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

Diagnosis: Type-one diabetes complicated by gastroparesis. 
Treatment: Inpatient Hospital Admission. 

The insurer denied: Inpatient Hospital Admission. 
The denial is overturned. 

This is an adult male patient with type-one diabetes complicated by gastroparesis who presented with four to five days of nausea/vomiting, abdominal pain, and chest pain. The patient's glucose was 353 milligrams per deciliter (mg/dL), anion gap was 26, and carbon dioxide (Co2) was 11.  Vital signs were notable for a heart rate of 127. The patient was treated with subcutaneous insulin, intravenous fluids, and Zofran. He was noted to have intractable nausea and vomiting and inability to tolerate oral intake. The request for inpatient hospital admission is under review. 

The inpatient hospital admission was medically necessary. 

This patient presented with nausea and vomiting with diabetic ketoacidosis with a glucose of 353 milligrams per deciliter (mg/dL) and carbon dioxide (CO2) of 11. He had intractable nausea and vomiting that required inpatient monitoring and intravenous hydration. He had ongoing nausea and vomiting complicated by hypokalemia of 2.8 requiring replacement. Therefore, yes, the inpatient hospital admission was medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal/Crohn's Disease.
Treatment: Pharmacy/Prescription Drugs/Stelara.
The health plan denied the requested medication, Stelara, as experimental/investigational. 
The health plan's determination is overturned.

The patient is a female with fistulizing Crohn's disease (CD) complicated by perianal involvement. She has failed Remicade and Humira. She started Stelara. She had onset of active disease symptoms. A colonoscopy showed active disease with large ileal ulcers and ulcerations throughout the colon. Fecal calprotectin was elevated at 193. The coverage is requested for Stelara 90 milligrams (mg) every 4 weeks for the treatment of Crohn's disease.

The health plan's determination is overturned, on whole.

Current medical literature supports dose escalation of Stelara to 90 mg every 4 weeks as likely to be more beneficial than any standard treatment or treatment for the patient's Crohn's disease. A large randomized controlled trial demonstrated safety and efficacy for induction and maintenance of remission in patients with moderate-severe Crohn's disease that was resistant to anti-tumor necrosis factor (TNF) therapy (Sandborn, et al). Another study showed a 73% response in patients with anti-TNF-resistant Crohn's disease, and 80% of responders maintained remission for 1 year (Kopylov, et al). The mechanism of Stelara (ustekinumab) is entirely different than that of anti-tumor necrosis factor medications, which the patient has failed (Tuskey, et al). A study showed dosing at 90 mg every 4 weeks was used frequently to address inadequate disease control, and a large proportion of patients were able to maintain response with dose escalation to 90 mg every 4 weeks (Kopylov, et al). Multiple studies have shown that a majority of patients in whom Stelara dosing every 8 weeks failed to control symptoms responded to dosing every 4 weeks (Wils, et al; Battat, et al; Khorrami, et al). In this case, the patient with fistulizing Crohn's disease status post multiple surgeries have had disease symptoms, active disease on colonoscopy, and elevated markers of disease activity (fecal calprotectin) while taking Stelara every 8 weeks. American College of Gastroenterology guidelines for the treatment of Crohn's disease state that "Those with continued symptoms should... have their medication dose adjusted to attempt to optimize therapy" (Battat, et al; Lichtenstein, et al). Continuation of dosing every 8 weeks or discontinuation of Stelara (even if an alternative is attempted immediately) may result in loss of disease control, with complications such as stricture, fistula, bowel obstruction, flare, hospitalization, need for surgery, or other complications. For these reasons, Stelara 90 mg every 4 weeks is supported as likely to be more beneficial than any standard treatment or treatment for the patient's Crohn's disease.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left labial cellulitis/abscess
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is overturned.

The patient is an adult female with a past medical history significant for diabetes mellitus, hypertension, and hypercholesterolemia who presented to the emergency department with complaints of an abscess on the left labia, associated with fever and chills.

Vitals on presentation included: Temperature 99.0 degrees F (Fahrenheit), Blood Pressure 179/90, Pulse 98, Respiratory Rate 18, oxygen saturation 99% on room air. Laboratory results included the following: WBC (white blood cell count) 15.3, HGB (hemoglobin) 13.9, HCT (hematocrit) 41.0, creatinine 0.54, glucose 291, and lactic acid 1.2.

The patient was admitted for a left labial cellulitis/abscess. She was treated with intravenous fluids and intravenous antibiotics (vancomycin and Zosyn). Wound cultures grew Group B Streptococcus agalactiae. The patient remained afebrile, hemodynamically stable, and she was discharged on oral antibiotics (Augmentin) to continue follow-up as an outpatient.

Based on above findings in a high-risk patient with poorly controlled diabetes and failure of outpatient management, a hospital admission was medically necessary for administration of intravenous antibiotics.  

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 the inpatient hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

This is a case of an adult female who presented to the hospital complaining of chest pain.  Past medical history was significant for myocarditis with preserved left ventricular ejection fraction (LVEF), hypertension and anemia.  Pain lasted for hours and radiated to her left arm.  She also noted a productive cough. On arrival to the hospital, vital signs were stable and lung exam demonstrated decreased breath sounds on expiration.  A 12-lead electrocardiogram revealed no evidence of ischemic ST/T (interval on electrocardiogram (EKG) wave abnormalities.  Serum troponin and B-type natriuretic peptide were not elevated. She was admitted to the hospital for monitoring and treatment. 

This patient presented with chest pain and a past medical history of myocarditis and hypertension. Her pretest probability of coronary artery disease was low (Reference 1). Utilizing the HEART (History, EKG, Age, Risk Factors, Troponin) score she was considered low risk (Reference 2). Utilizing the thrombolysis in myocardial infarction (TIMI) risk score she also had a low risk of developing major adverse cardiac events in the subsequent 30 days (Reference 3). Risk assessment of patients presenting with chest pain and no significant ST changes on ECG (electrocardiogram) was reviewed by Hedayati et al. (Reference 3). Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation.  Using the TIMI risk score, this patient would have a low risk of major cardiac events (all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation.  In conclusion, admission to the hospital to treat an acute cardiac event 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 admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Grade D (one or more mucosal break involving 75% [percent] of the esophageal circumference) esophagitis and gastritis

Treatment: Inpatient Level of Care

The insurer denied coverage for inpatient level of care

The denial is upheld

The patient had a history of pancreatitis and presented with abdominal pain, nausea, and vomiting. He was afebrile but had hypertension. The abdominal exam was benign. The lipase was 171. An abdominal computed axial tomography (CAT) scan was normal. Intravenous (IV) hydration and proton pump inhibitor (PPI) therapy were given. An endoscopy revealed grade D (one or more mucosal break involving 75% [percent] of the esophageal) esophagitis and gastritis. 

Clinical indications for admission for Undiagnosed Abdominal Pain (Milliman Care Guidelines [MCG]) include hemodynamic instability, peritoneal signs, inability to maintain oral hydration after observation care, bacteremia, and the need for a procedure that cannot be performed on an ambulatory basis. The patient did not have these conditions.

Clinical indications for admission for Esophageal Disease (MCG) include esophageal perforation, complete obstruction, mediastinitis, severe vomiting that is not responsive to antiemetics, severe electrolyte abnormalities, severe pain that is not responsive to analgesia, and an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

This patient had abdominal pain and vomiting and was diagnosed with grade D esophagitis and gastritis. IV hydration, antiemetics, and PPI therapy could have been given in the emergency room (ER) with observation status. He was stable to have had the endoscopy performed on an ambulatory basis. He did not have CAT scan findings or abdominal exam findings that were consistent with acute pancreatitis. He did not meet MCG criteria for admission for either Undiagnosed Abdominal Pain or Esophageal Disease. 

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 level of is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chronic Kidney Disease.
Treatment:  Inpatient hospital admission.

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

This patient with chronic kidney disease was admitted for worsening swelling and pain in the lower extremities. They were also evaluated by nephrology and did not require emergent dialysis and were treated with intravenous diuretics. 

Specialty society guidelines, based on systematic evidence reviews, conclude that most patients with a deep vein thrombosis (DVT) can be treated as outpatients. [1]

A systematic review and meta-analysis of 7 randomized trials (1839 patients) concluded that home treatment of DVT was safe, with no differences in major bleeding, minor bleeding, or mortality as compared to hospital treatment. [2]
 
Traditional outpatient treatment includes subcutaneous low-molecular-weight heparin transitioning to an oral vitamin K (fat-soluble vitamin) antagonist (e.g. ["for example"], warfarin); however, a specialty society guideline concludes that given the advantages of oral factor Xa (anticoagulants) inhibitors and oral direct thrombin inhibitors (i.e. ["that is"], predictable anticoagulant activity obviating the need for regular laboratory testing), selected low-risk patients with acute DVT may be safely discharged from the emergency department and treated at home with one of these agents (i.e., direct discharge on apixaban or rivaroxaban; or discharge on dabigatran or edoxaban following days of low-molecular-weight heparin). [3]

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 hospital admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Recurrent Hypoglycemia and Metabolic acidosis.
Treatment: Full Hospital Admission.

The insurer denied coverage for the full hospital admission.  The denial is overturned.

This male child presenting with vomiting, lethargy, and diaphoresis with normal vital signs except for respiratory rate of 32 revealing tachypnea. Blood sugar was low at 48. Complete blood count (CBC) demonstrated elevated white blood cell count (WBC) with increased neutrophils. Electrolytes confirmed low blood glucose of 45 associated with mild acidosis [bicarbonate level (HCO3) 18.7]. Apple juice was given resulting in vomiting, and he was then treated with intravenous (IV) hydration and ondansetron with a rise in blood sugar to 226. Subsequently he developed lower abdominal pain and was evaluated radiographically for acute appendicitis, which was ruled out. Blood sugar was noted to fall again to 54 requiring another IV bolus, and he was admitted for ongoing inpatient monitoring including blood sugar monitoring.

The plan has denied admission, stating that the hypoglycemia was not associated with severe symptoms such as hypotension, persistent vomiting, confusion, severe weakness or problems caused by diabetes medication and, therefore, not an indication for admission. However, the presentation of the patient included the altered mental state, and severe weakness, recurrent vomiting when challenged initially with oral intake, decline in blood glucose after initial treatment requiring a second treatment with more continuous IV therapy. 

The patient unequivocally demonstrated hypoglycemia, as defined according to pediatric endocrine guidelines [1] as: 1) having a low plasma glucose; 2) signs and symptoms consistent with hypoglycemia; 3) symptoms relieved by treatment of the hypoglycemia. Evaluation of hypoglycemia requires establishing whether persistence exists requiring further work-up. [2] The patient was admitted with both vomiting and hypoglycemia to establish resolution versus persistence requiring more invasive work-up [1;3] and safety for discharge. 

The insurer has not acted reasonably in the best interest of the patient, since the patient manifested all the requirements for admission and required prolonged hydration and observation with ongoing blood glucose measurement to establish the absence or presence of persistence. 

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

Diagnosis: Dental Caries. 
Treatment: Crown on tooth # (number) 31. 

The insurer denied coverage for crown on tooth #31.  The denial is upheld. 

The only objective documentation provided for review is a copy of one updated post treatment/ post crown placement bitewing radiograph. There are no other dental treatment records provided for review. It appears that there is no evidence of fracture or other pathology specifically affecting tooth #31 based on the image provided for review. There does not appear to be any radiographic evidence of caries. The radiograph does not substantiate the requested dental services as enumerated above, and, therefore, the crown is deemed not medically necessary. 

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

The medical necessity for a crown on tooth #31 is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Pain.
Treatment: Inpatient hospital admission.

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

This is the case of an adult male that presented to the hospital complaining of chest pain radiating to his left arm that was exacerbated by deep inspiration. Past medical history was significant for transient ischemic attack (TIA). Upon arrival to the hospital, vital signs were stable with blood pressure (BP) of 122/75 and heart rate (HR) of 71. Physical examination was unremarkable. A 12-lead electrocardiogram (EKG) revealed normal sinus rhythm with ST (interval on EKG) segment depressions in the inferior leads and ST elevation. Serum blood testing revealed normal troponin levels. Urine toxicology was positive for cocaine and opiates. Echocardiogram revealed a reduced left ventricular ejection fraction of 25% (percent) and moderate aortic insufficiency. He was referred for cardiac catheterization but ultimately signed out against medical advice prior to the procedure. 

This patient presented with chest pain in the setting of active cocaine use. 

Echocardiography revealed severely depressed left ventricular systolic function and aortic regurgitation. This was a new finding, not present on a previously performed echocardiographic study. The patient's pretest probability of coronary artery disease is moderate (1). Utilizing the HEART (History, EKG, Age, Risk factors, and troponin) score, he was considered moderate risk (2). Utilizing the TIMI (Thrombolysis in Myocardial Infarction) risk score, he also had a moderate risk of developing major adverse cardiac events in the subsequent 30 days (TIMI score=1) (3). Risk assessment of patients presenting with chest pain and no significant ST changes on EKG was reviewed by Hedayati et al. (3) Using the HEART score risk stratification schema, this patient would have a moderate risk of major adverse cardiac events [myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death] in the six weeks following presentation.  

In addition to his moderate risk for major adverse cardiac events, this patient was actively using cocaine. Investigators studying more than 300,000 hospital admissions for chest pain in the setting of cocaine abuse, found that middle-aged patients, with concomitant heart failure and valvular disease had the highest risk of major adverse cardiac events and mortality. They concluded that such patients did require hospital admission (4). 

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

The insurer's denial of coverage for the inpatient hospital is overturned. Medical Necessity is substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Pneumonia, Myelodysplasia. 
Treatment: Posaconazole delayed-release tablet. 

The insurer denied Posaconazole delayed-release tablet. 
The determination is overturned. 

This is a patient with myelodysplasia. He has neutropenia and progressively worsening lung infiltrates on computed tomography (CT) scan. Although bronchoalveolar leverage was negative, with multi agent antimicrobial coverage including Posaconazole; this is under review. 

The National Comprehensive Cancer Network (NCCN) Guidelines recommend Posaconazole as a category 1 recommendation in this clinical scenario. The alternative agents are category 2b. The use of Posaconazole in this setting is supported by the authors of UpToDate, The authors of UpToDate state "....Posaconazole prophylaxis was associated with a significant reduction in proven or probable invasive fungal infections (2 versus 8 percent) that was due entirely to a reduction in invasive aspergillosis. Posaconazole was also associated with a significant reduction in all-cause mortality (16 versus 22 percent)...". For these reasons, the use of Posaconazole would be considered to be more effective than the formulary alternatives.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: DVT (deep vein thrombosis) 
Treatment is an inpatient admission.
The insurer denied coverage for an inpatient admission.
The denial is modified.

According to the clinical documentation provided for review, the patient is a male with the medical diagnoses of non-Hodgkin's lymphoma, in remission, autoimmune hemolytic anemia, and multiple deep vein thromboses (DVTs). The patient presented to the emergency room (ER) with complaints of right leg pain, ecchymosis, and swelling. The patient's computerized tomography (CT) scan showed a right thigh hematoma. There was bleeding suspected, and the patient was transfused. A DVT was also diagnosed at that time. An inferior vena cava (IVC) filter was placed. 

This was not a simple non-complicated DVT, but one caused by a significant hematoma. However, the entire admission was not necessary. Once the IVC filter was placed, the patient could be safely discharged to complete outpatient anticoagulation, or an oral anticoagulant could have been used on an outpatient basis. The patient's Hb (hemoglobin) remained at 8.2 to 8.3 for the next several days. Even if that may have been an issue, the observation level would have been appropriate. Therefore, the request is partially approved and medically necessary for this patient. 

"The purpose of this pictorial essay is to review different etiologies for lower extremity pain encountered on lower extremity venous sonography including acute deep venous thrombosis, chronic post-thrombotic change, central venous disease, common arterial pathologies, and nonvascular abnormalities." (Naringrekar, et al., 2019).

"A deep-vein thrombosis (DVT) is a blood clot that forms within the deep veins, usually of the leg, but can occur in the veins of the arms and the mesenteric and cerebral veins. Deep-vein thrombosis is a common and important disease. It is part of the venous thromboembolism disorders which represent the third most common cause of death from cardiovascular disease after heart attacks and stroke. Even in patients who do not get pulmonary emboli, recurrent thrombosis and "post-thrombotic syndrome" are a major cause of morbidity." (Waheed, et al., 2021).

The inpatient admission is considered partially medically necessary for this patient.                                              

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 modified.