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

Diagnosis: Knee osteoarthritis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient with advanced right knee osteoarthritis. He failed conservative management of this condition and opted to undergo elective right total knee replacement surgery. The surgery was successful with no documented complications. The patient was admitted to the hospital after the surgery and was subsequently discharged. The patient's health plan denied coverage for the inpatient hospital admission with a determination that it was not medically necessary. At issue in this case is the medical necessity of the inpatient hospital admission.

The requested health service/treatment of inpatient admission was not medically necessary for this patient. The provided records document that this patient underwent elective right total knee replacement surgery. The surgery was successful with no documented complications. The patient had normal lab values and vital signs following this elective operation. In addition, the records do not document that he had any clinical signs of postoperative infection or excessive bleeding. Also, there were no signs of deep vein thrombosis after surgery that would necessitate a two night inpatient hospital admission. Therefore, the provided medical records do not justify the medical necessity of the inpatient stay.
In addition, the current peer-reviewed orthopedic literature has documented the safety and efficacy of short stay and outpatient status for elective joint replacement patients. A recent article published by Kirkland and colleagues in the Journal of Arthroplasty in 2020 concluded that "Increased length of stay was associated with increased readmission risk. Patients with greater medical comorbidities stay longer to protect against readmission. Optimal length of stay (LOS) after total joint arthroplasty (TJA) is highly influenced by the patient's overall health. Despite a 300 percent (%) increase in TJA daily cost, readmission rate has changed minimally over the last 15 years." A second article published by Sutton and his co-authors in the Journal Bone and Joint Surgery concluded that "Early discharge was not an independent risk factor for 30-day major complications or readmissions following total hip arthroplasty (THA) or total knee arthroplasty (TKA). Rather, increased major complications and readmissions were attributed to patient comorbidities and perioperative variables. Early discharge within the first 2 days postoperatively for risk-stratified patients appears feasible without compromising patient care." Thus, based upon this peer-reviewed literature, the inpatient hospital admission for this patient was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute on Chronic Pancreatitis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient with a past medical history (PMH) of alcohol abuse, diabetes mellitus type 2 (DM2) and pancreatitis status/post (s/p) pancreatectomy who was admitted with complaints of (c/o) abdominal pain associated with emesis. Her vital signs were notable for pulse 113. The physical exam was notable for epigastric tenderness to palpation (TTP), non-toxic appearing. Lab work was notable for potential hydrogen (pH) 7.33, glucose greater than (>) 600 with decrease to 459 after emergency department (ED) treatment. An abdominal ultrasound (US) showed mild liver echogenicity. The patient was diagnosed with acute on chronic pancreatitis and hyperglycemia and treated with intravenous fluids (IVF), insulin, and pain control. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.
The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with complaints of (c/o) abdominal pain and vomiting and was diagnosed with acute on chronic pancreatitis. The patient did not have any evidence of impaired mental status, pleural effusion, systemic inflammatory response syndrome (SIRS), rebound tenderness, acute kidney injury, pancreatic necrosis, fever, or age greater than (>) 60. The patient's BISAP score was less than or equal (</=) 2 and she had a harmless acute pancreatitis score (HAPS) of 0, indicating that the patient was appropriate for a lower level of care, consistent with the patient's lack of toxic appearance, as well as discharge within 48 hours after admission. For the hyperglycemia, the patient was hemodynamically stable, responded to continuation of home insulin therapy, and there was no diabetic ketoacidosis (DKA), acute mental status change, end stage renal disease (ESRD), sepsis, acute cerebrovascular accident (CVA), acute Myocardial Infarction (MI) or significant complications, and did not have significant metabolic acidosis. Overall, this patient had non-severe pancreatitis that improved with conservative management and hyperglycemia that responded to continuation of home insulin therapy, and these interventions could have been safely provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

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

This is a male patient with a medical history of appendicitis, and marijuana use. He presented to the emergency department with nausea, vomiting, diarrhea, abdominal pain, a fever up to 102 degrees Fahrenheit, chills, and poor urine output. He thought he had eaten a bad burger. His vital signs were notable for an elevated diastolic blood pressure of 100 millimeters of mercury (mmHg) and rapid heart rate of 105 beats/minute. The physical examination was notable for an ill appearance, dry mucous membranes, diminished breath sounds at the bilateral bases, and soft distended abdomen with mild right flank tenderness. A computed tomography scan of the abdomen and pelvis showed no acute abdomen or pelvic pathology, and some mucosal fat deposition in the ascending colon consistent with prior infection/inflammation. He was treated with intravenous fluids, ondansetron, famotidine, Zosyn, and morphine. He was made nil per os. He had no further nausea or vomiting, was able to tolerate clear liquids and a regular diet, and was deemed stable for discharge to home.  At issue is the medical necessity for the inpatient level of care.
The inpatient level of care was not medically necessary. The patient had symptoms (nausea, vomiting, diarrhea, and abdominal pain) consistent with an infection such as gastroenteritis, without findings of complications such as abscess, colitis, or perforation on imaging. The standard of care for the evaluation of gastroenteritis was appropriately performed, including intravenous fluids, empiric antibiotics, and supportive care [1-4]. He had rapid improvement in symptoms. No other cause for the inpatient level of care, such as inflammatory bowel disease flare, peritonitis, toxic megacolon, fistula, or other complication was documented. He had an acute kidney injury, with rapid improvement with hydration [5,6]. The care which was undertaken, including observation, monitoring, labs, intravenous fluids, and empiric antibiotics, could have been performed without the inpatient level of care, at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity
Treatment: Mounjaro 15 milligrams (mg) / 0.5 milliliter (ml) pen injector
The insurer denied coverage for: Mounjaro 15 milligrams (mg) / 0.5 milliliter (ml) pen injector
The denial is: Overturned
The patient has obesity with a body mass index (BMI) of 40. The patient has tried multiple lifestyle modifications including several diets and exercise plans. The patient was started on Mounjaro and the BMI decreased from 47 and is now down to 32. The patient has improved both physically and mentally. Their doctor advises that the patient needs to remain on Semaglutide treatment. 

An article from The New England Journal of Medicine July 21,2022 Vol (volume) 387 titled "Tirzepatide Once Weekly for the Treatment of Obesity " has been referenced by the patient. The conclusion of this study was that Tirzepatide provided substantial and sustained reductions in weight. 

Up To Date has an article titled "Obesity in Adults: Drug Therapy." The article discusses the choice of pharmacologic agents. Options include GLP-1(Good laboratory practice) agonists such as Semaglutide and Liraglutide. Semaglutide has demonstrated efficacy in weight loss as well as improvement in glycemia and lipids. Another category of drugs are the dual acting GLP-1 and GIP (General Inpatient Care) receptor agonists. Mounjaro falls into this category and has been shown to be beneficial for weight loss. In an open-label trial including over 1800 patients comparing Semaglutide with Tirzepatide, reduction in body weight with all doses of Tirzepatide was greater compared with Semaglutide. 

The insurance company has offered other formulary GLP-1 receptor agonists. These include Victoza and Trulicity. These are drugs that are primarily used for diabetes but also result in weight loss. Tirzepatide is a novel GLP-1 and GIP receptor agonist that is effective in the treatment of obesity in patients with or without diabetes. 

This patient requires medical therapy for weight loss. The formulary drugs offered to the patient are approved for diabetes but are not as good as Mounjaro for weight loss. The medical literature supports the use of Mounjaro for weight loss. Mounjaro is medically necessary for this patient. 

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 Mounjaro 15 milligrams (mg) / 0.5 milliliter (ml) pen injector is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial fibrillation status-post elective catheter ablation
Treatment: Inpatient admission 
The insurer denied coverage for: Inpatient admission
The denial is: Upheld
Asked to review the case of an adult that presented to the hospital for elective catheter ablation of atrial fibrillation. Past medical history was significant for hypertension, diabetes mellitus, atrial flutter, and peripheral vascular disease (PVD). The patient underwent uncomplicated left atrial catheter ablation with pulmonary vein isolation and Cavo tricuspid isthmus ablation. Post procedure, minor bleeding from the groin was noted without hematoma. The day following the procedure, physical exam was unremarkable, and the patient was discharged.

This patient presented to the hospital for an elective electrophysiologic study and ablation. According to hospital records, the ablation was successfully performed without major complication. Observation following ablation was unremarkable and no post-operative issues were noted. The patient was discharged home the following day. In this case, there were no clinical reasons for hospital admission and the patient could safely be managed at a lower level of care. In two multicenter registry studies looking at healthcare utilization after electrophysiologic study (EP) catheter ablation, more than 80% of patients undergoing ablation were hospitalized for a single day, regardless of age or co-morbidity (Reference 1) Bartoletti demonstrated that patients undergoing atrial fibrillation ablation procedures could be safely discharged on the same day. (Reference 2) In a report involving over 6000 patients, same day discharge following catheter ablation of atrial fibrillation (AF) was found to be safe and comparable to outcomes in patients that were observed overnight. (Reference 3) In conclusion, acute inpatient admission was not medically necessary in this case.

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.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Covid-19
Treatment: Inpatient admission
The insurer denied coverage for: Inpatient admission
The denial is : Upheld
Patient is an adult who presented to the hospital with complaints of fever, chills, myalgia and diarrhea. The patient had reported fever to 101 degrees Fahrenheit (F) at home and oxygen saturation to 92% (percent).The patient tested Positive for Covid-19 and came to the emergency department (ED).

In the ED initial vital signs were: Temperature 99.4 degrees F, pulse 161, respirations 20, Blood Pressure 92/46, oxygen saturation on room air was 97%. The patient was admitted to the hospital for Covid-19. The patient was described to be in no acute distress (NAD). The physical exam was unremarkable. The patient was alert and oriented X 3 (person, place, time). Laboratory results were: White blood cells (WBC) 6.3K, Electrolytes were within normal limits (WNL), D Dimer was elevated and Covid-19 test was positive.

The patient was treated with intravenous (IV) fluids and Remdesivir and Decadron were also started. The patient had a computed tomography (CT) angiogram and no pulmonary embolus (PE) was detected. There was no consolidation or pneumonia (PNA) noted. The patient's vital signs (V/S) settled down shortly after admission - pulse decreased to 99 and then to 77, oxygen saturation was 100% on room air, electrocardiogram (EKG) had no acute ST-T changes.

The patient  was seen by Infectious Disease, who noted oxygen saturations of 100%. The patient was in NAD, the lungs were clear to auscultation. There was no evidence of Covid pneumonia, and pulmonary embolus had been ruled out. The patient was afebrile and hemodynamically stable. They recommended a second dose of Remdesivir in the afternoon and another dose on in the morning and subsequent discharge. The patient was tolerating food and fluids and was ambulatory. The patient was afebrile, hemodynamically stable, without hypoxia, and labs were within normal limits. The patient was discharged home.

This patient did not need acute hospitalization. The patient could have been placed in Observation status while diagnostic testing and treatment were initiated. The patient could have been in Observation for up to 48 hours. The patient remained stable after admission and was discharged the next day. The patient's tachycardia initially may have been secondary to dehydration as the patient had diarrhea. The patient improved rapidly after intravenous fluid and the Blood Pressure also improved.

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 a full hospital admission is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic migraine headaches and occipital neuralgia
Treatment: Nerve Blocks
The insurer denied Nerve Blocks.
The determination is upheld.

According to the submitted medical records, the patient has a listed diagnosis of migraine headaches. There is no evaluation for rebound headaches, despite reports of continuous headaches and the use of multiple abortive agents, is documented.
She is reported to be currently on eptinezumab, ubrogepant, Cefaly, tizanidine, Advil, Benadryl and ondansetron. "NB [nerve block] plus TPI [trigger point injection]" is also listed, unknown significance.
She previously used venlafaxine, amitriptyline, topiramate (single daily dosing when recommended use is twice daily), propranolol, Botox, and multiple calcitonin gene-related peptide (CGRP) blockers. The duration of such trials is unknown except for Botox, listed as "three rounds".
Also listed are pregabalin, gabapentin, which are not generally accepted as proven migraine prophylactic agents. Nerve blocks were denied by the health plan and are under review.
The proposed health service or treatment, nerve blocks, 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 insufficient evidence from high-quality peer-reviewed literature, large, well-designed, blinded, randomized trials to support long term safety and efficacy of the requested procedure, occipital nerve blocks, for the requested indication in this patient, migraine, as documented. This reviewer could also not identify any widely accepted guideline recommending such treatment. There is insufficient evidence from well-designed trials to recommend such treatment as standard for migraines.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic migraine headaches and occipital neuralgia
Treatment: Nerve Blocks
The insurer denied Nerve Blocks.
The determination is overturned.

The patient has chronic migraine headaches and occipital neuralgia. Continued treatments with nerve blocks is requested. The patient is currently treated with Vyepti. She has previously tried and failed an extensive list of preventative medications including injectable calcitonin gene-related peptide (CGRP) inhibitors, antidepressants, anticonvulsants, beta-blockers, anti-spasmodics, and anti-emetic drugs. At issue is whether nerve blocks are likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition.

Yes. The patient has failed nearly all available standard therapies for treatment of migraine headache disorders. As noted above and in the letter of medical necessity, the patient has tried and failed more than 15 standard therapies for prevention of migraine. These drugs including oral and injectable medications. Many of these drugs are approved for preventative treatment of migraine or recognized in the peer reviewed literature as effective for migraine. The patient has received nerve blocks for treatment of migraine with significant relief and continues injections are requested. The peer reviewed literature indicates that occipital nerve blocks are appropriate for refractory treatment of chronic migraine. These studies show that injection with local anesthetics could reduce headache frequency and intensity compared to placebo.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic migraine headaches and occipital neuralgia
Treatment: Nerve Blocks
The insurer denied Nerve Blocks.
The determination is upheld.

This is a female patient who came for a follow-up visit for treatment of chronic migraines without aura which are intractable, chronic daily headaches and she also has myofascial pain. The combination of Vyepti and nerve block overall has caused aslight reduction in headache severity. She was not needing acute medications as much. The plan was to continue nerve blocks (greater occipital nerve block, lesser occipital nerve block, auriculotemporal nerve block and supraorbital nerve block) and trigger point injections every 5 weeks and continue Vyepti and she was encouraged to use a Cefaly device.
The past rescue medications include eletriptan, Ubrelvy, ibuprofen, cyclobenzaprine and prochlorperazine. She has also tried nerve blocks which have helped her.
Past preventative medications include amitriptyline, venlafaxine, topiramate, Lyrica, gabapentin, pregabalin, propranolol, Emgality, eptinezumab, Ajovy, Vyepti infusion and Botox.
The nerve blocks were denied because nerve blocks for migraines are considered investigational and are not the usual procedure for migraines. Nerve blocks are under review.
The proposed health service (nerve blocks) is not considered to be more beneficial than any standard treatment for migraines.
Nerve blocks are not considered the standard of care and there is insufficient evidence in peer reviewed medical literature of the clinical validity and utility of nerve blocks in treating migraines.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Extruded disc herniation
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

This adult female patient presented with right leg pain. A computed tomography (CT) showed L (Lumbar) 4-L5 extruded disc herniation. Exam revealed no focal deficit. The patient was seen and recommended for right L4-L5 microdiscectomy. The patient was transferred to a different hospital and underwent L4-L5 discectomy. The patient was discharged on post-operative day three (POD3).

The acute inpatient hospitalization was medically necessary for the dates in question.

The notes indicate that the patient underwent surgery; inpatient hospitalization was medically necessary due to the need for observation immediately after surgery. On postoperative day #2, the patient had severe pain that was not allowing for adequate ambulation and was found to have significant weakness 3+/5 in right extensor hallucis longus (EHL). This warranted acute inpatient hospitalization, as this was worsening neurological function compared with admission. On day #3, inpatient level of care was medically necessary, as the patient continued to have a neurological deficit that warranted acute inpatient hospitalization and physical therapy (PT), as well as pain medications. The patient was noted to have 1/5 right extensor hallucis longus strength. On day #4, inpatient level of care was also medically necessary, as the patient was not able to ambulate and required continued physical therapy (PT) and continued pain control. Therefore, all dates in question were medically necessary and appropriate for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Dental issues.
Treatment:  Crown tooth 31.

The insurer denied a crown tooth 31.  The health plan's determination is overturned. 

The patient is a male, who presents for the treatment of tooth # (number) 31. Provided for review are letters of appeal and denial, correspondence from the patient, explanation of benefits, health plan language, and radiographic images. 

A crown for tooth 31 is medically necessary for this patient. When reviewing the documentation, the current restoration is overhanging and causing periodontal plaque trap. The size of the amalgam is restoring a large portion of the tooth and shows to have cuspal involvement, all factors making it medically necessary for the patient to have an indirect restoration. Therefore, the crown is indicated.