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

Diagnosis: Chest pain. 
Treatment: Inpatient admission. 

The health plan denied inpatient admission. The denial is upheld. 

The patient is an adult male with no significant past medical history. He presented to the emergency department for evaluation of chest pain. 

On arrival to the ED (emergency department), the patient was afebrile, blood pressure was 140/66, heart rate was 72 bpm (beats per minutes), and SpO2 (pulse oximetry) was within normal limits on room air. Initial CBC (complete blood count), CMP (comprehensive metabolic panel), and troponins were unremarkable. Twelve-lead EKG (electrocardiogram) showed ST (segment) elevations in leads V2-V5. He was loaded with aspirin and was admitted to the inpatient unit for further care. He was evaluated by electrophysiology and it was noted that his EKG (electrocardiogram) findings were unchanged from prior. A transthoracic echocardiogram was obtained which did not demonstrate any significant findings. He remained hemodynamically stable and was ultimately discharged with outpatient follow-up. 

The patient was hemodynamically stable and was not hypoxic. There was no evidence of sepsis, no mental status changes and no end organ malperfusion. There was no evidence of acute coronary syndrome, given that the troponins were within normal limits, and EKG (electrocardiogram) was unchanged from prior. Additionally, transthoracic echocardiogram did not demonstrate any wall motion abnormalities. Consequently, based on the provided documentation, there is insufficient clinical data to support medical necessity for inpatient level of care. Observation level of care would have been appropriate in this case.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: syncope
Treatment: inpatient stay
The insurer denied the inpatient stay. 

The health plan's determination is overturned.

This case involves a woman admitted with near syncope fatigue, headache, and nausea. The medical team notes the patient had several near syncopal episodes before arrival. She also had two syncopal episodes lasting for a minute or two while sitting on the couch at home. She had no headache but reported blurry vision. Associated symptoms included nausea but no vomiting. The patient was admitted to the hospital with a diagnosis of syncope. The medical team ordered telemetry, cardiac troponins, orthostatic blood pressures, and neurology consultation.

The inpatient hospital admission was medically necessary for this patient. Based on the provided documentation, the patient was experiencing near syncopal and syncopal episodes, with unresponsiveness when ambulating both at home, and subsequently continued to experience these in the hospital. It was reasonable to continue to monitor the patient, given the persistence of these episodes and safety concerns regarding discharge. The patient was monitored on telemetry and was noted to have non-sustained ventricular tachycardia (VT) episodes. It was also reasonable to perform a complete neurologic assessment to evaluate for neuro cardiogenic causes of syncope. The documentation states the patient required sternal rubs during the syncopal spells to return to her senses. Since this was not an isolated episode, with multiple recurrences, inpatient admission to evaluate for life-threatening causes of syncope was warranted.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female who initially presented to the emergency department with concerns for right lower quadrant abdominal pain of several week duration. Pertinent history included hysterectomy with salpingectomy one-month prior, prolonged QT status/post (s/p) automatic implantable cardioverter defibrillator (AICD), hypothyroidism, and nephrotic syndrome. Initial vital signs revealed a temperature of 97.8-degree Fahrenheit, heart rate (HR) 90, blood pressure (BP) 123/69, respiratory rate (RR) 16, and peripheral capillary oxygen saturation (SpO2) 100%. Initial examination documented tenderness to right lower quadrant without distension or peritoneal signs. Initial laboratory testing revealed a white blood cell count (WBC) 8.9, Hemoglobin (HGB) 12.1, platelets (Plt) 330, blood urea nitrogen (BUN) 4, and Cr (creatinine) 0.48. Urinalysis was relatively unremarkable. A computed tomography (CT) abdomen/pelvis revealed a right adnexal structure measuring 3.1 centimeter (cm), likely the right ovary containing a corpus luteum. A transvaginal ultrasound revealed a left 2.5 cm hemorrhagic cyst. 

The inpatient hospital admission was not medically necessary. Evaluation and management could have been performed at a lower level of care. The patient presented with right lower quadrant abdominal pain. Initial evaluation documented as afebrile, hemodynamically stable, and without peritoneal signs. Laboratory testing was relatively unremarkable. CT (computed tomography) abdomen/pelvis was relatively unremarkable but did note a right ovary containing a corpus luteum. A transvaginal ultrasound revealed a left ovarian 2.5 cm (centimeter) hemorrhagic cyst. OBGYN (obstetrician-gynecologist) consulted and cleared the patient for discharge. Treatment plan thereafter included analgesia. Following observation care, pain was controlled with an oral regimen and the patient was deemed stable for discharge.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Uncontrolled hypertension and new onset congestive heart failure
Treatment: Inpatient admission
The insurer denied coverage for Inpatient admission
The denial is overturned

Patient is an adult male with a history of hypertension who was not taking any meds. He presented to the emergency department (ED) with complaints of exertional dyspnea and orthopnea for about 3 weeks. He complained of some chest pain (CP) on the day of presentation so came to the ED.

At presentation his blood pressure was 202/143, pulse 106 beats per minute. Lung exam revealed bibasilar rales and his heart sounds were normal. No pedal edema was observed. A bedside echocardiogram revealed decreased left ventricular ejection fraction (LVEF). White blood cell count, hemoglobin and electrolytes were normal except for a borderline low potassium level of 3.4. Blood urea nitrogen/ creatinine (BUN/Cr) 20/1.22. Chest X-ray showed cardiomegaly. Electrocardiogram (EKG) was normal except for left ventricular hypertrophy noted. The patient was diagnosed with Uncontrolled hypertension (HTN) and new onset congestive heart failure (CHF) and admitted to the hospital.

Patient was given intravenous (IV) Lasix in ED and Amlodipine by mouth (PO). His blood pressure remained over 200 systolic. Cardiology was consulted. They recommended Entresto twice daily (BID), Toprol, and IV Lasix. The patient had serial EKG and cardiac enzymes. He was admitted to Telemetry unit.

Given presentation with chest pain, uncontrolled HTN and new onset CHF it was appropriate to admit this patient for observation and treatment. His BUN/ Cr increased with IV Lasix. This patient with history of hypertension who was noncompliant and not on any meds needed admission and close monitoring of his treatment to avoid any bad outcome in terms of complications. He had evidence of end organ damage at presentation, and it was not safe to treat him at a lower level of care.

Based on the above, the insurer's denial must be overturned. 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 the hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multiple sclerosis
Treatment: Vitamin D testing
The insurer denied coverage for Vitamin D testing.
The denial is overturned.

This case involves an adult patient who been treated for a history of falls, neuropathic pain, depression, and multiple sclerosis.  The patient received orders for laboratory testing to include hemoglobin A1c, lipid panel, vitamin B12, urinalysis with culture reflex, complete blood count (CBC) and differential, a comprehensive metabolic panel, and thyroid-stimulating hormone with reflex.  Additional testing was ordered to include vitamin D 25-hydroxy, vitamin B12, vitamin B6. The follow-up noted the patient's primary diagnosis was multiple sclerosis.  Symptoms began with the patient noticing a large numb patch on the left anterior torso.  This came on suddenly and had since resolved but upon further work-up, a lesion was found on the patient's spine.  He began experiencing paresthesia in 3 (three) digits bilaterally on the hands and then toes, which was occurring intermittently.  He began having paresthesia affecting the lower extremities that moved up from the toes to below the knees.  He reported prior episodes of syncope while out for a run and was fatigued from not sleeping well claiming that he had consumed alcohol the night before.  During that episode, he claimed to have hit his head.  He reported taking around 5000 IU (international units) of vitamin D per day.  The report referenced an outpatient hospital visit whereupon laboratory testing was conducted with vitamin D 25 hydroxy within normal limits at 44.  His vitamin B6 was elevated at 35.7.  This review pertains to the vitamin D testing.

Literature states that vitamin D deficiency can lead to an array of problems.  Vitamin D deficiency is associated with the incidence and prevalence of a variety of neurologic disorders, including multiple sclerosis.  The treating physician claimed that the patient had vitamin D deficiency diagnosis in addition to multiple sclerosis with use of Ocrevus infusions.  Prior to the testing, there was no supporting documentation to confirm a vitamin D deficiency.  However, because of the patient's multiple sclerosis (MS) diagnosis, and medical literature noting that there is a connection between vitamin D deficiency and MS, it would be reasonable for the physician to submit a request for testing to assess the patient's vitamin D 25-hydroxy to confirm that he was responding to the supplementation.  Given the provided documentation, the testing was medically necessary for this patient.

Based on the above, the insurer's denial must be overturned. 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 Vitamin D testing is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Insomnia
Treatment: Belsomra
The insurer denied Belsomra.
The determination is upheld.

This is a female patient with chronic insomnia. The treating provider is requesting the coverage of Belsomra. The patient tried and failed or has been intolerant to Dayvigo, Trazodone, Hydroxyzine and melatonin. At issue is whether the formulary drugs will be or have been ineffective, would not be as effective as the non-formulary drug, Belsomra, or would have adverse effects.

There is no evidence that the formulary drugs ramelteon, zolpidem, zolpidem extended release (ext rel) are less effective or have more adverse effects than the preferred formulary medications.

The patient has chronic insomnia. She tried and failed Dayvigo, Trazodone, Hydroxyzine and melatonin. The request is for the Belsomra. However, there is no convincing or objective evidence in the submitted documents that the patient has a contraindication to or a potential drug interaction with formulary alternatives (ramelteon, zolpidem, zolpidem ext rel). There is no evidence that the patient is intolerant to or has had a confirmed adverse event with formulary alternatives (ramelteon, zolpidem, zolpidem ext rel). There is no evidence that the patient has demonstrated an inadequate treatment response after a trial of formulary alternatives (ramelteon, zolpidem, zolpidem ext rel)
There are no adequate or well-conducted randomized controlled or cohort trials in the prevailing peer-reviewed published medical literature that established the long term efficacy and safety of Belsomra over preferred formulary drugs, such as ramelteon, zolpidem, zolpidem ext rel, for the treatment of this patient's medical condition.
There is no high-quality literature showing an improvement in health outcomes with the use of Belsomra over preferred formulary (ramelteon, zolpidem, zolpidem ext rel) for this patient's condition. There are no national guidelines that support the routine use of Belsomra over ramelteon, zolpidem, zolpidem ext rel for the treatment of chronic insomnia as in this patient's case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Nerve Treatment (ablation treatment)
The insurer denied: Nerve Treatment (ablation treatment)
The denial is Upheld

The patient is an adult male who has had low back pain for years. Past treatments include home exercise, weight loss, diclofenac, Advil, Aleve, facet rhizotomy, and epidural steroid injection. MRI (magnetic resonance imaging) of the lumbar spine shows multilevel degenerative changes, facet joint arthrosis, disc bulge, foraminal narrowing, and Modic type I changes at L4-5 (lumbar). The request for Intracept was denied coverage by the health plan, as it has not been shown to be effective, and was therefore deemed not medically necessary. The denial is being appealed.

The requested health service is not medically necessary.

Review of literature shows moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic back pain who are selected based on Type I or Type II Modic changes as well as other inclusion and exclusion criteria used in published literature to date. However, non-industry funded high-quality, large prospective studies are needed to confirm these findings.
At this time, there is not enough valid scientific evidence to show that the expected health benefits from the procedure, supply, equipment, or service are clinically significant and will have a greater chance of benefit, without a disproportionately greater risk of harm or complications, than other possible treatments; and that generally approved forms of treatment that are less invasive have been tried and did not work or are otherwise unsuitable. There is a lack of sufficient (enough) peer reviewed literature and data regarding the long-term outcomes of the procedure. As such, the requested health service is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Heart Problem
Treatment: Inpatient hospital admission 
The health plan denied: Inpatient hospital admission 
The determination is: Overturned

The patient is a male with chronic heart failure, hypertension (HTN), diabetes type 2, stage 4 metastatic lung cancer treated with chemotherapy/immunotherapy/radiation, and chronic obstructive pulmonary disease (COPD) who presented to the emergency department (ED) for evaluation of worsening shortness of breath, cough, and fever. In the ED, the patient was febrile and tachycardic. The blood pressure (BP) was normal. His peripheral capillary oxygen saturation (SpO2) was 91 percent (%) on room air. His brain (or B-type) natriuretic peptide (BNP) was elevated to 1,585. A computed tomography (CT) scan was negative for pulmonary embolism (PE). The patient was started on intravenous (IV) Lasix in the ED and admitted to telemetry service under inpatient level of care for evaluation and treatment of acute heart failure with volume overload, COPD exacerbation, and rule out sepsis. The patient was treated with IV Lasix daily, nebulizers, supplemental oxygen, and steroids. Blood cultures were obtained, and the patient was treated initially with IV antibiotics due to concerns for sepsis. After IV diuresis and treatment for COPD exacerbation, the patient's symptoms resolved, and he was discharged home in stable condition.
At issue is the medical necessity of the inpatient hospital admission. 
The health plan's determination is overturned in whole.
The requested health service/treatment of inpatient hospital admission is medically necessary for this patient. Given the patient's high degree of medical complexity highlighted by acute on chronic respiratory failure due to COPD and congestive heart failure (CHF) exacerbations in the setting of stage 4 lung cancer, and high BNP and hypoxia requiring supplemental oxygen by nasal cannula, the inpatient level of care was medically necessary and in the best interest for the safety of the patient to achieve optimal patient outcomes supported by peer reviewed medical literature and expert consensus guidelines on acute heart failure management [1-5].
While the patient's history of heart failure was not clear based on the case records, the patient presented in respiratory distress with hypoxia requiring 4 liters per minute (LPM) via nasal cannula of supplemental oxygen, a high BNP, and pleural effusions on chest imaging consistent with high-risk status for respiratory failure and short-term mortality. Furthermore, due to the patient's significant comorbid conditions, the patient required comprehensive workup to exclude other potential acute etiologies of respiratory failure, including pulmonary and infectious causes most appropriately evaluated as an inpatient with serial lab assessments, telemetry, and vital sign monitoring.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is Upheld

The patient is an adult female. She was hospitalized for chest 
pain, and she underwent elective cardiac catheterization. Her PMH (past medical history) is remarkable for HTN (hypertension), recurrent chest pain and abnormal stress test concerning for ischemia. The patient's TTE (Transthoracic Echocardiogram) showed LVH (left ventricular hypertrophy), 
along with LVEF (left ventricular ejection fraction) of 58%. VS (vital signs) were stable. She had LHC (left heart catheterization) with successful PCI (percutaneous coronary intervention) with DES (drug eluting stent) to the ramus branch. There were no procedural complications, she had overnight observation and was discharged to home. The health plan denied coverage of the inpatient admission as not medically necessary. The denial is being appealed.

The Inpatient Hospital Admission was not medically necessary.

In this particular case, the patient underwent elective, successful and uncomplicated cardiac catheterization with coronary angiography and PCI (percutaneous coronary intervention) on the same day. The information provided does not support the medical necessity for admission after her coronary intervention. This procedure is routinely performed in the ambulatory setting with overnight observation. There is no documentation of unstable medical conditions like AMI (acute myocardial infarction), contrast nephropathy, stroke, acutely decompensated CHF (congestive heart failure), life-threatening cardiac arrhythmia, procedural complications, or other medical instability or acute care needs that would require acute inpatient management. There was no clinical decline or inadequate response to treatment which required inpatient hospital stay. The care she received, including elective cardiac catheterization with a successful and uncomplicated PCI (percutaneous 
coronary intervention), like in this case, 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: Overturned

Diagnosis: Missing Teeth.
Treatment: Partial Lower Denture (D5214).
The insurer denied: Partial Lower Denture (D5214).
The denial is overturned.

The patient is an adult female. The request is for lower partial denture. The request was denied coverage by the health plan, because the patient was reported to have more than eight posterior teeth touching. The denial is being appealed.

The Partial Lower Denture (D5214) is medically necessary.

The patient's physician noted that the patient has a problem with mastication and choking on food. This is due to the patient not having enough teeth to properly chew her food. There is medical necessity to correct this problem with the partial lower denture. 
The health plan notes that there must be fewer than eight posterior teeth touching for there to be benefits for a partial denture. It erroneously noted that the patient had more than eight posterior touching. According to the x-rays provided, there are fewer than eight posterior teeth touching. Therefore, the requested lower partial denture is medically necessary.
Appeal type: Medical necessity
Decision: Upheld



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

This case involves a woman admitted with abdominal pain. The abdominal pain was diffuse, radiating to the chest, non-positional and constant. Vital signs showed normal temperature, heart rate, respiration, and blood pressure of 158/86 mmHg (millimeters of mercury). Examination revealed a soft abdomen, tender to palpation in all four quadrants to light touch, but normal bowel sounds and negative Murphy sign. The rest of the exam is unremarkable. Laboratory studies show normal white blood cell count, stable hemoglobin electrolytes, and renal function.

The inpatient hospital admission was not medically necessary. The documentation provided fails to demonstrate an inpatient qualifying diagnosis. The patient had somatic symptoms related to anxiety without evidence of an acute medical process that would warrant an inpatient admission. Cardiac work-up is unremarkable, including enzymes, electrocardiogram (EKG), and an echocardiogram. The Abdominal pain, which was the presenting symptom, resolved within 24 hours, and the imaging was fairly unremarkable. The documentation showed that anxiety plays a big part in her symptomatology. There is no clinical indication to admit this patient under an inpatient level of care. A lower level of care is appropriate.