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

Digestive System/Gastrointesinal
Inpatient Hospital

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

This is a female patient with a past medical history of diabetes mellitus type 2 (DM2), gastroesophageal reflux disease (GERD), hypertension (HTN) and dyslipidemia who presented to the emergency room with abdominal pain, diarrhea nausea and vomiting of a day's duration. She was hemodynamically stable and afebrile. Her abdominal examination revealed tenderness to palpation, without guarding, rebound or rigidity. She had leukocytosis, an elevated anion gap and hyperglycemia. A computed tomography (CT) scan of the abdomen revealed bowel wall thickening of the terminal ileum, cecum and proximal ascending colon. She was admitted as an inpatient. At issue is the medical necessity of an inpatient stay.
The requested health service/treatment of inpatient hospital admission is not medically necessary for this patient. The patient could have been managed at a lower level of care.
The patient was started on intravenous fluids (IVF), a proton pump inhibitor (PPI), antibiotics and her home medications. Stool studies were negative for Clostridium (C) difficile. Her symptoms gradually resolved and she was discharged home with outpatient follow up.  The medical records provided indicate that she had evidence of systemic inflammatory response syndrome (SIRS) but not sepsis. She did not have cholangitis or pancreatitis. There is no indication that she was febrile and hemodynamically unstable and did not have peritoneal signs and hence did not meet criteria for inpatient status.
Inpatient admission for acute abdominal pain is medically necessary for one or more of the following:
-	Inability to maintain oral hydration
-	Fever
-	Severe pain (eg, not controllable with oral medication or oral 
 medication not tolerated)
-	Hypoxemia
-	Hemodynamic instability
The patient had none of these. Therefore, she could have been managed at a lower level of care than acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Skin
Pharmacy/prescription drugs

Diagnosis: Psoriasis Vulgaris
Treatment: Tremfya
The insurer denied Tremfya as not medically necessary. 
The health plan's determination is upheld in whole.

The patient has moderate to severe psoriasis (10% body surface area involvement) that includes the lower arms, lower legs, and back. Prior to starting Tremfya, the patient had tried and failed topical betamethasone, triamcinolone, halobetasol, and Vtama. When the patient started taking Tremfya, the patient's psoriasis was over 70% body surface area involvement, and overall cleared after starting Tremfya. However, the patient now has psoriasis returning after approximately six weeks between each dosage.

The requested Tremfya 100 milligrams (mg) every six weeks is not medically necessary for the patient.
If the patient cannot have his psoriasis controlled at the standard Tremfya dosing of every 8 weeks, then consideration and conclusion that Tremfya has failed to control this patient's psoriasis must be confronted. Supplementation with Methotrexate and/or Phototherapy, or to alternative biologic agents to treat this patient's psoriasis, are more medically appropriate than increasing the patient's Tremfya higher than its standard dosage.
The patient has no documented treatment failure with, or true medical contraindication to, supplemental therapy with either Methotrexate and/or Phototherapy, or to other biologic therapies such as Humira, Skyrizi, or Stelara, all of which are of similar potency and efficacy to the requested Tremfya. These alternative medications are as medically appropriate for the treatment of this patient's particular clinical condition as is the requested Tremfya dosed every 6 weeks (and which must be considered to be a treatment failure if the patient's psoriasis is not controlled at the standard Tremfya dosage. )Therefore, consistent with current medical literature reviews the requested Tremfya dosed every 6 weeks is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

This is a male patient with a past medical history (PMH) of diabetes mellitus type 2 (DM2), hyperlipidemia (HL), hypertension (HTN), and chronic alcohol abuse who was admitted with complaints of (c/o) abdominal and chest pain and denied a history of withdrawal seizures. His vital signs were unremarkable. The physical exam was notable for ill-appearing, abdominal tenderness to palpation (TTP), Clinical Institute Withdrawal Assessment (CIWA) 4. The patient was diagnosed with abdominal pain and uncomplicated alcohol withdrawal and treated with benzodiazepines (BZDs), multivitamin (MV), intravenous fluids (IVF), and CIWA. The patient was discharged  in stable condition. At issue is the medical necessity of an inpatient level of care.

The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with complaints of (c/o) abdominal and chest pain and was diagnosed with uncomplicated alcohol withdrawal. The patient did not have associated high-risk features, such as severe acute renal failure, congestive heart failure, or liver failure, nor did the patient have any hemodynamic instability, bowel obstruction, diabetic ketoacidosis, appendicitis, pyelonephritis, ascending infection, or immunosuppression. For the alcohol withdrawal, the patient did not have an acute co-morbid illness requiring inpatient treatment, high risk for delirium tremens, history of withdrawal seizures, long-term intake of large amounts of alcohol, serious psychiatric condition (e.g., suicidal ideation, psychosis), or severe alcohol withdrawal symptoms. The patient presented with abdominal pain and mild uncomplicated alcohol withdrawal, was treated and responded to BZDs, MV, IVF, and CIWA, and these interventions could have been safely and appropriately provided at a lower level of care. The patient did not have an elevated risk due to alcohol or sedative withdrawal, severe alcohol withdrawal, or severely complicated opioid withdrawal.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain

Treatment: Inpatient admission 

The insurer denied coverage for inpatient admission

The denial is upheld

The patient has a history of Hepatitis C that was treated with interferon and presented with abdominal pain. The patient was afebrile and the vital signs were stable. The abdominal exam was benign. There was no leukocytosis. The liver enzymes were elevated. An abdominal ultrasound showed hepatocellular disease and multiple gallstones without evidence of acute cholecystitis. The common bile duct (CBD) was not dilated. It was felt that the patient passed a gallstone without the need for any intervention. There was a plan for an outpatient laparoscopic cholecystectomy. 

Medical necessity was determined based on Milliman Care Guidelines (MCG) guideline M-555 for Gallbladder or Bile Duct Inflammation of Obstruction. Clinical indications for admission include having acute cholecystitis or acute cholangitis with systemic signs of inflammation. In this case, the patient did not have these conditions and the imaging studies did not show either acute cholecystitis or bile duct obstruction. The patient also did not have hemodynamic instability, severe vomiting, severe dehydration, or bacteremia. 

This patient has liver and gallbladder disease with evidence of gallstones but not acute cholecystitis. There was no evidence of sepsis and no acute interventions were needed. The patient did not have acute liver failure and the liver function could have been monitored as an outpatient. The patient did not meet MCG criteria for admission for Gallbladder or Bile Duct Inflammation or Stone. The patient could have had an outpatient workup. The health care plan acted reasonably and with sound medical judgment. Inpatient admission was not medically necessary. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

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

Diagnosis: Cellulitis. 

Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is overturned. 

This is a patient with a past medical history significant for hypertension, hyperlipidemia, and diabetes mellitus who presented to the emergency department with complaints of worsening right lower leg wound. 

Vitals on presentation included: Temperature 99.0 Fahrenheit, Blood Pressure 219/92, Pulse 110, Respiratory Rate 19, oxygen (O2) saturation 97% on Room Air. Laboratory results included the following: white blood cell count (WBC) 12.9, hemoglobin (HGB) 9.7, hematocrit (HCT) 33.1, creatinine 1.21, glucose 173, C-reactive Protein (CRP) 33.72, and lactate 1.59. 

The patient was started empirically on intravenous (IV) antibiotics (vancomycin and Zosyn) for an infected lower extremity ulcer. X-ray of the right tibia and fibula showed a large soft tissue defect/ulceration involving the medial aspect of the distal calf. Infectious Diseases consulted and adjusted antibiotics. Vascular surgery was consulted for local wound care. She remained afebrile, hemodynamically stable, and clinically improved. The patient was discharged to continue oral antibiotics (Levaquin) as an outpatient. 

According to documentation, the patient presented with a worsening 10 x 10 centimeter (cm) purulent foul-smelling lower leg ulcer despite outpatient intervention. The patient had a low-grade fever, tachycardia (pulse 110), and elevated blood pressure (219/92). Laboratory results were significant for elevated WBC (12.9), inflammatory markers, and anemia. Based on the above abnormal findings including failure of outpatient management, the patient met the criteria for hospital admission. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.  

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

Diagnosis: Chest pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.
 

Patient is an adult female who presented to the hospital with complaints of left sided chest pain. The pain radiated to her left arm and back.  There is a past medical history of tuberculosis (TB) and a history of recent travel.

Vital signs at presentation Temperature 98.5 degrees Fahrenheit, Blood Pressure 118/69, Heart Rate 54, Respirations 20, oxygen (O2) saturation 99% (percent) on room air. On exam the patient was in no acute distress, lungs were clear, heart sounds normal, and she was alert and oriented x 3 (person, place, and time).

White blood cells (WBC) were 7.8, electrolytes normal, D Dimer was mildly elevated, and electrocardiogram (EKG) showed no acute ST-T changes. A computed tomography (CT) Angiogram was done and Pulmonary Embolism was ruled out but it revealed bilateral apical scarring. Large paraseptal emphysematous bullae seen in bilateral upper lobes Left > Right - linked secondary to old TB.

Patient was admitted for observation and was treated with pain medications. The patient remained stable after an overnight stay and was discharged home. This patient did not need acute inpatient hospitalization. She could have been placed in observation status while diagnostic testing and treatment were initiated. She was afebrile and stable, was not hypoxic, no pneumothorax (PTX) noted on imaging, no Pulmonary embolus (PE) or myocardial infarction (MI). Her chest pain had subsided with pain meds. There was no evidence of any infection. This patient was hospitalized just for 1 day and discharged the next day.  This patient could have been placed in Observation, PE and MI and PTX ruled out. Subsequently, she could have been discharged home after a period of observation (which could be for up to 48 hours) without inpatient acute hospitalization.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

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

Diagnosis: Hemiparesis, diabetes and lymphedema

Treatment: consumer and self-directed personal assistance services (CDPAS) 80 hours a week

The insurer denied coverage for consumer and self-directed personal assistance services (CDPAS) 80 hours a week

The denial is overturned

 
This is an adult female with chronic medical problems including hemiparesis, diabetes and lymphedema.  She lives alone in a private residence.  Her son is 1 of 2 paid caregivers.  The patient is approved for consumer directed personal assistance services (CDPAS) 49 hours/week, and the request is for an increase of CDPAS 80 hours/week; leading to an external review.   

According to the Uniform Assessment System (UAS) report the patient's cognition is described as minimally impaired.   She is "able to activate emergency plan, personal emergency response system (PERS) in home and call 911 in case of an emergency."  The patient reportedly requires maximal assistance for performing much of her Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.  She is reportedly total dependent for locomotion and is non-ambulatory (described as bedbound).  The patient reportedly requires maximal assistance for bathing, lower body dressing and toilet use.  Extensive assistance is reportedly needed for personal hygiene, upper body dressing, and bed mobility.  Limited assistance is reportedly needed for eating.  She reports being frequently incontinent of bladder and bowel.  Her activities of daily living (ADL) status and self-sufficiency have reportedly declined and deteriorated, respectively over the prior 90 days.  There have been no reported falls over the prior 90 days.  

The clinical notes from her treating physician Dr. Sethi, documenting her underlying medical conditions and need for additional home care services were reviewed.  The patient's clinical condition and functional deficits are at a level and unpredictable as to require increasing CDPAS 80 hours/week; particularly given her moderate to severe lymphedema (with frequent pump management), hemiparesis and limited mobility.  The insurer's recommended "bed pan, adjustment pillows, hospital bed and barrier cream" are appropriate, however insufficient to meet the functional needs of the patient.  Based on the clinical records, attention to Ms. Parris' functional needs are more appropriately provided and maintained by increasing CDPAS to 80 hours/week.  

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for consumer and self-directed personal assistance services (CDPAS) 80 hours a week is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: psoriasis
Treatment: Taltz
The insurer denied Taltz
The health plan's determination is upheld.

The patient is a male with psoriasis and psoriatic arthritis. His Achilles tendon and MCP (metacarpophalangeal) joints are affected. He has tried and failed halobetasol cream and mometasone cream. The medication under review is Taltz.

Taltz is not medically necessary for this patient.
There is no documentation provided that the patient has tried and failed, has a contraindication to, or intolerance to two of the preferred treatments: Humira, Stelara, Trefmya, Cimzia, Skyrizi, Cosentyx or Enbrel. The aforementioned medications have been shown to be effective for psoriatic arthritis and psoriasis and are appropriate for use in this patient.

The evidence-based literature confirms that preferred agents are appropriate agents for the treatment of the patient's psoriasis and psoriatic arthritis. The formulary medications should be tried and failed prior to initiating Taltz. There is no documentation provided that would justify the patient requiring treatment with Taltz prior to the formulary alternatives such as Humira or Stelara. There is no proof or documentation provided the patient has tried these preferred drugs and had an adverse effect or proof that these formulary tried drugs did not work for the patient.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Amyotrophic lateral sclerosis (ALS)

Treatment: Formulary Exception for Relyvrio

The insurer denied coverage for Formulary Exception for Relyvrio.

The denial is overturned.
 

The patient is an adult male seeking coverage for a formulary exception for Relyvrio for use in the treatment of amyotrophic lateral sclerosis.

The patient presented for a therapy session related to motor neuron disease.  The patient had decreased trunk rotation, lowered eye gaze, and decreased ankle clearance.  The patient had fallen over a kitchen mat at their brother's home after playing golf.  The patient was independent with transfers with mild use of hands from the chair.  The patient reported that they continued to drop things.  The patient reported improved back pain with acupuncture.  The patient had decreased range of motion of the bilateral shoulders at 110 degrees.  The patient had weak intrinsics with weakness more evident in the left hand than the right.  There was right tricep and bicep weakness.  

The patient was seen for neurology evaluation.  The patient had upper limb onset gene-negative amyotrophic lateral sclerosis of 22 months duration.  Since last visit, the patient had some areas of decline and others that have been largely stable.  Of note, the patient was recently diagnosed with prostate cancer.  The exam findings noted bilateral right worse than left painless progressive weakness.  There was hand going down, mostly with activity.  There was increased atrophy but no change in strength or function.  The patient was doing home stretching.  There was mild gait instability.  Cramping continued in the legs and feet.  The patient reported some muscle fatigue when walking upstairs or for a distance.  Pulmonary function testing reported forced vital capacity of 97.  The peak cough flow was 500 liters per minute (LPM).  The peak expiration flow was 297 LPM.  Prior forced vital capacity was 129% (percent) with very loud exhalation.  The patient had slowly progressive, lower motor neuron predominant, gene-negative ametropic lateral sclerosis.  It was predominantly bi-brachial syndrome with no bulbar signs or symptoms.  There were mild respiratory complaints.  There were no cognitive or behavioral changes.  There was no evidence of lower extremity involvement and spirometry was normal.  There was a plan for Relyvrio.  

It cannot be determined if formulary medications are likely to cause the patient an adverse reaction as no formulary drugs were identified within the final adverse determination.  

It cannot be determined if formulary medications had been ineffective as no formulary drugs were identified within the final adverse determination.  

It cannot be determined if the requested medication would be more effective than formulary alternatives as formulary alternatives were not listed.  

The carrier's denial of a request for a Formulary Exception for Relyvrio for use in the treatment of Amyotrophic lateral sclerosis is overturned.
Appeal type: Medical necessity
Decision: Upheld

Substance Abuse/Alcohol abuse/Addiction/alcohol withdrawal
Inpatient Hospital/inpatient hospital stay
The health plan denied the requested inpatient hospital stay as not medically necessary. The health plan's determination is upheld.

The patient is a male with a past medical history of alcohol abuse, hypertension, and chronic pancreatitis who was admitted with complaints of abdominal pain. Vital signs were notable for a pulse of 109 beats per minute (bpm). Physical exam was notable for an abdomen diffusely tender to palpation, mild tremors in the upper extremity (bilaterally), a Clinical Institute Withdrawal Assessment (CIWA) score of 4, and glans swelling. Lab work was notable for a lipase of 11. Imaging studies included a computed tomography (CT) of the head which showed no acute intracranial abnormalities, a CT of the chest which showed no acute pathology, a CT of the abdomen/pelvis which showed chronic pancreatitis and gastritis, and an ultrasound of the testes/scrotum which was within normal limits. The patient was discharged in stable condition.

What is at issue is the medical necessity for the inpatient hospital stay.

I uphold, in whole, the health plan's determination of medical necessity.

No, the hospital stay was not medically necessary at an acute inpatient level of care. 

This patient presented to the Emergency Department with complaints of abdominal pain and was diagnosed with gastritis versus pancreatitis. The patient was diagnosed with abdominal pain secondary to alcoholic gastritis vs pancreatitis and was treated with intravenous fluids, Librium protocol, proton pump inhibitor, and a Urology consultation, who recommended no acute interventions. Gastroenterology evaluated the patient and recommended outpatient follow-up. The patient did not have any evidence of impaired mental status, pleural effusion, systemic inflammatory response syndrome (SIRS), rebound tenderness, acute kidney injury, pancreatic necrosis, or fever.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tooth Decay
Treatment: Porcelain fused to metal crown (high noble metal), and custom abutment for tooth number (#)18
The insurer denied the request for a porcelain fused to metal crown (high noble metal), and custom abutment for tooth #18.

The patient is a male patient with tooth number (#)18 that has a crown. Recurrent decay was noted, periapical radiolucency was noted on #18 and the tooth needs extraction. The current treatment plan includes an implant in the #18 area after extraction.

The health plan in its determination of medical necessity, did act reasonably, with sound medical judgment and in the best interest of the patient.

The porcelain fused to metal crown (high noble metal), and custom abutment for tooth #18 is not medically necessary. There are other treatment options available for the patient, like a partial denture and in this case the patient does not meet the implant criteria for the plan. The case does not meet the requirements of medical necessity based on New York state Medicaid guidelines for implants. Per the criteria, the implant is not needed to keep 8 teeth in occlusion and the treating office does not demonstrate why another, less invasive treatment option, like a partial denture is not viable. The patient also has a missing contralateral tooth in the mandible, which adds to the viability of a partial.

The plan's determination of medical necessity is upheld in whole.