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

Diagnosis: Respiratory distress

Treatment: Inpatient admission 

The insurer denied coverage for inpatient admission

The denial is overturned

This is a patient with a history of asthma who had been admitted to the pediatric intensive care unit (PICU) three months prior for bronchiolitis. He was born to a diabetic mother at 35 weeks gestation and was cared for in the neonatal intensive care unit (NICU). He was sick with a cough and a runny nose for two weeks. On the day prior to admission, he was noted to have increased work of breathing with wheezing and rapid breathing. The mother was concerned about his difficulty breathing and brought him to the emergency room (ER) for further treatment.

In the ER he was noted to have respiratory distress with grunting, intercostals retractions and increased work of breathing. On physical exam he had nasal flaring. He was noted to have tachypnea, decreased breath sounds at the lung bases and bilateral expiratory wheezing. His pulse oximeter was 92%. He was treated with 2 liters of oxygen, an intravenous (IV) fluid bolus of normal saline, prednisone and 3 doses of albuterol and atrovent. A blood gas showed a respiratory alkalosis with a pH of 7.49 and a partial pressure of carbon dioxide (pCO2) of 21. When his symptoms did not improve, he was treated with IV magnesium sulfate and his oxygen was increased to a High Flow nasal canula of 15 liters (L) of 35%. When he did not improve with treatment in the ER the decision was made to admit to the PICU with a diagnosis of status asthmaticus for ongoing treatment with albuterol every 1 hour and atrovent every 6 hours. 

The insurer has denied the admission as not medically necessary and indicated that there was no documentation in the medical record to support the need for inpatient treatment.

The patient was treated appropriately in the ER for a cough, wheezing and respiratory distress. He has a history of recent previous admissions to the PICU for bronchiolitis. Despite appropriate treatment in the ER there was hypoxia, respiratory alkalosis persistent wheezing and increased work of breathing. It was appropriate and consistent with the standard of care to admit him to the PICU for ongoing treatment with albuterol every 1 hour. He was not stable enough to be sent home.

The health care plan did not act reasonably and with sound medical judgment and 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: Glaucoma
Treatment: Combigan 0.2 -0.5% OP (ophthalmic)  SOLN (solution)
The insurer denied: Combigan 0.2 -0.5% OP (ophthalmic)  SOLN (solution)
The denial is upheld

This is an adult male with neovasular glaucoma in the left eye and proliferative diabetic retinopathy in both eyes. On most recent exam, the vision was hand motion in the right eye and 20/200 in the left eye. The intraocular pressures were 11 in the right eye and 44 in the left eye. The patient was on Combigan, latanoprost, and dorzolamide drops. The provider is appealing the prior authorization denial request for Combigan drops.

The proposed treatment with Combigan is not medically necessary.
Per the prior denial, the patient must have tried and failed generic Combigan drops. However, for this patient, there was no trial and failure of generic Combigan drops and there was no documentation of a contraindication to using generic Combigan drops.  There are not enough randomized clinical trials in the literature showing the effectiveness of brand name Combigan over generic Combigan in treating primary open angle glaucoma.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Complex ileocolonic Crohn's disease
Treatment: Lab testing for serum measurement of serum antibodies to tumor
necrosis blockers due to adalimumab (80145)
The insurer denied the Lab testing for serum measurement of serum antibodies to
tumor necrosis blockers due to adalimumab (80145)
The denial is upheld.

The patient is a female with moderate to severe Crohn's, status post ileocolonic
resection. She has been treated with Humira 40 milligrams (mg) weekly, dose
escalating from 40 milligrams every other week at that time. She was seen and
noted to be doing well. At the time she was having three formed bowel movements
per day, without abdominal pain .Last imaging with magnetic resonance
elastography (MRE) revealed the patient to be in remission. A colonoscopy was
planned.  It is noted that serum Humira levels were drawn routinely.

No, the health plan should not cover the proposed lab testing for serum
measurement of serum antibodies to tumor necrosis blockers due to adalimumab
(80145).
While serum Humira drug and antibody levels have been shown to be effective in
the management of patients with ongoing active disease on Humira, to see if the
lack of response to Humira is due to low serum Humira levels or antibodies, the
literature is inconclusive as to the efficacy of such testing in patients who are in
clinical remission. As this patient at the time of the requested testing was doing
well, with formed bowel movements, no abdominal pain and no evidence of active
disease, the requested Humira drug and antibody levels were not clinically
appropriate, accepted standard of care or medically necessary and should not be
covered by the health plan.

No, the requested health service or treatment is not more beneficial than any
standard treatment for the insured's condition or disease.
As above, there is no medical literature to support routine monitoring of drug and
antibody levels in patients in remission. Therefore, the requested health service or
treatment is not more beneficial than any standard treatment for the insured's
condition or disease.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal - Knee pain.
Treatment: Physical Therapy - 10 Outpatient visits .
The insurer denied Physical Therapy - 10 Outpatient visits.
The denial is upheld. 

This is a male patient. The patient has been diagnosed with knee pain. Records indicate that a request for additional physical therapy was previously denied by the health plan and on appeal the denial was upheld as it was noted the progress notes did not support a need for more skilled care.
The therapy note is an initial evaluation stating that the patient had complaints of right knee pain. It was noted the patient had previously been treated in this clinic a few months ago for back and knees, both and currently has no back pain but is having continued knee pain. It was noted that the patient saw his provider and was told that his right knee is "bone on bone" and will need a total knee arthroplasty. The patient ambulates very slowly due to knee pain and pain is rated at 9/10. On examination there was limited flexion and extension to the right knee, decreased motor strength in the bilateral knees, poor balance, and positive deep knee bend test. Plan was to continue skilled therapy to address his impairments and limitations.
At issue is the medical necessity of Physical Therapy-10 Outpatient visits.

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

No, the requested health service/treatment of Physical Therapy - 10 Outpatient visits is not medically necessary for this patient.
Per Official Disability Guidelines (ODG) by Milliman Care Guidelines (MCG), "Recommended as indicated below. As with any treatment, if there is no improvement after 2-3 weeks, treatment protocols should be modified or re-evaluated. Arthritis (Arthropathy, unspecified): Medical treatment: 9 visits over 8 weeks." This request has previously been denied as information provided did not support the need for more skilled care and included progress reports with updated objective measures as well as functional goals status showing that the skilled care was helping the patient. Current information provided includes a therapy note which was the initial evaluation that stated the patient had previously had physical therapy for both knees. There is no documentation of how many sessions were completed, any specific objective improvement, goal progression, or functional gains. There is no indication as to why the patient would be expected to benefit from further supervised therapy at this point given the patient recently completed therapy and it was also noted that the patient reportedly spoke to their provider who stated that the patient's knee is "bone on bone" and the patient will need total knee arthroplasty. It would be expected the patient can perform an independent home exercise program at this time while awaiting surgical treatment.
Therefore, the requested health service/treatment of Physical Therapy - 10 Outpatient visits is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Primary Infertility.
Treatment: Donor services for in vitro fertilization (sperm or embryo) case rate.

The insurer denied Donor services for in vitro fertilization (sperm or embryo) case rate. 
The denial is upheld.

The patient is a gravida (G) 0 who has a greater than 4 year history of primary infertility. Her history is significant for endometriosis and pelvic floor dysfunction requiring multiple pain medications to control.

Her endometriosis was diagnosed showing minimal disease. Subsequent laparoscopy has shown more evident disease.

She has been diagnosed with decreased ovarian reserve. Anti-Mullerian hormone (AMH) levels 0.065, and 0.08. She underwent an in vitro fertilization (IVF) cycle where she grew 3-4 follicles. One egg was retrieved and fertilized with frozen sperm from her husband. This embryo was frozen on day 1. A frozen embryo transfer was unsuccessful.
She did an IVF cycle with donor eggs. 3/6 eggs were fertilized and were frozen on day three. She subsequently went through 3 frozen embryo transfer cycles but was unsuccessful. Labs: estradiol 23.47/ follicle-stimulating hormone (FSH) 14.3. Repeat hysterosalpingogram (HSG) was normal with bilateral patent tubes.

Her history is also complicated by her husband's severe male factor. On one specimen, there was 0.2 million/milliliters (ml) and 50% motility. Subsequent analyses showed azoospermia. The patient is requesting services for egg donation and is also planning to use donor sperm.

The subject under review is the medical necessity for the donor services for IVF (sperm or embryo) case rate.

The requested services are not medically necessary for this patient. The use of donor eggs will probably increase the pregnancy rates for this patient. However, the standard criteria for approval for donor eggs requires that the patient meet the guidelines for medical necessity which include: bilateral oophorectomy, premature ovarian failure, having a genetic disease that can be transmitted, and IVF treatment failure, etc. There is nothing that states what IVF treatment failure means or how many cycles this entails. Therefore, a single failed cycle using her own eggs may not necessarily be indicative of her egg quality but rather her husband's severe male factor and would not qualify as "IVF treatment failure" after one cycle. She is also not in premature ovarian failure, and her FSH level of 14.3 is less than the FSH < 19 guidelines for use of donor eggs. In addition, a young patient with decreased ovarian reserve does not necessarily have a lower chance of pregnancy, but a decreased AMH indicates less response to stimulation. This patient had an egg donor cycle and underwent 3 frozen embryo transfer cycles and did not conceive, which would indicate other infertility issues other than just egg quality.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Esophagogastroduodenoscopy (EGD) 
The health plan denied: Esophagogastroduodenoscopy (EGD) 
The denial is: Upheld

The patient is a female with severe epigastric abdominal pain prompting an emergency room visit. She was started on a proton pump inhibitor. The attending provider did an esophagogastroduodenoscopy (EGD) to evaluate her epigastric pain which he felt was due to atypical gastroesophageal reflux disease (GERD) or peptic ulcer disease or Helicobacter (H) pylori induced gastritis. He substituted the proton pump inhibitor (PPI) with a histamine (H)2 receptor antagonist prior to the EGD to increase yield of H pylori organisms. The EGD revealed no evidence of gastritis or esophagitis or peptic ulcer disease. However duodenal biopsies revealed evidence of celiac disease. The subject under review is the medical necessity for the EGD.

The requested health service/treatment of EGD is not medically necessary for this patient.
Dyspepsia is a poorly characterized syndrome thought to originate from anatomic or functional disorders of the upper gastrointestinal (GI) tract. Dyspepsia encompasses a variety of symptoms including epigastric discomfort, bloating, anorexia, early satiety, belching or regurgitation, nausea, and heartburn. Dyspepsia symptoms overlap significantly with those associated with peptic ulcer disease, gastroesophageal reflux disease (GERD), other functional disorders such as epigastric pain syndrome and irritable bowel syndrome, malignancy, adverse effects of medications, pancreatitis, biliary tract disease, vascular disease, and motility disorders. Alarm symptoms that may be associated with dyspepsia are unintended weight loss, iron deficiency anemia, gastrointestinal (GI) bleeding, dysphagia, odynophagia, persistent vomiting, a family history of upper GI malignancy in a first-degree relative or abnormal imaging showing structural disease.
According to current guidelines, dyspeptic patients older than 50 years of age or those with alarm features should undergo upper endoscopy. Endoscopy should be considered for patients in whom there is a clinical suspicion of malignancy even in the absence of alarm features.
This patient had no alarm symptoms and had response to a PPI. Even though the provider was concerned about H pylori gastritis, this could have been tested by non-invasive testing or gastric biopsies taken during the EGD.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is female who initially presented to the emergency department with concerns of left lower quadrant abdominal pain. Pertinent history included diabetes mellitus type 1, gastroparesis, and recent admission for diabetic ketoacidosis. Initial vital signs revealed a temperature of 98.1oF, heart rate (HR) 122, blood pressure (BP) 130/86, respiratory rate (RR) 19, and peripheral capillary oxygen saturation (SpO2) 100% on room air. Initial examination did not reveal peritoneal signs. Initial laboratory testing revealed a white blood cell count (WBC) 10.7, HGB 9.5, platelets (Plt) 416, blood urea nitrogen (BUN) 21, Cr (creatinine) 0.8, Na (sodium)134, K (potassium) 4.2, carbon dioxide (CO2) 23, Glucose 214, Lactate 1.4, Lipase 9, and Tbil (total bilirubin) 0.3. Urinalysis revealed mildly elevated WBCs but was negative for bacteria. Pelvic ultrasound was unremarkable. A computed tomography (CT) abdomen/pelvis revealed moderate constipation, otherwise no pathology. The patient was placed in the hospital thereafter with an impression of intractable abdominal pain, nausea and vomiting, and gastroparesis. 

The inpatient hospital admission was not medically necessary.  Evaluation and management could have been performed at a lower level of care. In this particular situation, the patient had a history of gastroparesis, cholecystectomy, and salpingectomy who presented with abdominal pain, nausea, and vomiting. An extensive evaluation was performed and unremarkable for an acute pathological process. Treatment included intravenous fluids, analgesia, and anti-emetics. Following observation care, the patient's symptoms significantly improved and she was discharged to home. No other issues or complications were documented.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a previously healthy man who presented to the emergency department (ED) with a history of progressively worsening abdominal pain. Evaluation included physical exam, labs, and imaging. He was without fever at the time of presentation and the heart rate was 73/minute. Lab data identified a white blood cell (WBC) count of 9.2. His evaluation yielded findings consistent with appendicitis. Treatment was initiated with intravenous (IV) fluid and antibiotics. Surgical consultation was requested. The patient was admitted to the hospital.

The Acute inpatient admission was not medically necessary for this patient.
This patient presented with abdominal pain. The evaluation supported the diagnosis of appendicitis. He was admitted to the hospital. The initial treatment included nothing by mouth (NPO) status, IV fluid, and appendectomy that was performed. The early post-surgical course was uncomplicated and the patient was hemodynamically stable and tolerating a diet on the day of surgery. He was discharged from the hospital following the initial recovery period.
A lower level of care would have provided for presurgical assessment, operative treatment and post-surgical monitoring. This lower level of care would have also allowed for overnight monitoring, if needed.
Generally accepted guidelines of care indicate that in the absence of hemodynamic instability, sepsis or toxicity, significant electrolyte imbalance, bleeding, gastrointestinal (GI) obstruction or surgical complications the procedure may be performed with an observation level of care. An observational level of care would have appropriately provided for presurgical assessment, laparoscopic appendectomy, and post-surgical monitoring. Inpatient care was not required or medically necessary in this case per generally accepted medical standards.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stomach pain
Treatment: Hospital admission
The health plan denied the requested inpatient hospital admission.
The health plan's determination is upheld.

This patient was a previously healthy man who presented to the emergency department (ED) with the complaint of abdominal pain and repetitive vomiting. His past medical history included no active chronic health conditions. He was alert and oriented at the time of presentation. Vital signs at the time of presentation included a heart rate of 88/minute and a blood pressure of 94/80 millimeters of mercury (mmHg). A subsequent blood pressure was 116/74 mmHg. Examination revealed right lower abdominal tenderness. The white blood cell count (WBC) count was normal at 6.0. The metabolic panel was normal. A computed tomography (CT) scan of the abdomen showed no acute pathology or inflammatory process. The patient was admitted to the hospital.
The patient was kept nothing by mouth (NPO) and was monitored overnight. He received intravenous (IV) fluid. The role for an appendectomy was considered. The records indicate that the patient had normal vital signs and had improvement in his abdominal pain. The WBC count remained normal at 4.7. He continued to vomit, and this was attributed to cannabinoid hyperemesis syndrome. He was provided a diet and was monitored. The patient was considered to be stable for discharge home.
At issue is the medical necessity for the inpatient hospital admission.

The health plan's determination is upheld, in whole.

No. This patient presented with abdominal pain and intractable vomiting. The evaluation with examination, imaging, and lab data identified abdominal tenderness, but no obvious indication for acute surgical intervention. The patient was monitored overnight and was provided IV fluid. He remained clinically stable during the period of monitoring. The WBC count remained consistently normal. His condition was attributed to cannabinoid hyperemesis syndrome.
This patient's clinical needs could have been satisfied with an alternate level of care. This alternate level of care would have provided for clinical assessment, IV fluid supplementation, and monitoring, including overnight monitoring, as was performed. He remained clinically stable during the period of monitoring and did not require acute surgical intervention.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is upheld.


The patient presented to the emergency department complaining of sudden onset chest pain and dyspnea. His medical history was remarkable for peripheral vascular disease, morbid obesity, obstructive sleep apnea, and daily alcohol use. His blood pressure was 138/93 millimeters of mercury (mmHg) with a heart rate of 115 beats/minute. His respiratory rate was 24 breaths/minute with a room air oxygen saturation of 97% (percent). An electrocardiogram showed atrial fibrillation with a ventricular rate of 141 beats/minute. His serum troponin level was normal. He was treated with intravenous fluid and a diltiazem bolus and infusion. He was admitted to the hospital. Within hours of presentation, his rhythm converted to sinus spontaneously. He remained in sinus rhythm overnight. An echocardiogram performed showed low normal left ventricular systolic function. The right ventricle was mildly dilated. The patient was discharged. At issue is the medical necessity of an inpatient hospital stay.

Based on the documentation provided, an inpatient level of care was not medically necessary.

This patient presented with acute atrial fibrillation (AF). He was hemodynamically stable, without evidence of decompensated heart failure or acute ischemia. For stable patients presenting with acute AF, the safety of a lower-level care or discharge to home with close follow-up has been well demonstrated. As stated by Lin, et al, "There is growing evidence to suggest that outpatient management is a safe and effective alternative to hospital admission for the management of many patients with acute AF or atrial flutter. Protocols for early rhythm control, clinical decision rules to guide the decision to initiate antithrombotic therapy, and low molecular weight heparin and direct oral anticoagulants have reduced the need for acute inpatient hospitalization." Likewise, Conti, et al, based on an observational study of 3475 patients concluded, "In patients with AF, beyond the standard approach, the novel organization with an additional intensive observation unit for early pharmacological interventions and an outpatient clinic for elective treatment and short-term follow-up significantly reduced admission irrespective of independent predictors of hospitalizations." Vinson, et al, based on a smaller study and a review of the literature, agreed with this approach and stated, "The short-term home observation management approach for atrial fibrillation/flutter patients who present early in their symptomatic course has been mentioned in the literature (sometimes called the 'wait and watch' method), but it has not been well described. In our sample, 11 of 16 patients (69%) managed with this approach spontaneously cardioverted to normal sinus rhythm within 48 hours (h) of symptom onset. Our findings are consistent with previous studies, which have reported that up to two-thirds of selected patients with presumed recent-onset atrial fibrillation spontaneously convert to normal sinus rhythm within 2-3 days."