was no documentation of deep vein thrombosis for which inpatient care would be medically necessary.

Furthermore, the current, peer-reviewed literature, including an article published by Malik and colleagues found that outpatient ankle fixation surgery is both safe and effective. In their peer-reviewed article in the Journal of Foot and Ankle Surgery in 2020, these authors concluded that "After matching and multivariate analyses, patients with outpatient ankle fractures, compared with patients with inpatient ankle fractures, had statistically lower rates of pneumonia, myocardial infarction, acute renal failure, urinary tract infections, and pressure ulcers. Outpatient ankle fractures also had lower rates of 90-day readmissions and emergency department visits." Therefore, based upon the provided records and peer-reviewed research, the inpatient hospital admission was not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Left knee pain.
Treatment:  Hyaluronan Injection (gel one injection - J7326).

The insurer denied: Hyaluronan Injection (gel one injection - J7326).  The denial is upheld.

The patient is an adult male with left knee pain. He had received an injection last year. The physical examination was significant for effusion, 0-120 range of motion, and joint line tenderness. The magnetic resonance imaging (MRI) report was significant for 
chondromalacia, tear to meniscus, and effusion. An injection was provided nine months later. His physician recommended Gel one injections.

The requested Hyaluronan Injection is not medically necessary.

The scientific literature had previously recommended viscosupplementation for the treatment of osteoarthritis if all other courses failed prior to surgery. However, the recommendations for use of viscosupplementation have changed. A review of the Clinical Practice Guideline (CGP) by the American Academy of Orthopaedic Surgeons (AAOS) noted the changes. The osteoarthritis knee treatment Clinical Practice Guideline contains one significant recommendation change from the 2008 Clinical Practice Guideline, and this is with regard to the issue of viscosupplementation. The 2008 osteoarthritis knee Clinical Practice Guideline included an "inconclusive" recommendation regarding the use of intra-articular hyaluronic acid (HA) injections that was largely the motivating factor for the expedited update of the Clinical Practice Guideline. The second edition Clinical Practice Guideline recommendation reads, "We cannot recommend using hyaluronic acid (HA) for patients with symptomatic OA [osteoarthritis] of the knee," with a "Strong" rating, based on supporting evidence from three high-quality and 11 moderate-quality research studies that met the inclusion criteria. The work group understands the potential impact that this recommendation could have on clinical practice. Nonetheless, the Clinical Practice Guideline's best evidence synthesis does not support the efficacy of viscosupplementation. Although statistically significant outcomes were seen in some studies with higher molecular weight hyaluronic acid preparations, these outcomes were not clinically significant, based on a lack of minimum clinically important improvement (MCII). The Orthopedic group reports "strongly do not recommend use." This topic was reviewed again in 2021. Additional studies were reviewed with the opinion: No change to this Guideline. Additional references and expert opinion do not support benefit. A meta-analysis was completed of multiple references. This is a high-level evidence-based criteria which does not support use. The criteria report that the service is not necessary. Current literature supports this recommendation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cat Bite/Scratch
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is an adult female. She presented to the emergency department with cat bite and scratch to the right hand. The patient had been bitten by a cat the day before. The patient denied fever, chills, cough or vomiting. Her past medical history included depression. The patient is not allergic to any medications. The patient's vitals in the emergency department were temperature 98.5, blood pressure 102/69, pulse 61, respiration rate 18, and pulse oximetry 100% (percent). The patient's labs showed WBC (white blood count) 8.31K (thousand), Platelets 243, and BUN (blood urea nitrogen) 17. X-ray of the patient's hand showed air in the tissues of hand. The patient was treated with intravenous antibiotics, Adacel immunization, Toradol for pain control, and she was also given IV (intravenous) fluids. The patient was evaluated by hand surgery consult. The patient continued to improve and was discharged on oral antibiotics.

The inpatient admission was not medically necessary.

The patient presented with signs and symptoms consistent with cellulitis and was treated with IV (intravenous) antibiotics. On presentation, however, the patient was afebrile and had stable vital signs. The patient's clinical evaluation and lab results did not show any findings to indicate sepsis or septic shock. The patient did not have history of medical immunocompromised status, and the cellulitis was not located over a prosthesis or implanted device. There was no involvement of the eyes or orbit. The patient was alert and oriented without any change in mental status, and she was able to take oral medications. Inpatient medical admission was not medically appropriate. For the hospital, the patient was afebrile and had stable vital signs. The patient did not have new symptoms or intractable pain that would require continued management in an inpatient setting. The patient was tolerating oral intake and was clinically stable. Physical exam for this duration did not show any new exam findings that would necessitate further work up in an inpatient setting. Lab results were stable and did not reveal abnormalities that would indicate further need for work up or change in management plan in an inpatient setting. During the above duration, there were no new investigations ordered / work up initiated, and there was no change in management plans that would justify / necessitate continued inpatient stay in the hospital.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Relapsing-Remitting Multiple Sclerosis.
Treatment:  Panzyga.

The insurer denied: Panzyga.  The denial is overturned.

The patient is a 20-year-old female with relapsing remitting multiple sclerosis. She is taking Ocrevus. She has hypogammaglobulinemia secondary to Ocrevus. The provider wishes to prescribe Panzyga (intravenous immunoglobulin [IVIG]). The request was previously denied, as the patient's indication is not one of plan's covered indications.

The proposed treatment is medically necessary.

Hypogammaglobulinemia is a known side effect of Ocrevus. Treatment for this condition is intravenous immunoglobulin. Data in the medical literature suggests that intravenous immunoglobulin/subcutaneous immunoglobulin (IVIG/SCIG) may yield the greatest recovery in immunoglobulin G (IgG) while also reducing infection frequency and severity. Therefore, it is indicated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class I skeletal malocclusion
Treatment: Braces and Monthly Visits
The insurer denied Braces and Monthly Visits.
The denial is overturned.

The patient is a teenage female. The request is for orthodontic treatment and monthly visits. The patient has a Class I skeletal malocclusion with mild upper and lower crowding and a deep bite. The prior denial was due to the patient having 14 points on the handicapping index scale.

The requested health service is medically necessary.

The patient has an impacted permanent anterior tooth (number 11, upper left canine) where extraction is not indicated. This is an automatic qualifier according to the handicapping index scale. This tooth needs to be brought into its proper position in the mouth. Orthodontic treatment is needed to achieve this, and the monthly visits are needed to follow progress. Therefore, the requested health service is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity. 
Treatment: Wegovy. 
The insurer denied: Wegovy. 
The denial is overturned. 

This is an adult female that has a diagnosis of obesity. She has comorbid conditions of high blood pressure and high cholesterol. The denial of Wegovy (semaglutide) is being appealed. The health plan denied coverage because it covers weight loss medications for a maximum of 12 months per lifetime. The patient has been on Wegovy for more than 12 months. Initial weight was 329 pounds (body mass index [BMI] was 50) and current weight is 268 (body mass index is 40.7). She has tried and failed diet and exercise alone. She took Saxenda last year, when she was switched to Wegovy. 

The requested health service is medically necessary. 

Wegovy is United States Food and Drug Administration (FDA) approved as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index (BMI) of 30 or greater or body mass index of 27 in the presence of at least one weight-related comorbid condition. This patient has a body mass index greater than 30. She has been on glucagon-like peptide 1 (GLP-1) agonists for over one and a half years. After initial approval, continuation coverage is indicated if the patient has lost at least five percent of their initial body weight. This patient has lost approximately 12 percent of her initial body weight since staring glucagon-like peptide 1 agonists. Medical literature supports long-term use of Wegovy for weight management. This patient continues to respond to Wegovy. The requested Wegovy is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: back pain.
Treatment: Thermal destruction of intraosseous basivertebral nerve. 
The insurer denied Thermal destruction of intraosseous basivertebral nerve. 
The health plan's determination is upheld.

This is a female patient diagnosed with Vertebrogenic low back pain. Records indicate the patient was recommended to undergo the Intracept procedure (interosseous basivertebral nerve ablation), which was denied by the health plan.

Intraosseous Basivertebral Nerve Ablation Procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The patient is noted to have a history of chronic back pain that has not responded to medications, chiropractic treatment and injections. The provider feels that the patient's pain is coming from Modic changes and was recommended to undergo the Intracept System (intra-osseous basivertebral nerve ablation). However, it should be noted there are multiple abnormal findings on magnetic resonance imaging (MRI) likely responsible for the patient's pain including retrolisthesis at multiple levels, nerve root compromise at multiple levels, facet degenerative changes, and varying degrees of stenosis.
This procedure is not standard of care as there is a lack of high quality studies evaluating the long-term risks and benefits of this procedure. Although some results have been promising, additional studies are needed to establish the safety and efficacy.