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

Diagnosis:  Major depressive disorder.
Treatment:  Inpatient admission.

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

The patient is a female with a history of mental illness who was hospitalized.

The patient has been diagnosed with major depressive disorder.  There was a three-month history of depressed mood with neurovegetative signs including decreased appetite and focus.  There were multiple stressors including a recent breakup with her boyfriend.  The patient reported a suicide attempt by intentional overdose of ibuprofen.  She was brought to the emergency room for evaluation by emergency services and was noted to have a headache and abdominal pain on evaluation.  She was seen by the consulting psychiatry team who recommended inpatient psychiatric hospitalization.

The patient was medically cleared for psychiatric hospitalization and was admitted to the inpatient ward.  She was treated by a multidisciplinary team including psychiatry, nursing, and therapy staff.  She received group and individual therapy.  She received a psychopharmacology evaluation and was started on sertraline to target depressive symptoms.  The patient's nurse noted that the patient "needs reinforcement" in regard to her depression and received a Benadryl at nighttime for her symptoms.  The patient was noted to be without severe psychiatric symptoms.  She was noted to be stable and was discharged with a plan for outpatient psychiatric follow up.

Yes, the proposed continued inpatient admission was medically necessary.

The patient represented an acutely elevated risk of dangerous behaviors, and there was no less-restrictive treatment environment appropriate.  The acute risk factors of depression with the chronic risk factors of potentially dangerous behaviors suggest that the patient would have been at an acute risk of self-injurious behaviors (including but not limited to suicide) were they to have been discharged from the inpatient hospital setting.  The patient was discharged from the inpatient psychiatric hospital setting as soon as a less-restrictive treatment setting was appropriate for her.  

The patient represented an elevated risk of dangerous behaviors including self-injury, and suicide, and there was no less-restrictive treatment environment appropriate.  Therefore, the treatment was medically necessary.  While the patient was not endorsing active suicidality or homicidality, the patient was an ongoing elevated risk.  The patient had multiple static risk factors for potentially dangerous behaviors including history of recent suicide attempt and diagnosis with a severe mental illness.  Therefore, the patient represented a chronic risk of potentially dangerous behaviors.  The fact that patient remained with ongoing symptoms and need for as needed (PRN) medications were acute risk factors for dangerous behaviors.  Furthermore, the fact that there was no less-restrictive environment of care appropriate suggests that ongoing inpatient psychiatric hospitalization was medically necessary and should be covered by the patient's health plan.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Acute Cholecystitis.
Treatment:  Inpatient admission.

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

This is a female patient with a past medical history of obesity, gastritis, and status post myomectomy, who presented to the emergency department (ED) with complaints of abdominal pain radiating to the back, vomiting, and increased urination.  The initial exams showed an elevated blood pressure and mild right upper quadrant (RUQ) tenderness to palpation.  She was febrile with stable vital signs.  Her abdomen was soft, tender with RUQ pain, and negative Murphy's sign.  There was no rebound or guarding.  The patient was admitted to surgery.

An abdominal sonogram showed multiple small and large stones with thickened wall and trace pericholecystic fluid.  The assessment was acute cholecystitis, and the plan was antibiotics, IV fluid, nothing by mouth (NPO), and plan for cholecystectomy.  The patient underwent an uneventful lap cholecystectomy with the findings of a chronically inflamed gallbladder.  Postop, the patient did well and was eating a low fat diet.  The plan was for next day discharge.  The patient continued to do well and was discharged on day 4 of admission.

The medical necessity of hospital services and hospital admission was not justified at an acute level of care as this patient could have been treated on an ambulatory basis with observation. She did not have the lap cholecystectomy until day 3 of admission. This delay in performing the surgery is what kept her in the hospital. 

She did not meet the criteria of Magellan Care Guidelines (MCG) according to MCG Health Inpatient and Surgical care- 24th edition Gall bladder or bile duct inflammation or stone ORG: M-555 (ISC) clinical indications for admission to inpatient care.  This patient did not have signs and symptoms of acute cholecystitis as she only had RUQ pain in the setting of a normal white blood cell count.  She had no systemic signs of acute inflammation that warranted an acute admission.  She could have been treated in an observation setting and sent home following a laparoscopic cholecystectomy on day 1 or 2 of admission.  There was no reason for a delay of the surgery; she did not need acute inpatient stay, as there was no evidence that this was acute cholecystitis but rather biliary colic.  By day 2 of admission, she was feeling better in terms of pain.  She was not a high surgical risk, and if the provider wanted, he could have performed the cholecystectomy during this admission on a date earlier than day 3 of admission.  She did not require inpatient admission and service, as she did not meet criteria for admission. 

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

The medical necessity for inpatient admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Eczema with superimposed bacterial infection, Lymphadenitis, and Cellulitis.
Treatment:  Acute inpatient hospital services.

The insurer denied coverage for acute inpatient hospital services.  The denial is upheld.

This is a male child with a history of eczema, who presented to the Emergency Department (ED) with a 3 day history of right-sided facial swelling, fever, and not acting like his usual self.  He was seen by his physician 2 days prior and was prescribed Bactrim, but because of worsening symptoms the therapy was changed to clindamycin the next day.  On examination in the ED he was febrile, but other vital signs were within normal limits.  There was a firm and tender swelling of his right mandible and multiple lesions on his cheeks spreading to his neck and behind his ears. 

The workup included a bedside ultrasound of the neck which revealed right-sided lymphadenitis without any evidence of abscess formation.  His white blood cell (WBC) count was elevated at 29.2, and his C-reactive protein elevated at 10.6.  The admitting diagnosis was eczema with superimposed bacterial infection, lymphadenitis, and cellulitis.  At triage, the history included being fussy and lethargic; however, he was described in the nursing notes as comfortable in his mother's arms and feeding well.

There was no adequate justification made in the medical decision making area of the ED physician's notes as to why parenteral therapy and inpatient monitoring was indicated for this patient.  Elevated inflammatory markers alone are not indications for parenteral therapy.  He was not toxic or in pain that would preclude oral intake of medications.  It was noted that he was delayed on vaccinations.  He was treated with intravenous (IV) vancomycin for possible methicillin-resistant staphylococcus aureus (MRSA), which is not a vaccine-preventable infection.  Therefore, therapy could have been continued outpatient.  Oral clindamycin could have been continued, as there was not enough time to label this as a treatment failure after 1 day.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The carrier's denial of coverage for acute inpatient hospital services is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.  The denial is overturned.

The Inpatient admission was medically necessary.

The patient has a past medical history significant for CAD (coronary artery disease), s/p (status post) recent anterior wall myocardial infarction with PCI (percutaneous coronary intervention) of proximal and mid LAD (left anterior descending), ischemic cardiomyopathy, LV (left ventricle) thrombus, CHF (congestive heart failure), and dyslipidemia. He presented to the ER for chest pain, described as pressure-like, substernal, associated with jaw numbness. 

The patient's ECG (electrocardiogram) was abnormal with ST changes in leads V2-V4 and T-wave inversions in V5 and aVL. The first troponin was negative. A STEMI (ST elevation myocardial infarction) code was called for suspected ST-elevation myocardial infarction, suspected stent thrombosis. The patient was treated with antiplatelet and anticoagulation and was emergently taken to cardiac catheterization lab, and a coronary angiogram was performed. The prior LAD stents were patent and the patient was found to have severe stenosis of OM2 (obtuse marginal branch II), which was treated with medical therapy. The patient was discharged home.

The patient presented with new onset chest pain, suggestive of unstable angina / ACS (acute coronary syndrome) / MI (myocardial infarction). The patient had multiple risk factors for CAD, including a known history of coronary artery disease, s/p a recent MI, requiring percutaneous revascularization. The ECG was abnormal, consistent with ischemia / MI. There was a high index of suspicion for an ACS, and a cardiac catheterization was performed. Given the presentation, as well as clinical suspicion for an acute coronary syndrome / MI / unstable angina, he would not be an appropriate candidate for an ED chest pain observation unit. It would be consistent with the current standard of care that this patient be managed in an inpatient setting. Therefore, the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Liver disease

Treatment: LEDIP-SOFOSB TAB 90-400mg

The insurer denied coverage for LEDIP-SOFOSB TAB 90-400mg. The denial is reversed. 

This patient is a child with a past medical history notable for a disease of the liver. The patient had a genotype 1B infection. The patient's laboratories were notable for AST 39, ALT 70, platelet count 339, creatinine 0.5 and HCV viral RNA 608,000 IU/mL. The patient's abdominal sonogram was unremarkable. The patient's treating physician requested generic Harvoni to treat this patient. 

Based on the review of the medical record, this patient suffered from chronic disease of the liver with elevated liver enzymes (e.g., ALT) but had no signs of significant fibrosis by laboratories or imaging.

According to a review of hepatitis C in children from UptoDate, the authors conclude the following regarding treatment options. The treatment of chronic HCV infection is rapidly evolving. The development of direct-acting antiviral agents (DAAs) and combination drug regimens represents a major milestone in the treatment of HCV in adults and adolescents and is likely to transform practice in younger children in the near future. These agents permit effective, well-tolerated, all-oral, interferon-free regimens for most patients. Regimen selection varies by genotype and other patient factors, such as the presence of cirrhosis and treatment history. For children ages 3 to <12 years old, the clinical approach to treatment depends on the patient's genotype and the patient's ability to take the medications. Young children may not find the small granules palatable or be able to swallow them without chewing, so it may be prudent to wait until the medications can be reliably administered. For Genotypes 1, 4, 5, or 6, Ledipasvir-sofosbuvir for 12 weeks is recommended. This combination is approved in the United States for children ages three years and older with HCV infection; it is one of several preferred regimens for adults with these genotypes.

Also supporting the use of generic Harvoni (Ledipasvir/Sofosbuvir) for this child can be reviewed in the current American Association for the Study of Liver Diseases (AASLD) guidelines on HCV Antiviral Therapy for Children and Adolescents, Without Cirrhosis or With Compensated Cirrhosis (Child-Pugh A). As to date, other medications such as Mavyret is not yet approved for children <12 years of age. There is no proper dosing for this age group. Thus, based on this review of the literature, Ledipasvir/Sofosbuvir (LEDIP-SOFOSB) TAB 90-400MG is medically necessary to treat this patient's medical condition. 

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

The carrier's denial of coverage for LEDIP-SOFOSB TAB 90-400mg is reversed. The medical necessity is substantiated.
Appeal type: Step Therapy
Decision: Overturned

Diagnosis:  Atopic dermatitis.
Treatment:  Dupixent.
The insurer denied the Dupixent.  The denial is overturned.

The treatment with Dupixent is medically necessary.

The patient is a woman with atopic dermatitis for whom Dupixent is requested.  She has been on Dupixent with excellent control (less than 1% BSA [body surface area] affected).  She also uses topical steroids for the hands.  Other comorbidities are well-controlled and followed during Dupixent therapy.

The patient has severe atopic dermatitis, which has been well-controlled with Dupixent for the past year and a half. She also uses topical steroids. Because she is doing well on Dupixent and has been using it for a long time, this is continuation of therapy and is medically necessary to prevent a severe flare and setback of her disease.  Switching medications at this point to try other alternatives that are on the health plan's formulary would put the patient at risk of disease flare, and would not be consistent with generally accepted practice in the Dermatology community.

Dupilumab is an interleukin (IL)-4 and IL-13 receptor-alpha antagonist that was approved by the US Food and Drug Administration for the treatment of adolescents aged 12 years and older with moderate to severe atopic dermatitis not adequately controlled with topical prescription therapies.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Type 1 Diabetes.
Treatment:  Inpatient admission.

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

The patient is a male with attention deficit hyperactivity disorder (ADHD), who presented with polyuria and polydipsia and was found to have new onset diabetes with a glucose of 274.  The patient had negative ketones; pH was normal.  Beta hydroxybutyrate was elevated at 0.37.  The patient's glycated hemoglobin (A1c) was 11.6%.  He was diagnosed with new onset diabetes and admitted for diabetes education.  The patient was started on a basal bolus regimen with an insulin to carbohydrate ratio and an insulin sensitivity factor.

Yes, the health plan should cover the inpatient admission because it is medically necessary, as described below.

Yes, the inpatient admission was medically necessary.

Diabetes education consists of several components, nutritional counseling, self-monitoring of blood glucose and treatment of hyper and hypoglycemia.  The standard of care is that all patients with diabetes should receive all these components (1, 2). 

Practice patterns differ depending on the availability of educators, etc.  Whether a patient gets hospitalized for intensive insulin therapy initiation depends on the available program where the patient is seen.

The majority (75%) of medical centers in the US (3) that treat new onset type I diabetes admit their patients.  According to the American Diabetic Association (ADA) statement on treatment of type I diabetes (4), hospitalization is necessary regardless of severity if, "the center is not experienced in the outpatient management of newly diagnosed children with diabetes or is not adequately staffed to provide outpatient care because regional health care reimbursement is inadequate for initial outpatient care and education."  In type I diabetes, the initial hospitalization is to educate the patient and the family in self-injection, drawing up and mixing of insulins, checking blood sugar, recognizing and responding to hyper and hypoglycemia, and evaluating ketosis, as well as nutrition education on carbohydrate counting because there is only one treatment option (insulin).  Learning these skills is an overwhelming task for most patients and families and is the reason that this is done with a two- to three-day admission to the hospital (5-8). 

The patient is a child with new onset diabetes.  Admission to the hospital was required to initiate insulin and educate the family on all aspects of insulin therapy and management of hyper and hypoglycemia.  The request is consistent with generally accepted standards of medical practice.  Admission to the hospital was health beneficial to this patient.  The proposed treatment is, therefore, medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back Pain.

Treatment: Inpatient admission.

The insurer denied the inpatient admission.

The denial was upheld.

This is a male patient who presented to the Emergency Room (ER) with complaints of with an acute onset of low back pain. The patient's exam was normal. The patient was initially in observation and was admitted for persistent pain and inability to ambulate; there were no red-flag symptoms. An admitting note stated that the patient had 3/5 bilateral hip flexion weakness and was unable to tolerate sitting for the full length of exam. All other exams were normal. The hospital course noted that the patient was transitioned from Ketorolac around the clock to Motrin as needed with significant improvement in pain and mobility. The patient did not require NSAIDs throughout the night before discharge. The patient was discharged home with outpatient therapy.

Acute low back pain with or without sciatica usually is self-limited and has no serious underlying pathology. For most patients, reassurance, pain medications, and advice to stay active are sufficient. A more thorough evaluation is required in selected patients with "red flag" findings associated with an increased risk of cauda equina syndrome, cancer, infection, or fracture. These patients also require closer follow-up and, in some cases, urgent referral to a surgeon. In patients with nonspecific mechanical low back pain, imaging can be delayed for at least four to six weeks, which usually allows the pain to improve. There is good evidence for the effectiveness of acetaminophen, nonsteroidal anti-inflammatory drugs, skeletal muscle relaxants, heat therapy, physical therapy, and advice to stay active. Spinal manipulative therapy may provide short-term benefits compared with sham therapy but not when compared with conventional treatments. Evidence for the benefit of acupuncture is conflicting, with higher-quality trials showing no benefit. Patient education should focus on the natural history of the back pain, its overall good prognosis, and recommendations for effective treatments.

According to the medical records reviewed, the inpatient stay did not meet the InterQual Acute Adult Criteria for General Trauma - intractable pain - criteria for admission. The patient met the criteria for observational level of care as he was unresponsive to greater than two doses of analgesic that required additional analgesic greater than two doses, and a pain assessment at least every four hours. There were no red-flag findings. The patient had improvement with medication and required no NSAIDs overnight. The patient had no significant neurological deficit, and the patient did not require imaging and did not require surgery. Since this patient's care could have been provided at an observation level, inpatient admission was not medically necessary.

The health plan acted reasonably with sound medical judgment, and 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 should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Seizure Disorder.
Treatment:  Continued stay in a skilled nursing facility.

The insurer denied the continued stay in a skilled nursing facility.  The denial was upheld.

This a male patient, who was status post left frontal cortical dysplasia and resultant intractable seizure disorder that failed medical management status post stereotactic left premotor frontal lobectomy with intraoperative electrocorticography in late 2019.  The patient was initially admitted for rehabilitation following a lobectomy with initial improvement in seizures but developed increasing seizures and was transferred back for EEG monitoring.  The patient was discharged home after anti-epileptic medications were adjusted, but he developed progressive deterioration of function and language skills with multiple seizures on EEG.  The patient was readmitted for left functional hemispherectomy and again several weeks later for continued medical management, and comprehensive rehabilitation.  The patient was to be discharged home once they were able to advance of full oral diet and regain baseline skills and all services and equipment were in place.  The patient was to be transition to early intervention to continue therapies.  The records indicated that a tentative discharge range was longer.  

The documentation does not indicate that the patient was in need of care that could not have been provided by a trained caregiver in the home.  The patient does have documentation to support some neurological physical deficits, but there are no skilled treatments or assessments that are documented to support the need of skilled clinical facility.  There was no indication that the patient required skilled nursing or rehabilitation services on a daily basis for at least 5 days per week, participating at least 3 hours per day in some form of therapy.  He showed marked improvement in ambulation and seizures after 91 days, so no continued treatment was needed.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for continued stay in a skilled nursing facility for dates of admission/service is not substantiated.  The insurer's denial is upheld.