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

Diagnosis: Asthma
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient is a female. The service under review is Inpatient Hospital Admission for diagnosis of asthma. This service was denied coverage by the health plan as not medically necessary. This decision was appealed, denial was upheld, and now being appealed again.

Upon presentation in ED (emergency department) at 4PM, the patient's vitals were HR (heart rate) 144, RR (respiration rate) 30's-40's, SpO2 (pulse oximetry) 95%, and exam with nasal flaring, abdominal and suprasternal retractions, lungs with diffuse wheeze and diminished breath sounds. The patient's chest x-ray was with mild hyperinflation and peribronchial thickening.

The patient was given ipratropium-albuterol x3, dexamethasone. Repeat exam at 5:35PM revealed no further nasal flaring or retractions, less wheeze, air entry improved, still with tachypnea (respiration rate not documented) and belly breathing. At 7:32PM vitals were HR (heart rate) 88, RR (respiration rate) 48. At 9:41PM HR (heart rate) 112, RR (respiration rate) 36, SpO2 (pulse oximetry) 97%.

No, the Inpatient admission was not medically necessary.
Medical necessity is based on applicable and generally accepted practice guidelines developed by the federal government, national or professional medical societies, boards, and associations.

According to reference 1: "For children in an ED [emergency department], indications for hospitalization and ICU [intensive care unit] consultation can vary considerably. In general, children that should be admitted include those with ongoing need for supplemental oxygen; severe acute asthma exacerbations despite 12 hours of continuous nebulization salbutamol (potential ICU [intensive care unit] admission); continued moderate acute asthma exacerbations for more than 46 hours after corticosteroid administration; continued deterioration on conventional treatments; social environment limiting the delivery of care; and risk factors for fatal asthma with a child living at a major geographic distance from appropriate care."

The patient did not meet any of these criteria for inpatient stay.

Another publication [ref. 2] touts the usefulness of using a standardized Respiratory Scoring Tool to determine necessity of inpatient stay, where a respiratory score 9 after 1 hour of treatment is felt to be sufficient to warrant hospitalization. Using this tool, the patient would have a score of 4 out of 12, not meeting admission criteria.

Therefore, given the above, the Inpatient admission was not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope.
Treatment: Inpatient admission.
The insurer denied coverage for inpatient admission.
The denial is upheld.

This patient presented to the hospital with complaints of lightheadedness and syncope. Upon arrival she reported a burning sensation in the mid chest and right upper abdomen. Upon arrival to the emergency department vital signs were stable: blood pressure 101/70 millimeters of mercury (mmHg), pulse 82 beats per minute (bpm). No orthostasis was noted. Physical exam was significant for mild abdominal tenderness without distension or rebound. 12 lead electrocardiogram (EKG) revealed normal sinus rhythm without ischemic ST or T wave changes. Serum blood testing revealed a mildly elevated troponin level [0.08 nanograms per milliliter, (ng/ml)]. Echocardiogram revealed normal wall motion and left ventricular ejection fraction. Computed tomography (CT) head revealed no abnormality. The patient was monitored on telemetry and discharged with follow up. 

This patient presented with syncope while in bed. No significant cardiac findings were noted on EKG or echocardiography. There was a mild elevation in serum troponin and no other laboratory abnormalities. The patient was discharged after observation for a two-day period. According to the European Society of Cardiology, this patient was a low-risk patient for future morbidity and mortality. (Reference 1) In a study of individuals presenting to the emergency room, patients that were low risk for cardiac events (no significant cardiac history or acute cardiac findings on initial evaluation) had an excellent prognosis and did not require admission to the hospital for further testing. (Reference 2) Risk assessment of patients presenting with chest pain to the hospital and no significant ST changes on EKG was reviewed by Hedayati et al. (Reference 3) Using the HEART (History, EKG, Age, Risk factors, and troponin) score risk stratification schema, this patient would have a low risk of major adverse cardiac events [defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death] in the six weeks following presentation. In this case, the patient falls into a low-risk category and could be managed a lower level of care. In conclusion, acute inpatient admission was not medically necessary.

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

The insurer's denial of coverage for inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Preterm Labor.
Treatment: Inpatient admission.
The insurer denied coverage for inpatient admission.
The denial is overturned.

The patient is an adult pregnant female at 34 weeks gestation who presented complaining of abdominal pain. She was diagnosed with preterm labor based on cervical changes from closed cervix to 2 centimeters (cm) dilated. The patient was admitted and started on tocolytics, systemic steroids, and IV (intravenous) antibiotics for a urinary tract infection. Progress notes reported that the patient was still having contractions every 10 minutes. The patient refused to have a vaginal examination to check for additional cervical changes. The patient was stable and was discharged home.

Preterm labor is an indication for admission and tocolysis. Preterm labor is defined as uterine contractions with cervical changes.

During this admission, there was documentation of cervical changes. This patient was in preterm labor and admission was medically necessary to stop the contraction or deliver the patient if stopping labor was unsuccessful.

Later, the contractions have stopped, the patient was stable, and she was discharged home. The hospital admission was medically necessary.

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

The insurer's denial of coverage for the inpatient admission is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pyelonephritis
treatment: Inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is overturned. 

The patient is a girl who presented to the emergency department with persistent flank pain and fever. She was well until several days prior to presentation when she developed fever and flank pain. She was seen in urgent care and was prescribed Keflex for a suspected urinary tract infection. Her symptoms did not improve and she also developed chills, therefore she returned to urgent care and was prescribed Bactrim. However, she continued to have fevers as well as chills and nausea. She described flank pain which was worse on the right side compared to the left. Due to the persistence of her symptoms, she was brought to the emergency department for evaluation.

the requested Inpatient Hospital Admission was medically necessary for this patient.
This is a teenage girl who presented with acute pyelonephritis. She had been seen twice in urgent care and was appropriately treated with 2 different antibiotics. However, her symptoms continued to worsen. At the time of presentation she have fever, nausea, and flank pain and was tachycardic. Her laboratory evaluation revealed an elevated white blood count with left shift and pyuria, and her Computed Tomography (CT) scan was consistent with pyelonephritis. Therefore, she required inpatient admission for appropriate treatment with parenteral antibiotics, intravenous fluids to maintain her hydration status and avoid kidney injury, and close monitoring with additional treatments as needed.
Acute pyelonephritis can be complicated by progression of the upper urinary tract infection to renal corticomedullary abscess, perinephric abscess, emphysematous pyelonephritis, or papillary necrosis. Indications for inpatient management of pyelonephritis include an inability to maintain oral hydration or take oral medications or failure of outpatient therapy.
The decision making at the time of admission for this patient was consistent with her young age, the presence of pyelonephritis with significant symptoms that persisted despite appropriate outpatient therapy, the presence of nausea that would inhibit oral intake, and the need for treatment with intravenous antibiotics and fluids along with close monitoring for potential deterioration of clinical status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult female with a history of recent episodes of biliary colic, who presented with right upper quadrant (RUQ) pain, nausea and an episode of vomiting. She was afebrile and hemodynamically stable, with right upper quadrant tenderness on exam. Her labs revealed elevated transaminases, and an ultrasound revealed gallstones and a five-millimeter common bile duct (CBD). The patient was seen by gastroenterology (GI) and surgery and magnetic resonance cholangiopancreatography (MRCP) and hepatobiliary iminodiacetic acid (HIDA) scan were recommended. 
The hepatobiliary iminodiacetic acid (HIDA) scan was negative for acute cholecystitis. Magnetic resonance cholangiopancreatography (MRCP) was negative for a common bile duct (CBD) stone. The patient had no further abdominal pain, nausea or vomiting. An esophagogastroduodenoscopy (EGD) was planned and done which revealed gastritis. Diet was advanced, and the patient was discharged for outpatient laparoscopic cholecystectomy.

The proposed treatment was not medically necessary.

The patient presented with recurrent biliary colic. As there was no evidence of acute cholecystitis, common bile duct (CBD) stone, cholangitis, sepsis, intractable vomiting, dehydration, electrolyte abnormalities, hemodynamic instability or need for urgent surgical intervention, the patient was hemodynamically stable.  Observation status was medically appropriate on presentation. When there was no further abdominal pain and no evidence of acute cholecystitis, the patient was medically stable for discharge the following day. Therefore, acute inpatient hospital stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Systemic lupus erythematosus 
Treatment: Benlysta IV (intravenous) dosed every two weeks
The insurer denied: Benlysta IV (intravenous) dosed every two weeks
The denial is upheld

This patient is an adult female with a history of systemic lupus erythematosus (SLE).  The patient has inflammatory arthritis, rash and fevers.  The patient is currently receiving Benlysta every four weeks with partial relief of her symptoms.  She continues to have pain and swelling along with fever and rash.  She has previously tried and failed conventional disease modifying antirheumatic drugs (DMARDs) hydroxychloroquine, azathioprine, mycophenolate, tacrolimus, methotrexate and leflunomide.  
The reason that Benlysta was initially denied was due to the request being for ten milligrams per kilogram every 14 days which exceeds the Food and Drug Administration (FDA) approved dosing frequency.  The reason the provider is appealing the determination is because the provider feels that the medication is not lasting the entire four weeks and feels that increased to every other week would be more efficacious for the patient.

The proposed treatment is not medically necessary.
The proposed treatment is not medically necessary because there are no clinical studies indicating the efficacy and safety of Benlysta every two weeks. The Food and Drug Administration (FDA) approved dosing guidelines is for ten milligrams per kilogram every four weeks.  The provider also did not submit any supporting clinical research showing efficacy and safety of Benlysta every two weeks.  Therefore the proposed treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cough and Rhinorrhea
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is overturned

The patient is a young toddler male with known presentation of increased work of breathing, abnormal vitals and fever. The patient was noted to have an increased respiratory effort, with labored breathing as well as an oxygen requirement to maintain appropriate oxygen saturation and support respiratory effort. The patient also required IV (intravenous) fluid hydration to prevent aspiration as the patient could not feed by mouth due to signs of respiratory distress. 

The inpatient admission was medically necessary.
The patient was seen to be tachypneic, with an increased respiratory effort and labored breathing. The patient was at risk of aspiration due to this respiratory state and rate.  As such, the patient required IV (intravenous) fluids to maintain hydration as well as oxygen support. The patient had a fever. At the patient's age, if the patient had continued to have labored breathing with a decrease in oxygen saturation and an inability to feed safely, without admission and treatment, the patient would have decompensated rapidly once the patient's fatigue presented.

Therefore, given the above, the inpatient admission was medically necessary.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Stroke Preventative 

Treatment: Eliquis (apixaban)

The insurer denied coverage for Eliquis (apixaban)

The denial is overturned

This patient has a past medical history of atrial fibrillation status post left atrial catheter ablation (left atrial appendage electrically inert), arrhythmogenic right ventricular cardiomyopathy, implantable cardioverter defibrillator (ICD) in situ, diabetes mellitus and hypertension.  She was appropriately treated with oral anticoagulant therapy for stroke prevention and developed nose bleeding while taking Xarelto (rivaroxaban) therapy.  Eliquis (apixaban) therapy was initiated and has been well tolerated without nose bleeding.

The 2019 American Heart Association, American College of Cardiology and Heart Rhythm Society Guidelines list a Class I (level of evidence A) recommendation for treatment with novel oral anticoagulant regimen instead of warfarin.  This recommendation was based on several randomized clinical trials that enrolled thousands of patients.  The direct thrombin inhibitor medications and the Factor Xa (stuart prower factor) inhibitor medications (including Xarelto/Rivaroxaban) were at least non inferior and in some cases superior to warfarin therapy.  When Xarelto was utilized to treat patients with atrial fibrillation in a large randomized controlled study, results demonstrated non-inferiority to warfarin in preventing stroke or systemic embolism (Reference 2). 

This patient had clear evidence of bleeding while treated with Xarelto necessitating the use of an alternative such as apixaban (Eliquis). In fact, when Eliquis was utilized to treat patients with atrial fibrillation in a large randomized controlled study, results demonstrated superiority to warfarin in preventing stroke or systemic embolism.  In addition, patients treated with Eliquis had less bleeding and a lower mortality than those treated with warfarin (Reference 3). 

Formulary alternatives have caused bleeding (harm). Warfarin, another formulary alternative may also cause harm. The formulary drugs are expected to cause adverse effects. 

The formulary drugs were tried, and the patient did have an adverse reaction or contraindication. As the patient had been stable on apixaban. It is clear that the requested drug would be more effective.

The carrier's denial of Request for Formulary Exception for Eliquis (apixaban) is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder/Seizures
Treatment: Inpatient Admission
The health plan denied the requested inpatient admission as not medically necessary. 
The health plan's determination is upheld.

The patient was admitted for a continuous 24-hour electroencephalogram (EEG). He had a history of congenital hydrocephalus, consisting of right ventriculomegaly, status post endoscopic septal fenestration for loculated hydrocephalus. In addition, he had a history of pituitary deficiency, for which he was being treated with multiple hormone replacements. At the age of two months, he began to have paroxysmal events consisting of brief startle-like behaviors. Over time, the frequency of these events increased. To evaluate whether these events were myoclonic epileptic seizures, his physician admitted him for a continuous EEG. He was admitted. At that time, he was well. He was eating, sleeping, and arousing normally. He had no fever or vomiting. In the hospital, he underwent continuous EEG monitoring during which time he had none of his characteristic spells. His EEG was mildly abnormal, due to some slowing, but had no epileptiform activity or other evidence of epileptic seizures. He was discharged to home. 
At issue is the medical necessity of an inpatient admission.

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

No. The inpatient admission was not medically necessary.
When a baby is having recurrent startle-like episodes, then it is possible that the baby is having myoclonic seizures or infantile spasms. To assess for this possibility, it is necessary for the baby to undergo a continuous EEG, with the hope of capturing a spell to determine whether it is epileptic or not. Continuous EEG monitoring requires admission to a hospital. However, when the baby is well and shows no signs of illness, then it is customary and appropriate for the admission to be at an alternate level of care. This patient was well and did not need to be admitted at the acute level of care.
The patient was a healthy baby who was at his baseline. He was not febrile and was eating well. Admission at the acute level of care was not medically necessary. Care could have been provided at an alternate level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gender Dysphoria. 
Treatment: Bone Density Study. 

The insurer denied Bone Density Study. The health plan's determination is overturned. 

The patient is a transgender male (biological female) who has been diagnosed with gender dysphoria and on GnRH (Gonadotropin-releasing hormone) analog for two years to suppress puberty. Pubertal development at the time of starting GnRH was Tanner II and bone mineral density (BMD) was read as Z score -1.6 standard deviation (SD). The patient has been complaining of chronic musculoskeletal pain. The working diagnosis is amplified musculoskeletal pain syndrome (AMPS). 

The Outpatient Procedure - Diagnostic Testing: Bone Density Study is medically necessary for this patient. 

Gender dysphoria is listed in the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-V) and is assigned by a mental health professional. The proposed criteria for Gender Dysphoria (in adolescents) in DSM-V include a marked incongruence between one's experienced/expressed gender and secondary sex characteristics than assigned gender, a strong desire to get rid of one's primary and/or secondary sex characteristics and get secondary sex characteristics of the other gender which is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning. 

Endocrine Society published guidelines for the treatment of adolescents with gender dysphoria that recommended suppression of puberty by using GnRH at Tanner stage II/III for adolescents until age 16 years old, after which cross-sex hormones may be given. The primary risks of pubertal suppression in gender-incongruent adolescents may include adverse effects on bone mineralization. In those guidelines, in a protocol, bone mineral density using DEXA scan was recommended at baseline and every 1-2 years for follow-up during suppression of puberty.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis. 
Treatment: Inpatient stay. 

The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a female with a complaint of emesis and abdominal pain. She was found to have an elevated white blood cell count (WBC) and had an ultrasound (US) that was consistent with appendicitis. She was started on ABX (antibiotics) and taken to the operating room (OR) where she underwent an open appendectomy and had a non-perforated appendicitis. She was given ABX and pain meds postoperatively and discharged. 

The inpatient hospital admission was not medically necessary. 

An appendectomy can be performed as an observation procedure. In fact, many centers are focusing on same day discharge after routine appendectomy. One study cited that: Healthy children who undergo laparoscopic appendectomy for non-perforated appendicitis can be discharged home during the same day of the operation after a short period of observation. This approach is safe and does not result in more postoperative emergency department (ED) visits or hospital readmissions. In addition, there is a significant benefit when patients are discharged early. Another study indicated that there is significant parental satisfaction with same day discharge. 
While this case was performed in an open fashion, the appendix was non perforated, and discharge should still be possible within 24 hours. 

Finally, a third study found that community hospitals can perform appendectomy even with pediatric unit closures. Same-day discharge after laparoscopic appendectomy for uncomplicated appendicitis is safe and feasible. The decrease in postoperative length of stay (LOS) are not associated with higher complication rates.