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

Diagnosis: ischemic colitis

Treatment: inpatient hospital stay

The insurer is denied coverage for inpatient hospital stay

The denial is upheld. 

This female patient has a history of hypertension, diabetes, and gastroesophageal disease (GERD).

Milliman Care Guidelines (MCG) clinical indications for admission for Gastroenteritis (M-170) include a suspected severe infection, peritoneal signs, hemodynamic instability, severe vomiting, severe electrolyte abnormalities and an inability to maintain oral hydration after observation care. She did not have these conditions.

This patient had a colitis and responded to antibiotics. The vascular surgery consult advised that since there was stenosis in only one vessel, no surgical interventions were needed. The colonoscopy revealed only a mild colitis and could have been done on an ambulatory basis. There was no active bleeding, intravenous (IV) hydration could have been given in the emergency room (ER) and antibiotics given with observation care. She did not meet MCG Criteria for admission for gastroenteritis. The healthcare plan acted reasonably and with sound medical judgement. An inpatient admission was not medically necessary.

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 inpatient hospital stay is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle Cell Disease
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a male with a history of sickle cell disease and G6PD (glucose-6-phosphate-dehydrogenase deficiency). He presented for care with severe, progressively worsening left knee pain that failed oral opioid medications in the home setting. He presented with a temperature of 100.2 and tenderness to palpation overlying the left knee joint. His white blood cell (WBC) count was 11.6, his hemoglobin was 9.5 and his reticulocyte was elevated at 8.8%. He was given intravenous (IV) fluids, several doses of IV morphine, and IV ketorolac. He continued to have pain in the knee, so he was admitted for further treatment and monitoring. While admitted, he was given IV fluids, IV morphine 5 milligrams (mg) every 4 hours as needed, IV ketorolac every 6 hours, hydroxyurea, folic acid and serial pain assessments. His symptoms slowly improved, he was transitioned to oral pain medications on hospital day # (number) 2, and he was discharged home.

The inpatient hospital admission was not medically necessary for this patient as the treatment needs could be safely provided at a lower level of care.

The inpatient level of care was not medically necessary. This patient has a past medical history of sickle cell anemia with presentation of acute vaso-occlusive crisis, but no other symptoms. His counts were stable, and while he required as needed pain medication and IV fluid management, this could also have been provided at a lower level of care. He was clinically stable throughout the hospital stay, appeared to be at his baseline level of function, and had no concerning physical exam or evaluation findings.

This patient did not meet the typical criteria required for acute admission related to his sickle cell disease. There was no concern for acute chest syndrome, he had no severe vaso-occlusive episode that failed observation level of service, no clear aplastic or hemolytic crisis, no increasing splenomegaly, and no elevation in the serum bilirubin. While he had knee pain, he required as needed pain management and he had no specific concerns that could not have been safely met at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: benign prostatic hyperplasia

Treatment: procedure codes 52241, 52242, prostatic urethral lift

The insurer is denied coverage for procedure codes 52241, 52242, prostatic urethral lift

The denial is overturned. 

This male patient has a history of benign prostatic hyperplasia (BPH), gastroesophageal reflux disease (GERD), hyperlipidemia, and hypertension.

The insurer has denied coverage for procedure codes 52241, 52242 (UROLIFT) as not medically necessary. They stated that the procedure must meet certain criteria for coverage
i)	BPH must be diagnosed/evident
ii)	Prostate volume should be < 80 mls
iii)	Special X rays do not show an obstructing medical lobe
Per the insurer, the information provided does not indicate whether the patient has an obstructing middle lobe or not. The requested procedure is denied based on failure to meet the guidelines for surgical and minimally invasive treatment's for BPH.

The appeal by the Urologist specifically cites the ultrasound study from showing no enlargement of the prostate median lobe. Therefore, the patient is eligible for UROLIFT treatment for his BPH. The patient's prostate volume measures at 56.14 grams on transrectal ultrasound. As the patient has had suboptimal response to medical therapy and desires surgical treatment - minimally invasive for his BPH/bladder outpatient obstructing symptoms, he is felt to be an appropriate candidate for UROLIFT, based on prostate size and lack of an obstructive medical lobe obtained by transrectal ultrasound study.

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 procedure codes 52241, 52242, prostatic urethral lift is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic right toe ulcer/cellulitis

Treatment full hospital admission

The insurer denied coverage for full hospital admission.

The denial is upheld.

The patient is a male with a past medical history significant for chronic atrial fibrillation, cardiomyopathy, hypertension and peripheral vascular disease on chronic anticoagulation who presented to the emergency department with complaints of discharge from right great toe. He denied any systemic symptoms. According to documentation, the patient was referred to the hospital by his Podiatrist for a chronic right toe ulcer.

Vitals on presentation included: temperature 36.6 Celsius (C), blood pressure 146/90, pulse 70, respiratory rate 18 and oxygen (O2) saturations 97% (percent) on room air. Laboratory results included the following: white blood cell (WBC) 10.8, hemoglobin 15.7, hematocrit 46.3, creatinine 0.8 and glucose 87. The patient was admitted to the hospital for a right big toe ulcer/cellulitis. Infectious Diseases was consulted and recommended intravenous antibiotics (daptomycin and aztreonam). X-ray and magnetic resonance imaging (MRI) of the foot was negative for osteomyelitis. All cultures were negative. Vascular Surgery also evaluated patient and recommended local wound care; no vascular intervention was required. 

The patient remained afebrile and hemodynamically stable. He was discharged on oral antibiotics (Levaquin) to continue outpatient management. Based on above findings, the patient met criteria for an observation level of management. There was sufficient evidence to support that an inpatient admission was not considered medically necessary treatment for the patient's condition

The health care plan did act reasonably, with sound clinical judgment, and in the best interest of the patient.

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

Diagnosis: Joint Instability. 
Treatment: Knee Surgery (removal of one knee cartilage using an endoscope (cpt code(s) 29877). 

The insurer denied the Knee Surgery (removal of one knee cartilage using an endoscope (cpt code(s) 29877). 

The denial is overturned. 

The patient is a male. He reported a feeling of instability to his left knee. He had sustained injury over two years prior. He was diagnosed with a partial ACL (anterior cruciate ligament) disruption. He underwent an ACL (anterior cruciate ligament) reconstruction with debridement to the anterior horn lateral meniscus. 

Yes, the knee surgery was medically necessary. 
The records show that the young man had sustained a traumatic event and had chronic instability to his left knee. He noted subjective complaints. He was prescribed a brace. He was seen on several occasions with the complaint of knee giving way. He also was found to have positive physical findings for ligamentous disruption. His physician noted the positive Lachman and Drawer tests consistent with the diagnosis. 

The MRI (magnetic resonance imaging) was taken into consideration. The intraoperative finding of "empty wall sign" was indicative of a complete disruption, meaning that the ligament was not in continuity within the notch. It would be likely the episodes of giving way resulted in a complete disruption. 

Pathology was present with ongoing functional loss. The next step would be surgery, as was performed. 

Therefore, given the above, the knee surgery was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroenteritis

Treatment: inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld. 

This female patient has a history of tetrahydrocannabinol (THC) and hookah use.

Clinical indications for admission Gastroenteritis (M-170) include having a suspected severe infection such as bloody diarrhea, peritoneal signs, hemodynamic instability, severe vomiting that does not respond to treatment with observation care, severe dehydration, and a severe electrolyte abnormality. The patient did not have these conditions.
	
This patient had a gastroenteritis. IV hydration, famotidine, and Reglan could have been given with observation status. She did not meet Milliman Care Guidelines (MCG) criteria for admission for gastroenteritis.

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 inpatient admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low Platelets
Treatment: T-Cell Clonality Panel and TRB (T-cell antigen receptor, beta) Gene Testing
The insurer denied the T-Cell Clonality Panel and TRB (T-cell antigen receptor, beta) Gene Testing.
The denial is upheld.

The patient is a female.  She has a history of thrombocytopenia.  This had been present for one year.  She was noted to have positive antiphospholipid antibody titers.  It was noted that she had splenic lesions that felt consistent with splenic lymphangiomatosis.

Bone marrow biopsy was done and revealed mild fibrosis and normal hematopoiesis.  Flow cytometry revealed mild T-cell immunophenotypic changes.

The patient's CBC (complete blood count) was notable for normal white cell count, normal hemoglobin, and platelet count of 118.  CBC (complete blood count) testing prior was notable for mild leukopenia.

No treatment was recommended, but the patient's physician ordered a blood T-cell clonality study.

No, the T-Cell Clonality Panel and TRB (T-cell antigen receptor, beta) Gene Testing was not medically necessary.

There is no evidence supporting the medical necessity of this test.  The patient had a bone marrow biopsy done that revealed "mild" T-cell immunophenotypic changes, but did not reveal clear evidence suggesting presence of T-cell lymphoma.  There is no abnormal white cell population noted in peripheral blood.  There is no neutropenia.  Cytopenias are a presenting finding in patients with T-cell large granular lymphocytic leukemia, but there is also no indication that this patient has been found to have an abnormal population of LGL (large granular lymphocyte) cells.  Also, LGL (large granular lymphocyte) leukemia is commonly associated with neutropenia, and CBC (comprehensive blood count) testing in this case is not notable for neutropenia.

Therefore, given the above, the T-Cell Clonality Panel and TRB (T-cell antigen receptor, beta) Gene Testing was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dermoid Cyst
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is upheld.

The patient had right lower quadrant pain and presented to the emergency department. A pelvic ultrasound revealed an enlarged right ovarian mass 5.8 centimeters (cm). A computed tomography (CT) scan showed appendicitis. Laboratory tests were essentially normal. She had a laparoscopic appendectomy and right ovarian cystectomy for a right dermoid cyst and dilated appendix. She was discharged and doing well. At issue is the medical necessity of the inpatient hospital admission.

The requested health service/treatment of inpatient stay is not medically necessary for this patient.

The patient had a laparoscopic procedure secondary to a dermoid cyst and appendicitis. The procedure was done without complications. She had no hemorrhage, no anesthesia complications or pulmonary complaints. Her vital signs were normal and she had no cardiovascular complaints. She had no hemodynamic instability. She progressed well and was discharged within 24 hours after the procedure. She could have been treated at a lower level of care and there was no need for acute, inpatient admission. She had no signs of infection, bleeding nor severe anemia. She had no abnormal laboratory tests to support the need for inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Crohn's Disease
Treatment: Stelara (Ustekinumab)
The insurer denied the Stelara (Ustekinumab).
The denial is upheld. 

The patient is a male with stricturing small bowel Crohn's, status post resection, with an incidental adenocarcinoma of the small bowel. He developed antibodies to Remicade. His most recent MRE (magnetic resonance elastography) showed no recurrent disease. His provider is requesting treatment with Stelara over the plan-preferred Entyvio to maintain remission.

No, the treatment with Stelara (Ustekinumab) is not medically necessary.

Both Stelara and Entyvio are safe and effective treatment for moderate to severe Crohn's. Entyvio is recommended by ACG (American College of Gastroenterology) guidelines in patients with moderate to severe Crohn's who have failed anti-TNFs (tumor necrosis factors). [2] Sulz, et al noted that Entyvio should be given over Stelara in patients with a history of malignancy. [1] There are no large head-to-head studies showing that Stelara is safer or more effective than Entyvio for the treatment of small bowel Crohn's. The literature provided was a small study that concluded that further studies with large sample size were required to confirm the findings, but did conclude in the small study that either could be used to maintain remission. [3] 

Therefore, given the above, as the plan preferred agent is Entyvio, the proposed Stelara is not medically necessary over the plan-preferred Entyvio.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Type 2 Diabetes Mellitus
Treatment: Formulary exception for Januvia (sitagliptin)
The insurer denied the Formulary exception for Januvia (sitagliptin)
The denial is overturned.

The patient is a male diagnosed with T2DM (Type 2 Diabetes Mellitus). This request is for Januvia. As reported, he takes Januvia 50 mg (milligrams) once daily. He has previously been on Tradjenta and Ozempic with failure. He has been on Januvia for approximately seven months with an adequate response. His A1C (glycated hemoglobin) was 6.1 %.

Yes, the health plan should cover the Formulary exception for Januvia.
The DPP IV (Dipeptidyl Peptidase-4) Inhibitors have similar efficacy.  There are no trials showing superiority of one DPP IV (Dipeptidyl Peptidase-4) inhibitor over another, including linagliptin (tradjenta), saxagliptin (onglyza), vidagliptin (galvus), alogliptin (Nesina) or sitagliptin (Januvia) (1-4). The American Association of Clinical Endocrinologists' consensus statement regarding treatment of patients with type two diabetes recommends the use of metformin followed by the use of a DPP4 (Dipeptidyl Peptidase-4) inhibitor or a GLP 1 (glucagon-like peptide-1) agonist (5, 6).

The only formulary alternative suggested is Tradjenta. The patient is reported to have tried and failed Tradjenta. There is documentation of prescription of Tradjenta. Given the failure of Tradjenta, the request is consistent with generally accepted standards of medical practice. The request therefore is medically necessary and should be covered.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient stay. 
The denial is upheld. 

The patient is a male with history of heart failure without coronary artery disease (CAD) on catheterization, hypertension, atrial fibrillation on apixaban with previous ablation, obesity, hyperlipidemia, chronic lymphedema, biliary cirrhosis, and obstructive sleep apnea. Patient was chronic losartan, rivaroxaban, carvedilol, spironolactone, nifedipine XL 30 milligrams (mg) and furosemide. The patient presented to the emergency department (ED) with chest pain, dyspnea, and right leg swelling. In the beginning of the year the patient had been hospitalized for similar symptoms secondary to worsening heart failure. A recent echo showed normal left ventricular (LV) systolic function. ED physical examination revealed the patient was tachypneic (22 breaths/min), bilateral rhonchi, and moderate peripheral edema. Brain natriuretic peptide (BNP) was moderately elevated at 358 picograms per milliliter (pg/ml). Chest x-ray showed mild pulmonary vascular redistribution compatible with fluid overload. Electrocardiogram (ECG) showed no ischemia. 

The patient was given intravenous (IV) Lasix in the ED. The patient was admitted. By the time of admission, the patient was comfortable with respiratory rate of 20/min. There was peripheral edema with venous changes, but lungs were clearer than in ED.
Serial troponins were normal. Blood pressure was considered high, and Procardia XL was increased to 60 mg. Echocardiogram was performed and showed normal systolic function. Duplex ultrasound showed no evidence of venous thrombosis. Xeralto was switched to Eliquis at patient's request. The patient was transferred from Cardiology to Internal Medicine service. 

The health plan's determination is upheld in whole. 

The patient had dyspnea and chest pain similar to a recent admission. The patient may have had some worsening of fluid retention. It was reasonable to treat the patient with IV diuretics. Based on the patient's known history, it would have been reasonable to manage patient at a lower level of care status. The treatment and diagnostic modalities could have been accomplished without an inpatient stay. A full admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: positive blood culture

Treatment: inpatient admission

The insurer is denied coverage for inpatient admission

The denial is overturned. 

This male patient has a history of transient ischemic attack (TIA), rheumatoid arthritis, septic gout and dyslipidemia.

The patient was started empirically on intravenous (IV) antibiotics (Vancomycin and Zosyn) for a positive blood culture. Repeat blood cultures were negative. Infectious Disease was consulted and deemed the culture was likely a contaminant; Vancomycin was discontinued. A chest x-ray (CXR) showed a vague density in the left mid-lateral lung field overlying the scapula. Subsequent chest computed tomography (CT) showed a left upper lobe consolidation suggestive of pneumonia. He was discharged home on oral antibiotic (Cefuroxime) for pneumonia. 

According to documentation, the patient was admitted to the hospital due to a positive blood culture result. He was afebrile, with mild hypertension and mild tachycardia. Laboratory results were notable for leukopenia. It was unclear at the time of admission if the blood culture reflected true infection versus a "contaminant." The patient required repeat blood cultures for confirmation. CXR and CT scan of the chest was suggestive of pneumonia. Based on these findings in a high-risk patient with co-morbid conditions, this hospital admission was medically necessary.

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 inpatient admission is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: palpitations and shortness of breath (SOB).

Treatment: inpatient admission

The insurer is denied coverage for inpatient admission.

The denial is upheld. 

This female patient with no significant past medical history.

The submitted documentation indicated the patient presented with complaints of palpitations and dysuria.  The clinical scenario of a healthy patient with an uncomplicated urinary tract infection that does not require any type of invasive procedure does not warrant a prolonged inpatient admission.  The documentation does not indicate an extenuating circumstance detailing the need for the requested inpatient services.  It is unclear why she could not have been treated at a lower level.

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 inpatient admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Liver tumors

Treatment: Full hospital admission

The insurer is denied coverage for full hospital admission.

The denial is overturned. 

This female patient has a history of hypertension, diabetes, and recurrent metastatic endometrial cancer.

The denial of coverage for the full hospital admission should be overturned. The patient had a known complication for microwave ablation of a solid organ tumor. The evaluation and management of post-procedural bleeding was appropriate, and the patient ultimately required endovascular embolization of the site of vascular injury. It is appropriate for the patient to be admitted for observation following the endovascular embolization to monitor for any signs of re-bleeding or need for further treatment.

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

The carrier's denial of coverage for the inpatient hospital admission is overturned. The medical necessity is substantiated.