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

Diagnosis: Back and Leg Pain
Treatment: Caudal epidural steroid injection
The insurer denied caudal epidural steroid injection.
The determination is overturned.

This is a male patient who has low back pain with pain in both legs. His pain is aching and stabbing. He had tried physical therapy (PT) and nonsteroidal anti-inflammatory drugs (NSAIDs). A prior caudal epidural injection provided him with good pain relief. He is having difficulty working as landscaper due to this persistent back pain. Current medications include Baclofen, diazepam, hydromorphone, and medical marijuana. On physical exam (PE), there was tenderness to palpation (TTP) in the lumbar paraspinal muscle, decreased range of motion (ROM) of the lumbar spine. Magnetic resonance imaging (MRI) showed multilevel degenerative disc disease (DDD) with bilateral lumbar (L) 4/5 foraminal stenosis and a left L5-sacral (S)1 disc protrusion with contact of the traversing left S1 nerve root.
At issue is whether a caudal epidural steroid injection is medically necessary for this patient.
This patient has persistent pain. He is having difficulty working as a landscaper. Further treatments are medically necessary to improve his pain and function. He had tried and failed conservative treatments. The next step is a repeat caudal epidural injection. The other options are long-term use of opioid medications and lumbar spine surgery. However, none of these options has a high success rate, and all of them carry significant risks and complications. Therefore, a caudal epidural injection is medically necessary as the next step intervention.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcohol Abuse
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient with a history of hypertension who is undomiciled, with heavy alcohol use and presented with tremors and concern for alcohol withdrawal syndrome from a detoxification (detox) program. Her last alcohol use was one day prior. The symptoms include tremors.  In the emergency room (ER), the patient was given lorazepam (intravenous and oral), Tylenol and fluids. She was admitted and placed on a Clinical Institute Withdrawal Assessment (CIWA) protocol with vitamin supplementation, antiemetics and fluids. The patient left against medical advice (AMA). At issue is the medical necessity of an inpatient stay.
Question(s):

The inpatient stay was not medically necessary. Care could have been provided at a lower level. The patient did not provide a clear history nor was there documentation of complicated withdrawal syndromes (i.e. delirium tremens or seizures). At the time of evaluation, the patient was having minor symptoms of withdrawal with tremors (Lohr et al 1995). A patient may continue to have minor symptoms or may progress to more severe withdrawal (i.e. seizures, delirium tremens), in the first 24-48 hours (Lohr et al 1995). There are not any well-defined symptoms that predict who will have a complicated case of alcohol withdrawal (Wood et al 2018). Given that the patient's trajectory is unclear, it would be reasonable to initially admit the patient to a lower level of care then if the patient shows signs of complicated withdrawal (which would be expected in the first 24-48 hours) then requiring more intensive management, transitioning the patient to the inpatient level of care would be appropriate. Therefore, the patient does not meet criteria for the inpatient level of care at admission as the patient was not expected to stay greater than (>) 2 midnights and management was not medically complex (Hospital Inpatient Admission Order and Certification).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class 3 Malocclusion
Treatment: D8080 Braces and Monthly Visits x12
The insurer denied: D8080 Braces and Monthly Visits x12
The denial is upheld.

This case involves a teenage female. The denial of coverage of comprehensive orthodontic treatment is being appealed. The patient was diagnosed with a Class 3 malocclusion with bilateral posterior crossbite. The provider submitted a Handicapping Labio-Lingual Deviation score of 33. The plan's review gave the patient a score of 11.

The requested health service is not medically necessary.

For orthodontics to be medically necessary, a score of 26 on the Handicapping Labio-Lingual Deviation or an automatic qualifier must be present. The provider gave a score of 33. Based on the documentation submitted, this is not accurate. There is not 3.5 millimeters of anterior crowding in the maxilla and mandible. There is not 2 millimeters of mandibular protrusion. Based on the documentation submitted, the score is 15. The only difference between this score and that of the plan was 2 millimeters of open bite versus 1 millimeter. The denial of orthodontic treatment was appropriate. The requested health service is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic atrial fibrillation; non-ischemic cardiomyopathy
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is an elderly female. She was hospitalized for elective pacemaker ICD (implantable cardioverter defibrillator) upgrade for Cardiac Resynchronization Therapy (CRT) with Atrioventricular (AV) Node Ablation. Her past medical history includes chronic atrial fibrillation, nonischemic cardiomyopathy with ICD (implantable cardioverter defibrillator), coronary artery disease, type 2 diabetes, hypertension and hyperlipidemia. This was an uncomplicated procedure, and the patient had an uneventful hospitalization. Rhythm was V-paced (ventricular pacing), and her heart failure remained compensated. The requested coverage for Inpatient Hospital Admission was denied coverage by the health plan as not medically necessary. The denial is being appealed.

The inpatient admission was not medically necessary.

Based on the peer-reviewed medical literature, inpatient admission was not medically necessary. Criteria for inpatient stay were not met, including documentation of hemodynamic instability, respiratory distress, change in mental status, severe heart failure, cardiac arrhythmias of immediate concern, myocardial ischemia or myocardial infarction, positive troponin not explained by CKD (chronic kidney disease) and CHF (congestive heart failure), hypertension requiring inpatient hospitalization, CVA (cerebrovascular accident), pulmonary embolism, aortic dissection, pneumonia, severe electrolyte abnormalities, mental status changes, contrast nephropathy, acutely decompensated CHF (congestive heart failure), life-threatening cardiac arrhythmia, procedural complications like myocardial perforation, cardiac tamponade, vascular access complication requiring surgery, or other medical instability or acute care needs that would require acute inpatient management. In this particular case, there was no clinical decline or inadequate response to treatment which required inpatient hospitalization. The care that the patient received for elective, uncomplicated upgrade of her ICD (implantable cardioverter defibrillator) pacemaker to CRT-D (cardiac resynchronization therapy with a defibrillator) is routinely provided safely and effectively at a lower level of care. Therefore, based on the submitted information and the current published medical literature, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Epigastric and right flank pain
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is an adult female with a past medical history of obesity, bilateral breast implant removal, and abdominoplasty. She presented to the emergency department with sudden onset epigastric and right flank pain, along with nausea and vomiting.
Computed tomography (CT) of the patient's abdomen and pelvis was performed, along with laboratory work that showed gallstones and gallbladder wall thickening. She was admitted to the hospital for intravenous antibiotics, pain control, and intravenous hydration. On the same day of admission, the patient was taken for a laparoscopic cholecystectomy. She had a relatively uneventful post-operative course and was discharged the next day. The health plan denied coverage of the inpatient admission on the assertion that the clinical records did not support the patient meeting criteria for inpatient status. The treating provider's reason for appeal is that the patient's condition could not be managed safely at a lower level of hospital care or in an outpatient setting. The provider referenced MCG (Milliman Care Guidelines) Criteria under Ambulatory Surgery Exception Criteria, clinical indications for admissions to inpatient care. They note that in this specific case, intravenous pain medication was an indication for admission.

The inpatient admission was not medically necessary.

The MCG (Milliman Care Guidelines) Criteria note, "Acute inpatient admission after laparoscopic cholecystectomy is indicated when:
* patient fails to achieve discharge status criteria.
* conversion to open procedure
* care for comorbidities (eg, pancreatitis, sepsis, heart failure, renal failure)
* expect brief to moderate stay extension
* complications of procedure, including bile duct injury and intraoperative or postoperative bleeding.
The discharge criteria that needed to be met prior to discharged are: hemodynamic stability, ambulatory status, clean operative site, managed pain and absent nausea, achieved voiding status."
This patient's care could have been managed in a lower level of care. The patient received two doses of intravenous pain medication post-operatively, and it does not indicate when this was (post anesthesia care unit [PACU] versus floor), or if other alternatives were attempted prior to escalating to intravenous route. This patient could have received her intravenous antibiotics, intravenous hydration, and intravenous pain medication at a lower level of care within the hospital.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: flank pain
Treatment: inpatient stay
The insurer denied the inpatient stay.
The health plan's determination is upheld. 

The patient is a pregnant female complicated by diabetes. She presented complaining of right flank pain associated with vomiting. She initially reported to an outside hospital emergency room and was given intravenous (IV) fluids an anti-emetics. However, her pain worsened, so she came in for further management. She was hemodynamically stable. On exam, she had right costovertebral angel tenderness. Her labs showed a white blood cell count (WBC) of 17.8, a hemoglobin of 10.4 and a creatinine of 1.29. She was admitted for further workup and management. 

The inpatient admission was not medically necessary based on the documentation provided. The patient presented with right flank pain and was found to have an 8 millimeter (mm) obstruction right ureteral stone. She was hemodynamically stable. She did not have acute kidney injury that required inpatient admission. She did not have bilateral ureteral obstruction or unilateral obstruction of a solitary kidney. She did not have a complicated urinary tract infection. She did not have severe pain that required inpatient management. She did not require prolonged intravenous (IV) hydration due to severe or persistent nausea and vomiting. She underwent a stone removal procedure without complications. She could have been managed at a lower level of care with subsequent transition to outpatient follow up.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic Dermatitis

Treatment: Opzelura cream 1.5% [percent] (60 grams [g] per month).

The insurer denied coverage for Opzelura cream 1.5% (60 grams [g] per month).

The denial is overturned.

The patient has a diagnosis of severe atopic dermatitis involving the face.  The patient has previously failed multiple systemic and topical therapies.  The patient has had excellent clinical response to Dupixent for atopic dermatitis, but still suffers from eczema around the eye.   The request is for the concomitant use of Dupixent with Opzelura.  

Based on the submitted documentation and the standard of care, the use of Dupixent and Opzelura is medically necessary.  The patient has had an excellent clinical response to Dupixent for treatment of their atopic dermatitis.  The patient requires topical therapy for sensitive skin area, the periorbital area which cannot be safely treated with topical steroids.  The addition of topical Opzelura as an adjuvant to be used as needed is within the standard of care as Opzelura is a steroid free Food and Drug Administration (FDA) approved alternative.  Limited options exist and the use of an adjuvant topical is preferrable to switching to an alternative systemic therapy.  Dupixent and Opzelura work through varying mechanisms and there are no known contraindications or drug-drug reactions to the concomitant use of systemic Dupixent and topical Opzelura.  Opzelura can also be used to treat breakthrough eczema lesions.  Based on the provided documentation, the use of Opzelura with Dupixent is medically necessary and within the standard of care.  

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Opzelura cream 1.5% (60 grams [g] per month) is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Diabetes Mellitus Type 2
Treatment: Ozempic
The insurer denied Ozempic
The determination is overturned.

This is a patient with a known diagnosis of type 2 diabetes mellitus, with a hemoglobin A1c level of 7 percent (%). The patient also has a known diagnosis of obesity, hyperlipidemia and nonalcoholic fatty liver disease, and sleep apnea. The request is for the medication Ozempic. At issue is whether Ozempic is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Ozempic is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. The patient has a known diagnosis of type 2 diabetes mellitus with a hemoglobin A1c level of 7% (percent). She also has a known diagnosis of obesity, hyperlipidemia, nonalcoholic fatty liver disease, and sleep apnea. Ozempic is a glucagon like peptide (GLP-1) agonist therapy that is Food and Drug Administration (FDA) approved for the management of type 2 diabetes mellitus. Since the patient has an established diagnosis of type 2 diabetes mellitus and would also benefit from weight loss from the medication Ozempic, there is a compelling need given the elevated BMI (body mass index) and high risk of cardiovascular disease and the use of Ozempic is clinically indicated. It will enable the patient to improve her glycemic control and promote weight loss given the presence of comorbid conditions.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Diabetes Mellitus Type 2
Treatment: Ozempic
The insurer denied Ozempic
The determination is upheld.

This is a female patient with diabetes type 2 and fatty liver with fibrosis, requesting Ozempic. The request was denied as this drug was only Food and Drug Administration (FDA) indicated for type 2 diabetes. Per the provider's appeal, the patient has type 2 diabetes with an A1c (Glycated hemoglobin) of 7 percent (%) and has a body mass index (BMI) of 39 as well as nonalcoholic fatty liver disease. She would benefit from weight loss with Ozempic. Per an office note, the patient has a BMI of 39.24 and has an A1c of 6.5% and 6.2% (improved with lifestyle modification). She has lost 24 pounds (lbs). At issue is whether Ozempic is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The proposed health service or treatment Ozempic is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
There is increasing data showing potential improvement in liver histopathology in nonalcoholic fatty liver disease (NAFLD), particularly in those with concurrent metabolic issues such as type 2 diabetes and obesity (1, 2). 
No GLP1a has yet to gain this Food and Drug Administration (FDA) indication for treatment of nonalcoholic fatty liver disease. The main treatment for NAFLD remains weight loss. Other medical modalities traditionally include Vitamin E, caffeine and polyphenols, and dietary modification including low-glycemic index foods, increased monounsaturated fatty acids, omega-3 fatty acids, and fibers (2).
There is no evidence this patient has tried and failed conservative measures including diet and exercise for weight loss for management of her NAFLD. Additionally due to her lifestyle modifications, her A1c is now in the prediabetic range of medications.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Diabetes Mellitus Type 2
Treatment: Ozempic
The insurer denied Ozempic
The determination is upheld.

This is a female patient diagnosed with type 2 diabetes mellitus (T2DM). This request is for Ozempic. As per a letter, the patient is obese with a body mass index (BMI) of 39.2 and her comorbidities include elevated glucose, hyperlipidemia (HLD) and non-alcoholic fatty liver disease. As per a visit note, she has pre-diabetes and obesity. Her A1C (Glycated hemoglobin) was 7 percent (%); 6.5 %; and 6.2 %. At issue is whether Ozempic is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The proposed health service or treatment Ozempic is not likely to be more beneficial than any standard treatment.
Ozempic is a glucagon-like peptide-1 receptor (GLP1R) agonist(1) that is Food and Drug Administration (FDA) approved in the treatment of type II diabetes (2-7). There are no studies showing superiority of the requested medication over the formulary alternatives. Metformin is the first line treatment for type II diabetes. The patient has not tried a metformin-containing product as it is the first line of treatment for patients with diabetes.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is an adult female with end stage renal disease status post kidney transplant who was admitted for worsening kidney function. She was treated with intravenous (IV) fluid and underwent kidney biopsy. She was discharged in stable condition the next day.

The requested health service was not medically necessary.

The patient was admitted for dehydration and was noted to have elevated creatinine however, her acute kidney injury could have been treated safely under lower of care. The gold standard for the distinction between pre-renal disease secondary to volume depletion and post-ischemic and nephrotoxic acute tubular necrosis (ATN) is the response to fluid repletion per the Kidney Disease Improving Global Outcomes (KDIGO) and National Kidney Foundation guidelines. If sufficient fluid is given to reverse any signs of volume depletion (e.g., hypotension, cool extremities, low urine-sodium concentration), return of the serum creatinine to the previous baseline within 24 to 72 hours is considered to represent a correction of pre-renal disease, whereas persistent acute kidney injury (AKI) is considered to represent acute tubular necrosis. This patient's kidney function improved back to baseline in 48 hours, which is not consistent with serious, irreversible acute tubular necrosis which may benefit from inpatient admission to monitor kidney function and the need for renal replacement therapy. In addition, the patient was hemodynamically stable and was able to tolerate oral diet.
When taking into account the patient's exam, imaging, and lab findings as well as her lack of need for diagnostic testing beyond what was done under observation care and the availability of 
any additional diagnostic testing as an outpatient, the patient had no requirements for inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Calf and Ankle Pain.
Treatment:  Inpatient admission.

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

This patient is an adult. The patient presented to the hospital with complaints of calf and ankle pain. The patient had a diagnostic peripheral angiogram. Records show the procedure to have been performed without complications or issues warranting further care.

According to Omeh et al. (2023), "Angiography is performed to image the anatomical and structural details of the vascular system, including the cardiac chambers. Initially used for structural diagnosis of intravascular pathologies, angiography has been expanded to offer functional assessment and therapeutic options." 

"Conclusion: Peripheral vascular procedures performed in the outpatient setting are safe and effective" (Mesbah et al., 2015).

Per Janas et al. (2018), "Results: There were no differences between the groups in the ratio of same-day discharge (99% versus 99.5%, P = 0.6) and the mean time to ambulation was 287.4  43.4 minutes versus 285.8  45.7 minutes (P = 0.603). The ODD (one-day early discharge) was not applied in 2 patients greater than or equal to (>=) 70 year old (y.o.) due to two pseudoaneurysms requiring surgical repairs and in one from the control group due to retroperitoneal bleeding. There were no major adverse cardiovascular events (MACE) or creatinine increase at 24 hours (hr) in both groups. At 30 days, there was no incidence of MACE in the >= 70 y. o. group while 3 MACE occurred in the control. The ratio of access site complications was comparable between the groups." 

The procedure performed, a diagnostic angiogram, is routinely provided on an outpatient basis in physician offices and hospital departments. While fifteen years ago, overnight "observation care" was commonly accepted as needed for these patients, inpatient admission was not standard of care even at that time. The introduction of smaller caliber interventional equipment and reliable closure devices have rendered overnight observation obsolete. Under current standards, this procedure is performed on an outpatient basis unless active bleeding or other documented complications are reported. In this case, documented complications are absent. 

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 is not substantiated.