Persius/hicric huggingface dataset:
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Ulcerative Colitis
Treatment: Formulary exception for Mesalamine Delayed-Release Capsule
The insurer denied: Formulary exception for Mesalamine Delayed-Release Capsule
The denial is overturned.

The patient is a preschool male. He has been diagnosed with ulcerative colitis. He has been on mesalamine capsules and has been doing well. His doctor requested to continue mesalamine capsules. The health plan denied coverage of the request, because the patient has not tried formulary alternatives. The reason for appeal is that the patient cannot swallow tablets, and he can open the capsule and take it.

The health plan should cover the Formulary exception for Mesalamine Delayed-Release Capsule.

5-ASA (mesalamine) has been widely used in pediatric patients with mild to moderate inflammatory bowel disease including ulcerative. ImproveCareNetwork and guidelines recommend mesalamine dose of 60-100 milligrams/kilograms/day up to 4.8 grams/day for active colitis (1-3). Even though mesalamine has been used widely in children with ulcerative colitis, there has been no clinical studies to show that the specific mesalamine is better than any other mesalamine preparations, including balsalazide, mesalamine delayed-release tablet (generic Lialda), mesalamine extended-release (generic Apriso, Pentasa), sulfasalazine, sulfasalazine delayed-release. Thus, the formulary 
drug would be as effective as the requested non-formulary drug. There has been no documentation that the formulary drug is or has been ineffective for this patient or has adverse effects for this patient.
However, as documented, this preschool patient was recently diagnosed with ulcerative colitis and has been doing well with mesalamine capsules. Since the patient cannot swallow any tablets, opening a capsule or compound suspension would be the only options. All the formulary alternatives are tablets, and thus would not be appropriate for this patient. Therefore, continuation of mesalamine capsules is medically appropriate for this patient. The health plan should cover the formulary exception for mesalamine capsules.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Umbilical Hernia. 
Treatment:  Inpatient admission.

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

This is an adult patient, who was admitted to the hospital. The patient underwent laparoscopic ventral hernia repair with mesh and was discharged two days later.

Umbilical hernias are common surgical complaints. These hernias can become symptomatic and therefore are at an increased risk of incarceration and subsequent strangulation. In this situation, surgical repair is indicated. Emergency repair has been associated with an increased risk of mortality, reoperation, and readmission. Bowel compromise can occur regardless of the hernia size, and the belief that larger hernias do not incarcerate is inaccurate. Complex hernias have been defined as hernias with signs of incarceration, strangulation, infection, chronic pain, irreducible scrotal hernias, multiple recurrence(s), or a relevant history of lower abdominal surgery or radiation. Some complex hernias are suitable for ambulatory repair.

Per the clinical documentation, the patient presented with abdominal pain and was diagnosed with an umbilical hernia. The patient underwent laparoscopic ventral hernia repair with mesh. There were no reported complications.

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 the full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: abdominal pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
This case involves an adult female under review for medical necessity of hospitalization.

This patient with a significant history of asthma, hypertension, epigastric sleeve, and gastroesophageal reflux disease (GERD) was presented to the emergency department for complaints of abdominal pain, vomiting, migraine, chest pain/esophageal burning, blurry vision, and dizziness for 2 weeks. The patient reported that she is not able to eat or drink without vomiting; the patient reported that she took omeprazole, Mylanta, and Carafate without relief of symptoms.  Computed tomography (CT) abdomen/pelvis (small hiatal hernia) and ultrasound of the abdomen showed no acute gastrointestinal (GI) pathology.  Chest imaging and electrocardiogram (EKG) were unremarkable. Labs results were unremarkable. The patient received intravenous (IV) fluids, ondansetron 4 milligrams (mg) IV stat, famotidine 20 mg, and lidocaine viscous.  Despite treatment, the patient continued to report epigastric discomfort of unclear etiology.  GI was consulted and recommended inpatient admission.

Per the Milliman Care guidelines inpatient hospital admission is considered medically necessary if one or more of the following is met: 1) Hemodynamic instability: Acute peripheral ischemia (e.g., pulseless, cool, mottled, or cyanotic extremity). 2) cardiac arrhythmias of immediate concern. 3) severe respiratory findings. 4) severe airflow or ventilation abnormalities. 5) neurologic abnormalities. 6) altered mental status that is severe or persistent: physiologic disorder, suspicion for or diagnosis of abdominal catastrophe, temperature less than 95 degrees Fahrenheit/35 degrees, rectal. 7) severe electrolyte abnormalities requiring inpatient care. 8) severe anemia. 9) high-risk low platelet count. 10) severe pain requiring acute inpatient management: Inpatient intravenous opioid treatment required.  Pain control regimen for next level of care not established, suspected new or deteriorating disease process as etiology, palliative procedure planned that necessitates inpatient care for assessment and monitoring needs. 10) inpatient monitoring needed. 11) treatment requiring inpatient care. 12) emergency procedure as needed.

Patient underwent extensive evaluations as noted. Based on the Milliman Care Guidelines, the patient's clinical findings do not meet the general criteria for inpatient stay. Upon admission, the patient's vital signs were within normal limits. Laboratory results and imaging were unremarkable. There is no signs of respiratory distress or neurologic abnormalities that would necessitate inpatient stay. The patient's care needs can be provided in a lower level of care. 

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 full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: abdominal pain

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned


This is an older teen with a history of gastric bypass. The patient presented to the emergency department (ED) with the complaint of abdominal pain. As per the ED provider note, the patient had a 3 day history of gradually worsening right upper quadrant (RUQ) pain. The patient denied fever or chills. The abdominal exam revealed a soft non distended abdomen with right upper quadrant (RUQ) tenderness and voluntary guarding. Murphy's sign was positive. The patient was febrile to 103.3 degrees Fahrenheit and had a pulse of 107. The patient's white blood cell (WBC) count was 23.75. The clinical impression was possible cholecystitis. The plan was RUQ ultrasound and general surgery consult. An ultrasound of the gallbladder revealed a 2.1 centimeter (cm) stone, impacted in the neck of the gallbladder. The patient was seen by surgery and the impression was cholecystitis with the plan for urgent cholecystectomy given sepsis. The patient was taken to the operating room and underwent an uncomplicated robotic cholecystectomy. He was maintained on antibiotics due to gangrene of the gall bladder. Findings at the time of surgery included a distended inflamed gallbladder with patchy gangrene of the gallbladder wall. Pathology revealed acute gangrenous cholecystitis. After surgery, the patient had a down-trending WBC, now to 19. The patient was afebrile, resting comfortably and tolerating clear liquids. The plan was to continue antibiotics prior to discharge. 

Although Milliman Care Guideline (MCG) Inpatient and Surgical Care 27th Edition cholecystectomy by laparoscopy notes the operative status criteria is ambulatory, in this case acute inpatient admission was warranted. The patient presented with evidence of sepsis with tachycardia, significantly elevated white blood cell (WBC) count, fever and acute cholecystitis with gangrenous patches noted at the time of surgery. The patient required intravenous (IV) antibiotics postoperatively, as it was imperative that the infection be controlled. While the patient did have an uneventful laparoscopic cholecystectomy, it was prudent that the patient be admitted in this case, given the degree of inflammatory response. 

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 for the inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Epigastric pain. 
Treatment: Revenue code 0121 x 1 unit - Room & Board - Semi-Private Two Bed - Medical/Surgical/Gyn (gynecological). 
The insurer denied coverage for Revenue code 0121 x 1 unit - Room & Board - Semi-Private Two Bed - Medical/Surgical/Gyn. 
The denial is upheld. 

This is an adult female who presented to the emergency department (ED) with complaints of epigastric pain for the last 2 hours associated with vomiting. She was afebrile with stable vital signs. She denied fever. She reported similar episodes in the past but has never been worked up. On examination she had soft diffuse abdominal tenderness. White blood cells (WBC) count was 9.08. Liver function tests (LFTs) were normal. Computerized tomography (CT) of the abdomen showed cholelithiasis with gallstone at region of the gallbladder neck. The common bile duct (CBD) was mildly dilated to 7mm (millimeters). The sonogram of the abdomen showed no abnormal gallbladder wall thickening and negative sonographic Murphy sign. The impression was cholelithiasis without sonographic evidence of cholecystitis. The patient was reassessed, and surgery consulted. The patient was admitted to surgery. 

Surgical examination revealed right upper quadrant (RUQ) tenderness without rebound. The plan was for laparoscopic cholecystectomy possible open. The patient was made nothing per mouth (NPO) and given intravenous (IV) fluids. 

The patient underwent an uneventful laparoscopic cholecystectomy and lysis of adhesions. Pathology revealed acute and chronic cholecystitis with cholelithiasis. The operative note indicated acute cholecystitis with inflamed and edematous gallbladder, distended and decompressed with needle; appeared to be hydropic fluid. 

According to the guidelines of Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care- 27th edition Gall bladder or bile duct inflammation or stone ORG: M-555 [ISC (Inpatient & Surgical Care)], patients may be discharged to a lower level of care (either later than or sooner than the goal) when it is appropriate for their clinical status and care needs. This patient did not have any indication for acute inpatient admission. 

According to Milliman Care Guidelines (MCG) Inpatient and Surgical Care 27th Edition cholecystectomy by laparoscopy, the operative status criteria is ambulatory. Thus, this patient should have been managed without an inpatient acute admission for this procedure. 

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 Revenue code 0121 x 1 unit - Room & Board - Semi-Private Two Bed - Medical/Surgical/Gyn is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: heart disease, depression and Alzheimer's dementia

Treatment: 24 hours per day, 7 days per week (live in); personal care services, level 2

The insurer denied coverage for 24 hours per day, 7 days per week (live in); personal care services, level 2

The denial is upheld

 
This is an elderly  female with chronic medical conditions including heart disease, depression and Alzheimer's dementia.  She lives alone in a private residence.  The patient is approved for personal care services (PCS) level 2; 5 hours/day, 7 days/week.  The request is for PCS level 2, 24 hours/day (live-in); leading to an external review.  

The Uniform Assessment System (UAS) report was reviewed.  The patient's cognitive status is moderately impaired.  The patient is reportedly total dependent to maximal assistance for performing Instrumental Activities of Daily Living (IADL) tasks including shopping, ordinary housework and meal preparation.   She reportedly requires extensive assistance for bathing, lower body dressing and toilet use.  Limited assistance is reportedly needed for personal hygiene, upper body dressing, toilet transfer, locomotion and ambulation.  The patient also has a propensity for wandering and has reportedly fallen on 2 or more occasions over the prior 30 days.  She is reportedly at the supervision level for bed mobility and eating.  The patient is also reportedly occasionally incontinent of bladder and continent of bowel.  

The patient's medical condition, physical limitations and functional ability are not at the level or unpredictable as to require the requested PCS level 2, 24 hours/day (live-in), 7 days/week.  The patient's activities of daily living (ADL) status and self-sufficiency have not changed over the prior 90 days.  Her cognitive ability has not significantly changed.  The patient's functional ability has actually improved when compared to the prior UAS report.  The letters from the patient's treating physicians describing her clinical condition were reviewed.  One doctor recommended PCS "12 hours x 7 days" and the other doctor indicated "it is not recommended to leave patient alone any time of the day."  They did not provide the associated treatment notes to support their claim of the patient's reported incapacity.  

This physician would agree that the patient may benefit from additional monitoring; particularly due to her cognitive deficits, wandering and falls risk.  However, safety monitoring under PCS does not include monitoring an individual (e.g., with dementia, falls risk, general weakness) when no other Level I or Level II personal care services task is being provided.   The patient's health and safety are appropriately provided and maintained at home by the currently approved PCS level 2, 5 hours/day, 7 days/week for a total of 35 hours/week.    

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 24 hours per day, 7 days per week (live in); personal care services, level 2 services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Peripheral vascular disease
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient is an elderly male. He was admitted to the hospital. There was history of kidney disease, diabetes, hyperlipidemia, and peripheral vascular disease (PVD). He was admitted electively for stage lower extremity angiography and intervention. The patient's vital signs and oxygen saturation were essentially normal. There was history of gangrene of a right toe. He had undergone successful intervention of the right superficial femoral artery (SFA) and peroneal artery. He reported improvement of his symptoms. He was scheduled for a toe amputation. Angiography demonstrated severe disease of the right popliteal artery, occlusion of the right superficial femoral artery and anterior tibial artery, and occlusion of the right anterior tibial artery and peroneal artery. He underwent percutaneous intervention of the right peroneal, popliteal, and superficial femoral arteries. There were no complications. He remained stable and was discharged. The patient's inpatient hospitalization is under review.

The inpatient hospital admission was not medically necessary.

The patient underwent a successful and uncomplicated lower extremity arterial percutaneous intervention and remained stable. There was no procedure-related complication such as severe bleeding, need for urgent repeat procedure, acute coronary syndrome, CHF (congestive heart failure), hemodynamic instability, acute renal failure, need for ongoing intravenous in-hospital antibiotics, requirement for oxygen support, requirement for invasive cardiac monitoring. In the setting of this case, an inpatient hospitalization, compared to a lower level of care, has not been established as standard of care towards improved PVD (Peripheral Vascular Disease) outcomes. The inpatient hospital admission, therefore, was not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Blurred Vision
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

The patient is a male with a history of hypertension, hyperlipidemia, and atrial fibrillation who presented to the hospital for evaluation of blurred vision in his right eye. The patient underwent computed tomography angiography (CTA) of the head and neck and computed tomography (CT) perfusion. This showed a small perfusion abnormality in the anterior left frontal lobe. The patient was subsequently transferred to another hospital for further care and evaluation. The patient was evaluated by neurology and diagnosed with a right cranial nerve 4 palsy likely secondary to microvascular disease. The patient was treated with aspirin, Plavix, and atorvastatin and subsequently discharged home. At issue is the medical necessity of an inpatient stay.
Acute hospitalization for a cranial nerve 4 palsy is not medically necessary. The patient presented to the hospital with blurred vision. The patient was subsequently transferred to a hospital with neurology. The neurologist evaluated the patient and determined that the patient had a cranial nerve 4 palsy which was likely secondary to microvascular causes. The patient was recommended to take aspirin, Plavix, and a statin. The patient did not have a disabling deficit. The patient did not have significant vital sign or laboratory abnormalities. The patient did not have significant imaging abnormalities that required in-hospital interventions. The patient was able to discharge home after the diagnosis was established. The patient did not have acute rehabilitation needs.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is overturned.

This is a female patient with no significant past medical history (PMH) who was admitted for supervised cocaine withdrawal.  The physical exam was notable for tremors, Clinical Institute Withdrawal Assessment (CIWA) was 13. Lab work was notable for urine drug screening (UDS) positive (+) for cocaine and cannabinoids. The patient was diagnosed with alcohol and cocaine withdrawal and treated with Clinical Institute Withdrawal Assessment (CIWA), Clinical Opiate Withdrawal Scale (COWS), benzodiazepines (BZD), and clinical monitoring. 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. The patient had a medical history and physical exam clinically concerning for acute alcohol intoxication and withdrawal in the setting of cocaine withdrawal. This presentation was further compounded by the patient's tremors and agitation requiring chemical sedation with CIWA scores not consistent with a mild withdrawal, and these types of patients are not appropriate for a lower level of care due to the close clinical monitoring that is required to ensure no respiratory depression and adverse events, especially in the setting of clinical concern for seizures and concomitant cocaine withdrawal. The patient required close clinical monitoring for potential intervention that could not have been safely provided at a lower level of care while receiving benzodiazepines (BZDs).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: facial droop
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld. 

The patient is a female with a past medical history of Type 2 Diabetes with Neuropathy who presented to the Emergency Room with complaints of facial droop and headache. According to her daughter, the patient had been experiencing bilateral posterior headache and neck pain for several days, accompanied by generalized weakness and postural lightheadedness. The patient had been taking over-the-counter pain relievers (Tylenol and Aleve) with minimal relief. Her daughter also noted some gait instability. On the day of presentation, the patient was unable to get out of bed due to the headache and had developed slurred speech, prompting her visit to her Primary Care Physician, who subsequently referred her to the emergency room (ER).

The inpatient hospital admission was not medically necessary.
The patient was admitted to the hospital with facial asymmetry and essentially was diagnosed with Bell's palsy. There was no overwhelming evidence that the patient had a transient ischemic attack (TIA) or cerebrovascular accident (CVA) based on the physical exam or imaging studies.
Furthermore, there was no evidence that the patient had severe symptoms such as complete facial paralysis, or severe pain requiring frequent administration of parenteral pain medications. There was no evidence that the patient had complications of Bell's palsy such as corneal exposure leading to corneal ulceration, secondary bacterial infection, or severe hearing loss due to involvement of the inner ear. There was no evidence that the patient had uncontrolled diabetes or was immunosuppressed. Overall, the patient's clinical symptoms had not worsened during the entire period of the hospitalization.
Therefore, an inpatient hospital admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: dizziness/hypotension. 
Treatment: inpatient admission. 
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

The case involves a male with a history of cerebrovascular accident (CVA), admitted with dizziness and low blood pressure complaints. The measured blood pressure was 97/79, and as low as 85 systolic at home, though the blood pressure machine may have been malfunctioning. The patient continued to take multiple blood pressure medications. 

The inpatient hospital admission was not medically necessary. 
Based on the documentation, the patient has dehydration, which is read as an acute kidney injury, readily responsive to IV (intravenous) fluid hydration, and withholding nephrotoxic agents. However, there were no severe electrolyte abnormalities, metabolic acidosis, uremia, hypoxemia, or hemodynamic instability. There was no altered mental status, just some generalized weakness, expectedly. The creatinine increased from 1.5 to 2.6, which does not represent a typical threefold rise, to qualify for an inpatient stay. After initiating IV fluids, the hypotension resolved within hours of presentation, as evidenced by the admission history and physical vital signs. Finally, there is no evidence of severe intrinsic renal failure related to severe conditions such as vasculitis. Treatment of dehydration with AKI (acute kidney injury) can be readily accomplished under observation care.