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

Diagnosis: Sleep Apnea

Treatment: Pre-service request for a nerve stimulator

The insurer denied coverage for pre-service request for a nerve stimulator

The denial is overturned

This is a male with a history of chronic rhinitis, gastroesophageal reflux disease, obesity, sleep apnea, borderline diabetes, high cholesterol, and hypertension. He presented to the Otolaryngologist's office for a follow up visit after having a septoplasty turbinectomy tonsillectomy. A sleep study was performed. Apnea hypopnea index was 43.4. The patient has tried continuous positive airway pressure and various masks without relief. He has also tried a dental appliance without relief. The physician is requesting a hypoglossal nerve implant to treat sleep apnea.

In an appeal letter, the patient stated that he has suffered from severe sleep apnea for most of his adult life.  He had a heart attack. The Cardiologist recommended consulting with a sleep apnea specialist because of the strain on the heart. He reported trying continuous positive airway pressure without relief. The patient had his tonsils removed but still suffered from severe sleep apnea. The patient is requesting an inspire implant in order to improve his quality of life.

The pre-service request for a nerve stimulator is considered medically necessary for this patient.  The upper airway stimulator was approved by the Food and Drug Administration and due to its success the inclusion criteria were expanded in years later to include patients with apnea hypopnea index up to 65.

The American Academy of Otolaryngology-Head and Neck Surgery policy statement supports the upper airway stimulator as a second line treatment after continuous positive airway pressure has failed.

The Inspire Upper Airway Stimulation system. 64568 - incision for implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator 0466T - insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator is medically necessary based on recent, and relevant peer literature.

The insurer's denial of coverage for the pre-service request for a nerve stimulator is reversed. Medical is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Uterine fibroids. 
Treatment: Inpatient admission. 

The insurer denied coverage for the inpatient admission. 

The denial is upheld. 

This is a female patient with a history of uterine fibroids. She was admitted to the hospital for a laparoscopic myomectomy with robotic assistance. Her medical history was positive for morbid obesity. The procedure was performed without complications and a 500 cubic centimeters (cc) blood loss. She was transferred to the post-anesthesia care unit (PACU) and recovered without incident. The patient was then transferred to the inpatient floor. 

According to the medical records the patient was afebrile in the PACU. Her vital signs were normal and stable during the PACU stay. The patient required intravenous (IV) pain medications for a short period of time, and her pain was satisfactorily controlled with oral pain medications on the first postoperative day. According to the inpatient records the patient had progressed to a normal diet, was ambulating without difficulty, and had normal bowel sounds and a non-tender abdomen by the first postoperative day. She was voiding normally. The patient underwent an uncomplicated laparoscopic myomectomy. The procedure time was not longer than expected and the blood loss was as expected at 500 cc. The post-operative period in the PACU was not significantly complicated and the patient's condition was stable, with stable vital signs on discharge to the inpatient service. The patient did not have serious co-morbidities to be a complicating factor in her preoperative and postoperative care plans. The patient was likewise stable on admission from the PACU. Stable postoperative patients who have undergone uncomplicated procedures such as laparoscopic myomectomy do not necessarily require acute inpatient admission after their discharge from the PACU. They may be reliably observed, by the standard of care, in a lesser level of care prior to their eventual discharge. Therefore the patient could have been reliably discharged from the PACU to a lesser level of care rather than the acute inpatient service. The treatment did not have to be provided in an acute inpatient setting and was not medically necessary. 

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

The insurer's denial of coverage for the inpatient admission is upheld. Medical necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Allergic Contact Dermatitis.
Treatment: Formulary Exception for Desoximetasone 0.05% OIN, Pre-service.

The insurer denied the formulary exception for Desoximetasone 0.05% OIN, Pre-service.  The denial is overturned. 

The patient is a male with allergic contact dermatitis of the hands for whom desoximetasone 0.05% ointment was requested. The patient had patch testing, which showed an allergic reaction to group A topical corticosteroids.

Yes, the health plan should cover the formulary exception for Desoximetasone 0.05%.

The available options in the formulary are not class C corticosteroids, except for desoximetasone. However, the formulary desoximetasone 0.25% cream/ointment/spray is a class II (high potency) topical steroid, whereas the requested desoximetasone 0.05% ointment is a class IV (mid potency) topical steroid. Therefore, it is not equivalent and cannot be substituted. The remaining formulary topical steroids are all in categories that are not recommended for use in individuals with an allergy to topical steroids.

Contact dermatitis experts divide corticosteroids into the following five groups for allergy purposes, based on their molecular structure:  1) Group A, known as the hydrocortisone type, 2) Group B, the triamcinolone acetonide type, 3) Group C, the betamethasone type, 4) Group D1, the betamethasone dipropionate type, and 5) Group D2, the hydrocortisone-17-butyrate type.

In the United States, because of usage patterns, at least 90% of cases of corticoid allergy involve Group A, and most of those involve hydrocortisone. Allergy to Group B steroids is the next most common, accounting for 5%-7% of cases. Most of the rest involve Group D. Group C steroids are almost never allergenic. Group C, which almost never causes contact allergy, is a select group that comprises clocortolone pivalate, desoximetasone, and dexamethasone. When allergy to corticosteroids is known or suspected, a switch to a Group C steroid is the safest choice. Clocortolone cream is the hypoallergenic mid-potency steroid of choice, whereas desoximetasone cream or ointment is the safest mid- to high-potency option.

Therefore, given the above, the health plan should cover the formulary exception for Desoximetasone 0.05%.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Type I Diabetes Mellitus.
Treatment: Formulary exception for Humalog (insulin lispro (human)).
The insurer denied the Formulary exception for Humalog (insulin lispro (human)).
The denial is overturned. 

The patient is a male with type 1 diabetes on insulin pump therapy. His A1C (glycated hemoglobin) is 8.3%. The patient has been on Humalog for many years. The patient has had difficulty controlling glucose on Novolog. The request for Humalog is under review.

Yes, the health plan should cover the Formulary exception for Humalog.

Novolog is aspart insulin. Fiasp is also aspart insulin with additional excipients. Novolog and Fiasp result in similar glucose control in people living with type 1 diabetes [1]. As the patient has tried and failed Novolog, the patient can reasonably be expected to fail Fiasp insulin. Without Humalog, this patient is at risk of hyperglycemia, which can cause retinopathy. Therefore, yes, the health plan should cover the formulary exception for Humalog.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Seborrheic Dermatitis. 
Treatment: Formulary Exception for Clobetasol to Treat Seborrheic Dermatitis. 

The insurer denied coverage for Formulary Exception for Clobetasol to Treat Seborrheic Dermatitis. 

The denial is overturned. 

This is a female patient with a history of acne and seborrheic dermatitis of the scalp who has failed treatment with lower potency steroids (Capex/fluocinolone solution) as well as high potency steroids (fluocinonide solution).  The patient has also documented failure of anti-fungal shampoo (ketoconazole) as well as over the counter (OTC) salicylic acid-based shampoos. 

The requested medication of clobetasol shampoo is approved for the treatment of her medical condition given the failure of numerous prescription steroid solutions as well as ketoconazole and salicylic acid shampoos.  Furthermore, in a review of the published data regarding treatment of seborrheic dermatitis, Naldi and Diphoorn found support for use of clobetasol propionate shampoo from a randomized trial.  The requested medication, clobetasol shampoo, is more likely effective compared to formulary clobetasol alternatives.  High potency solutions have failed to alleviate the patient symptoms; as such, a shampoo vehicle is a reasonable next step for treatment of the patient's seborrheic dermatitis.  

The insurer's denial of coverage for Formulary Exception for Clobetasol to Treat Seborrheic Dermatitis is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis of left knee.
Treatment: Inpatient admission.

The insurer denied the inpatient admission.  The denial is upheld. 

The patient is a female with osteoarthritis to her left knee. She had underlying medical problems of DM (diabetes mellitus) and hypertension. She underwent a left total knee replacement.

No, the Inpatient admission was not medically necessary, based on the documentation provided.

The records show the patient underwent a primary total knee replacement. Her operation and post-surgical course were non-complicated. Her vital signs remained stable. Her wound was without problem. There was no evidence of bleeding or infection. She was able to tolerate oral pain medication. She made steady progress with PT (physical therapy). She did not require treatment for an underlying medical problem or need additional imaging/tests.

There were no extenuating circumstances to warrant the inpatient admission.

This patient's condition is typically managed at a lower level of service, such as observation in accordance with the standard of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia.
Treatment: Inpatient stay.

The insurer denied coverage for the inpatient stay.  The denial is upheld.

This is a female patient who presented to the Emergency Department (ED) with complaints of syncopal episodes.  The documentation detailed her husband witnessed her have 3 syncopal episodes.  She did indicate the day prior she felt nauseous with some pain to the right upper arm.  She does have a past medical history of breast cancer with a right mastectomy.  She has had right upper extremity lymphedema since surgical intervention.  She was not on any active chemo or radiation.  The physical examination revealed the patient was alert an oriented.  She was actively vomiting.  The recommendation was made for her to undergo multiple laboratory and diagnostic studies.  The chest x-ray was normal as well as the computed tomography (CT) scan of the head.  The physician indicated the patient should receive Zofran and undergo an electrocardiogram (EKG).  The patient did have hemoglobin at 6.5.  She had a negative guaiac.  She did sign consent for a 2-unit transfusion.  She was also found to have low potassium, magnesium, and calcium.  She was given intravenous (IV) potassium as well as magnesium and calcium.  It was recommended that she undergo admission for further treatment due to anemia.  The patient continued with treatment, and there was improvement overnight.  The patient was discharged the next day. 

The inpatient admission was not medically necessary.  The patient presented with history of recurrent bouts of syncope.  She was found to be anemic with hemoglobin of 6.5 and underwent a blood transfusion, CT imaging study of the head, which was negative for acute findings, and an EKG.  The care provided, including laboratory testing, diagnostic imaging, and blood transfusion, could have been performed in the ED setting and at an observation level of care.  Therefore, the inpatient admission was not medically necessary. 

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

The insurer's denial of coverage for the inpatient stay is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Sickle Cell Painful Crisis.
Treatment: inpatient admission.

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

This female patient has a history of sickle cell disease.  The patient was sent to the Emergency Room (ER) for pain crisis by her primary care physician due to 10 out of 10, back pain despite Dilaudid use at home.  The patient's blood pressure (BP) was 96/58, afebrile on exam and had no shortness of breath.  The patient's labs showed a white blood cells (WBC) of 12.5, and hemoglobin was 7.7.  The patient's chest X-ray (CXR) was negative, and the patient's electrocardiogram (EKG) was normal. The patient was admitted to the hospital for pain management and intravenous fluid (IV) fluids for an uncomplicated sickle cell pain crisis. The patient was later discharged home.
As per the American Health Information Management Association (2018), "Generally a person is considered to be in inpatient status if officially admitted as an inpatient with the expectation that he or she will remain at least overnight. The severity of the patient's illness and the intensity of services to be provided should justify the need for an acute level of care. An inpatient admission solely because the patient has been kept in observation status over 23 hours would not be considered medically necessary." 

As per the Society of Hospital Medicine (2021), "Observation was meant to be a short period of time for providers to assess whether patients required admission for inpatient care, or could be discharged. Typically, this was meant to last fewer than 24 hours and only rarely spanned more than 48 hours." 

As per Yawn et al. (2014), "Hydroxyurea and transfusion therapy are strongly recommended for many individuals with [sickle cell disease (SCD)]. Many other recommendations are based on quality of evidence that is less than high due to the paucity of clinical trials regarding screening, management, and monitoring for individuals with SCD." (Yawn, B. P. 2014)               

Based on the review of the medical record and literature, inpatient hospital admission was not medically necessary for this patient. This patient could have been managed in an alternative level setting such as observational status. An uncomplicated sickle cell pain crisis does not require acute level hospitalization for management. There were no findings of stroke, acute chest, aplastic crisis or other emergent sickle cell associated diagnosis that would warrant acute level hospitalization for this patient. Therefore, inpatient hospital admission from is not considered medically necessary for this patient.

The health plan did  act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left Knee Osteoarthritis.
Treatment: Hospital Admission.

The insurer denied coverage for Hospital Admission.  The denial is upheld .

This patient is a female patient with a past medical history which includes hypertension, left Achilles tendon repair, and left knee osteoarthritis who presented for open medial unicompartmental arthroplasty of the left knee. The patient successfully underwent the procedure with no intraoperative complications. The patient was admitted inpatient for status post (s/p) partial knee arthroplasty.  The patient reportedly did well postoperatively. The patient received intravenous (IV) fluids, IV antibiotics, pain medication and physical therapy (PT). The patient was discharged with home health service and outpatient Orthopedic follow-up. 

The medical record demonstrated a non-complicated post-surgical course. The patient's surgery was a unicompartmental arthroplasty, which is less extensive than total knee replacement (TKR). The patient's vital signs were stable.  The patient's pain was managed with oral analgesics. The pain management consultation recommended oral oxycodone and follow-up as needed (PRN). There were no problems with this patient's wound. There was no evidence of infection. The patient did not require additional imaging or treatment for an underlying medical problem. The physician record noted likely discharge today pending physical therapy. These findings do not substantiate the full hospital admission and length of stay as provided. Services could have been provided at a lower level of care. 

The full hospital admission is not considered medically necessary for this patient.

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

Based on the above, the medical necessity for the full hospital admission is not substantiated.  The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizures. 
Treatment: Hospital admission. 

The insurer denied coverage for the hospital admission.  The denial is upheld. 

This patient is a male child with a history of seizure disorder who was brought to the Emergency Department (ED) due to 2 episodes of seizures. The submitted documentation indicated the patient does utilize Keppra; however, it was noted he had missed the morning dose. The documentation indicated the patient was playing with his siblings and began to have a seizure episode. The seizure was not witnessed by his mother; however, she did notice the patient foaming from the mouth. The patient did have an additional seizure while in the ED lasting approximately 15 minutes. The physical examination did reveal hypertonic right and left upper and lower extremities. The patient was postictal, but, arousable. The physician indicated the patient should undergo multiple laboratory and diagnostic studies. It was also recommended they consult with Neurology and admit the patient. Upon reassessment it was noted the patient was up and walking. The patient did have stable vital signs. The patient was admitted and continued with further treatment. The documentation does detail the patient received intravenous (IV) medication and continued with ongoing monitoring and treatment. The documentation also detailed the patient did not have any further seizure activity. The patient was discharged the following day with instruction to follow-up. 

According to the guidelines provided by the InterQual 2019, this acuity of this case is considered to have required observation as the patient with a transient neurologic episodes consistent with known seizure disorder in the setting of missed medications. Upon arrival the patient, he had no deficits and remained in stable condition until the discharge the next day. No worsening was appreciated. The patient did not require an escalated level of care. 
 
The current literature indicates a patient may be admitted when there is evidence of a metabolic disorder persisting despite observation, recurrent seizure, increased intracranial pressure, new focal neurologic deficits, altered mental status that is severe persistent or there is evidence of hemodynamic instability. Within the documentation it was noted the patient presented with 2 breakthrough seizures. However, the submitted documentation does not detail the patient had a trial and failure of care at a lower level such as observation. The documentation does not detail any treatment interventions. The health plan acted reasonably with sound medical judgment, in the best interest of the patient. 

The carrier's denial of coverage for the hospital admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Accidental ingestion of an unknown substance.
Treatment: Inpatient admission.

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

This patient is a female child who was brought in by Emergency Medical Services (EMS) to the Emergency Department (ED).  The patient was accompanied by her mother who stated that she noticed that a bottle of her grandmother's topical pain management liquid had spilled on the ground.   When she picked up the patient, she noticed that the patient's breath smelled of the same medication.  The mother reported that the patient ingested the medication approximately 1 hour prior to the ED arrival.  The mother stated that she made the patient drink water, which the patient tolerated.  There was no vomiting or diarrhea.  However, the patient was complaining of burning pain in the eyes which was resolved after washing them with water.  The patient was observed in the ED for 6 hours. The patient's lab work was normal. The Poison Control was contacted, and they advised admitting the patient for monitoring for 24 hours.  The patient was admitted to the Pediatric Unit for management of accidental ingestion of an unknown substance.  It was later determined that the ingested medication contained Gabapentin, Lidocaine, Fluocinonide and Menthol.

The patient was observed in the floor and no more toxic effects noted.  There were no abnormalities, and there was no altered mental status.  The patient's heart rate (HR) was 101, and the patient's oxygen saturation was 97%. There was no neurotoxicity, no cardiac toxicity during the hospital course.  There was no evidence of acidosis or alkalosis.  The chance of toxicity in an accidental ingestion is very remote.  This chance is more diminished in accidental inhalation.  The gabapentin toxicity is not fatal usually in pediatrics.  Also, there are no reported fatalities in inhalation of gabapentin nor lidocaine nor Menthol nor Fluocinonide.  During the hospital course, if one were to take this patient's Pediatric Early Warning Signs (PEWS) score, it would always be 0 which is reassuring.  Another risk stratification score is Pediatric Risk of Score Mortality Pediatric (PRISM) and that PRISM could have been 0 also which is very desirable.  The patient could have been managed as an observational status.

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

The insurer's denial of coverage for the inpatient admission is upheld. The medical necessity is not substantiated.