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

Diagnosis: Immune Checkpoint Inhibitor Hepatitis.
Treatment: Inpatient Stay.
The insurer denied the inpatient stay.
The health plan's determination is upheld.

The patient is a female receiving Pembrolizumab as a component of therapy for inflammatory triple negative breast cancer who developed neutropenic fever secondary to Staphylococcus aureus. The patient developed fatigue and nausea while receiving outpatient Oxacillin and presented for evaluation. The patient had a decreased oral intake and had experienced syncopal events. At the time of presentation, the patient was noted to have transaminitis it was felt to possibly be secondary to the Pembrolizumab. She was admitted for inpatient care. The patent was started on steroids and was ultimately discharged.

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

The health service and treatment of an inpatient stay was not medically necessary for the patient. The patient had grade 2 toxicity from checkpoint inhibitor therapy. In this setting, there are no recommendations for hospitalization. The treatment administered which was steroids and withholding the checkpoint inhibitor does not require inpatient care. Monitoring of the liver tests also do not require inpatient care. Similarly, the other presenting complaints were addressed primarily with supportive care. 

Amongst other interventions that might mandate inpatient care, the patient didn't require intensive nursing, parenteral narcotics, hemodynamic support, or surgery. For these reasons, data supporting inpatient care is parse in both national guidelines, the peer-reviewed literature, and in UpToDate. Medical necessity cannot be established for this hospitalization.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bronchiolitis

Treatment: inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is overturned

This is a baby with chronic lung disease/bronchopulmonary dysplasia (CLD /BPD) presented to the emergency room (ER) with complaints of increased work of breathing (WOB) and tachypnea. The physical examination revealed an increased work of breathing, tachypnea, retractions, and congestion. Oxygen saturation was 80% (percent). Oxygen supplementation was provided, and oxygen saturation level increased to 100%. The patient was given saline nebulizers and oxygen via high flow nasal cannula (HFNC). The patient was admitted to the Pediatric Intensive Care Unit (PICU) with bronchiolitis. HFNC was gradually weaned. The patient remained stable on room air with an oxygen saturation level of 97%. The chest x-ray (CXR) was unremarkable. The patient was discharged. 

The child was born prematurely at 27 weeks with chronic lung disease /BPD. The patient has a poor pulmonary reserve. The patient presented at 2nd day of onset of symptoms. Peak symptoms of bronchiolitis present on the 3rd or 4th day. Hence, admission to hospital was appropriate. The patient had hypoxia, lethargy, increased WOB and was at risk of respiratory failure and cardiac arrest. The patient was on HFNC and severely hypoxic at 80 %. The patient needed hypertonic saline nebulizers and required monitoring in the PICU setting, particularly with prematurity, months and history of bronchopulmonary dysplasia. The admission to the acute care setting is justified as patient could rapidly decompensate to respiratory failure /cardiac arrest due to above risk factors. 

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 the inpatient hospital admission services is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes Mellitus
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is overturned

The patient is an adult with a history of uncontrolled diabetes who presented to the Emergency Department (ED) for infection and abscess of the right heel unresponsive to outpatient conservative measures and prior ED admission.  The patient exhibited uncontrolled pain for the last few days. Upon presentation, the patient's vital signs were stable but pain level was 10/10 and the patient appeared to be in acute distress, despite extensive use of narcotics.  A Podiatry consult was obtained, and records indicate that 3 cc (cubic centimeters) of purulence was expressed from the deep space infection, from what appeared to be a puncture wound to the area.  The patient was unsure how the infection came about. Blood work revealed mildly elevated White Blood Cells (WBC), as well as erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). Cultures were sent and came back as a methicillin sensitive staph aureus (MSSA) infection.  The patient was started on broad spectrum intravenous (IV) antibiotics prior to narrowing it to Unasyn. Due to concerns of osteomyelitis, the patient was admitted for further treatment and imaging. A follow up magnetic resonance image (MRI) revealed osteomyelitis. Concerns regarding vascular impairment were followed up with arterial studies.  A Physical Therapy consult revealed the patient would need to be managed at a subacute rehab.  On hospital day 2, the patient's white blood cell count (WBC) elevated to 11.8 prior to trending back down to the 7-8 range. Of note, the patients Hemoglobin A1C (glycated hemoglobin) was above 10.

The patient was an uncontrolled diabetic with elevated inflammatory markers and WBCs. In addition, the degree of uncontrolled pain and need for multiple narcotics further support inpatient admission.  

Diabetic foot infections can be life threatening and patients with these infections consistently suffer from a plethora of underlying conditions that require a multi-specialty approach to treat.  As such, timing and surgical intervention is crucial, which was the case in the presentation of this patient, who had to be admitted and consulted by various specialties, thereby making this a justified admission. Furthermore, due to diabetes patients with an infection may never "mount a robust systemic response," thereby complicating factors that may be deemed as necessary for admission, which again justifies the reasoning behind the admission.

The insurer's denial should 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 admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male who presented to the emergency department after a 15 minute episode of chest pain. His medical history was remarkable for coronary artery disease, myocardial infarction, percutaneous coronary intervention, coronary artery bypass graft surgery, hypertension and hyperlipidemia. By the time of presentation to the emergency department (ED), his chest pain had resolved. 

Based on the documentation provided an inpatient hospital admission was not medically necessary.
This man, with known coronary artery disease, presented with symptoms that were thought to be suspicious for acute coronary syndrome (ACS). Accordingly, observation until ACS could be ruled out was a reasonable approach. However, his chest pain had resolved by the time he presented to the ED and he had no further pain while hospitalized. He was hemodynamically stable, with normal cardiac biomarkers, and no acute electrocardiographic changes. He did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received for his chest pain did not require an inpatient admission and could have been provided under "observation" status. This approach has been shown to be both safe and cost-effective and is in accordance with current guidelines.
Upon presentation, the patient had an elevated serum creatinine level. There were no associated significant electrolyte abnormalities and his renal function improved with intravenous hydration. An inpatient level of care was not warranted on this basis.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atrial fibrillation

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned.

 
This is the case of an adult that presented to the hospital complaining of chest pain on exertion accompanied by dyspnea. The patient had no significant past medical history. On arrival to the hospital the patient was tachycardic with an irregular pulse of 142.  Blood pressure was 132/80. Physical examination was significant for a Body Mass Index (BMI) of 50 and bibasilar crackles. 12 lead electrocardiogram revealed atrial fibrillation with rapid ventricular rates. Serum blood testing revealed no elevation in troponin and normal thyroid function. The patient was admitted to the hospital for monitoring and treatment. Exercise perfusion study revealed no evidence of ischemia. Ultimately transesophageal echocardiogram and direct current (DC) cardioversion were successfully performed, and sinus rhythm was restored. 

Admission for monitoring and treatment was medically necessary. Patients presenting with atrial arrhythmia with ventricular rates up to 140 require acute therapy and further monitoring to ensure that medications control heart rate and rhythm without producing significant bradycardia. An analysis of 68 million Medicare patients admitted to the hospital for atrial fibrillation over a fifteen-year period demonstrated an average length of stay of 3 days. (Reference 1) This analysis also demonstrated decreased mortality and readmission rates following admission to the hospital. American Heart Association/American College of Cardiology Guidelines for the management of patients with atrial fibrillation recommend telemetry monitoring for patients treated with atrial fibrillation requiring treatment with rate control and antiarrhythmic therapies. The current standard of care is consistent with hospital admission when patients present with symptomatic rapidly conducted atrial fibrillation. This patient required both ischemia work up and DC cardioversion following presentation.

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 a hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Autism Spectrum Disorder.

Treatment: Physical therapy (PT) services.

The insurer denied coverage for PT services.

The denial is upheld.

This is a child with a diagnosis of Autism Spectrum Disorder (ASD). Treatment included several years of PT services, which is currently under review. 

The physical therapy treatment notes made available for review do not support the medical necessity of continuing a structured out-patient physical/occupational therapy treatment program for the time period under review. The patient has received several years of physical and occupational therapy treatment for the same condition. After several years of treatment, the patient's parents are well versed in the provision of a home exercise program (HEP). As documented in the physical therapy note, the patient's parents "continue to work on HEP for Lower Extremity/Upper Extremity (LE/UE) and core strengthening, balance, gait, locomotor activities and bilateral coordination activities with the patient consistently."  This physician would agree that "HEP needs to be continually monitored and adjusted by a skilled professional in order to modify movement for proper alignment." As a result, having the patient evaluated by the physical therapist during intervals of not more than quarterly; to modify the HEP as necessary would be clinically appropriate. 

Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board, and associations. All decisions are evidence-based. 

From a physical medicine & rehabilitation perspective, as well as within a reasonable degree of medical certainty, PT services were 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 physical therapy (PT) services is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tracheobronchiomalacia with Tracheostomy and Dysphagia.
Treatment: home health care.
The insure denied Private Duty Nursing to be Provided by a Licensed Practical Nurse: 24 Hours per Day, 7 Days per Week.
 The health plan's determination is overturned. 

The patient is a former premature infant with a tracheostomy who has been ventilator dependent. He has bronchopulmonary dysplasia as well as tracheobronchomalacia. 

Private Duty Nursing to be Provided by a Licensed Practical Nurse: 24 Hours per Day, 7 Days per Week is medically necessary for this patient.
This is a very young boy with a complex medical history including extreme prematurity, bronchopulmonary dysplasia, and a tracheostomy who recently presented in respiratory distress and required admission to the intensive care unit for respiratory support. He has intensive medical care needs outlined by his physician and his pulmonologist including frequent pulmonary toilet and suctioning which is required even more frequently when he becomes ill. Both his physician and his pulmonary specialist recommend continuation of 24 hour 7 day a week nursing care at least for the next month, and assert that an abrupt changes to his nursing care is not safe.
Children with tracheostomies as well as chronic lung disease are at risk for several problems which represent true medical emergencies that can make it hard or impossible for the child to breathe. These emergencies can include the tracheostomy getting clogged with mucus and it getting dislodged by accident and coming out. Proper medically-directed care is required in order for children with tracheostomies and complex medical histories to remain safely at home.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: ADHD (attention deficit hyperactivity disorder)
Treatment: Daytrana
The insurer denied Daytrana.
The determination is upheld.

The patient is a male with a history of attention deficit hyperactivity disorder (ADHD). He has been on Daytrana patch to control his symptoms. At issue is whether the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug Daytrana patch, or would have adverse effects.

The patient is currently receiving Daytrana patch, which is effective for his ADHD symptomatology. It is noted that the patient has trouble swallowing. Formulary medications include amphetamine-dextroamphetamines mixed salts, dexmethylphenidate, methylphenidate, Azstarys, Jornay PM, Mydayis, and Vyvanse. While Daytrana is a Food and Drug Administration (FDA) approved medication used to treat ADHD, there are other available formulary agents that may be administered in a chewable format or sprinkled and thus would be as effective as the non-formulary drug Daytrana and would not be expected to have adverse effects.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Non-traumatic cervical spinal cord injury secondary to hemangioma
Treatment: 16,800 units (84 hours) of personal care services (PCS) each week
The insurer denied coverage for 16,800 units (84 hours) of personal care services (PCS) each week.
The denial is overturned.

This is a patient with multiple medical problems that include Parkinson's disease, osteoarthritis and status cervical spine surgery. She lives with her son in a 2 bedroom apartment. The patient is approved for PCS 42 hours/week and requesting 84 hours/week, which is under review.  

According to the Uniform Assessment System (UAS) report, the patient is fully alert, oriented and modified independent cognitive skills. She requires maximal assistance for bathing and dressing. Extensive assistance is needed for personal hygiene, and toilet use. Limited assistance is needed for ambulation (with a walker; poor endurance and unsteady gait), bed mobility and toilet transfer. She is frequently incontinent of bladder and continent of bowel. The patient's impairments and continuing functional decline support the medical necessity of increasing PCS to 84 hours/week (16,800 units). Of particular concern is her deteriorating functional ability, poor balance and unsteady gait. Based on the enclosed documents reviewed, the patient's health and safety can be more appropriately provided and maintained by the requested increase PCS, 84 hours per 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 16,800 units (84 hours) of personal care services (PCS) each week services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission 

The denial is upheld

The patient is an adult with a past medical history of asthma and opioid use who presented to the emergency department (ED) with complaints of shortness of breath (SOB) and wheezing for 3 days. Vital signs at presentation were normal and the oxygen saturation was 98% on room air. The patient was in no acute distress. Peak expiratory flow (PEF) was 270. Lung exam revealed wheezing, heart sounds were normal. The patient was awake and alert and had a non-focal neuro exam. White Blood Cells were 7,000, electrolytes normal and arterial blood gasses 7.53/35/155/28. Chest x-ray showed no infiltrates and his electrocardiogram demonstrated normal sinus rhythm without acute changes. Urine toxicity was positive for Methadone, Opiate, and Cocaine.

The patient was treated with duo nebulizers, Magnesium and intravenous (IV) steroids.
As he continued to wheeze, he was admitted to the hospital for asthma exacerbation.

Patient remained stable after admission. He was complaining that he was not getting enough pain medications and he signed out against medical advice (AMA) after a few hours. This patient did not need acute inpatient hospitalization. He could have been placed in Observation status while diagnostic testing and treatment were initiated. He was tolerating food and fluids. There was no pneumonia or pleural effusion.

This patient could have been placed in observation status (which could be for up to 48 hours) and once he remained stable he could be discharged home on oral medications with close follow up in an outpatient setting.

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: Crohn's Disease
Treatment: Stelara infusion every six weeks
The insurer denied coverage for Stelara infusion every six weeks
The denial is overturned 

The patient is a child with a past medical history notable for refractory Crohn's disease (CD) recently diagnosed. His course has been complicated by perianal fistulizing disease with resulting scrotal abscess. He has been managed with biological medications with the following sequence:

1.	Remicade - stopped secondary to allergic reaction (anaphylaxis)
2.	Humira - stopped secondary to failure to respond
3.	Stelara - loading dose 280 milligram (mg) with subsequent 90 mg doses every (q) 8 weeks 

In addition to Stelara he remains on Pentasa 1000mg twice each day (BID) and vitamin D supplementation. He has had a clinical response to Stelara with normalization of inflammatory markers - C reactive protein (CRP) 0.83 and erythrocyte sedimentation rate (ESR) 4. His drug level was 5.2 micrograms/milliliter (ug/ml) and neutralizing antibody was non-detectable. He was noted on a follow-up video visit to have fatigue, decreased appetite and abdominal pain (similar to his presenting symptoms) starting 6 weeks after his last Stelara infusion that resolves within 24 hours of his subsequent infusion. For this reason, his treating team is requesting dose escalation to 90 mg q 6 weeks.
 
This patient's diagnosis is medication refractory CD partially controlled on Stelara 90mg q 8 weeks. His recurrent symptoms at 6 weeks post infusion with response within 24 hours of the subsequent infusion certainly suggests that dose escalation is needed. 

Medical necessity of off-label use of medications in pediatrics - Use of second-line biologic agents and/or escalation of doses beyond those approved by the Food and Drug Administration (FDA) may be appropriate and medically necessary for selected children with CD. The decision should be based on individual patient characteristics and clinical judgement by an expert clinician. According to a position statement by the American Academy of Pediatrics: "The purpose of off-label use is to benefit the individual patient. Practitioners use their professional judgment to determine these uses. As such, the term 'off-label' does not imply an improper, illegal, contraindicated, or investigational use. Therapeutic decision-making must always rely on the best available evidence and the importance of the benefit for the individual patient".

Substantial evidence supports a role for dose escalation, therapeutic drug monitoring, and utilization of drugs that are approved for adults in the management of pediatric CD. In many cases of refractory irritable bowel disease (IBD), off-label use is medically necessary and is in the patient's best interest. In addition, the use of dose escalation is supported by the Crohn's & Colitis Foundation.

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

The insurer's denial of coverage for Stelara every 6 weeks is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Laryngeal cancer

Treatment: Laryngoscopy

The insurer denied coverage for inpatient admission

The denial is overturned

This is an adult with a history of subglottic carcinoma of the larynx, tracheostomy, tracheal cutaneous fistula, and a percutaneous gastrostomy. At the time of admission, she was noted to have bleeding through a tracheal cutaneous fistula. She was hospitalized for preoperative stabilization before a planned laryngoscopy. She was documented to have an American Society of Anesthesiology (ASA) score of 3. She underwent the planned laryngoscopy under general anesthesia and was discharged from the hospital the same day.

The Milliman Care Guidelines (MCG) 24th Edition Ambulatory Surgery Exception Criteria GRG: CG-AEC (ISC GRG) Clinical Indications for Admission to Inpatient Care stipulates that one or more of several conditions for inpatient care.  The patient had a least two (2) of   these conditions. These were:

1)ASA score of 3
2)Preoperative bleeding at the site of the tracheal cutaneous fistula. 

The patient was documented as having bleeding at the site of the tracheal cutaneous fistula which required observation before the laryngoscopy could be safely carried out the next day. She was an ASA 3 which has been documented as a reason for inpatient care[1].

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.