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

Diagnosis: Bronchitis, Hyper-Reactive Airway. 
Treatment: Inpatient hospital admission. 

The insurer denied the inpatient hospital admission. 

The denial was upheld. 

This is a male patient who presented to the Emergency Department (ED) with complaints of shortness of breath (SOB) and a cough. The patient denied fever, chills or chest pain. The patient's presenting vital signs were: temperature (T) 98.2 F, heart rate (HR) 95, respiratory rate (RR) 17, and blood pressure (BP) 175/89 mm Hg. The patient's lung exam revealed wheezes. The patient was awake, alert and oriented. The patient's white blood cell (WBC) count was 9.8K, hemoglobin (Hb) was 14.6K, electrolytes were within normal limits and BUN/Creatinine was also within normal limits. The patient's chest x-ray showed no infiltrate and his influenza screen was negative. The patient was treated with intravenous (IV) fluids, bronchodilators and steroids. The patient was noted to have improved with treatment. The patient was admitted to the hospital with bronchitis/hyper-reactive airways. Pulmonary was consulted with recommendations that the patient start inhaler treatment with steroid and long-active beta-agonist (LABA), and to continue oral steroids for another day. The patient's echocardiogram showed normal left ventricular (LV) function. After a period of medical stability, the patient was discharged home with outpatient pulmonary follow up instructions. 

Based on the review of the medical record and literature, this patient did not need acute hospitalization. This patient could have been placed in observation status while diagnostic testing and treatment were initiated. The patient improved with treatment, and was in no acute distress. There was only some wheezing on lung exam that persistent after ED treatment. The patient was not hypoxic, and he was ambulatory and tolerating oral intake. The patient did not exhibit any respiratory distress. The patient was seen by Pulmonary who recommended the same management and added long-acting beta agonist (LABA) and inhaled corticosteroid (ICS) medications to his treatment regimen. The patient's antibiotics were discontinued. This patient was stable to be switched to oral steroids and discharged home on ICS/LABA and bronchodilators as needed (PRN) after a period in observation status, which could be allowed up to 48 hrs. The patient's diagnosis was bronchitis and if present, had a mild case of chronic obstructive pulmonary disease (COPD), which did not need acute hospitalization. Based on this patient's clinical presentation and response to ED treatment, only a period under observation statue would have been medically necessary. The patient did not have pneumonia and was not hypoxic. The patient's chest x-ray, electrocardiogram (EKG), and echocardiogram were all unremarkable. Thus, inpatient admission was not medically necessary for this patient. 

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 hospital admission should be upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Unstable angina.

Treatment: Inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

This male patient has a past medical history notable for hypertension, hyperlipidemia, myocardial infarction, tobacco smoking, and coronary artery disease status post stent placement. The patient presented to the Emergency Department (ED) with complaints of chest pain radiating to the jaw and dyspnea on exertion. Vital signs were stable. The patient's electrocardiogram (EKG) showed normal sinus rhythm, incomplete right bundle branch block and left anterior fascicular block. The patient's troponin level was negative. The patient was administered nitroglycerin, aspirin, intravenous fluid and Plavix, and then was admitted to the Telemetry unit for unstable angina. The patient was evaluated by cardiology, and underwent cardiac catheterization which revealed patent stents, 50% obstruction of the proximal left circumflex artery and an ejection fraction of 55%. Ongoing medical management was recommended. After treatment and once medically stable, the patient was cleared for discharge to home to follow-up with his primary care physician.

Based on the review of the medical record, the patient presented to the Emergency Department (ED) with chest pain. However, the initial evaluation in the ED was unremarkable, including a non-diagnostic EKG and negative cardiac biomarkers. Though it was appropriate and indicated for the patient's symptoms to be evaluated and to rule out acute coronary syndrome, inpatient admission was not medically necessary in this instance. The patient's care could have been provided under observational level of care, allowing for additional diagnostic testing, as was performed in this instance. There were no high-risk or concerning findings on diagnostic testing to necessitate further inpatient evaluation. During the patient's initial evaluation and subsequent hospitalization, there was no objective evidence of hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions warranting acute inpatient level of care. For all of these reasons, inpatient admission was not medically necessary for this patient.

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

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

Diagnosis: Eczema. 
Treatment: Dupixent Inj 200. 

The insurer denied coverage for the medication Dupixent injections 200. The denial is overturned. 

This patient is a male child who has a history of eczema and asthma. Per a clinic notes,  the patient is using Tacrolimus and Triamcinolone ointments without much improvement. The patient wakes up two times every night due to severe itching, which is severely affecting his quality of life. He has had to miss school often and has poor concentration at school due to severe pruritus. The patient has severe eczematous plaques covering more than 90% of his body, with multiple excoriation papules on his back. The patient needs systemic treatment and Dupixent injections were ordered. The patient is not a candidate for other systemic agents due to age and significant adverse effects. 

The appeal letter by Dr. Jacob Levitt states the patient has been diagnosed with severe atopic dermatitis that manifests as severe eczematous plaques with 90% body surface area (BSA). The patient is currently using Triamcinolone ointment and Tacrolimus ointment without much improvement. Dr. Levitt states Dupixent was approved by the Food and Drug Administration (FDA) for the treatment of patients aged 6 years and older with moderate-to-severe atopic dermatitis, whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable. The patient has tried and failed two medium or higher potency topical corticosteroids in the past 180 days, as required for approval. 

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

The patient has tried and failed medium to high potency topical corticosteroids and a topical calcineurin inhibitor. 

Dupixent has been found to be safe and effective in the pediatric population. Dupixent is approved for the treatment of atopic dermatitis by the FDA for the age of 6 and above. 

The patient has severe atopic dermatitis involving the body throughout. The patient has a 90% body surface area. The patient has tried and failed conservative therapy. The use of immunosuppressant medication would be inappropriate due to the potential for solid organ and bone marrow toxicity. Dupixent has been found to be safe and effective in the pediatric population. Dupixent is approved for the treatment of atopic dermatitis by the FDA for the age of 6 and above. Therefore, the request for Dupixent is medically necessary. 

In a case series of pediatric patients under 18, Treister and Lio found that "Dupilumab appears to be an effective treatment for AD in pediatric patients." 

Paller, et al. in a randomized trial of children 6-11 years old found that Dupilumab along with topical corticosteroids "resulted in clinically meaningful and statistically significant improvement in signs, symptoms, and quality of life (QoL) versus placebo+TCS in all prespecified endpoints." 

Based on the above, the medical necessity for Dupixent Inj 200 is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Rheumatoid arthritis.
Treatment:  Orencia Clickject 125 MG/mL Auto Injector.

The insurer denied the Orencia Clickject 125 MG/mL Auto Injector.  The denial is overturned. 

The patient is a female with rheumatoid arthritis (RA).  She failed treatment with Humira and had adverse reactions to the disease modifying anti-rheumatic drugs (DMARDs) methotrexate and sulfasalazine.  She was treated with Orencia 125 milligram (MG) weekly.  She moved from Puerto Rico to mainland United States.  She has not tried or failed the Plan-preferred alternatives Enbrel, Kevzara or Xeljanz.  Appeal is for resumption of Orencia Clickject 125 MG/mL Auto Inject for the treatment of RA.

Yes, the Orencia Clickject 125 MG/mL Auto Inject is medically necessary.

Orencia is FDA-approved for the treatment of RA, as seen in this patient.  This patient failed treatment with the tumor necrosis factor (TNF) inhibitor Humira and had adverse reactions to the DMARDs methotrexate and sulfasalazine.  Per 2015 published guidelines for the treatment of RA, "if disease activity is moderate or high despite single TNF inhibitor biologic therapy, we conditionally recommend using a non-TNF biologic".  

This patient was previously treated with the non-TNF inhibitor biologic Orencia and responded well to Orencia, as substantiated by attached documentation.  Although this patient has not tried or failed other Plan-preferred alternatives (i.e., Enbrel, Kevzara or Xeljanz), it would not be clinically appropriate to prefer one of these agents in a patient who has previously responded well to Orencia.  Re-treatment with Orencia for this patient with active RA would be clinically appropriate and in accordance with standard of care in the rheumatology community.  Therefore, the proposed Orencia Clickject 125 MG/mL Auto Inject is medically necessary for this specific patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain.
Treatment: Cardiac Catheterization and Ventriculography.
The insurer denied the Cardiac Catheterization and Ventriculography.
The determination is upheld.

The patient has a history of hypertension (HTN) and hyperlipidemia (HLD), having constant chest pain with no exacerbating or remitting factors. There was some shortness of breath and no diaphoresis. A Myocardial Perfusion Imaging (MPI) stress test was normal. He exercised for 9 minutes with no chest pain. Cardiac catheterization and ventriculography are under review for medical necessity.

No. Coronary artery angiography and intervention is generally indicated for treatment of an acute coronary syndrome, high risk non-invasive findings (i.e. ischemic cardiomyopathy, large MPI defect), or for treatment of medically refractory angina symptoms. In this case there was atypical chest pain and a normal MPI stress test. Catheterization in this setting, compared to medical therapy and evaluation for noncardiac causes of chest pain (reserving a catheterization for the development of medically refractory angina or high risk stress test abnormality), has not been established as standard of care towards improved cardiac outcomes. Therefore, the requested procedures are not considered medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Missed abortion
Treatment Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay
The determination is upheld.

This is a patient with a missed abortion. She was given several doses of misoprostol for passage of the retained products of conception, however, without success. She was admitted to the hospital for retained products of conception. A suction dilation and curettage was performed and she was discharged the same day. At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient stay is not medically necessary for this patient. The patient had retained products of conception and a suction dilation and curettage was performed which was appropriate; however, there was no need for inpatient hospital admission. The patient had no significant morbidity including pulmonary, hepatic or renal complications. There was no infection, sepsis, hemorrhage nor complications in the surgery. She did not need a transfusion or subsequent surgery. Vital signs were stable and she had no hemodynamic instability. She was monitored appropriately and then discharged. She could have had the procedure at a lower level of care. No acute inpatient hospital admission was required.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pancytopenia
Treatment:  Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This patient with a past medical history of rectal cancer with metastases to the liver, lung, bone, and lymph nodes, deep vein thrombosis on Lovenox,  presented to the emergency department with fatigue, generalized weakness, and labs drawn in the outpatient setting noting pancytopenia. His history was otherwise significant for having recently started Bactrim for cellulitis of his left nare.
On presentation, he was afebrile with a blood pressure of 116/76, heart rate 101, and with an oxygen saturation of 100% on room air. The exam otherwise was refused by the patient. Labs resulted with a white blood cell count (WBC)of 6.3, hemoglobin (HGB) 6.5, platelets 65, sodium 128, potassium 3.6, blood urea nitrogen (BUN) 20, creatinine 1.3, glucose 80, aspartate aminotransferase (AST) 17, alanine aminotransferase (ALT) 12, alkaline phosphatase 101, total bilirubin (T. Bili) 0.4. Fecal occult blood testing was negative. The patient was brought into the hospital with concerns for anemia possibly related to Bactrim or chemotherapy without concerns for bleeding and with plans for checking haptoglobin and G6PD, peripheral smear, transfusing 2 units, and consulting hematology.
Overnight, the patient was transfused 2 units packed red blood cells (PRBCs) with the hemoglobin increasing to 7.9. A repeat sodium was 132 with the rest of his basic metabolic panel stable and haptoglobin normal suggesting no evidence of hemolysis. No bleeding was noted and the patient was noted to be afebrile without tachycardia or hypotension. Hematology was consulted, but the patient preferred to leave against medical advice prior to being seen by their service. At issue is whether an inpatient stay was medically necessary.
Inpatient care was not medically necessary. This is a patient who presented in the setting of a sodium of 128 and low hemoglobin without evidence of bleeding and with concern for Bactrim or chemotherapy-induced pancytopenia. He had a heart rate of 101 on presentation but was otherwise hemodynamically stable and his tachycardia was not persistent. His hemglobin subsequently increased to 7.9 with transfusion, he felt better, and left against medical advice. In the absence of a suspicion for bleeding, acute coronary syndrome, syncope, cardiac arrhythmias, altered mental status, renal failure, clear evidence of hemolysis, or failure of hemoglobin to respond to transfusion, it is unclear why inpatient care was medically necessary or why prolonged length of stay would have been expected. Inpatient care was not medically necessary and treatment could have been provided at a lower level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal
Treatment: Inpatient Hospital
The insurer denied: Inpatient stay
The denial is: Upheld in whole

The patient is a female who underwent an L5-S1 anterior lumbar interbody fusion (ALIF) procedure and was discharged two days prior to presentation. She returned to the hospital emergency department (ED) via Emergency Medical Services (EMS) in the early afternoon for complaints of severe back pain, bilateral leg numbness, and blurred vision after taking oxycodone. The patient was noted in the ED to be extremely anxious, refusing to move her legs and screaming if anyone touched them. She was noted to be afebrile with mild tachycardia and tachypnea. She was seen by the neurosurgery resident and admitted as an inpatient to the neurosurgery service for pain control and further evaluation of her symptoms. While in the ED she was given intravenous Dilaudid and Ativan with good pain control and was noted after that to be able to walk independently. Once on the floor, a patient controlled analgesia (PCA) with Dilaudid was started in the on-demand mode. This was discontinued by the pain service consultant the next morning with the recommendation to avoid opioid medications given history of numerous negative reactions to them in the past. A psychiatry consult was also obtained, and the patient's home medication of Lorazepam was reordered. In the afternoon the patient left the hospital with her mother without alerting anyone. She later confirmed in a phone call that she had removed her IV and was safe, declining to come back to the hospital.

The health plan's determination is upheld.

No, the requested service of an inpatient stay was not medically necessary for this patient. Clearly the neurosurgical service did not feel that there were any significant postoperative issues regarding the ALIF procedure performed several days before, as they did not order any radiological studies of either the patient's spine or abdomen. She was admitted to the inpatient neurosurgery service for pain control. A lower level of care status would have been appropriate, allowing for both pain control, assessment and treatment of her anxiety, as well as any evaluation into the etiology of her symptoms. Should a serious complication be identified that required further intervention, then the status could have been changed to inpatient at that time. While a PCA was started, it was in "on-demand" and not continuous mode, and pain medication including IV Dilaudid could have still be administered at a lower level of care status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Seizure, Bradycardia, Rhabdomyolosis 
Treatment: Inpatient admission 

The insurer denied the inpatient admission. The denial was overturned. 

This is a male patient with a medical history of syncopal episodes. The patient presented to the Emergency Department by ambulance with complaints of multiple syncopal episodes earlier that morning. The patient was reportedly diaphoretic and had a period of confusion. The patient stated he lost approximately 50 pounds in the past 4-5 months. The blood pressure was 103/57 and his pulse rate was 48. The patient had a normal neurological examination. The pupils were equal and reactive to light. The muscle strength was normal. The speech pattern was clear. The cardiovascular evaluation was normal. Upon physical exam it was noted that the patient had a burn on his right upper back (around 10 x 10 cm) due to a prior fall on a heater. The ALT was 69, AST was 78, creatinine kinase 3154, creatinine 1.42 and PTT was 22.1. The urine toxicology was positive for cannabinoid. The patient was admitted for a seizure and symptomatic bradycardia with a prolonged QTC. The patient was treated with cardiac monitoring/Holter monitoring, seizure precautions, intravenous fluid bolus, and silver sulfadiazine cream. The patient had rhabdomyolysis. A computed tomography (CT) of the head was performed was negative. After a period of medical stability the patient was the patient was discharged home. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient as inpatient admission was warranted. 

The patient meets MCG criteria as he had syncope causing injury requiring hospitalization. The high CPK leading to Rhabdomyolosis required admission. The patient required inpatient admission for monitoring, treatment, and workup. The patient was appropriately admitted and evaluated. 

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

Diagnosis:  Left ovarian mass.
Treatment:  Inpatient admission.

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

The patient is a female, who was admitted to the hospital with a diagnosis of a left ovarian mass for a planned laparotomy, possible left ovarian cystectomy.  During the procedure, difficulty was encountered entering the pelvis from a transverse incision and the incision was extended vertically.  A left salpingo-oophorectomy was performed.  The procedure was performed without difficulty or complications, with a 20 cubic centimeter (cc) blood loss.  The patient was transferred to the post-anesthesia care unit (PACU) and recovered without incident. 

The medical record indicates that the patient was discharged from the PACU to the inpatient floor.  On postoperative day #1 the patient was taking oral pain medication and tolerating a liquid diet.  Her vital signs were normal, and she was afebrile.  On postoperative day #2 the patient was taking oral pain medication, ambulating and tolerating a normal diet.  Her vital signs were normal, and she was afebrile.  Her incision was healing well.  On postoperative day #3 the patient was taking oral pain medication, ambulating and tolerating a normal diet.  Her vital signs were normal, and she was afebrile.  Her incision was healing well.  The patient was discharged on postoperative day #3.

No, the proposed inpatient admission was not medically necessary.

The medical records and medical literature were thoroughly reviewed.  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 tolerating a liquid diet and was transitioned to oral pain medications 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.  The patient recovered without complications.  Acute inpatient admission was not required for the patient's postoperative care.  The patient required postoperative care; however, given her intraoperative condition and uncomplicated postoperative recovery, she could have been reliably discharged from the recovery room to an intermediate, lesser level of care, such as an observation unit rather than as an acute inpatient admission.  Therefore, the treatment was not within the standard of care to be provided in an inpatient setting.  Therefore, the services were not medically necessary.