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

Abdominal pain
Inpatient hospital stay

The patient presented to the emergency department with nausea, vomiting, and severe abdominal pain (10/10 in intensity). Vital signs were notable for temperature elevated to 99.3 Fahrenheit. Labs were notable for leukocytosis with white blood cell count of 17.4 K/uL, low hemoglobin of 10.6 g/dL and hematocrit of 33.9%, elevated neutrophil fraction of 91.1%, elevated blood urea nitrogen of 26 mg/dL, elevated alkaline phosphatase of 135 U/L, elevated amylase of 189 U/L (upper limit of normal 121 U/L), elevated lipase of 50 U/L (upper limit of normal 47 U/L), and elevated lactate of 1.9 mmol/L. Urinalysis contained blood and protein. Physical examination was notable for abdominal tenderness. The patient was treated with intravenous morphine, Zofran, ciprofloxacin, metronidazole, and fluids. The next day the patient had persistent abdominal pain and gastrointestinal discomfort, and was upset as the sister had passed away the night before. Physical examination was notable for abdominal tenderness with deep palpation. Labs were normal. Computed tomography scan of the abdomen and pelvis showed fluid-filled loops of small bowel with foci of small bowel thickening, possibly consistent with inflammatory bowel disease such as Crohn's disease, and possible related decreased small bowel motility or ileus. X-ray of the abdomen showed a nonspecific bowel gas pattern. Gastroenterology consultation concluded that there was enteritis of unclear etiology, and it was clinically improved; antibiotics and bowel rest were recommended. The patient had improvement in symptoms, and was tolerating a clear liquid diet. Labs showed hemoglobin of 8.0 g/dL. Patient was discharged on ciprofloxacin for 7 days and metronidazole for 10 days, with a plan for Gastroenterology follow-up in one week. The health plan's determination of medical necessity is upheld in whole. The patient  had nausea, vomiting, diarrhea, and abdominal pain consistent with acute gastroenteritis. Computed tomography scan of the abdomen and pelvis showed an enteritis, but there was no suspected or established complication such as gastrointestinal perforation, pancreatitis, intra-abdominal abscess, toxic megacolon, bowel obstruction, gastrointestinal bleeding, peritonitis, sepsis, or other complications warranting inpatient level of care. The patient was appropriately treated with intravenous fluids, empiric antibiotics, and supportive care, and  symptoms improved. Although pancreatitis was suspected, it was not present per guidelines. There was no evidence of gastrointestinal bleeding. The measures which were undertaken, such as observation, monitoring, labs, antibiotic administration, and intravenous fluid administration could have been performed without the inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sandifer Syndrome, Gastric Reflux
 
Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was reversed.  

This is a female child patient who was presented to the emergency department (ED) by her mother with reported seizure like movements. It was reported that a few hours after her feeding the patient began to move her arms in a circular motion and shake her head back and forth for several seconds. The mother reported that she picked the infant up and she began to cry; at no point did the infant become unresponsive or stop breathing. She described the episode with the infant arching her back with clear secretions coming out of her mouth. It was further reported by the mother two days prior to presentation to the ED the patient was evaluated by her pediatrician for 2 vomiting episodes; she was treated with Gas-X.   Neurology consulted on the patient. Her vital signs were stable. Laboratory work up was performed with a basic metabolic panel all within normal limits except for a result of hyperkalemia at 6.5.  She had an ultrasound of her head which was unremarkable. Seizure precautions were maintained and neuro checks performed every 4 hours. An electroencephalogram (EEG) was performed with results within normal limits. The patient was medically stabilized and was discharged home.

According to literature, careful observation, monitoring and frequent neurologic checks by trained personnel is recommended for the evaluation, assessment and diagnosis of seizures.  Given the clinical concern for seizures, careful observation, monitoring, neurologic checks by trained personnel every four hours and EEG were warranted for the patient.  Patient management in these cases is largely dependent on confirmation or exclusion of seizures, which would make the inpatient hospital stay medically necessary and appropriate for this patient.  

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

Based on the above, the medical necessity for the inpatient hospital services at the acute inpatient level of care is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital admission. 
The denial was upheld.

This male patient presented to an urgent care center complaining of toe pain. He was hypertensive and tachycardic. An electrocardiogram showed sinus tachycardia with right bundle branch block and right axis deviation. He was referred to the emergency department where his blood pressure was 190/98 millimeters of mercury (mmHg) with a heart rate of 136 beats/minute. He was afebrile. He denied chest pain or dyspnea. He reported having had a several second episode of chest pain about two months prior and a brief episode of palpitations two days prior.
His physical exam was remarkable for a tender left great toe with limited range of motion. Foot and chest x-rays were unremarkable. An electrocardiogram showed sinus tachycardia at 123 beats/minute with right bundle branch block. There were nonspecific repolarization abnormalities. A cardiologist reviewed the electrocardiogram and opined that there was no evidence of acute infarction. His serum troponin level was normal.
The patient was treated with acetaminophen, Toradol and intravenous fluid. He was diagnosed with gout and admitted to the hospital to rule out acute coronary syndrome. His heart rate slowed to the high 90's within several hours of admission. His repeat troponin level was normal.
An echocardiogram was performed and was normal. The patient was discharged. At issue is the medical necessity for the inpatient stay. 

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

The inpatient stay was not medically necessary for this patient.
This patient presented with pain in his great toe due to gout. He denied any acute cardiac symptoms. He was hemodynamically stable. While initially tachycardic, his heart rate slowed with intravenous fluid and pain control. He had no symptoms suggestive of acute coronary syndrome (ACS), no electrocardiographic signs of ACS and his cardiac biomarkers were normal. He did not require any treatment for potential ACS. Based on the records, there was no indication for inpatient admission. An inpatient admission was not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Congenital absence of right upper extremity, Carpal tunnel syndrome

Treatment: Myoelectric upper limb and hand prostheses with associated service codes: L7499-RT x 2, L7403-RT, L7400-RT, L6935-RT, and L6882-RT

The insurer denied coverage for myoelectric upper limb and hand prostheses with associated service codes: L7499-RT x 2, L7403-RT, L7400-RT, L6935-RT, and L6882-RT.

The denial is overturned.

This is a female patient with a history of congenital absence of right upper extremity as well as carpal tunnel syndrome and hernia removal who was seen with multiple complaints. She was experiencing increasing back and neck pain in addition to carpal tunnel syndrome as well as wrist pain, thumb pain, and then decreasing grip strength of the left side. The recommendation has been made for this patient to utilize a microprocessor hand. The submitted documentation indicates that this patient has demonstrated a cognitive ability to use and maintain the recommended prosthesis as she has demonstrated an ability to elicit, isolate and maintain ample neurological signal to operate and control the system. The patient has been using a body-powered prosthesis and is having signs and symptoms of overuse syndrome. Furthermore, due to her pain, she cannot establish the necessary force needed for grip and body-prosthetic use. Thus, the request has been received for multiple service codes related to the requested myoelectric prosthesis.

Evaluation has shown that the patient passed myoelectrode tests, and she is cognitively intact with the desire and motivation to get back to her prior level of function. Literature review supports that the myoelectric prosthesis is intended to give this patient full functional potential while minimizing the ongoing damaging effects of overuse of her left side. The patient's use of a body-powered prosthesis is precluded since this patient developed over-use, pain syndrome of the left side with its use, and is unable to establish the force required to maximize her grip. The patient has demonstrated cognitive ability to operate the myoelectric prosthesis and has had positive trials. The patient is an ideal candidate for this requested medical device and its associated services. 

The requested service is likely to be more beneficial than any of the standard treatments/ procedures for this patient. 

The carrier's denial of myoelectric upper limb and hand prostheses with associated service codes: L7499-RT x 2, L7403-RT, L7400-RT, L6935-RT, and L6882-RT should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lung infection (pneumonia).
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned. 

The patient is a male whose inpatient admission is under review. The patient has a history of homelessness, AIDS (acquired immune deficiency syndrome) (CD4 [cluster of differentiation 4] 5 cells/ul), polysubstance abuse, and HCV (Hepatitis C virus) infection. He presented to the hospital with fever, productive cough, nausea, and vomiting.

In the ER(emergency room), the patient's vitals were as follows: T (temperature) - 98.4, P (pulse) - 76, BP (blood pressure) - 146/94, and RR (respiration rate) - 20. On general examination, the patient was lethargic. Examinations of the patient's HEENT (head, eyes, ears, nose, throat) were positive for thrush. The examination of the patient's chest revealed bilateral rales. The examination of his CVS (cardiovascular system) and abdomen were normal.

The patient's labs were as follows: WBC (white blood count): 8.54; Hg (hemoglobin): 11.6 (low); Hct (hematocrit): 37.9 (low); Pl (platelets): 387;  Na (sodium): 145; K (potassium): 4.3; Cl (chloride): 1066; CO2 (carbon dioxide): 22; BUN (blood urea nitrogen): 27 (high); Cr (creatinine): 1.26 (high).

The patient's ABG (arterial blood gas) was notable for the following: pH 7.499, PCO2 (partial pressure of carbon dioxide) 31.3, PO2 (partial pressure of oxygen) 64 (low), A-a (alveolar-arterial) gradient. 47 (high). The patient's Chest CT (computerized tomography) revealed diffuse tree in bud patchy airspace opacities throughout upper and lower lobes.

In the ER, the patient was thought to have AIDS and pneumonia. He was initially started on IV (intravenous) ceftriaxone and doxycycline then changed to cefepime, azithromycin, and Bactrim to possible PCP pneumonia. During the hospitalization, the patient received consults from pulmonology (bronchoscopy performed), Infectious Diseases (PCP [pneumocystis pneumonia] pneumonia and HIV [human immunodeficiency virus] treated), and substance abuse (methadone weaned, suboxone started, and the patient placed in rehab and residential program). The patient improved and was discharged to a rehab and residential program on PO (oral) medications.

Yes, the Inpatient admission was medically necessary.

The patient meets multiple criteria for inpatient admission, including the following:

1)	Pneumonia in a severely immunocompromised individual (1).
2)	Severe PCP (pneumocystis pneumonia) pneumonia with hypoxia and elevated A-a (alveolar-arterial) gradient (2).
3)	Pneumonia in an individual with acute renal injury (standard of care would require admission and close observation).
4)	Pneumonia in the setting of homelessness and active substance abuse (standard of care would require admission and inpatient treatment of complex problems, as the patient could not be expected to take medications as an outpatient).

Failure to admit and treat such a patient could lead to readmission, pneumothorax, respiratory failure, relapse of substance abuse, and/or death.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders-Other-Alopecia
Treatment: Pharmacy/Prescription drugs-Tofacitinib
The health plan denied the Tofacitinib citrate Powder as not medically necessary. The reviewer upholds the health plan determination in whole. 

The patient has alopecia areata universalis of the scalp, eyebrows, and eyelashes. Topical steroids have been tried and failed, and she has cutaneous atrophy due to long-term use of these topical steroids.

The patient is an extremely young individual, with extensive alopecia areata universalis. The risks and benefits of topical Tofacitinib for individuals of this very young age, and the degree of internal absorption or tolerability of this agent, are entirely unknown at this time. Although it can be easily presumed that topical agents are safe for patients compared to oral/systemic therapies such as Xeljanz (oral Tofacitinib), all current literature reviews to date [1-6] fail to show sufficient benefit, sufficient long-term outcomes, and sufficient confirmation of safety and tolerability, for patients of this very young age.
The social/psychological impacts of alopecia areata are profound and very real, but the lack of physical and functional symptoms do not support the use of an untested agent for a patient so very young. The safety risks and lack of confirmed efficacy for topical Tofacitinib therefore leads to the conclusion that this medication is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Congestive heart failure, myocardial infarction. 
Treatment: Ambulance Transportation Service. 

The insurer denied the Ambulance Transportation Service. 
The denial is upheld.  

The patient is a male. The patient was hospitalized at a medical center on an unspecified date following a myocardial infarct. He underwent placement of multiple coronary stents on an emergent basis. He had congestive heart failure. 

The patient was transported by ground ambulance with a basic life support crew from the medical center where he was admitted to a skilled nursing facility. The "nature of call" was "transport." The crew was at the patient's bedside at the medical center. He was noted to have a history of Parkinson's. He was noted to have been "bedridden for a week" following a myocardial infarct. 

The patient had a normal mental status. Vitals were stable. Oxygen saturation was 97% on room air. He was transported by stretcher. The documented distance travelled was two miles. They arrived at the destination and care was transferred to the receiving facility's nurse. The ambulance was back in service at the base. 

Service A0428 (non-emergency basic life support ambulance service), with ground mileage, is under review for medical necessity. 

No, the ambulance transportation service was not medically necessary. 

The documentation available for review does not establish the medical necessity of ambulance services at the basic life support level on the date in question. There is no documentation of an actual clinical assessment of the patient's function and mobility on the date of service, to include his actual ability to transfer, and other specific limitations/restrictions on mobility, if any. There are no documented indications that he had any clinical instability. His vitals were stable without any supplemental oxygen. 

The only available records are from the ambulance crew who performed the transfer from the acute hospital to the skilled nursing facility. The crew checked his vitals and used a stretcher to take the patient on a very short trip, for the sole, stated purpose of transportation, to a facility where he would be continuing care after he was medically stabilized at the hospital. 

The services were not medically necessary, because the records do not establish that the services were necessary to meet the patient's basic health needs. The records do not establish that the services were rendered in the least intensive available manner.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary tract infection
Treatment: Hospital admission
The insurer denied coverage for the hospital admission.
The denial is upheld.

This female patient has a past medical history of gastroesophageal reflux disease (GERD), gastric sleeve and lap band placement, left total knee replacement (TKR), renal stones, and recurrent urinary tract infections (UTIs).  The patient presented to the Emergency Department (ED) with complaints of left flank pain, low grade fever, nausea, and decreased oral intake for two days.  There was positive left costovertebral angle tenderness (CVAT) on exam.  The patient's urinalysis (U/A) was negative but recent U/A was positive for urinary tract infection (UTI). The patient's white blood cell (WBC) count was 11. The patient's vital signs showed: temperature 99.2, blood pressure 118/51, heart rate 81, respiratory rate 18 and oxygen saturation of 100% in room air.  In the ED, the patient was given intravenous (IV) Toradol, IV amikacin, IV Levaquin, IV fluids, IV morphine, and IV Zofran.  The patient was admitted with diagnosis of UTI.  Infectious Diseases (ID) consult advised renal sonogram, treatment with 14-day course of oral Cipro.  The patient's symptoms improved, and she was discharged home with outpatient follow-up to finish her 14-day course of Cipro.  

Per Milliman Care Guidelines (MCG) for Urinary Tract Infection (M-300), the clinical indications for inpatient admission includes hemodynamic instability severe or persistent vomiting, altered mental status, and/or severe, persistence or worsening of clinical findings despite outpatient and/or observation care treatment.  In this case, the patient fails to meet clinical indications for admission to inpatient care. The patient was hemodynamically stable and had no clinical evidence of bacteremia, coagulopathy, pyelonephrosis or other renal findings that required invasive procedure, such as stone obstruction. The patient's renal ultrasound was normal, and the patient had neither hydronephrosis nor acute kidney injury. Thus, the patient also did not meet inpatient criteria for MCG Urologic Disease (MG-UD). Based on the review of the medical record and literature, inpatient admission was not medically necessary for this patient.

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 acute inpatient stay should be upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Primary hypertension. 

Treatment: Verapamil HCl 300 mg OR CP24 (generic Verelan PM). 

The insurer denied coverage for Verapamil HCl 300 mg OR CP24 (generic Verelan PM). 

The denial is upheld. 

This is a male patient with a medical history of primary hypertension who is requesting Verapamil HCl ER 300 mg OR CP24 (generic Verelan PM). The medication was denied and a formulary alternative (Verapamil SR (generic Verelan SR) 120 mg and 180 mg) was recommended by the insurer. 

To compare the steady state pharmacokinetics of the 200 mg verapamil PM CODAS (chronotherapeutic oral drug absorption system) formulation dosed nightly versus immediate-acting verapamil 80 mg tablets dosed 3 times daily, an open-label, single-dose, two-treatment, two-period, two-sequence, balanced, randomized crossover study was performed with a 7-day washout between two treatment periods. All subjects received CODAS verapamil PM 200 mg under fasting conditions dosed at nighttime or verapamil 80 mg dosed three times daily at 8-hour intervals in a randomized fashion. CODAS verapamil PM 200 mg dosed at night for 5 days resulted in a plasma profile with a lag time of approximately 4 hours suitable for nighttime dosing. Significantly lower plasma concentrations of both enantiomers of verapamil and norverapamil resulted in lower peak-to-trough fluctuations. Both medications tested in this study were well tolerated by the group of healthy volunteers. 

Results of another study showed that CODAS-verapamil produced its greatest antihypertensive effect during the morning period (6 a.m. to 12 noon) and also provided effective trough diastolic blood pressure reductions at 200, 300, and 400 mg. Significant trough systolic blood pressure reductions were achieved only with the 300- and 400-mg doses. The nighttime dosing regimen was not associated with excessive blood pressure reductions during the sleeping hours. 

Based on the documentation submitted for review, there is insufficient clinical data to support the request for Verapamil HCL 300 MG or CP 24 (Verelan PM). As per the literature review, medication Verelan PM is specifically designed to be administered at bedtime and then is released very slowly so the peak concentration of verapamil is delivered to the patient's system early in the morning, which may be beneficial to the patient. However, the documentation submitted for review shows no blood pressure determination that provides support for this medication use. Thus, Verapamil HCl 300 mg or CP24 (generic Verelan PM) 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. 
 
The carrier's denial of coverage for Verapamil HCl 300 mg OR CP24 (generic Verelan PM) should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Breast carcinoma in situ.
Treatment:  Intensity Modulated Radiation Therapy.

The insurer denied the Intensity Modulated Radiation Therapy.  The determination is overturned.

This is a patient with a left breast multifocal duct carcinoma in situ post lumpectomy with negative margins.  Radiation therapy is recommended to the whole left breast to decrease her risk of recurrence, and intensity-modulated radiation therapy (IMRT) with hypofractionation is requested.  At issue is the medical necessity of the IMRT.

The requested treatment of IMRT is considered medically necessary for this patient.  The recommended IMRT for this patient and her left breast carcinoma post lumpectomy is considered medically necessary based on a review of the provided clinical information.  The ordering physician has had dosimetric plans performed for both 3 dimensional (D) conformal radiation therapy and IMRT with associated dose-volume histograms showing that vital critical structures, such as the heart and lung, would receive too high of a radiation dose with 3D conformal therapy and acceptable doses with IMRT.  This is supported by the National Comprehensive Cancer Network (NCCN) Guidelines as category 2a and is considered medically appropriate and necessary.