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

Diagnosis: Abdominal Pain and Vomiting.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female. She presented with vomiting and abdominal pain. She was hospitalized. The health plan denied coverage of the admission on the basis of medical necessity

Per the ED (emergency department) note and admission history and physical, the patient was seen in the ED (emergency department) for abdominal pain and multiple episodes of vomiting; likely viral gastroenteritis.

The patient was admitted for inpatient care due to mild to moderate dehydration. Admission plans included IV (intravenous) fluids; Zofran; and liquid diet for the night.

Per the discharge summary, the patient was stable overnight. Her abdominal pain subsided. No vomiting was reported. The patient was discharged home.

No, the Inpatient admission was not medically necessary.
As documented in admission H&P (history and physical), ED (emergency department) note and discharge summary, this patient had acute abdominal pain and vomiting, likely due to acute viral gastroenteritis. She was admitted for IV (intravenous) hydration.

During hospital stay, the patient had been stable with no documented acute symptoms such as persistent vomiting, increased abdominal pain or diarrhea. She did not require any acute interventions. There was no documentation for suspected severe infection, severe abdominal tenderness, peritoneal signs, toxic megacolon, hemodynamic instability, sever or persistent vomiting, severe dehydration, electrolytes or metabolic abnormalities.

Therefore, given the above, requested inpatient admission was not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
As documented, this patient had abdominal pain and vomiting, likely due to acute gastroenteritis. The patient did not require any acute interventions or treatment. The health plan determined that the requested treatment did not meet acute inpatient level of care. The health plan acted reasonably, with sound medical judgment and in the best interest of the patient (1-2).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma

Treatment: Inpatient admission

The insurer denied coverage for an inpatient admission

The denial is overturned

This patient with a history of asthma. She had been well but the day prior to admission she developed a fever and a sore throat. When she then developed chest tightness and wheezing, she took albuterol in the home with no relief. Her father then took her to the ER (emergency room) for treatment.

In the ER, patient was noted to have a fever of 101.3 degrees, and on physical examination she was noted to have wheezing, tachycardia and increased respiratory effort. She was treated with 3 doses of duoneb and decadron. When she did not improve, she was also treated with IV (intravenous) magnesium sulfate with some clinical improvement noted. She continued to need albuterol for her wheezing every three hours. There was a history of 4 previous PICU (pediatric intensive care unit) admissions for moderate asthma and she had not been recently followed by the pediatric pulmonologist. The medical record also indicated that she was non-compliant with her prescribed daily inhaled steroid. In view of her non-compliant behavior, past history of multiple PICU admissions and when her respiratory symptoms did not improve with treatment in the ER the decision was made to admit her with a diagnosis of status asthmaticus for ongoing treatment with albuterol and IV fluids.  

The insurer has denied the admission as not medically necessary and indicated that there was no documentation in the medical record to support the need for inpatient treatment. The insurer did approve coverage for observation status in the ER.

The patient was treated appropriately in the ER for a cough, wheezing and respiratory distress. She had a history of frequent admissions to the PICU in the past for asthma and there was evidence of poor compliance with preventive asthma treatments. It was appropriate and consistent with the standard of care to admit her to the hospital for ongoing treatment with albuterol every 3 hours and IV fluids. She had failed outpatient management of her asthma and there was also concern for non-compliant behavior in managing her moderate persistent asthma. She continued to be wheezing with a diagnosis of status asthmaticus and not stable enough to be sent home. The admission to the hospital should be covered by the insurer.

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

The insurer's denial of coverage for the inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: High Blood Sugar.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female with a history of type 1 diabetes who presented to the emergency department with shortness of breath and palpitations.

The patient was hypertensive and tachycardic. Glucose was 411, sodium 129, phosphate 5.5, alkaline phosphatase 142. Glucoses at home had been running high. EKG (electrocardiogram) showed prolonged QT. It was felt that the palpitations were likely because of hyperglycemia and dehydration. pH (potential hydrogen) was 7.38. Urine ketones were negative. Beta hydroxybutyrate was normal at 0.15.

No, the Inpatient admission was not medically necessary.
Acute inpatient admission for patients with symptomatic diabetes is necessary when the patient has evidence of ketoacidosis or a hyperosmolar state [1-6]. Observation is generally sufficient for patients with ketosis or vomiting that resolves after hydration [7-9] and hyperglycemia without ketosis.

The patient had already been previously diagnosed with and treated for type 1 diabetes.

The patient presented with hyperglycemia, dehydration, tachycardia and some mild electrolyte abnormalities.  The patient could have been treated at an Observation level of care, but did not require acute inpatient admission.  The request is not consistent with generally accepted standards of medical practice and is therefore not medically necessary.

Yes, the health plan acted reasonably, without medical judgment, and in the best interest of the patient, as the request is not medically necessary as described above.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Endocrine/Metabolic/Nutritional-Ketosis. 
Treatment: Inpatient hospital stay. 
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination. 

This is the case of a patient admitted to the hospital for the diagnosis of alcohol withdrawal. The patient presented with ketosis as the reason for admission. The patient presented with acute onset of severe non-radiating epigastric pain and seizure like episode. Vital signs demonstrated temperature at 98.1F (degrees Fahrenheit) blood pressure 114/71, pulse 129, respiratory rate 20, and oxygen (O2) saturation 99% (per cent) on room air. Physical exam showed no acute distress with anxiousness and tremor. There was no altered mental status. Creatinine was 0.61 with bicarbonate of 16. The patient was placed on a Clinical Institute Withdrawal Assessment (CIWA) protocol with scoring 5-6. She had headaches, nausea, auditory hallucinations, and anxiety. It was noted that tremors were improving, and she was treated with intravenous fluids, Librium, Ativan, Naltrexone, Thiamine, multivitamin, and folic acid. There were no witnessed seizures during the hospital stay and the lactic acidosis and acidosis were thought to be related to alcohol ketosis or starvation ketosis and resolved. The patient was then discharged. 

Medical necessity of admission has not been established. 
According to Up to date, 2021: "Complications of Alcohol Withdrawal 
Minor withdrawal symptoms - Minor withdrawal symptoms are due to central nervous system hyperactivity and include: 
1) Insomnia 
2) Tremulousness 
3) Mild anxiety 
4) Gastrointestinal upset, anorexia 
5) Headache 
6) Diaphoresis 
7) Palpitations. 

Symptoms are usually present within six hours of the cessation of drinking and often develop while patients still have a significant blood alcohol concentration. If withdrawal does not progress, these findings resolve within 24 to 48 hours. The specific minor withdrawal symptoms in a given patient typically are consistent from one episode to the next. " 
The patient in this case appeared to have minor alcohol withdrawal symptoms with tremor, anxiety, and headaches. The patient did not have witnessed seizure in the hospital. There was no diagnosis of delirium tremens, advanced age, arrhythmia, hemodynamic instability, withdrawal despite an elevated alcohol level, renal insufficiency, rhabdomyolysis, fever, gastrointestinal (G.I.) bleeding or respiratory insufficiency. 
Although the patient had needs best addressed in the hospital setting the monitoring, diagnostic workup and therapeutic interventions prescribed could have been safely administered at a lower level of care. Therefore, medical necessity of inpatient admission has not been established.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Type 2 diabetes mellitus.
Treatment: Janumet XR (sitagliptin-metformin ER).

The insurer denied coverage for Janumet XR (sitagliptin-metformin ER.  The denial is overturned.

The patient has type 2 diabetes mellitus (T2DM). The request is for Janumet extended release (XR) 100/1000 milligrams (mg). Per letter submitted, the patient has been on Janumet XR 100/1000 mg for many years. The patient has failed Jentadueto and Alogliptin Metformin, due to adverse effects of severe diarrhea and abdominal pains.

Progress note indicates the patient was started on Jentadueto XR, and it caused severe diarrhea, fatigue, and he was unable to operate heavy machinery.

Telephone encounter note states patient is having sharp pains and diarrhea from Alogliptin.

On an office visit it is noted the patient is on Jentadueto XR. Laboratory report shows hemoglobin (Hgb) A1c of 10.8. It was 7.9, approximately 1 year prior, and over 1 year prior it was 6.8.

The formulary drug is likely to cause the patient an adverse reaction. 

The patient has tried Jentadueto XR and developed diarrhea, severe abdominal pain, and "felt out of it." Trying the same medication, but in different version is likely to have the same effects.      

The requested drug would be more effective than the formulary drug.

In this case, the patient has been on medication for years. Per records the patient was started on Janumet XR (sitagliptin-metformin ER) approximately 6 years ago. The patient has tried and failed Jentadueto XR, Alogliptin Metformin, and Metformin. Patient has tried formulary medication and requesting patient to try and fail same medication but in a different version is likely to have the same effect. The patient had reached HgbA1c levels under 7 while on Janumet XR (sitagliptin-metformin ER). Controlling diabetes is extremely important to prevent complications of diabetes in the future. 

Hayes, J., Anderson, R., & Stephens, J. W. (2016), "The combination of sitagliptin and metformin has been shown to adequately lower HbA1c to a greater extent than either agent alone, and this combination addresses different pathophysiological processes implicated in the pathogenesis of type 2 diabetes."

Food and Drug Administration (FDA) (2021), "JANUMET XR is a combination of sitagliptin, a dipeptidyl peptidase-4 (DPP-4) inhibitor, and metformin hydrochloride (HCl), a biguanide indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. "

Ji, M., Xia, L., Cao, J., & Zou, D. (2016), "For obese T2DM patients diagnosed with a glycosylated hemoglobin level >9%, oral sitagliptin/metformin combined with a low caloric diet effectively and economically maintained glycemic control and significantly improved life quality."      

The requested drug is likely to be more effective than the formulary alternatives.                                                 

The insurer's denial of coverage for Formulary Exception for Janumet XR (sitagliptin-metformin ER is overturned.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Right sided hemiplegia, developmental disorder of speech, difficulty walking, epilepsy, low vision in the right eye, microcephaly, and rosacea

Treatment: Consumer Directed Personal Assistance Services (CDPAS) 54.5 hours per week, current procedural terminology (CPT) code T1019

The insurer denied coverage for CDPAS 54.5 hours per week, CPT code T1019

The denial is modified

This is a patient with right hemiplegia, microcephaly, and epilepsy. She lives with her parents and brother in a private home. She attends a social day care program 6 hours/day (5 days/week). The most recent nursing assessment indicates that the patient's needs can be met with 22.75 hours of CDPAS per week. The patient is requesting a resumption of CDPAS 54.5 hours per week, CPT code T1019.  

The Uniform Assessment System (UAS) report was reviewed. The patient's cognition is described as severely impaired. However, she is "alert to person, place and situation." The patient requires maximal assistance for bathing, personal hygiene, and dressing. She is independent with toilet transfers/use. She is frequently incontinent of bladder and continent of bowel. According to the provider note, the patient "is able to walk independently." Her seizures were described as "not intractable, without status epilepticus, Hierarchical condition category (HCC)-chronic/persistent but manageable with current medications on board per neurology." According to the neurology physician assistance (PA) office visit note, the patient's "Epilepsy has been stable. She continues to have 4-6 seizures per month. Many of these seizures are short in length and last for less than 2 minutes." It was also noted "She doesn't fall over with her seizures. She doesn't lose bowel or bladder function or bite her tongue."  

The patient's limited cognitive deficits and significant functional impairments support the medical necessity of CDPAS. However, her condition and functional needs are not at a level or unpredictable as to require the requested CDPAS 54.5 hours per week; particularly with the social day care program 6 hours/day (5 days/week). This physician notes that an additional 12 hours (6 hours/day for 2 days) combined with the currently approved 22.75 hours of CDPAS per week for a total of 34.75 CDPAS hours/week, is medically necessary, allowing the patient the ability to continue living safely at home with her family.  

From a physical medicine and rehabilitation perspective, CDPAS 54.5 hours per week, is not considered medically necessary for this patient.  

An additional 12 hours (6 hours/day for 2 days) combined with the currently approved 22.75 hours of CDPAS per week for a total of 34.75 CDPAS hours/week, is medically necessary.

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

The insurer's denial of coverage for Consumer Directed Personal Assistance Services (CDPAS) 54.5 hours per week, current procedural terminology (CPT) code T1019 is modified. Medical Necessity is partially substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems-Coronary Artery Disease (CAD)
Treatment: Inpatient Hospital Stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

The patient has coronary artery disease (CAD), previous left anterior descending coronary stents, hypertension (HTN) and hypothyroidism who presented to the hospital following an abnormal stress test. Stress nuclear study showed medium size anterior and anterolateral partially reversible perfusion defects. The ejection fraction (EF) was 59 per cent (%). He had exertional chest pressure episodes for 6 months. His blood pressure (BP) was 183/81 millimeter (mm) of mercury (Hg) and pulse was 61 beats per minute (bpm). He received hydralazine for HTN.
He was admitted for a cardiac catheterization showing an 80% proximal left anterior descending coronary artery stenosis. This vessel was stented. He was given a Plavix loading dose. He was monitored overnight and remained stable. He was discharged home the next day on medical therapy, including cardiac medications - aspirin, atenolol, atorvastatin, losartan, and Plavix. 

No, inpatient hospitalization is not medically necessary. The patient had chest pain and an abnormal stress nuclear study. He presented electively for coronary angiography. This procedure is generally done at a lower level of care. There was no evidence for unstable angina, acute myocardial infarction or procedure-related complication which would necessitate inpatient hospitalization.

The patient presented electively for coronary angiography and was found to have a significant stenosis of the left anterior descending coronary artery, which was successfully stented. The procedure was uncomplicated. This is generally considered a lower level of care procedure. No clinical information was provided that would support inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient is a female. She presented to the emergency room with worsening right upper quadrant pain. The patient's past medical history includes morbid obesity.

The patient presented and on examination she had tenderness to palpation in the right upper quadrant.  The AST (aspartate aminotransferase) was 262 and ALT (alanine aminotransferase) was 500.  Abdominal ultrasound showed hepatomegaly with hepatic steatosis.  The patient was treated with intravenous Toradol, intravenous Zofran, intravenous Zosyn, and intravenous fluids.  The patient was discharged.

No, the Inpatient admission was not medically necessary.
An inpatient level of care was not medically necessary. The patient did not require any procedural or surgical intervention. The patient did not require to be nothing-by-mouth for a prolonged duration of time. The patient did not require prolonged treatment with intravenous hydration or intravenous medication. The patient did not have acute kidney injury. The patient did not have electrolyte derangement needing intravenous replacement, and did not have any complications such as intra-abdominal abscess or a surgical abdomen. Therefore, given the above, the Inpatient admission was not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left Hip Pain after Fall.
Treatment Healthcare Common Procedure Coding System (HCPCS) code A0428 [ambulance service, basic life support, non-emergency transport (BLS), modifier HS (ambulance transportation from hospital) and HCPCS code A0425 [ground mileage, per stature mile, modifier HS] x 58.
The insurer denied coverage for Healthcare Common Procedure Coding System (HCPCS) code A0428 [ambulance service, basic life support, non-emergency transport (BLS), modifier HS (ambulance transportation from hospital) and HCPCS code A0425 [ground mileage, per stature mile, modifier HS] x 58
.
The denial is overturned

This patient presented to the emergency room (ER) with complaints of left hip pain after a fall. He was seen by Orthopedics and had a left femur open reduction internal fixation (ORIF). His condition stabilized after treatment. The patient was transferred to a rehabilitation facility via non-emergency medical transport. 

The medical record demonstrates the patient underwent a bipolar hemiarthroplasty. He had associated medical issues and wound problems. These facts would place him at high risk for dislocation. It would be important for hip precautions to be adhered to. Transport in wheelchair or other form would likely place him at risk for the complication. The use of the stretcher would allow for satisfactory positioning. i.e. avoidance of flexion and adduction with no lever arms. The standard of care would be transport on stretcher as provided. 

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

The insurer's denial of coverage for Healthcare Common Procedure Coding System (HCPCS) code A0428 [ambulance service, basic life support, non-emergency transport (BLS), modifier HS (ambulance transportation from hospital) and HCPCS code A0425 [ground mileage, per stature mile, modifier HS] x 58 is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lumbar (L) spondylosis.
Treatment: Pain injection.
The insurer denied pain injection. 
The health plan's determination is overturned. 

The patient is a female with a past medical history (PMH) of lumbar (L) spondylosis status/post (s/p) L4-5 and L5-S (sacral)1 fusion with lower back pain which radiates to her R (right) posterior leg. Her pain is worse with prolonged standing, walking and sitting. It improves with shifting position, rest and medication. She received an L5-S1 epidural steroid injection (ESI) with benefit. She had > (greater than) 50% reduction in back and leg pain for >2 months. Caudal injections didn't provide as much relief. She has a + (positive) straight leg raise (SLR) on exam bilaterally. Her lumbar magnetic resonance imaging (MRI) demonstrates a grade 1/2 spondylolisthesis at L2-3 with severe stenosis and moderate stenosis at L3-4. She also participates in a home exercise program (HEP) and takes an occasional muscle relaxant in addition to Aleve and gabapentin.

The pain injection is medically necessary for this patient.

It would be considered standard practice to offer an epidural steroid injection in the setting of symptomatic lumbar stenosis causing radicular symptoms, as was the case with this patient. Standard of care typically includes conservative measures such as physical therapy (PT), home exercises, non-narcotic pain medications. If those don't provide durable relief, the addition of an epidural steroid injection is reasonable and within the standard of care (1). This modality has demonstrated efficacy with appropriate patient selection (3).