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

Diagnosis: Cholelithiasis
 
Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld.

This case involves a female patient who presented to the emergency room in early 2019 with right upper quadrant abdominal pain, that she reported had been happening for a week.  The patient rated the pain as a 7/10.  Objective findings were notable for right upper quadrant and epigastric tenderness to palpation.  An abdominal ultrasound revealed 2 echogenic lesions on the liver and hemangiomas.  An Magnetic Resonance Imaging (MRI) revealed gallstones.  The patient was started on nothing by mouth status and was given an intravenous (IV) bolus of normal saline, IV Zofran, IV Pepcid, Mylanta and intravenous morphine.  The patient was admitted to surgery for a diagnosis of cholelithiasis and right upper quadrant pain.  There was documentation that the patient continued to report abdominal pain at a severity of 5/10 on the pain scale.  Later in the day she reached her pain goal of 2/10 and after that denied pain and discomfort. Lab values were documented to be within normal limits.  There was no documentation of a fever, or C-reactive protein level > 10 or of a WBC count > 10,000, or that the patient was at a high risk for cancer or other symptomatic biliary disease, biliary dyskinesia with abnormal ejection fraction or suspected carcinoma of the gallbladder.  The patient's vital signs remained stable and the patient was discharged to home.

The MCG list clinical indications for admission to inpatient care for gallbladder inflammation or stone including acute cholecystitis as indicated by all of, right upper quadrant pain, mass or tenderness, systemic signs of inflammation as evidenced by fever, C-reactive protein level greater than 10, white blood cell count greater than 10,000, acute cholangitis as indicated by systemic signs of infection, evidence of common bile duct disease as evidenced by a total serum bilirubin level greater than or equal to 2, liver function test that is 1.5 times the upper limit of normal, hepatobiliary imaging showing biliary dilatation or evidence of etiology, vomiting that is persistent, dehydration that is severe persistent, hemodynamic instability, severe pain requiring acute inpatient management.

Based on the above, the medical necessity for the inpatient hospital services at the acute level of care at South Nassau Communities Hospital not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Unstable Angina
 
Treatment: Inpatient Hospital

The insurer denied the Inpatient Hospital. The denial was upheld. 

This is a female patient while visiting her primary care physician, she reported exertional dyspnea and chest discomfort. She was sent to the Emergency Department (ED) where her initial vital signs were: blood pressure of 141/102, a heart rate of 79, a temperature of 99.6F, and oxygen saturation on room air of 100%. Her EKG revealed normal sinus rhythm, left axis deviation, T wave inversions in V1, V2 and small R's in V3-6; however, an EKG later that evening was normal.  Laboratory test results included a white blood cell (WBC) count of 5.13, a hemoglobin of 11.6, a creatinine of 0.9 and a troponin of 0.00, with a subsequent troponin was also 0.00.  Her chest x-ray was normal.  The cardiac stress test performed during this admission revealed a negative EKG response to the pharmacologic stress component and the perfusion study revealed a small area of moderate ischemia involving the basal inferior region, mild, with an ejection fraction of 71%.  Coronary angiography revealed only 20% proximal and mid left anterior descending coronary artery lesions.  

The carrier's denial of coverage for the inpatient admission hospital services is upheld.  The medical necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Overturned

This is a patient who has a history of chronic psychotic disorder best characterized as bipolar I mood disorder with the most recent episode manic with psychotic features, and a clinical course with prior acute psychotic episodes in the context of mood disturbance and medication non-adherence and poor insight.  The patient has failed to respond to olanzapine quetiapine, fluphenazine and long-acting haloperidol due to a lack of effectiveness and/or adverse effect in the context of the non-adherence to medication regimen.
The health plan's determination is overturned.
In this case scenario, the patient has demonstrated a clinical response to Abilify Maintena, as noted in the clinical summary.  The patient has a history of medication non-adherence and non-compliance with treatment for her chronic psychotic and mood disorder resulting acute episodes of psychosis and mania requiring inpatient level treatment.  Thus, the requested benefit of Abilify Maintena at the current dosage is reasonable and in the patient's best interest in keeping with prevailing standards of medical practice, especially in view of the fact that she was able to tolerate the initial treatment with oral formulation while being monitored for compliance in the hospital setting.
Appeal type: Medical necessity
Decision: Overturned in Part

This patient is under consideration for bariatric surgery. On 4/19/19, the patient was 67 inches tall and weighed 226 lbs. This corresponds to a body mass index (BMI) of 35.4 kg/m2. On 11/20/18, the weight was 232.8 lbs (BMI 36.5 kg/m2). The patient has comorbid health conditions of hyperlipidemia, gastroesophageal reflux disease (GERD), and non-alcoholic fatty liver disease/steatohepatitis (NASH). Bariatric surgery and the corresponding inpatient admission is under review. 

The health plan's determination is overturned in part. Given this patient's diagnosis, her current health condition and the evidence based literature, the proposed sleeve gastrectomy procedure is medically necessary for this patient. Inpatient admission is also medically necessary and is consistent with the standard of care.
However, the pyloroplasty (CPT 43659) is not medically necessary as this procedure is not supported by evidence based literature within the bariatric surgical community as a standard of care intervention to minimize the risk of staple line leak.Sleeve gastrectomy is in accordance with generally accepted standards of medical practice, is clinically appropriate and considered effective for the member's disease, is not cosmetic or experimental, is proven to be more medically effective than any standard nonsurgical care and treatment, and is not for the convenience of the member or physician. The proposed sleeve gastrectomy is medically necessary for this patient and is consistent with the standard of care.
Appeal type: Medical necessity
Decision: Upheld

The patient has a past medical history significant for diabetes mellitus type 2, hypertension, hyperlipidemia, anxiety and depression. The patient requests prescription drug coverage for Onglyza 5mg for the treatment of diabetes mellitus. The health plans determination of medical necessity is upheld. There is no noted superiority of Onglyza versus Januvia or alogliptan. Medical necessity for this prescription is not met. There is not enough medical records provided which denote why this medicine must be used in regards to treatment of diabetes in comparison to the other listed medications. There are several other medicines which are equally efficacious in regards to treatment of diabetes. The patient has no medical contraindications for usage with the other medications.  Medical superiority has not been shown with this medication in comparison to the other listed medications noted.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Constipation
Issue under review: Inpatient admission

Determination:
The Inpatient admission was medically necessary.

The patient was seen in the ED a few days prior, and CT scan of the abdomen and pelvis revealed stercoral colitis and proctocolitis. She was given IV fluids, Zofran and antibiotics, and discharged home. As she did not have any improvement in her symptoms with outpatient management, she returned to the ED with persistence of symptoms of abdominal pain and distention, nausea and vomiting. She had a CT scan of the abdomen and pelvis, which revealed severe fecal impaction in the sigmoid colon and possible pericolonic stranding in the sigmoid colon and rectum. As she was complaining of nausea and vomiting, she was made NPO. The GI was consulted for the management of fecal impaction and possible stercoral colitis. She was started on antibiotics and started on Senna, Miralax, Mg Citrate, Fleet water enema, and also given a trial of GoLYTELY for the treatment of fecal impaction, but without any success. General Surgery was also consulted for management of abdominal distention and ileus, and their recommendation was to continue with laxatives, enemas as before, and antibiotics. She continued on Miralax 1pkt every hour around the clock, but there was no relief. She was seen by the GI in follow-up, and flexible sigmoidoscopy was done, which revealed no evidence of colitis up to 25cm and fecal impaction with large stool ball noted in the sigmoid colon. The biopsy of the sigmoid colon was normal except for hyperplastic changes. She was on antibiotics that were discontinued as there was no evidence of colitis. She was continued to Miralax 17g pkt every hour, and Mineral oil enema every eight hours. She was started on small sips of water and ice chip and no diet. The antibiotics were discontinued and she was continued with an aggressive bowel regimen for fecal impaction.

Due to persistent nausea and recurrent vomiting, the patient was given only ice chips and sips of water. She was continued with Mineral oil enemas, and Miralax as before. After a few days, she reported multiple bowel movements, mostly water with small amount of stools. The next day, her abdominal pain was much better and she was able to tolerate diet. The day after, she was discharged home. 

Given this clinical scenario, and the failure of outpatient management of fecal impaction in this case, the acute level care was medically necessary to treat severe fecal impaction and ileus.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lymphedema, chronic stasis dermatitis
 
Treatment: Pneumatic compression device with calibrated pressure and bilateral half-leg appliance

The insurer denied the pneumatic compression device with calibrated pressure and bilateral half-leg appliance. The denial was upheld.

This patient is a male who presented for an Unna boot application. The patient had been receiving Unna boot therapy and maintaining compression without significant improvement.  Problems included a non-pressure chronic ulcer of the left calf limited to breakdown of the skin, lymphedema of the lower extremity, stasis dermatitis, and morbid obesity. The patient was advised to lose weight and was to continue elevation and compression hose. It was stated that medication was not appropriate for the treatment of the patient's lymphedema. He was unable to tolerate a basic pneumatic compression device (PCD) and needed the Flexitouch. The patient had used a basic pneumatic compression device which was discontinued due to swelling. It did not reduce swelling, and caused intolerable pain. 

The standard of care for lower extremity lymphedema is multimodal therapy, which is aimed at improving patient comfort and reducing limb volume. Conservative/multimodal therapy consists of general measures for self-care such as monitoring, limb elevation, skin care, weight reduction with diet and exercise, and compression therapy such as compression bandaging, compression garments, and intermittent pneumatic compression, as well as physiotherapy.

The patient's condition had been caused by morbid obesity. The records failed to support that the patient had tried to exercise. The patient refused a bariatric consultation. The records failed to support that the patient had attempted to lose weight.   

Based on the above, the medical necessity for the 3-month rental of a pneumatic compression device with calibrated pressure and the purchase of bilateral half leg appliance is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left Foot Cellulitis
 
Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld.  

The is a male patient with a past medical history significant for gastroesophageal reflux disease (GERD), reactive airway disease and obesity who presented to the Emergency Department with complaints of left foot erythema and warmth. Vitals on presentation included: a temperature of 99.6F, a blood pressure of 122/82, a pulse of 80, a respiratory rate of 18, and an oxygen saturation of 99% on room air. Laboratory results included the following: white blood cell count 15.15, hemoglobin of 13.3, hematocrit of 39.5, creatinine of 0.9, and glucose of 149.

The patient was started empirically on intravenous antibiotics (Cefazolin) for left foot cellulitis. An x-ray of the foot was negative for any acute findings. Podiatry consulted and recommended dressing changes with betadine. All cultures remained negative. The clinical impression was "uncomplicated cellulitis." There was no evidence for a systemic infection and no surgical intervention was deemed necessary. The patient remained afebrile, hemodynamically stable and was discharged to continue outpatient management. 

Based on the above, the medical necessity for the inpatient hospital services at the acute level of care is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol and Substance Detoxification
 
Treatment: Inpatient Substance Abuse Admission

The insurer denied the Inpatient Substance Abuse Admission. The denial was reversed.

This is a male patient who was admitted to inpatient substance detoxification treatment in early 2019 for alcohol and substance detoxification treatment. He reportedly had withdrawal symptoms including nausea and vomiting, sweating, tremors, yawning, sleeping problems, irritable mood, teary eyes, urges/cravings, a CIWA of 10, and COWS of 17. He has a significant history of alcohol and heroin use. He has had multiple past inpatient substance detoxification and rehabilitation treatments. He reportedly was homeless and has an infectious disease. He tested positive for opiates, cocaine, and benzodiazepines. He took 2 detoxification medications including Librium and Methadone during this admission and he was discharged to inpatient substance rehabilitation.

The APA Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. This patient had been using multiple serious substances in large amounts. He was at high risk for overdose and withdrawal symptoms, and complicated and life threatening withdrawal.  He required inpatient substance detoxification treatment. According to the LOCADTR he did require 24 hour treatment as he could not safely and effectively be treated in outpatient detoxification settings due to his continued use of alcohol and serious substances despite numerous inpatient detoxification and rehabilitation treatments. He required 2 detoxification medications during this admission-Librium and Methadone.  He also lacked coping skills and ability to identify relapse triggers. He was homeless and lacked a sober support system. He could not safely and effectively maintain abstinence on his own and required outpatient substance detoxification setting. 

Based on the above, the medical necessity for inpatient substance abuse services is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis
 
Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld. 
This patient is a middle aged male with past medical history significant for diverticulosis, thyroid disease, anemia, and status post cyst removal from right side of chin who presented to the emergency department with complaints of left side chin swelling. 
Vitals on presentation included: Temperature. 100.0 F, Blood Pressure-153/93, Pulse-113, Respiratory Rate-18, oxygen saturation -99% on Room Air. Laboratory results included the following; White Blood Cell-14.45, Hemoglobin-10.3, HemotocritT-35.2, creatinine-0.8.
The patient was admitted with a left chin cellulitis after "squeezing a pimple." The patient had a localized infection with no evidence of systemic toxicity and no surgical intervention was deemed necessary. Moreover, patient had no trial of outpatient intervention. He was empirically started on intravenous antibiotics (clindamycin) and methylprednisolone. Hematology consulted for a chronic microcytic anemia and Infectious Diseases evaluated for antibiotic management; the latter recommended warm compresses and Bactroban ointment. The patient remained afebrile, hemodynamically stable. He was discharged to continue oral antibiotics. 
Based on the above, the medical necessity for the inpatient hospital services is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right renal colic
Treatment: Inpatient admission 

Summary:
An acute inpatient level of care was not medically necessary.  Care could have been provided at a lower level of care.  The patient was afebrile and hemodynamically stable throughout the hospitalization. There was no significant evidence for sepsis.  Following admission, there were no unstable vital signs reported.  He did not have a documented infection or kidney failure, solitary kidney or a kidney transplant, or need for an open surgery. He did not have bilateral obstruction, acute renal failure, severe vomiting.  Pain control, IV antibiotics and IVF discharge in a non-toxic patient can be provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Systemic Inflammatory Response Syndrome Criteria
 
Treatment: Inpatient Admission

The insurer denied the Inpatient Admission.  The denial was upheld. 

The patient has no past medical history, who was referred to the hospital in late 2018 for persistent fevers (up to 104.5F for 4 days along with abnormal lab results at the pediatrician's office) leukopenia 2,900, band count 11.9%, and absolute neutrophil count 1000. In addition, the history was significant for decreased oral intake, decreased urine output, chills and watery diarrhea, upon arrival he had a temperature of 100.6 F, blood pressure 140/87, heart rate of 167 beats per minute, respiratory rate of 30 breaths per minute, and a pulse oximetry reading of 96%. The patient was fussy, had a sunken fontanel and lacked tears when crying. The patient was dehydrated, and he needed bolus fluid for rehydration. 

He had mild neutropenia (defined as 1000-1500/mm3) without any indication of a congenital or hereditary hematological abnormality, or of an underlying disease that would predispose to neutropenia. The most likely reason for acute acquired neutropenia in a previously normal child is a viral infection. Occasionally, severe bacterial infections induce neutropenia, but the child will appear lethargic or toxic. Neutropenia, defined as absolute neutrophil count (ANC) of <1500/mm3 including bands, metamyelocytes and myelocytes, is confirmed by a calculation from a manual differential count of white blood cell (WBCs).

The risk of bacterial infection is then stratified according to the ANC. The risk of bacterial infection with mild neutropenia is very low. If the evaluation of the febrile neutropenic child suggests a viral infection-induced mild-to-moderate neutropenia, and the child is well-appearing, observation is the preferred management, but many clinicians prefer that a broad-spectrum antibiotic regimen should be initiated. 

Based on the above, the medical necessity for the inpatient hospital services at the inpatient level of care is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: NSCLC
Treatment: Guardant360
The Guardant360 was not medically necessary.

There is no evidence to support Guardant 360 testing in a patient with NSCLC who has already undergone FoundationOne one testing and been found to have an ALK mutation. The NCCN only recognizes molecular panel testing at initial diagnosis. They do not recommend multiple panel testing or repeat panel testing in patients with NSCLC.  

The SHIVA study has shown that the use of NGS (next generation sequencing) panel testing in advanced cancer patients does not improve clinical outcomes.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient admission
The inpatient admission for the management of this patient was not appropriate and medically necessary for the management of this patient's condition.

The patient has a history of alcoholic cirrhosis complicated by ascites requiring large volume paracentesis in the recent past. He presented with one day history of right lower quadrant pain and distention, and diagnosed with cellulitis of the abdominal wall at the site of previous paracentesis. He also had moderate ascites on CT scan of the abdomen for which he underwent large volume paracentesis. The ascitic fluid was negative for spontaneous bacterial paracentesis (SBP), and blood cultures drawn on admission revealed no growth. He was treated with Vancomycin IV during his hospital say, and then he was discharged home on oral Cipro. On admission, and throughout his hospital stay, he remained hemodynamically stable and afebrile, and tolerated diet without any nausea and vomiting, and he was mentating normally with no signs/symptoms of hepatic encephalopathy. Given this clinical scenario, he could have been safely and appropriately managed at lower level of care, and acute level inpatient care was not medically necessary.