Persius/hicric huggingface dataset:
Appeal type: Formulary Exception
Decision: Upheld

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

The formulary drug will not be, and has not been ineffective, would be as effective as the non-formulary drug, and would have the same adverse effects as the requested medication of Clobetasol spray. The patient has tried triamcinolone cream for granuloma annulare.  There are many topical steroids available that can be tried for granuloma annulare and current peer reviewed literature does not support the necessity of one over another. Intralesional steroids are commonly used for granuloma annulare. Generalized granuloma annulare is difficult to treat. Primary treatments for patients with generalized GA include topical calcineurin inhibitors and phototherapy. Topical corticosteroids can be useful for treating select lesions in generalized GA.
There are no contraindications to the formulary alternative Clobetasol foam and this medication would be considered equally effective. Formulary topical steroids would also be effective and would have the same adverse effects as the requested medication.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest pain, headache, vertigo, shortness of breath (SOB).
Treatment: Inpatient admission.
The insurer denied the inpatient admission.  The denial is upheld. 

The patient is a female with a history of hypertension, who presented to the ER for further evaluation/management of headache, vertigo, chest pain and shortness of breath.  Intake vitals were noted to be afebrile, hemodynamically stable.  Examination was non-focal with no significant abnormalities noted.  Electrocardiogram (EKG), head computed tomography (CT) and laboratory testing was without significant abnormalities noted. 

The patient was admitted in stable condition where she was treated with broad spectrum intravenous (IV) antibiotics and Reglan.  She also underwent further evaluation including head magnetic resonance image (MRI) and transthoracic echocardiogram which did not reveal any critical abnormalities.  The patient improved with the prescribed therapies and was subsequently discharged in stable condition. 

No, the proposed treatment of inpatient admission is not deemed medically necessary. 

There is no evidence of intensification of services throughout the course of this patient's hospital stay.  Hence, patient's care could have been safely furnished in a less intensive setting without adversely affecting patient's safety or outcome.  Hence, the proposed treatment of inpatient admission is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Palpitations and ventricular premature beats.
Treatment: Inpatient admission. 
The insurer denied the inpatient admission.  The denial is overturned. 

The patient is a female that presented to the hospital for an elective electrophysiologic (EP) study with ablation of ventricular premature beats.  She underwent successful diagnostic study and ablation.  Of note, during the study the patient received Isovue contrast agent as well as protamine and was noted to have facial erythema.  She was treated with Benadryl and admitted to the hospital for close monitoring. 

Yes, the proposed inpatient admission was medically necessary.

The patient presented with palpitations and ventricular premature beats.  She underwent electrophysiologic study with catheter ablation of ventricular premature complexes (VPCs).  Following administration of intravascular contrast and protamine, the patient developed facial erythema and was treated with IV antihistamine therapy.  She was observed in the hospital overnight for post-operative complications and ultimately discharged.  

Catheter ablation of VPCs is associated with three percent rate of major adverse cardiac events and a 1.2% rate of moderate adverse events (Reference 1).  In one registry study, including more than 400 patients undergoing catheter ablation for VPCs, the median length of hospital stay post procedure was three days (Reference 2).  In this case, the patient underwent a successful ablation but had an allergic reaction to medications administered interprocedurally.  Inpatient hospitalization for close monitoring and treatment was indicated and in the best interest of the patient.  In conclusion, this patient could not have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Cardiac/Circulatory Problems - Chest Pain
Inpatient Hospital
The insurer denied the inpatient stay
The denial is upheld

The patient is an adolescent male with a previous history of asthma on Advair, who was brought to the emergency department with a history of sharp, non-radiating, left-sided chest pain that lasted for 1.5 hours and then self-resolved. On arrival in the ED, he said he still had left-sided chest pain that he rated 2/10 in severity. He did not have sweating, shortness of breath, palpitations, fever, chills, rash, photophobia, or recent viral-like illnesses. He had been camping in August but had not noticed any tick bites.

He was afebrile with a heart rate (HR) of 106 on initial presentation at 728 AM with normal blood pressure and oxygen saturation. At 1251 PM and 229 PM, his heart rates were 66 and 72, respectively. His physical exam was completely normal.

The Cardiologist documented that "serial EKG's reviewed, Subtle ST segment changes which could represent early depolarization. No concerning EKG changes, normal voltages, normal PR and QTc and no ectopy. Multiple EKG's reviewed with no concerning changes or pattern of evolution." The cardiologist wrote that the EKG changes were consistent with a pericarditis and elevated troponin was consistent with a mild myopericarditis, likely from a viral cause. The cardiologist recommended that troponins and EKG's be trended and that ibuprofen and pepcid be used for pain and anti-inflammatory effect.

The health plan denied coverage for the acute inpatient stay.

The health plan's determination is upheld. The patient was only mildly symptomatic on presentation and did not have further symptoms during the hospitalization. The cardiologist documented that the EKG changes were subtle rather than concerning, and that the several EKG's done while the patient was in the ED were without any evidence over time of an evolving cardiac process. The troponins were only mildly elevated and consistent with a myopericarditis. He did not have any cardiac or other condition that required treatment in an acute inpatient setting. There was no concern that he was having a myocardial infarction (MI) or acute coronary syndrome. He was observed during the hospitalization and the serial troponin and EKG's can be performed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vertigo
Ipatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is upheld.

The patient has a past medical history (PMH) of hypertension (HTN) and chronic headaches who was admitted with complaints of (c/o) a sudden onset headache (HA) associated with vertigo, nausea, and vomiting. Vital signs were unremarkable. The physical exam was notable for horizontal nystagmus, no focal weakness. Lab work was unremarkable. A magnetic resonance imaging (MRI) scan of the brain showed non-specific subcortical signal hyperintensities without acute pathology. The patient was diagnosed with labyrinthitis and treated with Haldol, anti-emetics, meclizine, Fioricet, and intravenous (IV) fluids. The patient was discharged  in stable condition. At issue is the medical necessity of an inpatient stay.
The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with c/o headache associated with vertigo, nausea, and vomiting. She received a computed tomography (CT) scan in the ED that did not demonstrate any acute intracranial pathology, further confirmed with a brain MRI without evidence of stenosis or acute abnormality. This patient did not have a life-threatening cause of the headache, increased intracranial pressure (ICP), tumor, hydrocephalus, intracranial bleed, acute or subacute cerebrovascular accident (CVA), acute central nervous system (CNS) infection (encephalitis, brain abscess) or bacterial meningitis. In addition, the patient did not require immediate surgical intervention, have a hypertensive emergency, acute alteration in mental status, co-existing seizures, nuchal rigidity, acute visual loss, new focal neurologic deficits, abnormal pupils, apnea, abnormal respiratory pattern, or significantly abnormal vital signs. The patient was diagnosed with labyrinthitis and vestibular rehabilitation was recommended, and additionally treated with Haldol, anti-emetics, meclizine, Fioricet, and, steroids, IV fluids, and this diagnostic work-up, rehabilitation and medications could have been safely and appropriately provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Numbness, left sided weakness
Issue under review: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male with diabetes and hypertension who presented with left side weakness and numbness for two hours.  At presentation his neurological examination was normal and CT brain was negative. MRI after admission was negative for acute stroke.

No, the acute inpatient admission was not medically necessary.

The member presented with transient neurological deficits and was admitted for TIA. Risk stratification based on presentation symptoms; past medication history of clinical evaluation does not support acute inpatient level of care. The diagnostic studies, evaluation, monitoring and treatment could have been safely and effectively provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: ENT/Nasal airway obstruction
Treatment:Surgical Services
The insurer denied the Surgical Services
The health plan's determination is overturned in whole. The procedure was medically necessary. 

The patient had nasal airway obstruction that failed to improve with nasal steroids. Two otolaryngologists confirmed the history of obstruction. To be successful, treatment of nasal obstruction must address all areas of obstruction. This patient had nasal obstruction due to septal deviation as well as obstruction due to internal and external nasal valve collapse.
Alar spreader grafts are medically necessary for this patient. This patient had nasal collapse with internal and external valve obstruction. Photos show obvious collapse of the right nasal sidewall. Spreader grafts are necessary to open the internal nasal valves. The obstruction is anatomic rather than allergic, and nasal sprays will not improve  symptoms. The spreader grafts will improve function. Collapse of the internal nasal valves is a well-recognized source of nasal obstruction. According to Grabb and Smith's Textbook of Plastic Surgery (8th Edition 2019), "The internal nasal valve is the angle formed by the junction of the nasal septum and the caudal margin of the upper lateral cartilage, and is usually 10 to 15 degrees. It can be responsible for up to 50% of the total airway resistance, and is the narrowest segment of the nasal airway. Occasionally, the head (anterior-most portion) of the inferior turbinate can be hypertrophied enough to cause further diminishment of the cross-sectional area of this region. Traditionally, a positive Cottle sign (lateral traction on the cheek leading to increased airflow) signals collapse of the internal nasal valve and indicates the need for spreader grafts to increase the valve angle and stent the airway open." This patient had a positive Cottle sign and collapse of the internal valves. Spreader grafts are never used in cosmetic procedures. The placement of spreader grafts will widen the nose, which is not a desired goal in aesthetic rhinoplasty. The indication for spreader grafts is functional internal and external valve obstruction as was experienced by this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain; flank pain
Issue under review: Inpatient admission 
The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a male who presented to the emergency room of the hospital filing the appeal with the complaints of abdominal pain and flank pain for the four days prior to presentation. The patient noted emesis as well as a reduced appetite. The patient had abdominal pain in the epigastrium on palpation, an elevated white count, and a lipase of 462. A computed tomography (CT) scan showed calcifications in the pancreatic head. The patient was admitted with acute pancreatitis for supportive care, hydration and pain management.

No, the inpatient admission was not medically necessary.

While the patient evidenced abdominal pain and symptoms of acute pancreatitis, the patient also had evidence of chronic pancreatitis. The patient did not have a lipase three or more times the maximum normal level and there was no acute pancreatitis findings on radiology imaging. The entirety of the care could have been rendered at a lower level of service. 

Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had an infection; yet he did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for nothing by mouth (NPO) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission.  As such the care could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Gastritis 
Treatment: Inpatient admission 

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

This is a male patient who was admitted to inpatient hospital due to alcohol gastritis. The patient complained of burning epigastric pain, multiple brown vomiting, hematemesis, and chest pain. In the Emergency Department, the patient was noted to have lactic acidosis and possible dehydration. It was reported that the patient was put on a Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol with Ativan. The patient received intravenous (IV) fluids and thiamine supplementation. The patient left against medical advice (AMA). 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. It also states that patients with past complicated or life threatening withdrawal symptoms including withdrawal seizures or delirium tremens are in need of inpatient hospital treatment for the management of withdrawal
and reports that patients with comorbid medical condition that complicate the management of withdrawal are also candidates for inpatient detoxification. In this case, this patient could not have been safely treated in an outpatient detoxification as he reportedly had serious comorbid medical issues due to alcohol use complicating the management of his withdrawal. The patient had hematemesis and was on the CIWA protocol with Ativan as he was reportedly drinking heavily over the weekend prior to this arrival. The patient was noted to have alcohol gastritis with 9 out of 10 of severity, abdominal pain. The patient also had lactic acidosis and signs of dehydration that required intravenous (IV) hydration. The patient also had elevated blood pressure of 164/97 and had hypertension. Considering this patient's active medical issues associated with this patient's alcohol use, this patient was at risk for severe, complicated, and life-threatening withdrawal from alcohol. The Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) also supports that the patient required a 24-hour treatment as the patient could not safely and effectively be treated for detoxification in a less restrictive setting. Thus, inpatient 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 the inpatient admission is substantiated. The insurer's denial should be reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Transient Ischemic Attack (TIA), Angioplasty
Treatment: Interfacility transfer and inpatient admission
The insurer is denied coverage for interfacility transfer and inpatient admission.
The denial is upheld. 
This is a male patient with a history of coronary artery disease with stenting, a Roux-en-Y bypass, diabetes, obstructive sleep apnea, upper gastrointestinal (GI) bleed, a cerebrovascular accident (CVA), and hypertension. The patient was admitted to the hospital was subsequently readmitted the same day for an ischemic stroke to the left arm, a left thalamic stroke, and distal basilar artery stenosis of 90%. It was determined that the patient was scheduled to follow-up with a neurovascular surgeon for possible stenting. The patient had symptoms of dysarthria and vertigo but was not considered a candidate for stenting given his anatomy. The patient was medically managed, stabilized, and then transferred to another facility for a second opinion. The patient was admitted to the new medical facility for a further work-up given the transient ischemic attack (TIA) and a record of recent bilateral pontine strokes. The physician reviewed the patient's imaging studies and determined that the treatment plan would include angioplasty with the possibility of stenting to treat the basilar artery.

According to a letter the patient had survived two acute ischemic strokes and two transient ischemic attacks, which were all associated with posterior circulation symptoms. The etiology of these for vascular events was large vessel disease in his basilar artery. The physician stated that multiple attempts were made at aggressive medical management, and the patient was unable to tolerate statins due to muscle pain and joint pain. The physician went on to state that following this patient's Roux-en-Y bypass, the patient experienced a gastrointestinal (GI) bleed that required transfusion. The patient was placed on dual antiplatelet therapy following an endoscopy and was determined that an angioplasty of the basilar artery plus or minus stenting could not be offered at that facility. The case was discussed at length with the vascular neurologist on call and it was together determined that the patient would benefit from the procedure. There were concerns that it would be unsafe to transfer the patient in a personal vehicle given his multiple recurrent vascular events despite medical management. 

Based on the review of the medical record, the primary reason for the interfacility transfer was for angioplasty of the basilar artery, which was not medically indicated as per the review of standard of care and peer reviewed literature. 

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

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

Diagnosis: Cerebrovascular Accident
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is upheld.
This is a female patient; G2 P1001, who presented at 24 weeks gestation to the Emergency Room (ER) with complaints of left hand and facial numbness, blurry vision and dizziness. The patient's vital signs were stable. The patient's physical examination was normal. Laboratory studies were performed that were normal. Neurology was consulted and recommended stroke evaluation. The patient underwent a magnetic resonance imaging (MRI) and a magnetic resonance venography (MRV) and both showed normal findings. The patient was discharged home.

Based on the review of the medical record, the patient presented with left hand and facial numbness, blurry vision and dizziness. There was no evidence of elevated blood pressure, no vaginal bleeding, no evidence of preterm labor and no ruptured membranes. There was no evidence of fetal compromise.

Preeclampsia refers to the new onset of hypertension and proteinuria or hypertension and significant end-organ dysfunction with or without proteinuria after 20 weeks of gestation in a previously normotensive woman. So based on this patient's clinical presentation with normal blood pressure and normal laboratory evaluation, the patient did not have preeclampsia or pregnancy induced hypertension. However, there was concern for a possible stroke and more detailed evaluation in the form of MRI and MRV was needed. However, neither of those diagnostic tests required hospital admission. Once these ambulatory tests were performed and reported as normal, the patient could have been sent home to be followed by her obstetrician as outpatient.

As per the MCG's guideline, the clinical indication for antepartum admission includes:
Condition requiring premature delivery; Delivery; Fetal distress or demise; Preterm labor and positive fFN; Significant maternal disease, infection or comorbidity as cause; Significant vaginal bleeding or any vaginal bleeding with known placenta previa, vasa previa or placenta accrete; Tocolytic therapy that requires inpatient care; Complications of tocolytic treatment. In this case, this patient did not meet the MCG criteria for inpatient admission.

The inpatient admission was not 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: Medical necessity
Decision: Overturned

Diagnosis: Central nervous system other.
Treatment: Home health care.
The insurer denied Increase Personal Care Worker Service hours to 7 days per week, 24 hours per day; continuous care by more than one person, 168 hours per week. 
The denial is overturned in whole. 

The patient is a male with a past medical history of coronary artery disease, hypertension, gout, benign prostatic hyperplasia (BPH), urinary incontinence and dementia who had been assigned Personal care assistant (PCA) service hours of 7 hours/day, 5 days/week and 6 hours/day, 2 days/week to total 47 hours per week.
Yes, the requested health care treatment of increased personal care worker service hours to 7 day per week 24 hours per day 168 hours per week is medically necessary.
The patient had an over the phone assessment tool performed following his minor stroke but before major stroke with subdural hematoma that lead to right sided paralysis and dysphagia. The patient was then more recently hospitalized with altered mental status and gastrointestinal (GI) bleed. The computed tomography (CT) scan performed on the recent hospitalization showed slight worsening of subdural hematoma but the family opted for medical treatment only. Following the first subdural hematoma the patient had residual right sided deficits and dysphagia which would put him at an assistance level of maximum or total for bathing, personal hygiene, dressing upper/lower body, toilet use, bed mobility and eating. Due to subdural hematoma with right sided weakness the patient would have changed to total assistance for walking, locomotion and transfer toilet. The patient has loss of his informal helpers compared to his previous assessment. The PCA services were not just for safety and supervision alone but to prompt and queue Activities of daily living (ADL's) and Instrumental Activities of Daily Living (IADL's). Therefore the increased personal care worker service hours to 7 day per week 24 hours per day 168 hours per week is medically necessary.