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

Diagnosis: Colitis; Change in bowel habits

Treatment: Gastrointestinal pathogen panel test (code 87506)

The insurer denied coverage for gastrointestinal pathogen panel test (code 87506).

The denial is upheld.

This female patient has a history of colitis, gastroenteritis and polycystic ovary syndrome (PCOS) who presented with abdominal pain, rectal urgency and frequent bowel movements.  The progress note submitted show that the plan was for stool culture and ova and parasites as well as other testing.  In addition, a molecular panel for infectious disease detection by nucleic acid was ordered.

UpToDate has an article titled "Approach to the adult with chronic diarrhea in resource rich settings."  A work-up is described to include a stool testing for leukocytes, parasites, and Clostridium difficile toxin, and a testing for celiac disease and inflammatory bowel disease should be considered.  Blood tests for malabsorption are also advised. However, the pathogen panel test is not part of the advised work-up.

The FDA has approved the gastrointestinal pathogen panel.  However, it advises that positive results are presumptive and must be confirmed.  It states that positive cases do not rule out co-infection with other organisms that are not detected by this test and may not be the sole or definitive cause of the patient's illness.  

This patient has had diarrhea since she was a young child.  A work-up including stool testing is appropriate.  However, obtaining a nucleic acid pathogen panel test is not part of the recommended work-up for chronic diarrhea. Thus, the gastrointestinal pathogen panel test performed was not medically necessary for this patient.

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

The carrier's denial of coverage for the gastrointestinal pathogen panel test (code 87506) should be upheld.  The medical necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Genitourinary/Kidney DisorderMenopause
Pharmacy/Prescription Drugs

Diagnosis: Menopause
Treatment: Bijuva
The health plan has denied the use of the non-formulary drug Bijuva. The health plan's determination is upheld.

This patient is a female under consideration for Bijuva 1-100 mg oral capsules for the treatment of menopausal and female climacteric states (N95.1). The patient has not tried and failed the formulary alternative agent in this case of Estradiol. The patient has reported that Estrace cream caused irritation after a three-month trial. The patient had no prior trial that resulted in adverse events documented in the medical documents reviewed. In this case, both Estradiol and Progesterone are on formulary and can be used in place of the Bijuva if coverage is desired. There have been no adverse events with the formulary alternatives in this case.

The health plan's determination in this case is upheld, in whole.

In this case, the formulary alternative of Estradiol and Progesterone would be as effective as the nonformulary alternative for the treatment of menopausal and female climacteric states (N95.1) as requested in this case. The American College of Obstetrics and Gynecology supports the use of Estrogen and Progesterone replacement therapy as a treatment for menopausal and female climacteric states (N95.1) as follows:
"What hormonal medications are effective in treating vasomotor symptoms? Systemic hormone therapy (HT), with estrogen alone or in combination with progestin, is the most effective therapy for vasomotor symptoms related to menopause. Data do not support the use of progestin-only medications, testosterone, or compounded bioidentical hormones for the treatment of vasomotor symptoms."
Appeal type: Medical necessity
Decision: Upheld

Cardiac/Circulatory problems.
Inpatient hospital.

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

The patient is a man with a history of Parkinson's disease and hypertension who presented to the hospital. He presented with a chief complaint of syncope and also reported weakness and lethargy. He denied fevers and chills but did report some nausea. He was found on the floor by his wife. The patient was admitted for syncope. 

The inpatient hospital admission was not medically necessary. The patient had low acuity and did require further evaluation and treatment for weakness and syncope, but this evaluation could have been performed safely and effectively at a lower level of care. The reason is that the patient was hemodynamically stable and already had multiple studies in the emergency department that ruled out an acute diagnosis such as acute stroke, acute seizures, sepsis, or acute blood loss anemia.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Cardiac/Circulatory Problems. 
Treatment:  Inpatient Hospital. 
The insurer denied: Inpatient stay. 
The denial is: overturned in whole.

The patient is a female with a history of congestive heart failure, implantable cardioverter defibrillator implantation, hypertension, hyperlipidemia and diabetes.  She presented to the emergency department via ambulance complaining of acute onset dyspnea.  She had recently been prescribed antibiotics for a cough, and her furosemide dose had been decreased.  Per Emergency Medical Services (EMS), her initial oxygen saturation was in the 70s.  She was treated with two doses of nitroglycerin and continuous positive airway pressure (CPAP).  In the emergency department her blood pressure was 141/93 millimeters of mercury (mmHg) with a heart rate of 96 beats/minute.  Her respiratory rate was 24/minute with an oxygen saturation of 90%.  Her physical exam was remarkable for decreased breath sounds and rales.  Chest X-ray showed pulmonary venous congestion and a small right pleural effusion.  The patient's brain natriuretic peptide (BNP) level was elevated.  Her lactate level was mildly elevated.  She was treated with intravenous furosemide, supplemental oxygen and bi-level positive airway pressure (BiPAP) for ventilatory support and admitted to the hospital for management of acute decompensated heart failure.  BiPAP was discontinued and supplemental oxygen was continued.  The following day the patient continued to complain of cough and resting dyspnea.  Physical exam showed persistent rales.  At morning, she insisted upon leaving the hospital, despite medical advice to stay.  Medical necessity for an inpatient stay is at issue.

The health plan's determination is overturned in whole. 

An inpatient stay was medically necessary.  This patient presented with acute decompensated heart failure.  She was in respiratory distress, tachypneic, and hypoxic.  She required BiPAP for ventilatory support.  Her serum lactate level was elevated, which is a poor prognostic indicator.  Before she left the hospital, she had persistent resting dyspnea and rales.  She was at risk for malignant arrhythmias and the need for intubation and mechanical ventilation.  She required careful monitoring with the ability to intervene emergently, if needed.  An inpatient level of care was medically necessary for this acutely ill, high risk patient.
Appeal type: Medical necessity
Decision: Upheld

Digestive System/Gastrointestinal
Inpatient hospital

Diagnosis: Abdominal pain
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a woman who presented to the emergency department. She had a history of pituitary tumor and she presented with generalized abdominal pain and vomiting. She denied headache, fever, chest pain and shortness of breath. She underwent an outpatient ultrasound which demonstrated gallstones. The patient was admitted for abdominal pain thought to be secondary to constipation versus chronic opioid use. The plan of care included surgery consult, consideration of biliary source of pain, pain management, bowel regimen, and continue other home medications. Her symptoms improved and she was ultimately thought to have gastroenteritis. She was discharged in stable condition.

The inpatient hospital admission was not medically necessary. The patient primarily received a diagnostic work up and treatment for constipation and gastroenteritis. Based on her emergency department evaluation, the likelihood of high acuity illness causing her symptoms was low. In addition, there was no evidence of sepsis, bowel obstruction, acute cholecystitis, cholangitis, or acute pancreatitis. Overall, she could have received her care safely and effectively at a lower level.
Appeal type: Medical necessity
Decision: Overturned

Cardiac/circulatory problems
Inpatient hospital
Diagnosis: High INR
Treatment: Inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is overturned. 

The patient is a male who underwent vascular surgery 5 days prior to emergency room presentation. He underwent thrombolysis for right lower extremity deep vein thrombosis (DVT). The patient presents with a supratherapeutic international normalized ratio (INR) of 9.5 and acute renal failure. He was admitted for high INR and acute and worsening renal failure. The inpatient stay is under review.

The Inpatient admission was medically necessary for this patient.
Given the patient's very high INR, the patient was admitted appropriately because his risk of bleeding, especially given his recent vascular surgery procedure, was very high. The patient was also noted to be in acute renal failure. The patient was admitted and observed for bleeding. He was seen by vascular surgery and nephrology who hydrated him appropriately for his renal failure. His creatinine improved significantly through his hospital stay. Discharge of the patient upon admission had a high likelihood of acute bleeding due to the high INR. The patient was also at risk of permanent renal failure and hemodialysis had he not been admitted for observation and hydration given his worsening creatinine. The patient was appropriately discharged in stable condition.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis

Treatment: Inpatient admission

The insurer denied the inpatient admission.

The denial was overturned.

This is male patient with medical history of polysubstance abuse, bipolar disorder, depression, and recurrent cellulitis who presented to the emergency department with complaints of bilateral arm pain. His presenting vital signs included: Temperature 98.8 F, Blood Pressure-132/85, Puse-78, Respiratory Rate-18, oxygen (O2) saturationt-98% on room air. Laboratory results included the following: WBC-13.2, HGB-12.5, HCT-39.3, creatinine-1.24, glucose-97. The patient was started empirically on intravenous (IV) antibiotics for bilateral forearm cellulitis. An x-ray of forearm was performed that showed non-specific diffuse soft tissue swelling. He underwent an incision and drainage (I&D) procedure of the right arm. Methadone taper was begun. Infectious Diseases consulted and adjusted antibiotics. The patient remained afebrile and hemodynamically stable. He eloped from the hospital before completion of management.

According to documentation, patient was re-admitted with bilateral forearm abscess. Laboratory results showed an elevated WBC. Although patient was afebrile, he was prescribed oral antibiotics (Bactrim) as an outpatient, but his abscess progressed, requiring surgical intervention (I&D) and intravenous antibiotics. Based on the above findings including failure of outpatient intervention, in a high-risk patient with active intravenous drug abuse and recurrent infections, hospital admission was medically necessary. 

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

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

Diagnosis: Pneumonia
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial was upheld.

This is a male patient with a history of hypertension (HTN), end stage renal disease (ESRD) on hemodialysis (HD). The patient is status post renal transplant which failed (patient was back on HD). The patient presented to the emergency department (ED) on with complaints of shortness of breath (SOB), weakness, hemoptysis, and neck and chest pain. It was reported that patient had been non-compliant with his blood pressure (BP) meds. At presentation to the ED his vital signs were: temperature 99.1 F, heart rate (HR) 105, respiratory rate (RR) 18, blood pressure (BP) 199/129 mm Hg, oxygen saturation 96% on room air. The patient was in no acute distress (NAD). The lung exam revealed wheezing and rhonchi. Cardiovascular system was normal. The patient's abdomen was soft and non-tender. An electrocardiogram (EKG) was performed that revealed some non-specific T wave changes. Chest x-ray revealed bilateral perihilar haziness. The diagnosis included pneumonia vs fluid. There was no pleural effusion; there was no pneumothorax. The patient was treated with a nitroglycerine (NTG) patch, Clonidine, Rocephin and Azithromycin. The patient's symptoms improved and he was discharged.

As per the history and physical (H&P) the patient was in no acute distress, was awake and alert, had no jugular venous distension, some wheezing and rhonchi on lung exam, and the neuro exam was non focal. Influenza screen was negative.

This patient was continued on oral blood pressure meds and other maintenance meds. He was continued on antibiotics on pneumonia. The patient remained stable after admission, was afebrile, and hemodynamically stable. Troponins remained flat and EKG no changes from the first one at presentation. Cultures were negative. The patient denied on going chest pain. The patient was afebrile, HR 88, RR 17, BP 167/95 mm Hg, oxygen saturations were 100% on 2 liter nasal cannula. Myocardial infarction was ruled out.

This patient did not need acute inpatient hospitalization. He could have been placed on observation status while diagnostic testing and treatment were initiated. The patient's BP was elevated due to non-compliance with meds; he responded to treatment in ED; wbc was normal. The CURB 65 score was 1 (the patient had chronic kidney disease (CKD). By the second inpatient day the patient was on maintenance dialysis; tolerating oral intake; without chest pain; myocardial infarction was ruled out and BP was at baseline. The patient was stable to be switched to oral antibiotics and could have been discharged home with close follow-up in the outpatient setting.

The health plan acted reasonably with sound medical judgment in the best interest of the patient. Based on the above, the medical necessity for the hospital admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rectal prolapse.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female. She was admitted to the hospital for repair of long standing rectal prolapse. Her co-morbid factors include a history of GERD (gastroesophageal reflux disease), gastric ulcer and thyroid disease. 

The patient was taken to surgery on the day of admission, where she underwent a robotic assisted rectopexy. The patient's post-operative course was totally benign. 

(POD [postoperative day] #1) the surgical progress note states the patient was hemodynamically stable, ambulating well, tolerating diet, voiding freely and passing flatus. Her pain was well-controlled. Physical exam notes the abdomen to be non-distended and non-tender. She was discharged from the hospital to home that same day.

Inpatient care for this admission was denied by the carrier, noting that the patient did not meet any of the requirements for coverage based upon Milliman Care Guidelines for inpatient and surgical care. The provider is appealing this decision.

No, the Inpatient admission was not medically necessary.

The patient underwent a minimally invasive procedure for correction of chronic rectal prolapse. The medical records submitted clearly document a full and rapid return to her pre-procedure levels of function and activity. The care rendered during her stay was supportive and observational in nature and did not rise to the level of care necessary to support acute inpatient status as defined by the guidelines employed. This procedure can be successfully performed in the ambulatory setting as is documented in the peer review literature. The carrier has correctly denied the inpatient stay and treated the claim as an ambulatory procedure with an overnight stay.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Pain (s/p cardiac catheterization) 
Treatment: Inpatient admission 

The insurer denied the inpatient admission. The denial is overturned. 

The patient is a male at the time of admission to the hospital, with a past medical history significant for HTN (hypertension), dyslipidemia, diabetes mellitus, CAD (coronary artery disease), status post CABG (coronary artery bypass graft), LIMA (left internal mammary artery) to LAD (left anterior descending artery) and SVG (saphenous vein grafts) to OM (obtuse marginal artery) and RCA (right coronary artery) and PCI (percutaneous transluminal coronary angioplasty) x2, as well as aortic valve replacement, who presented to the ER with complaints of chest pain, left-sided, 8-10/10 in severity, new onset, described as pressure. The chest pain was triggered by emotional distress. The patient was hypertensive and had tachypnea on admission, with stable HR (heart rate) and oxygen saturation. Cardiac troponin was normal. ECG (electrocardiogram) was unchanged. 

Yes, the inpatient admission was "medically necessary". 

The patient presented with new onset chest pain, suggestive of unstable angina. The patient had multiple risk factors for CAD (coronary artery disease), including diabetes, as well as a known history of coronary artery disease, including a history of multiple percutaneous revascularization procedures and two open heart surgeries. There was a high index of suspicion for an ACS (acute coronary syndrome), and a cardiac catheterization was performed. Given the presentation, high risk features, as well as clinical suspicion for an acute coronary syndrome/unstable angina, he would not be an appropriate candidate for an ED chest pain observation unit, and 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. 

The patient was diagnosed with unstable angina and admitted to telemetry. The patient was evaluated by cardiology and a decision was made to proceed with cardiac catheterization. The coronary angiogram revealed two vessel CAD with left main artery disease. LIMA to LAD graft was patent and a jump SVG graft to OM and RCA was occluded. The patient was treated with medical therapy and discharged home with a plan for outpatient follow-up.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Ulcerative coliti. 
Treatment: Lialda. 

The insurer denied Lialda. The health plan's determination is upheld. 

The patient is a female with ulcerative colitis. She has failed treatment with Asacol, hydrocortisone foam and Prednisone. She has responded to Lialda. Her MD is requesting continued treatment with Lialda. 

The patient has ulcerative colitis. The planned preferred agents are balsalazide, Dipentum, Mesalamine 400 mg, mesalamine enema, mesalamine suppository, sulfasalazine and sulfasalazine ER.  The patient has failed mesalamine 400 mg (Asacol). As the patient has not failed two other preferred formulary alternatives (balsalazide, Dipentum and sulfasalazine would be reasonable alternatives), and as there is no medical literature to support that Lialda 1.2 grams is more effective than balsalazide, Dipentum and sulfasalazine, for the treatment of ulcerative colitis, the health plan should not cover Lialda 1.2 grams.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory Failure
Treatment: Long term acute care
The insurer denied Long term acute care
The determination is overturned.

The patient has a past medical history of diabetes and was initially admitted for acute hypoxic respiratory failure secondary to COVID-19 pneumonia requiring mechanical ventilation support. His course was complicated by renal failure requiring hemodialysis, a pneumothorax requiring chest tube placement, methicillin-resistant staphylococcus aureus (MRSA) sepsis and pneumonia. Currently the patient still requires ventilator support during the night and is undergoing pressure support trials during the daytime. At issue is the medical necessity of long term acute care.
The requested health service/treatment of long term care- acute is medically necessary for this patient.
This patient was admitted to long term care acute after hospitalization for acute hypoxic respiratory failure secondary to COVID-19 pneumonia requiring tracheostomy placement with mechanical ventilator dependence. Per the most recent clinical information, the patient is awake and responsive but is still requiring ventilator support during the night. The patient should be able to wean from the ventilator as evident by tolerating pressure support trials during most of the daytime. In addition, there was an indication he was working with physical therapy to improve his functional status for a potential return to his baseline. In addition, he is hemodynamically stable, tolerating feedings and needs frequent nursing/respiratory care greater than (>) 6.5 hours per day and daily physician assessments for continued weaning and suctioning needs. He could not be effectively weaned at a lower level of care and therefore, a long term care acute facility is medically necessary and appropriate for continued weaning.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis of the scalp and ears 
Treatment: Otezla 

The insurer denied the Otezla. The denial is overturned. 

The patient is a with psoriasis of the scalp and ears. The request is for Otezla. A visit note states the patient is on the bridge program for Otezla. She started Otezla in after having failed topical steroids and ketoconazole shampoo. At the time, she had moderate to severe disease affecting 5% BSA (body surface area). Currently, her condition is mild. 

Yes, the proposed Otezla (Pre-Service) is medically necessary. 

The patient had moderate to severe psoriasis of the scalp that has responded well to treatment with Otezla, started through the bridge program. 

Phototherapy is not appropriate for sensitive areas (scalp, ears) in addition to being almost impossible to obtain during the COVID-19 pandemic. The patient is not a candidate for conventional systemic therapy (methotrexate, acitretin) due to her gender and childbearing age. Cyclosporine is not a reasonable long term treatment for moderate to severe psoriasis due to the severe side effect profile. 

Otezla, an inhibitor of phosphodiesterase 4 (PDE4), is indicated for the treatment of adult patients with active psoriatic arthritis and patients with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy.  (Celgene, 2015)  Otezla is an oral small molecule inhibitor of phosphodiesterase 4 (PDE4) specific for cyclic adenosine monophosphate (cAMP) and is indicated for the treatment of adult patients with active psoriatic arthritis (PsA), as well as the treatment of patients with moderate to severe plaque psoriasis. (Celgene, 2016)  The patient has moderate to severe psoriasis, for which therapy with Otezla is appropriate and medically necessary.