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

Diagnosis: Chest pain
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.  The denial has been upheld.
The proposed inpatient admission was not medically necessary.

This male was hospitalized for chest pain. He presented to the emergency department for evaluation of abrupt onset of sharp, substernal chest pain with radiation to his left arm. His past medical history was pertinent for chemotherapy for seven months for lung cancer with poor oral intake, syndrome of inappropriate antidiuretic hormone secretion (SIADH), chronic obstructive pulmonary disease (COPD), hypertension, pneumothorax, pleural effusion and recent the COVID-19 infection. The patient's initial blood pressure was 90/56 and improved to 108/80. Treatment included intravenous fluid resuscitation, intravenous Pepcid and nebulizers with improvement. Serum sodium was 131 and low density lipoprotein (LDL) was 148. The patient had an echo cardiogram and was discharged to home with instruction to follow up with outpatient oncology and radiation oncology. The requested coverage for inpatient hospital admission was denied and the patient is appealing the decision.

Based on the current peer reviewed medical literature, there was not a medical need for the acute inpatient hospital stay, because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. Per the Milliman Care Guideline (MCG) for Chest Pain, #M-89, criteria for inpatient admission are not met, including hemodynamic instability, respiratory distress, pulmonary edema, angina with acute coronary syndrome, chest pain that is indicative of a serious cardiac condition like pulmonary embolism, aortic dissection or acute myocardial infarction, pneumonia, hypertension requiring inpatient hospitalization or any other medical condition, symptom or finding for which required inpatient hospital stay. 

In this particular case, there was no clinical decline or inadequate response to treatment which required inpatient hospital stay. The care the patient received, including treatment for chest pain presumed of gastrointestinal (GI) origin and responsive to histamine type two receptor antagonists/blockers (H2 blocker) therapy like in this case, is routinely provided safely and effectively at a lower level of care. Therefore, based on the submitted information and the current published medical literature, the proposed treatment is not medically necessary.       

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

In this particular case, there was no clinical decline or inadequate response to treatment which required inpatient hospital stay. The care the patient received, including treatment for hypertensive urgency and chest pain like in this case, is routinely provided safely and effectively at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Preterm Labor
Treatment: Full Hospital Admission
The insurer denied: Full Hospital Admission
The denial is: Upheld

The patient is a gravida (G)2 para (P)1 female who was sent from her physician's office for steroids and observation for preterm labor. The patient reported that she had contractions of 1 in 10 minutes with intensity of 5 of 10. She had no leakage of fluid and no bleeding present. Pain was present. She was admitted for steroids. Exam of cervix was 3 centimeters (cm) / 50% effaced / -3 station on exam. She had normal non-invasive prenatal screening (NIPS) after positive trisomy 21 on sequential screening. She had a history of depression on Lexapro and Wellbutrin. She denied any surgical history. She had a history of prior preterm birth at 34 weeks with her gravida one (G1) pregnancy. Vitals were stable and she was afebrile. Contractions were noted every (q) 2-3 minutes on tocodynamometer (toco) but the patient was comfortable. She was started on Nifedipine 20 milligrams (mg) q 6 hours ongoing and Ampicillin for group B streptococcus (GBS) prophylaxis was started.

The health plan's determination is upheld.

Based upon a review of the medical records, the recommendations of the American College of Obstetricians and Gynecologists (ACOG) and Milliman Care Guidelines (MCG), there would have been no medical necessity for full hospital admission. In this case, the patient was noted to have a singleton gestation at 33-5/7 weeks gestation with threatened preterm labor. There was a cervical exam on admission to document the cervix as 3/50%/-3 station by the physician. However, given preterm contractions, a plan was made for Ampicillin, nifedipine and steroids (a course of betamethasone). The fetal monitoring was reported as normal and reassuring with a singleton gestation that was normally grown by prior ultrasound. The patient completed nifedipine without complications. There was completion of two doses of betamethasone for fetal lung maturity. The patient had a trial of tocolysis that was successful and without complications with the oral nifedipine. In this case, the care rendered would have been appropriate at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Genetic Diseases/Sickle Cell Disease/Sickle Cell Pain Crisis. 
Treatment: Inpatient Hospital Admission. 

This case involves a man with sickle cell anemia who presented to the emergency department (ED) with generalized body pains for 2 to 3 days concerning for a sickle cell pain crisis. He was evaluated in the ED and was found to have an elevated blood pressure of 170/91 millimeters of mercury (mmHg), a pulse rate of 102 beats per minute (bpm) with a normal temperature and respirations. Oxygenation status was normal. The exam showed scleral icterus, soft abdomen, and normal pulmonary effort.
Laboratory studies were consistent with anemia with a hemoglobin of 6, a white blood cell count of 11.1, a creatinine of 4.5, and a bicarbonate of 18. The patient has a history of chronic kidney disease stage IV-V. High-sensitivity troponin was 60.4. The electrocardiogram (EKG) showed no evidence of ST-segment elevation. A chest x-ray was unremarkable. 

Given the patient's ongoing chest pain, he was admitted to the hospital for further management. The ED provided a blood transfusion before admission. 
The medical team assessed the patient, ordered additional cardiac troponins, and placed him on telemetry. They noted the patient had baseline elevation in his cardiac troponins between 40 and 60. They provided pain control with Hydromorphone and Acetaminophen. His home blood pressure regimen of Amlodipine and Clonidine was restarted. 

The following morning, labs showed improvement in the hemoglobin to 7.2, and similar for the creatinine and electrolytes. The troponin increased slightly to 73.7. The blood pressure was improved to 138/68 mmHg. The patient requested to leave and refused additional procedures or medical treatment. He signed against medical advice and left the hospital. 

At issue is the medical necessity for the inpatient hospital admission. 

I fully uphold the health plan's determination of medical necessity. 

No, an inpatient hospitalization was not warranted in this case. 
Based on the provided documentation, I found no evidence of a failure of observation treatment. The patient was experiencing an exacerbation of sickle cell pain, with worsened anemia, requiring a blood transfusion and parenteral narcotics to control the pain. There was no evidence of acute chest syndrome, as the patient has a normal chest x-ray, no hypoxia, and no dyspnea symptoms. The patient's troponins are chronically elevated in the setting of chronic kidney disease stage IV-V. The creatinine appeared to be at baseline. The hemoglobin appropriately improved after the blood transfusion. There is no evidence of further end-organ organ damage, such as acute stroke, secondary infection, or peripheral ischemia. Therefore, criteria for an alternate level of care were met. Inpatient admission was not indicated. An alternate level of care is adequate for treating sickle cell pain for up to 48 hours, in the absence of acute end-organ damage, acute chest syndrome, hypoxemia, or signs of infection.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma
Treatment: Inpatient hospital admission
The insurer denied coverage for an inpatient hospital admission.
The denial is overturned.

This is a toddler with a history of eczema and moderate persistent asthma who has had 4 previous hospitalizations for asthma. The most recent hospitalization was two weeks prior to this admission. She continued to have coughing with wheezing ever since she had been discharged and she was still requiring albuterol 1 to 2 times every day. On the day of admission, she had shortness of breath with retractions and increased work of breathing. She also had a fever of 101 degrees. She had been taking budesonide and albuterol treatments at her mother's home but when she was staying at her father's home on the day of her illness, she had not been given her asthma therapies. The mother administered 2 albuterol treatments at her home when the child returned from her father's home but when her wheezing did not improve, the mother brought her to the emergency room (ER) for additional treatment.

In the ER, she was noted to have increased work of breathing with wheezing and retractions. She was treated with DuoNeb on three occasions, dexamethasone and magnesium sulfate. A chest x-ray was normal, but her blood gas showed an elevated partial pressure of carbon dioxide (pCO2) of 44.7. When her wheezing and increased work of breathing did not improve with treatment in the ER, the decision was made to admit the child to the hospital with a diagnosis of status asthmaticus for continued treatment with albuterol every 3 hours.

The patient was treated appropriately in the ER for an acute episode of wheezing and difficulty breathing. The child has a history of poorly controlled asthma with multiple hospitalizations and the most recent was 2 weeks prior to this admission. Despite preventive therapy with budesonide which had been administered in the mother's home, the child had continued to have coughing and wheezing daily since the previous admission. When she did not respond to treatment in the ER and her pCO2 was elevated on her blood gas, the decision was made to admit her to the hospital with a diagnosis of status asthmaticus. She was not stable enough to be safely discharged since she required albuterol every 3 hours.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. 

The medical necessity for an inpatient hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Respiratory
Inpatient hospital

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

The patient is a young female brought to the emergency room with five days of fever and cough. Two days prior, she was seen by her primary care physician who prescribed prednisone for possible croup. At triage, her temperature was 99.6oF, respiratory rate 38, and oxygen saturation 97% on room air. On exam by the emergency department (ED) resident, she appeared non toxic, in no apparent distress. She had moist mucus membranes, no increased work of breathing or retractions, and coarse breath sounds bilaterally.

Inpatient Hospital Admission was not medically necessary for this patient. The patient had mild respiratory distress, was not dehydrated, and was not otherwise ill appearing. She had not received any antibiotics during her illness, so she had not failed an outpatient trial of antibiotics for the possible bacterial pneumonia superimposed on the parainfluenza virus respiratory infection. She did not need admission for respiratory support, oxygen, or intravenous antibiotics (since she had not failed oral antibiotics). A lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Iron deficiency anemia

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld
 

The patient is an adult with a diagnosis of uterine fibroids and Iron (Fe) deficiency anemia who presented with vaginal bleeding and abdominal pain. The patient has a history (hx) of anemia needing transfusions, the last being 6 months prior to presentation. She cited lightheadedness, nausea and shortness of breath but denies palpitations or chest pain. Pelvic examination showed scant bleeding. Hematocrit was 19.1/hemoglobin 5.3. She received 2 units of packed red blood cells in the emergency department (ED) and was admitted by Gynecology for continuous transfusion. 

This patient has symptomatic anemia. She fulfills the transfusion guidelines for use of blood components: her hemoglobin was less than 8 so, transfusion was necessary. It is obvious that transfusions are done routinely in outpatient settings (oncology clinics, infusion centers, even at home). So, the need for transfusion is not a reason for admission. The patient could have been transfused as an outpatient. Note that the patient was not actively bleeding.

Milliman Care Guidelines (MCG) lists the clinical indication for inpatient care for patients with anemia. These include active massive hemorrhage, active hemolysis, cognitive impairment, heart failure, chest pain, syncope. This patient was stable and did not have any of the above. The patient could have been transfused with the 3 units of packed red blood cells (PRBCs) and discharged home ensuring that the patient was stable.

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 hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is overturned
 
This case involves an adult patient who presented to the emergency department complaining of an acute onset of headache, dizziness, and abdominal pain. When she arrived, she endorsed that dizziness began about 1 hour prior and was associated with emesis. The patient had a history of hyperlipidemia, intracranial vascular stenosis, obesity, a history of smoking, and primary hypertension. The patient endorsed that she had not been taking prescription medications for 2 months due to side effects of nausea. Records stated the patient arrived at the emergency department with the patient complaining of dizziness. A focused assessment was completed with vital signs showing blood pressure at 204/103. The patient sepsis risk score was 0.93. She was found to have an elevated glucose of 140. Her blood pressure was 176/83 and she endorsed a pain level of 8/10 located in the head. Laboratory testing and imaging was obtained for further work-up. The patient was placed on a midazolam injection along with ondansetron. The patient's blood pressure was 159/85.  Records indicated that because the patient's blood pressure was elevated, a stroke code was activated. The patient was treated with Procardia, aspirin, atorvastatin, Brilinta, and was admitted for further work-up/care. The patient subsequently left against medical advice.

According to the Milliman Care Guidelines, a clinical indication for admission to inpatient care includes those individuals who have systolic blood pressure greater than 180 or diastolic blood pressure greater than 120 mmHg (millimeters of mercury) with one more the following to include hypertensive encephalopathy, cerebral infarction, intracranial hemorrhage, myocardial ischemia or infarction, heart failure, aortic dissection, increased creatinine (new) from baseline, papilledema, retinal hemorrhage, microangiopathic hemolytic anemia, seizure, or other acute or worsening organ damage due to severe hypertension. A hospital admission may also be indicated for individuals who display symptoms of atrioventricular conduction abnormalities to include dizziness.  

In this case, the patient presented with headache, dizziness, and abdominal pain. The initial blood pressure was 204/103. Given these findings, the inpatient admission was appropriate as the patient needed further work-up/care and was at risk for stroke and/or myocardial infarction. Even though she left against medical advice, inpatient admission was appropriate and medically necessary.

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

Diagnosis: Rule out cerebrovascular Accident (CVA)
Treatment: Inpatient stay
The insurer denied coverage for the inpatient stay.
The denial is overturned.
 
This case involves an adult under review for inpatient hospitalization. The emergency department (ED) note reported the patient presented with complaints of right facial droop since the prior morning. The patient also reported a 2-hour history of right extremity weakness.  Examination noted right facial droop with fluent speech and 5/5 motor strength. The patient was noted to be hemodynamically stable. The provider noted presentation was most concerning for cerebrovascular accident (CVA). It was noted that the computed tomography (CT) of the head and CT angiogram were negative for acute intracranial pathology. The patient was outside the window for administering tPA (Tissue plasminogen activator). Notes indicate the patient was admitted with a diagnosis of Bell's palsy and was awaiting for a bed on an inpatient unit. The patient was discharged.

In this case, the patient initially presented with right facial droop and right-sided weakness. Initial diagnostic work-up was negative for acute intracranial pathology. However, the fact that the patient had right arm weakness raises the possibility of transient ischemic attack (TIA) / Stroke. Even if the patient had transient weakness there is a high risk of having a stroke in the 24-72 hour window. As a result, patients are admitted to the hospital for stroke workup and close observation.

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 inpatient stay is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis
Treatment: Power Operated Vehicle (Electric Scooter)
The insurer denied: Power Operated Vehicle (Electric Scooter)
The denial is: Upheld

The patient is a female with sarcoidosis, osteoarthritis, lumbar laminectomy, failed back surgical syndrome, chronic pain, sciatica, adhesive capsulitis of the left shoulder, subacromial impingement of the shoulder, cervical radiculopathy, and Parsonage Turner syndrome. It was stated that she had recently undergone a thoracic (T)10 to pelvis surgical fixation with decompression of the thoracic spine from T10-T12.

At issue is the medical necessity for a Power Operated Vehicle (Electric Scooter).

The requested Power Operated Vehicle (Electric Scooter) is not medically necessary for this patient. The patient has sarcoidosis, osteoarthritis, lumbar laminectomy, failed back surgical syndrome, chronic pain, sciatica, adhesive capsulitis of the left shoulder, subacromial impingement of the shoulder, cervical radiculopathy, and Parsonage Turner syndrome. Her treating provider stated that the patient had recently undergone a T10 to pelvis surgical fixation with decompression of the thoracic spine from T10-T12. Her chronic musculoskeletal comorbidities limited her ability to ambulate and complete her activities of daily living as well as attend her multiple medical appointments. The treating provider stated that the patient needed a foldable motorized electric scooter as she lived on the second floor of an apartment building with no elevator and cannot carry a non-foldable scooter. She has "issues" with ambulating for long periods, even with a walker. She has difficulty carrying things for long periods. She lives in a four bedroom apartment and has problems with standing, reaching, bending, and twisting. The scooter will allow her to be mobile and complete her activities of daily living (ADLs) when she is alone in her apartment. The scooter will allow her to get to her many appointments.

In summary, the documentation provided does not support the medical necessity of a power operated vehicle (electric scooter) for this patient. The peer-reviewed medical literature in the United States at this time would not recommend a power operated vehicle (electric scooter) for this patient. Further the medical standard of care does not support the use of a power operated vehicle (electric scooter) for this patient.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Congestive heart failure. 
Treatment: Farxiga 10 milligram (mg) Tablet. 

The insurer denied Farxiga 10 mg Tablet. 
The denial is Upheld. 

The patient is a female with a history of coronary artery disease, ischemic cardiomyopathy and heart failure with reduced ejection fraction. By echocardiogram, her left ventricular ejection fraction was 37%. The subject under review is the use of the non-formulary drug Farxiga. 

There are no high quality data indicating that the formulary alternative Jardiance would be less effective that Farxiga in this instance, or that it would have more adverse effects.
This patient has heart failure with reduced ejection fraction (HFrEF). Both Farxiga (dapagliflozin) and Jardiance (empagliflozin) are members of a class of drugs called sodium-glucose cotransporter-2 (SGLT2) inhibitors. In a large, multi-center placebo-controlled trial, 4744 patients with New York Heart Association class II, III, or IV heart failure and an ejection fraction of 40% or less were randomly assigned to receive either dapagliflozin (Farxiga) or placebo. Farxiga was associated with a significant decrease in the primary outcome which was a composite of worsening heart failure (hospitalization or an urgent visit resulting in intravenous therapy for heart failure) or cardiovascular death. Farxiga is Food and Drug Administration (FDA) approved to reduce the risk for cardiovascular death and hospitalization for heart failure in adults with heart failure with reduced ejection fraction. In patients with HFrEF Jardiance (empagliflozin) has also been shown to lower the risk of cardiovascular death or hospitalization for heart failure as compared to placebo. Like Farxiga, It is FDA approved to reduce the risk of cardiovascular death and hospitalization in adults with heart failure with reduced ejection fraction (HFrEF). The two drugs have similar safety profiles; their most common side effects are urinary tract infection and vaginal yeast infection. At this point there have been no randomized trials directly comparing the two agents. While current guidelines endorse the use of an SGLT2 inhibitor in patients with HFrEF, they do not specify the use of one agent over the other.