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

Diagnosis: Adenovirus

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
This was young child, previously healthy, who came to the Emergency Room (ER) for persistent fever for about 8 days, between 100 and 102 degrees Fahrenheit, mostly in the evenings. About three weeks prior he had been treated for otitis media with 10 days of an antibiotic. He was diagnosed with a recurrence of otitis media in another hospital, and prescribed Augmentin which he completed on the day of this visit. Review of systems was negative and he had a normal appetite. 

Physical exam in the ER revealed a well looking toddler in no acute distress, with no focal signs of infection including the tympanic membranes (normal), and no signs of dehydration. His vital signs other than rectal temperature of 103.6 degrees Fahrenheit were normal.

Respiratory viral panel (RVP) showed adenovirus, and there was incidental discovery of neutropenia and elevated liver transaminases. A chest X-ray was normal. White blood cell count (WBC) was 4770 with 4% neutrophils.

There is not adequate medical decision making documentation that adequately justifies a clinical need for admission to the hospital. His fever, neutropenia, and elevated liver enzymes can all be associated with his adenoviral infection. Moreover, this is not a case of protracted neutropenia as will be seen in hematology-oncology patients, which would increase the risk of a secondary bacterial infection, as viral induced neutropenia is usually transient. Moreover, the patient was not dehydrated, toxic-appearing or otherwise ill-appearing in any other way. 

"An adenovirus infection in a previously healthy child like the patient is self-limited and treatment is supportive." (Munoz et al.) Otherwise healthy well appearing children with transient isolated neutropenia that is associated with an intercurrent infection, are at low risk of bacterial infection, and should be managed like children without neutropenia. A similarly febrile child without neutropenia would be managed in the outpatient setting, with follow up of blood counts in a few days to weeks to ensure resolution of neutropenia. (Ahmed et al.)

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Orthopedic
Inpatient hospital

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

The patient is a male with past medical history (PMH) of chronic obstructive pulmonary disease (COPD), HFrEF (heart failure with reduced ejection fraction) (ejection fraction (EF) 27%), gastroesophageal reflux disease (GERD), coronary artery disease (CAD) status/post (s/p) stents, and diabetes mellitus type 2 who was admitted with complaints of severe lower back pain with radiation to bilateral flanks without accompanying leg weakness, bowel/bladder dysfunction, or saddle anesthesia. 

The inpatient hospital stay was not medically necessary. This patient presented to the ED with complaints of back pain without evidence of severely compromised neurological function. The patient received a thorough diagnostic and imaging work-up, which did not demonstrate any acute fractures or dislocations. The patient did not have an abdominal aortic aneurysm, aortic dissection, cauda equina syndrome, epidural abscess or hematoma, acute spinal fracture, meningitis, osteomyelitis, progressive neurologic deficits, fever, discitis, or tumor. For the acute kidney injury (AKI), the patient did not have patient did not have hypertension (HTN) requiring continuous vasoactive medication, no concomitant febrile illness, and there was no urgent indication for dialysis, marked electrolyte abnormalities, volume overload, severe hyponatremia, hyperkalemia, metabolic acidosis, or acute respiratory distress, while the patient's decrease in glomerular filtration rate (GFR) was < 50% and it is clearly documented that the patient's HTN was without evidence of related end-organ damage. The patient received IV pain control, IVF, radiologic work-up, and physical therapy (PT), all of which could have been safely provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anaphylaxis and hypotension

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

 
This is a pre-teen male with a history of asthma and allergy to nuts. He ate some food which contained nuts and within one hour of the ingestion he began to have tingling of his tongue and a feeling of "tightness in his throat". He was given Benadryl at home for the possible allergy and when his symptoms worsened and he complained of difficulty breathing he was taken to the emergency room (ER) for treatment.

In the ER he was noted to be ill appearing with tachypnea and respiratory distress. On physical examination he was noted to be toxic appearing and sitting in a tripod posture with retractions and wheezing. He was treated with three doses of epinephrine and he was given an intravenous (IV) bolus of normal saline. He was also given ketamine, magnesium sulfate and dexamethasone. When his symptoms persisted he was started on bilevel positive airway pressure (BIPAP) and an epinephrine drip. A blood gas was drawn which showed an acidosis with a potential of hydrogen (pH) of 7.29 and an elevated carbon dioxide (CO2) of 52.6. He was then noted to have a low blood pressure with a low mean arterial pressure <60 (less than 60). He continued to have increased work of breathing and wheezing and the decision was made to admit him to the pediatric intensive care unit (PICU) with a diagnosis of anaphylaxis and hypotension. The plan was to continue inhaled albuterol every 2 hours.

The insurer has denied this admission and stated that there was no documentation in the medical record to establish the need for admission to the hospital.

The patient was treated appropriately in the ER for anaphylaxis and wheezing. He had a respiratory acidosis with an elevated CO2 indicating that he was at risk for respiratory failure. When his respiratory distress, wheezing and increased work of breathing persisted despite appropriate treatment in the ER, the admission to the hospital for ongoing treatment was consistent with the standard of care. He was not stable enough to be discharged to his home and the need for continued IV fluids to treat his low blood pressure and the need for inhaled albuterol every 2 hours could not have been safely administered in the home setting.

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

Diagnosis: Crohn's disease
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient with a medical history of Crohn's disease complicated by pyoderma gangrenosum, left leg ulceration, bilateral sacroiliitis, coronary artery disease status post stent placement, hypertension, asthma, schizoaffective disorder, and substance use disorder. He presented to the emergency department with severe abdominal pain, nausea, vomiting, and bloody diarrhea. He was noted to have leg pain with chronic left leg wounds. He had been admitted at another facility the prior week; he had been off Remicade. The physical examination was notable for a soft abdomen with generalized abdominal tenderness, and two open left leg ulcers, with underlying granulation tissue.  A test for coronavirus 2019 (COVID-19) was positive. A chest x-ray showed no focal consolidation to suggest pneumonia. 
He was treated with intravenous metronidazole, levofloxacin, morphine, Dilaudid, pantoprazole, diphenhydramine, SoluMedrol, and fluids.He had significant abdominal pain overnight. Infectious Disease noted symptoms for over a week, and did not recommend medical therapy. A gastroenterology consultation noted Crohn's disease complicated by pyoderma gangrenosum, with abdominal pain and bloody bowel movements; he was on metronidazole, SoluMedrol, and pantoprazole; the recommendation was to restart Remicade in the hospital and continue the current medical regimen. He eloped from the hospital against medical advice with a plan for Primary Care and Gastroenterology follow-up. At issue is the medical necessity for the inpatient level of care.
The inpatient level of care was not medically necessary. The patient presented with symptoms (bloody diarrhea, nausea, vomiting, abdominal pain) and imaging suggestive of a Crohn's disease flare; he was appropriately treated with corticosteroids and a plan for resumption of infliximab [1-6]. However, there was no complication such as a small bowel obstruction, intra-abdominal abscess, bowel perforation, toxic megacolon, peritonitis, fistula, or sepsis, which would require the inpatient level of care [1-6]. The patient was found to have COVID-19 infection, but did not have markers of progressive or complicated COVID-19, and did not need treatment [7,8]. The interventions performed during his stay, including labs, imaging, intravenous fluids, empiric antibiotic therapy, and corticosteroid therapy, could have been performed without the inpatient level of care, at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain, palpitations
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay.
The determination is upheld.

This is a male patient who presented to the emergency department (ED) via Emergency Medical Services (EMS) complaining of chest pain, palpitations, nausea, vomiting and diaphoresis. His medical history was remarkable for coronary artery disease, ischemic cardiomyopathy, heart failure with reduced ejection fraction, human immunodeficiency virus (HIV) infection, diabetes, anxiety, and stroke. The patient received aspirin and nitroglycerin from EMS en route to the ED. The patient was treated with intravenous (IV) fluid. His chest pain resolved during his stay in the ED.

He was admitted to the hospital to rule out acute coronary syndrome (ACS). His diuretics were held due to his elevated creatinine level. He was seen in consultation by a cardiologist who opined that ACS was unlikely and recommended adding Imdur to the patient's anti-anginal regimen if his blood pressure would tolerate it. He remained pain-free. The Imdur was not prescribed due to borderline low systolic blood pressures. An echocardiogram showed a left ventricular ejection fraction of 25 percent (%) with regional wall motion abnormalities; this was similar to prior studies. The patient's systolic blood pressure remained above 100 millimeters of mercury (mmHg) and Imdur was started. During the early morning hours, when he awoke from sleep for a blood pressure measurement, his blood pressure was 65/42 mmHg. He had no symptoms at the time. A repeat measurement was 100/73 mmHg. The Imdur was discontinued and he was discharged later that day. At issue is the medical necessity of an inpatient hospital stay.

Based on the documentation provided, an inpatient level of care was not medically necessary.

This patient, with known coronary artery disease, presented with symptoms that were thought to be suspicious for ACS. Accordingly, observation until ACS could be ruled out was a reasonable approach. However, he was hemodynamically stable, with no acute ischemic electrocardiographic changes. While his serum troponin level was minimally elevated, this was not thought to represent ACS. He did not require intensive monitoring or infusion of IV cardioactive medications. Urgent cardiac catheterization was not deemed necessary. The care this patient received for his chest pain did not require an inpatient admission and could have been provided at a lower level. This approach has been shown to be safe and is in accordance with current guidelines including the 2021 American Heart Association (AHA)/American College of Cardiology (ACC)/American Society of Echocardiography (ASE)/American College of Chest Physicians (CHEST)/Society for Academic Emergency Medicine (SAEM)/Society of Cardiovascular Computed Tomography (SCCT)/Society for Cardiovascular Magnetic Resonance (SCMR) Guideline
for the Evaluation and Diagnosis of Chest Pain and the 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Recent femur fracture and conditions that include cerebral infarct, history of falls, schizophrenia, seizures, hemiplegia, dysarthria, diabetes, and alcohol abuse
Treatment: Long-term custodial care admission
The insurer denied the long-term custodial care admission.
The denial is overturned.

This is an elderly male patient that had a recent femur fracture and conditions that include cerebral infarct, history of falls, schizophrenia, seizures, hemiplegia, dysarthria, diabetes, and alcohol abuse. He was admitted to rehab due to difficulty with ambulation and activities of daily living (ADLs). The patient has generalized weakness and deconditioning. Additional physical, occupational, and speech therapy is recommended. The patient is receiving an oral diet. Medication regimen has been established. The patient requires assistance with mobility and ADLs. He requires supervision with eating. He does not have a tracheostomy tube. He does not have decubitus ulcers. He requires a wheelchair for mobility and two-person transfer. He is incontinent.

The requested health service was medically necessary.

Custodial care is care primarily for the purpose of assisting a patient in ADLs or in meeting personal rather than medical needs, and which is not specific treatment for an illness or injury. It is care that cannot be expected to substantially improve a medical condition and has minimal therapeutic value. Such care includes assistance with walking, bathing, or dressing, transfer or positioning in bed, normally self-administered medicine, meal preparation, feeding by utensil, tube, or gastrostomy, oral hygiene, ordinary skin and nail care, catheter care, suctioning, using the toilet, enemas, or preparation of special diets and supervision over medical equipment or exercises or over self-administration of oral medicine. The health plan denied the long-term custodial placement due to lack of a custodial agreement. The information provided supports that the patient has been receiving custodial care. The patient requires assistance with ambulation, bathing, dressing, transfers, and toileting, and supervision with eating and medications. The requested long-term custodial care admission for the dates of service under review was medically indicated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic Dermatitis
Treatment: Dupixent Syn 300
The insurer denied: Dupixent Syn 300
The denial is overturned.

The patient is an adult female with atopic dermatitis to the hands and feet, severe. She has treated with triamcinolone, halobetasol, Eucrisa, mupirocin, Protopic, phototherapy, antihistamines, and ammonium lactate lotion. The provider is requesting Dupixent (dupilumab). The health plan requires use of at least two oral immunosuppressants. The patient has no other past medical history.

The proposed treatment is medically necessary.

Dupilumab is United States Food and Drug Administration (FDA) indicated for treatment of recalcitrant atopic dermatitis, approved in 2017. Two trials, SOLO-1 and SOLO-2 demonstrated that patients treated with Dupilumab experienced significant, clinically meaningful improvements in their atopic dermatitis at week 16 as measured by the Eczema Area and Severity Index (EASI). Dupilumab was well tolerated with the most commonly reported side effects including injection site reactions and conjunctivitis. Dupilumab is a novel interleukin-4 and interleukin-13 blocker, which inhibits the arm of the immune system responsible for atopic dermatitis. In clinical trials, after 12 weeks of monotherapy with dupilumab, 85% of patients had a greater than 50% reduction in eczema severity and pruritus scores decreased by 57.1%. In phase III clinical trials, dupilumab led to a 75% improvement in eczema severity, when compared to placebo, and decreased symptoms of anxiety and depression. It also led to a significantly decreased use of topical corticosteroids. The safety and efficacy were supported in a recent meta-analysis of all published dupilumab papers (3). The patient has tried and failed appropriate therapies and while there are no contraindications to oral immunosuppressants, these are far inferior to Dupixent.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroenteritis
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay.
The determination is upheld.

This is a male patient who presented for abdominal pain, vomiting, diarrhea, and decreased oral intake. At the emergency room (ER), his vital signs were normal. He showed signs of dehydration. He was started on intravenous (IV) fluids and was admitted for further management. He was given Zofran for nausea and vomiting in addition to Pepcid. He gradually improved and was discharged home in a stable condition. His final diagnosis was viral gastroenteritis and pharyngitis.

The admission to an acute inpatient level of care was not medically necessary.

Most gastroenteritis cases do not require inpatient care. However, a small percentage of patients develop severe dehydration and require IV rehydration and hospital care. Per Banyai, K., et al. (2018) "For treatment of dehydration caused by gastroenteritis viruses, the administration of reduced-osmolality oral-rehydration solutions [50-60 millimoles per liter (mmol/L) sodium] is the first line of therapy. Profuse vomiting, worsening dehydration with altered consciousness, or severe acidosis, hypovolaemic shock, abdominal distension, and ileus are indications for intravenous rehydration."

This patient presented to the ER for diarrhea and vomiting and developed signs of dehydration. He was unable to maintain oral hydration, therefore, continued outpatient management was not appropriate.

However, he was hemodynamically stable and did not have mental status changes or severe electrolyte abnormalities. He had no evidence of a bowel obstruction or ileus. He did not have evidence of a renal injury or other organ damage.

The provided care included IV fluids, antiemetics, and monitoring. The patient did not require invasive procedures or surgical interventions. He did not require a complex treatment regimen or respiratory support.

Therefore, the patient's condition and his care were manageable at a lower level of care. Acute level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumonia. 
Treatment: Inpatient Hospital Stay. 
The insurer denied the Inpatient Hospital Stay. 
The determination is overturned. 

This is a male patient who presented with a fever, cough, and respiratory distress. He was well until the day prior to presentation when he developed a fever, rhinorrhea and cough. He also vomited twice. He was brought to medical care, and a rapid strep test and viral panel were negative. He was sent home with Tylenol. However, he continued to have symptoms so he returned for care. His mother had a recent positive strep test.
On physical examination, he was noted to have bilateral erythematous tympanic membranes and enlarged tonsils. He also had a patch of eczematous rash on his cheeks. A chest x-ray revealed a right infra-hilar opacity consistent with pneumonia. He was tried on oral treatment but refused, so he was admitted for further care for dehydration with pneumonia. 
In the hospital, he was kept on intravenous fluids and parenteral ceftriaxone. He was also given a dose of dexamethasone and Flonase for congestion. He improved over time and later was felt to be stable for discharge to continue treatment with oral antibiotics and with follow up as an outpatient. At issue is the medical necessity of an inpatient stay.
The requested health service/treatment of Inpatient hospital admission was medically necessary for this patient. 
This is a young boy who presented with pneumonia and vomiting. He was found to have a positive rapid strep and pneumonia on x-ray. He refused oral treatment, and therefore required hospital admission for treatment with parenteral antibiotics and intravenous fluids to maintain his hydration status along with close monitoring for potential deterioration of clinical status. 
According to the Milliman Care Guidelines (MCG) Inpatient and Surgical Care Guidelines, 26th Edition, Pneumonia, Pediatric, hospitalization is indicated for patients with failure of outpatient treatment and dehydration that is persistent. This patient had vomiting and increased fluid needs due to pneumonia, and refused oral antibiotic treatment. He therefore required hospital admission for ongoing treatment with parenteral antibiotics, intravenous fluids, and close monitoring.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Total occlusion of the left anterior tibial artery - Proximal. 
Treatment: Inpatient hospital admission. 
The insurer denied coverage for the inpatient hospital admission. 
The denial is upheld. 
 
Asked to review the case of a woman that presented to the hospital for elective peripheral angiogram. She reported bilateral claudication with left lower extremity pain greater than right. Past medical history was significant for hypertension and diabetes mellitus. Peripheral angiography revealed peripheral arterial disease with a chronic total occlusion of the left anterior tibial artery - Proximal. The patient underwent successful percutaneous transarterial atherectomy/ atherotomy of the proximal left anterior tibial artery. There were no perioperative or post operative complications. Post procedure vital signs were stable and physical examination revealed no evidence of lower extremity hematoma with 2+ dorsalis pedis pulses bilaterally. The patient was discharged the following day.

This patient presented with lower extremity claudication and underwent successful elective revascularization of the proximal left anterior tibial artery. There were no periprocedural complications and the patient was discharged the following day. Several investigators have demonstrated safety and efficacy of same day or 23-hour observation post uncomplicated peripheral vascular interventions. (Reference 1,2). Such findings explain why trends noted in a large study of Medicare recipients resulted in a significant reduction in inpatient stays associated with endovascular intervention for peripheral artery disease. (Reference 3)

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 an inpatient admission is not substantiated.