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

Diagnosis: Fever
Issue under review: Inpatient admission

Determination:
The Inpatient admission was medically necessary.

The patient is a full term male infant. He presented to the ED with same day history of fever to 101.8, diarrhea (11-12 episodes), and decreased oral intake. He had not yet received his two-month vaccinations. 

The patient's vital signs included temperature 102.9, heart rate 170, respiratory rate 33, and 100% saturation in room air. Examination was significant for being asleep but rousable in no distress, non-bulging fontanelle, moist oral mucosa, tachycardia, strong pulses, clear lungs without grunting, benign abdomen, and good muscle tone with non-focal neurologic exam. Because of his age, fussiness, and irritability, a full septic work-up was undertaken including lumbar puncture. 

Laboratory evaluation was significant for negative urinalysis, WBC (white blood cell) count 7.3K with 28% neutrophils and 11% bands, hyperkalemia with no visible hemolysis (potassium 6.4), mild metabolic acidosis (CO2 [carbon dioxide] 22), mildly elevated total bilirubin (1.3), and elevated alkaline phosphatase (310). CSF (cerebrospinal fluid) was clear with 2 WBCs and 2 RBCs (red blood cells), no organisms on gram stain, with normal glucose and protein. Rapid influenza and RSV (respiratory syncytial virus) were negative. Electrocardiogram revealed normal sinus rhythm. 

The patient was treated with IV fluids, acetaminophen, and ceftriaxone. He was subsequently admitted for possible sepsis, to continue antibiotics pending culture results. Admission orders included acetaminophen as needed, vitals every four hours, ceftriaxone every 24 hours, follow-up cultures, IV fluids at maintenance, formula as tolerated, and repeat BMP (basic metabolic panel) the next morning. His fever curve improved overnight but he remained less active than usual. 

By hospital day two, the patient's appetite had improved and the diarrhea had lessened. He was back to his baseline level of activity. He was deemed stable for discharge by hospital day three when all cultures were negative for 48 hours. 

This infant presented with high fever, irritability, poor oral intake, and diarrhea. A full septic work-up was undertaken because of his irritability and concerns for meningitis. He remained on antibiotics pending cultures negative for 48 hours. Concurrently his symptoms improved so that when the cultures were negative, he was clinically stable for discharge. Based on the current recommendations, for an infant older than one month of age (unvaccinated) with signs of serious illness (in this infant's case irritability), acute inpatient admission is indicated for close evaluation, with antibiotic treatment pending culture results. The acute inpatient stay was medically necessary and appropriate. He could not have been safely managed at a lower level of care.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Osteoporosis
Treatment: 82523 - Collagen crosslinks analysis 
The health plan should not cover the proposed collagen crosslinks analysis. 

This patient is a female with osteoporosis with t-score -3.4, She has been treated with Forteo and zoledronic acid. Request for collagen cross link testing is under review. 

Collagen crosslinks testing is one of multiple available bone turn over markers. While the use of biochemical bone turn over markers in clinical trials has been helpful in understanding the mechanism of action of therapeutic agents, their role in the care of individual patients is not well established and are not widely used in clinical practice because of high analytical and biological variability that makes interpretation challenging. The American Association of Clinical Endocrinologists and American College of Endocrinology clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis - 2016 indicates "Their use in clinical practice, however, is limited by high in vivo and assay variability (e.g., urinary resorption markers), poor predictive ability in individual patients, and lack of evidence-based thresholds for clinical decision-making." Therefore, no, the health plan should not cover the proposed treatment.

The requested health service is not more likely to be more beneficial than any standard treatment or treatments for the insured's condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Osteoporosis
Treatment: 82523 - Collagen crosslinks analysis 
The health plan should cover the proposed collagen crosslinks analysis. 

This is a female with a history of osteoporosis. T-score is -3.4 at the spine. There is a history of vertebral fractures. She was treated with Forteo and subsequently zoledronic acid.  Her attending physician (AP) is seeking coverage for serum CTX (82523 - collagen crosslinks analysis).

According to the American Association of Clinical Endocrinologists (AACE) guidelines, bone turnover markers in a patient such as this one after vertebral fracture and with very low bone density at high risk for a subsequent vertebral fracture, a bone turnover marker such as CTX can be very helpful in assessing response to therapy such as zoledronic acid. If bone turnover marker remains elevated, shifting to a different course of therapy would be warranted. 

The requested collagen crosslinks analysis is likely to be more beneficial than any standard treatment or treatments for the insured's condition or disease. 

The measurement of CTX will provide useful short-term information regarding current course of therapy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Transient Ischemic Attack

Treatment: Inpatient Admission

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

This is a female patient with a history of hypertension, migraine, and currently smokes cigarettes. She presented to the Emergency Department (ED) with complaints of right-sided facial numbness, and slurred speech. On physical examination it was noted that her right-side hand grasp was weaker than the left and there was no facial droop or slurred speech noted. The patient reported that she takes amlodipine for blood pressure; however she only takes it when she feels like her blood pressure is high. An electrocardiogram (EKG) was performed that revealed normal sinus rhythm and possible left atrial enlargement. A bilateral Carotid Doppler was performed that showed evidence of minimal plaque in the bilateral common carotid arteries with extension to the carotid bulb and proximal internal carotid artery. The patient was medically stable and was discharged home. 

According to the patient records, the patient developed transitory right facial numbness and slurred speech with normal stroke workup. On exam, the patient exhibited no clear evidence of an acute neurologic change. There was no documentation that this patient had acute motor, sensory or visual deficit that was suggestive of an acute stroke. In the absence of acute stroke, hemodynamic instability, new focal neurological signs, and/or clinical signs of cardiovascular compromise or acute, prolonged metabolic decompensation or seizure, this patient did not meet the medical necessity, the MCG Health, 23rd Edition guidelines for acute inpatient care admission. 

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

The carrier denial of coverage for the inpatient admission is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Preterm Labor

Treatment: Inpatient admission

The insurer denied the inpatient admission. 

The denial was upheld.  

This is a female patient who is G3 P0020 who was admitted at 20.2 weeks gestation for management of a short cervix seen on ultrasound. The plan was to place a rescue cerclage. She received prophylactic antibiotics and Indocin 25 milligrams every 6 hours for tocolysis. Following the cerclage, a progress note documented that the patient could go home that day. It is unclear why the patient was not discharged following the surgery. The patient was discharged the following day.

Cervical cerclages are ambulatory procedures. This patient was found to have a short cervix. There was no evidence of preterm labor or ruptured membranes. The procedure itself was uncomplicated and the post-operative course was uneventful. Ideally, the patient would have had the cerclage placed on the day of admission and then discharged home that same day. There is no reason given for keeping the patient in the hospital and not doing the procedure on the day of admission. There was no fever, no evidence of infection and no bleeding. Both the mother and fetus were stable. Please note that ambulatory procedures include appropriate post-operative monitoring and an overnight stay if required.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.
 
Based on the above, the medical necessity for the inpatient hospital admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Respiratory problems/Other.
Treatment:  Inpatient hospital.

The insurer denied the inpatient hospital stay.  The denial is upheld in whole.

The patient with a remote history of asthma was transferred from one facility to the hospital emergency department  for management of spontaneous pneumomediastinum.  The patient  initially presented with one-day history of neck discomfort and dysphagia.  The patient denied chest pain, trauma, coughing, vomiting, and shortness of breath.

This  patient with remote history of asthma presented to the ED with acute onset neck pain and chest pain.  Imaging revealed pneumomediastinum with no evidence of esophageal rupture or pneumothorax.  Pneumomediastinum indicates the presence of free air within the mediastinum.  This condition is extremely rare in the population with some association with excessive coughing.  It is overall considered to be a benign condition.  Most patients are hospitalized for a lower level of care and pain management.  Long-term follow-up of these patients shows fairly rapid resolution and no increase in recurrence.

In this patient's case, he presented with neck and chest pain that resolved while the patient was in the ED.  Consistent with the current standards of care, the patient was admitted to the hospital.  The patient remained hemodynamically stable for the duration of the stay.  While it was not unreasonable to monitor in the hospital for pain management and signs of decompensation, the patient did not require acute inpatient management.  The patient could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Erectile dysfunction, Hypogonadism.

Treatment: testosterone gel.

The insurer denied coverage for testosterone gel.

The denial is upheld.

This is a male patient with a history of smoking, intravenous drug abuse, and erectile dysfunction. The patient had a phone consult due to Covid-19. The patient complained of ongoing fatigue, low libido, and extreme erectile dysfunction. The patient reported no sexual intercourse for 3 years. The physician noted that the patient could not use injectable medications because of a history of substance abuse.  

As per the review of the medical record, the patient had testosterone (TST) levels drawn on 2 separate occasions. The first one showed a TST level of 56 ng/dL (normal range 249-836 ng/dL) and Free TST level of 7 pg/mL (normal range 47-244 pg/mL). The second one was collected 2 weeks later, which results showed: TST 98 ng/dL (normal range 240-950 ng/dL) and Free TST 1.37 ng/dL (4.65-18.1 ng/dL). The second TST level was collected in the morning; however, the time at which the first TST level was collected was not documented. 

As per literature review, the patient must have an abnormal morning TST level confirmed by 2 morning blood draws to confirm a diagnosis of hypogonadism. This is because 30% of the time the second confirmatory morning TST level will be in the normal reference range. Thus, the diagnosis of hypogonadism must be confirmed on 2 separate blood specimens drawn in early morning, which is not in this case. As per the staff of the patient's physician office, the patient's first TST level was not drawn in the morning, prior to 10 am. Thus, there is inadequate clinical evidence to support this patient's diagnosis of hypogonadism and medical necessity of this treatment with testosterone. The requested testosterone 10 mg (2%) gel is not considered medically necessary for this patient.

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 testosterone 10 mg (2%) gel should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia, Acute renal failure

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

This is a female patient status post myomectomy and dilation and curettage with endometrial ablation. The patient was referred by her physician to the Emergency Department (ED) for blood transfusion. The patient was complaining of bleeding for 7 days, and was experiencing worsening dizziness, weakness and lightheadedness. The patient's initial evaluation showed low systolic blood pressure which later improved. The patient's hemoglobin was 5.1, and hematocrit was 17.2. The patient's pelvic ultrasound showed thickened endometrium. The patient was transfused with 2 units of packed red blood cells. The patient was admitted for further management of anemia and acute renal failure. The hospital course of treatment and management included an additional 2 units of packed red blood cells, continuous intravenous fluid, atorvastatin, levothyroxine, and blood sugar monitoring with an insulin sliding scale. After treatment, the patient was cleared for discharge to home with follow-up

Based on the review of the medical record, the patient had two admitting diagnoses: anemia and acute renal failure. This patient presented with symptomatic anemia. This patient fulfilled the transfusion guidelines for use of blood components. The patient's hemoglobin was less than 8 and she was symptomatic, so transfusion was medically necessary. However, blood transfusion does not warrant inpatient status. Transfusions are done routinely in outpatient settings (i.e. oncology clinics, infusion centers, and even at home). This patient could have also been transfused in the ED, monitored for a few hours, and then discharged home with a follow up, within 24 hours, with her surgeon and gynecologist.

Milliman Care Guidelines list the clinical indication for inpatient care for patients with anemia. These include: active massive hemorrhage, active hemolysis, cognitive impairment, tachycardia, orthostatic changes, heart failure, chest pain, and syncope. However, in this case, this patient did not have any of these conditions. The patient could have been transfused in the observation area and be discharged after receiving her transfusion.

As for the diagnosis of acute renal failure, the etiology of this patient's renal failure was due to volume depletion from excessive bleeding. As per literature review, management of patients with stage 1 acute kidney injury does not require admission and are usually managed on an outpatient basis. In this case, adequate hydration and blood transfusion in the ED and/or observation area would have been sufficient. The inpatient admission is not considered 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 inpatient admission should be upheld. The medical necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lumbar Degenerative Disc Disease
Treatment: Intercept Procedure
The health plan has denied the requested procedure. 
The health plan determination is upheld.

The patient has chronic low back pain. The patient has had prior injection treatments. The pain is exacerbated with prolonged sitting and standing, and relieved with positional changes. The patient has a prior history of lumbar microdiscectomy. Medication management has also been utilized. A magnetic resonance imaging of the lumbar spine  reported  L4-L5 degenerative changes status post left-sided hemilaminectomy, L3-4 disc herniation. There is a request for intraosseous ablation of the basivertebral nerve via Intracept procedure.

I uphold, in whole, the health plan's determination regarding the proposed health service or treatment.

The proposed health service or treatment Unlisted procedure, spine (Intracept procedure), destruction of intraosseous basivertebral nerve (BVN), first two vertebral bodies, including imaging guidance (e.g.,fluoroscopy), lumbar/sacrum is not likely to be more beneficial than any standard treatment or treatments for the patient's life threatening or disabling condition or disease The requested procedure consists of intraosseous RF (radiofrequency) ablation of the BVN using a unilateral transpedicular delivery system. There are insufficient large-scale, randomized, controlled studies showing the efficacy or long-term effects of this procedure. As such, this procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anxiety, Depression, Substance use disorder

Treatment: Inpatient substance use rehabilitation

The insurer denied coverage for inpatient substance use rehabilitation.

The denial is overturned.

This is a female patient with a history of suicide attempts and substance use. She was admitted for inpatient substance rehabilitation treatment. The patient was treated with medication, and she attended individual and group therapy.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that inpatient treatment is indicated primarily for individuals whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. In this case, this patient was considered in need of 24-hour substance rehabilitation treatment as she lacked sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient met criteria for inpatient substance rehabilitation treatment as she relapsed after past inpatient and outpatient substance treatments. The patient had serious depressive symptoms, multiple past and recent suicide attempts, and a history of Xanax overdose. She lacked the support, motivation, insight, and judgment needed to be treated outside of this 24-hour therapeutic inpatient substance rehabilitation treatment. The patient notably lacked coping skills, needed to better identify relapse triggers, and needed to learn relapse prevention skills. Without this structured and supervised therapeutic residential treatment, the patient likely would have relapsed again as evidence by her history of relapses despite inpatient substance treatment and outpatient substance treatments in the past. Inpatient substance use rehabilitation 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.

The carrier's denial of coverage for inpatient substance use rehabilitation should be overturned. The medical necessity is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Asthma 
Treatment: Formulary Exception for Dulera 

The insurer is denied coverage for Formulary Exception for Dulera. The denial is upheld. 

This is a female patient with history of moderate persistent asthma. As per the patient's medical doctor (MD), the patient is well controlled on inhaled corticosteroid (ICS)/long acting beta agonist (LABA) combination Mometasone/Formoterol - Dulera. The patient has not been able to tolerate any of the LABA/ICS combinations on her insurance plan's formulary namely Symbicort, Advair and Breo Ellipta. However no medical records are provided for review other than this statement. 

There is no information provided as to when each of these formulary drugs were tried and what the specific side effects with each of these drugs was. 

In terms of class of drugs all these formulations are a combination of a LABA (Long Acting Beta Agonist) and a different inhaled steroid. The class effect is the same for all. So without more specific information as to when each of the alternatives was tried and what specifically was the issue that led to the discontinuation of each of these alternatives LABA /ICS combinations one cannot approve Dulera. 

The carrier's denial of Request for Formulary Exception for Dulera is upheld.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Osteoarthritis to his knees and right hip avascular necrosis (AVN)

Treatment: Formulary Exception for Gelsyn-3

The insurer denied coverage for Formulary Exception for Gelsyn-3.

The denial is upheld. 


This is a male patient with osteoarthritis in his knees and right hip avascular necrosis (AVN). He reported severe pain to his left knee over a period of one week. There was no history of trauma. A request was made for Hyalogen injections. He has a history of receiving it. Coverage was denied based upon lack of documentation of previous cortisone injection and effect.

The facts are a telephone conversation was reported. The man had a one week history of left knee pain and could not place weight on his extremity. No other records were available.

These findings do not substantiate necessity for the viscosupplementation.

There was no physical examination or imaging completed. There was no differential diagnosis for the recent one week history of pain. There were no other treatments recommended besides bilateral knee sleeves and crutches. There were no additional records reporting response.

Criteria for use of viscosupplementation require a course of conservative treatment prior (i.e. corticosteroid injection). None was provided.

Nevertheless there was inadequate documentation to substantiate the injection. There were no extenuating circumstances to support the use of the Gelsyn 3.

The carrier's denial of Request for Formulary Exception for Gelsyn-3 is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Endocrine.
Inpatient stay.

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

The patient is a man who presented to the hospital. He had a history of hypertension, hyperlipidemia, coronary artery disease (CAD) and diabetes. He presented with a chief complaint of acute hypoglycemia and hypovolemia. He had reportedly not been adherent to his home medications. He also reported polyuria and polydipsia for the past three days. Blood glucose was reportedly 240 that evening. He took insulin and later had a glucose of 22 when Emergency Medical Services (EMS) arrived. At the time of presentation, he reported weakness and lethargy.

The inpatient hospital stay is not medically necessary. This patient presented with an uncomplicated case of hypoglycemia in the setting of insulin overuse and had no evidence of diabetic ketoacidosis or other complications. He did need further care, but this type of presentation is typically managed at a lower level, with adjustment of insulin and education. The patient did leave against medical advice, but this is unrelated to the determination that inpatient care was not medically necessary.