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

Diagnosis:  Cardiac/Circulatory Problems
Treatment:  Inpatient hospital

The patient is a woman with a history of asthma, hypertension, hyperlipidemia, borderline diabetes and obesity.  She presented to the emergency department after an episode of chest pain, palpitations and syncope.  She had had a similar episode two days prior.  Of note, the patient had previously been scheduled for cardiac catheterization after having had an abnormal cardiac stress test.  In the emergency department her blood pressure was 111/76 mmHg with a heart rate of 62 beats/minute.  Her cardiac exam was unremarkable. An electrocardiogram showed sinus rhythm with inferior and anterior T wave abnormalities.  Her serum troponin level was normal.  The patient was admitted to the hospital.  A repeat troponin level was normal.  A cardiac catheterization showed no obstructive coronary artery disease.  Coronary spasm was documented in the mid-left anterior descending and mid-ramus arteries.  The patient was discharged with calcium channel blocker therapy.  Coverage for an inpatient admission is at issue.

The health plan's determination is overturned.  The inpatient stay was medically necessary.  This woman presented with syncope that was associated with chest pain and palpitations.  The presence of chest pain and palpitations prior to loss of consciousness was suggestive of a hemodynamically significant arrhythmia, possibly precipitated by or associated with ischemia.  The patient's recent abnormal cardiac stress test suggested the presence of ischemic heart disease.  Per the 2017 American College of Cardiology (ACC) / American Heart Association (AHA) / Heart Rhythm Society (HRS) Guideline for the Evaluation and Management of Patients With Syncope, inpatient admission is recommended for patients presenting with syncope who have a serious medical condition potentially relevant to the cause of syncope identified during initial evaluation.  The possibility of myocardial ischemia was identified during this woman's evaluation and was potentially relevant to her syncope.  Thus, current guidelines support an inpatient level of care in this instance.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Digestive system/Cleft palate fistula/other.
Treatment:  Inpatient hospital stay.

The health plan denied the inpatient hospital stay.  The inpatient denial was upheld.
 
This is a pediatric patient with a cleft palate who underwent original repair previously, and then developed a residual fistula after the repair.  The patient underwent repair of the cleft palate fistula.  This patient under review underwent an uncomplicated surgery with minimal blood loss.  For this patient the objective documentation did not demonstrate a need for admission at the acute inpatient level of care.  The pain was well controlled, vital signs were stable, unlabored breathing, no respiratory distress, and tolerated a diet.  Therefore, the documentation supports that the admission was not medically necessary at the acute inpatient level of care.  The patient could have been safely and effectively managed at a lower level of care.

Cleft lip with or without cleft palate is the most common congenital malformation of the head and neck (Crockett et al).  Primary cleft palate repair is the standard management of a child with a cleft palate deformity (Shaye et al, Woo et al, Smith et al).  Generally, overnight observation is performed for comorbidity management, to monitor for airway issues, feeding issues, pain control, and wound dehiscence.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Sacral Fracture.
Treatment:  Inpatient stay.

The insurer denied the inpatient stay.  The health plan's determination is overturned. 

This was a female with history of spinal stenosis status/post (s/p) fixation and hemorrhoids who presented to the emergency department (ED) with complaints of coccygeal pain and constipation for a period of 9 days s/p fall from level ground.  The patient reported difficulty with bowel movements since the fall with straining and bright red blood per rectum.  She also reported difficulty urinating. 

The inpatient hospital stay was medically necessary for this patient.  Based on review of the available medical record, the inpatient admission was medically necessary.  The patient was found to have a sacral fracture with urinary and bowel symptoms.  Despite the patient being hemodynamically stable and the neurological examination being normal, the patient had acute urinary retention, which required foley catheter placement and appropriate specialty consultation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Overbite.
Treatment:  Braces.

The health plan denied Braces.  The health plan's denial is overturned.

The patient is a female child.  This patient has a deep, impinging overbite that is causing soft tissue damage to her palate.  This is an "automatic qualifier" according to the handicapping index scale.  Also, the patient has an upper left canine that is totally out of its proper position.  Without the canine in its proper position, it cannot help direct the forces on the other teeth during the chewing cycle.  There is a higher probability that the other teeth will suffer wear and/or fractures from the increased pressure during chewing.  Both of these are reasons for why the orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Abdominal pain.
Issue under review:  Inpatient admission.

The health plan denied Inpatient admission.  The health plan's denial is upheld.

This patient is an adult female.  She presented to the ED with the complaint of left abdominal pain of four-days duration.  She carries the diagnosis of asthma.  Examination revealed a nontender abdomen.  Vital signs were normal at the time of presentation.  The WBC (white blood cell) count was normal at 6.0 K.  Surgical and urology consultation was obtained.  CT scan was completed showing findings of acute appendicitis and left kidney stones.  The patient was started on IV antibiotics.  The patient underwent laparoscopy with appendectomy for the condition of suppurative, early appendicitis.

Following surgery, the patient was treated with IV fluid and analgesia.  Vital signs were consistently normal in the perioperative period.  She was transitioned to oral medications and diet.  She was discharged from the hospital.  Urology recommendation was for outpatient follow up.

The health plan rationale for denial is that the patient underwent uncomplicated appendectomy.  This procedure is usually performed with an outpatient level of care.  The denial letter references MCG.  Per this letter, there is no documentation of hemodynamic instability, fever, sings of perforation, complications of the procedure, or need for prolonged care.

Acute inpatient hospitalization was not medically necessary for this patient.  The medical records support that this patient could have been reasonably and safely monitored with an observational/ambulatory status.

This patient presented with abdominal pain.  Her evaluation with examination, lab data, and CT scan supported the diagnosis of acute appendicitis.  She underwent uncomplicated appendectomy.  She was admitted to an inpatient level of care and was discharged from the hospital two days later. 

There is no clinical documentation to support need for inpatient admission.  The patient remained hemodynamically stable throughout the perioperative period, there was no fever, or documented complication of surgery.  This patient's clinical needs could have been satisfied with an observational level of care.  This level of care would have provided for pre-surgical assessment, surgical treatment and post-surgical recovery including overnight observation.  The records support that the care provided was clinically appropriate.  It is the level of care (inpatient vs outpatient / observational) that is at issue in this case.

Alternative care would include an outpatient designation rather than acute inpatient care.  An outpatient level of care would have provided for pre-surgical assessment, surgical treatment and post-surgical recovery including overnight observation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Vomiting, decreased output, fever.
Issue under review:  Inpatient admission.

The health plan denied the Inpatient admission.  The health plan's denial is upheld.

The patient is a male child.  He presented to an outside ED with five-day history of vomiting, fevers, and decreased urine output.  His fevers responded well to ibuprofen, but the vomiting continued.  He was not drinking or eating well, and he had decreased number of wet diapers.  The family had returned from a foreign country eight days prior.  He did not receive any additional vaccinations, and he was given no medications. 

The patient's vital signs included temperature 37.2, heart rate 140, respiratory rate 28, and blood pressure 104/74.  Examination was significant for ill appearance, lethargic, dry mucous membranes, no tears with crying, benign abdomen, and non-focal neurologic deficits.  He was treated with a normal saline bolus and a dose of Zofran prior to transfer for higher level of care for acute viral gastroenteritis. 

Admission orders included metabolic panel with repeat the following morning, maintenance IV fluids, trial of oral nutrition the following morning, and Tylenol as needed.  Admission labs, including metabolic panel and CBC (complete blood count), were unremarkable.  Overnight, he had no further vomiting. He was able to tolerate a bottle and was making good wet diapers.  He remained on IV fluids and had not passed a stool. IV fluids were discontinued, and he was able to tolerate adequate food and fluids to sustain himself.  He was subsequently deemed stable for discharge home.

Acute gastroenteritis is a major problem worldwide, representing one of the leading causes of morbidity and mortality in children.  There are an estimated 2.5 million deaths each year attributable to gastroenteritis in children under the age of five years.  Most cases are caused by viruses, are self-limited, and require supportive treatment.  According to the World Health Organization, oral rehydration therapy is the treatment of choice, particularly where diarrhea is the prominent feature and dehydration is mild to moderate.  Intravenous rehydration is indicated when oral rehydration fails or when output is excessive.  Vomiting limits the success of oral rehydration, prompting use of anti-emetic medications.

This young child presented to the ED with several days of vomiting and signs and symptoms consistent with dehydration.  He was fluid resuscitated in the ED, and thereafter had no further vomiting.  He was able to advance his diet without difficulty and had good urine output.  While it was reasonable and appropriate to provide ongoing parenteral hydration, as his appetite improved and he was able to drink sufficiently to sustain himself, he was overall hemodynamically stable with no evidence of sepsis.  He did not require acute inpatient admission and could have been safely managed at a lower level of care, such as observation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal
Treatment: Enteral Formula
The insurer denied: Ensure
The denial is: Upheld in whole

The patient is a male with a past medical history significant for central nervous system (CNS) insufficiency, osteoarthritis, gait disturbance, benign prostatic hyperplasia (BPH) and dermatitis. The review is for medical necessity for Ensure, one can three times a day, which was denied by the health plan on the basis of medical necessity.

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

It is difficult to tell the patient's body mass index (BMI) because weight was not measured on the last noted progress note. Previously the weight according to a nurse visit was 135 with a height of 5.5 which calculates to a BMI of 22.46. The patient's clinical status was described as being stable, with no difficulty in his appetite or having difficulty swallowing. There were no noted other medical conditions in the progress notes which would require additional supplementation.
Progress note states his appetite and swallowing have been stable and there have not been any obvious recent cardiopulmonary symptoms. It also states there has not been any significant change in weight. Under the treatment plan it states that his appetite and swallowing are stable, and he is sleepy. General condition appears stable.
No weight was noted on that visit or height. There is a remark in the letter stating that they were unable to weigh him and then there is a second letter stating that his weight was 110 pounds.
There is a note from a video conference stating his weight is about 110. But no weight was actually measured.
The last measured weight was 135 pounds with a height of 5.5 which would make the BMI 22.46, which is considered normal weight. It also stated at that time the patient did not have any problems with swallowing. The patient was able to tolerate meals that were pureed or minced. No laboratory data was submitted for review.
In accordance with the standard of care, medical necessity is not established. There is no mention that the patient has difficulty swallowing, and there is no documented weight which would serve not only as a guide for any enteral or oral therapy, but also as a guide for response to therapy.
Appeal type: Medical necessity
Decision: Upheld

Mental Health
Mental Health: Inpatient
Diagnosis: Depression
Treatment: Continued Stay in a Behavioral Health Hospital 
The insurer denied Continued Stay in a Behavioral Health Hospital. 
The health plan's determination is upheld. 

The patient is a woman admitted to Inpatient Behavioral Health Hospital (IBHH) for psychiatric treatment after a couple weeks stay in an Intensive Care Unit (ICU) in another hospital. Case notes document that the patient attempted to end her life by suicide through an overdose of three medications in the context of multiple psychosocial stressors: death of grandmother shortly before overdose, prolonged grief from previous death of mother, financial difficulties, multiple medical diagnoses including myoclonic seizures, PCOS, migraines, anemia, and obesity.

The Continued Stay is not medically necessary for this patient. She could safely and with good medical judgment be discharged to a less restrictive environment. Case notes document that  the patient was "ready to move on." She had no suicidal or homicidal ideation. She had no difficulty with impulsivity. She reported her mood was "ok." She was compliant with her medications. On the proposed last day approved by the health plan, she had a normal affect. She appeared relaxed. She has no suicidal or homicidal ideation. She was not delusional. She showed no impulsivity. Therefore, it is reasonable that the patient could be discharged safely and with good judgment. The subsequent progress note documented mild irritability and anxiety; these symptoms could be adequately treated in a lower level of confinement. She continued on that date to deny suicidality or delusions. She would require continued care in a less restrictive environment, but not as an inpatient.
Appeal type: Formulary Exception
Decision: Upheld

Endocrine/Metabolic/Nutritional
Pharmacy/Prescription Drug
Diagnosis: hypopituitarism
Treatment: Androgel
The insurer denied Andgrogel. 
The health plan's determination is upheld. 

The patient is a male with history of hypopituitarism. The coverage request is for Androgel (Testosterone Gel). The medication was previously denied because the patient has not tried and failed or have a contraindication to all the formulary alternatives (testosterone solution, Androderm).

The patient has had a trial and failure of testosterone solution (Axiron), however, has not had a trial and failure of Androderm. The remaining plan alternative Androderm is a clinically reasonable alternative for the patient to try before requesting Androgel. Androderm would not be less effective or have more adverse effects than the requested Androgel.
Hypogonadism treatment in symptomatic men is recommended by the Endocrine Society 2018 guidelines, and the society does not differentiate between different types of testosterone preparations in terms of efficacy in treating hypogonadism and its symptoms. Similarly, the 2018 American Urological Association (AUA) guidelines on the topic also do not differentiate between different types of testosterone preparations in terms of treatment efficacy. Additionally, there are no high-quality clinical studies showing one preparation results in improved patient outcomes versus another testosterone preparation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pressure 
Treatment: Inpatient Admission 

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

This is a male patient who presented to the Emergency Department (ED) with complaints of numbness, chest pressure and shortness of breath. He has a history of post-traumatic stress disorder (PTSD), diabetes, hyperlipidemia, hypertension, enlarged prostate and colon cancer. His vital signs were: a temperature of 98.1F, blood pressure of 118/88, heart rate was 86 beats per minute, and oxygen saturation was 100% on room air. 

The patient's National Institutes of Health (NIH) stroke scale total was 1. The patient did appear uncomfortable; however, he had full range of motion of all extremities. There were no gross abnormalities or neurological deficits. The patient complained of tingling/decreased sensation to the left arm and left foot. Multiple laboratory studies were done all were within normal limits. An electrocardiogram (EKG) was done that showed normal sinus rhythm. A reassessment was performed that revealed the patient had improvement in symptoms; no chest pain. A computed tomography angiography (CTA) was negative. A computed tomography (CT) of the brain and abdomen were performed and were both unremarkable. The patient was admitted to the hospital with recommendations to continue treatment and observation. The documentation detailed that the patient did not have any adverse events while hospitalized overnight. The patient was discharge the following day with instructions to follow-up. 

In this case, the patient developed transitory numbness without evidence of acute stroke. The patient may have had a transitory ischemic attack. 

According to the medical records, there was no clear evidence of acute change in the patient's neurological examination suggestive of acute stroke. There was no acute motor, sensory or visual deficit suggesting an acute stroke. There was no instability, new focal neurological signs, acute stroke, hemodynamic or cardiovascular compromise or acute prolonged metabolic decompensation or seizure. Therefore, the patient's condition did not fulfill criteria for an acute inpatient care admission. 

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

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

Diagnosis: Dementia, persistent atrial fibrillation, peripheral vascular disease, bipolar disorder
Treatment: Increase personal care worker services: seven days/week, five hours/day; 35 hours/week 
The insurer denied the Increase personal care worker services: seven days/week, five hours/day; 35 hours/week.
The denial is overturned. 

Yes, the proposed treatment of an increase in personal care worker services to seven days/week, five hours/day; 35 hours/week is deemed medically necessary to offer increased ADL assistance.

The patient is a female with a history of dementia, persistent atrial fibrillation, peripheral vascular disease, bipolar disorder, lower extremity edema, hypertension and urinary incontinence .Due to impairments related to her various medical conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). 

Due to impairments related to her various medical conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Recent documentation from the patient's provider indicates that the patient has demonstrated continued, progressive functional decline since the date of her last in-home assessment with worsening cognitive impairment, mobility issues and mental health. For these reasons, the currently approved plan of five days/week, two hours/day (Monday-Friday), two days/week, three hours/day (Saturday-Sunday); 16 hours/week is insufficient to meet the patient's current needs. Hence, the proposed treatment of an increase in personal care worker services to seven days/week, five hours/day; 35 hours/week is deemed medically necessary to offer increased ADL assistance.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse

Treatment: Inpatient rehabilitation

The insurer denied coverage for inpatient rehabilitation. 

The denial is overturned.

This patient is a male who was admitted to inpatient substance rehabilitation treatment due to the need for substance rehabilitation.  The patient was drinking vodka and beer daily, snorting heroin daily even while taking Methadone Maintenance Treatment, and was using 2 mg of Xanax a few times per week.  The patient was also homeless. The patient's history was significant for multiple inpatient substance treatments, and this patient's continuous use of substances and alcohol. The patient was discharged with follow up instruction. 
The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders report that inpatient treatment is indicated primarily for individuals whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. In this case, this patient's history of substance use and recurrent relapse requiring inpatient detoxification warranted 24-hour substance rehabilitation treatment. This patient was using large amounts of alcohol daily and using serious substances daily including heroin as well as Xanax a few times per week. This pattern of substance use put this patient at a high risk for overdose and life-threatening withdrawals. The patient was also noted to be homeless, and lacked the coping skills and the ability to identify relapse triggers to stop use.  
According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), this patient met the clinical criteria for inpatient substance rehabilitation treatment as he continued to use large amounts of alcohol, heroin, and Xanax despite multiple past inpatient substance treatments as he reportedly had several inpatient substance detoxification treatments. The patient was also unable to remain abstinence even with the Methadone Maintenance program.  The patient was homeless and lacked sober supports to help the patient maintain abstinence outside of the 24-hour substance rehabilitation treatment. The patient needed to better identify relapse triggers and develop skills to prevent relapse. The patient required a structured and supervised therapeutic rehabilitation treatment in order to achieve these goals. Due to this patient's high risk for relapse, overdose and life-threatening withdrawals, inpatient rehabilitation was medically necessary to treat this patient's medical condition.
The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.
The carrier's denial of coverage for the inpatient rehabilitation should be overturned.  The medical necessity is substantiated.