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

Diagnosis: Bacteremia

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is overturned.

This male has a past medical history significant for immunocompromised condition, small bowel obstruction, status post exploratory laparotomy, rheumatoid arthritis, and polysubstance abuse who presented to the Emergency Department (ED) with complaints of multiple skin abscesses, malaise, chills, and sweats.  The patient's vital signs on presentation included: temperature 99.1 F, blood pressure 71/39, heart rate 106, respiratory rate 45, and oxygen saturation 93% on room air. The patient's laboratory results included the following: white blood cell (WBC) count 15.1, hemoglobin 12.5, hematocrit 37.1, creatinine 1.24, and potassium 3.2. The patient was started empirically on the intravenous antibiotics vancomycin and azithromycin for methicillin-resistant staphylococcus aureus (MRSA) bacteremia and Campylobacter infection. The patient had multiple skin abscesses likely related to active intravenous drug abuse. The patient had intermittent fevers. The patient's computed tomography (CT) scan of the lungs revealed multi-focal nodules suggestive of septic emboli. Infectious Disease serviced was consulted and they adjusted antibiotic coverage for the patient. Thoracic surgery placed a right-sided chest tube in the patient for drainage. The patient was also treated for oral thrush. The patient's echocardiogram was negative for vegetation. The Surgery team attempted drainage of multi-loculated collections of bilateral lower extremities. Interventional radiology performed CT-guided drainage procedure. The patient was treated, stabilized and was discharged home on oral antibiotic therapy.

According to documentation submitted for review, this patient presented with MRSA bacteremia. The patient was febrile and tachycardic with borderline blood pressures. The patient's laboratory results showed elevated leukocytes, cultures positive for MRSA and abnormal imaging studies. Based on these clinical findings in a high-risk patient with immunocompromised illness and active polysubstance abuse, inpatient admission was medical necessary. The patient had a complicated hospital course with persistent fevers despite intravenous antibiotics requiring multiple surgical interventions. Based on this patient's on-going risk factors, transfer to an in-network hospital would have posed unnecessary risk for this patient.  Thus, inpatient level of care admission was medically necessary for this patient.

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

Based on the above, the medical necessity for inpatient level of care admission is substantiated.  The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Depression, Suicidal Ideation.

Treatment: Inpatient hospital admission.

The insurer denied the inpatient hospital admission. 

The denial was overturned.   

This is a male patient who was admitted to inpatient mental health treatment due to depressive symptoms including depressed mood, suicidal ideation and reports that he did not trust himself to be alone, anhedonia, worthlessness, sleeping problems, panic attacks, anxiety disorganized behavior including walking aimlessly outside, and substance use. The patient's history was significant for two past psychiatric hospitalizations. The patient reportedly lived with his mother. During inpatient stay, the patient was treated with multiple medications, including Lexapro. The patient reported having feelings of improvement and was discharged with instruction for community aftercare.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Major Depressive Disorders reports that treatment settings for patients with major depressive disorder include a continuum of possible levels of care and in general, patients should be treated in the least restrictive setting that is most likely to prove safe and effective. It states that the psychiatrist should choose an appropriate site of treatment after evaluating the patient's clinical condition, including symptom severity, co-occurring conditions, level of functioning, and available support system. The estimated degree of risk to self and to others is another significant determinant of treatment setting. Decisions about treatment setting should also include consideration of the patient's ability to adequately care for him- or herself, provide reliable feedback to the psychiatrist, and cooperate with treatment of the major depressive disorder. 

The patient was not psychiatrically stable as he had sudden mental status changes going from good to bad quickly without warning signs which resulted in confusion and upsetting the patient. It was reported that the patient had thought-blocking, had racing thoughts, poor concentration, and minimal interaction, thought blocking, and dysphoric mood, feeling alone, anxious, and talking to himself in the middle of his admission.  The patient was discharged after a day of observation without severe psychiatric symptoms. Based on the review of the medical record, the patient exhibited significant psychiatric symptoms, was not at his baseline, and was at high risk for worsened symptoms during his denied hospitalization stay. 
The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

Based on the above, the medical necessity for the continued inpatient hospital stay is substantiated.  The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient Hospital. 
The insurer Denied: Inpatient Stay. 
The denial is overturned in whole. 

The patient is a female who presented to the emergency department, based on referral by her family doctor, due to 3 days of left leg pain and edema, with heaviness in the left leg. 

A D-dimer was obtained, which was elevated at 7000. Twelve-lead electrocardiogram (EKG) shows normal sinus rhythm, with a heart rate of approximately 90 beats per minute, no ST-segment elevations. A lower extremity duplex was done, which showed acute on chronic DVT in the left tibial and gastrocnemius veins, described as nonocclusive, and does not appear to be free-floating. 

The following day, the patient was resting comfortably, continued to have leg edema, and vital signs were stable. Hemoglobin remained at 7 gram/deciliter (g/dL). The medical team decided to transfuse the patient 1 unit of packed red blood cells and repeat hemoglobin later in the evening. The hematologist evaluated the patient and recommended continuing with Lovenox at 1 mg/kg subcutaneous every 12 hours. The medical team placed a consult to vascular surgery, for inferior vena cava (IVC) filter placement. Vascular surgery, the patient, and the family declined have an IVC filter placed. Gastrointestinal (GI) consultation was requested. 

The following day, the patient remained stable. Posttransfusion hemoglobin increased to 7.7 g/dL. The gastroenterology team assessed the patient and notes she has chronic anemia with occult GI bleeding, likely due to a history of ulcerative colitis. A decision was made to place an IVC filter and the following day start the patient on Xarelto.
The IVC filter was placed without complications. At this point, the patient was deemed stable for discharge. The question at hand is whether the hospital admission required an inpatient stay. 

The health plan's determination is overturned. 

This patient has ulcerative colitis, which predisposes the patient for thromboembolic events, however at the same time, carries an increased risk of gastrointestinal bleeding. During the hospitalization, the patient was guaiac positive, suggestive of actual gastrointestinal bleeding. Therefore, initiation of anticoagulation needed to be done in a careful fashion, after ruling out major causes of gastrointestinal bleeding endoscopically. It was appropriate to admit the patient under inpatient status in order to monitor closely, monitor the hemoglobin levels, obtain expert consultation from gastroenterology, and endoscopic evaluation. During the hospital stay, the patient was treated with a blood transfusion. The patient was initiated on anticoagulation with reversible agents, which can be rapidly stopped, should the patient start to exsanguinate rapidly. As a result, the evaluation and treatment extended beyond the spectrum of care at a lower level and required inpatient hospitalization.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Migraine Headaches
Treatment Eletriptan HBR 40MG TABLET
The insurer denied the Eletriptan HBR 40MG TABLET.
The determination is overturned.

The has with migraines. She is breast feeding. The patient was previously using sumatriptan. A change to eletriptan is requested and under review is the medical necessity of the eletriptan HBR.
The requested eletriptan is medically necessary for this patient. The patient is breastfeeding. She has acute migraines. Triptans are considered to be an effective treatment for acute migraine and are Food and Drug Administration (FDA) approved and compendia supported for treatment of this diagnosis. All of the triptans [including except Naratriptan, Rizatriptan, and Zolmitriptan which are on the plan formulary] except eletriptan are listed as "probably compatible" with breast feeding whereas eletriptan is listed as "compatible" with breastfeeding. As such, the best available science indicates that eletriptan is the safest choice for a breastfeeding mother. While the effects of eletriptan on the nursing infant are not known, the very low concentrations of the drug in the breast milk suggest that eletriptan is compatible with breastfeeding. Additionally, pumping or "pumping and dumping" several hours after the dose may decrease exposure to the infant even further.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis:  Chronic atypical facial pain.
Treatment:  Formulary exception for Levorphanol Tartrate 2MG Tablet.

The insurer denied the Formulary exception for Levorphanol Tartrate 2MG Tablet.  The denial is overturned. 

The patient is a male with chronic atypical facial pain.  He has been prescribed Levorphanol.  

Yes, the health plan should cover the formulary exception for Levorphanol Tartrate 2MG Tablet.

The patient has a diagnosis of atypical facial pain.  The patient has been on this medication for over three years.  This is a continuation of therapy.  The patient has failed one formulary alternative.  The patient has failed numerous other medications, such as gabapentin and Lyrica.  His pain is well-controlled with this medication, over 80% relief, and he has been on a stable dose.  Discontinuing this medication, in order to try a formulary alternative can lead complications.  The formulary alternatives are commonly understood to have a higher abuse and addiction potential.  

Levorphanol has greater norepinephrine uptake, and it can be more advantageous in the treatment of refractory neuropathic pain conditions, such as atypical facial pain.  Also, similar to opiate medications with norepinephrine uptake, its abuse potential tends to be less than the formulary alternatives.  

Therefore, given the above, the requested Levorphanol is medically necessary, and the health plan should cover the formulary exception for Levorphanol Tartrate 2MG Tablet.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Botox 200 units every 3 months. 
The denial is upheld in whole. 

The patient is a female with chronic migraine. The patient has greater than 15 headaches per month with greater than 8 migraines per month. The headaches last longer than 4 hours each and have been present for at least 3 months. The patient has previously tried and failed antidepressants, anticonvulsants, and beta-blockers. Treatment with Botox is the subject of this review. The dose requested is 200 units every 3 months rather than 155 units, which is the standard dose.

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

Botox at the dose of 155 units every 3 months is medically necessary as the patient has an FDA approved and literature supported diagnosis, chronic migraine. The patient has also tried and failed various oral preventative therapies such as anticonvulsants, antidepressants, and beta-blockers.

However, Botox at the requested dose of 200 units every 3 months is not medically necessary as this dose is not supported by the literature, manufacturer, Food and Drug Administration (FDA), or compendia. Additionally, the patient has not tried and failed the recommended dose of Botox, which is 155 units every 3 months.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyperglycemia, Vulvovaginitis

Treatment: Inpatient admission.

The insurer denied the inpatient admission.

The denial was upheld.

This is a female patient with a medical history of diabetes mellitus, schizophrenia and hyperlipidemia. She presented to the Emergency Room (ER) with vaginal discharge. She had recently been discharged on newly prescribed insulin but had not taken it for over a week.  Her schizophrenia required no treatment as indicated by psychiatry. Her vital signs were noted to be stable and her physical exam was unremarkable. The patient was noted to non-compliant with her diabetes regimen and had elevated blood sugars (740) and elevated anion gap - 19.  Urine was negative for ketones. The patient was treated in the ER with insulin and saline and admitted for further management of elevated blood sugars. At that time laboratory results indicated her BUN /Cr had normalized, and repeat BS was now 332 and anion gap was 9 and Na 132. She was treated for candida vulvovaginitis.  She was discharged in a stable condition.  

The health care did act in the best interest of the patient.  Inpatient admission was not needed.  The patient was clinically stable with no evidence of acute hyperosmolar syndrome or ketoacidosis. She responded to treatment with insulin and fluids with, essentially, normalization of her labs.  The patient could have been managed in observation and did not require acute an inpatient admission.

The carrier's denial of the acute inpatient stay is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest Pain, Acute Coronary Syndrome.
Treatment:  Inpatient admission.

The insurer denied the inpatient admission.  The denial was upheld.

This is a male patient with a history of homelessness, chronic obstructive pulmonary disease, hypertension and an immune deficiency disorder.  He presented to the Emergency Room (ER) with complaints of intermittent left-sided chest pain, which radiated to his back and arm.  He reported that the chest pain had been present for the past several months, but had worsened with deep inspiration and movement in the past few days.  He also endorsed shortness of breath, left arm numbness, frequent falls and a dry cough.  His vital signs were stable.  Two troponin levels were negative.  Chest radiography demonstrated no acute pathological findings.  An electrocardiogram (EKG) was performed that showed diffuse T-wave inversions, with concern for Wellen's syndrome.  It was noted that a repeat EKG was unchanged and consistent with left ventricular hypertrophy.  The patient was admitted and ruled out for myocardial infarction.  An echocardiogram revealed diffusely hypokinetic wall motion, decreased ejection fraction (left ventricular ejection fraction 15-20%) and normal right ventricular function.  Repeat troponin levels were negative.  The patient left the hospital against medical advice.

The patient presented with a history of chest pain which was concerning for cardiac etiology.  He underwent an appropriate initial evaluation in the Emergency Department, which was unremarkable.  This included normal hemodynamics, physical exam, a non-diagnostic EKG and negative cardiac troponins.  There were no other high-risk symptoms present to suggest acute coronary syndrome.  Although it was medically essential to evaluate the patient's symptoms, inpatient admission was not medically necessary in this instance.  The patient's care could have been provided under the observational setting, allowing for additional diagnostic testing.  During the patient's initial evaluation and subsequent hospitalization, there was no objective evidence of hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia or other medical conditions warranting acute inpatient level of care.  

The health care 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 services is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Psoriasis.
Treatment:  Otezla 30mg tablet.
 
The insurer denied the Otezla 30mg tablet.  The denial is overturned.

This is a man with psoriasis affecting 30% body surface area (BSA) for whom Otezla is requested.  He has tried and failed topical clobetasol and calcipotriene and been on Otezla samples for three months with about five percent decrease in BSA.  He believes he has plateaued.

Yes, the proposed treatment with Otezla is medically necessary.

The patient has moderate to severe psoriasis and has been on Otezla for three months with improvement.  Since the patient has achieved a positive clinical response, as evidenced by improvement in signs and symptoms since starting treatment with the requested drug, Otezla is medically necessary as continuation of treatment.

Otezla, an inhibitor of phosphodiesterase four (PDE4), is indicated for the treatment of adult patients with active psoriatic arthritis and patients with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy (Celgene, 2015).  Otezla is an oral small molecule inhibitor of phosphodiesterase four (PDE4) specific for cyclic adenosine monophosphate (cAMP) and is indicated for the treatment of adult patients with active psoriatic arthritis (PsA), as well as the treatment of patients with moderate to severe plaque psoriasis (Celgene, 2016).

It is not medically appropriate to stop current therapy in order to try other therapies (such as conventional systemic agents).  Additionally, stopping the current treatment with Otezla, on which he is improving, risks a disease flare.  Therefore, continued use of Otezla is medically appropriate and necessary for this member.
Appeal type: Medical necessity
Decision: Overturned

Respiratory System
Inpatient Hospital

The patient is a male who presented with fever. He was well until 3 days prior to admission when he developed fever, cough, and congestion. His temperature was up to 101.8 F at home. He had also been coughing and 'wheezy' according to his parents, and his eyes were noted to be swollen. He was drinking less than usual and having less urine output. On the day of admission, he was unable to feed due to nasal congestion.
In the emergency department he was found to have tachycardia with a heart rate of 165 beats per minute (bpm). Blood and urine cultures were sent, and he was given 2 intravenous boluses of normal saline. His tachycardia improved after that, and he was then started on maintenance intravenous fluids. Laboratory values were significant for an elevated potassium of 7.0, and therefore an electrocardiogram (EKG) was obtained. He was admitted to the hospital for continued intravenous fluid hydration and monitoring for possible sepsis with cultures pending.
Following admission, he was given intravenous fluids with cardiorespiratory monitoring. He became afebrile and his oral intake improved over time. By the date of discharge his cultures had remained negative and he was felt to be stable for discharge to home with follow-up as an outpatient.

This patient presented with fever, decreased oral intake, and tachycardia. He was not drinking at all on the day of presentation. He also was found to have a very elevated potassium, which can cause dangerous arrhythmias. He required inpatient admission for ongoing intravenous fluids along with close monitoring with further intervention as needed, while cultures were pending. Infants this young can become ill very quickly from sepsis due to their immature immune systems, and may demonstrate few, if any, clues to the underlying illness on physical examination. Admission is necessary when sepsis is being considered to allow for prompt initiation of treatment and to prevent potentially serious morbidity.
The decision making at the time of admission for this patient was consistent with his age, the presence of fever and tachycardia which raised concern for possible sepsis in an infant this young, and his decreased oral intake which required ongoing treatment with intravenous fluids along with close monitoring for potential deterioration of clinical status.
Appeal type: Medical necessity
Decision: Upheld

Digestive System/Gastrointestinal
Inpatient Hospital

This patient presented to the emergency department with abdominal pain. On presentation, the patient had a temperature of 98.2F, a pulse rate of 102 beats per minute (bpm), a blood pressure of 128/72 millimeters of mercury (mmHg), a respiratory rate of 20/minute, and an oxygen saturation of 100% on room air. Bloodwork was notable for a white blood cell count (WBC) of 9.1, a hemoglobin of 13.6, a hematocrit of 42.1, a platelet count of 193,000, a sodium of 140, a potassium of 4.5, a chloride of 104, a bicarbonate of 25, a total bilirubin of 0.8, an alkaline phosphatase of 49, an aspartate aminotransferase (AST) of 22, an alanine aminotransferase (ALT) of 14 and an albumin of 4.7. A computed tomography (CT) of the abdomen/pelvis revealed acute sigmoid colon diverticulitis with a small amount of free fluid in the pelvis. The patient was admitted to the medical floor and treated with conservative management with intravenous fluid hydration, antibiotic therapy and pain control. Gastroenterology service was consulted. The patient did improve over the course of the hospitalization and ultimately was discharged with close follow-up as an outpatient.

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

The requested health service/treatment of inpatient stay was not medically necessary for this patient. This patient presented with abdominal pain. On presentation, the patient was hemodynamically stable without fever, tachycardia or hypotension. Bloodwork did not reveal leukocytosis, anemia or significant electrolyte derangements. A CT of the abdomen/pelvis revealed acute sigmoid colon diverticulitis with small amount of free fluid in the pelvis. The patient was admitted to the medical floor and treated with conservative management with intravenous fluid hydration, antibiotic therapy and pain control. The gastroenterology service was consulted. The patient remained hemodynamically stable without development of phlegmon/abscess, bowel perforation, sepsis or require endoscopic or surgical intervention. Therefore, consistent with generally accepted standards of medical practice as supported by nationally recognized peer reviewed literature and guidelines, the patient could have been safely and effectively managed at a lower level of care and did not require an acute level of care and inpatient admission.