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

Diagnosis: Obesity, abnormal uterine bleeding (AUB). 

Treatment: Procedure code 15830, panniculectomy. 

The insurer denied coverage for procedure code 15830, panniculectomy. 

The denial is overturned. 

This is the case of a female patient with a history of hypertension, diabetes, obesity, supraventricular tachycardia (SVT), and abnormal uterine bleeding (AUB). She presented to the Gynecologic Oncologist's office for the evaluation of AUB. The patient had an abnormal pap smear, bilateral ovarian masses, and a thickened endometrium. The physician recommended performing a total abdominal hysterectomy with bilateral salpingo-oophorectomy. Plastic Surgery would evaluate the patient for a panniculectomy. A Plastic surgery consultation was done. A panniculectomy was indicated. The patient underwent a total abdominal hysterectomy with bilateral salpingo-oophorectomy and panniculectomy. 

According to Hardy et al, "Our findings reveal that panniculectomy combined with pelvic surgery in the morbidly obese is a safe procedure that can decrease the incidence of intraoperative complications and postoperative wound complications without significantly increasing operative time or blood loss."  

An extensive literature confirms the safety of this procedure in conjunction with pelvic surgery as well as its importance in improving operative exposure and enhancing the safety of pelvic surgery. Surgical access to the pelvis is compromised in the presence of a massive pannus, and panniculectomy will improve operative exposure and operative safety. This has been clearly demonstrated in the medical literature. This patient has an elevated BMI [body mass index], and her large pannus will compromise access to the pelvis. The standard of care as defined by the medical literature is to perform a panniculectomy at the time of pelvic surgery to improve access. The patient's Gynecologist appropriately requested that the plastic surgeon perform a panniculectomy to improve access and eliminate her infections. The medical literature strongly supports the concept that a panniculectomy is medically necessary for this patient to ensure the safety of her gynecologic surgery. 

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

The insurer's denial of coverage for the procedure code 15830, panniculectomy performed is reversed. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis 

Treatment inpatient hospital

The insurer denied coverage for inpatient hospital

The denial is upheld

The patient has a past medical history significant for diabetes mellitus, hypertension, hyperlipidemia, morbid obesity, gastroesophageal reflux disease (GERD), and obstructive sleep apnea who presented to the emergency department with complaints of right inner thigh pain, swelling, and erythema.  Vital signs on presentation included: Temperature 98, Blood Pressure 152/87, Pulse 106, Respiratory Rate 18, oxygen (O2) saturation 98% (percent) on Room Air. Laboratory results included the following: White blood cell count (WBC) 8.3, hemoglobin (HGB)-13.6, hematocrit (HCT)-42, creatinine-0.78, lactic acid-1.6, glucose-123.

The patient was admitted and started on intravenous antibiotics (Zosyn and clindamycin) for a right thigh cellulitis. Computed Tomography scan of the leg was consistent with cellulitis without gaseous collection. He underwent an incision and drainage procedure while in the emergency department (ED). Wound cultures grew methicillin-resistant Staphylococcus aureus (MRSA). Infectious Diseases consulted and recommended adjustments in antibiotic coverage. The patient remained afebrile, hemodynamically stable, and discharged on oral antibiotics to continue management as an outpatient.

According to documentation, patient was referred by Dermatology for a right lower extremity cellulitis. Otherwise, he was afebrile and hemodynamically stable; laboratory results were unremarkable including a normal WBC. The patient did not have any evidence for a disseminated infection and underwent a bedside incision and drainage (I&D) while in the emergency room. Based on above findings, patient met criteria for observation 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 the inpatient hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest discomfort. 

Treatment: Inpatient emergency admission. 

The insurer denied coverage for the inpatient emergency admission. 

The denial is upheld. 

This is a male patient with a history of hypertension, obstructive sleep apnea, gastric bypass, kidney stones, alcohol abuse, and a family history of coronary artery disease in his mother and brother.  He presented to the emergency department (ED) with a two week history of intermittent chest pressure that lasted for hours, was not exertional but began after shoveling snow, as well as exertional dyspnea.  Electrocardiogram (EKG) revealed sinus tachycardia, left ventricular hypertrophy, and non-specific T wave abnormalities.  Vital signs included blood pressure (BP) 155/90, heart rate 107, respiratory rate 18, and oxygen saturation on room air 99%.  Laboratory test results included white blood cell (WBC) count 8.5, hemoglobin 14.3, creatinine 0.75, and troponin 0.01.  Chest X-ray was also unremarkable.  He was transferred with initial vital signs BP 164/85, heart rate 87, respiratory rate 18, oxygen saturation on room air 100%, and temperature 97.9.  Cardiology recommended echocardiography and stress testing, rather than coronary angiography.  Echocardiogram was normal, as was pharmacological stress testing done with left ventricular ejection fraction 55%.  He remained hemodynamically stable, with no significant symptoms recorded, and was discharged to home on his home medications plus pantoprazole, atorvastatin, folic acid, and thiamine.

There is no evidence that this patient required an acute inpatient level of care to determine that his chest discomfort was not related to acute coronary syndrome or for diagnostic testing such as stress testing and echocardiography.  Evaluation for acute coronary syndrome could have been completed in the ED or at an observation level of care, followed by outpatient testing.

The health plan acted reasonably with sound medical judgment in the best interest of the patient. Denial of coverage for the inpatient emergency admission is upheld because there is no evidence that this patient was at increased risk for short term adverse cardiovascular events requiring inpatient monitoring and management, based on his clinical presentation and results of testing performed at the referring facility or in the ED.

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

Diagnosis: Respiratory System-Asthma.
Treatment: Pharmacy/Prescription medications-Xolair.
The health plan denied Xolair as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

This is a patient who has a history of Rheumatoid Arthritis (RA), Graves' disease, allergic rhinitis, and is being seen for eosinophilic asthma. She had at least 1 exacerbation requiring systemic steroids. She has numerous triggers on allergy testing. Total Immunoglobulin E(IgE) was 3066 international units per milliliter (IU/mL). She takes Breo, Singulair, and Flonase. Of note, she has several environmental sensitizations including dust mite, cat, dog, grasses, molds, and trees; she still has a dog that she refuses to part with. Xolair has been ordered to help with relief of her asthma symptoms. The patient has a body mass index (BMI) of 27.32 kilograms per square meter(kg/m2).

Xolair(omalizumab) is not medically necessary for this patient. The total IgE level was 3066 IU/mL. When considering her weight and her total IgE level, the amount needed to lower her total IgE levels to see a significant response is beyond any safe dosing.
There is no data to prove efficacy with an elevated IgE level as elevated as in this patient. Studies that have looked at using omalizumab in patients outside the standard range have not studied levels this high.  Even in other countries outside the United States with an extended range have cutoffs usually around 2000 IU/mL.  Additionally, Global Initiative for Asthma (GINA) guidelines would first support trigger avoidance as one of the first steps in controlling a patient's asthma, which this patient is not doing with her pet.  Again, given poor compliance and lack of any data supporting safety and efficacy in a patient with these criteria, omalizumab is not medically necessary.
With her total IgE level beyond what is safe In using omalizumab for a significant clinical response, Xolair is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain, Nausea, Vomiting and Difficulty Urinating. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission.  The denial is upheld. 

This is a female with type I diabetes, chronic kidney disease, and depression who presented with diffuse abdominal pain, nausea and vomiting for two days. She had missed her long-acting insulin. She had dysuria as well. 

The patient's blood pressure (BP) was 150/98, heart rate (HR) was 115, temperature (T) was 36.7 Celsius (C [98F]), respiratory rate (RR) was 22, and oxygen saturation (SpO2) was 100%. The patient was oriented to person, place, and time. Her white blood cell (WBC) count was 11.9, glucose was 254, creatinine was 1.73, carbon dioxide (CO2) was 20.8, and pH was 7.3. Urine culture was positive for Klebsiella pneumonia.  She was treated with Rocephin, Pepcid, Regular insulin subcutaneous, Toradol, intravenous fluids, Reglan, magnesium, Zofran, Lantus, Lispro, and Pamelor. Renal and bladder ultrasound showed right renal parapelvic cyst versus mild focal hydronephrosis. 

Inpatient stay is under review. The inpatient stay was denied as the patient did not fail an observation stay. 

No, the proposed inpatient stay was not medically necessary. 

This is a patient with known type I diabetes with a history of missed insulin doses with symptomatic urinary tract infection and mild diabetic ketoacidosis. The nurse noted that the patient's pain was controlled and she was in no apparent distress. Her creatinine and tachycardia, which were indicative of dehydration, improved with intravenous fluids. Her hyperglycemia and mild diabetic ketoacidosis resolved with subcutaneous insulin therapy. Patients with diabetic ketoacidosis can be safely managed in observation units unless they present with severe alteration of mental status or with critical illness such as sepsis [1], which is not documented in this case. The patient was afebrile, hemodynamically stable, and did not have evidence of pyelonephritis that required ongoing intravenous antibiotics. She was alert and oriented and did not have evidence of altered mental state. The documentation does not support that the patient failed a lower level of care. Therefore, the acute inpatient admission was not medically necessary. 

The health plan denied the inpatient stay, which was not medically necessary.  Therefore, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bilateral upper dermatochalasis and brow ptosis.
Treatment: Eyelid surgery (blepharoplasty).

The insurer denied coverage for eyelid surgery (blepharoplasty).  The denial is upheld.

The patient is a female with a diagnosis of bilateral upper dermatochalasis and brow ptosis.  Visual acuities were 20/20 in the right eye (OD) and 20/30 in the left eye (OS).  Exam showed dermatochalasis with temporal hooding and skin touching the lashes OU (both eyes), with pseudoMRD1 (marginal reflex distance-1 [MRD-1]) of 0.5 millimeters (mm) with elevation of skin MRD1 4mm OD, and pseudoMRD1 1 millimeter (mm) OD with elevation of skin MRD1 4mm OS.  It was noted that visual field showed > (greater than) 30 percent (%) improvement with taping of eyelid OD, and >20% improvement on taping eyelid OS.  A copy of the visual field taped OD was included in the records.

The patient's doctor noted that she has bilateral visually significant dermatochalasis and brow ptosis causing mechanical ptosis and temporal hooding.  It was noted that member has reduced peripheral vision that improved with elevation of the eyelid and brow. 

The health care plan acted reasonably and with sound medical judgement and in the best interest of the patient.  There is insufficient information in the medical records to support the medical necessity of blepharoplasty.  There are no external photographs or completed visual field testing (only taped visual field of right eye was included) provided.

The eyelid surgery (blepharoplasty) is not considered medically necessary for this patient.  The medical records do not have frontal and lateral external photographs documenting excess upper eyelid skin affecting the visual axis or visual field testing showing a superior field obstruction.

The insurer's denial of coverage for eyelid surgery (blepharoplasty) is upheld.  Medical Necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Migraine Headache
Treatment: Ubrelvy
The insurer denied the Ubrelvy.
The determination is upheld.

The patient has a history of migraines. She was evaluated by and was noted to have previously used topiramate and steroid injections that did not help with her headaches. Her neurological examination was normal, and a brain magnetic resonance imaging (MRI) scan was ordered to assess for structural abnormality.
The patient was again seen at which time she was noted to have more than 15 headache days per month, eight or more which were migraines, for more than four hours per day from for more than three over the previous 12 months, and had not responded to sumatriptan, propranolol and Lexapro. Her neurological examination remained normal, and she was diagnosed with chronic migraine with intractable breakthroughs and recommended the use of Ubrelvy. She was also recommended Botox. At issue is whether the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug or would have adverse effects.

There is no evidence that Ubrelvy is superior in efficacy to any and all triptan medications. The patient was previously treated with one triptan, with insufficient benefit. The failure of one triptan to provide adequate relief does not predict the failure of other triptans, and a trial of a second triptan would be reasonable. Alternatively, Nurtec ODT (oral dissolving tablet) is a formulary medication, and like Ubrelvy is an oral calcitonin gene-related peptide (CGRP) antagonist (gepant), and there is no evidence that it is inferior to Ubrelvy with regard to efficacy. The patient may therefore use an alternative triptan or Nurtec ODT without loss of efficacy in the treatment of her migraines.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Systolic Heart Failure.
Treatment: Inpatient stay.

The insurer denied coverage for inpatient stay.  The denial is upheld.

This patient is a male with a past medical history of diabetes, past heroin use, incisional hernia and non-ischemic cardiomyopathy. The patient's home medications included Entresto, metoprolol, Lasix, aspirin, atorvastatin, Jardiance, metformin, and methadone.  The patient presented to the Emergency Department (ED) with progressively increasing leg swelling and shortness of breath with exertion since a few months prior and was noted to have significant edema and ascites, with weight of 179 pounds. The patient's vital signs on ED presentation included blood pressure (BP) 126/96, heart rate 90, temperature 98F, and oxygen saturation on room air 100%.  The patient's electrocardiogram (EKG) revealed normal sinus rhythm, left atrial enlargement, and small R waves in leads V2-V4, with no significant change.  The patient's laboratory test results included white blood cell (WBC) count 11.8, hemoglobin 14.2, B-type natriuretic peptide (BNP) 2,969, sodium 135, creatinine 1.0 troponin 0.01 and potassium was 5.6.  The patient's chest X-ray revealed mild bilateral pleural effusions and mild congestion/fluid overload.  The patient was treated with intravenous (IV) Lasix with plans to transition to oral torsemide, and Entresto was held due to hyperkalemia. The patient's weight decreased from 179 pounds on admission to 163 pounds by discharge.  The patient's echocardiography revealed severe biventricular systolic dysfunction, grade 3 diastolic dysfunction, and biatrial enlargement.  The patient complained of abdominal pain, and the ultrasound of the abdomen revealed hepatomegaly with steatosis, bilateral varicoceles, bilateral inguinal hernias, ascites, and scrotal wall edema.  Records indicate that the patient was ambulatory and frequently left his room during his hospitalization.  The patient was discharged on his home medications, except for Entresto which was held until his outpatient follow-up with his cardiology. The patient furosemide was substituted with torsemide. 

There is no evidence that this patient required an acute inpatient level of care to treat his chronic systolic heart failure with fluid overload and mild pulmonary vascular congestion.  Treatment with IV diuretics, followed by conversion to an alternative oral regimen, should have been initiated in the ED or an observation unit, followed by outpatient care.

Thus, inpatient admission was not medically necessary for this patient. There is no evidence that this patient was at increased risk for short-term adverse cardiovascular events requiring inpatient monitoring and management, based on his clinical presentation and results of testing and treatment early during his hospitalization.

The health plan acted reasonably with sound medical judgement, and in the best interest of the patient.

Based on the above, the medical necessity for the inpatient admission is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: obstipation
Treatment: Inpatient stay
The insurer denied the inpatient stay. 

The health plan's determination is upheld. 

The patient is a man with a history of rheumatoid arthritis, severe obesity, and prior small bowel obstruction who was admitted to the hospital with intermittent abdominal pain. He reported that the pain was similar to a prior small bowel obstruction that was treated non-operatively. He denied nausea, vomiting, fevers and chills. Vital signs showed temperature 98.2 Fahrenheit, heart rate 84, blood pressure 140/79, and oxygen saturation 100%. On physical exam, heart was regular, breath sounds were normal, and the abdomen was soft and mildly tender to palpation. Labs showed sodium 140, potassium 4.1, glucose 59, creatinine 0.7, calcium 8.6, white blood cell (WBC) 5.3, hemoglobin 15.3, and platelets 192. A computed tomography (CT) showed dilated loops of small bowel without a discrete point of transition. The patient was admitted for suspected small bowel obstruction. 

The inpatient hospital admission was not medically necessary. The patient needed further care, but it could have been safely and effectively provided at the lower level of care. The patient had no evidence of clinical severity that usually requires inpatient level of care for abdominal pain, such as imaging evidence of an acute infectious process like cholecystitis or diverticulitis, sepsis, or severe pain. In addition, CT imaging demonstrated that the patient did not have small bowel obstruction, despite the initial concern and the patient's prior history of small bowel obstruction.
While he did need further imaging and management, there was no evidence of persistent vomiting, severe abdominal pain, sepsis, hemodynamic instability, bowel perforation, or hypovolemia. A nasogastric tube was placed, and surgery was consulted. Small bowel obstruction does usually need to be managed at the inpatient level of care, but this patient's clinical diagnosis was obstipation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right-upper-quadrant abdominal pain, nausea, vomiting, diarrhea, weakness, and muscle aches
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female. Her medical history included: obesity and COVID-19 infection. Her surgical history included: tonsillectomy, sleeve gastrectomy, appendectomy, C-section, "left-hip surgery," and upper endoscopy (which was negative five days prior to presentation).  

The patient presented to an emergency room with a two-to-three-day history of right-upper-quadrant abdominal pain, nausea, vomiting, diarrhea, weakness, and muscle aches. Her vitals were: temperature 98.4, pulse 80, blood pressure 114/70, respirations 18, oxygenation 100% on room air. Physical examination demonstrated tenderness-to-palpation and guarding of the right-upper-quadrant of the abdomen. Serum laboratories were normal; her white-blood-cell count was 5.29 and her COVID-19 test was negative. Abdominal ultrasound demonstrated "Cholelithiasis, mild gallbladder wall thickening and sonographic Murphy sign."

The patient was admitted at an acute inpatient level-of-care with a diagnosis of acute cholecystitis. She was made nil per os (NPO) and provided with intravenous fluids, antibiotics, and analgesics. The following day, the patient underwent laparoscopic cholecystectomy. Surgery and recovery were uncomplicated. 

Having returned to her baseline health and function, the patient was discharged home in good and stable condition with outpatient surgical follow-up.

No, the proposed inpatient admission was not medically necessary.

The proposed treatment, admission at an acute inpatient level-of-care, was not medically necessary. 

According to the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), "patients undergoing uncomplicated laparoscopic cholecystectomy for symptomatic cholelithiasis may be discharged home on the day of surgery" [SAGES]. Insofar as the patient did not demonstrate significant co-morbidities or physiologic derangements, and insofar as surgery and recovery were uncomplicated, the patient could have been treated at a lower level-of-care.