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

Diagnosis: Abdominal pain, ovarian cyst, rule out appendicitis
 
Treatment: Inpatient admission, monitoring

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

This is a teenage female with a history of hemorrhagic ovarian cyst (1 month prior).  She presented to the emergency department (ED) with a six hour history of periumbilical and right lower quadrant (RLQ) abdominal pain, and vomiting x 1.  The patient was afebrile upon presentation with stable vital signs.  The pain was mostly periumbilical and RLQ region.  She felt chills the previous day and had a temperature of 100 on the day of presentation.  She had no diarrhea. An examination revealed the abdomen to be soft, non-distended with pain on palpation in the epigastric, periumbilical, suprapubic region and RLQ.  Ultrasound of the appendix revealed neither a normal nor an abnormal appendix visualized.  Imaging of the abdomen revealed a cyst in the left ovary measuring 2.7 x 2.8 x 3.0 cm.  The appendix was identified and was fluid filled and distended up to 8.6 mm with borderline prominent appendiceal wall.  The impression was evidence of appendicitis with distended fluid filled appendix.  White blood cell (WBC) count was 16.2. Pediatric surgery noted the pain subsided while the patient had been in the ED without administration of antibiotics. The abdomen was soft, non-distended and non-tender.  The attending noted that her clinical course suggested a cause other than appendicitis.  Because appendicitis could not be excluded, they admitted the patient for further evaluation. A repeat WBC was 7.7.  Her symptoms resolved, and she was discharged.

This patient could have been treated with an observation admission and discharged within 23 hours. She did not have any indication for acute care admission as the patient was treated with observation for suspected appendicitis and serial exams, but in the end had an ovarian cyst as the cause.  

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: Dementia/ Congestive heart failure
Treatment:Home Care/Personal Care 

Summary:

This is a male with a past medical history pertinent for dementia, congestive heart failure and gait ataxia. For these reasons, he requires assistance with the majority of his activities of daily living (ADLs). Per the medical records, the patient has been exhibiting progressively worsening cognition and gait ataxia with increased fall risk. For these reasons, the proposed treatment of Home Care/Personal Care HHC-Level 2 Personal Care Services, per 15 minutes Increase to 42 Hours per week to better assist with completion of the patient's ADLs is deemed medically necessary. The health plan's currently approved 28 hours per week are not sufficient to meet this patient's needs.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Opioid dependence
Issue under review: Zubsolv

Determination:
The Zubsolv is medically necessary.

The health plan should cover the requested Zubsolv tablets at a dose of 11.4/2.9 in this case. The patient's opioid use disorder treatment is consistent with prevailing standards of professional practice and published practice guidelines, referenced below.  Specifically, the patient has a diagnosis of opioid use disorder and is in medication-assisted treatment to prevent relapse and address post-acute withdrawal symptoms and/or craving.  Prevailing standards of medical practice call for comprehensive treatment with counseling and social supports, as well as ongoing monitoring to ensure abstinence from opioid agonists with urine drug screens that serves to inform the clinical provider that the patient is adherent to the medication regimen and remains abstinent of opioid class substances of abuse.
 
In this case, the patient is in outpatient substance use disorder treatment with medication-assisted treatment of opioid use disorder with co-morbid stimulant use disorder. The use of Zubsolv Tablets at the current dose is clinically appropriate and reasonable in this case scenario because the plan's preferred formulary agents are not clinically appropriate in this case scenario.  A previous trial of Suboxone 8/2 mg resulted in adverse effects with nausea and mouth sores.  The patient is not a candidate for the use of Vivitrol in that she has been unable to remain abstinent for the seven to 10 days necessary to initiate treatment with naltrexone and subsequently switch to Vivitrol (long-acting injectable naltrexone).  Thus, the use of Zubsolv is reasonable and in the patient's best interest, and the preferred drugs under the plan are either not tolerable or cannot be reasonably prescribed due to contraindications, as noted in the clinical summary. 

The management of the patient's substance use disorder with the use of Zubsolv is in keeping with prevailing standards of professional practice, published practice guidelines, and FDA indications for the use of buprenorphine/naloxone preparations targeting opioid use disorder as part of a comprehensive substance abuse treatment program.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who presented to the emergency department (ED) with a history of progressively worsening abdominal pain.  Her evaluation included a physical exam, labs, and a computed tomography (CT) scan.  She did not have a fever at the time of presentation, and her other vital signs were normal at the time of presentation.  Lab data identified a white blood cell count (WBC) count of 6.3 thousand (K).  A CT scan yielded the diagnosis of acute appendicitis.
The patient underwent a laparoscopic appendectomy.  The health plan's determination is upheld.
The patient's evaluation with examination, lab data, and a CT scan confirmed the diagnosis of appendicitis.  The initial treatment included nothing by mouth (NPO) status, IV fluid, IV antibiotics and appendectomy.  The early post-surgical course was uncomplicated, and the patient was clinically stable.  Although she required urgent surgical intervention for acute appendicitis, a lower level of care would have been satisfactory for the care provided and would have been consistent with the accepted standard of medical care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient admission
The Inpatient admission was not medically necessary.

This patient presented for evaluation of chest pain. The diagnosis of an acute MI was ruled out by cardiac enzymes, which were negative. There was no evidence of acute myocardial infarction, ACS, decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability. Stress echo was planned, but was not completed. No further ischemic inpatient work-up was planned. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission, and the care required could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

The patient is a female with a skeletal Class I molar occlusion with an overjet of 2 millimeter (mm), 40% overbite, and mild mandibular crowding. The patient had trauma to the front teeth resulting in incisal fractures. There is damage to the maxillary anterior teeth from the trauma. The dental provider is requesting orthodontic treatment.
The subject to be determined is the medical necessity for orthodontic treatment.

The health plan's determination is upheld.

The dental services are not medically necessary for this patient. There are several criteria in the Handicapping Labio-Lingual Deviation (HLD) index that make up the total score to consider a case handicapping. This includes, overbite, overjet, ectopic eruption, crowding, labio-lingual spread, and unilateral crossbite. Considering all these criteria, the patient scored less than the required score of 26 to be considered medically necessary. Using the HLD index is the standard of care for determining medical necessity. 
Using the HLD index, the malocclusion would score a 12 with no auto qualifiers. Auto qualifiers include deep impinging overbite, anterior crossbite causing clinical attachment loss and recession of the gingival margin, overjet 9mm or greater and underbite 3.5mm or greater. As stated above, a score of 26 or more is required for treatment to be considered medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Vomiting and palpitations
Treatment:  Inpatient admission
The proposed treatment (inpatient admission) was not medically necessary. 

At the time this patient was admitted, she was clinically stable.  She had taken extra doses of her antidepressant medication.  This was not a suicide attempt.  The patient was never kept under constant observation.  In the ED, the patient was tachycardic but was showing no evidence of arrhythmia.  With IV fluid and medication for anxiety her heart rate improved.  She was never hypotensive.  She was never unresponsive.  There was no concern that she could not protect her airway.  There was no seizure activity.  The admission note for this patient indicates that she would be kept on a cardiac monitor for one day.  Her potassium would be replaced.  She would likely be discharged the following day.

Following this patient's ED evaluation it would have been reasonable to believe that this limited plan of care could be accomplished for a stable patient with a short stay in the hospital.  A one-night hospital stay was planned for the patient.  For this reason an inpatient level of care was not medically necessary.  The patient could have been safely and effectively managed at a lower level of care.  There was no severity of illness to justify an inpatient admission.  The patient had mild tachycardia, but her vital signs were otherwise unremarkable.  She had normal mental status.  There was no intensity of services planned for her to justify an inpatient admission.  She would be kept on a cardiac monitor overnight and would receive supplemental potassium.

In conclusion, the patient was clinically stable following her ED evaluation.  A limited plan of care was anticipated.  An inpatient admission was not medically necessary.  The patient could have safely been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Shortness of breath
Treatment:  Inpatient admission
The proposed treatment, inpatient admission, was medically necessary.

The patient presented with symptoms of acute CHF exacerbation with known severe systolic dysfunction, as well as COPD and CRI.  Although usual course of hospitalized patients with CHF exacerbation is brief with expected discharge in 24 hours with adequate diuresis, there are certain subsets of patients that require extended periods of hospitalization for control of their symptoms.  This patient with multiple co-morbidities, who presented with CHF exacerbation complicated by COPD exacerbation, acute on chronic renal dysfunction, was appropriately treated with IV diuresis.  He required close monitoring of his CHF, volume status, urine output and renal function, given the underlying kidney disease.  He needed surgical evaluation, as well, for his symptomatic hernia.  In addition, close management of his INR was necessary, given the presence of metallic aortic valve.  Given this presentation, acute CHF, as well as multiple risk factors, co-morbid conditions and known CAD, it would be consistent with the current standard of care that this patient be managed in an inpatient setting, and, therefore, the requested inpatient admission was medically appropriate in this clinical setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Opioid use disorder
Treatment: Continued inpatient admission -forward

Summary:
The treatment provided during the Continued inpatient admission through discharge could not have been effectively provided at a lower level of care in this case scenario. The patient in this case was using large quantities of heroin and marijuana that did warrant the admission and the continued inpatient level detoxification with withdrawal management and inpatient level monitoring. Detoxification with a methadone taper, as necessary, and other treatments pertinent to the detoxification treatment episode could not have been effectively provided at a lower level of care following the comprehensive assessment that was provided at the time of admission. Moreover, the patient's social environment was not conducive to an effective detoxification, and the patient had struggled with withdrawal symptoms, including persistent tremors, irritability, and insomnia that were being effectively addressed with methadone and supportive measures and PRN medications provided during the time interval under review.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gum disease
Issue under review: Deep gum and root cleaning, all four quadrants

Determination:
The Deep gum and root cleaning, all four quadrants is not medically necessary.

There is no evidence of any bone loss or calculus (tartar) on any of the x-rays presented. The reported probing depths of the gums do not correlate with the bone levels seen on the x-rays presented. Medical necessity for treatment has not been established based upon documentation presented.

While it is very true that a person who is a diabetic needs to keep their oral hygiene immaculate, this patient does not present with the signs and symptoms of someone who needs four quadrants of scaling and root planing. The standard in this situation would be a thorough dental prophylaxis (cleaning and polishing), and it would be advisable that this be done on a timely basis, depending upon the needs for that individual patient. Being a diabetic, this patient might need a prophylaxis more than twice yearly to make sure any inflammation in her gums (gingivitis) is kept under control, so it does not affect her diabetes. However, as stated above, there is no indication for the need to have four quadrants of the more aggressive scaling and root planing, based upon documentation supplied.
Appeal type: Medical necessity
Decision: Upheld

This patient  was transferred from an outside hospital to a Children's Hospital. The patient had experienced abdominal pain which evolved into nausea and vomiting. The pain had migrated to the right lower quadrant   at which time a computed tomography (CT) scan demonstrated an enlarged appendix. Patient was febrile with tachycardia.On the same day as the transfer, patient was taken to the operating room in the afternoon for a laparoscopic appendectomy. The procedure was uncomplicated, with no evidence of gangrene or perforation, and  had an uneventful recovery.The pathology from the specimen was entirely consistent with acute appendicitis without perforation. An inpatient hospital admission was not medically necessary, even for a patient with an emergent presentation. An inpatient stay could be justified if there was some diagnostic dilemma (e.g., complicated appendicitis when CT had been read as uncomplicated), an untoward perioperative event, intraoperative injury or complication, inadequate physiologic recovery, hemodynamic instability, acute organ injury, persistent altered mental status, fever or other signs of septic complications, surgical site complication, management of complex comorbid medical condition or a finding of an occult or new medical condition.
Surgical treatment of otherwise healthy pediatric patients with acute non-perforated appendicitis is usually provided at a lower level of care. No evidence presented in the documentation or in the primary medical records would indicate that an acute inpatient level of care was necessary for this patient. Data strongly suggest that for most patients with acute, nonperforated appendicitis who undergo an uncomplicated appendectomy, observation at a lower level of care in the hospital thereafter is entirely appropriate since their needs are low acuity and the recovery is generally smooth and uneventful.  the health plan's determination of medical necessity is upheld in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Lower Back Pain

Treatment:  Inpatient Hospital 

The insurer denied the Inpatient Hospital.  The denial was upheld. 

This case involves a young male patient who presented to the Emergency Department in mid-2019 complaining of low back pain, and associated right lower extremity numbness for 5 days after bending over.  The patient reported that he did not have alleviation of pain with the use of ibuprofen.  He does have a history of cerebral palsy, and a herniated lumbar discs.  The physical exam noted that there were intact reflexes bilaterally, however, the patient refused to move his legs due to pain during the examination.  The patient stated he was unable to walk due to pain.  It was noted that that the patient did have decreased sensation to the lateral side of the left lower extremity; however, this was residual from a previous disc herniation.  He had a magnetic resonance imaging which showed no sign of cord compression.  The patient was admitted for pain management.  The patient was recommended to receive ketorolac, Tylenol, diazepam, a lidocaine patch, and Flexeril for muscle spasm.  He was evaluated by physical therapy.  The patient documentation indicated there was slight improvement in his pain and he was able to ambulate with a walker.  He was discharged when deemed stable with instructions to follow-up.

According to current literature, a patient may be admitted to inpatient services to care for a patient with complaints of back pain when there is evidence of cauda equina or conus medullaris syndrome, progressive or severe neurologic deficits, spinal fracture, a suspected spinal infection, a suspected cause requiring inpatient treatment or evidence of severe pain requiring acute inpatient management.  This is indicated by pain being unresponsive to non-opioid analgesic and nonpharmacologic treatment, as well as oral, transdermal, or submucosal route not appropriate or sufficient, and the anticipated titration is not appropriate for a lower level of care.  

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

The patient was was seen by the primary care physician for a well-child check.  The patient had been a healthy baby throughout life.  The body size and his head circumference had both been noted to be large on previous well child checks.  At this 6-month well child check, the head circumference and body weight were both noted to be greater than the 99th percentile for age, but the head circumference had increased at a faster relative rate than had the body weight.  To assess why the head circumference had increased to such an extent, the patient was sent for a head ultrasound, which revealed ventriculomegaly of the lateral ventricles.  The patient was sent to the emergency room for further evaluation.  Outside of the large head, the patient had no symptoms.  The patient was not irritable, had no change in behavior, was meeting developmental milestones, had no fever, no vomiting, no abnormal eye movements, and no history of prenatal infection.

The health plan's determination is upheld.  The inpatient stay was not medically necessary.  The patient could have been cared for at a lower level of care.  The patient was a relatively large baby with a relatively large head and had no symptoms suggestive of an acute life-threatening or health-threatening condition.  The patient had no irritability, abnormal eye movements, lethargy, vomiting, or any other signs to suggest dangerously increased intracranial pressure.  The history and his physical exam were strongly suggestive of a condition known as prominent subarachnoid space, which is a benign condition of infancy in which cerebrospinal fluid accumulates within the subarachnoid space and leads to head enlargement.  Infants who are thought to have this condition are assessed by MRI scan or computed tomography (CT) scan as outpatients.  They do not need to be hospitalized for evaluation of this condition.  In fact, patients are rarely admitted for this condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute cholecystitis
 
Treatment: Inpatient admission, surgical intervention, monitoring

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

This is a female with a past medical history of gastroesophageal reflux disease. She presented with abdominal pain, nausea and diarrhea for the past day. She had a blood pressure 106/66, a heart rate of 84, respirations 18, temperature of 97.5 and oxygen saturation of 99% on room air.  The patient's pain was an 8/10 and she was unable to tolerate anything by mouth.  Her white blood cell count was 8.3, red blood cell count 4.31, hemoglobin 12.6, hematocrit 37.6 and platelets 355.  An x-ray of the chest revealed no evidence of acute chest disease.  An ultrasound of the gallbladder revealed mildly dilated common bile duct and minimal gallbladder wall thickening measuring up to 4 mm in thickness.  These findings were equivocal for acute cholecystitis and clinical correlation was needed.  The patient underwent a laparoscopic cholecystectomy the next day under general anesthesia.  There were no complications during the procedure and the patient was stable postoperatively. She was discharged the following day.

Medical literature indicates a laparoscopic cholecystectomy is an ambulatory procedure.  An extended stay may be indicated for patients who have failed to achieve discharge status criteria or if there was conversion to an open procedure.  An extended stay may also be indicated if there was systemic infection, care needed for active comorbidities or complications from the procedure. This patient had a laparoscopic cholecystectomy and had no complications during the procedure. She was stable following surgery.  There was no indication that the patient failed to achieve discharge status criteria and there was no indication there was conversion to an open procedure.  The patient did not have findings of a systemic infection and did not require care for active comorbidities. An observation level of care was appropriate rather than inpatient level of care.   

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated.  The insurer's denial is upheld.