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

Diagnosis: Fungal Skin Infection.
Treatment: Ketoconazole 2% (two percent) Foam.

The insurer denied: Ketoconazole 2% Foam.  The denial is upheld.

The patient is an adult male with human immunodeficiency virus (HIV) reporting fungal skin infection for whom ketoconazole two percent (2%) foam is requested.  However, per the medical records submitted, skin assessment did not reveal a rash.
The request was denied because, to approve this medicine, the patient must meet the following requirements: "our Non-Formulary Medication Exception Review Policy (Pharmacy-69) says that your doctor must show us that you have had serious side effects or drug failure with all formulary alternatives within this drug class. Formulary alternatives include ketoconazole 2% cream, econazole nitrate cream, nystatin cream/ointment.

The health plan should not cover the proposed treatment.

There is no documentation in the medical chart notes provided that the patient has a fungal skin infection for which the requested drug is indicated. EXTINA (ketoconazole) foam, two percent, is indicated for the topical treatment of seborrheic dermatitis in immunocompetent patients 12 years of age and older. There is no documentation of seborrheic dermatitis. In addition, the formulary alternatives include ketoconazole two percent cream, which is indicated for the topical treatment of tinea corporis, tinea cruris and tinea pedis caused by Trichophyton rubrum, T. mentagrophytes and Epidermophyton floccosum; in the treatment of tinea (pityriasis) versicolor caused by Malassezia furfur (Pityrosporum orbiculare); in the treatment of cutaneous candidiasis caused by Candida spp. and in the treatment of seborrheic dermatitis. Therefore, ketoconazole two percent foam has no advantages per the indications.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension
Treatment: Inpatient Admission
The insurer denied the inpatient admission.
The health plan's determination is upheld. 

The patient is a female who initially presented to the emergency department with concerns of elevated blood pressure and blurry vision. Pertinent history included hypertension. Review of systems noted that her presenting symptoms improved on arrival. Initial vital signs revealed a temperature of 97.7oF, heart rate (HR) 79, blood pressure (BP) 197/92, respiratory rate (RR) 20, and peripheral capillary oxygen saturation (SpO2) 100% on room air. Initial examination documented the patient as alert and oriented without focal neurological deficits. Initial laboratory testing revealed a white blood cell count (WBC) 4.5, HGB 13.6, platelets (Plt) 261, Troponin I 0.113 -> 0.135 -> 0.139, creatine kinase (CK) 78, blood urea nitrogen (BUN) 13, Creatinine 0.53, Glucose 134, Na (sodium) 139, and K (potassium) 4.2. Initial electrocardiogram (EKG) revealed normal sinus rhythm without acute ischemic changes. A computed tomography (CT) head did not reveal acute intracranial findings. Repeat blood pressure decreased to 145/90 without intervention. The patient was placed in the hospital with an impression of hypertensive urgency. 

Based on the clinical documentation provided, evidence based literature and standards of care, the acute inpatient level of care was not medically necessary. Evaluation and management could have been performed at a lower level of care. In this particular situation, the patient presented with an elevated blood pressure and met the aforementioned criteria for a diagnosis of hypertensive urgency. While in the emergency department, blood pressure decreased to 145/90 without intervention. Additional evaluation noted a mildly elevated troponin without a crescendo pattern and an unremarkable electrocardiogram (EKG), Echocardiogram, and computed tomography (CT) head. Treatment plan included resumption of home oral atenolol. The patient was deemed medically stable and discharged the same day she was placed in the hospital. No other issues or complications were documented.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right shoulder pain.
Treatment: Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement).
The insurer denied Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement). 
The determination is overturned.

The patient has a history of right shoulder pain. He underwent shoulder stabilization surgery many years earlier and developed post-surgical osteoarthritis of the right shoulder that was painful and function limiting. The patient was evaluated by an orthopedic provider who performed a clinical exam and reviewed plain radiographs and a magnetic resonance imaging (MRI) scan of the affected right shoulder. The assessment was advanced glenohumeral arthritis of the right shoulder. The patient had attempted a prior cortisone injection and use of oral anti-inflammatory medications without pain relief or improvement in function. The provider proposed right total shoulder replacement surgery. At issue, in this case, is the medical necessity of the proposed right total shoulder replacement.

The requested right total shoulder arthroplasty in this case is medically necessary. The provided medical records document that this patient has advanced glenohumeral arthritis proven on both pain radiographs and a subsequent MRI scan of the right shoulder. The records also document that the patient had an injection of cortisone and used oral nonsteroidal anti-inflammatory drugs (NSAIDS) without improvement in his pain. The orthopedic provider addressed the issue of physical therapy directly in his progress note.  He stated that a course of physical therapy will not help this patient based on the magnitude and severity of his shoulder osteoarthritis.   Thus, based on the provided documentation, the medical necessity of the proposed total shoulder replacement is established in this case. In addition, based on the recommendations of the peer-reviewed literature as documented by Piper and colleagues in the Journal of the American Academy of Orthopedic Surgeons and by Roberson and associates in the Journal of Shoulder and Elbow Surgery, the proposed right total shoulder replacement surgery is indicated and medically necessary in this case.
Based on the provided medical records, the patient has advanced glenohumeral arthritis and failed conservative treatment for this condition. Thus, he is a suitable candidate for total shoulder replacement surgery according to the recommendations of the current, peer-reviewed orthopedic literature.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sickle Cell Disease/Vaso-occlusive disorder
Treatment: Full hospital admission
The health plan denied the full hospital admission.
The denial is overturned.

The patient has a history of sickle cell disease and presented with left shoulder pain. Her pain was unresponsive to her home pain regimen. She was afebrile, non-hypoxic with a slightly soft blood pressure of 100/71. She was uncomfortable on exam. She also had chest wall tenderness. She had hemoglobin of 8.9. Her electrocardiogram (EKG) was unremarkable. Chest X-ray was unremarkable. She was started on intravenous (IV) Toradol, IV Dilaudid and IV fluids. She was admitted for pain control and Vaso-occlusive disorder. The patient was requiring frequent pain medications parenterally. She has requiring IV Toradol until the day of her discharge and IV morphine a day before her discharge. The patient was also maintained on her hydroxyurea. She was eventually discharged home on adjusted pain medications.

Yes, the inpatient stay was a medically necessity. This patient had failed home pain management as well as the pain management at a lower level of care. She required IV pain medications beyond the period of lower level care  and needed inpatient care.
She needed inpatient evaluation and management for her painful Vaso-occlusive crisis. Patients with painful sickle cell crisis can be managed at home with traditional pain medications but if the pain is not controlled with oral home pain medications, and the pain regimen is escalated to include opiates, and if in severe pain the patient may need IV pain medications including IV opiates, as in this patient [1]. Also, per Milliman Care Guidelines (MCG) health Inpatient & Surgical Care 26th Edition Sickle Cell Disease ORG: M-331, the inpatient admission is recommended when the pain is insufficiently controlled at a lower level of care and require IV pain medications including opiates as was the case in this patient [2]. Therefore, based on this the inpatient admission was indicated and a medical necessity in this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholecystitis
Treatment: Inpatient Admission
The insurer denied the inpatient admission.
The determination is upheld.

The patient presented to the emergency department (ED) with upper quadrant abdominal pain. Her past medical history included obesity. She was status post sleeve gastrectomy. At the time of presentation, the patient was without a fever and the heart rate was 65 beats/minute. She had a tender right upper abdomen per the examination. The white blood cell (WBC) count was 9.75 thousand (K). The complete metabolic panel identified normal transaminases with normal bilirubin. An ultrasound showed findings of gallstones. She was treated with a laparoscopic cholecystectomy. The records indicate an uncomplicated cholecystectomy procedure with findings of cholecystitis. The patient was treated with post-surgical monitoring, intravenous (IV) fluid, IV analgesia, and antiemetics. The immediate post-surgical recovery was uncomplicated. The pain was controlled with oral medications following surgery. The diet was advanced. The patient remained clinically stable and was discharged from the inpatient setting.
At issue is the medical necessity of an inpatient stay.

An inpatient admission was not medically necessary.
This patient presented to the hospital with cholelithiasis/cholecystitis. She was tender in the right upper quadrant and had normal liver enzymes. Based on her clinical condition and diagnostic test results, the indication for cholecystectomy was established. The patient underwent an uncomplicated laparoscopic cholecystectomy procedure. There were no peri-operative complications or other clinical issues that mandated an inpatient designation. There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care. Additionally, there is no documentation of failure to achieve discharge criteria, conversion to open surgery, care for comorbidities, procedural complications, or any other condition requiring inpatient admission. Acute inpatient care was not medically necessary for this patient as the care and treatment provided could have been rendered with a lower level of care. A lower level of care would have provided for emergency department (ED) assessment, surgical consultation, cholecystectomy, perioperative care and monitoring, provision of IV antibiotics and fluid, and overnight care. The patient was clinically stable following surgery as supported by the corresponding medical records. She was tolerating a diet and oral analgesia following the surgical procedure.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: cellulitis
Treatment: inpatient stay
The insurer denied the inpatient stay. 

The health plan's determination is upheld.

This is a case of a female admitted for a diagnosis of cellulitis of the right knee. The patient presented with right knee pain and redness for four days prior to admission. It was noted that she had a cortisone injection by rheumatology five days prior to the right knee and the following day developed pain and redness which was worsening. 

The inpatient hospital admission was not medically necessary. The patient in this case required treatment for cellulitis of the right knee and did not require urgent surgical intervention or treatment for septic arthritis. There was no diagnosis of severe sepsis, septic shock or a rapidly progressive infection. There was pain but no reported pain out of proportion to exam findings. There were no complicating factors such as involvement of infection with a vascular graft, joint prosthesis, or compartment syndrome. There was no necrotizing fasciitis, gas gangrene, fever, rapid progression of erythema, or inability to tolerate oral therapy. There was no soft-tissue abscess. There was no immunocompromising condition or medication use causing neutropenia. Arthrocentesis was performed which did not have pus and 20ml (milliliter) of only typical yellow fluid was removed. There was no hemodynamic instability and she had an improvement of erythema with typical treatments such as with intravenous antibiotics and physical therapy. The patient could have received these treatments at a lower level of care. She had full range of motion of the right knee and was neurovascularly intact. She was allowed to be weight-bearing as tolerated and was not restricted from ambulation.
Although the patient required services in the hospital setting, the monitoring, diagnostics, testing, and therapeutic interventions prescribed could have been rendered at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypernatremia.
Treatment: Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

The patient was brought to the emergency department (ED) when hypernatremia was found on lab values done at the pediatrician's office earlier in the day. The baby was born by Cesarean (C)-section for a non-reassuring fetal heart tracing. When seen as an outpatient, there was a greater than 10% weight loss from birthweight. The mom was instructed at that time to supplement breast feedings with formula feedings. The pediatrician saw the lab results from with a sodium of 156, so the baby was brought to the ED for a repeat lab test. In the emergency department (ED), the baby appeared well with normal vital signs. The repeat sodium was 152. The baby was given a normal saline bolus and admitted to the pediatric floor, where she was continued on a small amount of intravenous (IV) fluid and continued to feed and had a lactation consultation. The sodium the next day was 144, so she was discharged home. At issue is the medical necessity of an inpatient stay.

The inpatient stay was not medically necessary. The serum sodium of 156, coupled with the more than 10% weight loss observed in the pediatrician's office, required the return visit to recheck the baby and recheck the sodium. That visit could have been in the pediatrician's office, but the pediatrician directed the parent to go to the emergency department instead. There, the sodium had already improved to 152. The baby was already heading in the proper direction prior to admission. There is no documentation of further weight loss or any history of poor feeding that would suggest an ill baby. The baby appeared well. To whatever extent she was dehydrated, that was corrected by the normal saline bolus received in the emergency department. There was no indication for further IV therapy in a baby who is taking fluids orally. The interventions in the hospital, breast feeding advice with formula supplementation, could equally have been done at home with close outpatient follow up by the pediatrician.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Overbite.
Treatment: Braces and visits.
The insurer denied: Braces and visits.
The denial is: Upheld.

The patient is a male with a Class I occlusion with 5 millimeter (mm) overbite and 5mm overjet. He has moderate maxillary and mandibular crowing. He is treatment planned for orthodontics to correct his malocclusion. The subject under review is the medical necessity for the treatment with braces and visits.

The health plan's determination is upheld.

The requested treatment with braces and visits are not medically necessary for this patient.
There is no medical reason to correct his malocclusion with braces. He has crowding but no teeth are impacted. His overbite is deep but there is no indication of damage to the incisors in the photographs. His cephalometric radiograph shows the lower incisors are not contacting the palate in occlusion. There is no indication from the photographs there is severe soft tissue damage (or any soft tissue damage) on this patient. There are no anterior or posterior crossbites present. The mandibular second molars are unerupted, but they are not ectopic or impacted. There is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession.
There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence.[1] This patient presents with none of those conditions. Aligning his teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion.[2] The patient has a 5mm overjet but this amount of overjet does not affect oral health related quality of life.[3] If his teeth were aligned it would provide an esthetic improvement but it would not create a medically significant improvement to the patient's health. Braces and visits are not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumonia

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This is a patient with a history of asthma. He had been sick with the influenza virus 2 weeks prior to the admission. He then developed fever and a cough 2 days prior to the admission. He was seen at Urgent care with a fever of 104 and oxygen desaturation of 90%. He also was then seen twice by his pediatrician because of the illness with fever and coughing. The child had a history of asthma and was using albuterol at home. The child had been drinking less fluid and was also noted to have a decrease in the quantity of urine produced daily. The pediatrician ordered an outpatient chest x-ray which was read as showing pneumonia. The pediatrician treated with albuterol, Decadron and intramuscular (IM) ceftriaxone in the office. The child returned to the pediatrician the next day and was given a second dose of IM ceftriaxone. A respiratory viral panel was positive for the respiratory syncytial virus (RSV). When the pulse oximeter reading was low the pediatrician referred the child to the hospital for additional treatment for dehydration and pneumonia.

In the emergency room (ER) he was noted to be tired and pale in appearance. On physical examination he was noted to have rales and crackles over the right lung field. A chest x-ray showed bilateral diffuse haziness. The parents indicated that the child had been seen in the past by a pediatric pulmonologist because of a chest x-ray which showed an abnormality with a possible hernia with a portion of bowel seen in the chest. He was treated with 2 boluses of intravenous (IV) normal saline and started on IV vancomycin and ceftriaxone. After treatment in the ER, he was reevaluated, and he was noted to have persistent rales over the right chest and the decision was made to admit him to the hospital with a diagnosis of pneumonia for ongoing treatment with antibiotics and IV fluids.

The insurer has denied the admission as not medically necessary and indicated that there was no documentation in the medical record to support the need for inpatient treatment. The patient was treated appropriately in the ER for a cough, dehydration and a respiratory infection. He had been taking albuterol for 2 days at home and following treatment in the pediatrician's office for asthma and pneumonia, however he continued to have evidence of dehydration and chest congestion. He failed outpatient management of his pneumonia and had evidence of dehydration. Following treatment in the ER he continued to have rales and crackles over the right lung field, and he was not considered stable enough to be sent home. He was diagnosed with dehydration, and he required ongoing treatment with IV fluids. The admission to the hospital for treatment for pneumonia and dehydration was appropriate and consistent with the standard of care.

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

The insurer's denial of coverage for inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Varicose Veins
Treatment: Surgery (surgery and ablative procedure)
The health plan denied the surgery and ablative procedure.
The denial is overturned. 


The patient is a female. The patient presented with right leg varicose veins with symptoms of painful varicosities, leg aching, heaviness, and swelling. The patient has worn compression stocking regularly with minimal relief. Duplex showed severe reflux and enlargement of the right anterior accessory vein (AASV). The provider has recommended ablation of this vein.
Coverage was denied by the health plan on the basis that the documentation does not demonstrate symptoms severe enough to interfere with normal function. The denial is being appealed.
The requested health service is medically necessary.
The patient presented with right leg varicose veins with  symptoms of painful varicosities, leg aching, heaviness, and swelling. The patient has worn compression stocking regularly with minimal relief. Duplex showed severe reflux and enlargement of the right anterior accessory vein (AASV).
The provider has recommended ablation of this vein. Coverage was denied on the basis that the documentation does not demonstrate symptoms severe enough to interfere with normal function. 
Under widely accepted criteria [1-7], endovenous ablation of an axial saphenous vein is medically necessary when:
1) The patient has venous insufficiency symptoms severe enough to affect normal function.
2) The patient has failed a trial of prescription compression stockings.
3) The patient has duplex-proven reflux affecting the vein in question and the reflux can be reasonably construed as a cause of the patient's symptoms.

Requirement 1 has been met. The office note documents painful varicosities, leg aching, heaviness, and swelling. The symptoms can be reasonably expected to adversely affect normal function. The provider re-iterated the patient's symptoms in an appeal letter.
Requirement 2 has been met. As stated above, the patient failed prescription compression stockings, which have given her only minimal relief.
Requirement 3 has been met. The patient had a venous reflux study demonstrating enlargement and severe AASV (anterior accessory saphenous vein) reflux on the same side as her symptoms.
Therefore, the patient meets published, well-accepted criteria for right AASV (anterior accessory saphenous vein) ablation.
The denial letter stated that the documentation does not demonstrate adverse impact of the symptoms on the patient's normal function. However, the symptoms described in both the office note and the appeal letter can reasonably be expected to adversely affect normal activities.
The health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.