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

Diagnosis: Acute cholecystitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

Per clinical documentation, this patient presented to the emergency department (ED) with abdominal pain. There was associated nausea without vomiting. Vital signs in the ED were within normal limits. An ultrasound indicated cholelithiasis and common bile duct dilatation. The total bilirubin was elevated at 4.9. Alanine transaminase and aspartate aminotransferase were all elevated at 141 and 205, respectively. A magnetic resonance cholangiopancreatography (MRCP) was performed due to the elevated liver function tests and demonstrated gallstones and a prominent common bile duct without stones. The patient underwent a laparoscopic cholecystectomy. There were no reported complications. The patient was discharged.	

Acute cholecystitis and biliary complaints are a common inpatient diagnosis. Acute cholecystitis is also estimated to attribute to millions of ambulatory visits each year and is a leading cause of hospital admissions. [1] Studies have shown that ambulatory laparoscopic cholecystectomy is safe and avoids an overnight hospital stay. [2, 4, 5] Factors that contribute to admission after laparoscopic cholecystectomy include drain placement, conversion to open surgery, persistent abdominal pain, nausea, and vomiting. [3] In patients without abnormalities of the bile duct or abnormal liver function tests (elevated alkaline phosphatase and total bilirubin), ambulatory laparoscopic cholecystectomy is safe and feasible. [5, 8] A 50% (percent) increase in the liver function tests can be labelled as mild elevation and is considered negligible by many. [9] Ambulatory and/or outpatient laparoscopic cholecystectomies reduce hospital costs without compromising patient outcomes. [6]

The patient was afebrile and there were no systemic signs of infection. White blood cell count was normal at 7.9. Per MCG (Milliman Care Guidelines) criteria, admission is indicated when common bile duct obstruction is indicated via imaging and there are signs of systemic inflammation. [7] Peer-reviewed literature and MCG criteria indicate that inpatient admission is not necessary in these circumstances. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient. Per provided clinical documentation, inpatient admission was not medically necessary. 

The insurer's denial of coverage for the inpatient admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Uterine fibroids; menorrhagia; pelvic pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female. She presented to the emergency room with a history of uterine fibroids and menorrhagia and pelvic pain. Her medical history was significant for hyperthyroidism and hypertension. The patient's vital signs were normal. There was no vaginal bleeding. A pelvic ultrasound revealed multiple uterine fibroids.

An exploratory laparotomy, multiple myomectomy and lysis of adhesions was performed without complications, and a blood loss of 500 cc (cubic centimeters). The patient was transferred to the PACU (post anesthesia care unit) and recovered uneventfully. She was then transferred to the inpatient service. The patient was noted to be afebrile, had normal vital signs, had her pain well controlled, was tolerating her diet and was ambulating on postoperative day 1. The patient continued to have an uneventful postoperative course being afebrile and having normal vital signs, and was discharged.

No, the Inpatient admission was not medically necessary.
The medical records and medical literature were thoroughly reviewed. The patient presented with symptomatic uterine fibroids. The preoperative consult progress note reports that the patient had no active bleeding, was afebrile and had normal vital signs. She was hemodynamically stable and was in no distress or pain. The patient did not have any comorbidities that indicated immediate admission and surgery. Therefore there was no evidence that the patient required immediate inpatient admission to the hospital and immediate surgery for the uterine fibroids. According to the evidence on the medical record, the patient could have completed her evaluation as an outpatient and could subsequently have had a planned laparotomy procedure. Therefore, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain and swelling in the scrotum
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male who presented with abdominal pain and swelling in the scrotum. This patient had a known right inguinal hernia that worsened with coughing associated with his allergies. This patient underwent medical evaluation, and he was found to be high risk. This patient's hernia surgery was postponed.

No, the inpatient admission was not medically necessary.
This patient presented with a large known right inguinal hernia, which while evidenced to be incarcerated, was not obstructed. The plan was for semi-elective surgery after preoperative medical clearance was assessed. This patient's morbid obesity and sleep apnea put this patient at high risk, and surgery was postponed.

This patient did not met any of the MCG (Milliman Care Guidelines) National Criteria for Acute Admission related to his hernia including fevers/infection/perforation, obstruction, or ischemia. The expected length of stay for an elective inguinal hernia would be ambulatory. With this patient needing ongoing medical clearance, this patient met the criteria for Observation Care. Clinical care (eg, testing, monitoring, or treatment) was needed beyond the usual emergency department to assess his operative risk and suitability at that time for an inguinal hernia repair. After medical consultation, it was decided to discharge this patient for further medical evaluation and possible more elective outpatient ambulatory hernia repair.

This patient could have been placed in Observation Care, which is considered to be more timely, effective, and efficient level of care than a full Acute Inpatient Admission for this patient's presentation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cocaine Induced Angina

Treatment inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

This is the case of a woman with a history of hypertension, chronic obstructive pulmonary disease (COPD) and active cocaine use that presented to the hospital complaining of intermittent chest pain radiating to the left arm. Upon arrival to the emergency department (ED), the patient reported that chest pain had resolved. Vital signs were stable (BP 156/88, pulse 85). Physical examination revealed no significant abnormalities.  Twelve-lead electrocardiogram (EKG) revealed normal sinus rhythm without ST (interval on EKG) or T (interval on EKG) wave abnormalities. Serum blood testing revealed an elevated high sensitivity troponin level of 31.7 ng/L (nanogram per liter) that increased to 39ng/L and then dropped back down to 35ng/L. Urine toxicology testing was positive for cocaine. Echocardiogram revealed a preserved left ventricular ejection fraction without wall motion abnormalities. She was diagnosed with cocaine induced angina and discharged home the following day with cardiology follow up.  

This patient presented with intermittent chest pain in the setting of active cocaine use. Her pretest probability of coronary artery disease is low (1). Utilizing the HEART (History, EKG, age, risk factors, Troponin) score, she was considered low risk (2). Utilizing the TIMI (thrombolysis in myocardial infarction) risk score, she also had a low 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 low risk of major adverse cardiac events (defined as 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 (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation. Investigators studying more than 300,000 hospital admission for chest pain in the setting of cocaine, found that patients presenting with chest pain following cocaine and no other significant risk factors had a low risk of major adverse cardiac events and mortality. They concluded that most patients did not require hospital admission (4).

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 and in the best interest of the patient.
  
The insurer's denial of coverage for the inpatient is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Palpitations

Treatment inpatient emergency admission

The insurer denied coverage for inpatient emergency admission

The denial is upheld

The patient presented to the hospital complaining of weakness and palpitations along the left chest. Past medical history was significant for gastroesophageal reflux disorder (GERD) and old cerebral vascular accident (CVA).  Upon arrival, vital signs were stable (blood pressure (BP) 124/77, pulse (p) 90). Physical exam revealed no significant abnormalities.  Twelve lead electrocardiogram revealed normal sinus rhythm with no ST (interval on electrocardiogram [ECG]) segment abnormalities. Serum blood testing revealed no elevation in high sensitivity troponin level (6.3 ng/L [nanogram per liter]). Acute coronary syndrome was ruled out and the patient was diagnosed with an exacerbation of gastroesophageal reflux disease.  He was discharged with follow up.

The health plan acted reasonably and with sound medical judgement and in the best interest of the patient. 

Acute inpatient hospital admission was not medically necessary.  This patient presented with chest pain and no electrocardiographic (ECG) abnormalities. His pretest probability of coronary artery disease is low (Reference 1).  Utilizing the HEART (History, Electrocardiogram, Age, Risk factors, Troponin) score he was considered low risk (Reference 2). Utilizing the TIMI (Thrombolysis in Myocardial Infarction) risk score he 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 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 (defined as 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 (defined as 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 emergency admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nausea, abdominal pain, and vomiting. 
Treatment: Inpatient admission. 

The insurer is denied coverage for inpatient admission. 

The denial is upheld. 

This male patient has a history of asthma and cannabis use. 

Clinical indications for admission for Vomiting (Milliman Care Guidelines [MCG] M-370) include gastrointestinal obstruction, a significant metabolic derangement, hemodynamic instability, severe vomiting that is not responsive to antiemetic therapy, severe electrolyte abnormalities, acute renal failure as defined by a 3-fold rise in the serum creatinine, and an inability to maintain oral hydration after observation care. In this case, the patient did not immediately respond to the Zofran and Reglan. However, he did feel better after receiving Haldol. Subsequently his symptoms improved and he was able to tolerate a liquid diet. 

This patient had cannabinoid induced hyperemesis. Intravenous (IV) hydration and antiemetics could have been given with observation status. The abnormal creatinine rapidly corrected. He did not meet MCG criteria for admission for vomiting. The health care plan acted reasonably and with sound medical judgement. An inpatient admission was not medically necessary. 

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient. 

The carrier's denial of coverage for inpatient admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prostate Cancer
Treatment: Zytiga (abiraterone acetate) with Lynparza (olaparib)
The insurer denied the Zytiga (abiraterone acetate) with Lynparza (olaparib)
The denial is upheld.

The patient is a male with prostate cancer.  There is a request for olaparib to be given with Zytiga.  He has received prior Zytiga, docetaxel, and Casodex.  The patient's provider is basing their recommendation on a proposed phase III trial that has no clinical results.  The patient has a PALB2 (partner and localizer of breast cancer gene 2) mutation.

The request was denied by the health plan, as olaparib is not approved to be given with abiraterone. The provider has appealed this decision.

No, the requested Zytiga (abiraterone acetate) with Lynparza (olaparib) is not medicallly necessary.
A phase II trial and proposed phase III trial is not acceptable evidence of efficacy.  At this time, the NCCN (National Comprehensive Cancer Network) does not support the use of abiraterone with olaparib to treat prostate cancer.  This is of no established benefit.  It is not in line with accepted standards of practice. Therefore, given the above, the requested Zytiga (abiraterone acetate) with Lynparza (olaparib) is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis Vulgaris

Treatment Taltz

The insurer denied coverage for Taltz

The denial is overturned

The patient has a diagnosis of psoriasis vulgaris. The patient has failed topical therapy as well as systemic biologic therapy with methotrexate, neoral, humira, and tremfya.  The requested medication is Taltz.  

Based on the submitted documentation, Taltz is medically necessary.  The patient has failed topical therapy and requires systemic therapy for control and management of his psoriasis diagnosis. According to the provided notes, the patient has tried and failed numerous systemic agents including methotrexate, neoral, humira, and tremfya.  Taltz is Food and Drug Administration (FDA) approved for treatment of psoriasis vulgaris and it is reasonable to attempt this treatment option.  

The joint American Academy of Dermatology - National Psoriasis Foundation (AAD-NPF) guidelines for psoriasis treatment with biologics states that Taltz is recommended for monotherapy in the treatment of psoriasis with a strength of recommendation of "A" -the highest recommendation.  In this case, Taltz is a reasonable next therapy for the treatment of the patient's disease and is medically necessary.  It is noted in the documentation that the patient has a history of irritable bowel disease (IBD) and as such should be monitored closely by the treating physician for signs of exacerbation while on Taltz.  

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 Taltz 80mg/mL (milligrams per milliliter) injections is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left Ringing Ear and Shortness of Breath (when lying down)
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a female. She had a pregnancy and delivery complicated by chorioamnionitis and gestational hypertension. She was admitted post op day 3 with a complaint of tinnitus.

The patient was found to have multiple severe range blood pressures establishing the diagnosis of severe postpartum preeclampsia.  She was admitted and given magnesium sulfate and nifedipine.  Her condition improved and she was discharged on maintenance nifedipine.

The health plan's reason for the denial was that the patient did not meet admission criteria for hypertension and that she would have required documentation of end organ damage per InterQual criteria for adult hypertension, and that the care could be given without admission to the hospital.  The reason for appeal was that the patient met criteria per MCG (Milliman Care Guidelines) ORG M-285 Hypertensive Disorders of Pregnancy for preeclampsia with severe features including severe hypertension greater than 160/110 and cerebral symptoms and therefore the admission was medically necessary.

Yes, the inpatient admission  was medically necessary.

Admission criteria for hypertension during pregnancy and puerperium are different than those for adults who are not pregnant or postpartum, due to the possibility of the hypertension being due to preeclampsia and particularly preeclampsia with severe features. This patient met clinical criteria for preeclampsia with severe features based on the severity of the hypertension, exceeding 160 systolic, as well as the new onset of cerebral symptoms (tinnitus has been reported in conjunction with preeclampsia and in one study was present in 7% of cases). Untreated severe postpartum preeclampsia can lead to intracranial hemorrhage, seizures, renal failure, pulmonary edema, hepatic injury, disseminated intravascular coagulation, hemorrhage, PRES (posterior reversible encephalopathy syndrome) syndrome with cortical blindness, and death. For these reasons the American College of Obstetricians and Gynecologists recommends admission and treatment with intravenous magnesium sulfate seizure prophylaxis as well as anti-hypertensives, as was done in this case. Therefore, the admission was medically necessary.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
The health plan had declined coverage for the inpatient admission level of care, which was medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Osteoarthritis of Knee.
Treatment: lidocaine ointment compound.
The insurer denied the lidocaine ointment compound.
The determination is upheld.

The patient was diagnosed with bilateral knee osteoarthritis and right shoulder impingement syndrome and bursitis. This is a request for lidocaine ointment compound. The request was recommended for non-certification as the plan does not cover compounded drugs when any of the following apply: the drug is used for antiaging or cosmetic reasons, the drug is a compound kit, or the drug contains a full powder or a dietary supplement. Additionally, it is not documented that the formulary drugs (lidocaine 2% gel and lidocaine 4% solution) will be or have been ineffective.
There is a clinical note documenting a follow-up visit for right knee pain. The patient reported improvement from a corticosteroid injection that lasted several weeks. However, the pain has returned. On examination, there is right knee range of motion from 5-100, left knee range of motion from 0-120 degrees, crepitus, joint line tenderness, and swelling. The x-rays are consistent with severe tricompartmental right knee osteoarthritis. The treatment plan included a right knee intra-articular steroid injection. The treatment plan included knee exercises and discussion regarding a total knee arthroplasty in the future. There is a letter of medical necessity stating that the patient has chronic right shoulder rotator cuff impingement and bursitis, and bilateral knee osteoarthritis. There has been intolerance to oral non-steroidal anti-inflammatory drugs (NSAIDs), and the provider has recommended continuation of the topical compound that has provided relief of symptoms.

The article cited below from the Current Pain and Headache Report Journal states that topical lidocaine is a treatment option for localized neuropathic pain syndromes. The article cited below from the Postgraduate Medicine Journal states that topical lidocaine has been found to be effective for the treatment of postherpetic neuralgia. The article cited below from the Pain Management Journal states that compounded topical analgesics are becoming more popular and show promising results in the management of chronic peripheral neuropathies. In this case, the patient has bilateral knee osteoarthritis and right shoulder impingement syndrome and bursitis. There was no documentation of current findings consistent with neuropathic pain to support the request for a topical lidocaine compound. Based on the available information and current medical literature, the non-formulary drug lidocaine compound would not be supported. The formulary drugs would be as effective as the non-formulary drug lidocaine ointment compound in this case.