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

Diagnosis: Dehydration and Odynophagia 
 
Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was reversed.  

This patient is a female child with a medical history of asthma. She presented to the emergency department (ED) with complaints of inability to eat and drink due to the pain in her throat and ears. It was reported that she was status post tonsillectomy several days prior to presentation. Her vital signs were stable upon presentation. A physical examination was performed that revealed erythematous oropharynx with residual eschar. Laboratory work up was performed. The patient received intravenous (IV) fluids and Lidocaine plus prilocaine.  She was admitted to the hospital for further treatment of IV fluid administration and medication.  She was able to tolerate liquids and a soft diet. When clinical improved was noted she was discharged home with follow up instructions.  

This female was admitted for pain, dehydration, and odynophagia several days after tonsillectomy. In one study of over 31,000 patients, it was found that, aside from post-tonsillectomy bleeding, there were a significant number of revisits associated with acute pain (18.4%) and fever/vomiting/dehydration (28.2%).  In another study evaluating 3,198 patients after tonsillectomy, the most common diagnoses associated with unplanned visits to the ED were dehydration in 4.2% (133), hemorrhage in 3.3% (106), acute postoperative throat pain in 2.0% (65), infection/fever in 1.3% (42), nausea/vomiting in 1.0% (29).  In the same study, non-hemorrhage-related complaints accounted for the majority of reasons for ED visits after outpatient pediatric tonsillectomy and adenoidectomy [T&A].  Based on these studies, admission of a patient after tonsillectomy due to pain, dehydration, and odynophagia should be approved to decrease further complication.

The insurer did not act reasonably, or with sound medical judgment, or in the patient's best interest. 

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

Treatment: Inpatient Admission 

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

This patient is a female child who presented to the Emergency Department (ED) with complaints of abdominal pain and fever for a couple of days. She rated the pain to be 5/10 in severity. On physical examination it was noted that she was positive for right lower quadrant tenderness without guarding. She had an abdominal and pelvic ultrasound; the abdominal ultrasound did not show visualization of the appendix and the pelvic ultrasound showed no evidence of free fluid; there were reactive right lower quadrant mesenteric lymph nodes. The patient's white blood cell count was 18 and C-reactive protein was 8.5. She was consulted by pediatric surgery for suspicion of appendicitis. The patient was tolerating oral intake. Her pain was managed with Tylenol and Motrin. The patient was deemed medically stable and was discharged home. 

As per MCG guidelines for abdominal pain in pediatrics, inpatient admission is indicated for conditions, such as: the patient needs inpatient surgery, the patient has peritoneal signs, the patient has hemodynamic instability, the patient had severe pain requiring inpatient management, the patient had signs of intestinal obstruction, the patient has suspected megacolon, the patient had bacteremia, and the patient had severe electrolyte abnormalities requiring inpatient care. Otherwise, the MCG guidelines recommend observation care admission for suspected condition requiring continued monitoring, such as appendicitis. 

Based on the review of the literature on the management of abdominal pain and rule out appendicitis, this patient meets the MCG clinical criteria admission to observation care, rather than inpatient admission. The patient had abdominal pain and concern for appendicitis that was ruled out by the Surgery team, but the patient's CT scan and clinical presentation was not concerning for acute intervention, such as intestinal obstruction or megacolon. The patient's pain was well controlled on oral analgesics, Tylenol and Motrin, and was tolerating oral intake. Though the patient was noted to have some loose stools, the patient did not have vomiting. If the patient was first admitted to observation and had clinically worsened during this stay, then the status could then have been changed to inpatient admission. Since this patient did not fail on observation care and since the care that this patient received as inpatient status could have been provided at the observation status, inpatient admission was not medically necessary for this patient. During this patient's inpatient stay, this patient was observed, appeared stable and was discharged within 30 hours. 

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 services is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Severe migraine headaches 
Treatment: Inpatient admission 

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

This patient is a female with a history of hypothyroidism and migraines. This patient presented to the Emergency Department with complaints of elevated blood pressure and headaches. She had a normal spontaneous vaginal delivery five days prior to arrival. The patient's initial blood pressure in triage was 163/107 and then it decreased to 143/91. She was admitted for postpartum preeclampsia. The plan was to obtain preeclampsia labs, administer Magnesium Sulfate, perform routine postpartum care, and maintain deep vein thrombosis prophylaxis. Magnetic resonance imaging of the brain revealed no significant findings. Neurology was consulted. They noted that the patient was most likely having a migraine, given her previous history. They recommended administering 50-100 milligrams of oral Sumatriptan as needed for migraines and maintaining strict blood pressure control. There was no evidence of neurological complications of preeclampsia and no further workup was needed. The patient was discharged after a period of medical stability. She was given instructions to take Sumatriptan as needed for migraines. 

This patient presented 5 days after delivery with elevated blood pressure and headache. Delayed postpartum preeclampsia can be defined as signs and symptoms of the disease leading to readmission more than two days but less than six weeks after delivery, although various other definitions have been used. Signs and symptoms can be atypical; for example, the patient may have thunderclap headaches alternating with mild headaches or intermittent hypertension. Risk factors for delayed postpartum preeclampsia appear to be similar to those for preeclampsia during pregnancy, but some patients have no risk factors. 

The diagnosis of preeclampsia is based on the new onset of hypertension and either proteinuria or end-organ dysfunction after 20 weeks of gestation in a previously normotensive woman: Systolic blood pressure >=140 mmHg or diastolic blood pressure >=90 mmHg, and proteinuria >=0.3 grams in a 24-hour urine specimen or protein: creatinine ratio >=0.3, or signs of end-organ dysfunction (platelet count <100,000/microliter, serum creatinine >1/1 mg/dL or doubling of the serum creatinine, elevated serum transaminases to twice normal concentration). 

This patient did not have a diagnosis of preeclampsia. She had severe migraine headaches. Ideally this patient would have been observed in the ED, neurology consult would have been obtained. Once preeclampsia has been ruled out, the patient could have been discharged home on home blood pressure monitoring and migraine medication to return if any worsening of her blood pressure. Admission to the hospital was not medically necessary. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient. Based on the above, the medical necessity for the inpatient admission is not substantiated. The insurer's denial is upheld.
Appeal type: Formulary Exception
Decision: Overturned

Digestive System/Gastrointestinal
Pharmacy/Prescription Drugs

Diagnosis: Ulcerative Colitis. 
Treatment: Mesalamine 0.375mg ER 
The health plan's determination is overturned. 

The patient is a male with Ulcerative Colitis. He improved on Lialda 4.8 g (grams) daily and later on Apriso. He failed Colazal and mesalamine 4.8 daily (with diarrhea and bleeding). Only Apriso has entirely resolved symptoms. Colonoscopy showed moderate disease activity in the sigmoid colon to cecum and internal hemorrhoids. Biopsies showed severe colitis in the cecum, moderate colitis in the ascending colon, and mild colitis in the transverse colon to rectum. Coverage is being requested for mesalamine extended release 0.375 g, 4 tablets daily. The formulary alternatives are balsalazide, Dipentum, mesalamine delayed release 400 milligrams (mg), mesalamine enema, mesalamine suppository, mesalamine delayed release 800 mg and 1.2 g, sulfasalazine, and sulfasalazine delayed release.

Mesalamine 0.375mg ER is indicated for this patient.  Mesalamine has proven effective for the treatment of Ulcerative Colitis in randomized, double-blind, multicenter trials, although various formulations result in release at distinct times and locations in the gastrointestinal tract, making them clinically different from each other. Specifically, it is different from alternatives such as Lialda, Asacol, Salofalk, Mezavant XL, and Pentasa, and their respective generic formulations, each with release in different portions of the gastrointestinal tract and at different pH levels, and these mesalamines are different from other formulary alternatives such as balsalazide and sulfasalazine.
The result of changing therapy can be inadequate control by a different formulation which directs the drug to a different part of the gastrointestinal tract. Sulfasalazine is inferior to mesalamine and associated with a higher rate of intolerance in some studies. Additionally, Ulcerative Colitis flares can be induced by salicylate medications, and changing therapy can expose the patient to this risk. In this case, the patient has had uncontrolled disease or adverse symptoms with multiple 5-aminosalicylate formulations. An exception is supported in this case to continue Mesalamine 0.375mg ER as the patient has been stabilized on the medication and has failed multiple other alternatives.
Appeal type: Medical necessity
Decision: Upheld

Endocrine/metabolic/nutritional
Inpatient hospital

This case involves a female sent into the emergency room by her primary care physician because of fevers and low blood pressures in the office. The fevers started the day before; she has been taking ibuprofen with good relief. Unfortunately, she woke up again on the day of admission with subjective fever and went to see her primary care physician. Upon arrival in the emergency department, she is afebrile with a temperature of 97, tachycardic at 103, with respirations of 20. Blood pressure was 92/68. On physical exam, she is tachycardic, lungs are clear, abdomen is soft, and there are no rashes. Under review is the inpatient level of care. 

The health plan's determination is upheld. The inpatient hospital stay is not medically necessary for this patient. This is a young and healthy patient who comes in with a fever and dehydration, and history of prior urinary tract infections treated with Keflex. On arrival, she is afebrile, borderline tachycardic, and responded to the treatment of IV fluids. She does not have evidence of severe sepsis or septic shock. Lactate is normal. White blood cell count is normal. She only has 40 white blood cells on the urinalysis and has a CT scan without abnormalities. There is no evidence of organ dysfunction. Within 24 hours, vital signs are stabilized; she is no longer exhibiting tachycardia or low blood pressure as would be expected in a young individual. She does not have the typical symptoms of sepsis related to pyelonephritis; she does not appear bacteremic, although the cultures were only 24 hours out. This type of presentation can be managed at a lower level of care. This patient appropriately responded to treatment with IV fluids and broad-spectrum antibiotics. In conclusion, the inpatient hospital stay is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Endometriosis
Treatment: Inpatient Hospital

Summary: This patient has a history of advanced endometriosis and bilateral ovarian cystectomy in 2018. She underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy subsequently in 2018. Her surgery was complicated by a bowel perforation requiring an exploratory laparotomy. She required a sigmoid colectomy with open abdomen negative pressure therapy (ABTHERA) placement and needed further wash out. The patient required an ostomy revision for ischemia. She was kept on intravenous (IV) antibiotics and initially received total parenteral nutrition (TPN). Her general status improved and she was able to tolerate an oral alimentation. She was kept in the hospital as inpatient.

The insurer has denied coverage for the inpatient hospital admission as not medically necessary. The denial was upheld.
 
The records provided do not show that during the denied dates, the patient required any form of wound therapy that was beyond the scope of outpatient care. There was no documentation that the patient required complex wound care or wound care that could not be rendered as outpatient. The records provided do not show that during the denied inpatient days there was any significant and ongoing sepsis with an elevated white blood cell count or persistent ileus or peritonitis, or required complex wound care. According to the records, the patient was hemodynamically stable with stable and normal vital signs, and was receiving care for her colostomy by an enterostomal nurse. The care is generally rendered as an outpatient. The inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope
Treatment: Inpatient admission

The inpatient admission was not medically necessary.

Febrile seizures are not an uncommon event, occurring in two to five percent (2-5%) of children ages six months to five years. The peak occurrence is between 18 months and three years, with markedly decreased incidence in children after four years of age, and rarely occurring after seven years of age. Febrile seizures are more common in Asian and Indian populations. Males have a higher incidence than females, and there are two seasonal peaks (November-January, June-August) associated with prevalence of common viral illnesses (respiratory and gastrointestinal, respectively). Most febrile seizures are simple, meaning that they are generalized, lasting less than 15 minutes, occurring only once in a 24 hour period, with no significant postictal period. Complex febrile seizures exhibit one or more of these features. There is a family tendency, with some genetic associations. Progression to a diagnosis of epilepsy is more likely to occur in association with neurodevelopmental abnormalities, complex febrile seizures, family history of epilepsy, and longer duration of fever. 

Initial evaluation of a patient with febrile seizure includes history, examination, and diagnostic testing to identify the source of fever. Lumbar puncture may be indicated in specific populations of patients. Electroencephalogram (EEG) is of limited value, more likely to be necessary and abnormal in older children, those with complex febrile seizures, those with neurodevelopmental abnormalities, and family history of febrile seizure. Per the American Academy of Pediatrics, EEG should not be considered part of the routine evaluation of healthy children with simple febrile seizure. Neuroimaging is also not indicated in the routine evaluation of first simple febrile seizure. Treatment with anticonvulsants is not generally recommended unless there is higher risk of epilepsy or abnormal neurological development. Conversely, rescue therapy may be indicated. 

This little boy presented to the hospital after bumping his chin with two subsequent brief spells of unresponsiveness and low-grade fever. Minimal work-up was done in the ED in part because of inability to achieve IV access. He was transferred for observation on the pediatric floor. Upon admission, the patient was diagnosed with right otitis media, and an electrocardiogram was obtained and was normal for age. He was observed overnight for further spells, and was discharged the next day. While it was not unreasonable to monitor the patient for a period of time, he was overall hemodynamically stable, with no evidence of sepsis or persistent altered state. He did not require acute inpatient admission, and could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gastrointestinal bleeding

Treatment: Inpatient admission, diagnostic evaluation, blood transfusion

The insurer denied inpatient admission. That denial was reversed.

The patient presented after 7 episodes of rectal bleeding. The patient was on anticoagulation with Xarelto for atrial fibrillation. The patients's vital signs were stable. The hemoglobin was 8.1. The INR was 1.4. The patient was also an aspirin in addition to the Xarelto. DDAVP was given due to the Aspirin. He was transfused a unit of PRBC. The Xarelto was held. The bleeding stopped. 

Clinical indications for admission for lower GI bleeding are listed in MCG M-182. Indications include ongoing active bleeding, coagulopathy and anemia with signs of cardiac ischemia. 

This patient was having multiple episodes of bleeding and the hemoglobin went down to 8. The patient was anticoagulated with Xarelto. The patient was also on aspirin. The patient had cardiac disease with coronary artery disease and atrial fibrillation. At the time of admission, there was concern about ongoing bleeding in an anticoagulated patient. Therefore, an inpatient admission was medically necessary and the healthcare plan did not act reasonably or in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dyspnea. 
Treatment: Inpatient admission 

Summary:
The Inpatient admission was not medically necessary.
The only cardiac care that was provided was telemetry and routine cardiac catheterizations and ICD placement, all of which are frequently performed in a lower level of care. The cath showed no evidence of obstructive CAD (coronary artery disease). The ICD was placed without complications. The patient was admitted for monitoring, and the subsequent tests and therapy did not require an inpatient level of care. There was no complex care that required inpatient care. This patient had no evidence of CAD.  While there was always a potential for an adverse event, one did not happen, and no actual treatment was added.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Kidney Stones 
Treatment: Inpatient Hospital 

This is a male patient with a known ureteral stone. A stent had been placed as a first stage procedure prior to definitive intervention. The patient had severe, acute recurrence of colic mandating urgent admission. Ureteroscopy and lithotripsy of the stone was performed. Postoperatively, the patient had stable vitals, was afebrile, and tolerated orals well. The inpatient admission is under review. 

The health plan's determination is upheld. The inpatient stay was not medically necessary. Based on the submitted documentation and current standard of care, an inpatient admission was not medically necessary nor justified. The patient's vital signs including temperature, oxygenation, and blood pressure were normal. Orals were being tolerated. The patient had an uneventful, successful second stage procedure for treatment of a ureteral stone. Following the procedure, vitals were stable, oral were tolerated, and pain was controlled. The inpatient level of care was not indicated.
Appeal type: Medical necessity
Decision: Overturned

Cancer - Other
Chemotherapy

The patient is a male who was diagnosed with a desmoplastic small round blue cell tumor. He underwent chemotherapy, surgical resection, immunotherapy and radiation, which he completed. Last month he was found to have relapsed disease in his liver. The provider is requesting treatment with temsirolimus to be given in combination with cyclophosphamide and vinorelbine. Temsirolimus is approved only as a single agent and not in combination.

The health plan's determination is overturned. 

Yes, the treatment with Temsirolimus is medically necessary for this patient. Temsirolimus is being offered for treatment of recurrent disease. This tumor is very rare and aggressive, with a poor prognosis and limited treatment options. In addition to the two articles presented by the provider, there are two additional articles referenced below which describe the difficulty and challenges with treating this disease. One paper describes the limited to no benefit of treating with a single agent mTOR inhibitor (i.e. temsirolimus) and that it will likely be only of benefit in combination therapy. Salvage chemotherapy is medically necessary to have disease control. Unfortunately, there is currently no standard of care recommended for this disease.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Testicular / pelvic pain; CRPS
Treatment: DRG stimulator
The proposed treatment with DRG stimulator is medically necessary.

The patient is a male with a history of testicular/ pelvic pain / complex regional pain syndrome (CRPS) who has failed extensive conservative treatment over the last three years.  His conservative treatment included physical therapy, medications, nerve blocks and acupuncture.  The patient previously underwent a dorsal root ganglion (DRG) stimulation trial with an excellent response.

The patient is a male with a complicated pain history, chronic testicular / pelvic pain / CRPS. The patient has been treated with injections, medications, physical therapy and acupuncture. The requested DRG stimulation is likely to be of greater utility than traditional spinal cord stimulation, given the attached documentation.   DRG stimulation has been shown to be superior to traditional spinal cord stimulation in the literature for conditions such as complex regional pain syndrome. There is some evidence for its superiority already in conditions such as pelvic pain, pudendal neuralgia, amputee pain, post hernia pain, post mastectomy pain, and post herpetic neuralgia.  This patient is being treated for both CRPS as well as pelvic / testicular pain; these are the conditions that are most effectively treated with DRG stimulation versus traditional spinal cord stimulation. In addition, the patient has had a successful DRG stimulation trial.  There are multiple notations throughout the documentation that the patient had "excellent result", "profound pain relief", and "successful trial". Given the above, and the lack of response to conservative treatment, and the proven superiority of this modality to traditional spinal cord stimulation, the requested DRG stimulation is medically necessary.