Persius/hicric huggingface dataset:
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Postprocedural Hypothyroidism.
Treatment: Formulary exception for Cytomel.
The insurer denied: Formulary exception for Cytomel.
The denial is upheld.

The patient is an adult female with post-procedural hypothyroidism. She has tried and failed levothyroxine with a TSH (thyroid stimulating hormone) close to 20 IU/mL (international units per milliliter). She is currently treated with Synthroid and Cytomel. The request for continuation of Cytomel is under review. The prior request was denied coverage by the health plan, because the patient has not tried and failed or had an intolerance or contraindication to liothyronine. The provider is appealing this determination.

The health plan should not cover the Formulary exception for Cytomel.

This request is for the continuation of Cytomel for the treatment of post-procedural hypothyroidism. The formulary alternatives are levothyroxine and liothyronine. This patient has tried and failed levothyroxine. The remaining formulary alternative is liothyronine. There is a lack of data supporting the use of brand Cytomel over generic liothyronine. Generic liothyronine is expected to be equally safe and effective in this clinical situation. Therefore, no, the health plan should not cover the proposed treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Nausea/vomiting.
Treatment:  Inpatient stay.

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

The patient is a female admitted to the hospital with nausea, vomiting and diarrhea. She was recently admitted about 10 days before with nearly identical symptoms. There was concern that she could be actively using ethyl alcohol (ETOH). She does have a history of (H/O) ETOH abuse. Recently, she was found to be C diff + (clostridium difficile positive). On admission, she was found to be afebrile with stable vital signs. There was a normal abdominal exam. She has a H/O of a cholecystectomy. On admission, she was found to have a markedly elevated alanine aminotransferase (ALT) and T bili (total bilirubin) along with hypokalemia. A computed tomography (CT) showed a fatty liver, but there was no radiographic evidence of pancreatitis. 

The inpatient hospital admission was not medically necessary. The patient presented with viral like symptoms perhaps from extensive ETOH (ethyl alcohol) intake. Initially, she was thought to have pancreatitis but did not meet criteria. With simple measures and supportive care, by the day after admission, the patient's symptoms were largely resolved. The patient was eating and minimally symptomatic. There was never any concern that she had sepsis or had severe enterocolitis or another life-threatening disorder, which required inpatient management. The patient could have safely and effectively been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Syncope.
Treatment:  Inpatient hospital admission.
The health plan denied the inpatient hospital admission.
The determination is upheld.

The patient is a male with past medical history (PMH) of coronary artery disease (CAD) status/post (s/p) stents, who was admitted with complaints of syncope associated with prodrome associated with a cough. His vital signs were unremarkable. The physical exam was unremarkable. The lab work was notable for a mildly elevated creatinine and positive COVID-19 (Coronavirus disease 2019). Imaging studies, including a chest x-ray showed no acute pathology. Magnetic resonance imaging (MRI) of the brain showed no acute pathology. The electroencephalogram (EEG) was within normal limits (WNL). An electrocardiogram (EKG) showed normal sinus rhythm (NSR) with right bundle branch block (RBBB). The patient was diagnosed with syncope related to dehydration from COVID-19, with cardiac cause being considered less likely, and was treated with telemetry, Remdesivir, and intravenous fluids (IVF). The patient was discharged in stable condition.

At issue is the medical necessity of the inpatient level of care.

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

The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with syncope associated with prodrome associated with a cough. The patient was found to have mild/asymptomatic COVID-19 and was treated with telemetry, Remdesivir, and IVF. The patient was hemodynamically stable, did not require intubation or non-invasive positive pressure intubation, did not have any severe respiratory distress, tachypnea, use of accessory muscles in the neck, severe intercostal retractions, cyanosis, or hypoxia on admission. The patient did have syncope, but it is documented that the syncope was not considered to be cardiac in origin, and the patient's creatinine responded to IVF. The patient was diagnosed with COVID-19 without sepsis or hypoxia and was treated with IVF, Remdesivir, and supportive care. These interventions could have been safely provided at an alternate level of care.
Appeal type: Medical necessity
Decision: Upheld

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

This is a male patient with a past medical history (PMH) of hypertension (HTN), diabetes mellitus type 2 (DM2), and coronary artery disease (CAD) status/post (s/p) stents who was admitted with complaints of (c/o) pleuritic chest pain. His vital signs were unremarkable. The physical exam was notable for no apparent distress (NAD). Lab work was notable for coronavirus disease 2019 (COVID-19), negative troponin. Imaging studies included a chest x-ray (CXR) which showed no acute consolidations. An electrocardiogram (EKG) showed no acute ischemia. The patient was diagnosed with atypical chest pain and asymptomatic COVID-19 and treated with acute coronary syndrome (ACS) rule out and telemetry. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

No, the hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with pleuritic chest pain. The patient was found to have mild/asymptomatic COVID-19 and was treated with observation. The patient was hemodynamically stable, did not require intubation, non-invasive positive pressure intubation, did not have any severe respiratory distress, persistent tachypnea, use of accessory muscles in neck, severe intercostal retractions, cyanosis, or hypoxia on admission. The patient was diagnosed with COVID-19 without sepsis or hypoxia and was treated with intravenous (IV) fluids and supportive care, and these interventions could have been safely provided at a lower level of care.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Prostate cancer
Treatment: Ablation of Malignant Prostate Tissue Transrectal 
with High Intensity Focused Ultrasound (code 55880)
The insurer denied: Ablation of Malignant Prostate Tissue Transrectal with High Intensity Focused Ultrasound (code 55880)
The denial is Upheld

The patient is an elderly male with clinically localized prostate cancer. The request is for HIFU (High Intensity Focused Ultrasound) for primary treatment.

The health plan should not cover the Ablation of Malignant Prostate Tissue Transrectal with High Intensity Focused Ultrasound (code 55880). Many therapies have been investigated for the treatment of localized prostate cancer. High-intensity focused ultrasound (HIFU) is an investigational treatment for prostate cancer allowing for either whole gland or hemi-gland treatment.
Regarding this treatment option, the American Urologic Association prostate cancer guidelines state, "if HIFU (high-intensity focused ultrasound) is offered as an alternative treatment modality for localized prostate cancer, it should be done within the context of a clinical trial. Prospective randomized or comparative trials with other treatment modalities are lacking. Published five-year oncologic outcomes are variable and attributable to the lack of consensus on objective response criteria."
NCCN (National Comprehensive Cancer Network) prostate cancer guidelines do not recommend HIFU (high-intensity focused ultrasound) as an initial treatment option for clinically localized prostate cancer, instead reserving this option for radiation therapy recurrences.
The results of well-designed comparative clinical trials are awaited in order to define the appropriate role of this technology in the management of localized prostate cancer. For this reason, HIFU (high-intensity focused ultrasound) remains an investigational treatment option for the treatment of localized prostate cancer.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Prostate cancer
Treatment: Ablation of Malignant Prostate Tissue Transrectal 
with High Intensity Focused Ultrasound (code 55880)
The insurer denied: Ablation of Malignant Prostate Tissue Transrectal with High Intensity Focused Ultrasound (code 55880)
The denial is Upheld

The patient is an elderly male with a diagnosis of intermediate risk prostate cancer. The request for HIFU (High Intensity Focused Ultrasound) is under review.

The health plan should not cover the Ablation of Malignant Prostate Tissue Transrectal with High Intensity Focused Ultrasound (code 55880).

HIFU (High Intensity Focused Ultrasound) consists of focused ultrasound waves emitted from a transducer, that cause tissue damage by mechanical and thermal effects as well as by cavitation. The goal of HIFU (High Intensity Focused Ultrasound) is to heat malignant tissues above 65 degrees Celsius so that they are destroyed by coagulative necrosis. HIFU (High Intensity Focused Ultrasound) has increasingly been used for treatment of localized prostate cancer within the last decade. It has the theoretical potential of decreasing gastrointestinal, genitourinary and sexual toxicity. Potential candidates are patients with low to moderate risk prostate cancer. The available literature mainly consists of prospective case series and retrospective studies from Europe showing short- to intermediate-term outcomes for localized prostate cancer. No controlled trials are available for analysis, and no long-term survival data are available. There are no validated biochemical and surrogate endpoints for cure. The National comprehensive Cancer Network Guideline on Prostate Cancer, 2019 states the following about focal therapy and HIFU (High Intensity Focused Ultrasound), "At this time, the panel recommends only cryosurgery and HIFU [High Intensity Focused Ultrasound] as options for RT [radiotherapy] recurrence in the absence of metastatic disease."
EAU (European Association of Urology) Guidelines for prostate cancer, 2019 state, "Similar to cryosurgery, the lack of any long-term prospective comparative data on oncological outcomes prevents whole-gland HIFU [High Intensity Focused Ultrasound] from being considered as a reasonable alternative to the established curative treatment options."
AUA (American Urological Association)/ASTRO (American Society for Radiation Oncology)/SUO (Society of Urologic Oncology) Guideline of Clinically Localized Prostate Cancer, 2017 states, "Clinicians should inform low-risk prostate cancer patients who are considering focal therapy or high intensity focused ultrasound (HIFU) that these interventions are not standard care options because comparative outcome evidence is lacking."
As such, HIFU (high intensity focused ultrasound) is not considered a clinically appropriate and generally accepted standard of care for management of localized prostate cancer. Therefore, it should not be covered by the health plan in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Human rhinovirus positive.
Treatment:  Inpatient admission.

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

Patient is an adult with a past medical history significant for anxiety, depression, and asthma, who presented to the emergency room with complaints of shortness of breath and cough.

Vitals on presentation included: Temperature 36.5 degrees C, Blood Pressure 153/96, Pulse 112, Respiratory Rate 16, oxygen (O2) saturation 97% (percent) on Room Air. Laboratory values were notable for the following: white blood cell count (WBC) 25.2, Hemoglobin (Hgb)-13.7, Hematocrit (Hct)-39.9, creatinine-0.86, glucose-114, procalcitonin-0.14. COVID test negative.

Patient was empirically started on intravenous fluids (IV), antibiotics (Rocephin and Zithromax), and nebulizers. Patient tested human rhinovirus positive. Chest x-ray (CXR) was negative. Computed tomography (CT) scan of the lungs showed trace ground glass opacity in the lungs, nonspecific, and no lung consolidation. Patient remained afebrile and hemodynamically stable. She requested discharged to continue outpatient management. 

According to medical records, patient presented with upper respiratory illness-like symptoms and tested positive for rhinovirus viral infection. She was afebrile, hemodynamically stable. Laboratory results were unremarkable except elevated WBC, but patient had recently received a course of steroids by her primary clinician. Additionally, CXR was negative, and her oxygen saturation was stable. Rhinovirus is the etiologic agent of most common colds and is responsible for one-third to one-half of cases in adults annually. Symptoms are typically self-limiting; there is no indication for antibiotic therapy in the absence of evidence of secondary bacterial infections.  Based on findings, patient met criteria for observation level of management.

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 the acute inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Atopic dermatitis
Treatment: Dupixent
The insurer denied Dupixent.
The determination is upheld.

This is a female patient with atopic dermatitis. The body surface area affected is greater than 10 percent (%). She has failed triamcinolone, fluocinolone, prednisone, and methotrexate. The medication under review for medical necessity is Dupixent.

The requested health treatment of Dupixent is not medically necessary for this patient. According to the American Academy of Dermatology Atopic Dermatitis Clinical Guidelines and dermatology literature, the health plan's preferred medications, such as tacrolimus ointment, are effective treatments for the management of atopic dermatitis (1, 2).
A Cochrane Database of Systematic Reviews for Topical tacrolimus (which is a preferred, formulary drug) for atopic dermatitis concluded that "In summary, tacrolimus ointment seems to be safe and effective for moderate to severe atopic dermatitis in children and adults" (3).
It is noted that the patient has tried and failed topical steroids. However, the patient has no true contraindications to the other preferred, formulary medications which have been shown to be effective for the treatment of atopic dermatitis. The preferred agents, such as tacrolimus ointment, are appropriate agents for the treatment of the patient's atopic dermatitis. The formulary medications should be tried and failed prior to initiating Dupixent. Therefore, Dupixent is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vaginal bleeding

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld.
 

The patient is an adult female who presented to the emergency department (ED) for evaluation of vaginal bleeding. The patient was found to have a missed abortion measuring 15 weeks gestation. She was admitted overnight and underwent a Dilatation and evacuation. Post-operatively, she was stable and was discharged home.

This patient presented with a diagnosis of missed abortion requiring a Dilatation and curretage (D&C); D&C are ambulatory procedures.  

D&Cs are done in offices and surgery centers. Dilatation and curettage can be performed safely in the office or other outpatient setting using manual vacuum aspiration or sharp curettage. Admission to an acute level of care is not customary or medically necessary. There was no evidence laboratory or otherwise of coagulopathy. Post operatively, the patient was stable. She was voiding and tolerating oral intake.

The procedure was uncomplicated and there was no concern about a surgery complication like injury to bladder, bowel or uterine perforation. It is unclear why the patient was not taken immediately to the operating room rather than waiting until the next day for the D&C especially that she was bleeding. 

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 the hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Uncontrolled diabetes

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient is an adult male with type two (2) diabetes. The patient presented to the emergency room (ER) with generalized weakness, polyuria, and polydipsia. The chest x-ray (CXR) and electrocardiogram (EKG) were normal. The patient was started on intravenous (IV) fluids and given insulin to bring his blood sugars down. The patient was admitted for elevated blood sugars and poorly controlled diabetes; blood sugars were stabilized. Laboratory results on admission show hemoglobin/hematocrit of 13.7/38.2, low sodium 127, and elevated glucose of 653. Urinalysis showed a glucose of more than 1000.

Patient was on glargine, lispro and metformin but the patient was poorly adherent due to perceived side-effects. Chart reveals multiple emergency room (ER) visits for hypoglycemia. The patient reported blurred vision and numbness in toes. 

The patient was seen by Endocrinology and was started on Actos, metformin twice a day (BID), Januvia, and a basal-bolus regimen. Blood sugars stabilized and the patient was discharged.

Endocrine evaluation could have been performed on an outpatient basis after stabilization and referrals for follow-up.

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 the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Dizziness/Vertigo
Treatment: Inpatient Hospital Stay
The health plan denied: Inpatient Hospital Stay
The determination is: Partially overturned

The patient is a female with past medical history (PMH) of diabetes mellitus type 2 (DM2), rheumatoid arthritis (RA), and hypothyroidism who was admitted with complaints of syncope after suffering profuse diarrhea. The patient previously had a complicated hospital stay due to left ankle abscess complicated by lumbar 5 - sacral 1 (L5-S1) discitis and methicillin-resistant staphylococcus aureus (MRSA) bacteremia and was on prolonged antibiotics. Her vital signs were notable for a blood pressure (BP) of 93/64 millimeters of mercury (mmHg) and a pulse of 117 beats per minute (bpm). The physical exam was notable for abdominal tenderness to palpation (TTP). The lab work was notable for a white blood cell (WBC) count of 3.5. The patient was diagnosed with dehydration secondary to Clostridium difficile (C. diff) diarrhea and was treated with intravenous fluids (IVF) and oral vancomycin. The patient was discharged on 12/16/2022 in stable condition. At issue is the medical necessity of the inpatient hospital stay.
The health plan's determination of medical necessity is overturned in part.
In part, the requested health service/treatment of inpatient hospital stay was medically necessary for this patient. This patient presented to the emergency department (ED) after a syncopal episode associated with profuse diarrhea, prolonged antibiotic exposure, and sepsis with hypotension. With appropriate work-up, the patient was found to have severe dehydration secondary to clostridium difficile infection. Clostridium difficile colitis requires close observation for hypotension, hematochezia, signs of sepsis or toxicity, intractable vomiting, severe electrolyte abnormalities, and altered mental status, especially in a patient with severe dehydration and sepsis. This complex patient with diabetes and severe dehydration required close clinical monitoring and aggressive management that could not have been safely provided at an alternate level of care, given the hemodynamic instability. However, after 5 days, the patient is documented to have no diarrhea, vital signs had stabilized, and infectious disease signed off, and beginning on this date the patient could have been safely and appropriately treated at an alternate level of care. It is noted that the patient had an issue with insurance authorization, which likely contributed to the patient's prolonged hospital stay.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sepsis with Acute Bronchitis

Treatment: Inpatient Admission

The insurer denied coverage for inpatient admission

The denial is overturned
 

Patient is an adult male with benign past medical history who presented to the emergency department with complaints of cough and chest pain. Patient had no history of smoking.

Vitals on presentation included: Temperature 102.3 degrees F, Blood Pressure 125/72, Pulse 96, Respiratory Rate 19, oxygen (O2) saturation 95% on room air. Laboratory results included: white blood cell count (WBC) 19.8, Hemoglobin 10.7, creatinine 0.7, glucose 114, lactic acid 1.02, procalcitonin 0.99.

Patient reported 4-5 days of pre-admission productive brownish sputum and left-sided pleuritic chest pain, and was admitted  with diagnosis of Sepsis with Acute Bronchitis and rule out atypical pneumonia.

The patient was empirically started on broad-spectrum antibiotics (Rocephin and Azithromycin) for possible lung infection. Computed tomography (CT) scan of chest showed "bilateral tree-in-bud nodularity with predominance in the lower lobes is suspicious for an infectious etiology. Scattered nodules in the right upper lobe, mild bibasilar patchy opacities, mild bilateral lower lobe bronchial wall thickening." Infectious Diseases consulted and noted clinical improvement. All cultures remained negative. Patient remained afebrile, and hemodynamically stable. He was discharged to continue outpatient management on oral antibiotics. 

According to medical records, patient presented with fever (102.3 F). Laboratory results were notable for elevated white blood cells (WBC) (19.8), anemia (Hgb-10.7), and elevated procalcitonin, Additionally, CT scan of chest showed acute on chronic changes suspicious for an underlying infectious etiology. Based on above findings, hospital admission was medically warranted for administration of intravenous antibiotics and further diagnostic testing including serial sputum cultures, legionella and mycoplasma serology. Patient showed improvement after 48 hours of IV antibiotic administration and was able to resume diet.

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 the inpatient admission is substantiated.