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

Diagnosis: Sickle cell disease

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient has a history of Hemoglobin Sickle C Disease (HbSC) disease, presented to the emergency room (ER) with a history of with fever, sore throat, abdominal pain, and congestion. The parent described the child as crying "hysterically" at one point. Triage vital signs were Temperature 39.1 degrees Celsius, heart rate 166, but blood pressure was normal and oxygen saturations were normal.

Physical examination documented as the child being in no acute distress, and the only abnormalities were posterior oropharyngeal erythema, cervical adenopathy and a fine non-pruritic papular rash on the trunk and inner thighs.

The history and physical documentation states acute streptococcal pharyngitis with pain crisis in a child with HbSC with low suspicion for acute abdominal pathology.

The only significant abnormal lab finding was elevated white blood cell count of 19000, with 84% neutrophils, indicative of a stress response to infection, which warrants empiric treatment for pneumococcal bacteremia with ceftriaxone, which was administered.

The ER physician note does not provide adequate medical decision making or rationale for inpatient level of care. The child's diagnosis was febrile streptococcal throat infection, with no evidence of any type of sickle cell crisis, sepsis, systemic inflammatory response syndrome (SIRS), pneumonia or abdominal pathology. The rash is consistent with streptococcal infection. The abdominal pain was also a symptom of acute streptococcal infection though the history of constipation could be contributing.

The reviewer agrees with the health plan that the patient could have been safely treated at an observation level of care. There is no evidence in the chart to support a suspicion of acute sickle cell crisis. 

Current guidelines for management of sickle cell disease, referenced below, support the conclusion. Additionally, there are specific Emergency Medicine guidelines for the management of sickle cell disease that must be followed:
DISPOSITION
"Consider admission if pain is not well-controlled; patients usually know if their pain has stabilized at a manageable level; Other complications found (such as infiltrate on chest x-ray; suspect serious or systemic infection); consider admission for young (&lt; 1 year) patients, or older patients with fever if they cannot seek care quickly or follow-up with sickle cell disease provider the next day; consider alternative treatment settings for improving but not relieved pain, such as observation units, to allow for a longer duration to treat pain and spare a hospital admission."
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 an inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, heart failure, chronic kidney disease, and chronic obstructive pulmonary disease
Treatment: Personal care assistance services 168 hours/week
The health plan denied Personal care assistance services 168 hours/week. The denial is overturned.

The patient is an elderly female. Her medical conditions include dementia, heart failure, chronic kidney disease, and chronic obstructive pulmonary disease. Denial of personal care assistance services, a total of 168 hours per week is being appealed. The health plan approved 84 hours per week plus 84 hours/week shared with her husband, for a total of 168 hours per week.

Uniform Assessment System (UAS) evaluation completed earlier this year shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, and managing finances; maximal assistance with shopping, transportation, and bathing; extensive assistance with managing medications, phone use, personal hygiene, dressing, and toilet use; and limited assistance with walking, locomotion, bed mobility; and eating. The patient has bowel and bladder incontinence. Compared to UAS (Uniform Assessment System) evaluation completed last year, there has been a decline with meal preparation, housework, and managing finances, bed mobility, and eating.

An appeal letter notes the patient lives with her husband, and they are completely dependent for ADLs (activities of daily living). There has been a decline in the patient's status. She is at risk for wandering.

Medical records have been provided for recent hospital admission due to altered mental status. She is receiving wound care to buttocks and sacrum related to urinary and fecal incontinence. Recommendations include posting every 2 hours.

This patient has multiple chronic conditions, including recent hospital admission. The health plan denied an increase in hours with the contention that the current hours support the patient's ADLs (activities of daily living). Uniform Assessment System (UAS) evaluation completed this year showed the patient requires assistance with all ADLs (activities of daily living). Compared to UAS (Uniform Assessment System) evaluation completed last year, there has been a decline with meal preparation, housework, and managing finances, bed mobility, and eating. She is incontinent of bowel and bladder. The appeal statement indicates the patient's health has deteriorated. The statement supports the patient is dependent with ADLs (activities of daily living) and is at risk for wandering. Medical records show the patient recently admitted with altered mental status. She has sacral wounds due to incontinence. Management includes turning/repositioning every 2 hours.

The information provided supports the patient is dependent with all ADLs (activities of daily living) and requires frequent turning/repositioning. This patient has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The requested personal care assistance services for a total of 168 hours per week is medically necessary.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Atopic dermatitis
Treatment: Dupixent Syn 300
The insurer denied coverage for Dupixent Syn 300.
The denial is overturned.

The patient is an adult with a diagnosis of atopic dermatitis (AD) affecting > (greater than) 70% (percent) total body surface area (TBSA), including the face, trunk, and extremities.  The patient has failed oral prednisone as well as topical steroids and Opzelura cream. The request is for Dupixent. 

The patient has AD that involves a larger surface area. The patient requires systemic therapy given the extent of involvement and the use of Dupixent would appear to be reasonable given that it is Food and Drug Administration (FDA) approved for the treatment of AD. The request for Dupixent is supported by the medical literature and specialty society guidelines. Dupixent is the first systemic therapy approved by the FDA for the management of AD. In early 2017, the FDA approved Dupixent for adults with moderate-to-severe AD who are inadequately controlled with topical treatments (1-3). According to consensus guidelines, "Dupilumab has shown strong efficacy and safety for treatment of moderate-to-severe AD... Considering the safety profiles of conventional systemic therapies, which are not FDA-approved for AD treatment, it is recommended that dupilumab be used as a first-line systemic treatment... with moderate-to-severe AD who are uncontrolled with topical therapies" (1).  

The insurer states Dupixent is denied because current plan approved criteria does not allow coverage of Dupixent unless the patient will not receive Dupixent concomitantly with other biologic drug or targeted synthetic drug.

While it is noted that the patient is currently using Opzelura topical, it is documented that the physician will discontinue that once Dupixent is approved. As such, the decision is reversed and Dupixent is approved. 

The carrier's denial of a request for a formulary exception for Dupixent Syn 300 to treat atopic dermatitis is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal/Stomach Pain
Treatment: Inpatient Hospital Stay
The health plan denied the inpatient hospital stay.
The determination is upheld.

The patient is a male with a medical history of alcohol abuse, pancreatitis, diabetes mellitus, and hypertension. He presented to the emergency department with epigastric abdominal pain for two days, nausea, vomiting, and loose bowel movements. He had restarted alcohol use 2 days prior. His vital signs were notable for an elevated blood pressure of 149/91 millimeters of mercury (mmHg) and tachycardia with heart rate of 132 beats per minute. The physical examination was notable for right sided and epigastric abdominal tenderness, tongue fasciculation, and tremor. The labs showed an elevated creatinine of 2.6, an elevated glucose of 332, an elevated aspartate aminotransferase of 228, an elevated alanine aminotransferase of 404, and a normal lipase. His urine drug screen was positive for cocaine and opiates. A chest x-ray showed no acute cardiopulmonary process. A computed tomography (CT) scan of the chest, abdomen, and pelvis with angiogram showed no aneurysm or dissection, no pulmonary embolism, no clear explanation for chest pain or right-sided back pain, hepatic steatosis, and prior splenectomy and distal pancreatectomy, with residual fluid collection adjacent to the pancreatic stump with unchanged appearance. He was treated with intravenous Ativan, morphine, morphine sulfate, Zofran, pantoprazole, amlodipine, thiamine, folate, fluids, and oral sucralfate and Maalox. He was placed on a Clinical Institute Withdrawal Assessment (CIWA) protocol. He left against medical advice, with a plan for Primary Care follow-up.

At issue is the medical necessity of the inpatient hospital admission.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of inpatient hospital admission is not medically necessary for this patient. In this case, the patient presented with abdominal pain, nausea, vomiting, and diarrhea in the setting of alcohol intake [1-3]. He did not meet criteria for pancreatitis, and there were no complications such as pancreatic necrosis, pseudocyst, or abscess [4-6]. No procedural interventions such as endoscopic ultrasound were necessary. He was appropriately treated with intravenous fluids. His liver enzymes were elevated, but there was no acute liver failure or alcoholic hepatitis [7, 8]. He was monitored for alcohol withdrawal, but no complications of alcohol withdrawal such as seizure were documented [9, 10]. The interventions performed during his short stay, including labs, monitoring, imaging, and alcohol withdrawal protocol, could have been performed without the inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

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

This is a male patient with a past medical history (PMH) of recurrent left lower extremity (LLE) cellulitis with complaints of (c/o) left lower extremity (LLE) erythema and swelling to the thigh after failing outpatient antibiotics. His vital signs were notable for temperature (T) 101.1 degrees Fahrenheit and, tachycardia. The physical exam was notable for left lower extremity (LLE) swelling, erythema, and warmth. The patient was diagnosed with sepsis secondary to LLE cellulitis and treated with intravenous (IV) antibiotics, telemetry, and intravenous fluids (IVF). The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.
The hospital stay was medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with c/o LLE erythema and swelling to the thigh associated with high leukocytosis, persistent tachycardia, and an elevated lactate. Given the patient's presentation, he met sepsis criteria, met the Infectious Diseases Society of America (IDSA) definition of severe cellulitis, and the expected length of stay was greater than 48 hours. In addition, the presence of failure of outpatient antibiotics further indicates that the patient had a severe enough infection. Overall, this patient presented with severe cellulitis and sepsis suggesting that the patient required immediate treatment for the infection with intravenous antibiotics and that an inpatient level of care was required for safe medical evaluation and treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Heart disease, chronic obstructive pulmonary disease (COPD) and arthritis.
Treatment:  Increase in personal care worker (PCW) services to 7 days per week, 8 hours per day; 56 hours per week.

The insurer denied coverage for increase in personal care worker (PCW) services to 7 days per week, 8 hours per day; 56 hours per week.  The denial is overturned.
 
The patient is an adult with multiple medical problems including heart disease, chronic obstructive pulmonary disease (COPD) and arthritis.  The patient lives alone in a private residence.  Under review is an increase in personal care worker (PCW) services from 7 days per week, 5 hours per day; 35 hours per week, to 7 days per week, 8 hours per day; 56 hours per week.

The Uniform Assessment System (UAS) report was reviewed.  The patient's cognitive skills are described as "modified independent."  However, she reportedly requires maximal assistance for much of her instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary house work, and shopping.  She reportedly requires extensive assistance for bathing, personal hygiene, dressing and toilet use.  Limited assistance is reportedly needed for eating, locomotion, toilet transfer and ambulation. The patient is independent with bed mobility. The patient is frequently incontinent of bladder and continent of bowel. The patient's functional ability has declined when compared to the prior UAS report.  The patient's clinical condition and functional ability are at a level that is unpredictable as to require the requested PCW 7 days per week, 8 hours per day; 56 hours per week.  Based on the enclosed documents reviewed, attention to the patient's physical needs are more appropriately provided and maintained by increasing PCW services 7 days per week, 8 hours per day; 56 hours per week.

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 to increase (PCW) services from 7 days per week, 5 hours per day; 35 hours per week, to 7 days per week, 8 hours per day; 56 hours per week is substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

This is a male patient with no past medical history (PMH) who was admitted with complaints of (c/o) chest pain and syncope. His vital signs were unremarkable. The physical exam was notable for no apparent distress (NAD), non-toxic appearing. Lab work was unremarkable. Imaging studies included a computed tomography (CT) scan of the head which showed no acute pathology, a chest x-ray (CXR) showed no acute disease, a transthoracic echocardiogram (TTE) showed no acute pathology. An electrocardiogram (EKG) showed normal sinus rhythm (NSR). The patient was diagnosed with syncope and was treated with telemetry, transthoracic echocardiogram (TTE), and cardiology consult. 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 complaints of (c/o) syncope associated with chest pain. The patient did not have structural heart disease, hematocrit (HCT) less than (<) 30, shortness of breath (SOB), persistent hypotension, or family history of sudden cardiac death. Additionally, the patient did not have any history of dilated cardiomyopathy, aortic stenosis, hypertrophic cardiomyopathy (HCM), left ventricular outflow disease, pre-excitation syndrome, QT interval abnormalities, or conduction blocks. The patient did not have a subarachnoid hemorrhage, pulmonary embolism, acute gastrointestinal (GI) bleed, malignant arrhythmia, sustained bradycardia, supraventricular tachycardia (SVT) or ventricular tachycardia (VT), confirmed acute coronary syndrome (ACS), evidence of heart failure, cerebrovascular accident (CVA), shock, coma major trauma or cardiac arrest, or exertional syncope. The patient was diagnosed with chest pain and syncope and treated with telemetry, acute coronary syndrome (ACS) rule-out, and imaging work-up. Overall, this patient could have been safely treated at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Duchene Muscular Dystrophy
Treatment: home ventilator with mask
The insurer denied coverage for home ventilator with mask.
The denial is overturned.
 
Patient is an adult male with a history of Duchene Muscular Dystrophy who is wheelchair and Respirator dependent as per last MD (medical doctor) notes. Another more recent note was sent but it is very fuzzy and unable to be read. The patient has had weakness since age one when he was diagnosed. He has had a motorized wheelchair for several years.  The patient had symptoms of hypoventilation and daytime hypercapnia which have resolved since he was placed on nasal noninvasive ventilatory support (NVS). He has been sleeping better since then.

Patient has been on nasal NVS (noninvasive ventilatory support) at night and also 1-2 hours post lunch for naps. Patient's current device is Trilogy 100 A/C 765. Set at a rate of 12 currently. Spirometry revealed vital capacity (VC) 280. Previous readings were 320,300,350. Oxygen (O2) saturation 95% End tidal carbon dioxide (EtCo2) 40. Previous readings were 44,37,45. Prior O2 saturations were under 90% prior to NVS (nasal noninvasive ventilatory support). Now normal. Daytime gases also normal since using the NVS. Patient has been on NVS many years.

As per MD (medical doctor), NVS has normalized his CO2 (carbon dioxide) and daytime hypercapnia. He previously had very diminished VC (vital capacity). Since his ventilation has normalized with NVS it should be continued at this time.

Based on the above, the insurer's denial must be reversed. 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 continuation of a home ventilator with mask provided by Lincare is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pancreatitis
Treatment: Inpatient hospital services
The health plan denied: Inpatient hospital services
The determination is: Overturned

The patient is a female admitted to the hospital. The patient had an endoscopic retrograde cholangiopancreatography (ERCP) on the day of admission and developed worsening abdominal pain after the procedure. The patient had associated nausea with vomiting. The ERCP included a sphincterotomy along with common bile duct (CBD) brushing. On admission the patient had epigastric tenderness without rebound and a mild increase in white blood cells (WBC). A computed tomography (CT) scan showed acute interstitial pancreatitis with peripancreatic fluid collections. The next day, the patient stated the pain was improving. Her vital signs were normal without fever. The abdomen exam was still tender. A clear liquid diet was started. She was tolerating liquids. On exam, she was in no apparent distress (NAD), with mild epigastric tenderness. The liver function test (LFT) values were up trending, with a total bilirubin (T bili) up to 6.3. A repeat ERCP was planned, but the patient ate, and it was cancelled. On day 3, the patient was now icteric with a fever. Her appetite improved, and she was tolerating liquids. The T bili was 9.4. The following day, the patient was comfortable and afebrile. Her abdomen was soft and non-tender. The T bili was 2.9. After that, she was doing well. The ERCP was cancelled due to improved LFT's. She was discharged with outpatient Gastroenterology follow up.
At issue is the medical necessity of the inpatient admission.
The health plan's determination of medical necessity is overturned in whole.
Yes, the requested health service/treatment of inpatient hospital services was medically necessary for this patient. ERCP carries a post-ERCP pancreatitis (PEP) rate of 2-10 percent (%), which could be as high as 30-50% in high-risk cases. PEP is severe in up to 5% of cases, with potential for life-threatening complications, including multi-organ failure, peripancreatic fluid collections, and death in up to 1% of cases. In this case the patient had fluid collections. In addition, she developed fever a few days after hospitalization along with a rising bilirubin and concern for the development of ascending cholangitis. This patient needed to be managed with an acute inpatient level of care. She is fortunate that she improved and did not require a second ERCP, which could lead to even more complications. Therefore, the inpatient hospital services were medically necessary.