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

Diagnosis: Digestive System/Gastrointestinal.
Treatment: Inpatient Hospital.
The insurer denied: Inpatient stay.
The denial is: Upheld in whole.

The patient is a male with no pre-existing comorbid conditions who presented to the emergency department (ED) for abdominal pain of less than 24 hours. His white blood cell (WBC) count was 18 thousand (K). Ultrasound (U/S) of the right lower quadrant (RLQ) showed simple appendicitis. He was taken to the operating room (OR) the same day for uncomplicated, single incision laparoscopic appendectomy. His recovery was uneventful, and he was discharged from the post-anesthesia care unit (PACU). The subject under review is the medical necessity for the acute inpatient level of care.

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

An acute inpatient level of care was not medically necessary for this patient. The patient could have been safely and appropriately managed at a lower level of care status. An inpatient stay could be justified if there was complicated appendicitis (e.g., perforated appendicitis with generalized peritonitis), an untoward perioperative event, intraoperative injury or complication, inadequate physiologic recovery, hemodynamic instability, acute organ injury, persistent altered mental status, fever or other signs of septic complications, surgical site complication, management of complex comorbid medical condition or a finding of an occult or new medical condition.

Surgical treatment of otherwise healthy pediatric patients with acute non-perforated appendicitis is usually provided at a lower level of care status. No evidence presented in the documentation or in the primary medical records that would indicate that the patient had complicated appendicitis, and the operative note clearly defines the perforation as a technical result of the operation, not as a pathophysiologic issue which may require an acute inpatient stay.

Indeed, in one study authored by Aguayo et al., in over 500 cases, approximately 28% (number [n]=128) were discharged on the day of surgery. Of the remaining patients, 12.9% (n=59) stayed overnight for medical reasons, 0.4% (n=2) stayed for social reasons, 3.9% (n=18) stayed because the operation ended late in the evening, and 82.8% (n=381) stayed because of clinical care habits. Compared with patients who stayed overnight, there was no statistically significant difference in readmission rates (0.7% versus 1.9%, probability [P]=0.6%), follow-up before scheduled appointment (5.4% versus 5.4%, P=1.0), and complication rate (0.7% versus 2.6%, P=0.3). Patients whose operation ended later in the day had a longer hospital stay. Indeed, these data strongly suggest that for most patients with acute, non-perforated appendicitis who undergo an uncomplicated appendectomy, a lower level of care is entirely appropriate since their needs are low acuity and the recovery is generally smooth and uneventful. 

Based on the literature and widespread experience with modern treatment of pediatric acute appendicitis, an inpatient acute level of care is not justified for acute, uncomplicated appendicitis.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Ears/nose /throat/allergy.
Treatment: Pharmacy /prescription drugs.
The insurer denied Azelastine-fluticasone 137-50 MCG/ACT NA SUSP.
The denial is upheld in whole.

This is a young male patient with request for Azelastine-Fluticasone 137-50 MCG/ACT Na Susp for allergic rhinitis. The patient has multiple environmental and food allergies related to  pollen allergies. The patient has used Azelastine + Flonase, but the combination spray is being requested to increase the patient's compliance.
No, the formulary alternatives Flunisolide, Fluticasone, Mometasone, or Triamcinolone with Azelastine would not be ineffective for this patient. There are no head to head studies which have shown that the requested non-formulary medication is more effective than the formulary alternatives. The patient has tried Flonase + Azelastine and did well, but the combination spray is being requested to increase the patient's compliance.  Therefore, in this case the formulary drugs would be appropriate.
Appeal type: Medical necessity
Decision: Upheld

Substance Abuse/Addiction
Substance Abuse: Inpatient

Diagnosis: Substance Abuse
Treatment: Inpatient Rehab
The insurer denied inpatient rehab. The health plan's determination is upheld. 

The patient is a young adult male who was admitted to inpatient rehabilitation substance use disorder treatment of opioid (heroin), stimulant (cocaine), sedative-hypnotic-anxiolytic (Xanax) and cannabis (marijuana) use disorders. Despite participating in a methadone maintenance treatment program (MMTP), the patient was using 12 to 20 bags of heroin and 3 to 4 blunts of cannabis daily with use of up to $100 worth of crack cocaine and 2 milligrams (mg) of Xanax at a frequency of three to six times per week. His use of these substances began in adolescence and progressed with significant risk to health and impairing his ability to function. He was also tobacco dependent. His self-referral was prompted by health concerns. He had at least five prior substance use disorder treatment episodes and ongoing medication assisted treatment with methadone with only nine months of sobriety and relapses including the most recent relapse while in the MMTP.

The structure and intensity of services necessary for the rehabilitation/substance use disorder treatment could have been effectively provided at a lower level of care in a less restrictive treatment setting with sober supports. There is no evidence that the inpatient level structure and 24-hour monitoring is medically necessary for a successful outcome in this case. And, there were no biomedical, psychiatric or general medical issues that warranted the requested inpatient level services. The patient's opioid (heroin), sedative-hypnotic-anxiolytic (Xanax) stimulant (cocaine) and cannabis use disorders and co-occurring psychiatric disorders were amenable to treatment at a lower level of care in this case scenario, and was consistent with the application of NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria/Guidelines.
Appeal type: Medical necessity
Decision: Overturned

Shortness of breath
Inpatient hospital

The patient is a girl who presented to the emergency department with shortness of breath. She was well until 2 days prior to admission when she developed rhinorrhea and congestion. She then developed cough with shortness of breath and chest tightness. She went to school on the day of admission, but was noted to have difficulty breathing and was sent to the emergency department for care. She had been prescribed albuterol several years ago, but was never diagnosed with asthma.

The health plan's determination is overturned. The Inpatient Hospital Admission was medically necessary for this patient. This is a young girl who presented with significant shortness of breath and wheezing. She was tachypneic and sitting upright upon presentation. She required intensive treatments in the emergency department including nebulized breathing treatments, corticosteroids, and magnesium sulfate. However, she continued to have significant wheezing and shortness of breath. She was therefore admitted to the hospital for ongoing intensive treatments and monitoring.
The decision making at the time of admission for this patient was consistent with her young age, the presence of significant wheezing and shortness of breath that persisted despite appropriate treatment in the emergency department, and the need for ongoing, frequent breathing treatments (every 3 hours) along with close monitoring for potential deterioration of clinical status.
Appeal type: Medical necessity
Decision: Overturned

Respiratory System
Inpatient Hospital

This is a patient who presented with a cough and respiratory distress. She was well until 2 days prior to admission when she developed a fever, nasal congestion, and cough. She was also drinking less than usual and making fewer wet diapers. Her temperature went up to 101.3 degrees Fahrenheit (F). She then developed labored breathing and wheezing, and therefore she was brought to the emergency department for evaluation. Her past history was significant for prematurity. She was in the custody of her grandmother.

On physical examination in the emergency department, she was described as appearing tired with tachypnea, wheezing, retractions and accessory muscle use. She was diagnosed with probable bronchiolitis. She was given a bolus of fluids as well as albuterol and dexamethasone, with limited effectiveness. Following this treatment, she continued to have wheezes and retractions. She was found to be positive for respiratory syncytial virus (RSV) infection. A chest x-ray was obtained which revealed hyperinflation.
She was admitted to the hospital for ongoing care with intravenous fluids, normal saline nebulized treatments every 3 hours, and acetaminophen or ibuprofen for fever. Following admission, she continued to have tachypnea with coarse breath sounds. Over time, she began to improve, and her intravenous fluids were decreased to 1/2 maintenance. She continued to receive every 4 hour saline nebulized treatments as well as nasal suctioning. The health plan's determination is overturned.

This is a very young girl who presented with wheezing, tachypnea, and respiratory distress related to RSV bronchiolitis. She continued to have significant symptoms despite appropriate management with dexamethasone and a trial of albuterol in the emergency department setting. She also had decreased oral intake and required intravenous fluid administration. She was admitted for ongoing saline nebulized treatments, respiratory monitoring, and intravenous hydration.

Hospitalization for supportive care and monitoring is indicated for infants and young children with RSV infection who have poor feeding and are unable to keep up with the increased demands for fluids with their illness. Inpatient management of bronchiolitis centers on support of hydration and respiratory status as necessary.
The decision making at the time of admission for this patient was consistent with her for her young age, the presence of persistent respiratory distress and wheezing, and the need for ongoing care in an inpatient setting with intravenous hydration, saline nebulized treatments, and close monitoring for potential deterioration of clinical status.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a past medical history of bipolar disorder who presented to the emergency department after taking Ativan, Trazadone, and Lithium in a suicide attempt.
On presentation, the patient was afebrile with blood pressure 99/59, heart rate 85, respiratory rate 20, and oxygen saturation 99% on room air. Her exam otherwise noted the patient to be alert and oriented without neurologic deficits or nystagmus, to have a depressed affect, and to have lice. Lab results revealed white blood cell count (WBC) 8.2, hemoglobin (HGB) 13.2, platelets (PLT) 392, sodium (Na) 138, potassium (K) 4.4, blood urea nitrogen (BUN) 6, creatinine 0.64, lithium level 1.1, Tylenol and salicylate levels negative, alcohol level negative, and venous blood gas with potential hydrogen (pH) 7.34/ partial pressure of carbon dioxide (pCO2) 50.9/ bicarbonate (HCO3) 26.7. A urine drug screen was negative. An electrocardiogram (EKG) showed normal sinus rhythm without QTc prolongation. The patient was brought into the hospital with plans for telemetry monitoring, serial labs every 6 hours, serial EKGs, IV fluids, and a 1:1 sitter, and permethrin.
The patient was hemodynamically stable and alert and oriented without nystagmus or neurologic deficits. Her renal function remained normal, her lithium level decreased to 0.8, and she had no arrhythmias on telemetry. She remained on 1:1 sitter given ongoing depression and expression of suicidal thoughts with plans to transfer to an inpatient psychiatry bed once she was medically clear.
The patient was ultimately transferred to inpatient psychiatry.
The health plan's determination is upheld.
This patient presented with an intentional overdose on Lithium, Trazadone and Ativan in the setting of suicidal ideation. She was noted to be alert and oriented on presentation, hemodynamically stable, with normal renal function and otherwise unremarkable lab results, lithium level of 1.1, and with an EKG that showed no evidence of QtC prolongation or other arrhythmia. In this setting, she was appropriate to bring into the hospital for intravenous (IV) fluids, serial labs, monitoring of her mental status, and telemetry monitoring. A lower level of care was appropriate for this hemodynamically stable, alert and oriented patient with a lithium level of 1.1 on presentation, normal renal function, and normal EKG with short length of stay expected for laboratory monitoring, IV fluids, and telemetry. She remained alert and oriented, hemodynamically stable throughout her course with normal renal function and without arrhythmias, and with her hospital stay subsequently prolonged given she needed ongoing psychiatric services rather than medical services. She required care for her ongoing suicidal ideation and unstable psychiatric illness, but admission was not medically necessary for medical issues; therefore, the inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a past medical history of diabetes, hypertension, active tobacco smoking, and alcohol abuse with 2 months of sobriety, who presented to the emergency department with left-sided chest pain associated with shortness of breath.
On presentation, he was afebrile with a blood pressure of 150/81, a heart rate of 77, a respiratory rate of 15, and saturating at 97% on room air. The exam otherwise noted no abnormalities. The patient's labs resulted with a troponin of 0.01, and a complete blood count and comprehensive metabolic panel grossly within normal limits. An electrocardiogram (EKG) was obtained which showed no evidence of acute ischemia or arrhythmia. A chest x-ray showed no acute process. The patient was brought into the hospital with the assessment that he had chest pain lasting for 30 minutes and resolved at the time of admission with several episodes of chest pain recently, and plans for telemetry, repeating an EKG, an echocardiogram, serial troponins, and a cardiology consult.
The patient was seen by cardiology with the assessment that he had atypical chest pain with low suspicion for acute coronary syndrome but with high risk for coronary artery disease and plans for an echocardiogram and brain (or B-type) natriuretic peptide (BNP) and plans for an outpatient stress test if there were no high risk findings on echocardiogram.
The patient remained hemodynamically stable and it is noted that the discharge summary was dictated with the patient medically stable for discharge with an outpatient cardiology follow up.
The patient was hemodynamically stable without any new acute issues. The plan was to continue to arrange discharge to the shelter. The health plan's determination is upheld. This is a patient at high risk of coronary artery disease given his history of diabetes, hypertension, and tobacco smoking, who presented to the emergency department with chest pain. He was appropriate for a lower level of care with serial troponins, telemetry, and an echocardiogram given his risk factors. It is noted, however, that his troponins and EKG were not suggestive of acute ischemia, the patient appeared comfortable, and the impression from cardiology was that the patient likely did not have acute coronary syndrome. Given his unremarkable EKG, negative troponins, hemodynamic stability, and low suspicion for acute coronary syndrome, the inpatient hospital admission was not medically necessary. It is further noted that the patient was medically stable for discharge with a discharge summary dictated, but he stayed in the hospital waiting for shelter placement.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a Class I occlusion with moderate maxillary crowding, moderate mandibular crowding, and moderate overjet and moderate overbite. The issue under review is the medical necessity for braces.
The health plan's determination is upheld.
Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 12 with no auto qualifiers. Auto qualifiers include a cleft palate deformity or cranio-facial anomaly, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9 millimeters (mm) or greater and underbite 3.5 mm or greater. The patient requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary. Thus, comprehensive orthodontic treatment is not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Spastic Paraplegia 
Treatment: Neuromuscular Stimulation (WalkAide) 

The insurer denied the Neuromuscular Stimulation (WalkAide). The denial is upheld. 

The patient has a diagnosis of significant spastic paraplegia secondary to transverse myelitis of the cervical spine. She had the development of right dorsiflexion following Botox injections. Her physician noted "She has been using a single point cane more often due to this instability. She initially used her ankle-foot orthosis (AFO) following the injections due to extreme weakness not using her brace currently but has not restarted her baclofen." At issue is the medical necessity of neuromuscular electrical stimulation. 

No, the requested health service of neuromuscular electrical stimulation (WalkAide) is not medically necessary for this patient. The patient has ahistory of transverse myelitis of the cervical spine. All records were reviewed but did not support medical necessity. The clinician's documentation did not include any range of motion or muscle strength testing. It also did not include gait speed or timed walk with an AFO and with WalkAide. In addition, therapy noted that while the patient wanted to get a WalkAide and "reports that it was very helpful the size of the device was a little challenging." The physical exam described the patient walking with a cane, with a "very stiff R [right] LE [lower extremity], no ROM [range of motion] in her knee or ankle, pt internal rotates." During this session therapy discussed passive stretching of right ankle and knee and noted "pt reports that her hands limit her and her husband does try to stretch her" which leads this reviewer to question if she will be able to independently don/doff WalkAide. It is also not clear from the information provided if the patient would be compliant with use as therapy noted that "She has an AFO but only wears it occasionally because it makes her feel clumsy." Similarly, it is noted, "states that she owns a right AFO yet states that the last time she wore it was 3-4 months ago when she felt "really weak." Therefore, it is not medically necessary for a WalkAide when 1) the patient is not consistently wearing her AFO and 2) the WalkAide evaluation lacked significant information.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastrointestinal/abd pain 
Treatment: Inpatient hospital stay 

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

The inpatient stay was not medically necessary. 

The patient presented with right lower quadrant abdominal pain. The patient had associated nausea and vomiting, and non-bloody loose stool. Physical exam demonstrated tenderness to deep palpation in the right lower quadrant. The patient's labs demonstrated a white blood cell count of 22.3 with a left shift, and a lactic acid of 3.7. The computed tomography (CT) scan demonstrated thickened jejunum and ileum, and an abnormal appearing appendix. The patient received 2L of intravenous fluid and received ceftriaxone and flagyl in the emergency room. The patient was hospitalized and kept nothing by mouth (NPO). The next day the white blood cell count had improved from 22.3 to 11.1. The patient was seen by gastroenterology who recommended continuing antibiotics and clear liquid diet to advance as tolerated. The patient tolerated regular diet. The patient's abdominal exam improved. The patient was discharged home on oral antibiotic therapy. 

The patient had enteritis and possible appendicitis, but did not have evidence of other complications. The patient did very well after initial treatment in the ER and was discharged on hospital day number 2. There is no evidence that additional complex testing or therapy other than the CT scan that was performed was necessary. There is no evidence of a complicating event during the hospitalization that required a higher level of care. There is no documentation that the treating team identified conditions or problems specific to the patient that would have required inpatient care. While admitted the patient did not have significant dehydration, hemodynamic instability, severe pain requiring frequent or high doses of narcotics, signs of intestinal obstruction, peritonitis/peritoneal signs, bacteremia, suspected toxic megacolon, severe electrolyte abnormalities, or other interventions that can only be performed as an inpatient. The provided documentation does not support the medical necessity of inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive system /Gastrointestinal Abdominal pain
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay 
The denial is upheld in whole

This is a  patient with a history of constipation and anemia who presented to the hospital with abdominal pain and bright red blood per rectum. Of note, she recently underwent a colonoscopy which revealed a hyperplastic polyp which was resected.
No, the requested health service/treatment of inpatient stay is not medically necessary for this patient. Of note, she recently underwent colonoscopy which revealed hyperplastic polyp which was resected. On the presentation, the patient was hemodynamically stable without fever, tachycardia or hypotension. Bloodwork did not reveal leukocytosis, anemia or significant electrolyte abnormalities. The patient remained hemodynamically stable without ongoing gastrointestinal bleeding or requiring transfusion with packed red blood cells or required endoscopic or surgical intervention to stop the bleeding.

Therefore, the inpatient hospital stay is not medically necessary this was consistent with generally accepted standards of medical practice as supported by nationally recognized peer reviewed literature and guidelines.