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

Diagnosis: Dizziness
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient is an adult male with diabetes, tobacco abuse, hypertension, and prostate cancer status post prostatectomy. He presented to the hospital with a syncopal episode following an episode of dizziness.  

On presentation, the patient complained of chest pain.  The patient was afebrile with a blood pressure 170/104.  Labs were notable for a creatinine 1.4, potassium 4.3, and hemoglobin 11.8.  The electrocardiogram showed sinus rhythm without acute ischemic changes, and cardiac enzymes were negative.  Computed tomography of brain demonstrated no acute process.  The patient was monitored on telemetry, and intravenous fluids were provided.  The patient left the hospital against medical advice (AMA).

The patient's syncope was not accompanied by evidence of arrhythmia, focal neurologic deficit, seizure activity, injury, acute coronary syndrome, or acute cerebrovascular accident.  Computed tomography of the brain demonstrated no mass or acute process.  The patient was hemodynamically stable and afebrile.  The patient's chest pain was documented as being likely due to reflux and to be of noncardiac etiology.  The creatinine was only mildly elevated, and there was no evidence of uremia, hyperkalemia, acidosis, or volume overload.  

In summary, inpatient admission was not medically necessary.  The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient in making its determination.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: diabetes mellitus, dysthymic disorder, hypertension, coronary artery disease, asthma, dizziness, insomnia, dementia, urinary incontinence and osteoarthritis. 
Treatment: Increase Consumer Directed Personal Care Assistance from 84 hours/week to 24 hours/day, seven days/week (split shift)
The insurer denied the Increase Consumer Directed Personal Care Assistance from 84 hours/week to 24 hours/day, seven days/week (split shift). 
The denial is overturned. 

Yes, the proposed treatment of an increase in Consumer Directed Personal Care Assistance to 24 hours/day, seven days/week (split shift) is deemed medically necessary. 

The patient is a female with a history of diabetes mellitus, dysthymic disorder, hypertension, coronary artery disease, asthma, dizziness, insomnia, dementia, urinary incontinence and osteoarthritis. Due to impairments from her multiple medical issues, she requires assistance for completion of the majority of her activities of daily living (ADLs). 

Since the time of her last in home assessment, the patient has been hospitalized twice for recurrent syncopal episodes, dizziness and dyspnea with accidental falls. Further cardiac workup has revealed the presence of severe aortic stenosis for which she underwent an aortic valve replacement surgery. Due to her worsening functionality, recurrent syncopal episodes, dizziness and dyspnea with accidental falls; the currently approved plan of 84 hours/week Consumer Directed Personal Care Assistance is insufficient to meet the patient's current needs. Hence, the proposed treatment of an increase in Consumer Directed Personal Care Assistance to 24 hours/day, seven days/week (split shift) is deemed medically necessary to offer increased support and ADL assistance.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic idiopathic constipation.
Treatment: Linzess (linaclotide).
The insurer denied the Linzess (linaclotide).
The denial is overturned. 

Yes, the Linzess (linaclotide) is medically necessary.

The patient is a female with chronic idiopathic constipation. She has failed metamucil, senna, Miralax and Dulcolax. The doctor is requesting treatment with Linzess.

The patient has chronic idiopathic constipation. In order for criteria for Linzess to be met, the patient must have tried and failed a bulk laxative, a stimulant laxative and an osmotic laxative. As the patient has failed a bulk laxative (metamucil), a stimulant laxative (Dulcolax) and an osmotic laxative (Miralax), the requested Linzess is medically necessary, and the plan did not act reasonably, with sound medical judgment and in the best interest of the patient by denying it.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory/Asthma
Treatment: Inpatient hospital stay
The insurer denied the Inpatient hospital stay.
The health plan's determination is upheld in whole.

The inpatient hospital stay was not medically necessary for this patient. 

Although the patient had failed a course of prednisone and does have a history that raises concern for more severe asthma, the presentation was quite mild, and the prednisone course that was failed seems to be lower than the typical dose.
At presentation, the patient had no encephalopathy, hemodynamic instability, respiratory distress or gas exchange abnormality, acute kidney injury or electrolyte abnormality, and no evidence of infection. Although the history of prior ICU admissions and intubation (as a child) are concerning, initial presentation suggested a fairly mild flare.
While the patient was on prednisone prior to admission, the dose seems to have been fairly low (30mg), less than the typical dosing for an asthma flare, so it is difficult to say that the patient failed a course of outpatient treatment.
As the patient was not in any distress, no signs of impending respiratory failure, no organ dysfunction or evidence of other pathology, the patient did not need close monitoring or inpatient only treatment. The patient had failed an outpatient course of treatment (albeit a bit lower than typical, as above), an admission at a lower level of care to ensure patient improved would have been reasonable.
The patient was not critically ill, did not need close monitoring or inpatient only treatment. An admission at a lower level of care was reasonable.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Gout

Treatment: Formulary Exception for Indomethacin 50mg capsule

The insurer denied coverage for Formulary Exception for Indomethacin 50mg capsule. The denial is overturned.

This patient is a male with a history of gout.  His internist is requesting authorization for indomethacin.  In an appeal the doctor notes that the patient has been successfully treated with indomethacin and is currently having a flare.  He has tried and failed Naproxen as well as Sulindac 200 mg BID (twice daily). As discussed in www.uptodate.com "Treatment of Gout Flares," non-steroidal anti-inflammatory drugs (NSAIDS) such as indomethacin, sulindac and naproxen are effective treatments for gout. There are many NSAIDs, and many have shown efficacy in gout (although no one of them is universally effective).  In this case, the treating medical doctor (MD) has noted that the patient has previously failed naproxen and Sulindac.

While the formulary drug(s) is not likely to cause the patient an adverse reaction, the formulary options have been ineffective. The patient has tried and failed treatment with insurer's formulary drugs and has had success with the requested drug, indomethacin.

The requested drug has been more effective that the formulary options. He is currently having a flare and this is his best most effective option.

The carrier's denial of Request for Formulary Exception for Indomethacin 50mg capsule is overturned.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: COPD (chronic obstructive pulmonary disease)
Treatment: Formulary exception for Trelegy Ellipta 100-62.5-25MCG/INH IN AEPB 
The insurer denied the Formulary exception for Trelegy Ellipta 100-62.5-25MCG/INH IN AEPB.
The denial is overturned. 

This is a patient with chronic obstructive pulmonary disease (COPD) that is being treated with Trelegy Ellipta.

The patient has tried and failed or has contraindication to Symbicort, Spiriva, Incruse, BREO, Anoro and Arnuity. The patient has been treated with Trelegy Ellipta with good clinical response. The continuation of treatment is medically necessary. 

Patients with symptomatic COPD at risk of exacerbations, once-daily FF/UMEC/VI (Trelegy Ellipta), compared with FF/VI or UMEC/VI, improved patient-perceived health-related quality of life (HRQoL) and symptoms. Triple therapy showed improvements in lung function, health status using the St. George's Respiratory Questionnaire, and exacerbations when compared to single or double therapies.  The current literate data suggest that the triple therapy (Trelegy Ellipta) is likely superior to single or double therapy. In conclusion, the Trelegy Ellipta is recommended over the other formulary alternatives, Advair and Bevespi.  Therefore, the continued use is medically necessary in this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute diverticulitis.

Treatment: acute inpatient hospitalization.

The insurer denied coverage for acute inpatient hospitalization.

The denial is upheld. 

This is a male patient who presented to the hospital with abdominal pain. The patient's outpatient computed tomography (CT) scan revealed diverticulitis. The patient was treated with antibiotics as outpatient but continued to have abdominal pain and was referred to the hospital. On hospital presentation, the patient was afebrile and his vital signs were stable. On the patient's exam, there was no abdominal rebound or guarding.  The patient's white blood cell (WBC) count was 11.5. The patient was initially started on intravenous (IV) antibiotics but the gastroenterology consult advised a course of outpatient oral antibiotics.

According to Milliman Clinical Guidelines for acute diverticulitis (M-150), the clinical indications for inpatient admission include: hemodynamic instability, peritoneal signs, persistent gross bleeding, or a complicating factor seen on imaging; this can be a fistula, obstruction, perforation, or abscess. However, in this case, the patient did not have any of these conditions. The patient did not have severe pain, severe vomiting, or severe dehydration that warranted an inpatient level of care. Based on the review of the medical record, this patient had an uncomplicated diverticulitis. The patient was still having pain and a change in antibiotics was advised. However, switching antibiotics could have been done outpatient. The patient did not meet the criteria for an acute inpatient hospitalization as listed in the MCG (M-150) guidelines. 

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 acute inpatient hospitalization should be upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetic Ketoacidosis

Treatment: Inpatient hospital admission

The insurer denied the inpatient hospital admission.

The denial was overturned.

This is a male patient with a history of Type 2 Diabetes Mellitus (DM), chronic kidney disease (CKD), hypertension, hyperlipidemia and seizure disorder. He presented to the emergency department (ED) as a resident from a rehabilitative facility with complaints of elevated blood sugars (BS) over the prior few days. He was noted to have a cough, fatigue, chills and mild shortness of breath for the prior week with noted respiratory syncytial virus (RSV). The labs showed glucose-461, bicarbonates,-17, eGFR-51 and creatinine-1.33, urinalysis showed glucose greater than 500 and ketone-20. The patient was admitted for diabetic ketoacidosis (DKA) and treated accordingly. He received intravenous bolus fluid and started on subcutaneous insulin. He was medically managed in the intensive care unit (ICU). After a period of medical stability he was discharged back to the rehabilitation center with instructions to follow up with the endocrinologist.

"Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are acute metabolic complications of diabetes mellitus that can occur in patients with both type 1 and 2 diabetes mellitus. Timely diagnosis, comprehensive clinical and biochemical evaluation, and effective management is key to the successful resolution of DKA and HHS. Critical components of the hyperglycemic crises management include coordinating fluid resuscitation, insulin therapy, and electrolyte replacement along with the continuous patient monitoring using available laboratory tools to predict the resolution of the hyperglycemic crisis. Understanding and prompt awareness of potential of special situations such as DKA or HHS presentation in comatose state, possibility of mixed acid-base disorders obscuring the diagnosis of DKA, and risk of brain edema during the therapy are important to reduce the risks of complications without affecting recovery from hyperglycemic crisis. Identification of factors that precipitated DKA or HHS during the index hospitalization should help prevent subsequent episode of hyperglycemic crisis." (Gosmanov, et al, 2018)

"Uncontrolled blood glucose levels in hospitalized patients with diabetes are associated with potential harms such as deleterious effects on wound healing, increased risk of infection, and delays in surgical procedures or discharge from the hospital" (Kodner, C. et al. 2017)                                                         

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

Based on the above, the medical necessity for the inpatient hospital admission is substantiated. The insurer's denial is overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Scoliosis.  
Treatment:  Back Device (self-operated spinal unloading device; code L1499).  

The insurer denied the back device (self-operated spinal unloading device; code L1499).  The denial was reversed.  

This is a young female patient with a diagnosis of adolescent idiopathic scoliosis of the thoracic and lumbar spine.  Recently, the patient was recommended to be fitted with a Rigo Cheneau brace.  The patient's x-rays at that time revealed a right thoracic curve measuring 31 degrees and a left lumbar curve measuring 38 degrees.  The patient was noted to have a large curve and a significant amount of growth remaining.  The patient was premenarchal and Risser 0/Sanders stage 3.   

Based upon the patient's spinal curvature, skeletal immaturity and current literature the use of bracing is appropriate for this patient.  The scientific evidence in peer-reviewed literature support that bracing results in improvement of health outcome.  

According to Sanders et al. (2014), "Within the limitations of a non-randomized prospective study design, bracing for adolescent idiopathic scoliosis was found to substantially decrease the risk of curve progression to a range requiring surgery when patients were highly compliant with brace wear."  As per Weinstein, et al. (2013), "Bracing significantly decreased the progression of high-risk curves to the threshold for surgery in patients with adolescent idiopathic scoliosis.  The benefit increased with longer hours of brace wear."  

The requested self-operated spinal unloading device; code L1499 also has final approval from the appropriate regulatory bodies for this diagnosis.  Therefore, based upon this patient's spinal curvature, and skeletal immaturity she is a good candidate for this requested self-operated spinal unloading device; code L1499.  
    
The requested service, self-operated spinal unloading device; code L1499 is likely to be more beneficial than any of the standard treatments/procedures for this patient.  

The carrier's denial of a back device (self-operated spinal unloading device; code L1499) should be reversed.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Scoliosis.
Treatment:  Back Device (self-operated spinal unloading device; code L1499). 

The insurer denied the back device (self-operated spinal unloading device; code L1499).  The denial was reversed. 

This is a female patient with idiopathic adolescent scoliosis.  The patient was evaluated by a nurse practitioner, who recommended a thoracic-lumbar-sacral orthosis (TLSO). The medical record indicates that this patient's scoliosis was of moderate degree.  This patient's treating orthopedic information indicated that this patient's right thoracic curve was 31 degrees and left lumbar curve was 38 degrees. These findings were significant.  The patient had a great likelihood of progression based upon her chronologic age, bone age and curve magnitude. 

According to literature review, standards of orthopedic surgery recommend bracing with a suitable TLSO.  The function of this rigid device was to halt the progression and at times provide correction.  The scientific evidence in peer-reviewed literature supports that TLSO results in improvement of health outcome.  In addition, the requested self-operated spinal unloading device; code L1499 has final approval from the appropriate regulatory bodies for this diagnosis.  If bracing is not effective, the next step would be surgery. 

Based on the review of the medical record and the literature, this patient is a good candidate for the requested self-operated spinal unloading device; code L1499.  The requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient. 

The carrier's denial of a back device (self-operated spinal unloading device; code L1499) should be reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Laceration - right hand
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The decision is upheld. 

No, the Inpatient admission is not "medically necessary".

This patient is a male, who presented to the ED as a trauma activation with a laceration of the right hand sustained by punching through a glass window.  There was a 4x2-cm laceration of the right dorsal hand with arterial bleeding that had been controlled with application of a tourniquet.  Vital signs were significant for a heart rate of 120/min at presentation.

Following evaluation, the patient was taken to surgery and underwent ligation of the transected deep palmar arterial branch of the radial artery and the wound was closed.  He was stable throughout this procedure.  He remained clinically stable in the post anesthesia care unit and was able to be discharged from the PACU.

The health plan rationale for denial is that the patient's condition and ongoing care needs did not warrant inpatient admission.  Rather, the patient's clinical needs could have been appropriately satisfied with a lower level of care.

An observation level of care would have satisfied the clinical needs of this patient.  This level of care would provide for monitoring with repetitive vital signs, neurologic signs or vascular checks, lab data, imaging, surgical treatment, and overnight care.  

An inpatient designation was not medically necessary or mandated by generally recognized standards of medical care.  This patient was clinically stable at the time of presentation and remained stable throughout the period of hospitalization. The tachycardia noted at presentation did not present hemodynamic instability and the hemoglobin value was normal.  There was no medical condition that required inpatient care.
Appeal type: Medical necessity
Decision: Upheld

Digestive System/Gastrointestinal
Inpatient hospital

The patient is a man with a history of cholecystectomy in 2018 who was admitted to the hospital. He presented with a chief complaint of abdominal pain. He reported intermittent abdominal pain since his cholecystectomy and had been found to have pancreatic collections and a small common bile duct on magnetic resonance imaging (MRI). Review of systems was negative for fevers, chills, chest pain and shortness of breath. He denied alcohol use but did report smoking cigarettes. Initial vital signs showed temperature 97.6 Fahrenheit, heart rate 78, blood pressure 147/87, and respiratory rate 16. On physical examination, heart was regular, breath sounds were normal, abdomen was soft and nontender. He had a surgical scar in the right upper quadrant. There were no cranial nerve deficits. The patient was admitted for abdominal pain and pancreatic collections with a small common bile duct stone. 

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient presented with abdominal pain and required an ERCP for a common bile duct stone and a pancreatic collection, but this procedure can be performed as an outpatient in patients who are hemodynamically stable and have no complications such as acute cholangitis or sepsis. This patient had no complications and had no evidence of acute infection or any acute symptoms beyond abdominal pain at the time of his presentation. He therefore could have been safely and effectively managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vaginal Bleeding while Pregnant
Treatment: Inpatient admission
The proposed treatment, inpatient admission, was medically necessary.  

The patient is a G2P1001 with a history of marginal placenta previa who presented to the hospital at 29 weeks one day complaining of heavy bleeding and a large clot at home.  This was the second episode of vaginal bleeding during this pregnancy and she had previously been treated with betamethasone.  She was admitted to the hospital and placed on intermittent heart and contraction monitoring.  Transvaginal ultrasound revealed complete placenta previa.  The patient was significantly anemic with hemoglobin of 10.7.  She was given intravenous iron.  The bleeding resolved and the patient was discharged home.  

Placenta previa is one of the most serious complications of pregnancy with the prospect for exsanguination of the patient in a relatively short period of time.  Standard recommendations are for hospitalization for initial presentation and then in selected cases management at home after the initial hospitalization.  However, second significant hemorrhagic events should be managed with hospitalization until delivery (Hull, et al).  The imperative for hospitalization was even greater in this patient due to her anemia, which reduced her capacity to tolerate hemorrhage.  Therefore, the proposed treatment, hospitalization, was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite
Treatment: Braces, Monthly Visits

The proposed braces and monthly visits are medically necessary. 

The patient has an anterior tooth (lower left canine) that is in crossbite and has attachment (gum) loss. This is an "automatic qualifier" according to the handicapping index scale. Orthodontic treatment is needed to correct this problem. The monthly follow up visits are to monitor the treatment progress and are also medically necessary.