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

Diagnosis: Mental Health (Altered mental status)
Treatment: Inpatient Hospital

Summary: This patient was admitted to inpatient hospital due to altered mental status. He was lethargic, confused, had thought blocking, odd speech, was nonverbal, had poverty of thought, prolonged speech latency, auditory hallucinations, and was not eating or sleeping well. It was reported that he was flushed, diaphoretic, had cool extremities, appeared dehydrated, and had dry scaly lips. He had worsened symptoms after taking Seroquel and Klonopin prescribed by his outpatient Psychiatrist due to reports that his condition was very severe. He took Zyprexa and Benadryl as needed (prn), had intravenous (IV) fluids, a medical work-up, and was discharged.

The insurer has denied coverage for inpatient hospital admission as not medically necessary. The denial was reversed.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Delirium reports that when delirium is comorbid with other psychiatric disorders, the delirium should be treated first. Because of the patient's mental status changes, one could not ascertain whether this was a primary psychotic disorder such as schizophrenia or a delirium or both; therefore, treating the patient for possible delirium first in a medical/pediatric hospital was considered medically necessary and appropriate treatment. This was the case with this patient, as it was unclear if this was delirium, a primary psychotic disorder, or both. Treating him in this medical hospital first was appropriate. The psychiatric consultant reported that it was unclear if this was altered mental status from delirium or schizophrenia, as he had psychotic symptoms with his altered mental status including thought blocking, nonverbal behavior, poverty of thought, prolonged speech latency, and auditory hallucinations with confusion. He took antipsychotic medication, Zyprexa, and improved by discharge. The diagnosis from the psychiatric consultant was altered mental status. Notes reported that Klonopin was discontinued. He still had reports of intermittent blank staring, was poorly related, had significant latency to respond, and it was reported that he was still sedated. It was reported that there was a question of whether his diagnosis was Schizophrenia or altered mental status verses delirium. The APA Practice Guidelines for the Treatment of Patients with Schizophrenia reports that patients with hallucinations, delusional thinking, disorganized thinking or behavior, severe agitation are in need of hospital treatment. In this case, this patient had severe disorganization with confusion, in addition to hallucinations, thought blocking, poverty of thought, prolonged speech latency, and was not verbal initially. He also had not been eating or sleeping. This patient had severe symptoms requiring hospital treatment and could not safely and effectively be treated in a less restrictive setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Abuse/ Addiction
Treatment: Inpatient Hospital

Summary:  This patient was admitted to this inpatient hospital treatment due to alcohol withdrawal and abdominal pain. He was drinking heavily daily including more than 12 beers and 12 liter of vodka per day with his last reported drink the day prior to admission. He had abdominal pain at an intensity level of 9 out of 10, and withdrawal symptoms that consisted of tremors, flushing, nausea, leg cramps and bloating. He had alcohol hepatitis, transaminitis, and polycythemia, in addition to alcohol withdrawal. He was put on a Librium protocol and had a gastrointestinal work up as well. He had a past admission 2 months prior. He requested to leave against medical advice (AMA), but eloped the following day. 

The insurer has denied coverage for the inpatient hospital admission as not medically necessary. The denial was reversed.
 
The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. In this case, this patient had been drinking large amounts daily, including drinking more than 12 beers and 12 liter of vodka. According to the Level of Care for Alcohol & Drug Treatment Referral (LOCADTR), he did require 24-hour treatment as he could not safely and effectively be treated in outpatient detoxification settings. This was evidenced by his continued use of large amounts of alcohol daily; therefore, he required and needed detoxification medications to modify withdrawal, including a Librium protocol. He needed 24-hour treatment as he was at risk for worsened severe, life-threatening, or complicated withdrawal symptoms if not in this 24-hour setting. Additionally, he had withdrawal symptoms and co-morbid medical issues. It was unlikely that he would remain abstinent while still having withdrawal symptoms. He had medical issues as well, and had a gastrointestinal work up, in addition to managing withdrawal and detoxification. He required the time in this treatment setting to stop withdrawals and decrease the chance that he would relapse again when not in this 24-hour setting. This treatment setting was also necessary to prevent possible life-threatening withdrawal symptoms. The risk of complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use; therefore, he required the entire time including the denied days.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Kawasaki disease
Treatment: Inpatient Hospital Admission

Summary: This patient with a history and treatment of Kawasaki disease was treated with intravenous immunoglobulin (IVIG) and within 3-4 days of treatment, returned to the emergency department (ED) with a fever of 100.5F. The patient was readmitted with possible refractory Kawasaki disease. In the ED, other than the findings typical of ongoing Kawasaki disease, i.e. desquamation of skin on fingertips, the patient was described as "well appearing", with "normal mental status", in no distress and well hydrated. A temperature of only 100.5F was recorded (subsequent recordings were normal). The elevated erythrocyte sedimentation rate and white blood count was consistent with the recent diagnosis of Kawasaki disease. 

The insurer denied coverage for the inpatient hospital admission as not medically necessary. The denial was upheld.

The key to the decision to admit or not was the diagnosis of left otitis media made in the ED. Therefore, this patient had another explanation for the fever. If the decision in the ED, in consultation with pediatric cardiology, was that this patient needed to be treated with further IVIG therapy, admission would have been justified. (The normal repeat echocardiogram performed on admission could have been performed in the ED). However admission to the hospital was made for observational purposes only and could have been provided in the ED. Therefore admission to the hospital was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Foot Disorder (Metatarsalgia)
Treatment: Orthotics/Durable Medical Equipment/Foot Care (Foot insert)

Summary: This patient is currently diagnosed with foot metatarsalgia. The letter of medical necessity noted that the patient was to receive custom orthotics as a conservative treatment option for the patient's foot pain to prevent the need for surgical intervention. The patient had been using custom orthotics and they were improving his symptoms in the extreme. It is highly unlikely to achieve complete relief of symptoms with an over-the-counter orthotic. The progress note noted that the patient was seen for follow-up. The patient reported limited success with the use of the custom orthotics for athletic activities; however, he now reports pain and discomfort with regular walking. The patient also reports having limitations at his job as he travels quite a bit. The patient was to proceed with a second pair of orthotics.

The insurer has denied coverage for L3020 Foot, insert, removable, molded to patient model, longitudinal/ metatarsal support, each (right and left foot) as not medically necessary. The denial was upheld.

The medical literature indicates that custom foot orthotics are indicated for patients with arch, heel or other foot pain, as well as a foot condition as indicated by diplegic cerebral palsy; juvenile idiopathic arthritis; pes cavus; plantar fasciitis with adjustment of activities failed to improve symptoms; anti-inflammatory medications failed to improve symptoms; prefabricated orthotics failed to improve symptoms; stretching of the calf muscles and plantar surfaces failed to improve symptoms and symptoms are present for three months or more. The documentation indicated that the patient did have metatarsalgia with continued foot pain. The patient had been utilizing the custom foot orthotics. However, literature does not support the use of custom-made orthotics for patients with metatarsalgia. There was no evidence of diplegic cerebral palsy, juvenile idiopathic arthritis, pes cavus or plantar fasciitis. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

The patient with history of diabetes, pulmonary hypertension, atrial fibrillation off anticoagulation, presented to the hospital with shortness of breath and edema. The patient was admitted for acute congestive heart failure, shortness of breath and edema. The patient was treated with diuretics, and treatment for hypertension. Cardiology and pulmonary consults were obtained. The health plan's determination is upheld. 

The patient was hemodynamically stable and did not have significant evidence of acute congestive heart failure. The patient did need diuresis, but the care and management the patient received could have been provided at a lower level of care status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Major depressive disorder
 
Treatment: Inpatient hospital mental health services

The insurer denied the continued Inpatient mental health admission. The denial was reversed

This patient was admitted to inpatient mental health treatment due to worsened depressive symptoms, suicidal thoughts, irritable mood, agitation, poor impulse and anger control.  He reportedly had a diagnosis of Major Depressive Disorder.  He was living in a shelter and was unemployed and had poor social support.  He reportedly had multiple past psychiatric hospitalizations.  He had been prescribed Abilify, Buspirone, Depakote, and Trazodone.  He was reportedly refusing medication at times.  He was agitated and required intramuscular (IM) medications.  

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Major Depressive Disorders report that treatment settings for patients with major depressive disorder include a continuum of possible levels of care and in general, patients should be treated in the least restrictive setting that is most likely to prove safe and effective.  It states that the psychiatrist should choose an appropriate site of treatment after evaluating the patient's clinical condition, including symptom severity, co-occurring conditions, level of functioning, and available support system.  The estimated degree of risk to self and to others is another significant determinant of treatment setting.  Decisions about treatment setting should also include consideration of the patient's ability to adequately care for him- or herself, provide reliable feedback to the psychiatrist, and cooperate with treatment of the major depressive disorder.  Patients with suicidal or homicidal ideation, intention, or plans require close monitoring.  

In this case this patient was unable to care for himself adequately as he was refusing medications, getting agitated, was depressed, had poor impulse and anger control, felt he needed more help, had been refusing oral medications and he required intramuscular (IM) medications. He received IM Geodon and Ativan, and IM Zyprexa on the dates in question so this was considered active psychiatric hospital treatment.  Notes reported that he was depressed, had increased anger and irritability, needed more help, and was not ready for discharge.  Discharge was delayed due to his feeling that he could not adequately care for himself and he wanted to remain longer in the hospital.  Notes that he was discharged but that he returned stating that he wanted to hurt himself, was depressed and angry, had poor impulse control and frustration tolerance, and he reported that he needed more help.  He appeared to still be in need of hospital treatment at the time, as he still had thoughts of: hurting himself, anger, depression, and had difficulty caring for his needs.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diverticulitis
Treatment: Inpatient Hospital 

Summary: This patient had a history of diverticulitis and presented with abdominal pain. He initially had tachycardia but it resolved. There were no peritoneal signs. A Computed Tomography (CT) scan revealed sigmoid diverticulitis without a fluid collection. The patient was treated with intravenous (IV) antibiotics.  The abdominal pain improved and his diet was advanced.

The insurer has denied coverage for the inpatient hospital admission as not medically necessary. The denial was upheld.

MCG lists clinical indications for admission for acute diverticulitis. Admission is indicated for peritoneal signs, hemodynamic instability, persistent bleeding, or a complicating condition seen on imaging studies. This abnormality can be an abscess, fistula, obstruction, ileus, or free perforation. The patient did not have any of these conditions. He also did not have severe vomiting, severe dehydration, bacteremia or a need for a surgical intervention. This patient had acute diverticulitis that was not complicated by an abscess. He could have been treated with a course of oral antibiotics as an outpatient. He did not meet MCG criteria for admission for diverticulitis.
Appeal type: Medical necessity
Decision: Overturned

The patient presented to the emergency department (ED) with dyspnea and a cough with findings of a worsened pneumonia. The patient had previously been treated for pneumonia less than two weeks prior and was treated with Levaquin for a seven-day course. 

The health plan's determination is overturned. The inpatient stay was medically necessary. This is a patient with a recent history of pneumonia who presented within 2 weeks of a previous hospitalization with evidence that his pneumonia had worsened. He had a new pleural effusion and was also noted to have had worsening of his baseline infiltrate. His signs and symptoms on arrival are consistent with a systemic immune response known as sepsis and he was treated early and aggressively with intravenous (IV) fluids as well as abx (antibiotics).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skin Disorders (Atopic Dermatitis)
Treatment: Pharmacy/Prescription Drugs (Dupixent) 

Summary: This patient with atopic dermatitis has itchy skin rashes on her forearms, forehead, face, neck and legs. Past medication tried and failed includes Elocon, Fluocinonide, Protopic, Vanicream, Halobetasol and Prednisone. The physician noted that continual use of topical therapies is not appropriate for this patient considering the severity of her condition and the body surface area affected. Cyclosporine has many intolerable side-effects and phototherapy is time consuming and will interfere with the patient's schooling.  The patients' Allergist-Immunologist has prescribed Dupixent.
  
The insurer has denied coverage for Dupilumab (Dupixent) 300mg/2ml SC SOSY as not medically necessary. The denial was reversed. 

Eucrisa would be inappropriate and impractical for this patient due to the large surface areas involved and would be difficult to treat with a tube of Eucrisa. Because of the young age of the patient, long-term use of cyclosporine would lead to fibrosis of the kidneys, as well as the potential adverse effects of hypertension, and elevated creatinine. Long-term use of phototherapy in such a young individual would lead to increased risk of photo aging and skin cancers. According to the FDA guidelines regarding Dupixent, the medication is approved for atopic dermatitis, when patients have tried and failed a topical corticosteroid. As in this case the patient has tried and failed topical corticosteroids such as Elocon, fluocinonide, and a class I corticosteroid halobetasol, as well as the systemic corticosteroid, prednisone. The patient has generalized atopic dermatitis involving the forearms, forehead, face, neck and legs.  Therefore, the patient has tried and failed conservative therapy. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Binge eating disorder
Treatment: Vyvanse 60mg OR CAPS
The requested Vyvanse is not medically necessary.
There is no information suggesting that the treatment being offered is more successful than another alternative such as Adderall XR.  There is no information suggesting that another medication on formulary would not be as effective or would cause additional side effects as opposed to the current medication.  Therefore the treatment is not medically necessary.
The patient's treatment is not medically necessary.  There is no information suggesting that a similar medication on formulary would not be as effective as Vyvanse or that Vyvanse is better tolerated than an alternative treatment.  Therefore this treatment should not be covered by the patient's health plan.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with aggressive and high risk behaviors who was medically screened in the emergency department and admitted for acute inpatient psychiatric treatment. The patient had become increasingly anxious and depressed with suicidal ideation and deterioration in functioning culminating in her presentation. 

The patient has a history of bipolar disorder and severe depressive episodes and psychiatric treatments with multiple psychiatric hospitalizations and ongoing therapy and medication management. She was also diagnosed with attention deficit hyperactivity disorder (ADHD). Her presentation was characterized by worsening symptoms of depression and suicidal ideation in the context of multiple psychosocial stressors and trauma related symptoms.
The health plan's determination is overturned.
The patient required the admission and continued acute inpatient level care; and, the continued structure of an acute inpatient level setting through discharge was warranted in order to provide safety monitoring and to administer active treatment for the psychiatric disturbances while conducting an evaluation, and while observing the patient's functioning with the resumption/adjustment of clinically appropriate medications including the addition of a mood stabilizer and change in medication to address the co-morbid ADHD.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pineal Cyst
Treatment: MRI of brain with and without contrast
The requested MRI of the brain is not medically necessary.
There are no clinical guidelines or high quality clinical trials indicating that repeat MRI is appropriate for a person with an asymptomatic pineal cyst. Pineal cyst is a common finding and natural history studies have demonstrated that the vast majority of lesions do not increase in size, do not become symptomatic and do not require intervention. Therefore, repeat imaging in the absence of new clinical findings is not appropriate, necessary or standard of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Heart failure
Issue under review: Inpatient admission

Determination:
The inpatient admission was not medically necessary.

This patient had known CHF and presented with mild SOB (shortness of breath). She was hemodynamically stable with normal oxygen saturation. Her treatment consisted of low dose IV diuretic. Echocardiogram showed normal Ejection Fraction. Her diagnosis most likely is HFpEF (heart failure with preserved ejection fraction). This is a common occurrence in the elderly, and standard care is in outpatient. 
	
Determination of level of care is primarily dependent on the actual care a patient receives, and whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results. It is highlighted in the orders for care.

In this case, the patient's symptoms were mild. Her exam and cardiac findings were consistent with compensated CHF. Her Biomarkers and EKG (electrocardiogram) showed no evidence of acute ischemia. CXR showed cardiomegaly. Echocardiogram showed no wall motion abnormality. The physicians' treatment did not reflect any new concern about the patient's cardiac condition.  Orders did not include medical therapy for ACS (acute coronary syndrome) such as IV heparin, dual antiplatelet inhibitors, high dose beta blockers or IV NTG (nitroglycerin).   

The letter of appeal was carefully considered, but it offered no evidence to support an inpatient level of care. The only cardiac care provided was telemetry, which is frequently performed in a lower level of care. 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. The statement that this patient could not be "managed" in an outpatient setting is not consistent with guidelines or usual community practice. This patient had no evidence of CAD (coronary artery disease). In fact, all tests showed absence of ischemia.  While there was always a potential for an adverse event, one did not happen, and no actual treatment was added. There are no examples of care requiring inpatient level of care.

Milliman criteria requirements for admission for CHF were not fulfilled, as there was never any evidence of instability present. Since all testing and therapy that were provided would have been appropriate, safe and guidelines-consistent in a lower level of care, inpatient level of care was not medically necessary.

The denial explanation was consistent with guidelines and usual community care.