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

Diagnosis:  Distal Tibial Diametaphyseal/Metaphyseal Fracture. 
Treatment:  Interfacility transfer and hospital admission. 

The insurer denied the interfacility transfer and hospital admission.  The denial was overturned. 

This is a female patient with a history of hypertension, hypothyroidism, pulmonary embolism, Guillian-Barre, idiopathic thrombocytopenic purpura (ITP) and quadriparesis.  She slipped and twisted her right ankle with visible bone.  It was reported that she initially presented to a medical facility and underwent incision and drainage and external fixation.  She was transferred to another hospital for definitive management.  Computed tomography (CT) showed externally fixed comminuted and displaced distal tibial diametaphyseal/metaphyseal fracture with possible intra-articular extension and air between the fracture fragments and in the soft tissues contiguous with a skin/soft tissue injury indicative of an open fracture.  She underwent reduction open fixation internal tibial plateau, removal hardware.  The patient was discharged to subacute care. 

The transfer and hospital admission was medically necessary for this patient. 

The medical record demonstrates the woman sustained a serious and complex injury.  She also had several underlying comorbidities. 

She was found to have an open (compound fracture) to the distal tibia.  There was intra articular extension with findings consistent with pilon fracture.  There was comminution.  These findings substantiate soft tissue injury and extensive intra articular bone involvement.  Management of this condition should be performed by well qualified and experienced Traumatologist.  Even in the best of hands, complications are common.  This type of fracture pattern is high risk for infection, nonunion and permanent dysfunction. 

Based upon the description of initial hospital and second institution, it would be best for definitive management to be completed in a medical center environment.  The initial hospital lists "basic ortho" among its services and does not include it in its list of center of excellence.  The department of Orthopedics at the transferring hospital is among the top 10 in the USA as per US News and World Report.  Furthermore, it lists a specific department dealing with foot and ankle surgery.  The faculty members of the Foot and Ankle section have published their research regarding foot/ankle surgery and have a large training program for residents and fellows.  It would be in the best interest of this patient to be transferred to the other medical facility for continuation of care.  It would be unlikely the same services could be obtained at the original facility. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

Based on the above, the medical necessity for interfacility transfer and hospital admission is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive system/gastrointestinal abdominal pain.
Treatment: Inpatient hospital.
The insurer denied the inpatient hospital stay.
The denial is upheld in whole.

This is the case of a  patient with past medical history of asthma and anemia who presented to the emergency department with 2 days of abdominal discomfort in the setting of history of menometrorrhagia without current bleeding.

No, the inpatient stay was not medically necessary.

This was a patient who presented with abdominal pain with a wide differential of diagnoses. The patient was hemodynamically stable, did not have associated renal failure, did not require emergent surgery or other interventions, and was seen by numerous specialists (gastroenterology, gynecology, and surgery) with ultimate plan to pursue symptom management and follow up as at a lower level of care r The symptoms were also subsequently able to be adequately managed within a reasonable period of time and the patient  was discharged.

In the absence of hemodynamic instability, interventions required in the hospital other than symptom management with it felt the patient could otherwise follow up as an outpatient, and with the patient symptoms adequately managed within a reasonable period of a lower level of care  it is unclear why the patient could not have been safely cared for at the lower level of care services in lieu of requiring inpatient care. Inpatient care was not medically necessary in this case.
Appeal type: Formulary Exception
Decision: Upheld

Orthopedic/Musculoskeletal
Pharmacy/Prescription Drugs

Diagnosis: Pain
Treatment: Indomethacin
The insurer denied Indomethacin. The health plan's determination is upheld. 

The patient is a male who presents with progressive worsening of pain in right arm radiating into bilateral hands with pain. Under review is the use of Indomethacin. Past medical history is notable for high cholesterol and rheumatoid arthritis. 

Indomethacin can be used for pain relief in patients with rheumatoid arthritis. While the patient reports a history of rheumatoid arthritis, there is no documentation that the patient is currently receiving treatment for this diagnosis and part of the treatment plan was a Rheumatology consult with differential diagnosis of "Rule out rheumatoid arthritis."
Furthermore, there is no documentation of previous medications tried and failed. Formulary drugs include diclofenac, etodolac, ibuprofen, ketoprofen and naproxen. Given the limited information provided, all of the formulary drugs are reasonable options to try first as there is no data to suggest that these medications will be or have been ineffective or would have adverse effects.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mental Health/anxiety
Treatment: Mental health outpatient 
The insurer denied Outpatient treatment-Mental Health Services
The denial is overturned in whole 

The patient is a male who was in treatment with multimodal psychotherapy for management of a pervasive developmental disorder (autism spectrum disorder); traumatic brain injury with associated symptoms of social anxiety disorder (social phobia); attention deficit hyperactivity disorder; non-verbal learning disorder; and, recurrent episodes of depressive disorder, as well as obsessive-compulsive related disorders that included skin picking and hair pulling (trichotillomania and excoriation disorders).
Yes, the requested outpatient mental health services are "medically necessary" for this patient.
The requested services of the extended outpatient mental health visit(s) for the DOS under review is consistent with prevailing standards of care and in keeping with evidence-based and empirical-based treatment principles and techniques that are being employed in this case, including treatment of the co-morbid conditions and ongoing issues related to executive functioning, communication, autism spectrum disorder/developmental disorder, obsessive-compulsive related disorders, social phobia and associated behavioral disturbances. Moreover, the treatment is clinically appropriate and medically necessary for this patient.
The outpatient mental health treatment and length of session(s) under review is consistent with prevailing medical standards or clinical guidelines pertaining to patients with the conditions diagnosed in this case, as well as the scientific literature involving evidence-based treatments, known to benefit patients with the conditions diagnosed in this case. The patient has moderately severe symptoms of mood and anxiety disorders, and obsessive compulsive and narcissistic personality traits with obsessive-compulsive related disorders, and ongoing stressors related to the developmental and communication disorders related to nonverbal learning disorder. The case is complicated by the multiple conditions that impact communication, social functioning and ability to maintain mood stability in the context of executive function problems, as well as social, emotional and cognitive impairments.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute asthma exacerbation due to influenza infection. 
Treatment: Inpatient hospital admission. 

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

This is a female patient with a history of asthma, transient ischemic attack (TIA), and renal stones who presented to the emergency department (ED) with a complaint of coughing, pleuritic chest pain, and hemoptysis. Her vital signs were: temperature 98 F, blood pressure 142/72 mm Hg, heart rate 102, respiratory rate 20, and oxygen saturation 100% on room air. The patient was in no acute distress, speaking in full sentences, was awake, alert and oriented. 

Physical examination revealed lungs with vesicular breath sounds and bilateral expiratory wheezing. Cardiovascular systems were normal. A chest x-ray showed no acute infiltrates. Influenza A was positive. The patient was treated with intravenous steroids, bronchodilators, magnesium, azithromycin, and Tamiflu. She was admitted to the hospital with an asthma exacerbation, was not hypoxic, was afebrile, and hemodynamically stable. This patient did not need acute hospitalization. There was subjective improvement after bronchodilation in the emergency department, but wheezing persisted. The patient was ambulating, in no acute distress, tolerating oral intake, remained stable, and there was no further hemoptysis. The patient was discharged in 2 days. 

This patient could have been placed on observational status while diagnostic testing and treatment were initiated. She could have been discharged home on oral antibiotics, oral steroids, and other maintenance asthma medications after a period of observation with close follow-up outpatient. 

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

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

Diagnosis:  Paroxysmal Atrial Fibrillation.
Treatment:  Inpatient hospital admission.

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

This is a female patient with a history of hypertension and paroxysmal atrial fibrillation (AF), who underwent an uncomplicated elective electrophysiological (EP) study with ablation.  According to hospital records, the ablation was successfully performed without complication.  The period of observation following this patient's ablation was unremarkable, and she had no post-operative issues.  The patient was discharged home the following day.  

Based on the review of the medical record, there were no clinical reasons for hospital admission for this patient.  The patient could have been safely managed at a lower level of care.  In two multicenter registry studies looking at healthcare utilization after EP study catheter ablation, more than 80% of patients undergoing ablation were hospitalized for a single day, regardless of age or co-morbidity.  However, a newer study demonstrated that patients undergoing atrial fibrillation ablation procedures could be safely discharged on the same day.  The current standard of care in an uncomplicated atrial fibrillation ablation is to manage patients at a lower level of care, which can be ambulatory or overnight observation.  Thus, acute inpatient admission was not medically necessary for this patient.

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

The carrier's denial of coverage for the inpatient hospital admission should be upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Comminuted Fracture of the Distal Fibula.
Treatment:  Air ambulance transport.

The insurer denied coverage for air ambulance transport.  The denial is upheld.

This is a female patient with a history of osteopenia.  She sustained a comminuted fracture of her distal fibula while skiing abroad.  The day after her injury she underwent intramuscular (IM) nailing to her tibia with open reduction internal fixation (ORIF) to her fibula.  She was transported home by air ambulance two days after the procedure.

The medical record demonstrates a non-complicated post-surgical course with transfer to home.  There was no medical condition requiring emergent and non-emergent air ambulance transportation.  The surgical site was without problem; vital signs were stable, and there were no underlying medical conditions to warrant treatment.  The patient did not require intravenous (IV) medications.  Her injuries were isolated to her leg/ankle area.  Prior to departure, she was able to ambulate to the bathroom independently with a rolling walker and CAM boot.  

The insurer allows for air ambulance when land ambulance is not appropriate, and medical condition requires immediate and rapid transportation.  Air ambulance transportation to home is not considered medically necessary.  These facts do not substantiate a medical condition to require emergent and/or non-emergent air transport as provided.  Possible increased rate of thromboembolic phenomena after surgery is a recognized complication but does not substantiate the need for emergent air transport.  There was no reason the patient could not have been transferred to a sub-acute setting abroad prior to going home. 

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

The carrier's denial of coverage for air ambulance transport is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Genitourinary / Kidney Disorder
Treatment:  Pharmacy/Prescription Drugs
The health plan denied the Aranesp.  The decision is upheld.

The patient is a male with end-stage renal disease status post renal transplant on 1/29/20.  Aranesp was prescribed for anemia.  The hemoglobin ranged between 9.0-9.7 between 2/18-3/16/20.  The subject under review is the medical necessity for Aranesp.

The health plan's determination is upheld.

The treatment with Aranesp is not medically necessary for this patient.  Standard guidelines for anemia due to chronic kidney disease recommend that adequate iron stores be maintained, as signified by an iron saturation at least 20% and ferritin at least 100.  Although the patient has anemia with a hemoglobin ranging between 9.0-9.7, there is no documentation of iron stores to substantiate adequate iron levels.  It has been shown that correction of iron deficiency, if present, reduces or eliminates the need for treatment with erythropoietin stimulating agents.  In summary, Aranesp is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary artery disease, congestive heart failure, dementia 
Treatment: Consumer Directed Personal Assistance Services level II, 2/12 hours per day, seven days per week (split-shift) 

The insurer denied Consumer Directed Personal Assistance Services level II, 2/12 hours per day, seven days per week (split-shift). The denial is overturned.

The proposed treatment of an increase in consumer directed personal assistance services level II, to 2/12 hours per day, seven days per week (split-shift) is deemed medically necessary. 

The patient is a female with a history of coronary artery disease, congestive heart failure, diabetes mellitus and dementia. Due to restrictions/limitations related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Appeal review requested for potential approval of an increase in consumer directed personal assistance services level II, to two 12 hours per day, seven days per week (split-shift) to offer increased assistance with completion of the patient's ADLs. 

This is a female with a history of coronary artery disease, congestive heart failure, diabetes mellitus and dementia. Due to restrictions/limitations related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Although an in home assessment of the patient's functionality and need for ADL assistance was completed; there is more recent documentation from the patient's attending physician. In this correspondence, the provider notes that the patient has demonstrated progressively worsening functional decline secondary to worsening dementia with significant safety concerns involving wandering behavior, turning on the kitchen stove and forgetting to turn it off and increased gait ataxia with frequent falls. For these reasons, the currently approved plan of consumer directed personal assistance services level II 44 hours/week is insufficient to meet the patient's current needs. Hence, the proposed treatment of an increase in consumer directed personal assistance services level II, to 2/12 hours per day, seven days per week (split-shift) is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Dx: Respiratory System
Tx: Inpatient Hospital
Denied: Inpatient stay
Denial: UPHELD in whole

This is the case of a female who presented to the emergency department (ED) with a complaint of fever to 103 Fahrenheit (F), cough, diarrhea 3-4 times daily, and decreased urine output. Symptoms began 3 days prior to presentation.
Emergency department (ED) vitals showed T 37.7 Celsius (C) (rectal), heart rate (HR) 187, respiratory rate (RR) 28, blood pressure (BP) 84/65, oxygen (O2) saturation 97% on room air. Physical exam was notable for absence of tears, nasal congestion with rhinorrhea, and bilateral rhonchi. Labs showed white blood cell (WBC)=9.2, hematocrit (Hct)=38.7, platelets (Plt)=187. Electrolytes were normal. Influenza and strep testing was negative; respiratory virus panel testing was positive for respiratory syncytial virus (RSV). The patient was given intravenous fluids (IVF) bolus x 2, tolerated some sips of Pedialyte but an oral challenge produced large emesis. The decision was admitted for further management and intravenous (IV) hydration. The patient remained afebrile, her condition improved overnight, and she was able to be discharged home the following day. At issue is the medical necessity for the inpatient stay.

The health plan's determination is upheld in whole. 

The requested inpatient hospitalization was not considered medically necessary. This patient's care could have been safely managed at a lower level of care status.
This toddler presented with moderate dehydration, as evidenced by tachycardia, absence of tears, and decreased urine output. Remaining vital signs were normal, and laboratory evaluation including complete blood count (CBC) and electrolytes was also normal. The patient received IVF in the ED and was kept overnight for further IV hydration due to emesis with oral challenge. Given the patient's stable condition and only 1 vital sign abnormality, she could have been safely cared for at lower level of care status.
Appeal type: Medical necessity
Decision: Overturned

Skin Disorder
Inpatient stay

Diagnosis: Cellulitis. Treatment: Inpatient stay. The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a man who presented to the hospital with a chief complaint of left foot swelling, left-hand swelling and fevers. He had a history of hyperlipidemia, prostate cancer, diabetes and deep vein thrombosis (DVT). He reported three days of swelling in the left hand, left wrist, left ankle, and left foot. He also reported associated fevers and chills. He denied chest pain and shortness of breath. The patient was admitted for joint swelling and suspected acute gout along with suspected left hand cellulitis.

Inpatient care was medically necessary because of the acuity of the patient's presentation along with his need for IV antibiotics and acute treatment of gout. A patient with gout and concurrent cellulitis requires close monitoring to evaluate response to therapy and escalate therapy if needed. He also required multi-disciplinary management, and this intensity of care is more appropriate for the inpatient level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholelithiasis
Treatment: acute inpatient stay
The insurer denied coverage for acute inpatient stay. 
The denial is upheld. 

This patient is a female with no significant past medical history who presented to the Emergency Department (ED) with complaints of 10 out of 10 left upper quadrant abdominal pain, vomiting, and diarrhea. Upon arrival to the ED, the patient's temperature was 97.4 F, heart rate was 88, respiratory rate was 20, blood pressure was 120/76, and pulse oximetry reading was 100%. The patient presented to the ED and was afebrile with stable vital signs. The patient was admitted with complaint of nausea, pain and vomiting that started about 2 hours prior. The patient reported having abdominal pain for the last couple of weeks with history of gallstones. On exam, the patient's abdomen was soft with tenderness in the left upper and right upper quadrants, and epigastrium. The patient had a positive Murphy's signs. Surgery consult was called. The patient was recommended magnetic resonance cholangiopancreatography (MRCP).

According to the MCG Health guideline for gall bladder, bile duct inflammation or stone (ORG: M-555 (ISC)), the goal length of stay is ambulatory or 2 days and assumes an optimal recovery, decision making, and care. Patients may be discharged to a lower level of care (either later than or sooner than the goal) when it is appropriate for their clinical status and care needs. The clinical indications for admission to inpatient care include 1 or more clinical conditions.

In this case, the patient did not have any of these clinical sign and symptoms for acute cholecystitis as the patient's HIDA scan was negative. The patient had a history of cholelithiasis but was afebrile. The patient also did not have findings consistent with acute cholangitis that would have necessitated an acute inpatient admission. The patient had a normal sonogram, and CT and MRI of the abdomen. The patient's clinical presentation was most likely due to cholelithiasis with biliary colic with the possibility that she passed a stone, all of which only required observation level of care. The patient was admitted on one day and by the next the patient's tests came back negative for acute cholecystitis and the patient was feeling better with improvement of her labs. The patient was tolerating a clear liquid diet. This inpatient care and monitoring could have been safely and effectively provided at a less intensive level of care, such as observation care. The patient had neither acute cholecystitis nor acute cholangitis. The patient had biliary colic, and the patient did not have significant elevation of liver enzymes that required inpatient admission. Thus, inpatient admission was not medically necessary for this patient.

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

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