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

Diagnosis: Dehydration

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld. 

This female patient has a history of major depressive disorder, chronic alcohol abuse, chronic pancreatitis, chronic cholecystitis, hypertension, hyperlipidemia, and diabetes mellitus.  The patient presented to the Emergency Department (ED) with a 5-day history of not eating due to nausea and a 3-day history of vomiting, with dizziness and low blood pressure (81/55) at home that day, worse with standing up.  The patient also reported taking her lisinopril 40 mg that morning. The patient's initial vital signs included: Blood Pressure 75/49, Heart Rate 103, Temperature 97 F, Respiratory Rate 18, and Oxygen Saturation on room air 100%.  The patient's electrocardiogram (EKG) showed normal sinus rhythm with no significant ST-T wave abnormalities and QTc of 0.48. The patient's laboratory test results included white blood cell (WBC) count of 6.1, hemoglobin of 14.5, blood urea nitrogen (BUN) of 23, creatinine of 2.08, potassium of 2.8, sodium of 133, chloride of 89, glucose of 237, magnesium of 0.9, alanine aminotransferase of 239, aspartate aminotransferase of 279, lipase of 73, amylase of 38, lactate of 2.0, and troponin of 0.02.  The patient's toxicology screen was negative. The patient was treated with intravenous (IV) saline, potassium chloride, magnesium, famotidine, and Reglan. The chart records indicated that the patient felt better after hydration and was ambulating without dizziness. The patient's laboratory test results included creatinine 1.19, potassium 3.0, and magnesium 1.6, and the patient remained hemodynamically stable during her hospitalization. The patient was discharged to home for outpatient management on aspirin, atorvastatin, bupropion, clopidogrel, escitalopram, famotidine, folic acid, ibuprofen, lisinopril, metformin, multiple vitamins, naltrexone, and nicotine patch.

Based on the review of the medical record and literature, inpatient hospital admission was not medically necessary for this patient. There is no clinical evidence that this patient required an acute inpatient level of care to treat her dehydration, which was most likely related to this patient's chronic pancreatitis and alcohol abuse.  This level of patient care could have been safely provided and completed in the Emergency Department (ED) or at an observation level of care.

The health plan did 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 upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Substance abuse
Issue under review:  Inpatient admission

Determination:  The Inpatient admission was medically necessary.

The patient is an adult male.  He was admitted for inpatient substance use disorder treatment to address opioid (heroin); and sedative-hypnotic-anxiolytic (benzodiazepine) and cannabis (marijuana) use disorders.  The patient has a history of poly-substance abuse with progression to daily continuous use of substances, including past use of heroin and medication assisted treatment with Suboxone (20 mg total daily dose of buprenorphine) and benzodiazepines (prescribed Klonopin and non-prescribed Xanax) and marijuana.  He presented with serious medical complications from use that included withdrawal symptoms, frequent blackouts, withdrawal seizure with the last occurring in 2019, and a history of treated hepatitis C virus.  The patient had experienced a dramatic decline in functioning related to the severe substance use disorders including unemployment and homelessness.  The patient had been diagnosed with co-occurring psychiatric disorders that included posttraumatic stress disorder (PTSD), unspecified depressive disorder and generalized anxiety disorder, as well as presenting with prominent sleep disturbance and trauma related symptoms related to being a victim of a robbery at gunpoint.

In this case scenario, the patient's co-occurring psychiatric disorders, persistent post-acute withdrawal symptoms, and lack of awareness or limitations of insight together with the seriousness of the substance use disorders is illustrated by his continued use despite functional decline, and despite having access to treatment in the community.  The presence of high-risk behaviors with use of non-prescribed Xanax together with Suboxone and trauma related symptoms complicate this case.  Additionally, the patient's co-occurring mental health issues that included mood disturbance and PTSD and the anxiety disorder were triggering the patient's use of substances including prominent symptoms including nightmares related to the PTSD.  The patient's recovery environment was not sufficient for treatment with lower level services, and the patient did not have sober supports to sustain a recovery effort in a less restrictive environment. These factors are the reason that the patient could not have been/could not be safely or effectively treated at a lower level of care during the time interval under review.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal pain.
Treatment: Inpatient stay.

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

The patient was woman who presented to the hospital with a chief complaint of abdominal pain. She had a past medical history of asthma, human immunodeficiency virus (HIV), gestational diabetes, anemia and nephrectomy. She stated the pain started one day prior to presentation and was sharp and severe. She denied fevers and vomiting. She had presented at an outside hospital and been diagnosed with gastritis. Vital signs showed blood pressure 147/87, heartbeat 115, temperature 97.3 Fahrenheit, and respiratory rate 20. On physical exam, she was in acute distress, breath sounds were normal, and there was left sided abdominal tenderness to palpation. Initial labs showed white blood cell (WBC) 21.6, lactate 2.9, and troponin negative. Analysis of urine was positive for leukocytes. An electrocardiogram (EKG) showed normal sinus rhythm. Computed tomography (CT) imaging demonstrated small gallstones and a 10 millimeter (mm) stone in the distal right ureter. The patient was admitted for complicated urinary tract infection with right ureter stone and sepsis. 

The inpatient hospital stay was medically necessary. Patients with sepsis from infection such as UTI (Urinary Tract Infection) are not typically treated at a lower level. They require close monitoring of vital signs to ensure that the patient does not experience deterioration, and to ensure that the patient's hemodynamic instability resolves rapidly.
This patient presented with ureteral obstruction, urinary tract infection (UTI), and sepsis given suspected infection, marked leukocytosis, and tachycardia. These patients require a higher level of care because of the risk of worsening sepsis and septic shock. They are also at increased risk for end organ injury, including acute kidney injury (AKI). This patient was septic and this usually requires management at the inpatient level. Hospital discharge was premature due to her leaving against medical advice.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary Artery Disease, Congestive Heart Failure, Polyarthritis and Diabetes Mellitus. 
Treatment: Increase in Consumer Directed Personal Assistance (CDPAS) Services From 49 To 84 Hours Per Week. 

The insurer denied the Increase in Consumer Directed Personal Assistance (CDPAS) Services From 49 To 84 Hours Per Week.  The denial is upheld. 

The patient is a female with a past medical history pertinent for Coronary Artery Disease, Congestive Heart Failure, Polyarthritis and Diabetes Mellitus. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). An appeal review was requested for potential approval of 84 hours/week Personal Assistance Services to offer increased ADL (activities of daily living) support. 

No, the proposed treatment of 84 hours/week Personal Assistance Services is not deemed medically necessary. 

The patient is a female with a past medical history pertinent for Coronary Artery Disease, Congestive Heart Failure, Polyarthritis and Diabetes Mellitus. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). However, an assessment of the patient's functionality and ability to perform ADLs (activities of daily living) was completed and revealed that the currently approved plan of 49 hours/week Personal Assistance Services is sufficient to meet the patient's current needs. 

Specifically, the assessment revealed that the patient is cognitively intact, not home/housebound, is able to make her basic needs known, is limited assist with bed mobility and only requires supervision/set up assistance for eating. 

There is no additional documentation which demonstrates that the patient has sustained further functional loss since the date of this last assessment. For these reasons, the proposed treatment of 84 hours/week Personal Assistance Services is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Coronary Syndrome.
Treatment: Inpatient Admission.

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

The patient is a female with no significant past medical history who was sent to the Emergency Department (ED) from her doctor's office after electrocardiogram (ECG) revealed new onset "left bundle branch block."  The patient had no symptoms of chest pain or dyspnea and felt fine both prior to and on presentation.  Vital signs and physical examination were normal on arrival.  ECG revealed sinus rhythm with an interventricular conduction delay and QRS duration of 138 millisecond.  Serial troponin studies were less than 0.015 (normal).  Myocardial perfusion testing revealed a normal left ventricular ejection fraction and no evidence of ischemia.  The patient was ultimately discharged from the hospital. 

This patient presented with an abnormal ECG, no symptoms and no significant past medical history.  Her pretest probability of coronary artery disease was low. (1)  Utilizing the History, EKG (electrocardiogram), Age, Risk factors, and Troponin (HEART) score she was considered low risk. (2)  Utilizing the thrombosis in myocardial infarction (TIMI) risk score she also had a low risk of developing major adverse cardiac events in the subsequent 30 days. (3) Risk assessment of patients presenting with chest pain and no significant ST (ST elevation myocardial infarction) changes on ECG was reviewed by Hedayati et al. (3)  Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events [defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death] in the six weeks following presentation.  Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation.  In conclusion, acute inpatient admission to the hospital to treat an acute cardiac event was not medically necessary.

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

The insurer's denial of coverage for the inpatient admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Shortness of Breath and Leg Swelling.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned. 

The patient is a male with a history of persistent atrial fibrillation and heart failure with preserved left ventricular ejection fraction (LVEF).  The patient presented with worsening lower extremity edema and dyspnea on exertion.  Electrocardiogram (ECG) revealed atrial fibrillation (AF) with a controlled ventricular rate. On ambulation, the patient was noted to desaturate to 89%.  Serum brain natriuretic peptide (BNP) was elevated.  Computed tomography angiogram (CTA) ruled out pulmonary embolism.  The patient was admitted for diuresis and was noted to have runs of non sustained ventricular tachycardia that required treatment with amiodarone therapy.  Ultimately the patient's symptoms improved following diuresis.

Yes, the proposed inpatient admission was medically necessary.

This patient presented to the hospital with decompensated acute on chronic heart failure with preserved left ventricular ejection fraction (LVEF) and required treatment at a higher level of care.

This patient presented with decompensated congestive heart failure. Oxygen saturation was depressed on ambulation and lower extremity edema was present on physical exam.  He also had commitant atrial fibrillation and runs of non sustained ventricular tachycardia on telemetry requiring treatment with anticongestive therapy and amiodarone.  This patient could not have been managed at an alternate level of care and required inpatient treatment/follow up. There have been several studies including a meta analysis of more than 50,000 patients demonstrating poor outcomes for patients that are discharged from the emergency department after presenting with congestive heart failure.  These findings were true in both systolic and diastolic congestive heart failure (CHF). (Reference 1, 2). In conclusion, it was appropriate to manage this patient at an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status post bariatric surgery
Treatment: Excision, excessive skin and subcutaneous tissue (including lipectomy); other area medial thighs (15839) Pre-service
The insurer denied the Excision, excessive skin and subcutaneous tissue (including lipectomy); other area medial thighs (15839) Pre-service
The denial is upheld.

This is a female patient that has excess skin in her hips. She has lost 200 pounds following bariatric surgery. She was treated with bilateral thigh lifts.  She complained of pain and difficulty ambulating.  A two stage procedure was planned to first remove the lateral thigh tissue and a second procedure to remove the medial thigh tissue. According to her PCP (primary care physician) and physical therapist, the patient has problems with rashes, pain and ambulation.

No, the proposed treatment is not medically necessary.

This patient has significant truncal lipodystrophy despite bariatric surgery. The hip and thigh distribution is consistent with the pattern seen with lipedema. Liposuction is the standard treatment for lipedema. Plan is for a medial thigh lift, but the majority of her lipodystrophy is lateral. Moreover, a standard thigh lift is unlikely to remove sufficient tissue to significantly alter her gait or the contact area in her medial thighs.  She has peau d'orange changes in her skin, which significantly increase the risk of surgery in an area that is notoriously difficult to heal.  The records do not provide compelling documentation of problems with rashes.  PCP (primary care physician) notes describe rashes, but clinical notes documenting cellulitis or medical treatment for rashes are not provided. This patient has a more complex problem that loose hanging thigh skin. As noted, her appearance is more consistent with lipedema, and thigh lift is not confirmed to be the most appropriate treatment for this diagnosis.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Crohn's Disease.
Treatment: Stelara at a dose of 90mg every 4 weeks.
The insurer denied the Stelara at a dose of 90mg every 4 weeks.
The denial is overturned. 

The patient is a male. He has history of psoriasis, inflammatory arthritis, Crohn's disease (ileocolitis) complicated by perianal fistulizing disease. He had failed Remicade in the past. He had undergone total colectomy and had undergone ileal pouch-anal anastomosis (IPAA), revised to end-ileostomy. He was also treated with Humira, but was discontinued due to drug-induced liver injury. He was started on Ustekinumab (Stelara). The patient continued to have an active disease and persistent perianal fistulae as demonstrated on pouchoscopy and MRE (magnetic resonance elastography), and MR (magnetic resonance) pelvis.

The patient was started on Methotrexate as an immunomodulator, as the dose-escalation of Ustekinumab was denied by the insurance company. As the patient continued to have persistent perianal fistula, and active pouchitis, and anal stricture, the provider has requested to dose escalate ustikinumab from every 8 weeks to every 4 weeks in an attempt to induce remission of very aggressive Crohn's disease in this patient.

Yes, the health plan should cover the Stelara at a dose of 90mg (milligrams) every 4 weeks.

Yes, the treatment with Stelara at a dose of 90mg every 4 week is likely to be more beneficial in potentially inducing remission of his active Crohn's disease and healing of anorectal fistula.

The patient continues to have active/aggressive disease, and dose-escalation of the biologics has been shown to be effective in controlling and inducing remission.

Improving response rates to biologic agents remains a significant problem in clinical practice. Optimizing biologic therapy by decreasing dosing intervals has been shown to recapture response in patients treated with biologics.

Previous studies reporting on the efficacy of ustekinumab for CD (Crohn's disease) have described a subset of patients who underwent dose intensification. In a Spanish study of ustekinumab for refractory CD (Crohn's disease) in which 116 patients were enrolled, the authors reported on 11 patients who underwent dose escalation and found that eight (73%) patients recaptured response (1). In another report of 104 patients looking at long-term efficacy of ustekinumab in patients with CD (Crohn's disease), 17 (16.3%) patients required dose escalation, and response was recaptured in 9 of 17 (52.9%) patients (2). In a retrospective study, the authors found that shortening the dose interval of ustekinumab to every 4 weeks for patients with CD (Crohn's disease) who did not respond to doses every 8 weeks improved clinical and biological indices of disease activity, and that 28% of patients with active CD (Crohn's disease) achieved clinical remission (3).

Therefore, patients who lose response to the standard dose of ustekinumab are evidenced to potentially benefit from dose interval shortening, which was effective and safe in all clinical studies.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital admission for medical necessity. 
The denial was upheld.

The patient is a male with a known medical history of diabetes mellitus (DM) requiring insulin, hypertension, gastroparesis, smoking and marijuana use. He presented to the emergency department (ED) with complaints of nausea, vomiting for 1 week and an inability to keep anything down for 1 day. In the ED, his vital signs showed an elevated blood pressure (BP) with systolic BP in the range of 190-200. His other vital signs were unremarkable. His physical exam was within normal limits.
His lab work revealed an elevated glucose at 363, creatinine (Cr) was 1.65, lactate was 3, and creatine kinase (CK) was 1837. He was treated with as needed labetalol, and subcutaneous insulin. Due to a persistently elevated BP, he was started on a nicardipine drip in the ED at 5 milligrams (mg)/hour (hr).
He was initially admitted to Intensive Care Unit (ICU) for management of hypertensive urgency with a nicardipine drip and up-titration of oral anti-hypertensives and for control of nausea and vomiting. He was administered intravenous (IV) fluids. The nicardipine drip was decreased to half dose within 2 hours of initiation and the admission was downgraded to a step-down unit. The nicardipine drip was stopped with an improved control of his blood pressure. The drip was infused for a total of approximately 8 hours. His blood pressure control improved, and his oral anti-hypertensives were adjusted in consultation with cardiology.
He was downgraded to a medical floor with continued hydration and monitoring. He continued to improve and was able to tolerate through mouth (per orem), by mouth, or oral nutrition (PO) and was discharged in improved condition.

At issue is the inpatient stay for medical necessity.
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.
Although the patient's blood pressure was elevated requiring a brief period of administration of a nicardipine infusion, there were no findings suggestive of hypertensive emergency like mental status changes with encephalopathy, chest pain, shortness of breath, or syncope. His creatinine was mildly elevated which was partly due to dehydration in the setting of mild rhabdomyolysis likely to respond to IV fluids. The patient had a hypertensive urgency which was adequately and appropriately treated with administration of oral and as needed (PRN) antihypertensive after a brief period of administration of nicardipine.
The inpatient stay was deemed not medically necessary after review of medical records and the patient's diagnosis of hypertensive urgency with no end organ damage or evidence of hypertensive emergency. The patient could have been managed at a lower level of care status.