Persius/hicric huggingface dataset:
Appeal type: Formulary Exception
Decision: Overturned

This is a patient with a diagnosis of Type 2 diabetes and Obesity. Her recent body mass index (BMI) was 35.7. Her last Hb1c was 7.9% with a creatinine of 0.68. She is currently on Metformin extended release [ER] (MOD) 2000 milligrams (mg) daily, Basaglar Insulin, Glimepiride, and Invokana. She had tried and failed immediate-release Metformin due to gastrointestinal (GI) side effects. She also tried and failed generic Glucophage extended release (XR) and had G.I side effects.
Per the letter written by her provider, she has tried and failed generic Metformin ER and Fortamet due to G.I side effects. She has been on the requested medication per review of clinical documentation. The health plan's determination is overturned. The patient has tried and failed formulary drugs due to adverse effects in per review of the provided documentation. She has Type 2 diabetes and obesity. Some formulations of Extended-release Metformin preparations are seen to have more tolerability compared to immediate-release preparations. She had tried and failed formulary medications including Immediate release Metformin and Generic Extended-release Metformin but is unable to tolerate them and they were also less effective. She has been tolerating Glumetza well and it is medically necessary for her to continue therapy with the requested medication.
Appeal type: Medical necessity
Decision: Upheld

The patient presented to the ED with left sided chest pain. The pain felt like a pressure for 4 days prior to this presentation. The chest pain was midsternal with radiation to the left chest area and into the left arm. Patient also had nausea and a headache. The pain was not caused by exertion and not relieved by rest. It was not related to food intake. The patient also had several pillows used for orthopnea. The patient was fatigued even walking half a block. 

Medical history is significant for CAD, and  a coronary stent which was placed in 2016 in the PDA and another coronary stent in the mid left anterior descending (LAD) in 2018. Patient also has hypertension, hyperlipidemia, obstructive sleep apnea (OSA) and benign prostatic hyperplasia (BPH). The patient was evaluated in the emergency department (ED). Vital signs were stable. ECG revealed sinus bradycardia, no ST changes noted. CXR was unremarkable without any acute findings. Labs were unremarkable. Troponin was normal. The patient underwent a chest computed tomography (CT) to rule out pulmonary embolism (PE) and it was negative. The health plan's determination of medical necessity is upheld in whole. The patient presented with atypical chest pain. Patient has multiple coronary risk factors including hypertension, hyperlipidemia, CAD, and coronary stents. Cardiology felt the impression was that the pain is atypical, and pulmonology felt that the chest pain was musculoskeletal. Patient was stable clinically, with normal vital signs and an unremarkable physical examination, labs and imaging studies. Patient was admitted and was observed on telemetry and ruled out for a myocardial infarction (MI) with serial cardiac enzymes.
The patient's condition and care provided did not meet inpatient level of care. A lower level of care would be more appropriate.
Appeal type: Medical necessity
Decision: Upheld

Blood disorder/other
Inpatient hospital

The neonate was born at 38.3 weeks estimated gestational age by spontaneous vaginal delivery to a Gravida 3 Para 2 woman. The mother's blood type was O+, and the neonate was noted to be B+ Direct Coombs positive. The mother was Group B Streptococcus positive and only received one dose of Penicillin prior to delivery (inadequate treatment). The infant received 48 hours of ampicillin and gentamicin and was discharged home when the blood culture was read as negative. On the day prior to admission, she was seen by her Pediatrician who noted that the bilirubin was 18 mg/dL. The patient then presented to the Emergency Department where a repeat bilirubin was 22 mg/dL. She was admitted, placed on intravenous fluids, continued to breast feed, and was managed with phototherapy. 

The health plan's determination is upheld. The inpatient stay was not medically necessary. Although the neonate's bilirubin was 22 mg/dL at admission, which is just under exchange level for a newborn with risk factors, the bilirubin nomogram (3,4) is meant to guide physicians when to perform an exchange transfusion after intensive phototherapy has been instituted and if the neonate does not respond (i.e., bilirubin decrease). In addition, the patient was hemodynamically stable, breathing unassisted room air, able to orally feed, and did not have evidence of hemolysis (reticulocyte count was within normal limits for a newborn infant).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Cardiac Heart Problem
Treatment:  Inpatient Hospital 

The patient who with right sided weakness and aphasia.  Work-up was unrevealing except for the diagnosis of patent foramen ovale (PFO) diagnosed by transesophageal echocardiography (TEE).  The patient was seen by Neurology who recommended PFO closure.  The patient underwent PFO closure and was admitted.  The patient  was observed uneventfully overnight and discharged.  Uphold in whole the health plan's determination of medical necessity.
No, the inpatient stay was not medically necessary.  The patient had a significant cardiac procedure, namely, transseptal puncture and implantation of a left atrial appendage closure using the Watchman device.  It is important to carefully monitor the patient with electrocardiogram (ECG) and vital signs.  This requires continuous medical observation.  It was reasonable to observe the patient overnight; however, this could have been performed at a lower level of care.  The expectation is that patient could be discharged within 24 hours in the absence of complications.  Thus, it was reasonable to follow this patient on a lower level of care status.  A full admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Varicose veins

Treatment: Vein Procedures

The insurer denied coverage for Vein Procedures. The denial was upheld.

This patient is a female with a history of varicose veins. The documentation detailed that she presented with a longstanding history of symptomatic bilateral varicose veins left greater than right.  She also had complaints of fatigue and swelling despite compression.  The patient reported having undergone vein injections over 10 years ago and having an adverse reaction to the solution.  The patient did undergo a left leg reflux study; according to the physician there was no evidence of deep vein thrombosis (DVT).  According to the physician she had deep vein reflux and refluxing varicosities.  The physical examination revealed moderate to large viscosities to the right leg.  There were very large varicosities in the left posterior leg with no ulcerations.  The physician indicated the patient should undergo a left leg phlebectomy due to symptomatic varicose veins despite compression. The reflux study revealed evidence of mild deep venous reflux with no evidence of great saphenous vein reflux.  There was also no evidence of small saphenous vein reflux.

The health care plan acted reasonably and was found medical judgment and in the best interest of the patient.
This patient has no GSV or small saphenous vein, (SSV) or any superficial reflux at all on the left lower extremity.  There is deep reflux and SFJ reflux found in the left lower extremity.  By the history and physical exam, there is pain and edema of the left leg with enlarged varicose veins. Thus, we have a situation where there is no superficial reflux, there is deep venous reflux, and clinical findings of enlarged varices with pain and edema are present. There is no data provided regarding the etiology of the deep venous reflux. Eg, venogram or IVUS of the iliac vein.  The documentation provided does not support the need for stab phlebectomy.

The carrier's denial of continuation of coverage for Vein Procedures is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Teeth Spacing Problem
Dental/Orthodontic Procedure
The patient in question is a male with a Class I, crowded occlusion and a 100% deep bite causing soft tissue damage on his palate. His treatment plan is for 18-24 months of orthodontics to correct his malocclusion. This is the subject of this review.

The health plan's determination is overturned. Braces are medically necessary for this patient. A deep bite on its own is not a reason to treat with orthodontics. However, the patient is already damaging the soft tissue of his palate and causing wear to the incisal edges of his teeth. This will worsen with time if left untreated and can lead to periodontal problems in the future that will be more invasive and expensive to correct than the orthodontic problem he currently has.
Appeal type: Medical necessity
Decision: Upheld

Apnea/Sleep Apnea
Inpatient Hospital

The patient has sleep apnea. The patient was diagnosed with severe sleep apnea. The apnea hypopnea index (AHI) is not documented. There are no other health problems documented. The patient underwent an uneventful tonsillectomy and adenoidectomy. There were no operative or peri-operative complications and was admitted overnight. There were no complications and the patient was discharged the day after surgery.
The Inpatient stay is subject of this review.

The health plan's determination is upheld. The inpatient stay was not medically necessary. There is no documentation to support an inpatient admission. The patient had severe sleep apnea without any comorbid medical issues or surgical complications. A lower level of care which allows for an overnight stay is an appropriate level of care per current standards in the United States. The patient's vital signs were stable and there were no bleeding or airway concerns.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diaphoresis, dizziness, and vomiting
Treatment: Inpatient stay

Summary:
The patient is a male. He presented to the emergency room with sudden onset of diaphoresis, dizziness, and vomiting, and coworkers noted he was walking like he was drunk. While in triage, the patient vomited dark brown emesis and felt as if his chest was burning and that the room was spinning. He denied headache. His medical history was notable for vertigo, cerebral cyst, obesity, and recently diagnosed type II diabetes.  

The patient was neurologically stable, did not have a neurological deficits, his balance and gait were preserved. Therefore, there was no need in inpatient stay and the patient's neurological care could have been continued at a lower level of care.

The patient underwent all of the essential tests, such as brain imaging to rule out stroke or any other neurological conditions. Therefore, the health plan did act reasonably, with sound judgment and in the best interests of the patient.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who was gravida (G) 1 para (P)0 and presented at 26 weeks gestation from the Maternal Fetal Medicine provider with a known issue of cervical incompetence. She had undergone a cerclage on with a cervical length of 0.43 centimeters (cm) and 1 cm dilation as the indication. The patient was then seen on the date of admission with a repeat transvaginal cervical length of 0.22 cm and 1-2 cm dilation despite the cerclage in place.
The patient had a past medical history of endometriosis. She had a prior surgical history noted for a diagnostic laparoscopy and cerclage placement. She was a non-smoker and had past alcohol use. She had no prior illicit substance use.
She was started on indomethacin 25 milligrams (mg) every (q) 4 hours. She was to continue on vaginal progesterone 25 mg at night. The review of systems was noted for pelvic pressure and abdominal pain. Vital signs were stable. She was afebrile. Her blood pressure was normal at 118/68. She had a normal physical exam noted. A nonstress test (NST) was reassuring and noted for irregular contractions. The patent was planned for magnesium for neuroprotection, indocin for tocolysis, ampicillin for Group B Streptococcus (GBS) prophylaxis, and Celestone for fetal lung maturity. The patient was admitted to labor and delivery (L&D) and a plan was made to transfer to a higher level of care at an outside hospital given the prematurity. The patient was transferred on the date of admission. The health plan's determination is upheld. In this case, the patient was preterm with a cerclage in place due to possible incompetent cervix. The patient had a short cervix of 2.2 mm noted. She was noted to have an incompetent cervix with a cerclage in place. There was evidence of preterm labor with irregular contractions and the cerclage was in place. In this case, the standard of care would be for steroids to be administered and magnesium for neuroprotection would be considered for 12 hours. This may be continued to achieve 48 hours of tocolysis to complete steroids. The American College of Obstetricians and Gynecologists (ACOG) states the following regarding this practice: "Tocolytic therapy may provide short-term prolongation of pregnancy, enabling the administration of antenatal corticosteroids and magnesium sulfate for neuroprotection, as well as transport, if indicated, to a tertiary facility. However, no evidence exists that tocolytic therapy has any direct favorable effect on neonatal outcomes or that any prolongation of pregnancy afforded by tocolytics actually translates into statistically significant neonatal benefit." The acute inpatient level of care would not be medically necessary in this case in a patient without any acute status for preterm labor beyond 24 hours or delivery.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: PE
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient is an adult female. She was admitted for evaluation of the pain and was found to have PTE (pulmonary thromboembolism).  She was placed on Lovenox and transitioned to Pradaxa and discharged. 

The appropriate workup for a patient with a prior history of PE presenting to the ER with pleuritic chest pain with shortness of breath would be CT angiogram and lower extremity US (ultrasound).  In patients with PE, acute hospital admission is not warranted in patients who are hemodynamically stable.  These patients can be safely treated with Lovenox on an outpatient basis with transition to oral anticoagulation or safely managed in observational status.  

Therefore, the hospitalization was not necessary, as this patient was hemodynamically stable and could have been safely managed in a lower level of care. There was a delay in performing the appropriate testing to evaluate for PE.   Therefore the acute level hospitalization was not medically necessary at an acute level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Hernia
Treatment:  Inpatient Hospital

This case involves a patient who presented for bilateral open inguinal hernia repair.  The patient underwent repair and was admitted thereafter for pain control.  Patient experienced an uncomplicated recovery.  The pain scores did not indicate any unusual pain and pain was managed with Tylenol.  Patient was discharged home in good condition with  parents on the following day.  The health plan's determination of medical necessity is upheld in whole.  The vast majority of all pediatric hernia repairs are done on an ambulatory basis with no overnight stay post-operatively.  The obvious exception to this is for a former premature infant who is not yet 60 weeks corrected gestational age who is at risk for apnea of prematurity.  There is nothing documented in the medical record that would indicate any elevated risk for unusual pain or adverse outcome of general anesthesia or surgery.  For that reason, an inpatient medical stay cannot be justified.
Appeal type: Medical necessity
Decision: Upheld

This is a  male with a history of alcoholic cirrhosis and chronic pancreatitis who presented to the emergency department with abdominal pain, hematemesis and melena. On presentation, the patient had a temperature of 36.6, pulse rate of 82, blood pressure of 98/65, respiratory rate 18, and oxygen saturation 94% on room air. Blood work was notable for white blood cell (WBC) count 5.3, hemoglobin 12.6, and hematocrit 38.8, platelet count 121,000, sodium 139, potassium 3.2, chloride 105, and bicarbonate 24, total bilirubin 0.7, alkaline phosphatase 192, aspartate aminotransferase (AST) 54, alanine aminotransferase (ALT) 21 and albumin 3.0. The patient had left against medical advice but then represented the same day on 4/30 and was subsequently admitted to the medical floor and treated with conservative management with intravenous fluid hydration and antibiotic therapy. Gastroenterology service consulted and the patient was taken for esophagogastroduodenoscopy (EGD) which revealed non-bleeding esophageal varices and portal hypertensive gastropathy. The patient had a cough and was found to have right lung infiltrates and acid fast bacilli (AFB) cultures were sent to assess for tuberculosis. The patient did improve over the course of the hospitalization and ultimately was discharged with close follow-up as an outpatient.

The health plan's determination is upheld.

This patient presented with abdominal pain, hematemesis and melena. On presentation, the patient was hemodynamically stable without fever, tachycardia or hypotension. Blood work revealed no evidence of leukocytosis or anemia with mild electrolyte abnormalities.   The patient remained hemodynamically stable throughout the hospital course without development of tachycardia or hypotension to suggest ongoing active gastrointestinal bleeding and the patient did not require transfusion with packed red blood cells.  The patient was found to have hemoglobin 12.6 and hematocrit 38.8 which remained stable with a hemoglobin 12.3 and hematocrit 38.2.  The patient did not require endoscopic or surgical intervention to stop bleeding.  

Based on the Milliman Care Guidelines (MCG) guidelines, the patient did not have active bleeding, high risk endoscopic features, severe liver disease, significant active comorbid disease, previous aortic graft placement, coagulopathy, syncope, associated condition requiring hospitalization, hemodynamic instability, complicated anemia, severe pain requiring acute inpatient management, high risk low platelet count, requiring intravenous fluid administration, or immediate surgery and therefore an acute level of care and inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Blood Disorder
Treatment:  Inpatient Hospital
The patient is a female FT (full term), NSVD (normal spontaneous vaginal delivery), vacuum assisted delivery, sent from the clinic for a bilirubin check.  Mother states that the baby sleeps most of the day and wakes every 5-6 hours, cries, feeds and then goes back to sleep.  Mother states she has been feeding the baby both breastmilk and formula only during these awake periods and does not wake the baby to feed.  Mother reports no wet or soiled diapers since the AM the day prior.  Per mother, the baby was having trouble breastfeeding at home and only took 5 oz of formula the day prior. Patient was seen in clinic on the day of arrival to the emergency room (ER) and was sent for repeat bilirubin level.  Bilirubin at discharge the day prior was 14.2 on day 2 of life which was in the high-risk zone.  The day of admission level rose to 18.1, so she was sent to ER for further management.  In the ER, the baby was sleeping but awoke for feeding.  Borderline tachycardia and tachypnea was noted.  The heart rate (HR) was 166, respiratory rate (RR) 62.  A normal saline (NS) bolus was given in the ER.

The health plan's determination is overturned.  The inpatient admission was medically necessary.  For a patient with high risk bilirubin levels who is failing at breastfeeding, an inpatient admission for intense phototherapy and close monitoring is in the best interest of this patient and is medically necessary.  When a newborn is readmitted with bilirubin levels >95th percentile, bilirubin levels should be repeated 2-3 hours after initiation of phototherapy to assess response.  Given the main complication of uncontrolled bilirubin levels is neurologic dysfunction, admission for intense phototherapy and monitoring would be in the best interest of the patient.  Also, with intensive phototherapy it is important to monitor the neonate's hydration status as well as body temperature.  This patient already had physical findings of dehydration and history of significantly decreased urine output prior to the initiation of phototherapy.  She was given a normal saline bolus in the ER, after which the infant produced urine.  These infants are at risk for hyperthermia and excessive weight loss.  Monitoring her hydration status closely is of paramount importance.  Exaggerated hyperbilirubinemia can also be a sign of sepsis.  Monitoring for sepsis is also necessary.  For these reasons, the inpatient hospital stay is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting; Abdominal pain

Treatment: Inpatient admission 

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

This patient is a male who presented to the Emergency Department with complaints of vomiting of coffee-ground emesis, hypertension, tachycardia and high capillary blood glucose. The patient had a temperature of 99.8 F, with a heart rate of 103, respirations 18, blood pressure 196/103, oxygen saturation 99% on room air. The patient was placed on cardiac monitor and vomited 600 cc upon arrival of dark brown vomit. The patient was alert and oriented x3 however he was restless and lethargic. The chest x-ray done at the bedside was negative. The patient stated he had been vomiting and having abdominal pain for the previous two days and stated he had an episode of diarrhea the previous morning. The patient was not compliant with insulin. The patient complained of pain and discomfort to the chest and abdomen that was a 9/10 on a scale of 10. The patient was given sliding scale insulin of 6 units. The patient was also given intravenous (IV) fluids and Lactated Ringer's. In the Emergency Department the patient received Humulin 10 units, Reglan 10 mg, pantoprazole 40 mg. The patient had a white blood cell count of 16.6 K, red blood cell count 5.66, hemoglobin 17.7, hematocrit 51.2, platelets 335, PT 11.9, INR 1.2, sodium 136, potassium 4.2, chloride 86, carbon dioxide 22, glucose 564, urea nitrogen 27, creatinine 1.7, calcium 9.9, albumin 4.5, alkaline phosphatase 130, lipase 27, troponin 0.01. The patient was then placed nothing by mouth (NPO). The patient underwent a computer tomogram angiogram (CTA) of the abdomen after admission with no evidence of obstruction or inflammatory change but positive circumferential thickening of the distal thoracic esophagus. The patient symptoms then resolved. The patient was discharged several days after presenting.

The patient did not have any acute complications of diabetes necessitating inpatient admission. He had coffee ground emesis but his blood pressure was not low, his hemoglobin was 17, creatinine at 1.7 which is slightly high but not acute elevation. The Gastroenterology (GI) service was consulted and the endoscopy was unnecessary, imaging studies did not show any acute pathology. 

The patient was appropriate for an Observational level of care rather than inpatient level of care. Therefore, the requested inpatient admission is not medically necessary.

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

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