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

Diagnosis:  Excess Abdominal Skin.
Treatment:  Panniculectomy.

The health plan denied the panniculectomy.  The health plan's determination is overturned.

This female has lost weight. Her weight is stable. She has skin rashes in skin breakdown in the areas of her abdominal pannus where she has skin on skin contact. She has been treated for rashes with oral antibiotics and topical medications. Primary care physician (PCP) and plastic surgery notes document rashes or a history of rashes in the pannus fold. Photos show skin changes in the pannus fold. A panniculectomy is planned.
At issue is the medical necessity for the requested panniculectomy.

I overturn, in whole, the health plan's determination of medical necessity.

A panniculectomy is medically necessary. According to the American Society of Plastic Surgeons (ASPS) Position Paper "Treatment of Skin Redundancy For Obese and Massive Weight Loss Patients," "When surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patient's appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature and not a compensable procedure." For example, a panniculectomy to eliminate a large hanging abdominal panniculus and its associated symptoms would be considered reconstructive. In situations where a circumferential treatment approach is utilized to also treat the residual back and hip rolls or the ptotic buttock tissue, only the anterior portion of the procedures would be considered reconstructive, the remaining portion of the procedure would be considered cosmetic. Only in rare circumstances will buttock, thigh or arm lifts be needed to treat functional abnormalities. Typically, these procedures are performed to improve appearance and are therefore cosmetic in nature." The records indicate that the patient has failed conservative treatment for her longstanding rashes, including treatment by her PCP. Photos show skin changes under the pannus fold. A panniculectomy will eliminate her rashes. The patient's condition also meets the Milliman Care Guidelines (MCG), 26th edition guidelines for a panniculectomy.
Per the guidelines: Panniculectomy may be indicated when ALL of the following are present:  1) Patient has complications from panniculus (e.g., chronic or recurrent intertrigo, other skin infection, ulceration, or skin irritation that has been persistent despite nonsurgical treatment), 2) Pannus interferes with activities of daily living, and 3) Patient's weight has reached stable plateau, and 1 or more of the following: a)Adherence to multidisciplinary nonsurgical program of weight maintenance, and b) One year or more has elapsed following bariatric surgery.

The patient has persistent rashes despite medical treatment including prescription topical and oral medications. The records confirm problems with activities of daily living. Photos show a female with skin changes under her pannus. Her weight is stable based on the clinical notes.

Based on the ASPS, and MCG guidelines, a panniculectomy is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Symptomatic atrial flutter
Treatment inpatient admission
The insurer denied coverage for inpatient admission.
The denial is upheld.

This is a patient who presented to the hospital complaining of palpitations and right arm numbness. Past medical history was significant for bioprosthetic aortic valve replacement. Upon arrival to the hospital pulse was 145 bpm (beats per minute) and blood pressure was 143/108mmHg (millimeters of mercury). Physical exam revealed no other abnormal findings. A12-lead ECG (electrocardiogram) revealed atrial flutter with a ventricular rate of 150bpm. The patient was treated with diltiazem and anticoagulant therapy and admitted to cardiac telemetry. He reverted to sinus rhythm spontaneously and was discharged the following day.

The health plan did act reasonably. This patient presented with symptomatic atrial flutter and was effectively treated with AV (atrioventricular) nodal blocking agents. Following evaluation and additional testing, the patient reverted to normal sinus rhythm and was released from the hospital. Bellew et al. studied patients presenting to the hospital with rapidly conducted atrial fibrillation and compared outcomes between those admitted to the inpatient service and those that were observed in the emergency department. In this study of almost 600 patients, there was no difference in outcome. AHA (American Heart Association) guidelines note that admission to the hospital for management of atrial fibrillation in patients that achieve rate control do not require hospital admission (Reference 2). This patient reverted to normal sinus rhythm several hours after presentation. In conclusion, this patient could have been managed at a lower level of care.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission services is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pregnancy
treatment: Chromosomal Microarray (CMA) Testing
The insurer denied CMA testing.
The health plan's determination is overturned.

The patient is a female. She is under consideration for medical necessity of genetic testing in the form of chromosomal microarray (CMA) testing. The patient was noted to have an ultrasound that revealed a fetal cleft lip, cleft palate, 2-vessel umbilical cord, ventricular septal defect and possible anterior aorta coarctation. She had a prior history for aneuploidy with a mosaic Turner syndrome fetus. The patient was at 18-6/7 weeks when she was seen at the fetal diagnostic center. The ultrasound noted all of the aforementioned anomalies on ultrasound at that time. The patient underwent amniocentesis for acquisition of fetal cells for plan of microarray analysis given the findings. In this case, the infant was noted to have a diagnosis of Schuurs-Hoeijmakers Syndrome.

Genetic testing: CMA testing is medically necessary for this patient.

The patient in this case had a current pregnancy affected with multiple fetal anomalies that are characteristic for genetic abnormalities given the multiple organ systems (facial, heart, vascular, and fetal cord) affected. In this case, the fetus was noted to have fetal cleft lip, cleft palate, 2-vessel umbilical cord, ventricular septal defect and anterior aorta coarctation by fetal echo ultrasound. The patient was counseled on these findings and that underlying genetic condition may be the cause for this presentation. The patient then underwent an amniocentesis and CMA testing.

In this case, the findings on ultrasound in the prenatal assessment of this fetus found multiple fetal anomalies that are characteristic of a genetic abnormality. Thus, there would be medical necessity for performance of the testing - CMA analysis in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ventral hernia
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult male who presented to the emergency department and was admitted to the hospital.  He was status post repair of a ventral hernia five years ago.  The records also indicate that the patient had undergone an incision and drainage procedure for an abdominal wall abscess.  

At the time of the presentation the patient had fluid drainage from the anterior abdominal wall in the area of the prior operative repair.  A computed tomography scan identified a recurrent bowel containing ventral hernia without bowel obstruction.  The white blood cell (WBC) count was normal at 7.7 thousand (K).  Surgical consultation was obtained.  The plan was for removal of the abdominal wall mesh and repair of the ventral hernia.  

The records describe performance of evacuation of the abdominal wall fluid collection, abdominal wall explantation of the mesh, and primary fascial repair of the ventral hernia.  

Post operatively the patient was afebrile and was clinically stable.  Post-surgical care included management of a surgical drain and provision of antibiotics.  A diet was started.  The next day, the patient was afebrile with normal vital signs.  He was without complaint and was tolerating a regular diet.  The patient was considered to be stable for discharge home the following day.

The health plan has denied inpatient admission, per the submitted letter, as not medically necessary because according to the health plan, there was no documentation of severe problems during or after surgery such as a very large hernia, trapped bowel or need for added surgery.  The appeal material references Milliman guidelines.

The proposed inpatient admission was not medically necessary.

The medical record does not support that inpatient admission was medically necessary for this patient.
Per Milliman criteria: for patients with a very large ventral hernia, patients with poorly controlled comorbidities that require inpatient monitoring, or operations that require significant surgery beyond the hernia repair, an inpatient status is warranted.  

This patient had an abdominal wall fluid collection that complicated a prior hernia repair operation.  At the time of presentation the patient was without fever, leukocytosis, or sign of sepsis.  His past medical history does not detail significant comorbid health conditions that required inpatient admission.  Finally, the operation involved evacuation of the abdominal wall fluid collection, abdominal wall explantation of the mesh, and primary fascial repair of the ventral hernia.  

On the first post-surgical day, the patient was clinically stable and was tolerating a diet.  The records support that he was stable for discharge from the hospital the day after surgery.  A lower level of care would have satisfied this patients clinical needs.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute blood loss anemia
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

The patient with a history of fibroids and abnormal uterine bleeding presented to the emergency room (ER) with complaints of ongoing bleeding since a Mirena intrauterine device (IUD) was placed. The IUD was removed and the bleeding continued. Her hemoglobin was 7.4.

She was admitted with acute blood loss anemia secondary to AUB (abnormal uterine bleeding). She was given intravenous (IV) Premarin 25 milligrams (mg) every 6 hours (Q6H). Tylenol was given as needed (PRN). No blood transfusion was given. The patient was discharged after a period of medical stability. 

This patient presented with acute vaginal bleeding; she received IV Premarin. IV estrogen appears to result in cessation of bleeding in most patients within five hours of the first dose by promoting rapid regrowth of the denuded endometrium, stabilizing lysosomal membranes, and stimulating proliferation of endometrial ground substance.

The American College of Obstetricians and Gynecologists (ACOG) recommends estrogen intravenously every four to six hours, for up to 24 hours.

Other than receiving IV Premarin, no other treatment was provided in the hospital. The patient could have been observed for a few hours. After reevaluating the patient and reporting that the bleeding has slowed down, the patient could have been sent home on oral Premarin. While the patient was anemic, she was asymptomatic. 

In summary, this patient could have been managed at the observation level of care. Admission was not medically necessary.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient. 

The medical necessity for the full hospital admission services is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic Dermatitis.
Treatment: Dupixent 200MG (milligrams)/1.1ML SC (subcutaneous) SOSY (solution prefilled syringe).
The insurer denied the Dupixent 200MG (milligrams)/1.1ML SC (subcutaneous) SOSY (solution prefilled syringe).
The denial is overturned.

The patient is a male with atopic dermatitis, treated with topical steroids, topical calcineurin inhibitors, and emollients.  The provider is requesting Dupixent.  The patient has 20% body surface area (BSA).  The health plan requires use of a systemic immunosuppressant agent.

Yes, the proposed treatment with Dupixent is medically necessary.
The patient has tried and failed appropriate topical therapies and has severe disease.  Dupixent is likely to be more effective than systemic immunosuppressants.

The Food and Drug Administration (FDA) also approved dupilumab for the treatment of patients aged six years and older with moderate to severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable.  This approval followed a phase III, randomized, double blinded placebo controlled trial that enrolled 367 patients to evaluate the safety and efficacy of dupilumab in children (ages six to 11 years) for treatment of atopic dermatitis (Paller et al).  Significantly and clinically meaningful improvements in patients' signs and symptoms of atopic dermatitis as well as quality of life were reported.  As seen in adults, treatment in pediatric population was reportedly well tolerated with the most commonly reported side effects including injection site reactions and conjunctivitis.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory System - Asthma
Treatment: Inpatient Admission 
The health plan denied the Inpatient Admission as not medically necessary. 
The health plan's determination is overturned.

The patient is a female with asthma (with prior intubation), depression, and chronic pain, who presented to the emergency department (ED) with dyspnea, wheeze, and dry cough over the prior day.
In the ED, her vital signs included a blood pressure (BP) of 100/71 millimeters of mercury (mmHg), a heart rate (HR) of 61 beats per minute (bpm), a respiratory rate (RR) of 20 per minute, and a peripheral capillary oxygen saturation (SpO2) of 88 percent (%) on room air (RA). She was not in distress, wheezy and tachypneic, alert and oriented. Her labs included a white blood cell count (WBC) of 8.0, a sodium (Na) of 141, a bicarbonate of 35, and a blood urea nitrogen (BUN)/Creatinine (Cr) of 23/0.97. The patient was coronavirus disease 2019 (COVID-19) and flu negative. Her chest x-ray (CXR) was clear.
She was diagnosed with an acute asthma exacerbation and started on intravenous (IV) steroids and nebulizers.
She was improved in the morning but over the course of the day became increasingly bronchospastic with the frequency of nebulizers increased, oral steroids converted back to IV, and supplemental oxygen (O2) continued.
The next day, she was continued on IV steroids and nebulizers. She was desaturating to 85% on RA.
The day after, she was better, still with shortness of breath (SOB) but improved and off O2. The patient was discharged on prednisone and an inhaled corticosteroid-and-long-acting beta agonist (ICS-LABA).

At issue is the medical necessity of the inpatient admission.

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

Yes, the requested health service/treatment of Inpatient Admission was medically necessary for this patient.
An inpatient admission was medically necessary. The patient presented with dyspnea and hypoxemia and was diagnosed with an asthma exacerbation. She was at high risk for a severe flare given her prior intubation. She improved initially, but she then worsened, suggesting a more severe flare and increasing the risk of needing intensive care unit (ICU) care, and the need for prolonged inpatient care for ongoing inpatient only treatments (IV steroids and frequent nebulizers) and close monitoring to ensure the patient did not worsen. Given her status as a high risk patient and her lack of improvement over the initial time frame, an inpatient admission was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rheumatoid Arthritis.
Treatment:  Actemra SQ 162mg Syringe / Actpen Autoinjector.

The insurer denied the  Actemra SQ 162mg Syringe / Actpen Autoinjector.  The denial is overturned.

This patient is a female with history of rheumatoid arthritis.   The patient has previously tried and failed conventional disease modifying anti-rheumatic drugs (DMARDs) methotrexate, leflunomide and hydroxychloroquine along with biologic disease modifying anti-rheumatic drugs Enbrel, Humira and Kevzara.  She has a history of a deep venous thrombosis (DVT).  

The request for Actemra was initially denied due to the patient not having tried and failed all the formulary alternatives including Humira, Enbrel, Kevzara, Rinvoq and Xeljanz.   The reason the provider is appealing the determination is because the patient has a contraindication to the remaining formulary alternatives Rinvoq and Xeljanz given her history of deep vein thrombosis and these medications can increase the risk of thrombosis.

Yes, the proposed treatment is medically necessary.

The patient has long standing history of rheumatoid arthritis.  The patient has tried and failed formulary alternatives Humira, Enbrel and Kevzara.  The remaining formulary alternatives Rinvoq and Xeljanz are Janus kinase inhibitors and they have an increased risk of thrombosis and are typically avoided when a patient has a history of prior deep vein thrombosis or pulmonary embolus (PE).  This patient has a history of a deep vein thrombosis; therefore, these medications would be contraindicated for her.  Therefore the patient has either tried and failed or has a contraindication to the use of all formulary alternatives.  Actemra is Food and Drug Administration approved for the treatment of rheumatoid arthritis.  Therefore, the proposed treatment is medically necessary.

No, the health plan did not act reasonably, with sound medical judgement and in the best interest of the patient.

The health plan did not take into account contraindications to the use of certain medications such as in this case where the remaining formulary alternatives are contraindicated for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crowding, crossbite, and overjet
Treatment: Braces and periodic orthodontic treatment visits
The insurer denied Braces and periodic orthodontic treatment visits.
The determination is overturned.

The patient has a crossbite of tooth number (#) 6. She presented with a skeletal Class I malocclusion with moderate crowding in the maxilla and mandible. She has a 6-millimeter (mm) overjet and 3 mm overbite. She is treatment planned for 24-30 months of orthodontics to address the crowding, crossbite, and overjet. At issue is the medical necessity of braces and periodic orthodontic treatment visits.

The requested treatment is medically necessary.

This patient presents with an anterior crossbite on tooth #6, as well as moderate crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. (1,2,3) It appears the lower anterior teeth are migrating labially in the arch.

If left untreated, the damage that will likely occur to the patient's teeth will be much more time consuming to correct than the patient's existing orthodontic problem. For this reason, the treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory/Asthma
Treatment: Inpatient Hospital Admission
The health plan denied the requested inpatient hospital admission as not medically necessary.
The health plan's determination is overturned.

The patient is a female with a history of asthma, seasonal allergies, and current pregnancy at 22 weeks. Presenting complaints were dyspnea, coughing, and wheezing. She attempted outpatient therapy with Albuterol/Ipratropium nebulizer. She also noted that her peak flow dropped to 150 from her normal 300-350 (normal range variably charted as 250 or 300-350). On arrival to the emergency department, the patient's vital signs were a blood pressure of 111/78 millimeters of mercury (mmHg), a heart rate of 114 beats per minute (bpm), a respiratory rate of 20/minute, with an oxygen saturation of 98% on room air. A physical exam was notable for respiratory distress, increased work of breathing, use of accessory muscles; wheezing was auscultated. Labs were notable for a venous blood gas potential hydrogen (pH) of 7.31, and a carbon dioxide (pCO2) of 45. In the emergency department, she received steroids, Magnesium, and nebulizer therapy. After this the patient reported persistent dyspnea and a peak flow (PF) of 250 compared to a reported baseline of 300-350. The patient was admitted to inpatient service and therapy was continued. 
At issue is the medical necessity for the inpatient stay.

I overturn, in whole, the health plan's determination of medical necessity.

Yes, an inpatient level of service would have been the safest pathway, and therefore it was medically necessary.
The patient demonstrated failure of outpatient management (unresponsive to her home nebulizer therapies), continued dyspnea after initial care in the emergency department (ED), and increase in pCO2 >2 mmHg beyond normal (her pCO2 was 45 from a normal value of 40). It is also reported in the documentation that the patient has had multiple ED visits for asthma, which is a signal for poorly controlled asthma. These factors combine to make the patient at high risk for recrudescence of symptoms after discharge or in an observation setting, so inpatient admission would have been appropriate. Recrudescence of symptoms would have potentially been fatal to the life of the patient or her fetus if it occurred in an outpatient setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pancreatitis
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The health plan's determination is overturned. 

The patient is a female who presents to the emergency department with abdominal epigastric pain for the last 2 days. The pain started after eating a large fatty meal associated with loss of appetite. Physical exam shows epigastric tenderness to palpation. Laboratory studies reveal a white count of 22, 700, serum lipase of 1415 and her liver function tests were normal. A computed tomography (CT) abdomen pelvis showed acute pancreatitis, right small kidney stone, incidental finding of bilateral adrenal adenomas, and left renal angiomyolipoma. A right upper quadrant ultrasound shows gallbladder wall thickening, dilated gallbladder, pericholecystic fluid and gallstones consistent with cholecystitis. The patient was admitted to the surgical service and started on intravenous (IV) antibiotics. 

The Inpatient Hospital Stay was medically necessary for this patient.
The patient was admitted with gallstone pancreatitis. Once her pancreatitis resolved, she underwent laparoscopic cholecystectomy with intraoperative cholangiogram and umbilical hernia repair. She required IV and oral pain medication on post operative day 1. The stay would have exceeded the 48 hour observation stay period. The patient was required to be monitored for recurrent pancreatitis after her cholangiogram.
Acute pancreatitis is a common inpatient diagnosis among gastrointestinal disorders. Acute inpatient admission for pancreatitis is associated with improved outcomes in mild acute pancreatitis. Guideline-based educational interventions have a beneficial impact on management of mild acute pancreatitis by admitting teams even without pancreatitis consultation.