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

Diagnosis: Deep Vein Thrombosis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld. 

The medical records indicate the patient presented with inability to ambulate due to right lower extremity (RLE) pain, swelling and heaviness. The patient was also found to be anemic, with a hemoglobin (Hgb) of 7.6. The patient was admitted with right lower extremity (RLE) deep vein thrombosis (DVT), RLE cellulitis and menorrhagia with significant blood loss anemia. 

Orders included blood transfusion, Zosyn, Lasix, Ferrous Gluconate Complex, Eliquis, Biktarvy, Omeprazole, Abilify, Zoloft, Oxycodone, and Hydrocortisone cream. Labs were trended; vaginal bleeding with clots and tachycardia were noted. The patient continued intravenous (IV) iron to treat their anemia. 

A deep vein thrombosis (DVT) does not require an admission now that direct oral anticoagulant (DOAC) medications are easily available. The patient's Hgb (hemoglobin) was 7.6; however, the patient did not appear to have been symptomatic. A transfusion on an outpatient basis, in the emergency room (ER), followed by oral iron or scheduled intravenous (IV) iron would have sufficed.      

The patient's anemia was not acute and a transfusion in the ER of two (2) units followed by treatment of iron deficiency on the outpatient basis and treatment of the DVT with DOAC (direct oral anticoagulant) oral medications would have been sufficient. DOACs represent the better anticoagulant approach especially for patients that discharge directly or after a brief observation in the ER. 

"The outpatient treatment of select emergency department patients with acute pulmonary embolism (PE) or deep vein thrombosis (DVT) has been shown to be safe, cost effective and associated with high patient satisfaction" (Kabrhel, C., et al).

"Treatment of DVT aims to prevent pulmonary embolism, reduce morbidity, and prevent or minimize the risk of developing post-thrombotic syndrome....The cornerstone of treatment is anticoagulation. National Institute for Health and Care Excellence (NICE) guidelines only recommend treating proximal DVT (not distal) and those with pulmonary emboli. In each patient, the risks of anticoagulation need to be weighed against the benefits....Once DVT is diagnosed, the treatment is with an anticoagulant for 3 to 6 months, and again, monitoring of the international normalized ratio (INR) by a hematology nurse or pharmacist is necessary. Further, these patients need to be monitored for bleeding. Open communication between the interprofessional team is the only way to treat DVT and lower the morbidity of the drugs safely" (Waheed, S. M., et al).                                                         

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

Diagnosis: Transient Ischemic Attack
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient who was admitted to the hospital after presenting to the emergency room with slurred speech. On initial evaluation, the patient did not have significant slurred speech and had no other neurologic deficits. The patient was evaluated by neurologic imaging including  magnetic resonance imaging (MRI) of the brain. Vessel imaging and an echocardiogram were not performed and were referred to the outpatient setting. The MRI of the brain was negative. The patient was diagnosed with a possible transient ischemic attack. Stroke was ruled out as a diagnosis. The patient was subsequently discharged on aspirin, antihypertensives, and a statin drug. At issue is the medical necessity of a hospital admission.
The requested health service/treatment of the hospital admission is not medically necessary for treatment of this patient. The patient was diagnosed with a transient ischemic attack. The patient presented to the hospital with a history of slurred speech. On examination, the patient did not have significant slurred speech, facial droop, or other neurologic deficits such as weakness in the arms and legs. The patient underwent an MRI of the brain that was negative. The patient did not complete other diagnostic studies such as an echocardiogram or carotid ultrasound as these were defer to the outpatient setting. The patient was subsequently discharged with aspirin and a statin. Transient ischemic attack is not treated at the inpatient level of care. This evaluation is routinely performed under observation. The patient did not even have a complete evaluation for transient ischemic attack and numerous studies were deferred to the outpatient setting which further lessens the intensity of services provided by the hospital.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, rheumatoid arthritis, glaucoma, asthma, and frailty syndrome
Treatment: Personal Care Assistance for a Total of 84 Hours per Week
The insurer denied Personal Care Assistance for a Total of 84 Hours per Week.
The denial is overturned.

This is an elderly female patient that has conditions including dementia, rheumatoid arthritis, glaucoma, asthma, and frailty syndrome. She lives alone. The denial of personal care assistance for a total of 84 hours per week is being appealed. The health plan approved 48 hours per week. Uniform Assessment System evaluation completed 3 months ago shows moderately impaired cognition and functional status of assistance to dependence with all activities of daily living (ADLs). The patient has bladder incontinence. Letters from the Provider note the patient's dementia and physical condition have worsened. The patient is dependent on a wheelchair for mobility. She has incontinence. She has behavioral disorder and wanders. A letter from the patient's daughter states she is no longer able to provide informal assistance. The patient's health continues to decline.

The requested health service is medically necessary. 

Personal Assistance Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. This patient has multiple chronic conditions. The denial of personal care assistance for a total of 84 hours per week is being appealed. The health plan approved 48 hours per week. Uniform Assessment System evaluation completed 3 months ago shows moderately impaired cognition and functional status of assistance to dependence with all activities of daily living. The patient has bladder incontinence. Appeal statements note there has been a decline in the patient's mental and physical status. She requires a wheelchair for mobility. Her daughter is no longer able to provide informal assistance. The information provided shows that this patient has significant limitations in functioning that have declined. She is losing informal support. The approved personal care assistance 48 hours per week is insufficient to meet this patient's needs for assistance with activities of daily living. The proposed increase in personal care assistance to 84 hours per week is medically indicated.
Appeal type: Medical necessity
Decision: Upheld

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

This patient is an adult male. He was a previously healthy man with a left inguinal hernia of longstanding duration. He presented to the emergency department with this condition stating that while the hernia had previously been reducible, now it is incarcerated. At the time of presentation, he complained of left groin pain. He had a normal heart rate of 74 beats per minute and a blood pressure of 138/60 millimeters of mercury (mmHg). 
The patient's physical exam revealed a tender, reducible, left inguinal hernia. White blood cell (WBC) count was normal. Computed tomography (CT) scan showed a small bowel containing left inguinal hernia with an associated small bowel obstruction. The patient was admitted to the hospital with the diagnosis of small bowel obstruction and left inguinal hernia. 
A surgical consultation was obtained. The patient was started on a diet. He was passing flatus and had no symptoms of bowel obstruction. He was deemed, by the surgical service, to be stable for discharge home. He was discharged from the hospital on the same day with instructions for outpatient follow-up. The health plan denial letter that the patient had a "hole in the groin that kept bulging. This had been present for several months. The initial obstructive symptoms resolved quickly, and he was able to go home the same day." Criteria for inpatient admission were not met.

The requested health service was not medically necessary.

This patient was a previously healthy man with a left inguinal hernia. The patient presented to the emergency department with complaint of left inguinal pain. He was clinically stable at this time. He was admitted to the hospital. While the patient had a left inguinal hernia on physical exam and on imaging with computed tomography scan, he was deemed by the surgical service to not require urgent surgical repair of the left inguinal hernia. The patient was started on a diet. He was considered by the surgical service to be stable for discharge. He underwent repair of the right inguinal seven months earlier. The operation was performed without complication. The corresponding progress notes from that time document clinical stability. Extended stay or inpatient stay may be needed for emergent surgery; significant peritoneal adhesions complicating surgery; surgical complications; an obturator hernia; open repair of a large, recurrent, or incarcerated incisional hernia; parastomal hernia; postoperative ileus; morbid obesity with body mass index (BMI) greater than 40 kilograms per meter squared (kg/m2); or active comorbidities. In this case these clinical conditions did not exist to warrant an inpatient level of care. The patient's symptoms of pain resolved. The surgical assessment noted the patient did not have a bowel obstruction. He did not require urgent surgery for the left inguinal hernia. The care during this time could have been rendered with a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Scrotal pain/swelling
treatment: Inpatient stay

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

This case involves a male admitted with left testicle swelling and pain. The symptoms were present for two weeks and were associated with dysuria and burning micturition. He was treated in the outpatient setting with azithromycin and Levaquin until testicular swelling developed. He was then switched to doxycycline, which he completed for a week. A urologist completed a testicular ultrasound that showed epididymo-orchitis. 

The inpatient hospital admission was not medically necessary. Based on the provided documentation, the patient has stable vital signs and was experiencing testicular swelling caused by bilateral epididymitis. There is no evidence of an acute systemic illness. The vital signs are stable, and the physical exam does not show the patient as toxic or septic. Lactic acid is normal. Within 24 hours of treatment with IV (intravenous) antibiotics, the patient feels improved. There was no evidence of resistant organisms. Blood cultures were negative, and STIs (sexually transmitted illnesses) were ruled out. Therefore, a lower level of care is appropriate for this presentation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Pain Crisis (sickle cell disease).
Treatment:  Inpatient admission.

The insurer denied Inpatient admission.  The denial is upheld.

The patient is an adolescent female with a history of sickle cell anemia. She was admitted to the hospital and discharged the next day. The inpatient admission was denied coverage by the health plan as not medically necessary. The denial is being appealed.

The inpatient admission was not medically necessary.

At the time of admission, the patient had hemoglobin SC (sickle cell) and presented with pain in the left arm. In the emergency department, the patient was evaluated and complained of pain in the extremities, upper and lower. The patient was given morphine. The patient had a normal white blood cell count of 11.9, hematocrit of 30. The patient was admitted and put on IV (intravenous) fluids. The next day, the white count was 10.6 and the pain was controlled on Tylenol and Advil. IV (intravenous) fluids were discontinued, and the patient was discharged home.

In this case, the patient was admitted to the hospital for vaso-occlusive pain crisis of the left arm. The patient was admitted and managed for pain. The patient was not febrile. There were no other extenuating circumstances or clinical findings that warranted inpatient level of care in this case. Patients are admitted typically initially under observation level of care, because patients with sickle cell anemia may typically turn around and resolve their pain issue quickly. An observation level of care would have been appropriate. The patient did not have a fever, or any other critical factors that would mandate that Inpatient level of care was appropriate. The patient does not 
meet any criteria for acute inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Esophageal Ulcer

Treatment: diagnostic esophagogastroduodenoscopy (EGD), procedure code 43239

The insurer denied coverage for diagnostic esophagogastroduodenoscopy (EGD), procedure code 43239

The denial is overturned

The patient had dysphagia in and had an endoscopy which showed an esophageal ulcer. The patient was treated with omeprazole 40 milligrams (mg) per day as well as famotidine 40 mg a day. The patient was no longer having dysphagia. The patient's physician advised doing a follow-up endoscopy to evaluate for healing of the esophageal ulcer. The repeat endoscopy showed only mild esophagitis with no residual ulcer. The biopsy was read as reflux esophagitis with erosion. 

Medical necessity was determined based on Milliman Care Guidelines (MCG) guideline A-0203 for Upper Gastrointestinal (GI) Endoscopy. Gastrointestinal reflux disease is an indication for endoscopy if the patient has a history of severe erosive esophagitis and needs follow up after 8 weeks of proton pump inhibitor (PPI) therapy. The patient had severe esophagitis with an esophageal ulcer. The patient met the MCG guideline for doing an Upper GI Endoscopy because it was appropriate to follow up after treatment to see if the severe esophagitis with an ulcer had healed. 

The health care plan did not act reasonably or with sound medical judgment. The endoscopy was medically necessary. The denial is reversed.

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 diagnostic esophagogastroduodenoscopy (EGD), procedure code 43239 is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity
Treatment: Wegovy 2.4MG (milligrams) Injections
The insurer denied: Wegovy 2.4MG (milligrams) injections.
The denial is upheld.

This patient is an adult male with a history of obesity who is taking Wegovy (semaglutide). His provider is requesting continuation. The patient's weight prior to starting Wegovy was 250 pounds; his current weight was 270 pounds, which is a weight gain of 6.7 percent. The patient's current body mass index (BMI) 36.57.

The requested health service is not medically necessary.

There is no documentation that the patient has achieved weight loss of greater than or equal to 5 percent of baseline body weight since being on Wegovy. The patient actually gained 17 pounds since starting Wegovy, which is a 6.7 percent weight gain. Therefore, Wegovy is not medically necessary.

Continuation of therapy for Wegovy may be approved for up to an additional 12 months of therapy when all of the following criteria are met:

1) Documentation of weight loss of at least 5 percent of baseline body weight after the initiation of treatment 2) Documentation that the member is compliant with therapy and can tolerate the recommended maintenance dose of medication for at least 3 consecutive months 3) Documentation that the member continues with a comprehensive weight management plan including a reduced-calorie diet, increased physical activity and behavioral modifications. 

The patient has not achieved a weight loss of 5 percent since being on Wegovy and has actually gained weight; therefore, Wegovy is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pulmonary Embolism

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

 
The patient presented to the hospital with complaints of rash and malaise after taking Amoxicillin and Meloxicam for a dental infection.  The patient has a history of hypertension (HTN), hyperlipidemia (HLD), and congestive heart failure (CHF). The patient also had recent spinal surgery. The patient reported that they had an allergy to penicillin (PCN) but did not know that Amoxicillin had penicillin in it. The patient denied shortness of breath (SOB), difficulty in breathing, throat or lip swelling or any hoarseness of voice.  

Vital signs on presentation were: Temperature 98.7 Fahrenheit (F), Respiratory Rate (RR) 17, Heart Rate (HR) 111, Blood Pressure (BP) 128/91, and Oxygen (O2) Saturation 98% on Room Air (RA).  There were no signs of angioedema or anaphylaxis.  Lung sounds were clear bilaterally.  Cardiovascular assessment revealed normal heart sounds in S1 and S2.  The patient was alert and oriented x3.  The patient's white blood cell (WBC) count was normal.  Hemoglobin (Hgb) was 14 and hematocrit (Hct) was 47.  The patient's D Dimer was elevated at 1631.  

The patient was treated with intravenous (IV) steroids, Benadryl, and Pepcid.  The plan was to discharge the patient home on these medications.  However, the patient was noted to have an elevated lactate level, and a computed tomography (CT) of the abdomen and computed tomography angiogram (CTA) of the chest were done.  The CTA of the chest revealed a pulmonary embolism (PE) in the right main and lobar arteries.  There was no right heart strain noted.  An electrocardiogram (ECG) was done that showed no acute ST or T wave changes.  An echocardiogram showed normal left ventricular (LV) function and no right heart strain.  The patient was started on IV fluids and Lovenox.  

The patient remained afebrile and hemodynamically stable throughout their stay.  There was no evidence of diabetic ketoacidosis or any other pathology such as sepsis.  No hypoxia was noted.  The patient was switched to oral Apixaban and subsequently discharged to home.  

This patient did not need acute inpatient hospitalization for their PE. The patient was afebrile, hemodynamically stable, had no noted hypoxia, was tolerating oral intake, had no right heart strain, and had no new ECG changes.  The patient could have been placed in observation status while diagnostic testing and treatment were initiated.  Observation can be for up to 48 hours.  This patient was stable from the pulmonary embolism perspective and could have been discharged home on oral anticoagulation after a brief period under observation.  The drug rash the patient presented with was from Amoxicillin, was mild, and did not meet criteria for acute inpatient stay.  

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: Experimental/Investigational
Decision: Overturned

Diagnosis: Lymphedema
Treatment: Hemic or Lymphatic System (Code: 38999x12); Intraoperative Identification of Sentinel Lymph Node(s) includes Injection of Non-Radioactive Dye when Performed (Code: 38900); Duplex Scan of Extremity Veins including Responses to 
Compression and other Maneuvers Unilateral or Limited Study (Code: 93971); Microsurgical Techniques, Requiring Use of Operating Microscope; Two Inpatient Days (Code: 69990)
The insurer denied: Hemic or Lymphatic System (Code: 38999x12); Intraoperative Identification of Sentinel Lymph Node(s) includes Injection of Non-Radioactive Dye when Performed (Code: 38900); Duplex Scan of Extremity Veins including Responses to Compression and other Maneuvers Unilateral or Limited Study (Code: 93971); Microsurgical Techniques, Requiring Use of Operating Microscope; Two Inpatient Days (Code: 69990)
The denial is overturned.

The patient is an adult female. She has lymphedema of the right leg. She has failed conservative therapy.

The health plan should cover the proposed treatment.

According to the consultation note, the patient is an adult female with lymphedema of the right leg. The swelling is worse from the knee to the thigh area involving the groin. The patient denies any history of trauma. The patient has gained 12 pounds. The patient 
also reports nerve pain on top of her leg with feeling of tightness and itching. The patient has been unable to do running exercise for a long period of time. The patient has used Flexitouch pump and manual lymphatic drainage as well. Symptoms affected her daily activity at home and putting clothes on. The patient had previous venous closure 8 years ago. The patient has two-plus (+2) edema in the right lower extremity with volume excess of 2007 cubic centimeters. Lymphoscintigraphy showed the patient with migration abnormal in the right lower extremity. No pelvic or para-aortic lymph nodes are seen. There is significant general retention of tracer in the right lower extremity. There is normal tracer migration in the left lower extremity. Under discussion, it states the patient has a diagnosis of stage II or greater lymphedema. The patient has failed conservative therapy for at least six months. The patient has significant functional impairment. The requested proposed treatment is appropriate and medically indicated since lymphaticovenous anastomosis (LVA) and/or vascularized lymph node transfer (VLNT) demonstrated a considerable reduction in limb volume and improvement in subjective findings of lymphedema in the majority of patients. The maintained effectiveness of this treatment modality in long-term follow-up suggests great efficacy of lymphaticovenous anastomosis in the lower extremity lymphedema treatment. A two-day inpatient stay is not experimental/investigational, and is indicated, when carried out with these procedures.