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

Diagnosis:  Orthopedic/Musculoskeletal - Back Pain
Treatment:  Chiropractic Services

The patient is a male, who presented for chiropractic treatment of low back pain.  The original diagnoses were low back pain and lumbar segmental dysfunction, with treatment including spinal manipulation, manual therapies and electrical stimulation.  Notes on the first date of service under review indicated Visual Analog Scale (VAS) 6-7/10, with spasm and subluxation.  Notes from a date of service 5 weeks later indicated VAS 5-6/10, which was 4-5/10.  Subluxation and spasm were noted on each date of service, as was full spine manual therapy, and thoracic spinal manipulation.
The subject under review is the medical necessity for the chiropractic services.

The health plan's determination is upheld.

The chiropractic services were not medically necessary for this patient.  The treating chiropractor reported and diagnosed low back pain and segmental dysfunction and reported on treatment as being a combination of thoracic spinal manipulation and full spine manual therapies.  The manual therapies were paid as medically necessary.  While thoracic spinal manipulation was reported and billed, there was no report of thoracic pain, and no thoracic diagnosis to establish medical necessity for thoracic spinal manipulation.  As such, it was not medically necessary.  While lumbar spinal manipulation would be considered medically necessary in this case, lumbar manipulation was not reported in the notes; only manual therapy of the lumbar spine.
According recognized national standards of care on record keeping and treatment, spinal manipulation needs to be documented for its clinical relevance and correlated with appropriate diagnoses.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System - Cough
Treatment: Inpatient Hospital

The patient is a male with a history of diabetes, gout, and arthritis.  He presented to the emergency room with a productive cough, diarrhea, and urinary frequency.  He was afebrile, the oxygen saturation was 96% on room air, and the other vital signs were unremarkable.  The physical exam was notable for some left upper arm tenderness.  The white blood cell (WBC) count was normal, the creatinine was minimally elevated, and the glucose was around 170.  According to one provider, the chest x-ray showed a left lower lobe infiltrate.  However, another reporter indicated that there was no obvious infiltrate (A formal radiology report was not included in the information provided).  The electrocardiogram (EKG) showed no acute ischemia.  The patient was admitted for further treatment and evaluation.  
Upon admission, the patient was treated with intravenous fluids, intravenous antibiotics, and oral medications.  The hospital course was clinically uneventful, and the patient was discharged. 

The health plan's determination is upheld.  

No, the requested health service/treatment of inpatient stay was not medically necessary for this patient.  Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary.  Upon presentation, there was no objective evidence on physical exam, labs, imaging, or EKG of an imminently life-threatening cause of the patient's complaints.  There is no evidence that he failed appropriate outpatient therapy or that he required intravenous fluids or intravenous medications.  He was afebrile, there was no hypoxia, the vital signs were unremarkable, the WBC count was normal, the creatinine was minimally elevated, and there was no other evidence of sepsis or metabolic disarray.  Even if pneumonia was present, which is not clearly substantiated, based on the standard of care and peer reviewed literature the inpatient level of care was not medically necessary, and the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Primary Diagnosis:  Digestive System/GI
Secondary Diagnosis: Cholecystitis
Treatment:  Inpatient hospital stay

This is a patient with a history of cholelithiasis, gastroparesis, and marijuana abuse, who presented to the emergency department (ED) on with complaints of a one-day history of nausea, vomiting, and epigastric pain.  Vital signs were normal.  Physical exam revealed right upper quadrant tenderness.  Ultrasound showed cholelithiasis with a normal common bile duct and hepatosteatosis.  The white blood cell (WBC) count was elevated to 14.2 with a left shift.  Liver function tests were normal.  The patient was admitted, started on antibiotics, and offered a laparoscopic cholecystectomy.
2 days later the patient underwent a laparoscopic cholecystectomy that was essentially uncomplicated, except for pulsatile bleeding from the liver bed that was quickly and easily controlled with clips.
The next day the patient met discharge criteria including normal vital signs, adequate pain control, tolerating a diet, and ambulating well.  Patient was discharged to home and asked to follow-up in a week.  The health plan's determination of medical necessity is upheld in whole.  Although 24 hours of IV antibiotics did resolve this patient's leukocytosis, this patient was not "septic"; therefore, there was no medical benefit in delaying surgery for this.  The literature does not support a medical benefit for delay to laparoscopic cholecystectomy for antibiotic treatment of cholecystitis.  This patient was discharged to home within 24 hours after surgery, consistent with an ambulatory procedure.  The patient could reasonably have undergone the laparoscopic cholecystectomy procedure at a lower level of care and been discharged the next day.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Cellulitis
Treatment:  Inpatient Hospital

The patient is a woman who presented to the hospital with a chief complaint of skin infection to the buttock and failed outpatient antibiotics.  She recently presented to urgent care for a bug bite on the left buttock.  The original size was 1 inch in diameter. She had taken bactrim but felt that her symptoms were worsening.  Review of systems was negative for fevers and chills.  On physical examination, she was in no distress, heart was regular, breath sounds were normal, she had chronic right sided weakness, and the left buttock had cellulitis with warmth and erythema.  Labs showed a white blood cell (WBC)count of 12.2, hemoglobin 12.3, platelets 300, sodium 138, potassium 4.0, and a creatinine of 0.82.  An ultrasound of the buttock showed no evidence of abscess or fluid collection.  The patient was admitted for cellulitis with failed outpatient antibiotics and suspected cystitis.  The plan of care included intravenous (IV) antibiotics, blood cultures, urine cultures, IV fluids, infectious disease consult, physical therapy, occupational therapy, and acetaminophen as needed.  Her hospital stay was notable for complaints of claustrophobia, and she continued to be monitored for abscess formation.  Glucose control was maintained to improve response to antibiotics.  Infectious disease service noted that there was high risk for development of abscess.  She ultimately developed an abscess and required drainage.  The infection improved after drainage and with antibiotics, and she was discharged.  The health plan's determination is overturned, in whole.  The health plan in its determination of medical necessity did not act reasonably, with sound medical judgment or in the best interest of the patient.  The patient presented with an infection that was worsening despite initial therapy with outpatient antibiotics, and she developed an abscess, all in the setting of poorly controlled diabetes.  Development of an abscess increases the risk of sepsis, and a patient with her risk factors would reasonably be treated at the inpatient level, if she did not have prompt improvement as an outpatient.  Moreover, the infectious disease service was concerned for abscess development, and this is stated in the documentation provided.  The patient was at increased risk of abscess formation, sepsis development, and bacteremia.  She had moderately poorly controlled diabetes, and the infectious disease service expressed early concerns about development of abscess.  It would generally not be appropriate to treat this type of patient at the outpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol dependence and substance abuse

Treatment: Rehab for alcohol dependence

The insurer has denied inpatient admission. That denial was reversed.

This male patient was admitted to inpatient substance rehabilitation treatment as he reportedly was drinking 1 gallon of whiskey 1-2 times per week, smoking a blunt of cannabis daily, using 30 mg of Percocet 1-2 times per week, and could not maintain abstinence. It was reported that the patient was discharged after threatening violence towards a staff member. It also was reported that he was picking and scratching his head. He refused aftercare referrals.

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 he was using multiple substances; including alcohol, opiates, and cannabis. According to the LOCADTR, he met criteria for inpatient substance rehabilitation treatment as he continued to use multiple substances despite past inpatient treatments. It was reported that he was increasing frequency and amount of use. He was unable to stop substance and alcohol use without being in a sober and supervised therapeutic inpatient residential setting. Without this structured and supervised therapeutic residential treatment he likely would have relapsed quickly. 

Based on the above, the medical necessity for the inpatient hospital stay is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hip pain
 
Treatment: Inpatient admission, medication, monitoring

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

Patient was brought in by ambulance to the Emergency Department (ED) with severe left hip pain and could not walk.  Past medical history was significant for spinal stenosis and chronic hip pain.  She was admitted to the hospital and provided with a Lidocaine patch and Flexeril.  Imaging did not demonstrate a fracture.  She was evaluated by physical therapy (PT) who recommended rehabilitation.  She was discharged and provided with Celebrex. 
The hospital record demonstrated improvement after prescription pain medication was provided.  The physical examination reported full range of motion to the left hip, but with pain. Consultations did not recommend additional testing, invasive management or parenteral medications. Her vital signs were stable. She was able to tolerate oral medications.  She did not require treatment for underlying co-morbidities.  All services could have been provided in the ED or in an outpatient setting.  There were no extenuating circumstances to warrant the level of service provided (admission).
Appeal type: Medical necessity
Decision: Upheld

This is a patient who was mandated to outpatient treatment of cannabis use disorder. When he did not attend the assigned outpatient program, his parole officer reportedly mandated him to an inpatient program. He did not think that his use impacted his family but recognized he had trouble quitting on his own and was motivated to maintain the conditions of his parole. Per the notes he smoked cannabis one to two times per week. The health plan's determination of medical necessity is upheld. Inpatient substance use rehabilitation treatment was not medically necessary for this patient.  He has no past history of substance use disorder treatment other than the most recent outpatient program mentioned in the chart that he failed to attend. Based on the information included in the chart, it is not clearly documented that he had a serious substance problem related to his own use of cannabis. The patient reported using cannabis only one to two times per week and only using one blunt per day. On admission, he indicated that he had already not used in five days and was motivated for sobriety because it was a condition of his parole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis and Psoriatic Arthritis
Treatment: Pharmacy/Prescription Drugs

Summary: This patient with psoriasis and PsA (psoriatic arthritis) has mechanical knee pain and inflammatory back pain. There is no synovitis and some clearing of skin lesions of the left elbow and knees is noted. Osteoarthritis of multiple sites and psoriasis is noted. A history of hair loss with methotrexate (MTX) is noted. The plan is for Humira at psoriasis dosing. The prior approval form indicates that the request is for the treatment of psoriasis.  There is no indication that the patient has gotten Humira yet. In a letter accompanying the appeal request the MD notes that the patient has ongoing PsA and that weekly Humira can be used when the patient is not on MTX.  

The insurer has denied coverage for Humira Pen 40mg/0.4ml SC PNKT. The denial was upheld.

Humira treats both psoriasis and PsA. The FDA-labeling for Humira indicates one vial SQ every other week for PsA. This can be increased to every week if needed, if the patient is not on MTX. The dosing for psoriasis is 80 mg followed by one vial SQ every other week. The documentation in this case is inconsistent. The office note and Prior Approval request indicate that the Humira is for the psoriasis, but the medical doctor (MD) appeal letter notes it is needed for PsA. If the request is for the use of Humira in the treatment of psoriasis then the insurer is correct in denying every week as the indication is for every other week. If in fact the request is for the treatment of PsA then the insurer's denial is still valid, as there has not been any trial of the every other week dosing. The weekly dosing is used if every other week fails. No synovitis is noted at the office visit, and there is no documentation that supports the need to bypass the standard every other week dosing and going straight to every week. Humira Pen 40mg/0.4ml SC PNKT once weekly is not considered medically necessary for this patient.  As noted above, the every other week dosing is appropriate. The patient's clinical condition does not meet national criteria for weekly dosing of Humira Pen 40mg/0.4ml SC PNKT.  Every week is not indicated for psoriasis, and there has been no trial of the standard every other week for PsA.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:Digestive system/GI
Secondary: Abd pain
Treatment: Inpatient stay

This patient has a past medical history (PMHx) significant for morbid obesity status/post (s/p) laparoscopic gastric sleeve procedure who presented to the emergency room (ER) with complaints of diffuse abdominal pain and nausea. Vital signs were stable. Labs were unremarkable. Initially a cat scan was obtained that revealed some thickened colon. An ultrasound did not reveal gallstones, however, the patient persisted with pain now localizing to the right upper quadrant (RUQ). The work up continued with a hida scan which was positive for chronic acalculous cholecystitis. A decision was made to take the patient to the operating room for laparoscopic cholecystectomy. Pathology confirmed chronic cholecystitis. The patient had routine post-operative recovery, tolerating a diet and pain controlled with oral meds and was discharged home. Overturn in whole the health plan's determination of medical necessity.
This patient presented with diffuse abdominal pain and the initial work up was unrevealing for etiology. The pain persisted and localized to the RUQ. The patient did not have gallstones on ultrasound and required additional diagnostic evaluation with hida which was positive for chronic cholecystitis. Based on this finding a decision was made to take the patient to the operating room for acute on chronic cholecystitis which was confirmed pathologically. This was not able to be performed at a lower level of care and required acute inpatient admission for diagnosis, work up and treatment.
Although most elective cases of lap cholecystectomy for routine cholelithiasis can be performed as outpatient or ambulatory level of care, this patient presented with pain that required 3 diagnostic tests before a decision was made to take the patient to the operating room. The laparoscopic cholecystectomy and postoperative course was routine and uncomplicated but decision to treat with surgery was made after the hida scan was obtained, as the patient persisted with abdominal pain. This was not able to be completed in a lower level of care time period.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a past medical history of hypertension (HTN), hepatitis C virus (HCV), depression, and schizophrenia. He presented to the emergency department (ED) with 5 days of dyspnea, orthopnea, subjective fever, and cough productive of yellow sputum. On exam, his temperature was 98.2 F., with a blood pressure (BP) of 140/80 millimeters of mercury (mmHg), a heart rate (HR) of 64 beats per minute (bpm), a respiratory rate (RR) of 13-21/minute, with an oxygen saturation of 97% on room air (RA); he was comfortable, had a regular heart rhythm and no edema, was breathing comfortably with wheezing and basilar crackles. A chest x-ray (CXR) was clear.
The concern was for a respiratory infection (possibly with undiagnosed underlying chronic obstructive pulmonary disease (COPD)) versus congestive heart failure (CHF). He improved with DuoNebs in the ED and was admitted for further evaluation. He was started on Prednisone and DuoNebs; a transthoracic echocardiogram (TTE) was ordered.
Serial cardiac enzymes were negative. He was better though symptoms hadn't fully resolved. He was breathing comfortably with clear lung exam, and Prednisone was stopped. He had a TTE that found a normal ejection fraction (EF) and changes suggestive of prior myocardial infarctions (MIs). The plan was for outpatient cardiology follow-up, and he was considered ready for discharge, but he refused due to lack of home support.

At issue is the medical necessity of the inpatient stay.
He presented with a cough, dyspnea, and a subjective fever. He was breathing comfortably and saturating well on room air (RA). He was not encephalopathic, hemodynamically unstable, in respiratory distress or hypoxemic/hypercarbic, or suffering from any other organ dysfunction (AKI, profound electrolyte abnormality, etc). His symptoms had already begun to improve with nebulized bronchodilators in the ED. Serial cardiac enzymes were negative, and a TTE showed no acute or worrisome changes. Concern for acute coronary syndrome or new, decompensated CHF was at this point low, and he received no further testing or treatment for this with outpatient cardiology follow-up recommended. He was felt ready for discharge on day 2 but remained an extra two days  as he did not feel safe being discharged; during this time, no additional medical tests were performed or treatments provided.

He was not ill at admission and by vital signs and routinely used scoring systems for acute COPD exacerbation (BAP 65, DECAF [Dyspnea, Eosinopenia, Consolidation, Respiratory Acidosis and atrial Fibrillation) and a general score predicting risk of death or needing ICU care (MEWS), he was at low risk for a bad outcome (mortality, need for ICU care, need for intensive respiratory support). As such, he did not need the close monitoring or specific treatments of an inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Kidney stone
Treatment: Admission
The inpatient admission was not medically necessary.

This female was admitted with left renal colic and low grade fever to 100.1.  She had been seen at an outside ER the day before.  Vitals were 100.6 F - 169/93 - 90.  The white blood cell (WBC) count was 12,400.  The creatinine was 1.6.  Computed tomography (CT) imaging demonstrated a 16 by nine millimeter (mm) left proximal ureteral calculus with hydronephrosis.  Intravenous (IV) pain medications, nausea medications, IV antibiotics and IV fluids were administered.   

The next day, a cystoscopy with left ureteral stent placemen was performed.  The patient failed a voiding trial.

The following day, the patient was discharged home.  She was afebrile and hemodynamically stable throughout the stay.


An acute inpatient level of care was not medically necessary.  Care could have been provided at a lower level of care.  The patient was afebrile and hemodynamically stable after admission. There was no significant evidence for sepsis.  Following admission, there were no unstable vital signs reported.  She did not have a documented kidney failure, solitary kidney or a kidney transplant, or need for an open surgery. She did not have bilateral obstruction, acute renal failure, severe vomiting.  Pain control, IV antibiotics and IV fluids followed by stent placement in a non-toxic patient can be provided at a lower level of care.  Although the patient had a low grade fever and obstruction, she was non-toxic and responded to IV fluids and IV antibiotics.
Appeal type: Medical necessity
Decision: Upheld

ADHD
Pharmacy/Prescription Drugs

The patient has attention deficit hyperactivity disorder (ADHD). According to the health plan denial letter, the patient had failed treatment with methylphenidate, Metadate, and Adderall. The plan's pharmacy claim data and chart notes submitted showed only a trial of methylphenidate ER. Jornay PM or CP24 was denied, and the formulary alternatives were listed. The original clinic notes stated the patient was stable on methylphenidate, a formulary drug, so there was no clinical reason provided for a change from methylphenidate to the requested medication (Jornay PM/CP24).

The health plan's determination is upheld. Jornay PM 60MG or CP24 is not medically necessary for this patient. Jornay PM is another type of extended release methylphenidate that is engineered to be given at night. A bioactive outer layer is absorbed during sleep and upon awakening, the active stimulant layer begins absorption. Jornay PM is marketed to address disruptive ADHD symptoms in the early morning, upon awakening. The results of the phase 3 trial were published in August, 2019, just one year after Food and Drug Administration (FDA) approval. Initial efficacy and safety studies were published in August, 2017. The positive phase 3 trial was on a small number of patients in a highly-controlled, laboratory school setting. There is still very little actual, real-world experience with this very new medication, and the AAP's (American Academy of Pediatrics) Subcommittee on ADHD did not take a position on it in the most recent Guideline update, published in October, 2019.

From the one progress note mentioning problems with the current regimen, there are concerns documented about morning symptoms and duration of stimulant action into the afternoon. But these concerns were no longer an issue a month later.

If an alternative to extended release methylphenidate were under consideration to address the concern that the medication "last longer," the plan's formulary drugs include other extended release stimulants such as Adderal XR and Focalin XR that can be tried. The other stimulants on formulary, Adderall, Zenzedi, Dexedrine, Focalin, are more short-acting.

Therefore, the requested medication is not medically necessary for this patient at this time.