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

Abdominal pain
Inpatient stay

The patient is a female with a history of (h/o) hypertension (HTN), diabetes, hyperlipidemia, chronic kidney disease (baseline Creatinine 1.9), pancreatitis, and pyelonephritis. She presented to the emergency department (ED) with acute right upper quadrant (RUQ) abdominal pain radiating to her back as well as 3 days of nausea and vomiting. She denies having any blood in the vomitus and denies having any fever or chills.

In the ED, her vital signs were stable. She was in no acute distress. Her exam was normal except for epigastric tenderness. Abnormal blood work included a Bun 27, Cr 3.0, HGb 11.7, and Hematocrit (HCT) 36.8. Her LFTs (liver function tests) were normal as was her lipase. An abdominal ultrasound showed severe hepatic steatosis. A computed tomography (CT) scan of the abdomen and pelvis showed duodenal inflammation. She received Pepcid, Maalox, Rocephin, and intravenous (IV) fluids.
The patient was admitted for epigastric abdominal pain.

The health plan's determination is overturned. The inpatient stay was medically necessary. This patient meets Milliman Care Guideline M-05 for abdominal pain given the patient's evaluation in this case required her not to eat or drink for an extended period of time. Also, she meets Milliman Care Guideline MG-GAS for a gastroenterology condition, symptom, or finding for which ER and observation care is not appropriate. The main finding to meet this is the large duodenal ulcers that were found. According to an article in Gastrointestinal Endoscopy journal from 2010, there is a much higher risk of ulcer perforation and bleeding when the duodenal ulcers found are > 2 centimeter (cm), as they were in this case. Based on this, she required the inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Dental Problems.
Dental/Orthodontic Procedure.

Diagnosis: Class I Malocclusion. 
Treatment: Comprehensive Orthodontic Treatment.

The insurer denied the Comprehensive Orthodontic Treatment. The health plan's determination is overturned. 

The patient in question is a male with a Class I malocclusion and anterior crossbite of tooth #10. He is treatment planned for 24 months of orthodontics to correct his malocclusion. 

The Comprehensive Orthodontic Treatment of the Adolescent Dentition is medically necessary for this patient. The patient has significant anterior crowding with #10 in crossbite. This tooth has a high risk for restorative problems in the future due to its traumatic occlusion with the mandibular teeth. Studies have shown that even the untreated dentition shows increased anterior irregularity with time, which will make treating this occlusion at a later time more difficult. Tooth #10 is already damaged due to its position in the arch, and this will get worse if the crossbite is not corrected. Orthodontic treatment now will likely prevent the need for future expensive periodontal and restorative procedures. For these reasons orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Uncontrolled Diabetes, Dehydration 
Treatment: Inpatient admission 

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

This is a female patient with a history of Type 2 Diabetes. She presented to the Emergency Room (ER) with complaints of nausea, vomiting, abdominal pain and fatigue. Lab worked showed an anion gap of 22, beta-hydroxybutyrate 4.89, potassium of 5.0, blood urea nitrogen (BUN) of 29, serum osmolality of 333, lactic acid of 1.8, hemoglobin A1C of 10.8, and blood glucose of 344 to 415 mg/dl. The urinalysis showed glucose and ketones. She was admitted to the hospital for uncontrolled diabetes. Endocrine was consulted. She was started on sliding scale insulin, Zofran and fluids. The patient was medically stable and discharged to home with outpatient follow-up instructions. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The patient clearly had issue with elevated blood sugars, gastrointestinal (GI) upset and dehydration. 

The patient is a female with a history of Type 2 Diabetes.  She presented to the Emergency Room for concern of nausea, vomiting, abdominal pain and fatigue.  Lab worked showed an anion gap of 22, beta-hydroxybutyrate 4.89, potassium of 5.0, blood urea nitrogen (BUN) of 29, serum osmolality of 333, lactic acid of 1.8, hemoglobin A1C of 10.8, and blood glucose of 344 to 415 mg/dl. The urinalysis showed glucose and ketones. She was started on sliding scale insulin, Zofran and fluids.  In this case, the patient clearly had issue with elevated blood sugars, GI upset and dehydration.  Therefore, inpatient admission was medically necessary. 

Corsino, L. (2017), "In addition, patients hospitalized with a diagnosis of diabetes stay in the hospital for longer than those without a diagnosis of diabetes admitted for the same condition [9]." 

Per Kodner, C. et al. (2017), "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" 

Per Horton, W. B., Weeks, A. Q., Rhinewalt, J. M., Ballard, R. D., & Asher, F. H. (2015), "After education, more patients (23% vs 8%; P=0.024) were placed on basal-plus-bolus regimens. We observed a decrease in mean FSG (158.7 mg/dL vs 165.1 mg/dL; P=0.028) and LOS (5.03 days vs 6.98 days; P=0.042). Rates of hypoglycemia (4.6% vs 1.5%; P<0.001) and severe hypoglycemia (0.71% vs 0.24%; P=0.089) increased." 

The carrier's denial of coverage for the inpatient admission is overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Intractable Back Pain.

Treatment: Inpatient admission.

The insurer denied the inpatient admission.

The denial was upheld.

This is a female patient with a history of C-section, heart murmur, abdominoplasty, and ovarian cyst. She presented to the emergency department (ED) with complaints of bilateral lower back while reaching something in the fridge. She was unable to move or sit up. The patient reported taking Ibuprofen at home without relief. Initial exams showed limited flexion of the back due to back pain. Initial treatment and management included Percocet, Robaxin, intramuscular (IM) Toradol, and intravenous (IV) Morphine. Urinalysis showed presence of blood. An electrocardiogram (EKG) was done that showed short PR interval. The patient was admitted for further evaluation of intractable back pain. Her hospital course of treatment and management includes IM Toradol, IV Morphine, Percocet, Tylenol, Robaxin and Lidocaine patch. The patient continued to complain of lower back pain and inability to ambulate. Urine toxicology showed positive for opiates. Magnetic Resonance Imaging (MRI) of the lumbar spine revealed a left paracentral disc protrusion at the L4-L5 level with thecal sac compression. Neurosurgery and physiatrist were consulted. Physical therapy consulted on the patient with recommendations for home therapy. Repeat laboratory studies were performed that revealed elevated BUN/Creatinine ratio of 21. The patient was medically stable and was cleared for discharge to home.   

The pertinent facts in record include:
1) The woman had reported back pain since her epidural for C section several weeks prior with recent exacerbation. "She had been having back pain for a long time now and took Ibuprofen." 2) VAS scores were 7-0. 3) Morphine was provided on 3 occasions. 4) Her physical examination did not demonstrate any focal deficits. 5) The MRI was completed and interpreted the findings were limited with no evidence of nerve compression. 6) Physical therapy services provided a walker. 

These findings demonstrate services could have been provided at an Observation Level. Her vital signs were stable. Her intractable pain had been sufficiently managed with ability to tolerate oral narcotics. See dosages of Morphine and VAS scores.  Subspecialty consultations had been completed. She did not require treatment for any other medical condition. She was not indicated for additional imaging nor an operation. MRI completed a few days after admission and interpreted. Physical therapy could have been provided as outpatient. 

There were no extenuating circumstances to substantiate the acute level admission and care provided. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

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

Diagnosis: Right Chest Malignancy.
Treatment: Inpatient stay.
The insurer is denied coverage for the inpatient stay.
The denial is overturned.

This is a male patient with a right chest wall malignancy. The patient was taken to the operating room and had a right video thoracoscopy and a formal right thoracotomy and en-bloc resection of the mass and multiple ribs/chest wall resections as well. His post operative medical treatment included a chest tube and pulmonary toiletry with intravenous patient controlled analgesics (PCA). The patient was observed for 24 hours and transitioned from IV to oral analgesic medication. The patient was medically stable and discharged.

Thus, the discharge after 24-hours of observation and was medically necessary.

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

Based on the above, the medical necessity for the continued inpatient stay is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia, Fever 
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial was upheld.  

This is a female patient with no history of asthma, who presented with cough and fever for several days. She was treated a couple weeks prior with Tamiflu. She was well for a week and then her fever (up to 104F) and cough relapsed. On the ED exam she had mild distress, good hydration RR 20/min, and was afebrile. Chest X-Ray showed "bilateral perihilar densities consistent with bilateral infiltrates within the lungs." Labs were normal.
The patient did not have lobar pneumonia by chest X-ray, which would have indicated bacterial pneumonia, even if we consider the bilateral perihilar infiltrates to be suspicious for pneumococcal pneumonia secondary to her recent influenza infection.

The patient did not meet criteria for admission for pneumonia (UpToDate, Barson et al), which include:
1)	Hypoxemia (peripheral capillary oxygen saturation [SpO2] <90 percent)
2)	Dehydration 
3)	Moderate to severe respiratory distress: Respiratory rate >50 breaths per minute for older children; retractions; nasal flaring; difficulty breathing; apnea; grunting
4)	Toxic appearance
5)	Underlying conditions that may predispose to a more serious course of pneumonia (eg, cardiopulmonary disease, genetic syndromes, neurocognitive disorders, (eg, immunocompromised host)
6)	Complications (eg, effusion/empyema, necrotizing process, abscess)
7)	Suspicion or confirmation that the pneumonia is due to a pathogen with increased virulence, such as Staphylococcus aureus or group A Streptococcus (GAS)
8)	Failure of outpatient therapy (worsening or no response in 48 to 72 hours)
9)	Recurrence of pneumonia 
10)	Age younger than 8 weeks. 

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

Diagnosis: Genitourinary/Kidney Disorder. Treatment: Pharmacy/Prescription Drugs. The insurer denied Myrbetriq. The denial was upheld in whole.

The patient is a male with benign prostatic hyperplasia (BPH) with obstruction/lower urinary tract symptoms. He has been using Myrbetriq 25 milligrams (mg) with good result and requested coverage for continued use. He has Parkinson's disease and should avoid anticholinergic medications per the attending physician (AP) notes. He has had adverse effects with anticholinergic medications such as oxybutynin and tolterodine. Myrbetriq is a non-formulary medication and coverage has been denied.

The health plan's determination is upheld in whole. 

The formulary medication, trospium and trospium extended release (ER) has not been ineffective for this patient, as he has not tried this quaternary amine. The stated reason by the AP for use of Myrbetriq is the presence of Parkinson's disease, a central nervous system disease process. The AP provided side effects of overactive bladder medications but did not specify this patient's specific side effects with anticholinergic medications. While anticholinergic agents can cause cognitive dysfunction, trospium does not cross the blood-brain barriers in human cerebrospinal fluid and has minimal cognitive effects.
Per Sakakibara's systematic review, "Anticholinergics are the first-line treatment for bladder dysfunction in Parkinson's disease (PD) and multiple system atrophy (MSA) patients, but care should be taken for the management of bladder dysfunction-particularly in MSA patients due to the high prevalence of difficult emptying, which needs clean, intermittent catheterization."
Appeal type: Medical necessity
Decision: Overturned

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

The patient  presented to the emergency department (ED)  with a history of progressively worsening abdominal pain of 3-days duration. Comorbid health conditions included no chronic conditions. His evaluation included a physical exam, labs, and computed tomography (CT) scan. He was without a fever at the time of presentation. Lab data identified a white blood cell count (WBC) count of 7.6. Blood urea nitrogen (BUN) and creatinine (Cr) were normal at 16 and 0.9. A CT scan supported the diagnosis of acute appendicitis. There was periappendiceal inflammatory change without mention of abscess. Treatment was initiated with intravenous (IV) fluid and antibiotics. Surgical consultation was obtained on the day of presentation.
He was admitted to the hospital and treated with IV antibiotics. The surgical note describes a very small contained perforation.
He was tender in the right lower abdomen. The WBC count was 8.9 thousand (K). He was being treated with nothing by mouth (NPO) status and was receiving IV antibiotics and IV fluid.
The patient reported improved abdominal pain. He was without a fever and vital signs were normal. He still had right lower abdominal tenderness and was kept NPO. The WBC was 7.9 K. BUN and Cr were 11/0.8.
The vital signs were normal. The abdomen was nontender. He was tolerating a diet. The patient was discharged from the hospital with continued oral antibiotics.
At issue is the medical necessity of an inpatient stay.
The submitted clinical documentation does support the medical necessity of inpatient admission. The patient required urgent surgical evaluation as performed, follow up lab data for WBC count assessment. provision of IV antibiotics, and IV fluid during the period of NPO status. It was appropriately anticipated that this treatment would span a period of greater than 48-hours. Admission to inpatient care is indicated in the setting of peritoneal signs or other signs or symptoms of acute abdominal disease. In this case, the patient had significant right lower abdominal pain and tenderness and he had confirmed abdominal disease based on the CT scan. The nonsurgical treatment for the diagnosis of perforated appendicitis that was provided was most appropriately provided with an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Enlarged lymph gland in stomach and DVT (deep vein thrombosis)
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male. He presented with right lower extremity swelling and pain.  It was noted that he had been seen as an outpatient and found to have a foot mass and inguinal adenopathy.  There was concern for sarcoma.  He had a biopsy done but the results were not available.  He had pain and was treated with pain medication.  He was also found to have a DVT (deep venous thrombosis) involving that leg. 

The patient was admitted to observation for pain control and elevation to help reduce swelling. He was noted to have 4/10 pain the following morning, without any acute events noted.  He was seen by pediatric oncology and it was decided to admit him for pain control. It was noted that his biopsy had revealed alveolar rhabdomyosarcoma.  While in the hospital imaging studies were performed and revealed metastatic disease involving lungs and bones. He was noted to have a thyroid nodule and while in the hospital endocrine was consulted.  He had a fungal infection of his foot and that was treated with ketoconazole cream. He was diagnosed with tinea pedis. He was treated with Tylenol and ibuprofen for his pain.  

No, the proposed inpatient admission was not medically necessary.

This patient had pain that was treated with Tylenol and ibuprofen.  Both are treatments that could have easily been given on an outpatient basis.  He was admitted to expedite his medical evaluation, but that does not support the medical necessity of acute care inpatient admission.  He had a DVT that was treated with oral anticoagulation therapy.  His evaluation and treatment could have safely been carried out in the outpatient setting.  He had no acute medical issue necessitating inpatient admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: respiratory system /breathing problems  
Treatment: Inpatient hospital  
The insurer denied the inpatient hospital stay
The denial is overturned in whole 

This is a patient, at the time of admission with history of albuterol use admitted for acute respiratory failure secondary to respiratory syncytial virus (RSV) bronchiolitis.

Yes, the requested health service/treatment of the inpatient hospital stay was medically necessary for this patient. Based on the literature, the patient met two clinical criteria that are strong predictors of clinical deterioration and possible need for major intervention. The patient  exhibited increased work of breathing with accessory muscle use and age . Based on these clinical findings at presentation which included significant distress requiring high flow nasal cannula for respiratory support, inpatient level of care was medically necessary. The need for higher acuity of care once admitted is evidenced by need for respiratory support with high flow nasal cannula along with the need for close and frequent respiratory monitoring. The patient's respiratory status was also so severe that the patient  was unable to feed and had to be placed NPO with IVF and eventually NG tube feeds to provide his nutritional support.

Patient would meet criteria for inpatient admission based on criteria of tachypnea and retractions severe or persistent. His symptoms were severe enough to necessitate an intervention reserved for infants with possibility of impending respiratory failure. These patients require close monitoring of their respiratory status as deterioration is a great risk in the event, they are not responding to the HFNC and need stepped up care.

For these reasons, the inpatient hospital stay was medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory system/other 
Treatment: Pharmacy prescription drugs 
The insurer denied Tobramycin Inhalation Solution
The denial is overturned in whole

This is a  patient with chronic respiratory failure, bronchiectasis, ventilator dependent, status/post (s/p) tracheostomy, has been having increased tracheal secretions and clinical symptoms suggestive of tracheitis.

Yes, the Tobramycin inhalation solution is medically necessary as per the physician's documentation, the monthly tobramycin has avoided hospitalizations. Hospitalization in this Covid time can be fatal for this medically complicated patient. There are reported iatrogenic transmission of this deadly virus to vulnerable patients. Bacterial tracheitis is an uncommon cause of upper airway obstruction that can potentially result in a life-threatening situation. In bacterial tracheitis, pathogenic bacteria invade the trachea and stimulate both local and systemic inflammatory responses. Tracheitis can be fatal in patients with ventilator and can be rapidly fatal if not controlled. Even though patient does not have cystic fibrosis (CF), the physiology and airway in this patient  is similar to CF. and patient has shown great response to tobramycin so far. There are numerous studies that shows the efficacy of inhaled tobramycin in non-CF conditions. The inhaled tobramycin is a lifesaving therapy in this child; therefore, it is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Migraines
Issue under review: Aimovig

Determination:
The Aimovig is not medically necessary.

The patient is an adult female with migraine headache disorder. She reports having tried gabapentin and amitriptyline in the past.  There is no documentation that she has failed topiramate, divalproex sodium, propranolol, timolol, metoprolol or venlafaxine for migraine prevention.

There is no documented reason provided as to why the patient cannot be treated with a preferred formulary agent for her condition. The preferred agents are all considered standard of care, first line oral migraine preventive agents (Silberstein, 2015). There are no high quality clinical trials or standard of care guidelines supporting the preferential use or superiority of Aimovig relative to these medications.