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

Diagnosis: Dilation and curettage (D&C) complicated by hemorrhage. 
Treatment: Inpatient admission. 

The insurer denied coverage for the inpatient admission. 

The denial is overturned. 

This is a female patient who presented to the hospital for a scheduled dilation and curettage (D&C) procedure after having a vaginal delivery. The patient reported having increased vaginal bleeding and there was a suspicion of retained products of conception. The procedure was performed and was complicated by severe bleeding necessitating insertion of an arterial line (A-line), blood transfusion and insertion of a Foley catheter inside the uterine cavity to control the bleeding. The patient was discharged later that day. 

This patient had retained products of conception and was bleeding. She was not febrile. The management of retained products of conception is a dilation and curettage (D&C). Dilation and curettage (D&C) are ambulatory procedures. However, this patient's procedure was complicated by hemorrhage (blood loss estimated at 2 liters) and instability necessitating blood transfusion with 2 units. A balloon catheter was inserted into the uterine cavity to control the bleeding. An A-line was inserted to monitor the patient's vital signs and the patient had to be admitted to the surgical intensive care unit.
Postpartum hemorrhage is the leading cause of maternal death and admission was medically necessary for this patient. 

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

The medical necessity of the inpatient admission is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hip pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female with several months of pain and tenderness to her right hip. She was found to have a radiolucent lesion to the posterior superior acetabular wall. Her physician performed an open biopsy, frozen section, curettage. The size was 2 x 2 cm (centimeters). He then packed the area with crushed cancellous bone graft. The estimated blood loss was 20cc (cubic centimeters).

No, the Inpatient Admission was not medically necessary.

The medical records demonstrate that the young woman underwent a limited open biopsy and curettage. The procedure itself was not complex nor extensive. There was limited blood loss of 20 cc (cubic centimeters). No drain was placed.

The post-surgical course was not complicated by pain, fever, infection nor bleeding. The vital signs were stable. There was no need to provide treatment for other underlying medical conditions. No additional  imaging or procedures were required. There were no delays expected with mobilization. There was no problem with tolerating oral medication.

These findings do not substantiate the level of service provided. A lower level of care would have been more appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Broken Tooth #4. 
Treatment: Crown to Tooth #4. 

The health plan denied the requested service. The health plan's determination is upheld. 

The patient is a female. She presents with a palatal cusp fracture on tooth #4. A crown is being requested at this time. 

At issue is the medical necessity of the requested service. 

The health plan's determination is upheld, in whole. 

According to the provided radiographs, the existing restoration on tooth #4 appears intact and sealed with no visible signs of radiographic decay or fracture. The provider indicated that the palatal cusp on tooth #4 fractured to the gingival level. However, because there were no intra-oral photographs submitted to verify that the palatal cusp had been fractured to the gingival level, a crown, in this case, would be considered for cosmetic purposes. Therefore, the request for a crown-porcelain on tooth #4 is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rule out acute coronary syndrome.
Treatment: Inpatient admission.
The insurer denied coverage for the inpatient admission.
The denial is upheld. 

This is a female patient with a history of a stroke with mild left-sided weakness and current tobacco use.  The patient discontinued aspirin two months prior to presentation but was taking atorvastatin.  The patient presented to the Emergency Department (ED) with gradual onset of mild chest aching, which was intermittent over a few days, as well as dyspnea with sensation of bounding, slow irregular pulsation in her chest.  The patient's laboratory test results included: white blood cell (WBC) count 9.7, hemoglobin 13.7, creatinine 0.76, D-dimer 187, influenza A and B negative, severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) polymerase chain reaction (PCR) negative, and troponin <0.03, with a subsequent troponin level of 0.00.  The patient's electrocardiogram (EKG) revealed sinus tachycardia and flat lateral T waves. The patient's chest X-ray and computed tomography (CT) angiography of the chest were normal. The patient's echocardiography was also unremarkable, with left ventricular ejection fraction 63%.  The patient was discharged for outpatient monitoring and management.

Based on the review of the medical record and literature, inpatient admission was not medically necessary for this patient. There is no clinical evidence that this patient required an acute inpatient level of care to determine that her chest discomfort, dyspnea, and palpitations were not related to acute coronary syndrome.  This diagnostic workup and care could have been safely provided in the ED or at an observation level of care, followed by outpatient monitoring and management. Thus, the denial of coverage for the inpatient admission should be 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 her clinical presentation and results of testing performed in the ED.

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

The carrier's denial of coverage for the inpatient admission should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse
Treatment: Inpatient Substance Abuse Services
The insurer denied Inpatient Substance Abuse Services. The health plan's determination is upheld.

The patient is male who self-referred to an emergency department and requested continued detoxification from alcohol. He was diagnosed with poly-substance use with alcohol, stimulant and cannabis class substances of abuse. The patient was using alcohol on a continuous daily basis with beer and liquor together with methamphetamine and cannabis. He reported substance use beginning in adolescence. The patient provided no history of withdrawal seizures, delirium tremens or severe alcohol withdrawal symptoms; vital signs were normal, and the Clinical Institute Withdrawal Assessment (CIWA) scale score was 9 with mild symptoms including mild tremor, sweats, headache and reports of irritability and anxiety. 

The Inpatient Substance Abuse Services were not medically necessary for this patient. 

The proposed inpatient detoxification treatment could have been safely and effectively provided at a lower level of care. The clinical features and indicated treatment dimensions of this patient's alcohol use disorder, and other substance use disorders, did not require or warrant the structure of an inpatient setting or 24-hour monitoring. The patient displayed no serious disturbance of mental status despite having a history of ongoing substance use disorder with alcohol and past treatment for psychiatric disorders. Moreover, the patient had been evaluated and cleared with regard to safety concerns in the emergency department, and did not show evidence for suicidal or aggressive behavior or risk, severe cognitive impairment or psychosis, or general medical concerns that would have warranted an inpatient level admission and treatment. 

The treatment for alcohol use disorder in this case could have been provided, as clinically appropriate, at a lower level of care following the comprehensive assessment and stabilization in the emergency department.
Appeal type: Medical necessity
Decision: Overturned

Dental 
Dental/Orthodontic Procedure

Diagnosis: anterior crossbite 
Treatment: braces
The insurer denied braces. The health plan's determination is overturned. 

The patient in question is a male with an anterior crossbite on tooth 10. He presents with a skeletal Class I malocclusion with crowding in the maxilla and in the mandible. He is treatment planned for 24-30 months of orthodontics, but the treatment was denied due to lack of medical necessity.

Braces are medically necessary for this patient. This patient presents with an anterior crossbite on tooth 10, as well as significant crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects.
If left untreated, the damage that will likely occur to the patient's teeth will be much more time consuming and difficult to correct than the patient's existing orthodontic problem. For this reason, the requested treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis.
Treatment: Otezla.

The insurer denied Otezla. The health plan's determination is upheld.

The patient is a male with moderate to severe psoriasis of the scalp, legs, and arms. The patient is using atorvastatin for elevated cholesterol. Disease modifying anti-rheumatic drugs (DMARDs) such as Methotrexate have been avoided because of the COVID-19 pandemic. Coverage of Otezla is under review for medical necessity.

Otezla is not medically necessary for this patient.

The patient has no documented treatment failure with, or true medical contraindication to, standard, first-line systemic therapies such as either Methotrexate or Acitretin. These are both appropriate treatments for this patient's clinical scenario as per current medical literature. Both Methotrexate and Acitretin are appropriate for this patient's condition and are compatible with the current pandemic. Therefore, Otezla is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Digestive System
Inpatient hospital

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

This case involves a female who was otherwise healthy and presented to the emergency department with a several hours history of central abdominal pain moving to right lower quadrant (RLQ), and nausea. An ultrasound of her abdomen and pelvis did not visualize the appendix but did find free fluid and laboratory assessment demonstrated an elevated white blood cell count to 16K (thousand). She was admitted with the possible diagnosis of appendicitis due to the elevated white count, abdominal pain and tenderness in the right lower quadrant. 

An acute inpatient level of care was not medically necessary. The patient could have been safely and appropriately managed at a lower level of care.
An inpatient stay might be justified if there was a serious medical or surgical condition identified which required more complex management. However, this patient was simply observed with symptomatic treatment for abdominal pain. There were no complications of this pain, no physiologic derangements, hemodynamic instability, acute or chronic organ dysfunction, persistent altered mental status, fever or other signs of sepsis, management of complex comorbid medical condition or a finding of an occult or new medical condition.
Even if surgery were needed for treatment of an otherwise healthy adolescent with acute appendicitis, it is routinely provided at a lower level of care. No evidence was presented in the medical records that would indicate that the patient had a serious medical condition requiring an acute care inpatient admission.
In the U.S., nearly one million children present to the emergency department (ED) annually with a primary diagnosis of functional abdominal pain, with the highest incidence of ED visits for this diagnosis in the 10-14-year age group. For such patients, only 1% to 1.5% require admission to the hospital, thus the overwhelming majority of patients without a clear-cut medical or surgical diagnosis are treated and released, or managed at a lower level of care.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Hypertension
Treatment: Formulary exception for Edarbyclor 40/12.5mg, Pre-service
The insurer denied the Formulary exception for Edarbyclor 40/12.5mg, Pre-service.
The denial is upheld. 

The patient is a female being treated for hypertension. The request is for the use of edarbyclor. The patient has been on this drug, possibly with samples. There is no documentation of intolerance or ineffectiveness of similar drugs that are on the health plan's formulary.

No, the health plan should not cover the Formulary exception for Edarbyclor.

The patient has a diagnosis of hypertension. The provider is requesting Edarbyclor. The health plan denied the request, on the basis that the patient has not met the formulary requirements. There is no documentation that the patient has intolerance or ineffectiveness of similar drugs that are on the health plan's formulary.

The alternative medications on the formulary are well-documented. The drugs on the formulary would provide the patient with the appropriate care for her condition. Having the patient try the formulary alternatives would not be reasonably expected to be health-detrimental for the patient.

Edarbyclor is a fixed combination of a diuretic and an ARB (angiotensin II receptor blocker). Alternative medications that would be expected to be equally safe and efficacious for the patient's condition, both alone and in combination, are available on the health plan's formulary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Neurofibromatosis.
Treatment:  Koselugo 10mg.

The insurer denied the Koselugo 10mg.  The denial is overturned. 

The patient is a female. She has a history of neurofibromatosis type 1 who has a plexiform neuroma in her right arm. It is not surgically resectable and progressed after treatment with Mekinist. The provider is recommending she be treated with Koselugo 10 mg (milligram) tabs.

Yes, the treatment with Koselugo is medically necessary.

Neurofibromatosis 1 (NF1) is an autosomal dominant tumor predisposition disorder that affects about 1 in 3,000 people. The NF1 (Neurofibromatosis 1) gene is located on chromosome 17q11.2. It encodes for neurofibromin, a cytoplasmic protein that is expressed in the nervous system. Neurofibromin negatively regulates proto-oncogene Ras and acts as a tumor suppressor through the reduction of cell proliferation and differentiation by preventing the activation of downstream signaling pathways such as PI3K/AKT/mTOR (phosphoinositide 3-kinase/protein kinase B/mammalian target of rapamycin) and Raf/Mapk/MEK/ERK (Rapidly Accelerated Fibrosarcoma/mitogen-activated protein kinase/ mitogen-activated protein kinase kinase/extracellular signal-regulated kinase). As a result, an individual with NF1 (Neurofibromatosis 1) has a predisposition to develop both benign and malignant tumors. The characteristic lesion is benign neurofibroma, but there is also an 8%-13% lifetime risk of developing malignant peripheral nerve sheath tumor.

Selumetinib has received breakthrough designation for NF1 (Neurofibromatosis 1) PN (Plexiform Neurofibroma) based on phase I / II trials in children. In a recent phase 2 study in adult patients showed that 71% of the 21 evaluable patients had a partial response. The majority of patients experienced a reduction in plexiform neurofibroma volume and patient-reported tumor pain intensity and pain interference scores. The authors concluded, "Selumetinib shrinks the majority of adult PN [Plexiform Neurofibroma] and results in molecular target suppression and clinical benefit. "

Since the patient has failed other therapies, the use of Koselugo would be considered medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest pain.
Treatment:  Inpatient stay.

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

The patient is a woman who presented to the emergency department complaining of chest pain and dyspnea. She also reported a lesion on her toe. Her medical history was remarkable for diabetes, hypertension, hyperlipidemia, asthma and nonobstructive coronary artery disease. Her blood pressure was 122/63 mmHg (millimeter of mercury) with a heart rate of 67 beats/minute. Her respiratory rate was 19/minute with a room air oxygen saturation of 100%. She was afebrile. Her physical exam was remarkable for mild wheezing, right foot erythema and a hemorrhagic blister on her toe. An electrocardiogram showed sinus rhythm with lateral T wave inversions. Her serum troponin level was normal. Chest X-ray showed no acute pathology. Foot X-ray showed a fracture of the metatarsophalangeal joint. The patient was seen by a podiatrist who reduced the fracture and unroofed the blister. She was admitted to the hospital to rule out acute coronary syndrome and for treatment of possible cellulitis. 

The inpatient hospital admission was not medically necessary.

This woman presented with atypical symptoms that were thought to be suspicious for acute coronary syndrome (ACS). Accordingly, observation until ACS could be ruled out was a reasonable approach. However, she was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. She did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received for her chest pain did not require an inpatient admission and could have been provided at a lower level. This approach has been shown to be both safe and effective and is in accordance with the 2014 American Heart Association (AHA) / American College of Cardiology (ACC) Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.

The patient was also thought to have lower extremity cellulitis, which was eventually ruled out. However, even if she did have cellulitis, this would not have required an inpatient level of care. Inpatient admission for cellulitis is recommended for patients with uncontrolled infections despite adequate oral antibiotic therapy; those who cannot tolerate oral antibiotics; those who require surgery; those with initial severe or complicated infections; and those with underlying unstable comorbid illnesses or signs of systemic sepsis. This patient did not meet any of these criteria.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Polyuria and urinary urgency.
Treatment:  MRI Scan of lumbar spine.

The insurer denied the MRI Scan of lumbar spine.  The denial is upheld. 

The patient is a male with complaint of polyuria and urinary urgency. He has a normal neurological examination. He had normal electrodiagnostic studies. MRI (magnetic resonance image) brain and thoracic spine were normal.

No, the proposed MRI (magnetic resonance image) lumbar spine is not medically necessary.

This patient has a normal neurological examination. Specifically, there are no signs or symptoms of lumbar spinal cord lesion. It is not standard of care to complete MRI (magnetic resonance image) lumbar spine for urinary frequency and urgency in the absence of neurological examination abnormalities.  The possibility of a lesion or lesions in the in the lumbar spinal cord causing urinary incontinence but not manifesting as a detectable neurological examination abnormality is anatomically extremely unlikely, and, therefore, the diagnostic yield of MRI (magnetic resonance image) lumbar spine here is extremely low.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stenosis of lateral recess of lumbosacral spine. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for the inpatient hospital admission. 

The denial is overturned. 

This is a female patient with a history of hypertension, diverticulitis, and diabetes.  The patient presented to the Emergency Room (ER) with complaints of worsening lower back pain.  The patient's electrocardiogram (EKG) revealed sinus bradycardia with no ischemia.  The patient was seen in the past and did not want surgery for L5-S1 disc herniation.  The patient went for physical therapy (PT) and received epidural injections with no improvement.  The patient's computed tomography (CT) scan of the cervical spine revealed C4-C5 left foraminal narrowing, C5-C6 right foraminal narrowing, and C6-C7 bilateral foraminal narrowing.  The patient's CT scan of the thoracic spine revealed normal vertebral height and alignment.  The patient was admitted with stenosis of lateral recess of lumbosacral spine.  The care plan included strict bedrest, administering intravenous (IV) fluids, administering dexamethasone every 6 hours (q6h), administering acetaminophen, administering morphine, administering Protonix every day (QD), administering prehospital medications, and monitoring blood glucose checks with sliding scale insulin, and using an incentive spirometer every 1 hour (q1h). The Medicine team consulted over the case for medical clearance for surgery, and they noted that the patient is medically optimized to proceed with the laminectomy with fusion.  The procedure was performed without complications.  After the surgery, the patient was seen by PT services, and she was ambulating well.  The patient was eating well and voiding. The patient was discharged after a period of medical stability. 

As per the medical records and Milliman Care Guidelines (MCG), inpatient admission was medically necessary for this patient. The patient had intractable pain and could not function.  The patient reportedly had to crawl out of bed.  The patient had received an extensive course of non-operative treatment.  The patient had surgery recommended in the past but the patient deferred until now when her pain became unbearable and significantly limited her function.  The patient was advised by her surgeon to be evaluated in the Emergency Department (ED).  A diagnosis was previously established, and again the decision was made to perform the surgery.  The services provided could not have been completed as an outpatient basis based upon this patient's clinical presentation; this patient required urgent surgery which would necessitate the inpatient admission. 

The inpatient hospital admission is considered medically necessary for this patient. 

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 hospital admission should be overturned.  The medical necessity is substantiated.