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

 
Treatment: Inpatient Admission

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

This is a female patient with a medical history of hypertension, diabetes, hyperlipidemia, and coronary artery disease with stents. The patient was referred to the Emergency Department after being evaluated at her cardiologist's office for complaints of burning sensation in her chest and swelling in her hands and legs for 3-4 days. Her presenting vital signs were blood pressure 145/86, heart rate 90, and temperature 98.9. An electrocardiogram (EKG) and chest x-ray were performed with normal results. An echocardiography was done that revealed mildly thickened mitral valve and normal left ventricular systolic function. A coronary angiography was performed which revealed patient's left anterior descending (LAD) and diagonal stents and only 30% LAD stenosis. The patient was medically stable and discharged home. 

Based on the review of the patient's medical record and the literature guidelines on patients with unstable angina/non-ST-elevation myocardial infarction, there is no clinical evidence that supports that this patient required an acute inpatient level of care to determine whether or not this patient's chest discomfort was related to acute coronary syndrome. This determination could have been completed in the emergency department, or at most at an observation level of care. The patient's diagnostic coronary angiography could have been performed as a same day procedure.

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

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

Diagnosis:  Cardiac/Circulatory Problems
Treatment:  Inpatient hospital

The patient is an adult male with a history of hypertension, hyperlipidemia, diabetes, pulmonary embolism and prostate cancer, in remission.  He presented to the emergency department (ED) complaining of pleuritic left chest pain.  He reported noncompliance with his anticoagulant medication.  The patient  had been hospitalized approximately one month prior for similar chest pain.  Myocardial perfusion imaging at that time showed no evidence of ischemia.  By echocardiogram his left ventricular systolic function was normal.  He had grade II diastolic dysfunction.  He was admitted to the hospital. 

The health plan's determination is upheld.  The inpatient stay was not medically necessary.  This patient with multiple cardiac risk factors presented with atypical symptoms that were thought to possibly represent acute coronary syndrome (ACS).  Accordingly, observation until ACS could be ruled out was a reasonable approach.  On the other hand, he was hemodynamically stable with normal cardiac biomarkers and no ischemic electrocardiographic changes.  Myocardial perfusion imaging performed one month prior showed no evidence of ischemia.  His HEART score was 3, indicating a low risk for major adverse cardiac events.  The patient did not require intensive monitoring or infusion of intravenous cardioactive medications.  The care this patient received did not require an inpatient admission and could have been provided at a lower level of care.  This approach has been shown to be both safe and effective and is in accordance with the 2014 American Heart Association (AHA) / American College of Cardiology (ACC) Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Anaphylaxis 

Treatment:  Inpatient hospital stay

The insurer denied coverage for inpatient hospital stay.  The denial is upheld. 

This patient is a female with a history of rash and hives after eating fish.  Approximately 15 minutes after eating crab, the patient developed urticaria, nausea and vomiting, and presented to the Emergency Department.  Although the records state that the patient's initial heart rate was 180, initial vital signs were recorded as heart rate 145 and oxygen saturation 98%.  Subsequent vital signs included heart rate 96, respiratory rate 18, blood pressure 126/76, and oxygen saturation 99%.  The patient was treated with intravenous Solumedrol, ringers lactate boluses, Benadryl, magnesium, and Pepcid and with intramuscular epinephrine.  The patient's bedside echocardiogram was normal.  The patient's electrocardiograms (EKG) revealed premature ventricular contractions (PVCs) including a 3 beat run, and chart records also indicate that telemetry revealed 10 to 15 beat runs of non-sustained ventricular tachycardia at a rate of 100, which was attributed to epinephrine and anaphylaxis and was treated with a 1 mg/min amiodarone drip.  The patient was discharged home with prescription of an EpiPen and Pepcid, which the patient refused.

Based on this review of the medical record and the literature, there is no evidence that this patient required an acute inpatient level of care for monitoring and management.  There was no evidence for pathology other than a severe allergic reaction from seafood consumption, and the patient's ventricular ectopy was most likely related to her anaphylactic treatment with epinephrine.  The patient's monitoring and care could have been completed at an observation level of care.  

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

The carrier's denial of coverage for the inpatient hospital stay is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Prominent sensory Neuropathy

Treatment:  Inpatient Admission

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

This is a male patient with a past medical history of asthma.  He presented to the Emergency Department (ED) with complaints of bilateral foot numbness extended up to his knees.  His presenting blood pressure was 118/77, and his heart rate was 92.  He was consulted by Neurology.  His physical examination revealed normal range of motion with no tenderness, no bony tenderness, no swelling, no deformity, no lacerations and no edema with sensory deficit (hyperesthesia in the bilateral lower extremities including inner thigh not outer thigh).  Laboratory work up was performed revealing a white blood cell count of 13.5 and an erythrocyte sedimentation rate of 17.  Urine cultures were obtained that were positive for beta Streptococcus group B.  He had an infectious gastroenteritis panel performed that was positive for norovirus.  A magnetic resonance imaging (MRI) of the cervical spine/thoracic spine/lumbar spine was done that revealed no spinal canal stenosis with mild degenerative changes without significant canal stenosis or foraminal narrowing at any level.  A lumbar puncture was attempted but was unsuccessful.  Neurology diagnosed him with distal prominent sensory neuropathy.  He was treated with intravenous fluids and intravenous antibiotics.  He was medically stabilized and discharged home with instructions to follow-up with Neurology and Neuroradiology. 

The patient presented with ascending numbness in his legs bilaterally over the previous several days.  It is true that neuropathy can present with numbness in the feet, but the timing of this condition is concerning.  When a patient presents with a several day history of ascending numbness or weakness, Guillain-Barre versus a spinal cord lesion becomes at the top of the differential.  Because it is difficult to tell clinically without having further diagnostic testing, the inpatient admission for an acute evaluation for the possibility of Guillain-Barre Syndrome versus spinal cord lesion was medically necessary.  The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. 

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

Diagnosis:  Abdominal pain
Treatment:  Inpatient hospital

This patient is a male with history of subtotal gastrectomy for ulcer disease, who was sent to the emergency room (ER) by his PCP (primary care provider) for complaints of right lower quadrant (RLQ) pain for 3 days.  Vital signs were stable.  Labs were unremarkable.  The computed tomography (CT) scan did not clearly identify the appendix, which was not visualized.  The patient was admitted for serial abdominal exams and re-evaluation of complete blood count (CBC), which remained normal, but he was not started on intravenous (IV) antibiotics.  The patient did not require pain medication, tolerated clear and regular diet and was discharged home on HD (hospital day) #2.

The health plan's determination is upheld.  The inpatient hospital admission was not medically necessary.  The patient presented with RLQ pain and no clear evidence of appendicitis on CT scan.  He was admitted for observation and serial exams, did not require pain medication, had stable vital signs and stable labs, and was advanced on a diet and discharged home within a 23 hour observation period.  A decision to proceed to surgery was not made.  The patient did not require IV antibiotics or IV pain medication and could have been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Gastroenteritis
Treatment: Inpatient hospital services

The insurer denied coverage for inpatient hospital services.  The denial is upheld. 

This patient is a male who presented to the Emergency Department complaining of abdominal pain for several days.  The patient detailed that he had a home-cooked meal that started the onset of abdominal pain.  The patient stated that it was associated with emesis and diarrhea.  He also stated that he had subjective fever and chills.  He had no significant medical history.  A physical exam revealed a temperature of 98.1F with a blood pressure of 138/81.  The patient's heart rate was 89 beats per minute (bpm) and the oxygen saturation was 96% on room air.  The patient had clear and equal bilateral breath sounds with diffuse tenderness to palpation of the abdomen.  There was no rebound and no guarding.  It was recommended that the patient undergo laboratory and diagnostic studies. The laboratory studies revealed an anion gap of 5 with a white blood cell count of 13.7. A CT scan revealed findings consistent with pan-colitis, which was most pronounced in the ascending colon.  The patient was admitted and was treated with intravenous (IV) medication to include ciprofloxacin, as well as Flagyl.  He continued with treatment with no further significant adverse events. He was discharged the following day with instructions to follow-up given a period of medical stability. 

According to current literature, a patient may be admitted to inpatient services when there is evidence of vomiting that is severe or persistent, dehydration that is severe or persistent, hemodynamic instability or there is suspected severe infection as evidenced by bloody diarrhea.  Within the documentation, the above was not noted.  The patient did not need an inpatient admission and could have been managed under observation status. He seemed to have developed gastroenteritis with no alarming signs.  He had no comorbidities that made him high risk for mortality and morbidity.  Observation with IV fluids and antibiotics is considered an appropriate course of action.

The insurer acted reasonably, with sound medical judgment, and in the patient's best interest.

The carrier's denial of coverage for the inpatient hospital services is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Grade 1 L3-4 anterolisthesis; back pain 
Treatment: Inpatient hospital services 

The insurer denied coverage for inpatient hospital services. The denial is upheld. 

This patient is a female who has a past medical history to include uncontrolled hypertension, as well as asthma, chronic obstructive pulmonary disease (COPD), chronic back pain, thrombocytosis, a prior sigmoid abscess and morbid obesity.  The patient presented to the Emergency Department (ED) complaining of back pain.  She stated in route to the hospital that she started to have numbness of the right cheek.  She was also anxious in the ambulance.  The patient indicated that her systolic blood pressure had been high.  Upon physical examination, she was alert and oriented; however, as the exam progressed, she became confused with delayed answering.  It was recommended that the patient undergo laboratory diagnostic studies.  The patient underwent a CT scan which showed no evidence of acute intracranial pathology.  The documentation detailed that the patient may have cheek numbness secondary to anxiety.  The patient was given Tylenol and Robaxin for low back pain.  An x-ray of the spine revealed grade 1 L3-4 anterolisthesis.  The re-evaluation indicated that the patient was offered more pain medication; however, she declined to take narcotics.  She was admitted with the recommendation to continue medications. 

According to referenced literature, a patient may be admitted to inpatient services when there is evidence of vasculitis, altered mental status that is severe or persistent, or new onset of severe neurologic findings requiring inpatient services.  Furthermore, if there is a flare of a previously diagnosed neurologic condition requiring inpatient services, the patient may be admitted to the inpatient level of care.  An MRI did not show an acute process mandating surgery. Neurology was consulted and outpatient electrodiagnostic studies were planned.  The patient could have been evaluated in the ED on an observation basis with a CT and MRI of the spine performed along with neurological consultation.  Outpatient follow up with Neurology for electromyography (EMG) testing could have been set up.  The care provided did not warrant an inpatient admission.  

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 services is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Diarrhea
Issue under review:  Inpatient admission

Determination:  The Inpatient admission was not medically necessary.

The patient is an adult male.  He presented to the ED with a five-day h/o (history of) vomiting and diarrhea after eating some chicken at a barbeque place.  The vomiting resolved a day before coming to the ED, but he still had diarrhea, about 15 stools over the prior day.  He did experience some subjective fever and chills, but that resolved.  He had decreased oral intake over the prior 24 hours.  He went to the urgent care and was given Pepcid and Flagyl. 

In the ED, the patient was hemodynamically stable and afebrile.  He was alert and oriented x 3.  His labs showed BUN/Cr (blood urea nitrogen/creatinine) of 26/2.10.  His lytes reveled normal K (potassium) of 4.0 and Na (sodium) of 132.  The liver function tests were normal.  His HB/HCT (hemoglobin/hematocrit) were 17.7/53.5.  His WBC (white blood count) was 8.8, and Platelet count was 246.

In the ED, the patient was given 2 liters of normal saline, and then continued on Ringer Lactate 100ml/hr.  He was admitted to the hospital with the diagnosis of gastroenteritis, dehydration, and acute kidney injury.  His infectious panel for gastroenteritis showed Salmonella, and he was started on Cipro 500mg PO (by mouth) BID (twice daily).

On the two days following admission, the patient was given IV KCL (potassium chloride) for K of 3.2 and 3.3 respectively. With IV fluids, his renal function improved with BUN 8 and Cr 1.2.  He was able to tolerate diet with fewer bowel movements.  He was discharged home with a seven day course of Cipro 5000mg PO BID.

The patient presented to the ED with a five day h/o gastroenteritis after eating chicken at a barbeque place, and was diagnosed with salmonella infection.  He was severely dehydrated and had prerenal azotemia and hemoconcentration secondary to underlying dehydration.  He was treated with IV fluids and IV antiemetics (Zofran), and given Cipro for the treatment of Salmonella gastroenteritis.  His renal function improved, and BUN and Cr normalized after IV hydration.  His hypokalemia was corrected with IV K supplement.  After 48 hours, he was able to tolerate diet and was discharged home in a fair and stable condition on oral Cipro for gastroenteritis.  Given this clinical course, he could have been safely managed under lower level of care, and acute level inpatient care was not appropriate and medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pain, Swelling and Redness to the Left Knee (s/p insect bite)
Treatment: Inpatient admission
The Inpatient admission was medically necessary.

The patient is a male whose inpatient admission is under review. The patient presented to the ER two days after a bug bite to the right knee, and noted increasing swelling and erythema of the right knee.

On PE (physical examination), the patients vitals were as follow: T (temperature) - 103  P (pulse) -80   RR (respiration rate) -20  BP (blood pressure) -129/70. On general examination, the patient was NAD (no acute distress). Examination of the lower extremities revealed tenderness right knee, erythema right knee. Examination of the patient's skin revealed that it was warm and dry. Examination of the patient's right knee revealed pain with motion but able to flex and extend. There was swelling of knee and upper calf with warmth and redness. There was good popliteal and DP (dorsalis pedis) pulse, motor and sensation were intact.

The patient's labs were as follows:
WBC (white blood count) - 10.8 (increased to 11.2)
Hg (hemoglobin) - 14.4
Hct (hematocrit) - 42.2
Plt (platelets) - 192
Na (sodium) - 140
K (potassium) - 3.8
Cl (chloride) - 102
CO2 (carbon dioxide) - 24
BUN (blood urea nitrogen) - 17
Cr (creatinine) - 0.7
AST (aspartate aminotransferase) - 65 (high)
ALT (alanine aminotransferase) - 103 (high)
T. Bili (total bilirubin) - 1.5

In the ER, the patient was thought to have fever and cellulitis. He was started on IV vancomycin and Unasyn, and admitted. Initially, there was concern for a knee infection, but the patient remained stable and improved and was discharged home on PO (oral) Keflex.

The patient meets initial criteria for IV treatment and admission for cellulitis/abscess given by the Infectious Diseases Society of America (1), because there was evidence of systemic infection (temperature >100.4) as well as a concern for septic arthritis or bursitis. It was entirely appropriate to admit, treat with IV medications, and observe response to therapy, and consider invasive interventions to rule out a deeper infection. Thus, this admission was warranted, supported by IDSA guidelines. Failure to admit such as a patient can lead to loss of function, sepsis, deep abscess, or death.
Appeal type: Medical necessity
Decision: Overturned

Dental problems/ Impacted teeth 
Dental/Orthodontic Procedure 

The patient with an impacted tooth #6. The supplied dental cone beam tomography (CBCT) shows the impacted tooth is in very close proximity to the root of tooth #7. The patient presented with a skeletal Class II malocclusion. The plan for orthodontic treatment is to bring the impacted tooth into the arch.  The health plans determination of medical necessity is overturned in whole.
 Yes, the orthodontic treatment plan is medically necessary. It is in the best interest of the patients to be referred to an orthodontist and oral surgeon when an impacted tooth is discovered. 
Studies have shown almost 65% of untreated impacted teeth will cause some kind of pathology. The two most common types of pathology causes are periodontal bone loss and root resorption of adjacent teeth.2 If left untreated the damage that can occur to the patient's teeth will be more time consuming  to correct than the patient's existing orthodontic problem. Fortunately, we have a CBCT showing a 3Dimension image of the situation. The CBCT shows any further labial or incisal movement of the impacted tooth will almost certainly lead to root resorption of #7. For this reason, the orthodontic treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Urinary tract  infection 
Treatment: Inpatient admission
The inpatient admission was medically necessary.

The patient is a female whose inpatient admission is under review. The patient was diagnosed with a urinary tract infection (UTI) three days prior to the current emergency room (ER) visit, and was placed on Bactrim. The patient failed to improve and developed fever, nausea, and left greater than right (L>R) flank pain.

Examination revealed the following:
Temperature (T) - 101.8  
Pulse (P) - 99   
Blood pressure (BP) - 131/95   
Respiratory rate (RR) - 16
General - no acute distress (NAD)
Chest - normal
Cardiovascular system (CVS) - normal
Abdomen - normal
Back - bilateral flank tenderness

Labs revealed the following"
White blood cells (WBC) - 11.61 (high)
Hemoglobin (Hg) - 11.9
Hematocrit (HCT) - 35.7
Platelets (PLT) - 303
Sodium (Na) - 138
Potassium (K) - 3.9
Chloride (Cl-) - 106
Carbon dioxide (CO2) - 21
Blood urea nitrogen (BUN) - 10
Creatinine - 0.94

Urine analysis (UA) revealed WBC 0-5 and 0-3 red blood cells (RBC).  The patient's abdominal ultrasound (U/S) was normal.

In the ER, the patient was thought to have failure of outpatient antibiotics, was started on intravenous (IV) ceftriaxone, and was admitted for pyelonephritis. She was given IV morphine for pain control. The patient improved, urine culture came back as contaminated, and she was sent home on oral (PO) ciprofloxacin.

Outpatient treatment for pyelonephritis in women is given for uncomplicated cases (1). In this patient, the patient failed outpatient treatment and had fever and leucocytosis and severe pain in spite of three days of therapy, thus not a candidate for outpatient therapy. Standard of care would dictate admitting such a patient, ruling out renal abscess and antibiotic-resistant bacteria. Thus, this admission was warranted, supported by standard of care and the Infectious Diseases Society of America (IDSA) guidelines. Failure to admit such as a patient can lead to loss of function, septic shock, or death.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: HIV
Issue under review: Formulary exception for Symtuza 

Determination:
The health plan should not cover the Formulary exception for Symtuza.

The patient is an adult male. The patient is recently diagnosed with HIV, with viral load of greater than (>) than 10,000,000 HIV-1 RNA copies/ml, and CD4 in the 260 cells/ul. The provider started Symtuza and Tivicay. Symtuza is non-formulary, but the provider wants this for the extremely high viral load. No other information was given as to whether this represents acute/early HIV infection and/or lack of seroconversion.

The provider is choosing a four-drug regimen for the treatment of HIV, with the thinking that with the high viral load, a fourth drug is necessary. Such high viral loads are typically seen with acute HIV, and they are expected to drop even without antiretrovirals with an immune response to HIV. Even in this scenario, the guidelines give a variety of three-drug regimens as first line in acute/early HIV (1), which are covered by the health plan. This reviewer is not aware of any specific guidance of adding a fourth drug to the regimen, though it does happen sometimes in clinical practice. While the provider can certainly give a fourth drug, especially if they feel the patient cannot mount an adequate immune response (this was not specified), they could have chosen one covered by the plan along with another three-drug combo. No reason was given for specifically needing Symtuza versus another ARV (antiretroviral) that is on the health plan's preferred formulary.