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

Diagnosis: Adenotonsillar hypertrophy
 
Treatment: Inpatient admission, surgical intervention, post-procedure monitoring

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

This case involves a male child who had a history of sleep disordered breathing and adenotonsillar hypertrophy.  The patient was admitted for an adenotonsillectomy.  According to the operative note there were no complications during or after the procedure.  Given his stability, the patient was discharged from the post-anesthesia care unit shortly after surgical intervention.  There were no acute events overnight; there were no desaturations, and the patient tolerated oral intake.  The patient was discharged from the hospital with instructions to continue on a soft diet, with Tylenol/Ibuprofen as needed for pain.

According to current literature, the requested surgery is typically an ambulatory procedure.  While it is understood a period of brief observation after surgical intervention is recommended to monitor the patient's airway status, an inpatient admission did not appear appropriate.  There was a lack of documented complication as well as a lack of documented airway compromise.  There was no indication the patient had uncontrolled pain or any other significant concern. Therefore, inpatient hospital services were not medically necessary. 

Based on the above, the medical necessity for the inpatient hospital services is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest pressure; shortness of breath
Treatment:  Inpatient hospital admission
The inpatient admission was not medically necessary.

The patient endorsed having used cocaine prior to his symptoms of chest pressure and shortness of breath.  There was no evidence of ischemia on EKG, Echocardiogram, or cardiac enzymes.  The abnormal nuclear test did not show acute ischemia (and is often less reproducible for LV function than echocardiogram).  He was asymptomatic once in hospital, and no intervention was necessary.  In his discharge summary, he was told that his stress test was normal.

The determination of level of care is primarily dependent on the actual care that 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 atypical and unlikely to be representative of acute coronary syndrome (ACS) but with a high probability that the etiology was due to ingestion of cocaine.  The patient's exam (blood pressure) normalized, and cardiac findings were normal. Biomarkers and EKG showed no evidence of acute ischemia ("abnormal stress test" was borderline and possibly an artifact).  CXR (chest x-ray) was normal.  Echocardiogram showed no wall motion abnormality (WMA).  Nuclear scan was negative for acute CAD (coronary artery disease).  The physicians' treatment did not reflect any serious concern about the patient's acute cardiac condition.  Orders did not include medical therapy for ACS, 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 inpatient level of care.  The only cardiac care that was 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.  This patient had no evidence of CAD.  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.  The use of cocaine could explain the symptoms that were present prior to admission.  The nuclear stress test was likely a false finding, and the patient was told it was normal.  All other tests did not support diagnosis of ischemic heart disease.

Milliman criteria requirements were not fulfilled, as there was never any evidence of ACS present.  All of the testing and therapy that were provided would have been appropriate, safe and guidelines-consistent in a lower level of care.  Thus, inpatient level of care was not medically necessary.

The denial explanation was consistent with guidelines and usual community care.
Appeal type: Medical necessity
Decision: Upheld

The patient presented to the emergency department (ED)  with abdominal pain of 2-days duration. Patient was known to have gallstones from a prior evaluation. At the time of presentation the patient was without fever and vital signs were normal.The white blood cell (WBC) count was normal. The complete metabolic panel was normal. Ultrasound showed gallstones and no gallbladder wall thickening.Treated with intravenous (IV) fluid and IV antibiotics. Treated with laparoscopic cholecystectomy. The operative dictation and the anesthetic record describe an uncomplicated cholecystectomy procedure.
The immediate post-surgical recovery was uncomplicated. Patient did complain of pain on that was treated with pain medications and simethicone. The patient remained clinically stable and was discharged from the inpatient setting. Inpatient level of care was not medically necessary. A lower level of care would have permitted for the pre-surgical assessment, the surgical procedure  and perioperative IV fluid, IV antibiotics, IV antiemetics, and post-surgical monitoring. The patient was clinically stable following surgery as supported by the corresponding medical records. Inpatient care is indicated when there is right upper quadrant pain, AND systemic signs of inflammation (fever, C-reactive protein > 10, WBC count > 10 K). Inpatient admission is also indicated for acute cholangitis, common bile duct obstruction, vomiting that is severe or persistent, dehydration that is severe or persistent, hemodynamic instability, severe pain requiring acute inpatient management, signs of intestinal obstruction, bacteremia, need for percutaneous or open procedures, or other condition that requires inpatient admission. The HP determination is upheld in whole.
Appeal type: Medical necessity
Decision: Upheld

Injury
Inpatient Hospital

The patient is a male with a CHI (closed head injury) from a fall. There was a short period of LOC (loss of consciousness). One episode of emesis is noted. The patient had a normal exam. A computed tomography (CT) scan was normal. . There was no significant past medical history (PMH). The patient was admitted to the Pediatric Intensive Care Unit (PICU) overnight and discharged next day. The inpatient admission is under review.

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient could have been observed and released. There was brief loss of consciousness. There was some vomiting and bradycardia to raise enough concern for observation. However, the neurologic evaluation and the absence of CT findings, do not meet the criteria for an ICU admission. Sometimes, observation in a busy emergency department setting is not possible due to overcrowding or staffing. In that circumstance, observation in a floor bed would be an option. Nonetheless, the patient did not exhibit any signs clinically or have any finding on imaging that suggest the need for intensive care. He could have been safely been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
 
Treatment: Continued Inpatient Admission

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

This is a male patient who was admitted to a facility for substance detoxification treatment. His symptoms include tremors, sweats, diarrhea, nausea, joint pain, lethargy, irritability, anxiety, and sleep disturbance. At the time of admission, he had a positive toxicology screening for opiates, cannabis, benzodiazepines, cocaine, and methadone. His past history includes multiple years of inhaling several bags of Heroin daily, several years of cocaine use, and more than a decade of cannabis use. He has had a past drug overdose and an inpatient detoxification treatment. The patient reported that he had no coping skills. He was treated with a Methadone protocol, and received Ativan and Clonidine to assist in his detoxification. 

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. This was the case with this patient who had past substance detoxification treatments and still was using heroin, cocaine, and cannabis. It was reported that he needed better coping skills and identification of relapse triggers and could not stop substance use. 

Based on the above, the medical necessity for the continued inpatient admission is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of chest pain, chronic obstructive pulmonary disease (COPD), asthma, gastroesophageal reflux disease (GERD), arthritis, depression, basal cell carcinoma, hepatitis C, hyperlipidemia, drug abuse and seizures. The patient has a history of coronary artery disease (CAD) and two myocardial infarctions. He has a previous history of percutaneous coronary intervention (PCI) with coronary stents. 
The health plan's determination is upheld. The patient presented with chest pain which was different from the chest pain during previous episodes. He had a significant history of CAD and also multiple other medical problems. He also has a history of polysubstance abuse. The patient had an elevated blood pressure upon arrival, but it normalized quickly. His chest pain resolved and his troponin was normal. He was receiving oral Ativan according to the CIWA protocol, but he did not have evidence of withdrawal. His tremor was chronic. The patient did not have evidence of unstable angina, cardiac arrhythmia, congestive heart failure (CHF) or unstable hemodynamics. His hospital stay did not meet criteria for an inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Influenza A and myositis
Treatment:  Inpatient admission
The inpatient admission was not medically necessary.

The patient is a male child that presented to the emergency department (ED) with five-day history of fevers to 103.3 and cough, and two-day history of leg pain. The pain was in his calves, and on the day of presentation he was refusing to walk.  He was up-to-date on vaccines and had received an influenza vaccine. 

The patient's vital signs included temperature 39.5, heart rate 108, respiratory rate 21, and 98% saturation in room air.  Physical examination was significant for no distress, moist mucous membranes, regular heart rate and rhythm, clear lungs, benign-abdomen, and bilateral calf tenderness to palpation.  Laboratory studies were obtained revealing positive influenza A, unremarkable complete blood count (CBC) and metabolic panel, and elevated creatine kinase 2145.  He was treated with a normal saline bolus, re-examined every hour, and eventually admitted with influenza and acute myositis for intravenous (IV) fluid management.  Admission orders included anti-pyretics, IV fluids at 1.25 maintenance, regular diet, and repeat creatine kinase (CK) level.  He did well overnight, with repeat CK 1896 and no evidence of acute kidney injury.  He was able to bear weight on both legs, as well as walk and run.  He was subsequently deemed stable for discharge home.

This young child presented with signs and symptoms consistent with benign acute childhood myositis following viral infection with influenza A.  His creatine kinase was elevated, but there was no evidence of rhabdomyolysis or compartment syndrome.  He was overall hemodynamically stable with no evidence of other complications of influenza or myositis.  He did not require acute inpatient admission and could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

Asthma is an inflammatory process characterized by airway obstruction due to airway hyper-responsiveness, bronchospasm, airway inflammation, and mucus production. Gas exchange abnormalities are due to ventilation/perfusion mismatch, as a result of atelectasis and airway over-distention. Status asthmaticus is defined as "severe asthma that fails to respond to inhaled beta-agonists, oral or intravenous steroids, and requires admission to the hospital for treatment." (1) Unfortunately, asthma can still be a fatal illness if treatment is not initiated quickly or aggressively enough. "Despite advances in asthma management, acute exacerbations continue to be a major problem in patients... our review findings support the importance of controlling persistent asthma... early episodic intervention appeared to be crucial in preventing severe attacks and future exacerbations." (2)
 
In the ED, primary management strategies include correction of hypoxia, rapid improvement of airflow obstruction, and prevention of progression. This is achieved with supplemental oxygen, bronchodilators, and steroids. Fluid hydration may also be necessary. For patients with moderate to severe exacerbations that do not respond to such intensive therapy in the ED, admission is necessary.

This young male child with history of wheezing and albuterol use presented to the ED with signs and symptoms consistent with asthma exacerbation. He was aggressively treated in the ED with bronchodilators, fluids, corticosteroids, and magnesium. He required supplemental oxygen for desaturations. He was briefly treated with antibiotics for atypical pneumonia, but with return of the viral panel positive for entero rhinovirus, the antibiotics were discontinued. While it was appropriate to aggressively treat this young child, he was overall hemodynamically stable, with no evidence of sepsis or impending respiratory failure, he was able to tolerate fluids by mouth, and he responded well to bronchodilators. He did not require acute inpatient admission, and he could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Substance Abuse
 
Treatment:  Inpatient Rehabilitation

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

This is a male patient who presented to a substance rehabilitation facility for alcohol and substance detoxification.  His substance abuse history includes drinking several pints of vodka per day and smoking cannabis daily.  He had multiple past inpatient substance detoxification treatments and had past inpatient substance rehabilitation treatments.  He had past suicide attempts and suffered from depression.  It was reported that the patient lacked coping skills, relapse prevention skills, and the ability to identify stress triggers.  The patient left against medical advice (AMA) and was referred to a long term residential treatment.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that inpatient treatment is indicated primarily for individuals whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting.  In this case this patient was considered in need of 24 hour substance rehabilitation treatment, as he was using very large amounts of alcohol, as it was reported that he was drinking several pints of vodka per day, and smoking cannabis daily. 

He was at risk for severe, life threatening, or complicated withdrawal due to his large amount of use, and he could not stop use on his own.  According to the LOCADTR he met criteria for inpatient substance rehabilitation treatment, as he continued to use alcohol and substances despite multiple past inpatient substance treatments, including inpatient substance rehabilitation treatment and 5 past inpatient substance detoxification treatments. 

Based on the above, the medical necessity for the Inpatient Rehabilitation is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
 
Treatment: Inpatient Substance Use Rehabilitation

The insurer denied the Inpatient Substance Use Rehabilitation. The denial was reversed. 

This is a male patient who was admitted to an inpatient substance rehabilitation treatment facility after completing an inpatient detoxification treatment. He more than a decade long history of drinking 1 pint of alcohol a day, and 8 mg of buprenorphine and 5 mg of non-prescription methadone. He had previously been treated for inpatient substance detoxification and substance rehabilitation. His longest period of sobriety was 6 months. He has a medical history of seizure activity. His plan of care included a sober house living after the completion of treatment. The patient was caught smoking in another patients bathroom and was administratively discharged for non-compliance of the rules.
The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that inpatient treatment is indicated primarily for individuals whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting.

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), he met criteria for inpatient substance rehabilitation treatment as he continued to use alcohol, crack, and multiple opiates despite past inpatient substance rehabilitation and detoxification treatment. Additionally, he lacked supports as he was homeless and unemployed. It was not reasonable to expect that he could attend outpatient substance rehabilitation treatment then. He needed to be in a sober therapeutic 24-hour treatment setting to work on improving coping skills, to better identify relapse triggers, and to learn relapse prevention skills. He also had a reported history of seizures and was at risk for severe and complicated withdrawal if he were to resume use again and then stop abruptly. He also was at risk for overdose due to his alcohol and opiate use. In addition, he had comorbid psychiatric symptoms as he was taking Lexapro. He was unable to stop substance use without being in a sober and supervised therapeutic inpatient substance rehabilitation setting. Without this structured and supervised therapeutic inpatient rehabilitation treatment, he likely would have relapsed quickly. 

Based on the above, the medical necessity for Inpatient Substance Use Rehabilitation is substantiated. The insurer's denial is reversed.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Neutropenia
Treatment: Granix

The health plan should not cover the proposed formulary exception for Granix.

The patient is a male that underwent heart transplant for non-ischemic cardiomyopathy.  Post-transplant, the patient is suffering from neutropenia possibly due to medications; he is non-responder to drug decrease.  It is stated that the patient requires this drug for improvement in neutrophil count.  

The formulary is Zarxio; there is no indication that patient cannot take this drug; therefore, Granix is denied.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Fibromatosis 

Treatment:  Consumer Directed Personal Assistance Services

The insurer denied the Consumer Directed Personal Assistance Services.  The denial reversed.   

This is a male patient with a history of fibromatosis with various chemotherapy treatments.  It is reported that the patient has masses on his back, neck, and spine, and that they interfere with his activities.  Home care services were recommended by his physicians to assist with his care and his light housekeeping duties.  The patient currently lives with his mother and sister who help him with his activities of daily living (ADLs).

As a result of various symptoms associated with the patient's medical conditions (as previously noted), it is medically necessary for the patient to have assistance for various daily household and personal care activities as identified in the UAS and UAS-ATSP.  The patient needs help with most IADLs.  In addition, supervision is needed for toilet use, indicating some difficulty with toileting self-care and probably exacerbated by episodes of diarrhea.  It is also noted that the patient needs assistance with outdoor locomotion.  The patient reported that he has not been going outside to walk due to weakness.  The patient could benefit from being able to go outside on a regular basis, so providing time for assistance with outdoor ambulation is indicated.  The available records do not include a plan that describes how the patient's daily care needs will be provided by informal caregivers on a consistent basis.  Therefore, it is medically necessary for assistance/supervision for IADLs/ADLs to be provided by personal care services, in this case CDPAS.

The UAS-ATSP recommended approximately 11 hours of assistance for 5 days per week (Monday-Friday).  It is not clear from the available records whether the sister will continue to provide voluntary services on the weekends.  The patient needs assistance with activities/tasks 7 days per week.  Based on the number of hours allocated to Monday - Friday in the UAS-ATSP (11 hours), plus additional time for assistance with walking outdoors, plus supervision for toilet use, plus additional time for weekend assistance to supplement and/or replace informal caregiver assistance on Saturday and Sunday, 14 hours per week is approved for the services the patient needs.

The carrier's denial of coverage for Consumer Directed Personal Assistance Services (CDPAS) is reversed.  The medical necessity is substantiated.