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

Diagnosis: Status asthmaticus

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned.

 
This is a child with a history of asthma. He had been previously hospitalized in the pediatric intensive care unit (PICU) for asthma. He had been prescribed inhaled steroids to prevent asthma, but the mother was not administering this medication. Two days prior to the admission he developed a cough and chest congestion. On the day of admission, he began to have wheezing and increased work of breathing and when his mom administered one dose of albuterol with no improvement in his cough, she decided to take him to the emergency room (ER) for treatment.

In the ER he was noted to have a pulse oximeter reading of 94% (percent). He was coughing and vomiting in the ER and on physical examination he was noted to have mild retractions. His posterior pharynx was noted to be inflamed and his tonsils were enlarged. He had expiratory wheezing and prolonged expiration. In addition, there were crackles audible bilaterally and there were decreased breath sounds over the right lower lobe. He was treated with an intravenous (IV) bolus of normal saline. He also was treated with steroids and repeated doses of DuoNeb. When his wheezing did not improve, he was treated with magnesium sulfate and 3 additional treatments with albuterol. Following treatment in the ER he was still noted to have wheezing and the decision was made to admit him with a diagnosis of status asthmaticus for continued treatment with albuterol every 3 hours.

The patient was treated appropriately in the ER for a cough, wheezing and respiratory distress. He was noted to be in acute respiratory distress with retractions and increased work of breathing when he arrived in the ER. There is a note in the medical record to indicate that he required an IV bolus of normal saline and IV magnesium sulfate for persistent wheezing. He was requiring albuterol every 3 hours and he could not have been safely discharged to home. The admission to the hospital was medically necessary for status asthmaticus.

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

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

Diagnosis: sickle cell.
Treatment: Inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is upheld.

The patient is a female with a past medical history is significant for sickle cell disease. She has had multiple admissions in the past for vaso-occlusive crises, acute chest syndrome, asthma, and splenic sequestration. She is status post splenectomy. She presented with complaints of fever, cough, sore throat, decreased oral intake, and decreased urine output. She also had headache, back pain, and stomach pain, associated with 2 episodes of emesis.

The inpatient hospital stay was not medically necessary. This patient was admitted for a short stay to allow for intravenous (IV) antibiotic treatment, IV fluid management, and oral pain medication. While she has a history of sickle cell disease with multiple previous admissions, she did not have any concerning findings on her physical examination or lab tests at the time of admission. Specifically, there were no concerns of central nervous system injury, no infiltrate on x-ray suggestive of pneumonia or acute chest, no hypoxemia, no acute ischemia, no concerns about kidney function, no aplastic crisis with her hemoglobin at her baseline, no altered mental status, and no pain that required aggressive medical management. She had no concerning infection based on the respiratory viral panel testing, and her vital signs were not consistent with any sort of hemodynamic instability.
Her care could have been safely managed at a lower level of care with close follow-up. She did not require an extended stay in the hospital, and there was no medical management performed that truly required the acute inpatient hospital level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis, Lower Extremity
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

The patient is a female with past medical history significant for opioid dependency (on Suboxone), severe deep vein thrombosis who presented to the emergency room with complaints of bilateral leg swelling.  Vitals on presentation included: temperature 36.8C (celsius), blood pressure 104/65, pulse 106, respiratory rate 20, oxygen (O2) saturation 100% (percent) on room air. Laboratory results included the following: white blood cell count (WBC)10.1, (hemoglobin) HGB-10.4, (hematocrit) Hct-31.8, creatinine-0.65, glucose-95, procalcitonin-0.08.

The patient was started empirically on intravenous antibiotics (vancomycin and cefepime) for possible lower extremity cellulitis. Chest x-ray was negative. X-ray of knee showed no acute bone abnormality. Ultrasound of bilateral lower extremity showed leg edema but negative for deep vein thrombosis (DVT). Orthopedics performed a bedside aspiration of the left knee. Computed tomography (CT) scan of bilateral lower extremity showed anasarca/edema. Cultures remained negative. She remained afebrile, clinically, and hemodynamically stable. The patient was discharged to continue outpatient management.

According to documentation, the patient presented with possible lower extremity cellulitis.  Otherwise, patient remained afebrile, hemodynamically stable. Laboratory results unremarkable including normal WBC and procalcitonin. Cultures remained negative. The patient had no evidence of a disseminated infection or DVT. Based on above findings, the patient did met criteria for observation level of management. She did not fulfill criteria for acute hospital admission. 

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 emergency admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Drug Overdose
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld

The patient is an adult female with a past medical history of bipolar disorder. She presented to the ED (emergency department) after intentionally overdosing on her own lithium tablets. In the ED (emergency department), the patient had normal vital signs and was awake and speaking. Blood tests revealed an elevated lithium level. The patient was treated with IV (intravenous) Normal Saline. While in the ED (emergency department), the patient became agitated, requiring sedation. Following her ED (emergency department) evaluation, the patient was admitted to the hospital. The admission note for this patient indicates that she would have lithium levels checked every four hours. She would be kept on a cardiac monitor. Constant observation was ordered as well.
By the following morning, the patient had a normal lithium level. Her vital signs remained normal. There was no abnormal heart rhythm. Progress notes indicate that the patient had been medically cleared for transfer to a psychiatric unit. A psychiatric consultant found that the patient was too sedated to interview and chose to keep her on the medical unit. The patient was 
transferred to a psychiatry unit 2 days later. It is unclear why she was not transferred earlier.
The patient's health plan denied coverage for an inpatient admission on the grounds that it was not medically necessary. The denial is being appealed.

The Inpatient Hospital Admission was not medically necessary.

The patient was clinically stable following her ED (emergency department) evaluation. She was found to have an elevated lithium level after intentionally ingesting lithium to harm herself. Despite this, her vital signs were normal. She was awake and speaking. There was no concern for her airway being compromised.
The admission note for this patient indicates that she would be kept on a cardiac monitor and would have blood tests every four hours to trend her lithium levels. Constant observation was ordered as well. The patient was never critically ill. She never had a high intensity of required services. In less than 24 hours, her lithium level normalized. It is unclear why she remained on the medical service for two additional days before being transferred to psychiatry. The patient could have been safely 
and effectively managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient with a past medical history (PMH) of asthma and gout who was admitted with complaints of (c/o) sudden onset dizziness, nausea, and vomiting associated with a headache. His vital signs were unremarkable. The physical exam was notable for right-sided horizontal beating nystagmus. Lab work was unremarkable. Imaging studies included a computed tomography (CT) scan of the head which showed no acute intracranial findings. The patient was diagnosed with peripheral vertigo/benign paroxysmal postural vertigo (BPPV) and was treated with intravenous fluids (IVF), meclizine, and anti-emetics. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with dizziness and vertigo associated with sudden onset head movement. The patient did not have any acute hearing loss, double vision, fixed neurologic deficits, severe headache, associated head trauma, fever, high clinical suspicion for central vertigo or cerebrovascular accident (CVA), cerebellar infarct or hemorrhage, vertebrobasilar insufficiency, acute suppurative labyrinthitis, intractable nausea/vomiting or inability to ambulate. All imaging performed showed no acute intracranial pathology. The patient was treated with intravenous fluids (IVF), meclizine, and anti-emetics and ultimately diagnosed with BPPV. Given the patient's clinical stability and provided interventions and clinical monitoring, these could have been safely and appropriately provided at a lower level of care.
Regarding the provided criteria, the patient did not have acute bacterial labyrinthitis, cerebellar/brainstem/cerebral ischemia or hemorrhage, vertebral artery dissection, hemodynamic instability, severe and persistent symptoms, cardiac arrhythmias, or severe neurologic findings.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain complicating pregnancy, 3rd trimester. 
Treatment: Inpatient Admission. 
The insurer denied coverage for inpatient admission. 
The denial is upheld. 

The patient is a pregnant female at 28.3 weeks of gestation who presented to the emergency department with complaints of chest pain. The patient reported being on the phone and receiving bad news and developing shortness of breath and palpitations that lasted only for minutes. On presentation, she denied any chest pain or palpitations.  Her vital signs were normal. Her physical examination was also normal. Doppler ultrasound showed no evidence of deep venous thrombosis (DVT). Computerized tomography (CT) angiogram was performed with no evidence of pulmonary emboli or acute pulmonary disease. 

The patient had a minimally elevated troponin level. Electrocardiogram (EKG) was unremarkable. The patient was evaluated by cardiology who suspected paroxysmal SVT and recommended patient admission to telemetry for observation. Echocardiogram was done and showed normal ejection fraction. 

The patient underwent a full evaluation that was negative except for tachycardia. Chest pain was noncardiac in nature. Obstetrical ultrasound did not show any abnormality. The patient could have been monitored in the outpatient setting, without the need for inpatient acute care admission in an acute care hospital. Once a serious cardiopulmonary condition had been ruled out, the patient could have been discharged home. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient. The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical Necessity medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes: Increase to 105 Hours per Week
The insurer denied Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes: Increase to 105 Hours per Week. 
The health plan's determination is overturned.

The patient is a female with past medical history of dementia, hyperlipidemia, hypertension, urinary incontinence, bowel incontinence, coronary artery disease, and osteoarthritis who had been assigned PCS (personal care services).

Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes: Increase to 105 Hours per Week are medically necessary for this patient.
There is documentation from the patient's medical provider of worsening cognitive and physical functioning. The patient's assessment underestimated the patient's assistance needs with multiple tasks as documentation from the medical provider and her family indicate progression of her dementia with increase in assistance needs but the assessment showed improvement with tasks of managing finances, managing medication, stairs, transportation, walking, locomotion, transfer toilet, toilet use, bed mobility, and eating when comparing to previous assessment. The notes from the assessment stated the patient did have a decline in activities of daily living (ADL) status and a deterioration of overall self-sufficiency in the last 90 days. The patient has assistance needs with walking, locomotion, transfer toilet, and toilet use all of which are unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The requested increase in PCS services is not solely for safety and supervision but to assist the patient with safe completion of ADL and Instrumental activities of daily living (IADL). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The plan incorrectly assumed the patient had informal support outside of the currently assigned PCS service hours.
Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCS services 105 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Upheld

Central nervous system
Pharmacy/prescription drug

Diagnosis: relapsing-remitting multiple sclerosis
treatment: Plegridy
The insurer denied Plegridy. The health plan's determination is upheld.

The patient is a female with relapsing-remitting multiple sclerosis. Treatment with Plegridy is the subject of this review. The drug was denied because the patient has not tried and failed any of the available formulary alternatives.

Plegridy is not medically necessary. All of the formulary medications including Betaseron, glatiramer, fingolimod, dimethyl fumarate, Aubagio, or Tysabri are appropriate for treatment of relapsing-remitting multiple sclerosis. The patient is treatment naive. All of these are appropriate first-line options for treatment of relapsing-remitting multiple sclerosis. The physician indicates that the patient has severe symptoms and requires a highly effective disease modifying therapy; however, Plegridy is not generally considered to be a highly effective disease modifying therapy, especially when compared to other options on the formulary such as dimethyl fumarate, fingolimod, and Tysabri.
The patient does not have any absolute medication contraindications to the use of any of the available formulary drugs. These options include injectable, oral, and infusion options.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Major Depressive Disorder
Treatment: Spravato (esketamine nasal spray)
The insurer denied: Spravato (esketamine nasal spray)
The denial is: Upheld

The patient is a male with severe and recurrent major depressive disorder without psychotic features in the context of treatment refractory depression and treatment failure with multiple medication trials. The current medication regimen includes Prozac, Abilify, Depakote and low-dose quetiapine with supplemental use of clonazepam. The patient had previously been treated with Paxil, Zoloft and Effexor at clinically appropriate dosages without a sustained clinical response or adverse effects resulting in discontinuation. The patient has received augmentation, as noted without benefit. The patient has also received adjunctive psychotherapy. The patient is diagnosed with panic disorder and not diagnosed with other co-morbid psychiatric disorders, and the patient has no co-occurring substance use disorder or acute general medical problems though he is known to use marijuana. Patient Health Questionnaire (PHQ-9) scale score was 26 at baseline reflecting severe depression. Symptoms include low mood with hopelessness and insomnia together with low energy, concentration difficulties and past history of suicidal ideation with plan and intent, and ongoing passive suicidal ideation. 
The subject under review is the medical necessity for treatment with Spravato (esketamine nasal spray).

The health plan's determination is upheld.

The requested treatment of Spravato (Esketamine nasal spray) is not medically necessary for this patient. Specifically, the patient has failed to show evidence for improvement with at least eleven treatment sessions with Spravato as indicated by the submitted medical records and PHQ-9 scores. Thus, it is not reasonable to continue treatment with Spravato in this case scenario.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Spinal stenosis.

Treatment is spinal surgery (20939 x 1, 63048 x 3).

The insurer denied coverage for spinal surgery (20939 x 1, 63048 x 3).
 
The denial is upheld.

The records show multilevel disease. There is no clear-cut pain generator. There is evidence of osteophytes, stenosis, and disc bulges. The treatment plan varies from visit to visit. There have been recommendations for anterior lumbar interbody fusion (ALIF) to L(lumbar)4-5, L5-S(sacral)1, and isolated ALIF L5-S1 multilevel decompression L2-L5 with spinal fusion. 

A spinal fusion stabilizes abnormal motion. This is found with spondylolisthesis, pars defects or excessive posterior element resection. 

Indications for a spinal fusion to any level for this patient have not been met. There were no radiographic studies showing abnormal motion. There were no flexion extension views showing abnormal motion. The report of "trace" listhesis is not an accepted indication for spinal fusion.

In conclusion, no specific pain generator has been defined and no evidence of instability is present. Professional Services: spinal surgery (20939 x 1, 63048 x 3) is not considered medically necessary for this patient.

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 Professional Services; spinal surgery (20939 x 1, 63048 x 3) services is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Complex Regional Pain Syndrome status post Sports Injury.
Treatment: Inpatient Rehabilitation Services.
The insurer denied: Inpatient Rehabilitation Services.
The denial is overturned.

The patient is an adolescent female with complex regional pain syndrome (CRPS). Her pain developed following a sports-related fall. The patient underwent course of physical therapy and has been subjected to additional diagnostic work up including MRI (magnetic resonance imaging) scan and epidural injections provided by the pain management specialist.

The patient was diagnosed with CRPS (complex regional pain syndrome) in earlier this year. Following additional physical therapy, the patient has been recommended to undergo additional pediatric pain management program, including use of spinal cord stimulator due to recurrent progression of pain in the right knee.

The requested health service is medically necessary.

Based on the review of medical records, this patient has been subjected to various interventions, including intensive outpatient treatments, which have not led to favorable outcomes in the treatment of her CRPS (complex regional pain syndrome). Therefore, the patient has been recommended to undergo intensive inpatient treatment where standards of care have been applied in transdisciplinary settings. The extent and frequency of the treatment do not exceed limits, and in fact have been shown to be beneficial for this patient's condition, in both physical and mental aspects.

Therefore, the requested health service is medically necessary.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: Central Nervous System/ Neuromuscular Disorder - Speech Problem.
Treatment: Inpatient Hospital.
The health plan denied the inpatient hospital stay as not medically necessary. 
The health plan's determination is upheld.

The patient is a male with a history of stroke and hypertension. He presented to the emergency room after a 20-minute episode of left face and arm numbness and tingling, along with slurred speech. The symptoms resolved before arrival to the emergency room. The blood pressure was 146/75 millimeters of mercury (mmHg), and the other vital signs were normal. He was in no acute distress and did not appear toxic. The physical exam, including the neurologic exam, was normal. Laboratory studies were non-contributory. The electrocardiogram (EKG) was negative for acute ischemia or significant arrhythmia. The head computed tomography (CT) scan was not definitive for a new stroke. Magnetic resonance imaging (MRI)/magnetic resonance angiography (MRA) of the brain showed bilateral old strokes and subtle diffusion abnormalities that might represent new acute or subacute infarcts. The neurologist evaluated the patient and recommended admission for a transient ischemic attack (TIA) workup. The patient was admitted for further treatment and evaluation.
Upon admission to a monitored bed, the patient was treated with oral medications. An echocardiogram was performed and was essentially normal. A Holter monitor was placed, and 24 hours later it showed a predominant sinus rhythm, without atrial fibrillation, ventricular tachycardia, or significant pauses. The entire hospital stay was clinically uneventful, and the patient was discharged.
At issue is the medical necessity of the inpatient admission.
The health plan's determination of medically necessity is upheld in whole.
Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or EKG of an imminently life-threatening cause of the patient's complaints that required acute inpatient admission. There were no further symptoms, and the neurologic exam was normal. The imaging findings were not definitive of a stroke. The services provided - Holter monitoring and oral medication - were not at the acute inpatient level of intensity. Therefore, based on the standard of care, as well as the peer reviewed literature cited in the references, the acute inpatient level of care was not medically necessary.