Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Epilepsy.
Treatment:  Modafinil. 
The insurer denied Modafinil.  The health plan's determination is upheld. 

The patient is a female who has a listed diagnosis of epilepsy.  Cognitive dysfunction is also listed.  An appeal letter states that the patient has a static encephalopathy secondary to a traumatic brain injury, with associated concentration issues, adding that amphetamines would lower seizure threshold.  Modafinil is being requested. Another form reports sleep related issues.

Modafinil 100mg is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

There is no treatment proven to be effective for the patient's condition as described.  Modafinil is not proven helpful, despite some evidence from small, short studies.  There is minimal evidence from high quality peer reviewed literature, large, well designed, blinded, randomized trials to support long term safety and efficacy of the requested drug, modafinil for posttraumatic concentration, behavioral, cognitive and sleep related issues.  Small studies such as the ones by Kauser et al., and Castriotta et al. one decade ago suggested possible benefits, but as recently as 2019 Barra et al. indicated that future prospective studies were needed "to evaluate the safety, optimal dose range, and efficacy of stimulant therapies in this population", thereby underscoring the current lack of evidence for widespread use of such therapies.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Epilepsy.
Treatment:  Modafinil. 
The insurer denied Modafinil.  The health plan's determination is upheld. 

The patient is a woman diagnosed with epilepsy and cognitive dysfunction.  Treatment with modafinil is the subject of this review.  Modafinil is ordered for treatment of "focusing" problems related to a traumatic brain injury.  In the past, the patient was diagnosed with attention deficit hyperactivity disorder (ADHD) and treated with a stimulant such as Adderall.

Modafinil 100 mg is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.  In a randomized, placebo-controlled, multicenter trial of 117 adults with a history of TBI, baseline Epworth Sleepiness Scale (ESS) score >=10, and sleep latency less than eight minutes on a multiple sleep latency test (MSLT), patients treated with armodafinil 250 mg daily for 12 weeks showed significant improvement in sleep latency compared with placebo (+7.2 versus +2.4 minutes). Similar results were reported in a smaller randomized trial of modafinil.  Modafinil and armodafinil were well tolerated in both trials.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: New onset diabetes

Treatment: Inpatient admission

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

This patient is a male with a history of new onset diabetes. The patient presented to the Emergency Room (ER) with polyuria and polydipsia for the last several months. The patient denied and nausea, vomiting or impaired consciousness. Vital signs were normal. The exam was unremarkable. The patient was diagnosed with type 2 diabetes by his primary care provider (PCP) several months prior and was started on Metformin. The patient's basic metabolic panel (BMP) showed elevated blood sugar at 731 mg/dL, CO2 26, creatinine 1.1, BUN 12 and an anion gap of 17. Serum ketones negative. The patient's serum osmolality was 311, and the patient's urine analysis (UA) was positive for glucose and ketones. The patient was admitted for hyperglycemia.  The patient was given intravenous fluids, insulin and electrolyte replacement and monitoring. The patient's Hg A1C was noted to be elevated at 15.5%. The patient was discharged with follow-up with his primary care doctor as outpatient.	

Based on the review of the medical record, the patient presented with elevated blood sugar, anion gap, and ketones in his urine. However, there was no evidence of ketoacidosis or hyperosmolar syndrome. The patient could have been observed and treatment reinitiated with reinforced teaching. This did not require acute inpatient care.  Thus, the inpatient admission was not medically necessary.

The health care plan did act reasonably with sound medical judgment and in the best interest of the patient.

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

Diagnosis: Gastroenteritis

Treatment: Inpatient hospital

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

This patient is a male who presented to the Emergency Department (ED) with abdominal pain. The patient was noted to have tachycardia. On exam, there was no abdominal rebound or guarding. The patient's white blood cell (WBC) count was initially 9.5, and the patient's computed tomography (CT) scan of the abdomen and pelvis was read as negative. Several hours later in the ED, the patient's heart rate went up to 121 beats per minute, and the patient's temperature spiked to 102.2. The patient's WBC count went up to 15.6, and the review of the CT scan was now read as thickening of the right colon and concern for possible colon cancer. The patient's colonoscopy revealed erythematous mucosa and the patient was felt to have an infectious colitis.

According to the MCG clinical criteria for inpatient admission for gastroenteritis (M-170), the clinical indications include a suspected severe infection such as bloody diarrhea, severe abdominal pain; peritoneal signs, hemodynamic instability, severe vomiting, and severe dehydration. The patient did not have these clinical conditions. The patient had increased tachycardia and fever while in the emergency room (ER). However, later that day, the patient was no longer tachycardia and the temperature came down to 99.8.

This patient had a gastroenteritis and required intravenous (IV) hydration. The patient's fever responded to Tylenol. The patient's lactate level was normal at 1.2. The patient did not meet MCG criteria for admission for gastroenteritis, and could have been managed with observation status. If antibiotics were felt to be necessary, the patient could have been given oral antibiotics to be treated as an outpatient. The patient's colonoscopy could have been done as an outpatient, as the patient's abdominal pain did not require inpatient surgical intervention. The inpatient admission was not medically necessary to treat this patient's medical condition.

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

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

Diagnosis: Respiratory System, Cough 
Treatment: Inpatient hospital 

The patient with a past medical history significant for hypertension, congestive heart failure (CHF), dyslipidemia, obstructive sleep apnea on continuous positive airway pressure (CPAP), asthma, morbid obesity, and nephrolithiasis. The patient came to the emergency department with complaints of a cough for 4 days. The patient reported symptoms of a common cold that included a runny nose, excessive sneezing, and headaches. The cough was initially dry, but subsequently, started to cough up yellow, foul-smelling mucus. The health plans determination is upheld in whole. 

The requested health service/treatment of inpatient hospital stay was not necessary in this case based on the severity of the patient's condition and intensity of the services provided. 

This patient presented to the hospital with complaints of shortness of breath and productive cough. At the time of the initial evaluation, the patient remained in a stable clinical condition. At the time of admission and throughout the hospital stay, this patient was afebrile and hemodynamically stable, had normal respiratory rate and oxygen saturation on room air. The physical exam was reassuring, and the chest x-ray did not show any evidence of acute abnormalities including pneumonia. 

According to Merck Manual Professional Version, "Acute bronchitis is inflammation of the tracheobronchial tree, commonly following an upper respiratory infection (URI), that occurs in patients without chronic lung disorders. The cause is almost always a viral infection. The pathogen is rarely identified. The most common symptom is cough, with or without fever, and possibly sputum production. The diagnosis is based on clinical findings. Treatment is supportive; antibiotics are usually unnecessary. Prognosis is excellent." 

This patient was in stable clinical condition at the time of admission and throughout the entire hospitalization. Therefore, the inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sickle cell pain crisis
Treatment: Inpatient admission for acute level of care 
The insurer denied coverage for inpatient admission for acute level of care. 
The denial is reversed. 

This patient is a male child with known sickle cell disease and history of multiple hospitalizations who presents with severe pain consistent with sickle cell pain crisis.  The patient tried home analgesia that was insufficient to control his pain and presented to the Emergency Department (ED) with 10/10 pain.  Intravenous (IV) analgesia in the ED helped mitigate pain and patient was hospitalized for further analgesia and management.
 
According to InterQual criteria: "Patients with [vaso-occlusive crisis] VOC present with severe pain.  The diagnosis is based upon the history and physical examination.  Laboratory tests are not useful to confirm the disorder.  Analgesic administration should be individualized based on the patient's home regimen.  Aggressive and timely pain management is key to rapid resolution of VOC.  In order to avoid under-treatment of pain, use of patient controlled analgesia if age appropriate or scheduled analgesic administration is recommended.  
Additional supportive measures include hydration..."

It is commonly understood and widely published that in children and young adults with sickle cell disease the description of pain is often the only sign of sickle cell crisis.  As such, for a patient in whom ambulatory analgesia has not been sufficient, hospitalization for management of pain is standard of care.  Hospitalization for management of pain with IV analgesia, IV hydration and to monitor for escalation of care as needed was within standard of care.  The prior denial is reversed.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The inpatient admission for acute level of care was medically necessary.

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

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Stay. The insurer denied the Inpatient Hospital Stay. 
The denial was upheld.

This is a patient with a past medical history (PMH) of major depressive disorder (MDD), human immunodeficiency virus (HIV), congenital portal vein obstruction, hypertension (HTN), immune thrombocytopenic purpura (ITP), biliary stricture, Roux-en Y hepaticojejunostomy, splenic artery ligation and chronic splenic infarct who was admitted with complaints of (c/o) left upper quadrant (LUQ) abdominal pain, similar to a prior admission several months before. Vital signs were unremarkable. The physical exam was notable for mild LUQ tenderness. Lab work was notable for platelets of 52. A computed tomography (CT) scan of the abdomen/pelvis showed a suspected thrombosis of the right portal vein. The patient was diagnosed with chronic portal vein thrombosis, without a new infarct, and hematology/oncology was consulted. However, they recommended against treatment given the patient's thrombocytopenia. The patient was discharged in stable condition.

This patient with a history of chronic portal vein thrombosis presented to the ED with c/o LUQ pain similar to prior admission several months prior. The patient did not have mental status changes, recent abdominal surgery, fever, leukocytosis, or severe/persistent vomiting, or bowel obstruction. The patient's imaging demonstrated suspicion for portal vein thrombosis without new infarction, which is consistent with the patient's known history of chronic portal vein thrombosis. In addition, no treatment was recommended due to the patient's chronic thrombocytopenia. The patient was hemodynamically stable in no apparent distress (NAD) and non-toxic appearing, did not require acute surgical intervention, did not have peritoneal signs, was able to keep fluids down, did not require intravenous (IV) antibiotics, and had no unstable co-morbidities requiring inpatient admission (such as myocardial infarction (MI), diabetic ketoacidosis (DKA)). Overall, this patient was treated with pain control and specialty consultations, which could have been safely provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal swelling
Issue under review: Inpatient admission
The health plan denied Inpatient admission.

Determination:
The health plan's denial is upheld.

The patient is an adult male. The patient has a history of congestive heart failure, ascites as a result of liver cirrhosis, asthma, alcohol dependence, and polysubstance abuse. The patient has had multiple prior admissions to the hospital for provision of a paracentesis. The patient presented with increasing shortness of breath and dyspnea as a result of abdominal swelling. He also had pedal edema, low blood pressure, tachycardia, and hypothermia with a sodium of 120. The patient had tenderness of the abdomen, raising suspicion of spontaneous bacterial peritonitis. The patient was admitted and underwent a paracentesis, and he was then discharged when deemed stable. 

The performance of repetitive large volume paracentesis for end stage cirrhotics does not require a full hospital admission. The patient did not evidence a fever, and spontaneous bacterial peritonitis can be ruled out by the analysis of the peritoneal fluids once removed. The patient had end stage cirrhosis, so a low sodium is baseline for the patient, as were his other findings and complaints, including a lower blood pressure. There was no cogent need for a full medical admission, as the entirety of the care as provided could have been rendered at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: overbite, crossbite
Treatment: braces
The insurer denied the braces.  The denial us overturned.

The Braces are medically necessary.  The patient presents with two "automatic qualifying" issues, per the handicapping index (2). First, she has a deep, impinging overbite. Her lower front teeth are biting into her palate behind her upper front teeth. Second, she has tooth #22 in buccal crossbite. When there is an anterior tooth in crossbite with attachment (gum) loss, this is a reason for orthodontic treatment. This patient has both qualifiers. Orthodontic treatment is medically necessary to correct these problems.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain (Appendicitis)
Treatment: Inpatient admission
The insurer denied the inpatient admission.  The denial is upheld.

The Inpatient admission was not medically necessary.

The patient is a female. Her medical history included congestive heart failure, hypertension, dyslipidemia, type-II diabetes mellitus, asthma, obesity, depression, anxiety, post-traumatic stress disorder, prior tobacco use, prior crack use, and prior heroin use. She presented to an emergency department with a three-to-five-day history of right lower quadrant abdominal pain, anorexia, nausea, and lightheadedness. 

The patient's vitals were temperature 98.0, pulse 97, blood pressure 141/73, pulse 18, saturations 97%. Examination demonstrated tenderness to palpation of the right lower quadrant of the abdomen. Serum laboratories demonstrated a normal white-blood-cell count of 7.8. Computed tomography demonstrated non-perforated appendicitis. 

The patient was admitted at an acute inpatient level care with a diagnosis of "Possible Beginning stages of Appendicitis." She opted for non-operative management. She was made nil per os [NPO]; and received intravenous fluids, antibiotics, analgesics, and anti-emetics; and underwent serial examinations and laboratories. 

Later, the patient reported resolved pain. She tolerated a regular diet. Having returned to her baseline health and function, she was discharged home in good and stable condition with outpatient surgical follow-up and oral antibiotics. 

According to peer-reviewed journal articles, patients with acute non-perforated appendicitis can be treated at a lower level of care [Di Saverio et al; Talan et al]. Indeed, most patients required fewer than 24 hours in a hospital. 

In accordance with the medical literature, admission at an acute inpatient level of care was not medically necessary. If surgery -- usually an outpatient procedure -- was not possible, the patient may have been effectively and safely treated with antibiotics at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain; shortness of breath
Treatment: Inpatient admission
The insurer denied the inpatient admission.  The denial is upheld.

The inpatient admission was not medically necessary.

This patient is a woman who underwent laparoscopic cholecystectomy.  She presented to the ED with worsening chest and abdominal pain and shortness of breath.  She was tender in the epigastrium and right upper quadrant.  Vital signs were normal in the ED.  Lab data identified significant elevation of serum transaminases and bilirubin.   The white blood cell (WBC) count was normal (6.8 K).  The patient was admitted to the hospital.  

A computed tomography (CT) scan of the chest showed no evidence for pulmonary embolism.  Ultrasound showed biliary ductal dilatation and no fluid collection in the area of cholecystectomy.  There was an echogenic focus in the mid common bile duct.  Magnetic resonance cholangiopancreatography (MRCP) showed biliary ductal dilatation.  There was clinical concern for choledocholithiasis (common bile duct [CBD] stones) so Gastroenterology (GI) consultation was obtained. The patient underwent endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy.  Lab data improved post ERCP and the diet was advanced.  The patient was tolerating a diet and her pain had improved.  She was considered to be stable for discharge.

The denial letter references MCG 23rd ed. Abdominal Pain, Undiagnosed.  Per these criteria, vital signs were normal, there was no bowel obstruction, dehydration, ongoing vomiting, or need for immediate surgery that required inpatient care.  Per the denial letter, the care provided could have been rendered with an observation level of care.

The available medical record includes the hospital records that correspond to the inpatient admission.  Based on this clinical data, the medical necessity of inpatient acute hospital care during this period of time is not established for this patient.  

This patient presented to the hospital with abdominal pain, chest pain and shortness of breath.  She was several days status post laparoscopic cholecystectomy.  She was hemodynamically stable in the ED with normal vital signs.  Lab data identified elevated liver enzymes and bilirubin.  GI consultation was obtained.  ERCP with sphincterotomy was not performed until day #3.  

The records support that this patient presented with a retained common bile duct stone.  She was hemodynamically stable with normal vital signs, no fever and a normal WBC count.  The care and treatment provided could have been rendered with a lower level of care (observation).  The medical necessity of inpatient admission is not established in this case.  While this patient presented with choledocholithiasis, there was no indication of cholangitis or other infection that required an inpatient designation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope

Treatment: Inpatient hospital admission

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

This patient is a male who presented to the Emergency Department (ED) with a complaint of a syncopal episode.  The documentation from the ED only included triage notes and nursing documentation.  The submitted notes do include on a specified date indicate that the patient had no relevant medical history and woke up that morning when he collapsed to the floor.  The patient was noted to have pain in his third finger.  The patient's physical examination revealed swelling to the left third finger with tenderness and limited range of motion.  The documentation indicated the patient had a dislocated finger that was reduced in the ED.  The patient's computed tomography (CT) scans of the head and of the cervical spine did not reveal any significant acute pathology or fracture. The patient was admitted to Telemetry for syncope. The patient was recommended additional monitoring but left the facility the following day against medical advice.

Based on the review of the medical records submitted, this patient had a syncopal episode at home. However, upon evaluation, the patient's neurological exam was within normal limits, and the patient's computed tomography (CT) of the head was negative for acute stroke. There was no documentation of acute motor, sensory or visual deficit that suggest an acute stroke. There was no instability, new focal neurological signs, acute stroke, hemodynamic or cardiovascular compromise or acute prolonged metabolic decompensation or seizure that warranted an inpatient admission as recommended per literature. The patient did not meet the MCG guideline for inpatient admission.  Therefore, from a neurological standpoint, the acute inpatient care admission was not medically necessary to treat this patient's medical condition. 

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

The carrier's denial of coverage for the inpatient hospital admission is upheld. The medical necessity is not substantiated.