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

Diagnosis: Chest pain

Treatment: inpatient hospital admission

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

This patient is a male who came to the ED by himself with past medical history of hypertension and hyperlipidemia presents to the ED with a complaint of chest pain. He also has polysubstance abuse and came to the hospital with substernal chest pain which started the previous evening and was associated with numbness, tingling in the neck and left hand. The pain was moderate, constant and was accompanied by shortness of breath and nausea. The patient had recurrent ED visits in the past with similar symptoms but always left AMA prior to an ischemic workup. The patient had a stress test in mid-2018 which was normal. His family history reveals that his father had a myocardial infarction (MI) at a specified age. His mother has a history of arthritis. The patient was seen by cardiology who suggested a nuclear stress test which the patient declined since he said he preferred to do this as an outpatient. 

A 2014 study from Sweden evaluated the significance of undetectable troponin levels and EKGs which did not show signs of ischemia in patients presenting to the emergency department with chest pain. (1) They conclude that all patients with chest pain who have an initial hs-cTnT level of <5 ng/l and no signs of ischemia on an ECG have a minimal risk of myocardial infarction (MI) or death within 30 days, and can be safely discharged directly from the ED. This approach is accepted as standard as reviewed in the guidelines. (2)  This patient had a past history of hypertension and hyperlipidemia and presented to the hospital with complaints of chest pain. The patient had prior episodes that were similar but always left against medical advice before completing an ischemic workup. His last stress test was in mid-2018 and that was reported as negative. Troponin x2 was within normal limits and his EKG showed no evidence of ST segment elevation or T-wave change consistent with acute myocardial injury or ischemia. 

Inpatient hospital admission for the date of service specified was not medically necessary for this patient. Therefore, the health plan acted reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the inpatient hospital admission for date of service specified is not substantiated.  The insurer's denial is upheld.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Dry eyes

Treatment: Xiidra DRO 5%

The insurer has denied coverage for Xiidra DRO 5%. The denial was reversed.

The patient is a female with dry eyes for whom coverage of Xiidra is requested.  Coverage was denied as the patient had not tried and failed the formulary alternative of Lacrisert. The provider noted that the patient has been controlled with relief of symptoms since mid-2017 using Xiidra.  Additionally, it is noted that the patient had a history of failing Restasis, Lacrisert, Refresh, Systane, and Ocular Fresh. The formulary drug (Lacrisert) is not identified as having caused an adverse reaction in this patient when she tried it.  She did however try it and it did not provide adequate relief for her.  The requested drug Xiidra DRO 5% would be more effective than the formulary medication in this case.

 According to Holland, E. J., et al. (2019), "Dry eye disease (DED) is a multifactorial and complex disease of the ocular surface, with a high prevalence in adults."  They go on to state, "Potentially more effective, ophthalmic pharmacological drugs targeting various distinct pathophysiological pathways of DED have been investigated in the past two decades, but this effort has resulted in the approval of very few new drugs.  Overall, these drugs either reduce ocular surface inflammation or stabilize the tear film [7], although currently, it is not clear which drugs are best suited for those patients who exhibit aqueous deficient DED (ADDE) or evaporative DED."

Lastly, according to Keating, G. M. (2017), "Lifitegrast is a novel small molecule integrin antagonist that blocks the binding of intercellular adhesion molecule 1 (ICAM-1) to lymphocyte function-associated antigen 1 (LFA-1).  Lifitegrast ophthalmic solution 5% (Xiidra) was recently approved in the USA for the treatment of dry eye disease.  The efficacy of lifitegrast ophthalmic solution 5% was compared with vehicle in a 12-week phase 2 study and three 12-week phase 3 studies (OPUS-1, OPUS-2 and OPUS-3) in patients with dry eye disease.  Taken as a whole, results of these trials support the treatment effect of lifitegrast ophthalmic solution 5% in improving a symptom of dry eye disease (i.e. the change from baseline to day 84 in the eye dryness visual analogue scale score) and a sign of dry eye disease (i.e. the change from baseline to day 84 in the inferior corneal fluorescein staining score).  Lifitegrast ophthalmic solution 5% was generally well tolerated. In conclusion, lifitegrast ophthalmic solution 5% provides a new option for the treatment of dry eye disease."

Based on the above, the denial for the request for a Formulary Exception for Xiidra DRO 5% is reversed.
Appeal type: Medical necessity
Decision: Upheld

The patient inpatient detoxification level of care related to use of heroin and benzodiazepines. The patient was reported to be using 10-12 bags daily of heroin and had used for bags earlier on the day of admission. The patient had been using heroin for 6 years. The patient was also reported to take 2 milligrams (mg) of an unnamed benzodiazepine 3-6 times per week. Initial urine drug screen was positive for opiates and cocaine, and notably negative for benzodiazepines. Initial diagnoses were opioid dependence with withdrawal, cocaine dependence, uncomplicated, nicotine dependence, and asthma. During the admission, the patient received supportive medications for her opioid withdrawal. There was no evidence that the patient had severe medical complications from her withdrawal. The patient decided to terminate the treatment and left Against Medical Advice.

The health plan's determination is upheld. The Inpatient Detoxification Treatment was not medically necessary for this patient.According to the LOCADTR tool for admission level of care, the patient did not require immediate hospitalization due to a life-threatening medical condition or severe psychiatric crisis. The patient had problematic use of opioids, benzodiazepines, and cocaine. Benzodiazepine use was not the focus of treatment. The patient had been using a modest amount of benzodiazepines with last use prior to admission by 2 days. Opioids was the focus of treatment. There is no evidence in the clinical records that continuous access to medical and nursing care was needed for the patient is safely detoxify from opioids. The patient could have been safely and effectively managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Difficulty breathing
 
Treatment:  Inpatient Admission 

The insurer denied the Inpatient Admission.  The denial was upheld.  

This is a female patient who presented to the emergency Department (ED) with complaints of difficulty breathing.  The patient reported that she had a productive cough, wheeze and fever for three weeks.  She stated that she had been diagnosed with pneumonia one week prior to presentation that had been treated with oral antibiotics and steroids.  She had a chest v-ray that was unremarkable.  Her computerized tomography of the chest revealed left lower lobe pneumonia.  An EKG was performed that showed a normal sinus rhythm.  She was treated with intravenous antibiotics and steroids.  She was given bronchodilators via nebulizers.

Based on the above it appears that this patient did not need acute hospitalization.  She could have been placed in Observation status.  By the day after admission the patient was afebrile, hemodynamically stable and tolerating fluids and food orally.  The patient was not hypoxic at presentation.  She had leukocytosis but was on systemic steroids.  The oxygen saturations were 95% on room air at presentation.  The patient could have been switched to oral antibiotics and steroids and discharged after a period of observation.  On the day after admission the patient appeared to be stable for discharge on oral medications with close follow-up in an outpatient setting.  The patient had Low CURB 65 score and did not need continued acute inpatient hospitalization.  
 
The carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

The patient was admitted following medical screening to inpatient level services for monitoring and detoxification and withdrawal management of severe opioid (heroin and non-prescribed methadone) and stimulant (cocaine) use disorders. The patient was using up to 6 bags daily of heroin with IV administration together with one cup of non-prescribed methadone and $40 worth of crack cocaine per day. The patient had experienced moderately severe opioid withdrawal at the time of admission, and had severe withdawal symptoms in the past requiring detoxification services on multiple occasions including a detoxification treatment with discharge with relapse. The patient also uses alcohol intermittently.

The health plan's determination is overturned. The proposed inpatient services and detoxification treatment and withdrawal management for severe alcohol use disorder and other services noted in the clinical summary could not have been safely and effectively provided at a lower level of care. The inpatient treatment of this patient's substance use disorders and associated general medical complications and psychiatric co-morbidity did require the admission and the continued structure of an inpatient level setting and 24-hour monitoring in view of the severity of the substance use disorders. Withdrawal symptoms were managed with tapering dosages of methadone requiring monitoring and prn medications, as well as comfort medications, and antidepressant medications and the availability of medication to address the COPD. Thus, the patient did require a safe and effective detoxification with withdrawal management and 24-hour monitoring during the time frame under review, as it was reasonable that the patient would have been unable to abstain from the substances of abuse if detoxification and the other treatments were to be attempted at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Acute Appendicitis

Treatment:  Inpatient Admission

The insurer denied the Inpatient Admission.
The denial was upheld. 

This case involves a young male who was seen in the Emergency Department in early 2019 with complaints of periumbilical pain for one day.  It was reported that the patient's episodes of pain were causing him the inability to move.  He denied nausea, vomiting, diarrhea or fever.  The physical examination revealed his abdomen to be nondistended with bowel sounds in all four quadrants.  The patient underwent an abdominal ultrasound that revealed no evidence of intussusception, mass, enlarged lymphadenopathy, or free fluid identified.   A pelvic ultrasound revealed an acute appendicitis.  He underwent a computerized tomography (CT) scan indicating that there was diffuse thickening of the wall with mild infiltration of the surrounding spaces.  There was no evidence of perforation or abscess formation.  The patient had an appendectomy without complications.  He postoperatively recovered well and was discharged.

According to current peer-reviewed literature, a pediatric patient undergoing an appendectomy, which is uncomplicated, is typically hospitalized for a short observation postoperatively.  This is typically an ambulatory procedure, and most children with acute uncomplicated nonperforated appendicitis will not need to be admitted to an inpatient status.  An inpatient stay may be needed when there is complicated appendicitis, such as evidence of perforation or a significant co-morbid illness.  Within the documentation, the above was not noted.  
	
Based on the above, the medical necessity for the inpatient admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left facial swelling

Treatment: Inpatient admission

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

This female patient had extraction of teeth #17 and #18 under intravenous (IV) sedation and intravenous antibiotics were administered. According to the medical record, there was no difficulty breathing, no fever, nausea or vomiting and vital signs and labs were within normal limits. Therefore, the patient could have been scheduled for extractions of #17 and 18.

The healthcare plan acted reasonably and with sound medical judgment and in the patient's best interest. Based on all documents reviewed, the inpatient admission was not medically necessary.

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

Diagnosis: Trouble breathing and cough
Treatment: Inpatient admission
The proposed inpatient admission was medically necessary.

The patient is a male with history of asthma with worsening shortness of breath and cough who was treated as outpatient with systemic steroids without any improvements. The patient was evaluated in the emergency room, received nebulization treatments and intravenous (IV) steroids. Despite emergency room care treatment with nebulizations and IV steroids, the patient remained dyspneic, hypoxic requiring supplemental oxygen. 

The patient was admitted for IV steroids and nebulization treatment. Pulmonary consultation was requested. The patient remained dyspneic and wheezing two days and required IV steroids, antibiotics and nebulizations. On third day, the patient's wheezing improved; the patient was off oxygen and was discharged home on oral steroids.

The patient had failed outpatient treatment for asthma exacerbation. The patient did not improved significantly with emergency room care. The patient continued to have significant dyspnea, wheezing, and oxygen requirements beyond 24 hours observation care. Thus, the acute in hospital stay from was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Bedbound; nonverbal
Issue under review:  Increase in personal care services

Determination:
The Increase in personal care services is medically necessary.

This is an elderly female who is nonverbal and bedbound due to multiple underlying medical issues.  For these reasons, she requires in home personal care services for assistance with completion of her activities of daily living (ADLs).  Specifically, she is a total/maximum assist with bed mobility and transfers, requiring the use of a mechanical/Hoyer lift to get into and out of bed.  Due to her chronic inability, she requires frequent repositioning in bed every two hours to prevent the development of skin breakdown and/or pressure ulcers.  Lastly, she is maximum/total assist regarding performing meal preparation, housekeeping, laundry, shopping, dressing, bathing, toileting, medication management and personal hygiene.  For these reasons, the proposed increase in personal care services to better assist with completion of patient's activities of daily living is deemed medically necessary. 

The health plan's currently approved personal care services would not be adequate to meet the patient's needs as outlined above.
Appeal type: Medical necessity
Decision: Upheld

Cellulitis
Inpatient hospital

This is the case of a female with past medical history of migraines and hyperthyroidism who presented to the emergency department with redness of her right thigh. The lesion had started has a pimple. She had been seen in the office and was prescribed doxycycline and underwent incision and drainage with subsequent worsening of her thigh wound after taking three doses of antibiotics. She denied fevers, chills, nausea, vomiting, or other complaints. The inpatient admission is under review. 

The health plan's determination is upheld. The inpatient stay was not medically necessary. This is a patient who presented with thigh cellulitis despite outpatient treatment with doxycycline for three doses in addition to incision and drainage. Given worsening of her cellulitis despite outpatient therapy, she was certainly appropriate to bring into the hospital for IV antibiotics. However, in the absence of any signs of sepsis (no fever, hypotension, tachycardia, lactic acidosis), uncontrolled diabetes/other immunocompromise, severe edema or other condition placing her at increased risk of sepsis and failure to respond to IV antibiotics, it is not clear why this patient could not have safely been cared for with IV antibiotics at a lower level of care. Inpatient care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This patient with past medical history significant for recent fall and ankle fracture, diabetes mellitus (DM), hypertension (HTN), hyperlipidemia (HLP), glaucoma, and dementia, presented to the emergency department after she fell and was unable to get up.  She had recently been treated for urinary tract infection (UTI) and her ankle fracture at an outside hospital.  There was no report of recent fevers, chills, dysuria, cough, chest pain, abdominal pain, nausea, vomiting or other complaints.  On presentation to the ED, she was noted to have vital signs within normal limits.  Labs were notable for complete blood count (CBC) grossly within normal limits with mild leukopenia, sodium (Na) 127, and blood urea nitrogen (BUN) and creatinine within normal limits.  The urinalysis (UA) did not show evidence of an infection.  She was treated with intravenous (IV) fluids and, given concerns for hyponatremia and inability to take care of herself, she was brought into the hospital.  She was seen by physical therapy, psychiatry, encouraged to take oral fluids, and placed on a free water restriction.  Acute inpatient admission was not medically necessary.  A lower level of care was reasonable for this patient who presented with hyponatremia that improved quickly and was not associated with acute kidney injuries or other acute medical issue requiring work-up or treatment.  She otherwise appeared, as noted above, to stay in the hospital for social reasons and not having a place to go.  Acute inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
 
Treatment: Inpatient admission, diagnostic testing, monitoring

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

This patient had a history of hypertension, polio with left lower extremity brace, chronic back pain, anxiety/depression and alcohol abuse with withdrawal seizures. He presented to the emergency department (ED) with a history of chest discomfort for more than a week, and had been in another hospital with similar symptoms one week prior, and discharged after an unremarkable CT angiography of the chest, stress test, and transthoracic echocardiogram. The chest discomfort was described as pressure, radiating to the axilla, and worse with palpation or exertion. Vital signs on presentation: blood pressure (BP) 140/86, heart rate 92, temperature 98.10F, and oxygen saturation on room air 100%. Electrocardiograms (EKG) were normal, as was a chest x-ray. Laboratory test results included white blood cell (WBC) count 5.57, hemoglobin 9.9, and creatinine 0.51. The Troponin High Sensitivity levels were 9, 8, 9, 10, and 9, with reference range <6-14.  Coronary angiography revealed 20 to 30% proximal left anterior descending, mid left circumflex, and mid right coronary artery lesions. There were no complications related to this procedure, and he remained stable during his hospitalization.  

There is no evidence the patient required an acute inpatient hospital stay to determine that his chest discomfort was not related to acute coronary syndrome (ACS) or for coronary angiography. The testing could have been completed in the emergency department (ED) or at an observation level of care as a same day outpatient procedure. 

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

According to the submitted medical records, the patient was admitted for an inpatient stay for an admitting diagnosis of anesthesia of skin. The patient was discharged.
She presented to the emergency department with complaints of left facial numbness for one day. She also had transient tingling in the left hand.
A code stroke was called. National Institutes of Health Stroke Scale (NIHSS) was zero, indicating no neurological deficits. Head computed tomography (CT) reported no acute abnormalities, no signs of stroke. There was no reported hemodynamic instability, fever, uncontrolled infection, new, or worsening neurological deficits, cardiac arrhythmias, uncontrolled hemorrhaging or any other acute changes requiring an immediate intervention. There were no medical or surgical interventions. No substantial changes in therapy. The subject under review is the medical necessity of the inpatient stay.

The health plan's determination is upheld.

The patient presented with one day of symptoms and had an unremarkable clinical and neurological examination. No evidence of acute stroke was identified. patient had no difficulties caring for herself, and no evidence of any impending neurological event that would immediately imperil the patient's health.
There was no reported hemodynamic instability, fever, uncontrolled infection, new, or worsening neurological deficits, cardiac arrhythmias, uncontrolled hemorrhaging or any other acute changes requiring an immediate intervention.
No interventions occurred in the hospital other than additional testing. There is no evidence to support such additional testing could not have safely been done at a lower level of care once initial evaluation ruled out an acute stroke.
There is no evidence to support that the patient could not have been safely managed at a lower level of care after the initial emergency evaluation detected no acute neurological, or any other acute clinical abnormalities that would present an immediate, high risk to the patient's health. Records do not support need for inpatient stay.
Appeal type: Medical necessity
Decision: Upheld

The patient has paroxysmal atrial fibrillation who presented to the Hospital for electrophysiologic study and catheter ablation. Patient underwent cryoablation of the pulmonary veins. The procedure was uncomplicated. Patient was discharged the next day. The inpatient hospital stay was not medically necessary.  For patients undergoing AF ablation, the usual length of stay, for those without procedural complications, is approximately one day, and observation status is standard of care. The hospitalization could have been handled at a lower level of care. In addition, per Milliman guidelines electrophysiologic (EP) testing and catheter ablation are ambulatory procedures. Inpatient admission can be considered for cases of hemodynamically unstable arrhythmia, procedural complications or unstable comorbid condition. None of these conditions apply in this case. The health plan's determination is upheld in whole.