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

Diagnosis: Alcohol Detoxification
 
Treatment: Inpatient Admission

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

This is a male patient who was admitted to inpatient substance detoxification treatment in early 2019 for alcohol detoxification. He had alcohol withdrawal symptoms including sweats, elevated blood pressure as high as 151/89, elevated heart rate of 91, joint pain, sleeping problems, anxiety, and irritable mood, and he had a CIWA of 12 and COWS of 6. He had a positive toxicology for Carboxy-Tetrahydrocannabinol (THC). He had been drinking two to four 22 ounce bottles of alcohol and smoking 1/2 blunt 3-6 times per week. He reportedly lacked support. He had a history of hypertension and diabetes. He had past inpatient substance detoxification treatment in early 2018. He had a comorbid psychiatric disorder. He reportedly had a Librium protocol and took Librium for detoxification for several weeks in early to mid-2019 and was then discharged.

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 patient had been drinking alcohol daily and had alcohol withdrawal symptoms. 

According to the LOCADTR he did require 24 hour treatment as he could not safely and effectively be treated in a less restrictive level of care such as an outpatient detoxification setting as he continued to use alcohol despite past inpatient detoxification, and he required and needed detoxification medication (Librium) to modify withdrawal and needed 24 hour treatment then as he was at risk for worsened withdrawal symptoms if not in this 24 hour setting then including: severe and life threatening withdrawal symptoms. He required and received detoxification medication (Librium) in mid-2019. The risk of life complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use so he required the entire time in this hospital. He also lacked support and had comorbid medical conditions including hypertension which put him more at risk medically and made it more likely that he would not be able to safely and effectively be treated for detoxification in a less restrictive setting. 

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

Diagnosis: Asthma Exacerbation.  
 
Treatment: Inpatient Admission

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

This patient is a young male child who presented to the Emergency Room (ER) with a coughing and wheezing for one day. Patient was noted to have been in the ER earlier the same day and was diagnosed with an asthma exacerbation. He was treated with three inhalation treatments with DuoNeb and prednisone. When there was improvement following treatment, the child was discharged to continue with treatments at home. When the child had a recurrence of his coughing, wheezing and increased rate of breathing, the mother returned to the ER.

According to UpToDate:  Acute asthma exacerbations in children: Inpatient management:
"GENERAL APPROACH - Most children who require admission for asthma are initially treated in the emergency department (ED), although some are admitted directly from clinicians' offices. Thus, inpatient treatment is typically a continuation of therapies and monitoring that were started in the ED. Patients usually have received several albuterol treatments, often combined with ipratropium (children with an asthma exacerbation experience a lower risk of admission to the hospital if they are treated with the combination of inhaled short-acting beta agonists [SABAs] plus anticholinergic versus SABA alone, systemic glucocorticoids, and supplemental oxygen, when necessary, before arrival to the inpatient unit.

Continuous therapy - We suggest that patients who have poor improvement after several inhaled beta agonist treatments or who require treatments more frequently than every two hours be treated with continuous beta agonist nebulization. Patients treated with continuous therapy who do not improve rapidly should be monitored closely for worsening respiratory status."

"During continued observation, patients with partial improvement should continue to receive albuterol nebulization every 30 to 45 minutes (or continuously) for another one to two hours, after which a decision regarding hospitalization or discharge home is made.

Hospitalization - Patients who were moderately to severely ill on arrival and who have little improvement after initial therapy with beta agonists and systemic glucocorticoids require hospitalization. This includes patients who continue to have significant wheezing and retracting, poor aeration, or altered mental status, such as drowsiness or agitation."

The carrier's denial of coverage for the inpatient hospital services at the acute level of care from is reversed. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Appendicitis

Treatment: Inpatient Admission

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

This is a young male child who presented to the Emergency Department in early 2019 after being seen in his primary care physician's office with complaints of right lower quadrant pain for one day prior to his presentation. He was also experiencing fever and 5-6 episodes of vomiting. It was noted that his last bowel movement and last meal were the night prior to presentation.  The physical examination revealed the patient had tenderness to palpation in the right lower quadrant and a negative Rovsing. The patient had no past medical or surgical history. The patient underwent an ultrasound, which revealed appendicitis. He was admitted to the hospital for an acute appendicitis.  The family elected for non-surgical management.  The patient's pain improved and he tolerated a regular diet. He was discharged on in stable condition.

The MCG notes that inpatient stays are recommended for children with complicated appendicitis (e.g., perforated without generalized peritonitis).  The records indicated the patient was a young male with no past medical or surgical history.  The patient had right lower quadrant pain and 5-6 episodes of vomiting.  The patient had no guarding or rebound tenderness.  The patient had a negative Rovsing. The ultrasound revealed the patient had acute appendicitis.  The patient was not noted to have complicated appendicitis.  The records failed to support the patient could not have been treated at an observation status.  The patient did not have undiagnosed abdominal pain, it was appendicitis. The family declined operative treatment.  The patient could have been admitted if he failed observation. There was an excellent clinical response without untoward event and accordingly, even with an overnight stay, this is not admission but observation level of care services.

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

The patient is a female with a diagnosis of adolescent idiopathic scoliosis who presented to therapy with Cobb angles of 28 degrees in her thoracic spine,  30 degrees lumbar, and 19 degrees in her upper thoracic spine.  Based on the onset of her menses, she is most likely at the end of her growth.  She was also noted to have generalized joint hypermobility, which is associated with idiopathic scoliosis.  She was referred for physical therapy using the Schroth method.  Per the documentation, the patient and family are highly motivated to participate in this form of scoliosis treatment. 

The health plan's determination is overturned.

The Schroth physical therapy method (also known as [aka] Schroth physiotherapy) incorporates exercises to strengthen weak muscles and lengthen shortened muscles while breathing into the concavities of the curve.  During these exercises, correction of the pelvis, ribs, and shoulder alignment is emphasized.  Schroth physiotherapy addresses the spinal rotation by corrections in all three planes.  Since the spine has shortened due to the rotation and curves, the spine needs to elongate.  This is why the Schroth based method is called a "three-dimensional treatment for scoliosis."  These exercises not only assist the brain and body with recognizing proper alignment of the spine but also in maintaining this alignment.  Schroth exercises use deep breathing to expand the rib cage, open the concavities of the curves, and re-align the body.  The exercises are performed in positions where gravity is eliminated from compressing the spine, and eventually transition to upright positions that do affect the spine.  These positions assist in strengthening and stabilizing the spine for normal movement and activities.
The physical therapy evaluation and services rendered in this case are medically necessary as physical therapy of this type, along with bracing, are the standard of medical practice for treatment of idiopathic adolescent scoliosis.  Given the amount of curvature present, the 3D Scoliosis specific exercises (Schroth method) is the most appropriate conservative treatment for the patient.  Treatment of this kind is usually fairly aggressive and has been shown in the medical literature to prevent progression of scoliosis, relative to other treatments.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Graft dysfunction secondary to acute cellular rejection
Issue under review: Actemra

Determination:
The actemra is medically necessary.

There is growing medical publications about the use of Tocilizumab for the treatment of antibody mediated rejection in patients that have undergone kidney transplant. Dr. Stan Jordan has published several seminal publications demonstrating the effectiveness of this agent to treat this difficult and devastating disorder that, without this treatment, leads to graft failure.  There is enough clinical information in these publications to recommend that this patient continue the use of Tocilizumab for the treatment of antibody mediated rejection, together with the conventional therapy that has been already administered to this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain
Treatment: Inpatient admission
The inpatient admission was medically necessary.
The patient presented with new onset chest pain at rest, suggestive of unstable angina. The patient had multiple risk factors for CAD, as well as a known history of coronary artery disease, including a previous MI (myocardial infarction), requiring bypass surgery and prior percutaneous revascularization. The presentation was even more concerning in the setting of recent nuclear stress test, which was abnormal. The ECG was unrevealing for ACS (acute coronary syndrome), but was abnormal, with findings of LBBB. There was a high index of suspicion for an unstable angina, a form of ACS, and a cardiac catheterization was performed. The patient was found to have obstructive coronary disease, and a PCI was performed.  Given the presentation, risk factors, as well as clinical suspicion for an acute coronary syndrome/unstable angina, she 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, and therefore, the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status Asthmaticus

Treatment: Inpatient Admission

The insurer denied the coverage for inpatient admission. The denial was reversed.


The patient is a female with a history of allergy to dogs who developed difficulty breathing when visiting her cousin's home where there were three dogs.  She was experiencing shortness of breath for 24 hours, and when the symptoms were getting worse, the decision was made to bring her to the Emergency Room (ER).

In the ER, she was noted to be in moderate respiratory distress with evidence of increased work of breathing, wheezing and chest tightness.  The lung exam was significant for tight breath sounds.  The adolescent received three doses of DuoNebs and Decadron.  The patient continued to have evidence of increased respiratory effort and the decision was made to admit her with a diagnosis of status asthmaticus for ongoing treatment with albuterol every 2 hours.
 
The patient was treated appropriately in the ER for a first episode of asthma related to exposure to a known allergen (dogs).  When her symptoms did not improve and there was ongoing respiratory distress and wheezing with tight breath sounds, it was appropriate and consistent with the standard of care to admit her to the hospital for ongoing treatment with albuterol every 2 hours. She was not stable enough to be sent home, since the need for frequent albuterol administration could not have been safely administered in the home.

The health plan did not act reasonably or with sound medical judgment or in the best interest of the patient.  The acute inpatient admission was medically necessary.

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

Diagnosis: Status Asthmaticus

Treatment: Inpatient Admission

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

This is a young female patient who had been seen by her pediatrician following a prior hospitalization for asthma. She was sent to the Emergency Room (ER) by her Pediatrician for asthma symptoms that were not responding to albuterol given at home.  Her ER assessment was significant for wheezing, along with a dry and unproductive cough. The patient was admitted with an acute asthma exacerbation. She had a history of premature birth at 27 weeks of gestation, asthma and an allergy to nuts and seafood.
In the ER, the mother indicated that the child was tired with some shortness of breath and was complaining of right-sided flank pain when lying down. The lung exam was significant for slight diffuse wheezing. The child continued to have wheezing and was admitted with a diagnosis of status asthmaticus.  Her treatment included albuterol every three hours. The plan of care was implemented and the patient's symptoms improved.  She was discharged after a period of medical stability. 
The patient was treated in the Emergency Room (ER) for persistent wheezing following a recent hospitalization for asthma related to an enteroviral infection.  The chart clearly indicates that the child was not in respiratory distress and the decision was made to not administer steroids during the ER visit. The ER staff did not order any testing to evaluate for other possible explanations for the failure of the child's wheezing to respond to treatment in the home. The ER staff also did not choose to initiate a step up in therapy with a repeat course of steroids, continuous albuterol or magnesium sulfate to address the ongoing wheezing.  The decision to readmit this child three days following discharge and not repeat treatment with steroids was not consistent with the standard of care for status asthmaticus.

The carrier's denial of coverage for the inpatient hospital services at the inpatient level of care is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Subtherapeutic international normalized ratio (INR)
 
Treatment: Inpatient admission, medication, monitoring
The insurer denied the inpatient admission. The denial was upheld.
The patient was a homeless woman with a history of alcohol abuse disorder, crack cocaine use disorder, anxiety, schizoaffective disorder, and a mechanical mitral valve.  The patient was admitted from the detoxification unit due to a subtherapeutic international normalized ratio (INR) level of 1.2.  She was admitted for a Lovenox bridge while her warfarin level returned to a therapeutic level.  The patient signed out against medical advice before reaching a goal INR level of 2.5 - 3.5.  

The acute inpatient admission was not medically necessary. The patient could have received subcutaneous low molecular weight heparin injections while awaiting return to a therapeutic drug level of warfarin all in the outpatient setting.  There were no findings or features which justified the need for a higher level of care.  The initial vital signs were stable and the patient remained hemodynamically stable throughout this hospitalization. This did not substantiate the need for the inpatient level of care.  There was no evidence of myocardial ischemia, hemodynamic instability, severe electrolyte abnormalities, severe derangements of blood counts, or other indications for acute inpatient admission.  There were no neurological deficits or imaging-confirmed acute neurological injuries. 

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: Tooth #6, #7, #8, #9 & #10 restored
 
Treatment: Crowns - porcelain fused to noble metal for Tooth #6, #7, #8, #9, and #10

The insurer denied Crown - porcelain fused to noble metal for Tooth #6, #7, #8, #9, and #10. 
The denial was upheld.   


This is a middle aged female who has been denied crowns for tooth #6, #7, #8, #9, and #10 because they can be restored with conventional restorations or be removed.
Her record consists of cryptic notes and radiographs which show that the teeth have been restored multiple times. In addition, there is no documentation that a significant portion of the crowns are missing such that a crown is the only restoration that is possible in this case.      

According to Malament, K. A., et al. (2018), "The objectives of a crown are to restore function and esthetics for a treated tooth. Much of the longevity and esthetic success of the crown restoration relies on both maintenance and prevention routines adopted by the patient."  They go on to state, "An important factor to consider in the contour of the restoration is the shape of the pulp. If the pulp is unusually wide, this may be a contraindication for crowning. Indications for the machinable lithium disilicate material are inlays, onlays, veneers, partial crowns, telescope primary crowns, and implant superstructures."

The carrier's denial of coverage for D2752- Crown - porcelain fused to noble metal for tooth #'s 6, 7, 8, 9 & 10 is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

The patient is a woman with diagnoses of Major Depressive Disorder (MDD), Generalized Anxiety Disorder (GAD), Personality Disorder, with Borderline Features (BPD), and suicidal ideation (SI). Case notes document that the patient had a history of chronic depressive and anxiety symptoms that worsened over the preceding 4 weeks and escalated in frequency and intensity in the four days prior to admission. She showed functional impairment in not being able to get up from the bathroom floor, not being able to work, with suicidal ideation (SI) of "not wanting to wake up." She had not required prior psychiatric hospitalization and had no past suicide attempts. She had made multiple futile attempts to get relief from her migraines from outpatient providers without benefit. On mental status examination, she was depressed, anxious, tearful, frightened, anhedonic, hopeless, with low energy and difficulty in concentrating. Her treatment consisted of several components. She was continued on her prior Lamictal and trazodone. Lexapro was added and titrated to optimal levels. Klonopin was added for anxiety. Regarding psychotherapy, she received individual and group therapy, and took part in family sessions.

The first seven days of the stay were approved. The health plan denied the last five days as not medically necessary. The health plan's determination is upheld.

The general guideline for patents with significant BPD features, is to treat acute, possibly emergent or life-threatening symptoms promptly, and when the patient is out of danger, discharge to outpatient follow-up, avoiding a long hospitalization. The deciding factors in this decision supporting a brief length of stay were her rapid improvement, and more clear manifestation of her personality disorder, with borderline features. Prolonged hospitalizations often result in the emergence of BPD driven complicating behaviors better treated on an outpatient basis. By this date, all acute care at the IMHT level would have been successfully accomplished. Additional days would not be medically necessary and might in fact lead to a more intense expression of her borderline personality features in behaviors against her best interest. As of the last covered day, she could safely with good medical judgment be transitioned to a less restrictive environment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary Artery Disease
 
Treatment: Inpatient Admission

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

This patient is a young male who presented to his physician's office with complaints of dyspnea with walking after five minutes.  He had a history of hypertension, diabetes, hyperlipidemia, obesity and current tobacco use. He was admitted to the hospital for a staged percutaneous coronary intervention (PCI) due to dyspnea on excursion and an abnormal stress test revealing inferolateral ischemia. The patient underwent coronary angiography with angioplasty and a drug eluting stent to the OM1.  This revealed an 80% distal left anterior descending (LAD) lesion not amenable to percutaneous intervention or coronary artery bypass graft (CABG), 40% first diagonal (D1), 40% second diagonal (D2), 25% proximal left circumflex (LCx), and a large first obtuse marginal (OM1) vessel that was completely occluded with left to left collaterals.  The dominant right coronary artery (RCA) was also completely occluded with left to right collateral flow.    Plavix was begun and he was referred for a staged percutaneous intervention of the totally occluded vessel OM1 and RCA.  He was hemodynamically stable during and post procedure, with no access site complications. He was discharged on his home medications, to return in five weeks for percutaneous intervention of his right coronary artery occlusion.

Based on the above, the medical necessity for the inpatient admission for acute level of care is not substantiated. The insurer's denial is upheld.