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

Diagnosis: Shortness Of Breath (congestive heart failure).
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a male with known CHF (congestive heart failure). He presented with dyspnea. His previous ejection fractions were 10% to 20%. His co-morbidities include chronic kidney disease with nephrotic syndrome, hypertension, alcohol abuse, and hyperlipidemia.

The patient was admitted with progressive symptoms of dyspnea. He was noted to be non-compliant, leaving AMA (against medical advice) from another hospital, and continuing alcohol use. The patient's VS (vital signs) showed tachycardia, and prolonged QTc (corrected QT interval). His cardiac enzymes were elevated minimally. He was admitted for aggressive management of his CHF (congestive heart failure) and alcohol withdrawal. He left AMA (against medical advice) before completion of proposed care. He presented with elevated lactate levels.  He had alcohol intoxication, with level of 246.

Yes, the Inpatient admission was medically necessary.
The patient presented with advanced heart failure and alcohol intoxication. His lactate level was elevated, and his cardiac enzyme was positive. His EKG (electrocardiogram) showed tachycardia and prolonged QTc (corrected QT interval). His previous EF (ejection fraction) was less than 20%. He was receiving complex care for both his decompensated heart failure and alcohol withdrawal. Inpatient level of care was required to stabilize and improve the patient. His repeated AMA (against medical advice) status does not alter the care that was needed and given.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: chronic inflammatory demyelinating polyneuropathy (CIDP) and features consistent with acute flaccid myelitis (AFM)
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male with history of extremely rare comorbid neurological conditions for this age group, described in the medical records as chronic inflammatory demyelinating polyneuropathy (CIDP) and features consistent with acute flaccid myelitis (AFM). The child underwent significant neurological evaluation at the tertiary Academic medical center, where contemporary treatment options have been offered, including, but not limited to, multiple rounds of immunoglobulin therapy.

The child's functional condition deteriorated as a result of the disease processes, hence the child has been referred to a Childrens Hospital for ongoing medical management, as well as comprehensive rehabilitation. Importantly, in this specific case, this child developed both upper and lower extremities weakness due to suspected comorbidities (chronic inflammatory demyelinating polyneuropathy and acute flaccid myelitis). In this case, the child has been receiving comprehensive pediatric transdisciplinary evaluation and treatment at the inpatient settings approximately two months. The last week of stay has not been approved by the insurance carrier due to lack of medical necessity. This decision has been made based on the review of clinical records indicative of significant functional improvement and lack of evidence for any barriers for discharge for outpatient therapies.

No, the Continued Hospital Stay was not medically necessary.
Based on the review of the medical records, the child made significant functional gains, permitting this child to receive outpatient therapy interventions without compromising safety of medical and rehabilitation care delivery. In addition, the child was reported to be medically stable.

Based on the review of available medical records, the health plan acted reasonably, and the decision has been based on sound medical judgment that took into consideration the best interest of patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bladder Tumor. 
Treatment: Hospital admission. 

The insurer denied coverage for hospital admission. 

The denial is upheld. 

This patient had a past medical history of type 2 diabetes, hypertension, and a bladder tumor. He presented for elevated transurethral resection of bladder tumor with instillation of chemotherapeutic agent postop. Postoperatively, the patient's urine was noted to be very bloody with a large amount of clots in the foley catheter. The Foley was changed to a 3-way Foley and continuous bladder irrigation was started. The patient was admitted for further management and observation. He improved. The continuous bladder irrigation was stopped and he was discharged home with a Foley catheter in place. The insurer has denied coverage for the hospital admission as not medically necessary. They stated the service provided describe a one-day ambulatory surgical procedure, and no complications noted requiring an inpatient status. Period of overnight observation is included in the ambulatory service. The appeal on behalf of the hospital is noted and read in detail. 

Per Milliman Care Guidelines (MCG) Urologic surgery or Procedure the patient appears to meet the discharge parameter within 24 hours postop. Per Milliman Care Guidelines Bladder: transurethral destruction of lesion, the patient appears to meet the discharge parameter within 24 hours post op. The patient was medically stable post op. There was no transfusion needed nor return to the operating room for control of bleeding, continuous bladder irrigation was discontinued and the patient was discharged home with the foley catheter that day. 

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

The hospital admission was not considered to be medically necessary for this patient. 

The insurer's denial of coverage for hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Behcet's disease.

Treatment: Acthar Gel.

The insurer is denied coverage for Acthar Gel.

The denial is upheld. 

This female patient has a history of Behcet's disease and inflammatory polyarthropathy.

The provider noted the patient did not respond well to repository corticotropin injection (RCI) 80 units twice weekly with minimal improvement in fatigue and joint pain. The patient had episodes of precordial discomfort of palpitations before starting RCI and another the week before the office visit. The patient developed a rash that partially responded to increase colchicine 1g (gram) twice a day. The patient saw a Cardiologist at Columbia who diagnosed extrasystole and possible recurrent pericarditis attributed to systemic inflammation. The physical examination revealed cardiac extrasystole. The patient was diagnosed with a Behcet's disease flareup.

The request form indicated the Acthar was being prescribed for inflammatory polyarthropathy.

The formulary drug is not likely to cause the patient an adverse reaction.

It is not clear whether the formulary drug has been ineffective based on the patient's clinical  history. The provider documented that the patient had been weaned off steroid therapy and it is  not clear why it was not restarted when the patient's arthritis flared up.

Based on the information provided in the medical records, the patient did not respond well to RCI which is the same as Acthar gel (brand name). Therefore, the requested drug would not be more effective.

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 the Acthar Gel is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Superficial Venous Insufficiency.
Treatment vein treatments (procedure code 36478) - Heat treatment of the main leg veins (endoluminal ablation of varicose veins).
The insurer denied coverage for vein treatments (procedure code 36478) - Heat treatment of the main leg veins (endoluminal ablation of varicose veins).
The denial is overturned

The patient is noted to be an adult male who by ultrasound, had reflux noted to be 1 centimeter (cm) from the saphenofemoral junction that was 1.92 seconds. The code requested was 36478. The undated appeal letter from the patient noted he had reflux of more than 0.5 seconds in duration. 

The patient had a venous duplex ultrasound that demonstrated clinically significant superficial venous insufficiency approximately 1 cm from the saphenofemoral junction that measured 1.92 seconds. The code requested was 36478. The treatment of clinically significant superficial venous insufficiency is endovenous laser ablation of varicose veins after failure of conservative measures (i.e. compression stockings).

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

The vein treatments (procedure code 36478) were considered medically necessary for this patient.

The insurer's denial of coverage for vein treatments (procedure code 36478) - Heat treatment of the main leg veins (endoluminal ablation of varicose veins), is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: bone graft.

Treatment: D4267, guided tissue regeneration - non-resorbable barrier, per site (includes membrane removal).

The insurer is denied coverage for D4267, guided tissue regeneration - non-resorbable barrier, per site (includes membrane removal).

The denial is overturned. 

This is a female patient 

The bone replacement graft in the #14 area was needed to prevent resorption of bone prior to implant placement. It is well documented that only partial bone fill of the alveolar socket occurs after an extraction. Studies show that 3 to 4 mm of both buccal - lingual and apicocoronal ridge resorption occurs within 6 months of extraction. The membrane (D4267) is needed to prevent soft tissue ingrowth into the bone graft and to promote healing.

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

The carrier's denial of coverage for the D4267, guided tissue regeneration - non-resorbable barrier, per site (includes membrane removal),  is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastrocutaneous fistula and decubitus ulcerations
Treatment: Facility transfer
The insurer denied the facility transfer.
The denial is upheld.

The patient is an adult female patient with a history of morbid obesity status post a Roux-en-Y (bariatric) surgery in the distant past.  The patient has a history of recurrent anastomotic strictures and a gastrocutaneous fistula at a prior PEG (percutaneous endoscopic gastrostomy) site who was admitted because of leakage at the GC (gastrocutaneous) fistula at site of a previous PEG/PEJ (percutaneous endoscopic jejunostomy).  The patient was status post repair with pain control that had been improving.  The patient also had pressure ulcers.  The patient developed bacteremia during the hospital stay.  The patient requested to be transferred to another facility for continued care and management of the gastrocutaneous fistula and decubitus ulcerations.

No, the transfer to another facility is not medically necessary. 

Based on the information provided specifically for the current status of decubitus ulcerations and gastrocutaneous fistula, further acute level of care at another facility is not required.  These are chronic conditions, which require skilled wound care, but do not require a hospital stay at another facility.  The current facility can provide wound care for the decubitus ulcerations and the persistent gastrocutaneous fistula.  A transfer to another facility is not medically necessary as the requested facility is not shown to have a superior wound care center or provide services not available at the current facility.  As such, the requested transfer to another facility is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ankylosing spondylitis
Treatment: Enbrel 50mg, Pre-service
The insurer denied the Enbrel 50mg, Pre-service.
The denial is upheld. 

The patient is a male with ankylosing spondylitis (AS), characterized by inflammatory arthritis with sacroiliitis on MRI (magnetic resonance imaging). He had been doing well on Enbrel for approximately a year.

At his office visit, the patient described increasing pain in his wrists, ankles, knees and buttocks, and held Enbrel for a few weeks. Celebrex was partially helpful. The provider switched Celebrex to diclofenac, and advised the patient to stop Enbrel and consider an alternate biologic, such as Humira. Of note, the patient was found to have a new positive quantiferon gold (negative a year prior). A chest X-ray was clear. Attached PA (prior authorization) request indicates that this patient has risk factors for tuberculosis, but treatment for latent tuberculosis was not initiated. Continuation of Enbrel was denied for this patient because there was no documentation of improvement in this patient's signs or symptoms with Enbrel. Appeal is for Enbrel for the treatment of AS (ankylosing spondylitis).

No, the requested Enbrel is not medically necessary.
Enbrel is FDA (United States Food and Drug Administration)-approved for the treatment of AS (ankylosing spondylitis), as diagnosed in this patient. For continuation of Enbrel, a positive response to ongoing treatment should be documented.

Per attached progress note, this patient was experiencing increased joint symptoms and discontinued Enbrel. At that time, the provider switched NSAIDs (nonsteroidal anti-inflammatory drugs) from Celebrex to diclofenac, and recommended stopping Enbrel to consider an alternate biologic such as Humira. This is in contradiction to the provider's assertion that the patient has improved on Enbrel. 

Furthermore, the patient was found to have a new positive quantiferon gold (negative a year prior). A chest X-ray was clear, suggestive of latent tuberculosis, but treatment for latent tuberculosis was not initiated. Per a recent UpToDate review and in accordance with the CDC (Centers for Disease Control and Prevention) guidelines, treatment of latent tuberculosis should be initiated for all patients who will take a TNF (tumor necrosis factor) inhibitor (e.g., Enbrel). Treatment with Enbrel is contraindicated in the setting of untreated latent tuberculosis, due to increased risk of tuberculosis reactivation.

Therefore, given the above, as the patient has not initiated treatment for a new diagnosis of latent tuberculosis, the proposed Enbrel for the treatment of ankylosing spondylitis is not clinically appropriate, or in accordance with standard of care in this patient. The proposed treatment with Enbrel is thus not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Brain Cancer

Treatment: Hospital admission

The insurer denied coverage for hospital admission.

The denial is overturned.

This case involves a patient who presented to the hospital for a planned placement of a stereotactic guided right frontal Ommaya reservoir.  The documentation indicated he has a history of primary malignant neoplasm of lung with metastasis to brain in carcinomatous meningitis.  The patient was initially admitted and underwent the procedure.  The patient tolerated the procedure well.  There were no surgical complications noted.  The patient did receive a dose of intravenous (IV) antibiotics 3 times.  The following day he was evaluated and there were no significant complaints.  He was able to tolerate a diet and void without any complication.

According to the provided documentation, the patient underwent a procedure which involves brain surgery.  The patient underwent a procedure where a catheter was inserted deep into the brain's ventricles.  Typically, this is not considered an outpatient procedure and a typical stay does include 2-day admission.  Therefore, given the above 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 hospital admission is reversed.  Medical necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Fibroid/ Adenomyoma. 
Treatment: Procedure Code 0404T, ablation with imaging guidance for the treatment of growths in the uterus. 

The insurer denied coverage for procedure code 0404T, ablation with imaging guidance for the treatment of growths in the uterus. 

The denial is overturned. 

This is the case of a female patient with history of a symptomatic uterine fibroid. 

The information provided includes a magnetic resonance imaging (MRI) which shows a small uterine mass which was interpreted as a degenerating fibroid or a cyst adenomyoma. The treating provider counseled the patient about a transcervical ablation with ultrasound versus hysteroscopic removal of her fibroid. The patient chose the ablation option. 

The documents submitted also contain multiple references to medical literature and physician testimonials for the Sonata procedure. All available medical documentation was reviewed. 

According to Shifrin et al., "Among 197 women (534 treated fibroids), 86% [percent] of women with only submucous fibroids and 81% of women with large fibroids (>5 cm [centimeters]) experienced bleeding reduction within 3 months post-ablation. Overall symptom severity and health-related quality of life showed sustained, significant improvements over 12 months... 

The scientific evidence in peer-reviewed literature does support a result of improvement in health outcome. 

The procedure code 0404T, ablation with imaging guidance for the treatment of growths in the uterus does have final approval from the appropriate regulatory bodies for this diagnosis. 

This patient is a good candidate for the procedure code 0404T, ablation with imaging guidance for the treatment of growths in the uterus. 

The patient's clinical circumstances made her a good candidate for transcervical ablation with ultrasound guidance. The size of her uterus and the nature of her fibroids were amenable to this procedure. There is no cutting and less potential blood loss in this procedure than hysteroscopic myomectomy, laparoscopic myomectomy, and open (laparotomy) myomectomy. 

The procedure code 0404T, ablation with imaging guidance for the treatment of growths in the uterus is the best available treatment for this patient at this time. 

The requested procedure is likely to be more beneficial than any other existing standard health service. 

This patient had multiple options for treatment. She was counseled and chose the transcervical ablation option. This was an appropriate choice for her individual circumstances. 

The carrier's denial of the procedure code 0404T, ablation with imaging guidance for the treatment of growths in the uterus should be overturned.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Post-traumatic syrinx with spinal cord tethering
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned, in part.

The patient is a male who had an motor vehicle accident (MVA) causing multiple
fractures. The patient developed left leg weakness and foot drop and was found to
have post-traumatic syrinx with spinal cord tethering. The patient underwent T4-8 (fourth thoracic spine vertebra to eighth thoracic spine vertebra)
laminectomy, intradural exploration and detethering. The patient eventually
developed left foot weakness and magnetic resonance image (MRI) showed
myelomalacia and cord edema from C4 (fourth cervical spine vertebra) to the thoracic spine. The patient continued to have weakness and repeat magnetic resonance image (MRI) showed extension of syrinx to C2 (second cervical spine vertebra). The patient was recommended to have thoracic laminectomy and syringopleural shunt placement.

Yes, in part; the proposed inpatient admission was medically necessary for the first
five days of admission. However, the proposed inpatient admission was not
medically necessary for the last 10 days of admission.
The patient underwent a surgery that requires opening the covering of the spine.
There are many risks that can occur in the immediate postoperative period such as
hematoma, weakness, or cerebral spinal fluid (CSF) leak. The patient also required
intravenous (IV) pain medication, close neuromonitoring and weakness in the
proximal right leg requiring intravenous medications which ended. The patient
required acute inpatient hospitalization due to the nature of the surgery, the
immediate postoperative recovery period and the need for observation to avoid new
complications. The remainder of the dates do not demonstrate any findings that
warrant acute inpatient hospitalization.

The dates that do not show any need for acute inpatient stay should not be
approved because there were no treatments that required inpatient level of care.
However, the initial dates were medically necessary for the patient's immediate
postoperative recovery.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Adult Physical Abuse

Treatment hospital admission

The insurer denied coverage for hospital admission.

The denial is upheld.

The patient has a past medical history of heroin abuse on Suboxone, valve replacement on Eliquis, and anxiety on Klonopin.  The patient presented to the hospital status post assault.  The patient reported that her boyfriend hit her and threw a drill at her causing her to lose consciousness for an unknown amount of time.  The patient had 2 episodes of vomiting and felt weak since then.  The patient endorsed headaches.  The patient noted she did not feel safe at home. The urine drug screen was positive. The patient underwent a computed tomography (CT) scan of the head showing no acute intracranial pathology.  The patient was admitted for social disposition and was evaluated by medicine and a social worker and was discharged to stay with her mother.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. The hospital admission is not considered medically necessary for this patient.

Medical care provided was medically necessary and appropriate for someone with a closed head injury, while on Eliquis.  But all medical care was administered in the emergency room, with no apparent medical issues that required a full hospitalization based on the medical records provided.

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

Diagnosis: Dizziness

Treatment inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is overturned.

This patient presented to the emergency department (ED) for severe and progressive dizziness, unsteady gait and nausea/vomiting.  She had past medical history of hyperlipidemia.  

She was evaluated by neurology who recommended inpatient admission given patient's persistent dizziness and ataxia.  

Given the patient's age and stroke risk factors as well as persistent ataxia in the ED, inpatient admission for acute stroke work up was medically necessary. The health plan did not act reasonably with sound medical judgment.

Based on the above, the medical necessity for the inpatient hospital admission is substantiated. The insurer's denial is overturned.