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

Diagnosis: Pyelonephritis.
Treatment: Hospital admission.

The insurer denied coverage for the hospital admission.  The denial is upheld. 

This is a female patient with a past medical history of urinary tract infection (UTI), nephrolithiasis status post stenting and removal, uterine fibrosis and migraines.  The patient presented to the Emergency Department (ED) with complaints of persistent, cramping suprapubic abdominal pain three times a day radiating to the left flank.  There was positive nausea and positive vaginal bleeding.  The patient's pelvic ultrasound was normal.  The patient's urinalysis was consistent with UTI, but the patient had pain/tachycardia.  The patient's computed tomography (CT) scan revealed likely pyelonephritis changes of left kidney.  The patient was admitted with diagnosis of pyelonephritis.  The treatment plan included intravenous (IV) fluids, IV antibiotics, anti-emetics, and pain control.  

The insurer has denied coverage for the hospital admission as not medically necessary.  The insurer noted a lack of documentation of a serious medical condition, such as low blood pressure, high fever, or worsening kidney function.  

Per the Milliman Care Guidelines (MCG) Health (24th edition) Urinary Tract Infection (UTI), the patient fails to meet clinical indications for admission to inpatient care.  The patient does appear to meet guidelines for Observation care for vital sign abnormality (i.e., tachycardia), and uncertainty of patient's response to, or ability to tolerate outpatient treatment regimen.  Since this patient's care could have been provided at the Observation status, hospital admission was not medically necessary for this patient.

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

The carrier's denial of coverage for the hospital admission should be upheld.  The medical necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Hearing Loss.
Treatment: Hyperbaric Oxygen treatment.

The health plan denied the Hyperbaric Oxygen treatment. The health plan's determination is overturned.

The patient is female who presented complaining of onset of left sudden hearing loss. An audiogram confirmed severe to profound sensorineural hearing loss (SNHL) on the left and normal hearing on the right. The patient was treated with a course of high dose Prednisone. On follow up there was no improvement in hearing on her audiogram, so a left intratympanic steroid injection was performed, then repeated twice. Due to the lack of improvement with oral and intratympanic steroids, the patient was scheduled for hyperbaric oxygen (HBO) for salvage therapy. The patient was seen by a 2nd ear, nose, and throat (ENT) doctor who agreed with HBO as a treatment for this patient.

Per the hyperbaric specialist's appeal letter, the patient had undergone 9 treatments of HBO at that time and had some improvement. A magnetic resonance imaging (MRI) performed was normal.

At issue is the medical necessity of the requested treatment.

Based on the provided documentation, I would overturn in whole the health plan's determination regarding this treatment.

Yes, hyperbaric oxygen (HBO) therapy is likely to be more beneficial than any standard treatment for sudden sensorineural hearing loss that has not responded to oral and intratympanic steroids. Guidelines for the treatment of sudden sensorineural hearing loss published by the American Academy of Otolaryngology state that hyperbaric oxygen is a salvage treatment option for patients who fail to improve with oral and/or intratympanic steroids if initiated within 30 days of symptom onset.

This patient has multiple audiograms showing that she did not improve with appropriate steroid treatments. Therefore, HBO treatment was initiated within 30 days of symptom onset. This is well within the guidelines created by the AAO/HNS (American Academy of Otolaryngology/Head and Neck Surgery.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Vision. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied: Lumigan. 
The denial is overturned.

The patient is a male with chronic angle closure glaucoma in both eyes. He has previously been treated with Latanoprost and Travatan Z without adequate control of his intraocular pressure. He was given a sample of bimatoprost (Lumigan) by his current eye doctor and his intraocular pressure (IOP) was reduced to an acceptable range using the Lumigan in combination with Combigan. He intraocular pressures came down in both eyes. The subject under review is whether the requested non-formulary Lumigan will be more effective for this patient.

The formulary drugs are not as effective. The patient has been treated with both drugs that are considered formulary alternatives in the past and his IOP was too high on treatment with the formulary medications. His IOP is acceptable on the Lumigan. If his IOP is not adequately controlled, he runs the risk of vision loss up to blindness in both eyes.
It is standard practice to advance patients to Lumigan if they are not getting adequate IOP control with Latanoprost or Travoprost as multiple studies have shown better IOP lowering efficacy with Lumigan compared to the other medications. The patient can't have another class for glaucoma medications added to his treatment regimen because he is already using brimonidine and timolol (Combigan). In order to reduce his risk of vision loss his IOP must be lowered further than 21 and 20. He was not adequately controlled on formulary medications and so Lumigan was added with better control of his IOP.
Appeal type: Medical necessity
Decision: Overturned

Digestive System
Inpatient hospital

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

This patient is a female with a history of hypertension (HTN), and hypothyroidism who presented to the emergency room (ER) with complaints of abdominal pain. On exam, the patient had elevated liver function test (LFT) with hyperbilirubinemia > (greater than) 3 and elevated hepatic transaminases. A gastrointestinal (GI) consult with magnetic resonance cholangiopancreatography (MRCP) was obtained to evaluate for choledocholithiasis which was negative. A surgical consult was obtained and the patient was taken to the operating room (OR) for laparoscopic cholecystectomy which was routine and uneventful. 

The Inpatient Hospital Admission was medically necessary for this patient.
Although elective cases of cholelithiasis are often managed with outpatient or ambulatory laparoscopic cholecystectomy, this patient presented with acute pain, findings of cholelithiasis and hyperbilirubinemia. GI consult and MRCP were required to determine if there was presence of choledocholithiasis which was negative. A decision to proceed with surgical intervention was made. During this time, the patient was managed with nothing by mouth (NPO), intravenous fluids (IVF) and intravenous (IV) antibiotics. The patient underwent lap cholecystectomy and was discharged to home on  postoperative day (POD)#1.
The Acute inpatient admission is supported by the medical records for treatment of acute symptomatic cholelithiasis, with passage of stone and hyperbilirubinemia necessitating other diagnostic imaging (MRCP) and transient delay in surgical treatment (lap cholecystectomy). Acute inpatient admission was medically necessary for diagnosis, treatment of choledocholithiasis with hyperbilirubinemia and spontaneous passage of gallstones, and symptomatic cholelithiasis.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mental Health. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital admission for medical necessity. 
The denial was overturned. 

This patient is a female with a history of anxiety and depression and hypertension who presented to the emergency department (ED) with an overdose with intent to commit suicide.
On exam, the patient appeared in no distress, had slowed speech, and moved all extremities on command. Poison control was contacted and recommended no further treatments.
The patient endorsed that she took 6 pills of metoprolol and 7 of clonazepam. The ED physician decided to admit the patient to the telemetry unit with psychiatry following. 
Psychiatry was consulted. The patient was placed on alcohol withdrawal monitoring with a Clinical Institute Withdrawal Assessment (CIWA) Scale and had a 1 to 1(1: 1) sitter. 
The medical team documented the patient was stable to be discharged to an inpatient psychiatric unit. 
She was deemed stable to be released to the care of her husband. The patient was discharged home with adjustment to her psychiatric regimen. 
At issue is the medical necessity of the inpatient stay.
The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of inpatient stay is medically necessary for this patient.
This patient presented to the hospital with a suicide attempt, ingesting numerous sedating medications, was alcohol-intoxicated, and had taken a long-acting beta-blocker agent, posing a significant risk for bradycardia arrhythmias, alcohol withdrawal, electrolyte abnormalities, seizures, and self-harm. The patient experienced bradycardia and hypotension in the emergency department requiring fluid boluses with lactated Ringer's and glucagon injection in brief continuous infusion. Medically the patient experienced stabilization and did not experience malignant arrhythmias or QTc prolongation. However, the psychiatric risk status was not acceptable for outpatient management. Per the psychiatry assessment, she achieved medical stability, but the patient needed ongoing inpatient involuntary psychiatric placement. The patient was at risk for reingestion and suicide attempt and required 1:1 continuous observation while in the hospital. 
Therefore, the requested service of inpatient stay was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Crohn's Disease

Treatment: Cimzia

The insurer denied coverage for the medication Cimzia

The denial is upheld

The patient is a female with a history of Crohn's disease with a fistula.  The patient had developed antibodies to both Remicade and Humira.  The patient's physician has prescribed Cimzia.  The insurance company has advised that the preferred drug on their pharmacy list is Stelara. 

Gastroenterology and Hepatology August 2018, Volume 14, Issue 8 has published an article titled "Perianal Fistulas in Patients with Crohn's Disease, Part 1: Current Medical Management."  The article reviews the biologic agents.  A subgroup analysis of the use of Stelara (ustekinumab) found that fistula healing rates were significantly higher in the treatment group compared to placebo.  In a study to evaluate Stelara maintenance, fistula response was seen in 80% of patients receiving Stelara compared to 46% in the placebo group.  A multi-center study from 2016 showed fistula improvement in 61% of patients treated with ustekinumab.  The article also reviews Cimzia (certolizumab) and several studies have shown fistula healing with certolizumab as compared to controls.

In this case, this patient requires biologic treatment for fistulizing Crohn's disease.  Both Stelara and Cimzia have been shown to be beneficial.  The insurance company has offered Stelara as a preferred product.  The patient has not failed treatment with Stelara.  It is considered an appropriate treatment option for this patient.  Thus, the requested medication, Cimzia is not considered medically necessary for this patient at this time.

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.
 
The insurer's denial of coverage for Cimzia to treat Crohn's Disease is substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: upper respiratory tract infection and pain crisis.
Treatment: inpatient admission.
The insurer is denied coverage for inpatient admission
The denial is overturned. 

This female patient has a history of sickle cell disease/anemia, status post splenectomy who presented to the Emergency Department (ED) with complaints of fevers, sore throat, pain, and possible syncopal episode. The patient's vital signs on presentation included: temperature 102.0 F(Fahrenheit), blood pressure133/81, pulse 128, respiratory rate 20, and oxygen saturation 100% on room air. The patient's laboratory results included the following: white blood cell count (WBC) 26.5, hemoglobin 8.7, hematocrit 24.8, creatinine 0.71, glucose 100, and lactic acid 1.5. The patient was admitted for possible upper respiratory tract infection and pain crisis. The patient was empirically started on intravenous (IV) antibiotics (i.e., Unasyn). The patient's rapid strep test and throat cultures were positive for beta hemolytic streptococci. The patient's chest X-ray (CXR) was normal. The patient's computed tomography (CT) scan of the abdomen/pelvis showed findings compatible with left lower lobe pneumonia. The patient's CT scan of neck showed enlarged right-sided cervical lymph nodes. The patient received one unit of packed red blood cell (PRBC) transfusion. All other cultures remained negative. The patient improved clinically, remained afebrile, hemodynamically stable. The patient was discharged to continue outpatient management on oral antibiotics (i.e., Augmentin).

According to documentation, the patient presented with fever (temperature of 102), tachycardia (heart rate of 128) following a syncopal episode at home. The patient's laboratory results were notable for a significantly elevated white blood cell (WBC) count and anemia. The patient's rapid throat test was positive beta-hemolytic streptococcus. Based on the above clinical findings in a high-risk patient with underlying sickle cell and status post (s/p) splenectomy, inpatient hospital admission was medically necessary for administration of intravenous antibiotics, blood transfusion, and pain management.

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 hospital admission is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain.  
Treatment: Inpatient hospital admission.  

The insurer denied coverage for the inpatient hospital admission.  

The denial is overturned.  

This is a female patient with multiple medical problems including coronary artery disease, hypertension and chronic obstructive pulmonary disease who presented to the hospital with 10/10 chest pain at rest.  The patient's pain was relieved with nitroglycerin and the patient was admitted to the hospital for evaluation.  Cardiac catheterization revealed triple vessel disease and revascularization of the left circumflex artery was performed.  

Based on this patient's elevated risk score using both the HEART (History, Electrocardiogram, Age, Risk factors, Troponin) score and thrombosis in myocardial infarction (TIMI) risk stratification, admission for observation and work up was indicated. 1-3 Risk assessment of patients presenting with chest pain and ST changes on electrocardiogram as well as negative cardiac enzymes was performed by Sanchis et al.3  Using their risk stratification schema, this patient would have a moderate to high risk of future myocardial infarction or death within one year.  This patient required diagnostic testing and treatment that included coronary artery revascularization.  

Inpatient acute admission to the hospital for further testing and treatment was indicated and medically necessary for this patient.  

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

The medical necessity for the inpatient hospital admission is substantiated.  The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Type 2 diabetes mellitus; Hyperglycemia with hyperosmolar state without coma. 

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is overturned. 

This is a male patient with a medical history of Type 2 diabetes mellitus with insulin use, schizophrenia, and polysubstance abuse.  The patient was brought in by Emergency Medical Services (EMS) to the Emergency Department (ED) due to hyperglycemia.  The patient reported noncompliance with medications at home.  The patient's physical examination was unremarkable.  The patient's lab studies were significant for blood glucose of 998, sodium of 141, elevated serum osmolality and urine toxicity positive for cocaine.  The patient received intravenous (IV) normal saline bolus and started on insulin drip.  The patient was admitted to the medical intensive care unit (MICU) for further evaluation and management of hyperglycemia with hyperosmolar state without coma.  The patient was transitioned to Levemir and Novolog subcutaneous.  Psychiatry was consulted with recommendation for Abilify oral daily which the patient refused.  The patient was given referral to detox.  The patient's blood sugar level was noted stable with no ketones and lactate was normal.  The patient was medically stabilized and discharged home with instructions to follow-up with endocrinology and behavioral health clinic.  It was noted that the patient left without accepting discharge papers or referral package to detox program.

The inpatient hospital admission is considered medically necessary for this patient.  The patient met diagnostic criteria for hyperosmolar non-ketotic state based on severe plasma blood glucose (BG) elevation of more than (>) 600 without ketosis or acidosis.  Although the patient was not in stupor or coma status, this was eventuality to happen if the patient was not treated for this medical emergency.  As per literature, not all patients with hyperosmolar non-ketotic coma (HONK) present with coma and it is seen in 25-50% of cases.  Hyperosmolar hyperglycemic state (HHS) occurs mostly in adults and elderly patients and has a higher mortality than diabetic ketoacidosis (DKA) with death.  The evolution of HHS is over several days to weeks, and the most common presentation is altered mental status.  Due to the lack of randomized controlled trials for the treatment of HHS, the American Diabetes Association (ADA) consensus has combined both DKA and HHS.

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 hospital admission should be overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bronchopulmonary dysplasia, feeding problems, hearing deficit, a neurodevelopmental disorder, pulmonary hypertension, hypothyroidism, retinopathy of prematurity and vocal cord paralysis.  
Treatment: Continued stay in a skilled nursing facility.  

The insurer denied coverage for the continued stay in a skilled nursing facility.  The denial is overturned.  

This patient is a male child who was born from a twin gestation.  The patient was intubated in the delivery room, given surfactant, and started on high-frequency oscillatory ventilation.  The patient was admitted to the neonatal intensive care unit.  The patient was subsequently admitted from the neonatal intensive care unit for the continuation of acute medical treatment.  He was transferred back to the initial hospital to rule out sepsis, and he was treated for tracheitis.  The readmission notes indicated the patient had bronchopulmonary dysplasia, feeding problems, hearing deficit, a neurodevelopmental disorder, pulmonary hypertension, hypothyroidism, retinopathy of prematurity and vocal cord paralysis.  Once readmitted he was treated by Neonatologist, Pediatric Pulmonologist, Pediatric Physiatrist, Respiratory Therapist, Physical Therapist, Occupational Therapist, Speech Therapist, and Rehabilitative Nurses.  The medications include clonazepam, Diuril, Pulmicort, Sildenafil, and Tirosint-Sol. 

The IDCP (interdisciplinary care plan) summary report noted the patient was making slow but gradual progress on ventilator weaning.  He was now up to 6 hours of trach collar.  He continued on azithromycin as an anti-inflammatory.  He was on contact/droplet precautions.  He had a tracheostomy with a ventilator.  He had a gastrostomy tube.  The patient continued to receive treatment as per the interdisciplinary care plan.  The parents were actively involved in planning for the patient and were participating in his care.  The plan was to bring the patient home with the necessary support services when he was medically ready for discharge.  Social work was to continue coordinating discharge planning with the interdisciplinary treatment team and family as appropriate.  The patient was progressing towards therapy goals.  

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

The continued stay in a skilled nursing facility is medically necessary for this patient.  The documentation clarifies that the level of treatment is best characterized as a Long Term Acute Care hospital and not a Skilled Nursing Facility.  The patient was making slow but gradual progress on ventilator weaning.  He had a tracheostomy with a ventilator as well as a gastrostomy tube. Given the level of care required, the continued stay was medically necessary.  

The medical necessity for the continued stay in a skilled nursing facility is substantiated.  The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ocular injury.
Treatment: Hospital admission.

The insurer denied coverage for the hospital admission.  The denial is upheld. 

This is a male patient with no significant past medical history who was brought in by ambulance to the Emergency Department (ED after being physically assaulted.  The patient was beaten and kicked in the right eye.  The patient complained of right eye pain and blurry vision.  The patient's computed tomography (CT) scan revealed a right medial orbital wall fracture.  The patient received pain management in the ED.  The findings were a corneal abrasion and hyphema.  The patient was admitted for service under Plastic Surgery, but he was also followed by Ophthalmology for hyphema and a corneal abrasion.  

Based on the review of the medical record and literature, inpatient admission was not medically necessary for this patient.  The patient had a significant ocular injury and was at risk for bleeding and elevated intra-ocular pressure.  The patient clearly required close follow-up from ophthalmology, but this close follow-up could have been performed with daily outpatient office visits to the ophthalmologist.  The patient could have been worked up in the Emergency Department (ED) with maxillofacial and ophthalmology consultations, and computed tomography (CT) scan of the head.  This work-up confirmed that the patient did not need acute surgery and required close ophthalmology follow-up.  Inpatient admission was not required for close ophthalmology follow-up.  Close follow-up could have been completed at an observation or outpatient level of care. The patient required non-operative care of a significant injury, but ophthalmology care for this injury could have occurred at an outpatient or observation level of care.  

In this case, this patient did not have any of conditions that warranted inpatient level of care.  The patient required non-operative care of a significant injury, but ophthalmology care for this injury could have occurred at an outpatient or observation level of care.  Thus, hospital admission was not medically necessary for this patient.

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

The carrier's denial of coverage for the hospital admission should be upheld.  The medical necessity is not substantiated.