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

Diagnosis: Fever, rash
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

The patient is a male child with medical history significant for complex febrile seizures and negative work-up that presented to the emergency department (ED) with five-day history to 103.5, cough, and runny nose, and one-day history of diffuse maculopapular rash sparing palms and soles. The patient was seen in the ED previously with fever and febrile seizure and discharged with azithromycin. He was given the antibiotic for three days. Then, he was taken back to the ED for persistent cough and fever, and was treated with anti-pyretics and ceftriaxone. The following day, he developed the rash. He was taken to the pediatrician earlier and prescribed Augmentin but had not been given any yet. 

Vital signs in the ED included temperature 39.2, heart rate 145, respiratory rate 24, and 98% saturation in room air. Physical examination was significant for being irritable but consolable, left tympanic membrane erythematous, white exudate on the tonsils, clear lungs, regular heart rate and rhythm, rose pink monomorphic maculopapular rash on the trunk/face/extremities sparing palms and soles, and non-focal neurologic exam. Laboratory evaluation was significant for concentrated urine on urinalysis, and unremarkable complete blood count (CBC) and metabolic panel. Chest x-ray revealed subsegmental left lower lobe opacity that could represent atelectasis. He was treated with intravenous (IV) fluids and anti-pyretics prior to admission for further management. The differential diagnoses included drug reaction, Kawasaki, and viral exanthem, with viral exanthem highest on the list. Rapid strep was added because of the tonsillar exudates and was negative. Admission orders included IV fluids at half maintenance, regular diet, and anti-pyretics as needed. The patient defervesced overnight and was active and playing the following morning. The rash was improving and he was eating and drinking well. He was deemed stable for discharge to follow up with his pediatrician. 
...
This young male child with history of complex febrile seizures presented to the ED for the third time for evaluation of recurrent fever and cough and new-onset rash. He had been seen by his pediatrician earlier that day. He was febrile in the ED and underwent comprehensive evaluation including lab work and chest x-ray. Of the different possibilities, acute viral infection with exanthem was the most likely diagnosis. He was admitted to the hospital for monitoring and fluid administration pending culture results. He defervesced the night of admission and remained hemodynamically stable throughout the hospital stay. His appetite improved and his activity improved as well. While it was reasonable to provide a prolonged period of monitoring, particularly in light of his history of complex febrile seizures and seizure earlier in the course of this illness, he was overall stable and did not require acute inpatient admission. He could have been appropriately and safely managed at a lower level of care such as observation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: s/p Trauma; Fracture to the fibula and distal tibia
Issue under review: Inpatient admission

Determination:
The Inpatient admission was medically necessary.

The patient is an adult male. He sustained trauma to his right leg. He was diagnosed with a fracture to the fibula and distal tibia. He was admitted to hospital. He underwent placement of intramedullary rod the following day. His post-surgical course was not complicated. He was discharged two days after admission. 

The patient was found to have a comminuted unstable fracture to his tibia and fibula. He had undergone a closed reduction and casting. The post reduction radiographs showed unsatisfactory alignment. He required operative intervention. The procedure was complex, i.e., placement of intramedullary nail through the quadriceps tendon. The operation would be expected to be painful with narcotic requirement after surgery. There would be increased risk for swelling secondary to type of fracture and reduction maneuvers completed. This type of operation and treatment is not provided in ASU (ambulatory surgical unit) or outpatient type facility. Based upon clinical record and indications for acute inpatient, the Inpatient admission was medically necessary and appropriate. One could not reasonably be expected to predict length of hospitalization, i.e. Observation status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Status post full arthrotomy with exposure of implants.
Treatment:  Inpatient admission
The insurer denied coverage for inpatient admission.  The denial is reversed.

This patient is female with a past medical history of hypertension, goiter, asthma and arthritis to her shoulders.  She was admitted to the hospital for an elective right total shoulder replacement.  This was a revision procedure as she was found to have a loose glenoid component.  The loose component was removed and a hemiarthroplasty was performed.  Her post-surgical course was non-complicated.  She was discharged.

This patient underwent a complex revision reconstructive procedure.  Her physician performed a full arthrotomy with exposure of implants.  Although removal of the glenoid component was without incident, the physician had concern for infection and obtained five cultures.  The physician had to await the interpretation from the Pathologist, as frozen section and gram stains were completed.  He then performed the head revision which required trials (for tensioning and size).  The anesthesia time was over three hours with a blood loss of approximately 200cc.  The operation is a major orthopedic procedure with all risks commonly associated with arthroplasty.  The patient would also be expected to have pain which would not be relieved by oral analgesics. 

In conclusion, this patient underwent a major orthopedic revision procedure.  The level of service could not be provided as outpatient.  The admission would thus be appropriate.  The insurer did not act reasonably, or with sound medical judgement, or in the best interest of the patient.

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

Diagnosis: Pneumothorax

Treatment: inpatient hospital admission

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

This patient is male with history of metastatic lung cancer - unknown primary - had undergone video-assisted thoracoscopic surgery (VATS) resection several months prior, history of pulmonary embolism (PE) on Xarelto (but had run out of medication) and Schizoaffective Disorder.  The patient presented to the Emergency Department (ED) with complaint of worsening shortness of breath (SOB).  The patient denied fever or chills.  The patient also complained of some non-productive cough and generalized aches and pains all over the body. The patient's vital signs at the ED presentation were: temperature (T) 98, heart rate (HR) 110, respiratory rate (RR) 22, blood pressure (BP) 121/73 mm Hg and oxygen (O2) saturation of 92% on room air.

The patient's exam revealed that the patient was in no acute distress (NAD); lungs revealed bilateral rales; cerebrovascular system (CVS) S1 S2 was normal; abdomen was soft.  The patient was awake and alert, with a normal neurological exam. The patient's bloodwork showed: white blood cell (WBC) count of 7.16, hemoglobin (Hb) of 11.8, hematocrit (Hct) of 36, and electrolytes were within normal limits (WNL). The patient's troponin was negative and lactate was 1.4. The patient's venous blood gas (VBG) showed: pH of 7.35, pCO2 of 52, and pO2 of 36. The patient's chest x-ray showed loculated pneumothorax and left opacification; it was noted that there was no significant change. The patient was admitted and was continued on maintenance medications, including Xarelto.  The patient was treated with oral pain medications. The patient was also started on chemotherapy. The plan was to admit the patient to Hospice care for his metastatic cancer.

Based on literature review, this patient did not need acute inpatient hospitalization. The patient was afebrile, hemodynamically stable. The patient was chronically ill but had no acute changes that required acute inpatient hospitalization.  The patient underwent incidentally esophagogastroduodenoscopy (EGD), colonoscopy to look for primary and also fecal occult blood (FOB). The patient could have been evaluated in the Emergency Department (ED), and subsequently discharged either to nursing home (NH) or hospice care.  

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.
The carrier's denial of coverage for the inpatient hospital admission should be upheld.  The medical necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis:  Asthma.
Treatment:  Dulera.

The insurer denied the Dulera.  The denial is overturned. 

The patient is a female with asthma.  She is being treated with Dulera. 

The patient is diagnosed with asthma.  The patient has tried and failed Symbicort and Advair.  The patient has been treated successfully with Dulera.  The patient has not tried Breo, which is a formulary alternative. 

Yes, the health plan should cover the Formulary exception for Dulera (mometasone furoate-formoterol fumarate).

The request for Dulera did not meet the formulary criteria.  However, the main ingredient in Advair and Breo is fluticasone, an inhaled corticosteroid.  Since the patient has tried and failed Advair, the Breo is not likely to improve the patient's asthma.  Since the patient is stable on Dulera, the continuation of Dulera is medically necessary.  Not continuing it is likely to lead to destabilization of asthma and worsening quality of life, as well as frequent doctor's visits.

Therefore, given the above, the health plan should cover the Formulary exception for Dulera (mometasone furoate-formoterol fumarate).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Atopic dermatitis.
Treatment:  Dupixent (Dupilumab) 300mg/2ml SC SOSY.
 
The insurer denied the Dupixent (Dupilumab) 300mg/2ml SC SOSY.  The denial is overturned. 

The patient is a female with atopic dermatitis (AD), asthma and hay fever for whom Dupixent is requested.  It affects her arms, scalp, neck, thigh, pubic skin and back.  She has tried and failed prednisone, ivermectin, tacrolimus, triamcinolone, fluocinonide and hydrocortisone.

Yes, the proposed treatment with Dupixent is medically necessary.

The patient has severe atopic dermatitis affecting multiple areas of the body.  She is a candidate for systemic therapy, as the body surface area (BSA) is too large for reasonable control with topical medications.  Topical calcineurin inhibitors (tacrolimus) and topical steroids have failed and are not appropriate therapy for severe, widespread atopic dermatitis, affecting sensitive areas, which should be treated with systemic therapy. 

Given its unprecedented efficacy, dupilumab is emerging as a first-line therapeutic for moderate-to-severe AD.  The member has failed topical steroids, calcineurin inhibitors, and systemic steroids.  Additionally, topical calcineurin inhibitors are not indicated for severe disease.

Phototherapy is not appropriate for sensitive areas (scalp, hands, pubic skin) and is impossible to obtain during the COVID-19 pandemic.  Cyclosporine, azathioprine, methotrexate, mycophenolate mofetil are not FDA approved for use in atopic dermatitis (Insufficient data exists to firmly recommend optimal dosing, duration of therapy, and precise monitoring protocols for any systemic immunomodulating medication.  Strength of Recommendation: B Level of Evidence: I or II, depending on agent), while Dupixent is.  She is not a candidate for conventional systemic therapy (methotrexate, azathioprine, mycophenolate) due to her gender and childbearing age.  Systemic steroids and cyclosporine are not a reasonable long-term treatment for moderate to severe atopic dermatitis due to their severe side effect profile.

Therefore, Dupixent is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Rheumatoid Arthritis.
Treatment:  Orencia.

The insurer denied the Orencia.  The denial is upheld. 

The patient is a female with seronegative rheumatoid arthritis (RA).  She is presently treated with Humira 40 mg every other week and methotrexate 20 mg weekly, but this regimen is losing efficacy.  The AP (attending physician) would like to discontinue Humira and treat with intravenous Orencia infusions.  

This patient has not tried or failed the plan-preferred alternatives Enbrel, Kevzara or Xeljanz.  The physician indicates that Enbrel is not appropriate as another TNF (tumor necrosis factor) inhibitor, since the patient is failing Humira.  The physician also asserts that Kevzara and Xeljanz are inappropriate, due to this patient's hyperlipidemia (pharmacy review indicates that she takes atorvastatin), and her GI (gastrointestinal) issues.  This patient has heartburn and was recently prescribed omeprazole, but there is no documented history of diverticulitis or any type of gastric or intestinal perforation.  The physician is also concerned about zoster risk with Xeljanz, although there is no documented history of zoster in this patient.  The physician also wishes to avoid an oral medication, such as Xeljanz, due to this patient's noncompliance with pills.  The physician also wishes to avoid further self-injectable biologics (i.e., Enbrel, Kevzara), due to active hand arthritis and dexterity issues.  The appeal is for Orencia infusions for the treatment of seronegative RA.

No, the treatment with Orencia is not medically necessary.

This patient with seronegative RA is demonstrating secondary loss of efficacy of Humira (a TNF inhibitor) in combination with methotrexate.  Orencia is a non-TNF inhibitor biologic that is FDA-approved for the treatment of RA and would be a clinically appropriate option for this patient.  However, the plan-preferred alternatives (i.e., Enbrel, Kevzara and Xeljanz) may also be appropriate for this patient.  

Therefore, although intravenous Orencia could be a clinically appropriate option for this patient with seronegative RA, it would not be expected to be more efficacious than any of the plan-preferred alternatives.  Therefore, the proposed intravenous Orencia for the treatment of RA is not medically necessary (versus the Plan-preferred alternatives) for this specific patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problem
Treatment: D6240 False Tooth for Bridge, Tooth 9 and Tooth 10, and D6750 White Glass with High Gold Content Cap for Bridge, Tooth 8 and Tooth 11 

The insurer is denied coverage for D6240 False Tooth for Bridge, Tooth 9 and Tooth 10, and D6750 White Glass with High Gold Content Cap for Bridge, Tooth 8 and Tooth 11.
The denial is overturned. 

This is a patient who presented for a dental evaluation. It was reported that the patient has caries on #10 and a preexisting fixed bridge with other missing teeth. It was stated that #10 was non maintainable and a replacement fixed bridge spanning from teeth #8-#11 was the recommended treatment plan from the dentist. 

Upon review of the documentation, in particular the radiographs it is evident that the preexisting bridge was failing and #10 was non maintainable with periapical pathology. To restore function to the right maxillary dentition, in this case since the patient has pre-existing fixed bridge, replacement with a fixed prosthesis spanning #8-11 site is the standard of care dental treatment in general dental practice, as recommended. As the dentition is already restored with a fixed bridge prosthesis the only treatment that would be considered appropriate would be for replacement of the fixed bridge. 

Reverse denial and approve coverage for D6240 false tooth for bridge tooth 9 and tooth 10 and D6750 white glass with high gold content cap for bridge tooth 8 and tooth 11 was medically necessary as this would be the standard of care dental treatment in clinical practice. 

The health care plan did not act reasonably and with sound medical judgement and in the best interest of the patient. 

The patient D6240 false tooth for bridge tooth 9 and tooth 10 and D6750 white glass with high gold content cap for bridge tooth 8 and tooth 11 is considered medically necessary for this patient. 

Based on the above, the medical necessity for D6240 False Tooth for Bridge, Tooth 9 and Tooth 10, and D6750 White Glass with High Gold Content Cap for Bridge, Tooth 8 and Tooth 11 is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cholecystitis.
Treatment: Inpatient admission.
The insurer is denied coverage for inpatient admission. 
The denial is overturned. 

This is a patient with a past medical history of hypertension, hyperlipidemia, and diabetes who presented to the Emergency Department with complaints of upper abdominal pain. The CT scan of the abdomen and abdominal ultrasound revealed cholecystitis. The laboratory results revealed a white blood cell count 14.1 and lactate 4.4. The electrocardiogram revealed hyper-acute T waves in the anterior leads. The troponin levels were negative. The patient was admitted to the hospital with acute cholecystitis. The patient received intravenous ceftriaxone and was to be kept nothing by mouth. The intravenous fluids were to be administered and the lactate levels were monitored. The patient was advanced to a clear liquid diet and tolerated the diet without difficulties. The patient was to continue with a clear liquid diet and advance as tolerated. The patient was medically stable and discharged with instructions to follow-up with a surgeon for a cholecystectomy.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The inpatient admission is considered medically necessary for this patient.

The patient presented with acute abdominal pain with elevated lactate indicating significant hypovolemia. Imaging showed acute cholecystitis. The patient has significant comorbidities including Diabetes. In the setting of diabetes, intraabdominal infections can be dangerous. It is difficult to predict if their cholecystitis will progress and lead to sepsis or not. The appropriate management is admission.

Based on the above, the medical necessity for the inpatient admission is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Deep Vein Thrombosis
Treatment: Inpatient admission
The insurer is denied coverage for inpatient admission.
The denial is overturned. 
This is a male patient with a medical history of coronary artery disease (CAD), hyperlipidemia, hypertension, prior myocardial infarction (MI) and cardiovascular accident (CVA), depression, pneumonia, and bilateral lower extremity weakness. The patient presented to the Emergency Department (ED) with complaints of chest pain and leg pain. The patient described the chest pain as left-sided, sharp, stabbing, worse with smoking cigarettes, worse with cough and worse with exertion. These episodes were reported to be intermittent and last several hours at a time. The patient denied shortness of breath, lightheadedness, dizziness, headache and abdominal pain. The patient's echocardiogram was done that showed normal left ventricular ejection fraction (LVEF). The patient reported previous neuropathic leg pain; he ran out of gabapentin last week. The patient's presenting vital signs were: blood pressure (BP) 152/87, pulse 51, temperature 97.8, respirations 20, oxygen saturation 99% and BMI 34.99. The patient's physical exam noted bilateral lower extremity swelling the left being greater than the right. The patient's laboratory results included sodium 140, potassium 5.0, BUN 10, and creatinine 0.8, an initial troponin was less than 0.012. The patient's electrocardiogram (EKG) revealed sinus bradycardia at a heart rate of 49 bpm. There was left anterior fascicular block and there was asymmetrical T-wave inversion in leads III, AVF, V3-V6. These were non-specific repolarization changes. The patient's chest x-ray showed fibrosis at both lung bases. There was no acute pulmonary disease and no change when compared with imaging done. The patient was found to have an acute venous thrombosis of the left bilateral lower extremities. At the time of discharge, the patient was advised to make outpatient appointments with his primary care provider, cardiology and hematology.

This patient with a history of CAD, prior MI, CVA was found to have a pulmonary embolus with lower extremity thrombus. The multiple comorbid conditions along with the presence of PE and lower extremity thrombus argue against outpatient management. Thus, as discussed in Up to Date, while out patient anticoagulation can be used for PE, this assumes carefully selected patients. Most patients are still initially admitted as an inpatient for several days followed by long term outpatient anticoagulation.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

Based on the above, the medical necessity for the inpatient admission is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Digestive System/Gastrointestinal
Inpatient hospital

The patient was a female with medical history of hypertension, hyperlipidemia, diabetes mellitus, osteoarthritis, bipolar disorder, depression, anxiety, and tobacco use. She presented to the emergency department with three days melena, diarrhea, and epigastric pain. Physical examination was notable for left-sided epigastric tenderness and lack of blood on rectal exam. Labs showed elevated alanine aminotransferase of 44 IU/L and elevated bilirubin of 1.4 mg/dL. Urinalysis showed blood, bacteria, and mucus threads. She was made nil per os (NPO). Gastroenterology consultation recommended esophagogastroduodenoscopy, and workup for liver disease with abdominal ultrasound, hepatitis panel, and transaminases. 

The health plan's determination is upheld. The inpatient level of care is not medically necessary. The patient had melena and diarrhea consistent with inflammation (esophagitis, gastritis, duodenitis, peptic ulcer disease) or gastroenteritis. However, there was no sustained hypotension or tachycardia, and hemoglobin was normal. The patient had close monitoring, which was warranted as bleeding can be severe and sudden in onset. Endoscopy showed gastritis, and proton pump inhibitor was appropriately initiated. There was no concern for a complication such as gastrointestinal perforation, pancreatitis, intra-abdominal abscess, toxic megacolon, bowel obstruction, peritonitis, sepsis, or other complications warranting inpatient level of care. The measures which were undertaken, such as observation, monitoring, labs, Gastroenterology consultation, and intravenous fluid administration could have been performed at a lower level of care.