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

Diagnosis: Iron deficiency anemia
Treatment: Inpatient admission

The inpatient admission was not medically necessary.

The patient in this case is a male. He presented to the emergency department with a one week history of dyspnea on exertion and generalized weakness.  His medical history was notable for hypertension, hyperlipidemia and also for coronary artery disease with stent placement.  He had symptoms for one week.  Outpatient labs had revealed a hemoglobin of 5g/dl.  He noted no chest pain or shortness of breath at the time of initial evaluation in the emergency department.  He also noted no apparent bleeding. 

The patient's physical examination and laboratory studies were unremarkable with the exception of anemia, with a hemoglobin of 5.5g/dl.   He was taken off Eliquis and seen by cardiology, who recommended transfusion to get his hemoglobin to 9g/dl. He was discharged.

This patient presented with symptomatic anemia in the setting of known treated coronary artery disease.  While he required blood transfusion, he did not require acute care inpatient hospital admission for that to be done.  There was no documentation of active significant bleeding, hemodynamic instability or active coronary ischemia.  Given those considerations, he could have been safely transfused at a lower level of care, without need for acute care inpatient admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma 
Treatment: Inpatient stay

The inpatient admission was medically necessary.

Summary:
The patient is a female child with medical history significant for mild asthma that presented to the ED with four-day history of cold symptoms, fever to 39.1, and wheezing. She was seen in the ED, treated with albuterol and steroids, and given a prescription for amoxicillin for suspected pneumonia. Overnight, after taking the first dose of amoxicillin (she had taken in the past with no problems), she developed shortness of breath, lip swelling, and urticarial rash. She was taken back to the ED in the early morning. 

This young female child with history of mild asthma and previous treatment with amoxicillin returned to the ED after an initial presentation for respiratory infection with asthma exacerbation, now with anaphylaxis following amoxicillin treatment. Laboratory evaluation revealed infection with influenza and coronavirus. She was treated appropriately and aggressively in the ED with steroids, epinephrine, H1 and H2 blockers, and IV fluids. She was admitted to the PICU for close monitoring and persistent symptoms. Although her respiratory status and swelling improved over the first day, nausea and urticaria persisted, necessitating ongoing hospital stay on the pediatric ward. Her symptoms had sufficiently resolved after another day so that she could be discharged home. This level of treatment, monitoring, and intervention, first in the ED then the PICU and finally the pediatric ward, is consistent with acute inpatient management despite the short two-day length of stay. Lower level of care would not have been sufficient for the management of this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dysmenorrhea

Treatment: Drospirenone-Ethinyl Estradiol-Levmefolate

The insurer denied coverage for Drospirenone-Ethinyl Estradiol-Levmefolate. The denial upheld.

This patient is a female requesting coverage for Beyaz. The patient's primary medical history included R85.313-High grade squamous intraepithelial lesion (HGSIL), on a cytologic smear of anus, colposcopies and Loop Electrosurgical Excision Procedure (LEEP). The patient's last menstrual period on a specified date was with medium bleeding for 4-7 days and mild cramping. The patient underwent a colposcopy thereafter.  The insurer denied coverage for the requested medication.

There are several types of combination pills. Monophasic pills contain the same dose of estrogen and progestin in each of the hormonally-active pills. Biphasic or triphasic pills have varying doses of hormone across the cycle (usually the progestin). There are no proven advantages to the multiphasic regimens. The estrogen component of nearly all oral contraceptives (Ocs) is ethinyl estradiol. Standard OCs today contain 30 to 35 mcg of ethinyl estradiol, but many pills now contain only 20 mcg or less. Contraceptive efficacy with the low dose pills is similar to the standard dose pills, as long as adherence is good. There are no proven benefits or less side effects with pills containing the lower dose of ethinyl estradiol. Most available progestins have both progestogenic and androgenic activity. To date, they have no proven clinical advantages over traditional progestins, and some have been associated with a possible higher risk of venous thromboembolism. 

All oral contraceptives have beneficial effects, decreasing blood loss, decreasing pain during periods, helping with acne and unwanted hair. There is no scientific evidence that one oral contraceptive is better than another since they all contain the same hormones. The requested oral contraceptive contains extra folic acid. There is no scientific evidence that the extra folic acid has any beneficial effect. Note that Beyaz is Yaz with folic acid. Generic Yaz is on formulary and the patient could take folic acid independently. 

In summary, any oral contraceptive on formulary should be adequate for contraceptive purposes for this patient, to decrease bleeding and to manage dysmenorrhea. There is no medical exception to the plan's drug policy criteria as supported by current medical literature for the requested medication, Beyaz (Drospirenone-Ethinyl Estradiol-Levmefolate).

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. Drospirenone-Ethinyl Estradiol-Levmefolate is not considered medically necessary for this patient. The medical record does not show any contraindication to the patient utilizing the formulary options listed by the insurer. The records do not indicate that the patient has had a reaction of intolerance to the formulary medication
  
Based on the above, the medical necessity for Drospirenone-Ethinyl Estradiol-Levmefolate is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient is a teen-aged male. He had acute abdominal pain and vomiting and was seen in the ED. He was found to have acute pancreatitis. He was admitted for IV hydration and routine monitoring.

On the day of admission, the patient received IV fluids in ED and had unremarkable abdominal ultrasound (no gallstones or pseudocyst). After consulted by GI, he was admitted for IV fluids and monitoring. He was stable and required no acute intervention or treatment. During the hospital stay, the patient was stable and had no further abdominal pain or vomiting. He tolerated low fat diet. There was no documentation for any cardiopulmonary instability. Therefore, the requested acute hospital stay was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mental illness
Issue under review: Continued inpatient admission

Determination:
The Continued inpatient admission was medically necessary.

The patient is an adult male with a history of mental illness who received treatment at the hospital.

The patient has a history of psychosis and was previously hospitalized.  There is a history of substance abuse including cocaine and marijuana abuse.  He was noted to have crashed his car, broken into someone else's home, and was brought in by police for psychiatric evaluation.  He was evaluated in the emergency room and was medically cleared for psychiatric admission.

The patient was assessed and was noted to be delusional and disorganized.  He was treated by a multidisciplinary team including psychiatry, nursing, and therapy staff.  He received individual and group therapy.  He was offered treatment with psychiatric medications and refused treatment.  He was noted to be uncooperative.  

By the first date of service under review, the patient was noted to be uncooperative with impaired judgment and poor insight.  He refused any involvement of collateral sources of information.  He continued to refuse all treatment on the following two days with poor insight.  

On the last date of service under review, the patient was noted to be safe for discharge and was provided with information for outpatient psychiatric follow up.

The patient represented an acutely elevated risk of dangerous behaviors and there was no less-restrictive treatment environment appropriate.  The acute risk factors of psychosis with the chronic risk factors of potentially dangerous behaviors suggest that the patient would have been at an acute risk of aggressive or self-injurious behaviors (including but not limited to suicide) were he to have been discharged from the inpatient hospital setting.  The patient was discharged from the inpatient psychiatric hospital setting as soon as a less-restrictive treatment setting was appropriate.  

The patient represented an elevated risk of dangerous behaviors including aggressive behaviors, self-injury, and suicide, and there was no less-restrictive treatment environment appropriate.  Therefore the treatment was medically necessary.  While the patient was not endorsing active suicidality or homicidality, the patient remained psychotic.  The patient had multiple static risk factors for potentially dangerous behaviors including substance abuse, previous illegal behaviors, and diagnosis with a severe mental illness.  Therefore the patient represented a chronic risk of potentially dangerous behaviors.  The fact that patient remained psychotic was acute risk factor for dangerous behaviors.  Furthermore, the fact that there was no less-restrictive environment of care appropriate suggests that ongoing inpatient psychiatric hospitalization was medically necessary and should be covered by the patient's health plan.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizures
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

This patient is a man with a history including schizophrenia, seizure disorder and alcohol abuse who presented to the emergency department (ED) with seizures.  The last seizure was one week ago.  

Vital signs (VS) included: 97.9, 95, 17, 139/86, and 98%.  Exam was unremarkable.  Head computed tomography (CT) showed no appreciable disease (NAD).  Chest x-ray showed (NAD).  Labs included: white blood cell (WBC) 3.8, hemoglobin/hematocrit (H/H) 12.7/39.5, platelets (PLT) 159, sodium (Na) 134, potassium (K) 4.0, blood urea nitrogen/creatinine (BUN/Cr) 11/1.4, creatinine phosphokinase (CPK) 946, and alcohol (EtOH) 27.  

The patient was admitted with a diagnosis of seizures.  Plan of care included continuation of intravenous (IV) fluids at 200 cc/hr, home medications, Neurology consult, monitor Clinical Institute for Withdrawal Assessment (CIWA) and Ativan protocol.  On the next day, vital signs were stable (VSS).  Continue current management.  On the following day, Neurology consult recommended treatment of alcohol withdrawal with benzodiazepine (BZP) and thiamine.  Noted anti-epileptic drugs (AEDs) are not effective for alcohol withdrawal seizure.  The following day, VSS. CPK was 360, Cr was 1.2, and CIWA was zero.  Possible discharge was pending social work clearance.  The next day, the patient was cleared for discharge.  

This patient with a history of alcohol withdrawal seizures was admitted after presenting with a complaint of recurrent seizures with most recent being one week ago.   Evaluation showed the patient was hemodynamically stable and afebrile.  Diagnostic studies were remarkable for alcohol intoxication and mildly elevated CPK.  He had mild acute kidney injury (AKI) but no severe electrolyte abnormalities.  The patient did not have nausea or vomiting (N/V) or inability to tolerate anything by mouth (PO).  The patient did not have altered mental status.  He did not display seizure activity in the ED.  He did not have signs of severe alcohol withdrawal.  The patient remained clinically stable during the hospital stay without alcohol withdrawal.  

Medically necessary services are those which are: safe, effective, generally accepted national standard of medical practice, not provided primarily for convenience of the patient or the practitioner, and the least intensive and/or most appropriate alternatives among diagnostic and treatment options. 

Inpatient admission was not in accordance with generally accepted medical standards because the patient was clinically stable and did not have ongoing seizure activity or alcohol withdrawal that required treatment at an inpatient level of care.  The patient had not failed a lesser level of care.  The requested inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

The patient is a male. He had a past medical history significant for syncope (negative work-up). He presented to the ER with complaints of new-onset non-exertional dull chest pain. 

The patient was hemodynamically stable. The electrocardiogram (ECG) revealed no acute ST segment changes. Serum creatine kinase (CK) was mildly elevated at 223, however troponin was negative. The patient was admitted to rule out acute coronary syndrome. An echocardiogram was done, revealing normal left ventricular (LV) function. No stress test or catheterization was planned. The patient was discharged home the next day with a plan for outpatient follow-up.

This patient presented for evaluation of chest pain. The diagnosis of an acute myocardial infarct (MI) was ruled out by cardiac enzymes, which were negative. No inpatient ischemic work-up was planned. There was no evidence of acute myocardial infarction, acute coronary syndrome (ACS), decompensated congestive heart failure (CHF), malignant arrhythmia or hemodynamic instability. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission and the care required could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia, asthma
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient is an adult male with history of hypertension, coronary artery disease (CAD).  The patient had shortness of breath for a few days and presented to emergency room. The patient was admitted to acute in hospital for the management of pneumonia and asthma exacerbation. The patient was started on intravenous (IV) antibiotics as well as IV steroids. The patient's condition improved and the patient was discharged home with oral antibiotics.

At the time of admission, the patient was hemodynamically stable. The patient's physical exam was within normal limits. The blood work was within normal limits. The chest x ray revealed cardiomegaly and lower lobe atelectasis. Computed tomography (CT) of the chest showed cardiomegaly and lower lob atelectasis.  The patient was able to take oral medications. 

The acute in hospital level of care is not medically necessary.  The appropriate level of care would be observation level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse
 
Treatment: Inpatient Admission

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

This is a male patient who presented to the Emergency Room (ER) requesting detoxification from heroin. He was transferred to the medical floor from the detoxification unit due to six bouts of loose stools and abdominal pain. He had a medical history of liver disease. His withdrawal symptoms included nausea, diarrhea, sweats, tremors, insomnia, anxiety, body aches, joint pain, restlessness, and irritable mood. It was reported that he had been in inpatient detoxification treatment several months prior to presentation. He was treated with tapering Methadone. He reportedly discharged himself against medical advice (AMA). 

This reviewer disagrees with the decision to deny coverage for inpatient hospital treatment as the chart notes did provide enough specific evidence to support that he required this level of treatment then.  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.  It also states that patients with past complicated or life threatening withdrawal symptoms including withdrawal seizures or delirium tremens are in need of inpatient hospital treatment for the management of withdrawal and reports that patients with comorbid medical condition that complicate the management of withdrawal are also candidates for inpatient detoxification.  This was the case with this patient.  

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) he did require 24 hour treatment as he needed detoxification medication of Methadone to modify withdrawal and prevent worsened or severe withdrawal.  He also had a history of heavy IV heroin use putting him at high risk for overdose and he needed 24 hour medical detoxification treatment in this hospital due to this risk and he was not considered to safe for detoxification in a less restrictive level of care. 

It did not appear that the health care plan acted reasonably or in the best interests of the patient.  

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

Diagnosis: Pain and swelling in right mandible
Treatment: Inpatient admission
The Inpatient admission was not medically necessary.

The patient is a healthy male. He developed pain and swelling in the right mandible over three days. He saw his PCP (primary care provider) ten days prior to admission and was given amoxicillin. The patient then reported to the emergency room and was evaluated by oral surgery. 

The oral surgery notes state that the patient's PTT (partial thromboplastin time) was slightly elevated, but there is no record that this was repeated, and it did not interfere with surgery. The patient was afebrile, and his swelling was limited to the facial aspect of the mandible with no airway impingement. 

The patient was admitted and seen in the oral surgery clinic the following day, where he underwent the removal of #30 with an incision and drainage with IV sedation. Discharge orders were written. 

Postoperatively, the patient complained of severe pain, which was controlled with one dose of IV Ketorolac. The patient was then discharged. The discharge note contradicts the pediatric note, as it states that postoperatively, the patient was febrile and his pain was not controlled with the Ketorolac. The pediatric note states that the patient was afebrile and his pain was controlled with one dose of Ketorolac. 

The literature regarding the course of odontogenic maxillofacial infections requiring hospital care shows that hospital admission criteria are as follows: threat to airways or other vital structures, need for general anesthesia, septic fever, marked swelling, need for inpatient control of a concomitant systemic disease, and need for intravenous antimicrobial treatment. This patient had none of these. He was admitted for convenience. 

The patient could have received his IV antibiotics at an Observation level of care. Additionally, provision of Ketorolac did not require acute inpatient admission. He did not require general anesthesia, did not have a septic fever, marked swelling that encroaches upon the airway and did not require an admission due to concomitant systemic disease.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ureteric Stone; Pneumonia,
 
Treatment: Inpatient Admission

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

This is a male patient with a medical history of hypertension, asthma, gastritis and methadone dependency. He presented to the emergency department (ED) with complaints of sharp lower quadrant abdominal pain. Laboratory work up was performed; white cell blood count was 9, hemoglobin 11.6, troponin was negative, and his electrolytes were within normal limits. An electrocardiogram was performed that showed a sinus tachycardia. A chest x-ray revealed perihilar opacity. A computed tomography of the chest, abdomen, and pelvis was done which showed possible pneumonia, hepatic stenosis and biliary dilatation. He received intravenous (IV) hydration and antibiotics. Nebulizing treatments and oral steroids were given to treat mild asthma exacerbation and possible pneumonia. He received analgesics for his lower abdominal pain. It was reported that his pain had resolved secondary to passing a ureteric stone. The patient was discharged the next day with improved symptoms.  

This patient did not need acute hospitalization.  He could have been placed in observation status with diagnostic testing and treatment initiated.  The patient remained stable after admission.  This patient could have been discharged home after a period in observation status with further follow up in outpatient setting.  The patient was afebrile and hemodynamically stable.  Labs were stable.  He was tolerating oral intake.  The patient was not hypoxic and pneumonia, if at all present, was mild with a CURB 65 score of 0 and a low pneumonia severity index (PSI).  The patient could have been discharged on oral antibiotics.  The patient's asthma exacerbation was also very mild.  There was an occasional wheeze on exam.  The patient's breathing was non-labored.  The patient was not hypoxic or using accessory muscles.  The prior denial is upheld. The insurer acted reasonably, with sound medical judgment, and in the patient's best interest. 

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

Diagnosis: Parkinson's disease, chronic atrial fibrillation, gait ataxia
Treatment: Increase of services to CDPAS five days/week, 12 hours/day and PCW two days/week, 12 hours/day 
The insurer denied Increase of services to CDPAS five days/week, 12 hours/day and PCW two days/week, 12 hours/day.
The denial is upheld.

The proposed treatment of an increase of services to CDPAS five days/week, 12 hours/day and PCW two days/week, 12 hours/day is not deemed medically necessary. 

This is a female with a history of Parkinson's disease, chronic atrial fibrillation s/p placement of cardiac pacemaker and associated gait ataxia with frequent falls. For these reasons, she requires assistance for completion of the majority of her activities of daily living (ADLs). However, the medical records indicate that a recent in home assessment of the patient's functionality was performed which indicates that the currently approved plan of CDPAS five days/week, six hours/day and PCW two days/week, six hour/day is sufficient to meet the patient's current ADL needs. Furthermore, there is no additional documentation noted in the medical record which demonstrates that the patient has sustained further functional decline since the date of this last assessment. For these reasons, the proposed treatment of an increase of services to CDPAS five days/week, 12 hours/day and PCW two days/week, 12 hours/day is not deemed medically necessary.