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

Diagnosis: Shortness of Breath, Cough.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient was brought to the emergency department (ED) by his parents with a one day history of cough, fever, increased work of breathing, and scattered wheezes. He had respiratory syncytial virus (RSV) three weeks prior. He was taking fluids and solids by mouth. At triage, he was afebrile with a respiratory rate (RR) of 60 and oxygen saturation of 97% (percent) in room air. The exam showed moist mucus membranes, subcostal retractions, and a mild expiratory wheeze. He was put on an ED "asthma pathway," including decadron and albuterol, and responded to albuterol with resolution of wheezing and significant improvement in retractions. Post albuterol treatments, however, he had an oxygen saturation on room air of 89%, so he was admitted to pediatrics for supplemental oxygen. When he arrived on the pediatric floor, his oxygen saturation was 93% on room air. He had normal capillary refill and moist mucus membranes. He did not have retractions, but did have a mild expiratory wheeze. It was noted that he was "currently not requiring respiratory support, tolerating by mouth (PO) well, not requiring intravenous (IV) fluids." He was kept overnight and discharged home the next day. At issue is the medical necessity of an inpatient stay.

The inpatient stay was not medically necessary.
The patient had mild respiratory symptoms upon presentation to the emergency department (mild tachypnea, mild retractions, bilateral wheezes), most of which had abated by the time he arrived to the pediatric floor (tachypnea and retractions gone, wheezes mild). He was not dehydrated. He did briefly have an oxygen saturation of 89% in the emergency department, but this was following albuterol administration. Transient mild hypoxemia due to ventilation-perfusion (V/Q) mismatch is common after bronchodilator therapy, and by the time he arrived on the floor, he did not require oxygen, so there was no medical necessity for the inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ischemic Heart Disease. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

This patient has a history of ischemic heart disease, hypertension, and diabetes mellitus that presented to the hospital for elective cardiac catheterization.  Previous catheterization revealed multivessel coronary disease and stents were placed in the left anterior descending and left circumflex arteries.  The patient was scheduled for revascularization of a right posterior descending artery lesion. A drug eluting stent was placed via right radial artery approach.  No perioperative complications were noted, and the patient was discharged the following day. 

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient. This patient presented for elective percutaneous revascularization. He underwent an uncomplicated procedure and stents were placed in the posterior descending artery. He was discharged the following day. Several investigators have studied the safety surrounding same day discharge following percutaneous intervention and demonstrated no difference between patients that are discharged on the same day as compared to patients admitted to the hospital (Reference 1-4). Current expert consensus from the society of cardiovascular angiography and interventions support treatment at a lower level of care (Reference 4). In conclusion, inpatient admission was not medically necessary.  The patient could have been managed at a lower level of care. 

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

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

Diagnosis: Choledocholithiasis. 

Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

Per clinical documentation, this is an adult female patient who presented as an outpatient for an elective cholecystectomy. The patient has a history of choledocholithiasis that was previously treated with endoscopic retrograde cholangiopancreatography (ERCP) and stent placement. The patient underwent a laparoscopic cholecystectomy with intraoperative cholangiogram without any immediate complications. Cholangiogram demonstrated filling defects within the common bile duct. The patient underwent a repeat ERCP. The patient's diet was advanced, and she was discharged. 

There was no reported abnormal pain. Amylase levels were not checked during the hospitalization. Acute pancreatitis is the most common complication after an ERCP. Acute pancreatitis is defined by serum amylase at least 3 times above the upper limit of normal post-procedure, with new abdominal pain consistent with pancreatitis. Risk factors for the development of post-ERCP pancreatitis include suspected sphincter of Oddi dysfunction, history of post-ERCP pancreatitis, and late adulthood. [1] ERCP has been shown to be a safe and effective outpatient procedure. Studies have also shown that most complications related to ERCP occur within 4 to 6 hours after the procedure. Therefore, observation alone with a 6-hour observation is sufficient and has been shown to decrease hospitalization rates. This was shown to also be true in elderly patients. [2, 3] 

This patient did not exhibit complications after 6 hours of observation. There was no concern for pancreatitis without measurement of lab values and no report of abdominal pain consistent with pancreatitis. Per provided clinical documentation, the requested inpatient admission is 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 admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain. 
Treatment: Inpatient hospital stay. 

The insurer denied the inpatient hospital stay. 
The health plan's determination is upheld. 

The patient is a female with a past medical history remarkable gastritis, hepatic steatosis, recent cholecystitis, who was admitted for diffuse abdominal pain. Review of system was positive for blood-streaked vomitus, diarrhea, and occasional melena. The patient was afebrile (Temp of 36.8 degrees C [Celsius]). She was described as well-developed and well-nourished. Her blood pressure was 99/57, pulse rate of 79, respiratory rate of 15, and oxygen saturation of 99% (percent) on room air. Physical examination was remarkable for diffusely tender abdomen mostly in the right upper and lower quadrants. The patient was admitted for abdominal pain, nausea, vomiting in the setting of recent cholecystectomy. 

The inpatient hospital admission was not medically necessary. The care could have been safely rendered at a lower level of care. 

The patient was admitted for acute on chronic abdominal pain in the setting of recent cholecystectomy. Her workup did not reveal findings such as infection, abscess, or clinical signs of sepsis. She was hemodynamically stable. The imaging demonstrated clinical improvement with no new findings that represented post-operative complications. Furthermore, the patient was tolerating ice chips and the documentation did not demonstrate worsening clinical status. 

Post-cholecystectomy syndrome (PCS) is the term used to describe the persistence of biliary colic or right upper quadrant abdominal pain with a variety of gastrointestinal symptoms like those in patients with cholecystitis prior to cholecystectomy. In general, patients may experience pain similar to cholecystitis during the post-operative period. Other causes of pain include biliary manifestations of PCS that may occur early in the post-operative period, usually because of incomplete surgery (retained calculi in the cystic duct remnant or in the common bile duct) or operative complications, such as bile duct injury and/or bile leakage. A later onset is commonly caused by inflammatory scarring strictures involving the sphincter of Oddi or the common bile duct, recurrent calculi or biliary dyskinesia. In this case, the magnetic resonance cholangiopancreatography (MRCP) did not reveal findings of biliary ductal dilatation, leakage or retained stones. Additionally, the patient's liver enzymes were within normal limits. As such, a lower level of care would have been most appropriate for IV (intravenous) pain medications, fluids, and anti-emetics.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's Disease. 
Treatment: Stelara 90 mg every 4 weeks. 

The insurer denied the Stelara 90 mg every 4 weeks. 
The determination is overturned. 

The patient has Crohn's disease complicated by rectal and anastomotic stricture. He failed mesalamine, corticosteroids, azathioprine, 6-mercaptopurine, high-dose infliximab, and high-dose Remicade. He started Stelara, with initial improvement. He has had recurrent symptoms 2-3 weeks prior to Stelara injections. At issue is the medical necessity of Stelara 90 milligrams (mg) every 4 weeks for the treatment of Crohn's disease. 

The request for Stelara 90 mg every 4 weeks is supported as medically necessary in this case by current medical literature. 
Stelara is Food and Drug Administration (FDA)-approved for the treatment of Crohn's disease, and a large randomized controlled trial demonstrated safety and efficacy of Stelara for induction and maintenance of remission in patients with moderate-severe Crohn's disease. Guidelines for the treatment of Crohn's disease recommend the use of Stelara. A study showed dosing intensification (90 mg every 4 weeks) was used frequently to address loss of response, and a large proportion of patients were able to maintain response. One study showed that dose escalation was required and approximately half of patients, and successful in 61.1% of dose escalation attempts. Another study showed efficacy of dose escalation to recover lost response in 73% of patients in whom it was attempted. Additionally, American College of Gastroenterology guidelines for the treatment of Crohn's disease state that "Those with continued symptoms should be treated with an alternative therapy for mild to moderate disease, have their medication dose adjusted in order to attempt to optimize therapy". In this case, the enrollee has failed multiple other medications for the treatment of Crohn's disease, and failed Stelara every 8 weeks. Continuation of dosing every 8 weeks may result in complications such as fistula, stricture, bowel obstruction, flare, hospitalization, need for surgery, or other complications in this enrollee with limited available alternatives for the treatment of Crohn's disease. For all of these reasons, continuation of Stelara 90 mg every 4 weeks is supported as medically necessary for the treatment of Crohn's disease in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Foot ulcer.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a male with type 2 diabetes and PAD (peripheral arterial disease) status post angiography. He presented with worsening foot ulcer. He had failed outpatient oral antibiotics times 2 weeks. He presented with 2 days of fever.

The patient was admitted for IV (intravenous) antibiotics and evaluation. His fevers resolved after IV (intravenous) antibiotics. His workup did not warrant further treatment.

Yes, the Inpatient admission was medically necessary.
Hospital admission for a diabetic with open wound and fever is the standard of care. Patients with poor circulation (as in this case with history of angiography) can rapidly progress, requiring acute monitoring by nursing and a multi-disciplinary effort to rule out other sources of fever, treat infection, prevent amputation and if necessary perform surgical management. This typically requires a minimum of two to three days of inpatient hospital care.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
As stated above, inpatient admission was necessary, given the patient's medical history and failed outpatient care with fever despite being on oral antibiotics.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Post-Transplant Hemolytic Anemia
Treatment: Daratumumab
The insurer denied the Daratumumab
The denial is upheld

The patient is a male with aplastic anemia treated with SCT (stem cell transplantation) now with resulting pancytopenia and ABO (blood types A, B, O) incompatibility. The patient's provider has requested daratumumab.

No, the health plan should not cover the requested Daratumumab.

No, the Daratumumab is not more beneficial.
There is no evidence that Daratumumab is of benefit in the treatment of ABO (blood types A, B, O) incompatibility/pancytopenia following SCT (stem cell transplantation). There is no literature in the form of prospective clinical trials that demonstrate that Daratumumab is safe or effective as therapy for this condition. The patient's provider has provided several case reports, however case reports are not considered acceptable evidence and do not establish the requested Daratumumab as an effective treatment approach. Absent any type of prospective trials, there is no evidence that this therapy is likely to be beneficial.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Post-Transplant Hemolytic Anemia
Treatment: Daratumumab
The insurer denied the Daratumumab
The denial is overturned

The patient in this case is a boy with aplastic anemia who underwent allogeneic stem cell transplantation. His post-transplant course has been complicated by autoimmune hemolytic anemia. He has both warm and cold reactive antibodies and also has been noted to have decreasing chimerism with falling white cell count. He has been treated with prednisone and tacrolimus and also with rituximab. An appeal letter states that he has failed these treatments and that there has not been any appreciable improvement in his chimerism studies. His physician has recommended treatment with daratumumab.

Yes, the health plan should cover the requested Daratumumab.
This patient has both autoimmune hemolytic anemia and worsening chimerism following allogeneic transplantation. He has failed standard first-line treatments (prednisone, rituximab and tacrolimus). There are multiple reports indicating that daratumumab can be effective for treatment of both autoimmune cytopenia as well as red cell aplasia following allogeneic transplantation. As daratumumab targets CD38 (cluster of differentiation 38), which is expressed on plasma cells, it is reasonable to expect it can be effective for these diseases. This is because they are antibody driven and antibodies are produced by plasma cells. Given that there is a sound physiologic mechanism supporting the efficacy of daratumumab to treat this patient's condition and given that there are multiple reports showing that this agent is beneficial, and given that this patient has failed standard treatments, daratumumab should be covered in this case.

Yes, the requested Daratumumab is more beneficial.
There is no standard treatment available to this patient, as standard treatments have already been tried without success.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Post-Transplant Hemolytic Anemia
Treatment: Daratumumab
The insurer denied the Daratumumab
The denial is overturned

The patient is a male with a history of aplastic anemia who underwent unrelated allogeneic bone marrow transplant He did well, but has developed coombs positive hemolytic anemia and thrombocytopenia. He has failed therapy with increasing his immunosuppression with steroids, tacrolimus and rituximab. The provider is recommending treatment with daratumumab 16 mg/kg (milligrams per kilogram) IV (intravenous) weekly for six weeks.

Yes, the health plan should cover the requested Daratumumab.
Pure red cell aplasia (PRCA) is characterized by anemia, reticulocytopenia, and RBC (red blood cell) transfusion dependence persisting over 3090 days after HSCT (hematopoietic stem cell transplant) along with bone marrow aspirate or biopsy showing isolated depletion or nearly depletion of erythroid precursors in otherwise normal marrow. PRCA (pure red cell aplasia) diagnosis demands the exclusion of other causes as viral infections, drug induced marrow suppression, hemolysis, or relapse. Nevertheless, some cases of PRCA (pure red cell aplasia) in which thrombocytopenia and severe pancytopenia were also present have been reported.

Front line therapies include steroids and rituximab, which the patient has failed. Daratumumab is a humanized IgG1 (immunoglobulin G 2)-kappa monoclonal antibody targeting CD38 (cluster of differentiation 38), broadly expressed on plasma cells as well as lymphoid cells, myeloid cells, and nonhematopoietic tissues. Daratumumab could selectively target the plasma cell clone producing the delayed erythroid engraftment.

Recently, five cases of PRCA (pure red cell aplasia) who were successfully treated with Daratumumab have been published. All these five patients suffered a long lasting PRCA (pure red cell aplasia) and had been heavily pre-treated. Daratumumab was administered at 163 days, 206 days, 390 days, 411 days, and 24 months after HSCT (hematopoietic stem cell transplant), at dose of 16mg/kg (milligrams per kilogram) per week for 2 weeks, 4 weeks, and 6 weeks. An early response after first and second dose was observed in three patients, while in two patients the response was achieved after the third and sixth dose, respectively.

Based on the above data, the use of daratumumab is medically appropriate for this patient.

Yes, the Daratumumab is more beneficial.
There are no other more effective treatment options for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right ovarian mass
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a woman with a diagnosis of a right ovarian mass. Her medical history included sarcoidosis, asthma, prediabetes and morbid obesity. She underwent an exploratory laparotomy and right salpingo-oophorectomy.

The procedure was performed without complications, and with a minimal blood loss. The patient was transferred to the PACU (post anesthesia care unit), where she recovered without incident. She was subsequently transferred to the inpatient service, where she recovered uneventfully. The patient was discharged.

Yes, the Inpatient admission was medically necessary.
The patient underwent an exploratory laparotomy. Exploratory laparotomy is not an ambulatory procedure. The postoperative care of patients who have undergone laparotomy includes inpatient observation for postoperative complications, including intra-abdominal hemorrhage, postoperative pelvic infection and progression to normal bowel function. The patient underwent an uncomplicated laparotomy procedure. The physician progress notes indicate that the patient was not tolerating a normal diet, not fully ambulatory, had a draining Foley catheter and did not have fully normal bowel function by the end of the first postoperative day. Her vital signs were normal and she was normally voiding and ambulating at the end of the first postoperative day. On the second postoperative day the patient was afebrile, had normal vital signs, was tolerating a normal diet and was ambulatory with good pain control. Therefore, the inpatient admission was medically necessary, and the patient's condition was appropriate for discharge at the end of the second postoperative day.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal 
Treatment: inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

The patient is a male with no significant medical history. He presented to the emergency department with left lower quadrant abdominal pain. He had consumed some alcohol two days prior. Vital signs were unremarkable. Physical examination was notable for mild left lower quadrant abdominal tenderness. Labs showed elevated white blood cell count of 12.9, elevated alkaline phosphatase of 135, and elevated lipase of 578. Computed tomography scan of the abdomen and pelvis showed findings consistent with acute interstitial pancreatitis with mild inflammation surrounding the pancreatic tail, but no pancreatic fluid collection. 

The inpatient stay was not medically necessary. The patient presented with symptoms, labs, and imaging consistent with acute pancreatitis. He was appropriately treated, with intravenous fluid administration, and gradual advancement of diet. However, there was no hemodynamic instability or other complications such as pseudocyst, pancreatic necrosis, thrombosis, ascending cholangitis, abscess, active gastrointestinal bleeding, peritonitis, or sepsis, which would require a higher level of care. The interventions performed, including labs, intravenous fluids, monitoring, imaging, and Gastroenterology consultation could have been performed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Uterine Fibroids

Treatment: radiofrequency ablation of uterine fibroids

The insurer denied coverage for radiofrequency ablation of uterine fibroids

The denial is upheld.

The patient is an adult female with a history of uterine fibroids and abnormal uterine bleeding. An ultrasound showed two fibroids 6 cm (centimeters) in size. She underwent a hysteroscopy with biopsy. The provider has recommended transcervical uterine fibroid ablation with ultrasound guidance, radiofrequency (CPT code 0404T) (The sonata system).

The Sonata system is FDA (Food and Drug Administration) approved for the management of fibroids. There are multiple studies documenting the safety and efficacy of this procedure in controlling symptoms due to fibroids.  The use of the Sonata system in this patient's case is  not medically necessary  as some of the fibroids are greater than the 5 cm size that is reported in all the published studies about the efficacy and safety of Sonata using the transcervical approach. Lukes et al included patients with fibroids of up to 5 cm in diameter. Shifrin et al in a study of 147 patients only had 4 (1% [percent]) of patients with a fibroid of 6cm or more. The Fast- EU (fibroid ablation study) trial also included only patients up to 5 cm. In other words, there are no data about the effectiveness of the sonata system in patients with larger fibroids. As such the requested procedure is still unsupported and the denial should be upheld.

In summary, the use of the Sonata system to manage fibroids above 5 using the transcervical approach is not medically necessary. 

As discussed above, the health care plan did act reasonably and with sound medical judgement and in the best interest of the patient. 

The insurer's denial of coverage for the radiofrequency ablation of uterine fibroids using the transcervical approach is upheld. Medical necessity is not substantiated