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

Diagnosis: Diabetic ketoacidosis.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient has a medical history of type 2 diabetes mellitus on an insulin pump and substance abuse (alcohol, cocaine, heroin) who was admitted for diabetic ketoacidosis secondary to non-compliance with his insulin with symptoms of nausea, vomiting, polyuria and polydipsia. On admission, he was found to have an elevated blood glucose of greater than (>) 200 milligrams per deciliter (mg/dL) (799 milligrams per deciliter (mg/dL)), a urinalysis showing ketonuria, acidosis with a potential hydrogen (pH) less than (<) 7.30 (7.27), serum bicarbonate of 12 milliequivalents (mEq/L) with an anion gap of 27. Due to a persistently elevated blood glucose level, he required treatment with a continuous intravenous insulin infusion. At issue is the medical necessity of an inpatient stay.

Yes, the requested health service/treatment of inpatient stay was medically necessary for this patient.
Based upon the severity of illness and intensity of required therapy, the inpatient level of care was medically necessary. This patient with a medical history of type 2 diabetes mellitus on an insulin pump and substance abuse (alcohol, cocaine, heroin) was admitted for diabetic ketoacidosis secondary to non-compliance with his insulin with symptoms of nausea, vomiting, polyuria and polydipsia. On initial evaluation, the patient was afebrile, hemodynamically stable, had an elevated blood glucose of > 200 milligrams per deciliter (mg/dL) (799 mg/dL), urine analysis showing ketonuria, acidosis with a potential hydrogen (pH) less than (<) 7.30 (7.27), serum bicarbonate of 12 milliequivalents per liter (mEq/L) with an anion gap of 27. However, due to a persistently elevated blood glucose level, at the equivalent of an observation level of care, he required treatment with a continuous intravenous insulin infusion. The hyperglycemia with diabetic ketoacidosis required a continuous intravenous insulin infusion. Therefore, due to the need for continuous intravenous insulin, due to failure to significantly improve the blood glucose level, the inpatient level of care would have been medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: atrial fibrillation
Treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a female who presented to the emergency department (ED) with palpitations associated with diaphoresis and shortness of breath and chest pressure. Her symptoms started at 3 am on the day of presentation. Initially, she thought it is a panic attack, but "it has not gone away". Her past medical history (PMH) was significant for thyroid disease, Hashimoto thyroiditis, obesity, obstructive sleep apnea (OSA) on continuous positive airway pressure (CPAP), anxiety and asthma. 

The requested inpatient hospital admission was not medically necessary for this patient.
The patient presented with atrial fibrillation with rapid ventricular rate, 150 (beats per minute (BPM), lasting for several hours. The patient spontaneously converted to sinus rhythm. She felt palpitations, but her blood pressure (BP) and oxygen (O2) saturation was stable. Her troponin was normal. Her chest x-ray (CXR) was normal. She was treated with Diltiazem drip, but only for a few hours.
Based on the above, the patient did not have indications for inpatient admission. A lower level of care would be more appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Preexisting large mesio-occluso-distal (MOD)
Treatment: D2750, crown; porcelain to gold tooth #13
The insurer denied coverage for D2750, crown; porcelain to gold tooth #13.
The denial is upheld.

Upon review of the documentation provided which includes copy of one bitewing radiograph, dental treatment record and notes, narrative letter from the dental office, and insurer correspondence, it appears that this patient presented for care involving tooth #13. The treating dentist recommended a full coverage crown for #13 due to preexisting large mesio-occluso-distal (MOD) direct placement restoration. The insurer has denied these services stating there is no clinical/ radiographic evidence, such as traumatic injury or decay, provided to support the necessity of this service, the documentation is insufficient to approve treatment, and therefore the service does not meet medical necessity criteria. 

The only objective documentation provided for review is a copy of one bitewing radiograph. There are no other relevant dental treatment records provided for review. It appears that there is no evidence of fracture or other pathology specifically affecting #13 based on the image provided for review. There does not appear to be any radiographic evidence of caries. The radiograph does not substantiate the requested dental service as enumerated above and therefore the crown is deemed not medically necessary.

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

The insurer's denial of coverage for D2750, crown; porcelain to gold tooth #13 is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status asthmaticus.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is overturned.

 
The patient had severe status asthmaticus/acute severe exacerbation. This is the second hospital visit in a matter of 7 days. This was evident from the fact that the patient had an increased work of breathing (WOB) in spite of multiple bronchodilators. The patient needed Magnesium sulfate and also was having increased WOB even after that. The respiratory rate (RR) was 35 after the Magsulfate (Magnesium Sulfate). The plan was to observe for any worsening of respiratory status and if the status worsens, the patient could have been admitted to the PICU (pediatric intensive care unit). There is no prior PICU admission; however, given the summertime and with allergy season at its peak, and in absence of winter or RSV (respiratory syncytial virus), the patient needed 2 hospital visits back-to-back. The patient was adequately treated with scheduled nebulization and the patient was discharged. 

In studies of near fatal asthma in pediatrics, it is reported that risk factors are the summer season, "quiescent" asthma status, and a previous near recent hospital visit. The patient had all these risk factors. Asthma can be the acute cause of hypoxia. As hypoxia is the most common cause for pediatric cardiac arrests this patient was appropriately managed in inpatient status with adequate and appropriate respiratory support/intense bronchodilators. Due to the above factors, this patient with severe acute exacerbation and severe acute status asthmaticus needed inpatient level care.

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 inpatient services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis
Treatment: Otezla
The insurer denied Otezla.
The determination is upheld.

The patient has a past medical history (PMH) of psoriasis. Body surface area affected is 20% (percent). They tried and failed clobetasol. At issue is the medical necessity of the medication, Otezla, for treatment of psoriasis.

The requested health treatment of Otezla is not medically necessary for this patient. There is no documentation that the patient has tried and failed, has a contraindication to, or intolerance to the preferred treatments acitretin and methotrexate. According to the American Academy of Dermatology Psoriasis Guidelines and dermatology literature, the preferred medicines such as methotrexate covered by the patient's insurance plan are effective treatments for the management of psoriasis. (1, 2)

Within the peer-reviewed literature, West, et al, 2016 conducted a review of eleven comparative, controlled studies that passed a Cochrane risk of bias analysis. They concluded that methotrexate achieved significant improvement in reducing psoriasis plaques. Methotrexate is a preferred treatment, and based on data analysis, 45.2% [95% confidence interval 34.160.0] of patients achieve Psoriasis Area and Severity Index (PASI75) at primary endpoint, thus, methotrexate is an effective first-line treatment for the management of psoriasis. (3)

The evidence-based literature is consistent. The preferred agent methotrexate is appropriate for the treatment of the patient's psoriasis. Methotrexate should be tried and failed prior to initiating Otezla. It is noted that the patient has tried and failed clobetasol. However, after review of the clinical documentation, there is no documentation provided that would justify the patient requiring treatment with Otezla prior to the plan preferred alternatives such as methotrexate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia.
Treatment: Home health care.
The insurer denied Personal Care Aide (PCA) Services: 12 Hours per Day, 7 Days per Week and 12 Hours per Day, 7 Days per Week - Total Amount of 168 Hours per Week (Split Shift). 
The health plan's determination is overturned. 

The patient is a male with past medical history of dementia, functional quadriplegia, urinary incontinence, dysphagia, history of cerebrovascular accident (CVA), history of intracranial hemorrhage, hyperlipidemia, depression, chronic kidney disease, and chronic oxygen therapy who had been assigned PCA (personal care aide) services.

Personal Care Aide (PCA) Services: 12 Hours per Day, 7 Days per Week and 12 Hours per Day, 7 Days per Week - Total Amount of 168 Hours per Week (Split Shift) are medically necessary for this patient. 
There is documentation from the patient's medical provider of medical necessity of increased PCA services. The patient requires total assistance with all activities of daily living (ADL) and Instrumental activities of daily living (IADL) except for phone use. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. Overnight care logs document the patient's assistance needs with ADLs in the overnight hours such that a PCA would not be able to obtain at least 5 hours of uninterrupted sleep. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The plan incorrectly assumed that the patient's wife could provide informal help for all of the hours outside of the currently assigned PCA service hours. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 12 Hours per Day, 7 Days per Week and 12 Hours per Day, 7 Days per Week - Total Amount of 168 Hours per Week (Split Shift) are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in his own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dyspnea 
Treatment: Inpatient Hospital Admission
The insurer denied the Inpatient Hospital Admission
The determination is upheld.

The patient has past medical history significant for hypertension, severe obstructive sleep apnea, and morbid obesity who presented to the hospital with complaints of shortness of breath, leg pain, and back pain for 1 day. The patient stated that they had these symptoms for a while, but they acutely worsened within the 1 day before presentation. The patient also complained of left leg pain and felt like someone was "twisting it". The patient stated that they were able to ambulate with a cane until their leg pain worsened. The review of systems was positive for chest pain and shortness of breath. The patient described chest pain as substernal chest pressure and stated that they had that for several days.

Upon initial evaluation in the emergency department, the patient was hemodynamically stable. An electrocardiogram (EKG) demonstrated normal sinus rhythm. Cardiac enzymes were checked in the emergency department and remained negative. An echocardiogram demonstrated normal left ventricular structure and function. It was also mentioned that the psychiatry service was consulted due to the patient's complaint of auditory hallucinations. The physical exam noted the patient was afebrile, heart rate was 92 beats per minute (bpm), respiratory rate 18 breaths per minute, blood pressure 121/91, and oxygen saturation 97% on room air. The patient was in no acute distress. At issue is the medical necessity of the inpatient hospital admission.

The requested health service/treatment of inpatient hospital admission was not medically necessary for this patient. The patient presented to the hospital with chest pain and dyspnea, which were not associated with hemodynamic instability or respiratory distress. There was no clinical evidence that the patient had angina or myocardial infarction. The chest pain and dyspnea were not indicative of a serious diagnosis other than coronary artery disease. The bilateral lower extremity edema was relatively mild and was not related to acute congestive heart failure (CHF) or venous thromboembolism. The patient's hallucinations were not associated with acute psychosis or suicidal or homicidal ideations. The patient did not need inpatient psychiatric treatment.

There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at a lower level of care. Overall, this patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the Inpatient Hospital Stay. 
The determination is upheld. 

This is a female patient with complaints of 3 days of abdominal pain who was sent from an outside hospital to rule out (r/o) appendicitis. An ultrasound (US) of the appendix was not able to visualize the appendix and an ultrasound of the pelvis was normal. The patient received Ceftriaxone/Flagyl. She had nausea and received anti-emetics. She was admitted to pediatrics given the clinical exam with significant right lower quadrant (RLQ) tenderness. A repeat US showed upper limit of normal appendix. The white blood cell count (WBC) count was normal at 9.12. She had a diagnosis of acute appendicitis. Intraoperatively, there was insufflation of the preperitoneal space and a single port appendectomy was performed. At issue is the medical necessity of an inpatient stay. 

No, an inpatient admission was not medically necessary for this patient. This patient could have been treated at a lower level of care. (1, 2, 3). The patient did have pain postoperatively documented in the nursing notes which may have precluded same day discharge; however, a lower level of care would have been appropriate. 

Studies have shown that same day discharge is not associated with adverse outcomes in pediatric patients. Another study showed that same-day discharge after laparoscopic appendectomy for uncomplicated appendicitis in community hospitals, even after pediatric unit closure, is safe and feasible. The decrease in postoperative length of stay (LOS) and the increase in same day discharge (SDD) are not associated with higher complication rates (2). 

Therefore, given the history and diagnosis of uncomplicated appendicitis, this patient would qualify for observation status and evaluated for early/same day discharge.
Appeal type: Medical necessity
Decision: Overturned

Skin
Inpatient hospital

Diagnosis: foot ulcer
Treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned. 

This is a case of a male admitted for diagnosis of left foot cellulitis and diabetic foot ulcer. The patient presented with chief complaint of presentation from clinic for worsening diabetic foot ulcer. He had prior magnetic resonance imaging (MRI) which was negative for osteomyelitis and an incision and drainage was performed by podiatry. He was treated with intravenous antibiotics. He was then seen in the podiatry office on the day of admission as he was felt to need more intravenous (IV) antibiotics. 

The inpatient stay was medically necessary. In the setting of dead or injured bone and/or infected fluid collections, surgical debridement (and revascularization, in some cases) is a cornerstone of therapy. Antimicrobial therapy alone is not effective for cure of infected, necrotic bone. In addition, antibiotic penetration into bone may be unreliable in patients with arterial insufficiency or prior scarring associated with trauma.
Surgical debridement also allows placement of local antimicrobials, either applied directly to the site of infection or mixed with absorbable (eg, calcium sulfate) or nonabsorbable (eg, polymethyl methacrylate cement) carriers."

The patient in this case underwent repeat imaging of the foot and acute osteomyelitis could not be excluded. The patient was planned to undergo surgical intervention in the operating room and aggressive intervention to this level would not be reasonable at the observation level of care. He also had tachycardia, leukocytosis, hyperglycemia and elevated C-reactive protein (CRP). It is usually recommended to withhold antibiotic therapy until bone culture data is available but infectious disease recommended vancomycin and zosyn upon admission due to his condition. He was also recommended to have vascular surgery consultation for vascular evaluation. It was documented that the patient was counseled on the risk with leaving against medical advice and there is no evidence that the early discharge was any fault of the treating facility.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Migraines

Treatment: Trigger point injection

The insurer denied coverage for pain injections (64405, 20553) x 1.

The denial is reversed.

This patient has a history of chronic migraines and trigger points (TP) in her neck.  It is clearly documented that the pain is severe and follows the course of the occipital nerve with notable allodynia.  She also has the diagnosis of occipital neuralgia.  The request is for trigger point injections and occipital nerve blocks.	

Robbins et al. (1) "When performed in the appropriate setting and with the proper expertise, TPIs [trigger point injecestion] seem to have a role in the adjunctive treatment of the most common headache disorders."

Calandre et al. (2) examined the prevalence of TPs in migraine, which were found in 94% as compared with 29% of controls. The number of TPs was related to both attack frequency and disease duration. The majority of TPs were found in the temporal and sub-occipital areas.

The patient has severe disabling pain with a clear diagnosis of occipital neuralgia as well as trigger points in her neck.  Both requested procedures are medically reasonable and necessary.

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 pain injections (64405, 20553) x 1 is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Hyperglycemia.
Treatment:  Inpatient admission.

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

The adult with diabetes mellitus (DM) and sickle cell disease presented to the hospital with an uncomplicated pain crisis. His blood sugar (BS) was above 400 without signs of diabetic ketoacidosis (DKA)/ Hyperglycemic Hyperosmolar Nonketotic Coma (HONK). His serum creatinine (CR) was 1.4 from baseline 0.8. He was treated with hydration, insulin and admitted. He improved and was discharged 2 days later.

This individual presented with an uncomplicated pain crisis. While his blood sugars were poorly controlled, he was not in DKA nor HONK and did not require an acute level care for the uncomplicated hyperglycemia. This individual could have been managed in a lower level of care. As this patient had a condition that could reasonably be expected to be stabilized within 24 hours, observational status would be appropriate.

"Generally, a person is considered to be in inpatient status if officially admitted as an inpatient with the expectation that he or she will remain at least overnight. The severity of the patient's illness and the intensity of services to be provided should justify the need for an acute level of care. An inpatient admission solely because the patient has been kept in observation status over 23 hours would not be considered medically necessary." (American Health Information Management Association, 2018)

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

The medical necessity for the inpatient hospital admission is not substantiated.