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

The patient is a male who presented to the emergency room with complaints of left flank pain.  Past medical history is significant for right kidney stone status post lithotripsy.  Medical history is also significant for cardiomyopathy, diabetes, obesity, hypertension, congestive heart failure (CHF) and atrial fibrillation.  He was afebrile and hemodynamically stable on presentation.  Examination revealed trace edema and left costovertebral angle (CVA) tenderness.  Computed tomography (CT) scan showed a left 5 millimeter (mm) ureterovesical junction (UVJ) stone with moderate hydronephrosis.  Labs showed a white blood cell (WBC) count of 12.7 and a creatinine of 1.5.  The patient was admitted on the inpatient service.  The patient passed a stone.  He was discharged the next day in a stable condition.

The health plan's determination is upheld.

The inpatient stay was not medically necessary for this patient.  The majority of patients who present with renal colic can be discharged within 24 hours of the presentation.  This patient didn't present with hemodynamic instability, renal failure, severe obstruction, sepsis or unstable medical problems requiring inpatient management.  The hospital course was essentially normal without any significant complications or major issues with pain control.  There was no procedure performed.  The information provided and the patient's clinical status does not suggest the need for acute inpatient care. A lower level of care status for this patient's clinical presentation was the safe, effective, generally accepted standard and the most appropriate treatment option.  Admission status may be changed anytime if the patient requires continuing services and monitoring, and if the patient's condition is severe enough to require inpatient treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Uncontrolled pain
 
Treatment:  Inpatient admission, medication, monitoring

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

This is a male with a past medical history of diabetes type 2, psoriasis, Lyme disease, Methicillin-resistant Staphylococcus aureus (MRSA) in the bilateral lower extremities, bilateral below-the-knee amputation (BKA), kidney stones and deep vein thrombosis. The patient was brought to the emergency department with "pain all over," high blood sugar, left phantom leg pain and a 10-second syncopal episode.  His current pain level was 10/10.  The patient's blood pressure was 139/94 and his heart rate was 110.  He had psoriasis covering most of his body and stated that it was painful.  He reported that he had run out of his insulin.  The patient reported intermittent chest pain with pain down his right arm.  Laboratory studies revealed leukocytosis, negative troponin level and glucose level of 350 on arrival.  He was given 20 units of regular insulin.  Cardiovascular exam was normal.  He was noted to be stable.  Given the patient's current social situation and uncontrollable pain, he was admitted to medicine observation. 

The Milliman Care Guidelines indicates a hospital admission for pain management may be appropriate for patients with severe pain requiring acute inpatient management, including the need for intravenous opiate administration, as indicated by pain that is unresponsive to non-opioid analgesia and non-pharmacologic treatment, when oral, transdermal, or submucosal route would not be appropriate or insufficient, when anticipated hydration is not appropriate for a lower level of care, or when pain control regimen for the next level of care is not established, as sufficient pain control cannot be achieved.  The patient had been given Percocet followed by Flexeril for pain, which improved his symptoms.  The records failed to support the patient had a necessity for intravenous opiate titration or had a pain control regimen for the next level of care that was not established, as it was documented sufficient pain control had been achieved. The records failed to support that the patient's condition did not improve after the oral medications.  The records failed to support the necessity for a full admission. 

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

Diagnosis:  Cervical radiculopathy, discectomy and fusion
 
Treatment:  Inpatient admission, monitoring

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

This case involves a male with cervical and lumbar radiculopathy, hypertension, thoracic aortic aneurysm with repair, gastroesophageal reflux disease (GERD), neuropathy, and benign prostatic hyperplasia.  He had a body mass index 31.0 - 31.9.  The patient presented for a scheduled anterior cervical discectomy, decompression, and fusion of C5-C6 and C6-C7.  He had an American Society of Anesthesiologists Class III classification.  The patient had numbness and tingling in both arms and pain in his neck.  He underwent surgical intervention and was admitted post-operatively.  There were no complications noted.  A progress note from the next day noted the patient's finger numbness and pain had improved.  He remained stable the following day and had full motor strength.  He required a straight catheterization overnight and was referred to urology as an outpatient to address urinary retention issues that existed before surgery and persisted after surgery.

Milliman Care Guidelines indicate a cervical anterior discectomy and fusion would generally be performed on an ambulatory basis.  Criteria for ambulatory surgery indicate ambulatory surgery would be appropriate for a 1 or 2 level fusion at or below C3 without myelopathy and without the need for more than 24 hours postoperative observation.  An inpatient stay would be appropriate for a patient who is elderly, who undergoes a multilevel fusion with 3 or more levels, or for patients requiring extended postoperative observation with unstable comorbidities.  The goal length of stay would be one day. 

This patient underwent an anterior cervical discectomy and fusion at C5-6 and C6-7 with plate fixation at 3 levels, C5, C6, and C7.  This would be considered a 3-level fusion.  The patient did not have myelopathy, and the surgery was performed below C3. Although the patient's classification was ASA Class III, the surgical procedure would have been considered low risk, as it was an ambulatory surgery.

Based on the above, the medical necessity for the inpatient hospital admission is modified.  The first day is approved; the remainder of the stay is denied.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient admission
The Inpatient admission was not medically necessary.

This patient presented for evaluation of chest pain. The diagnosis of an acute MI (myocardial infarction) was ruled out by cardiac enzymes, which were negative. There was no evidence of acute myocardial infarction, ACS, decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability. His previous work-up included a coronary angiogram three to four months prior to this admission, and revealed no significant coronary artery disease on catheterization. No additional inpatient ischemic work-up was planned. The clinical information provided in the record submitted for review does not support medical necessity for this admission. The care required could have been provided at an observational level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
 
Treatment: Inpatient admission, medication, monitoring

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

The patient was a man with a past medical history notable for mitral valve prolapse status post repair, recent acute epididymitis, and recent acute appendicitis status post laparoscopic appendectomy two weeks prior. He presented to the ER with complaints of chest pain, abdominal pain, and hematochezia. Vital signs and physical examination were unremarkable. Hemoglobin and hematocrit were normal. Stool testing was positive for fecal occult blood. Troponin was negative. The patient was given Nexium and IV fluids in the ER and admitted to telemetry for chest pain. The pain resolved. Troponins were all negative. EKG was unchanged from baseline. The patient improved clinically and was discharged home. 

The patient presented with chest pain. However, the initial evaluation in the ER was unremarkable, including negative cardiac troponin and a non-diagnostic EKG. Inpatient admission was not medically necessary for this patient. In the absence of elevated cardiac biomarkers and a diagnostic electrocardiogram, the patient's care could have been provided in the observational setting, allowing for additional cardiac testing. Further evaluation was warranted, however inpatient admission criteria was not met.  Although the patient had new onset symptoms, medical policy criteria were not met for any other additional extenuating circumstances. There were no other high-risk co-morbidities.  

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

Diagnosis:  Schizophrenia 

Treatment:  Continued Inpatient Psychiatric

The insurer denied the Continued Inpatient Psychiatric.  The denial was reversed. 

This is a young male patient who presented to the emergency department with hallucinations.  It was reported that he was sent from the shelter after being seen talking to himself.  He has a past medical history of Schizophrenia.  He has had a previous incarceration.  His reported symptoms include auditory hallucinations, responding to internal stimuli, religious preoccupation, talking to himself, laughing inappropriately, and pacing in hallways aimlessly.  It was noted that the patient was non-compliant with his medication administration, which resulted in changing his drug treatment to intramuscular injection.  The patient was discharged when stabilized. 


The APA Practice Guidelines for the Treatment of Patients with Schizophrenia reports that patients with hallucinations, delusional thinking, disorganized thinking or behavior, suicidal or homicidal plan or intent, agitation, or aggressive behavior, or inability to adequately care for basic needs are candidates for hospitalization.

In this case this patient still had psychotic symptoms during the denial period, including responding to internal stimuli, talking to self, religious preoccupation, laughing inappropriately out loud, and with his history of noncompliance and lack of support, he was at risk for worsened symptoms if discharged prematurely while still having psychotic symptoms.  He had command auditory hallucinations on admission and past incarceration, so he was at risk if not in this 24-hour hospital setting.  He had multiple medication changes and eventually took IM Invega sustenna due to his past noncompliance with medications. 

Based on the above, the medical necessity for the continued inpatient psychiatric is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who presented to the emergency department (ED) with complaints on chest pain for one day. He reports that he felt "blood is not flowing". The patient also felt palpitations. The episode lasted for two hours, on and off every 15 minutes and then resolved. The patient has a history of inferior myocardial infarction and a coronary stent in the right coronary artery (RCA). He has a history of hypertension (HTN) and diabetes mellitus (DM). He is not always complaint with his medications.  He was admitted to telemetry for observation. A cardiology consultation was obtained and the impression was that pain was not cardiac in nature. The patient ruled out for an MI with serial cardiac markers. His pain resolved by itself. He was monitored overnight, and his vital signs were stable.
He was discharged home the next day. The health plan's determination is upheld.
The care for this patient did not meet criteria for inpatient admission and could have been provided at a lower level of care. The patient presented with atypical chest pain. He had multiple coronary risk factors, including HTN, DM and a history of MI. He did not have any evidence of acute coronary syndrome. His ECG, CXR, cardiac enzymes were negative. He was appropriately placed on a  monitor and observed overnight. His condition was stable and his chest pain resolved. The cardiology consultation felt that his chest pain was not cardiac and recommended no further testing.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastritis
 
Treatment: Inpatient admission, medication, monitoring

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

The patient presented with vomiting. She was afebrile and the vital signs were stable. The abdominal exam was benign. There was no leukocytosis. The renal function was normal. The patient was treated for gastritis with a proton pump inhibitor (PPI). The vomiting resolved on a regimen of Reglan, Protonix, and Carafate.

Per MCG, clinical Indications for admission for vomiting (M-370) include gastrointestinal obstruction, a significant metabolic derangement, severe electrolyte abnormalities, high fevers, and acute renal failure. The patient did not have these conditions. She also did not have hemodynamic instability or severe pain.

Per MCG, clinical indications for admission for gastritis (M-560) include gastric outlet obstruction, perforation, peritoneal signs, severe dehydration, ongoing bleeding, and severe anemia. The patient did not have these conditions.

This patient had vomiting that was attributed to gastritis. She responded to PPI therapy and antiemetic. This treatment could have been given with observation status. IV hydration could also have been given in the emergency room. She did not meet MCG criteria for admission for either vomiting or gastritis.  

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

Diagnosis: Vaginal Bleeding
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

The medical records and medical literature were thoroughly reviewed. The patient had the diagnosis of menorrhagia, with a medical history of DVT and cardiac arrest. Her vital signs were stable and she was afebrile on admission to the hospital. She was evaluated by the anesthesia service and categorized as ASA 1. The procedure was performed without complications and with minimal blood loss. The patient was transferred to the post-anesthesia care unit (PACU) where her vital signs and electrocardiogram (EKG) were normal and she was afebrile. The patient recovered uneventfully in the PACU. She was documented as having no abdominal pain or excessive bleeding. There were no documented cardiologic abnormalities. She was alert, oriented and awake. She tolerated a normal diet. There is no evidence in the medical records that the patient's condition was of appropriate severity, and/or included co-morbidities, to indicate inpatient admission. Her estimated procedure time was short, her presenting medical history and physical examination were assessed and the patient was categorized as a low anesthesia risk of ASA 1. Therefore the patient could have been admitted as an ambulatory patient for post-procedure transfer to a unit requiring lesser intensive care than inpatient admission. Therefore the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rheumatoid arthritis 
Treatment: Humira Pen 40mg/0.4ml SC PNKT 

Summary:
The patient is a female with rheumatoid arthritis (RA).  She had arthritis symptoms for over 27 years and has severe joint deformities.  

Humira is FDA-approved for the treatment of moderate-to-severe RA, as seen in this patient. This patient has failed several attempts at treatment with methotrexate (up to 20 mg weekly) and prednisone, although it is not clear that she has been treated consecutively for three months with methotrexate, per pharmacy data.  Per 2015 American College of Rheumatology guidelines for the treatment of RA, "for patients with moderate or high disease activity despite DMARD monotherapy including methotrexate, we strongly recommend using combination DMARDs or adding a TNF inhibitor or a non-TNF biologic or tofacitinib (all choices with or without methotrexate) in no particular order of preference, rather than continuing DMARD monotherapy alone".  Thus, it would be clinically appropriate and in accordance with standard of care in the rheumatology community to add Humira to methotrexate therapy in this patient.  As this patient has not adequately responded to several attempts of methotrexate use and still requires a significant dose of prednisone, it is unlikely that she will respond significantly to three consecutive months of methotrexate therapy, per Plan criteria.  Thus, escalation of therapy with the addition of Humira to methotrexate is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Primary Diagnosis: Cardiac/Circulatory Problems
Primary Treatment: Inpatient Hospital

The patient is a woman with past medical history significant for hypertension (HTN), hyperlipidemia (HLP), obesity, gastroesophageal reflux disease (GERD), obesity, bipolar disorder, methadone dependence, and recent endometrial biopsy, who presented to the emergency department with chief complaints of chest pain at rest, dyspnea on exertion, weakness and dizziness as well as right leg pain. On presentation to the emergency department, she was noted to have vital signs and the rest of her physical exam within normal limits. A chest x-ray (CXR) showed no acute process and an electrocardiogram (EKG) did not reveal evidence of acute ischemia or arrhythmia. The health plan denied the inpatient stay as not medically necessary. The health plan's determination is upheld. 

This patient had numerous risk factors for acute coronary syndrome but presented with atypical chest pain given it had been ongoing for two days without associated EKG changes or elevation of troponin. She was not having cardiac arrhythmia. Given her numerous risk factors for coronary artery disease, she was certainly appropriate to observe, but it is unclear why acute inpatient admission was medically necessary in the absence of evidence of acute coronary syndrome, arrhythmia, hemodynamic instability, hypoxia, or other reason for acute inpatient admission. The patient could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Right foot infection
Treatment:  Inpatient admission

The Inpatient admission was medically necessary.

The patient is a female whose inpatient admission is under review.  The patient has a history of DM (diabetes mellitus), HTN (hypertension), and obesity.  She presented two weeks after having stepped on a splinter with right foot.  She had increasing pain and swelling two to three days prior, and went to the podiatrist.  The podiatrist gave PO (oral) cefdinir, but the patient's symptoms worsened while on antibiotics.  There was a blister since the prior night, and the patient had chills and pus.

In the ER, the patient's vitals were as follows: T (temperature) - 36.6, P (pulse) - 81, BP (blood pressure) - 185/105 (high), RR (respiration rate) - 18. On general exam, the patient was found to be NAD (no acute distress). Examination of her chest, CVS (cardiovascular system), and abdomen were normal. Examination of her extremities revealed an exam c/w (consistent with) right foot infection (medial aspect of ankle). 

The patient's labs were as follows:
1)  WBC (white blood count0 - 9.53
2)  Hg (hemoglobin) - 10.5 (low)
3)  Hct (hematocrit) - 33.4 (low)
4)  Plt (platelets) - 383
5)  Na (sodium) - 134
6)  K (potassium) - 4.9
7)  Cl (chloride) - 99
8)  CO2 (carbon dioxide) - 24
9)  BUN (blood urea nitrogen) - 27
10)  Cr (creatinine) - 0.98
11)  Glucose- 382 (high)
12)  ESR (erythrocyte sedimentation rate) - 80 (high)

X-ray of the patient's right foot revealed no osteomyelitis.

In the ED, the patient was thought to have cellulitis versus osteomyelitis, and she was thought to have failed outpatient therapy in the setting of diabetes.  The patient was treated with IV vancomycin and Zosyn.  Infectious Diseases and Podiatry were consulted.  Osteomyelitis and PVD (peripheral vascular disease) were ruled out by MRI and LE (lower extremity) duplex.  The patient improved and was discharged home on PO linezolid.

The patient meets the initial criteria for IV treatment and admission for cellulitis/abscess given by the Infectious Diseases Society of America (IDSA) (1), as she failed outpatient therapy.  There was also a concern that she may have had resistant bacteria (MRSA [methicillin-resistant Staphylococcus aureus]).  Thus, this admission was warranted, supported by IDSA guidelines, as well as standard of care.  Failure to admit such as a patient can lead to loss of function, sepsis, deep abscess, or death.
Appeal type: Medical necessity
Decision: Upheld

The patient is a male under treatment for heartburn. A recent esophagogastroduodenoscopy (EGD) was normal except for a small hiatal hernia. The patient has failed therapy on Omeprazole (after 3 years he lost response), pantoprazole, over-the-counter (OTC) Prilosec, Zegerid, and lansoprazole. The patient trialed esomeprazole OTC 20 milligrams (mg) which provided relief of symptoms although this was only partially effective. The patient was then prescribed esomeprazole 40 mg capsules by his provider, but this was denied as non-formulary. Esomeprazole OTC 20 mg, 2 capsules daily would be approved by the plan.

The health plan's determination is upheld.

No - esomeprazole 40 mg capsule is not medically necessary for this patient. Esomeprazole 24HR 20mg OTC taken twice daily is the pharmacologic equivalent of the requested drug. There is no medical reason why this would not provide the same degree of gastric acid suppression and symptom relief from heartburn.