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

Diagnosis: Upper Gastrointestinal bleed

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 

The patient was admitted for melena and was worked up for possible upper gastrointestinal (GI) bleed. A computed tomography was negative for acute intraabdominal process. She was also evaluated by nephrology for history renal failure and was treated with Benadryl for possible uremic itching. She was discharged in stable condition.

The patient was admitted for worsening anemia and underwent work up to rule out active bleeding.

However, she was hemodynamically stable, with normal oxygenation and negative cultures, did not have significant electrolyte disturbance.

She did not have cardiac arrhythmias, no altered mental status or persistent nausea and vomiting with dehydration. There was no documentation of refractory pain, and she was able to tolerate oral diet and did not require total parenteral nutrition.

Clinical Guidelines suggest that patients identified as having a very low risk for requiring transfusion or intervention (Glasgow-Blatchford score (GBS) of 0 or 1) may be safely discharged from the emergency department with outpatient scheduling of endoscopy.[1]

Considering the outcome of need for hospital-based intervention or death, an evidence-based specialty society analysis found that a GBS of 0 to 1 had at least a 99% sensitivity with a lower bound of the 95% confidence interval of 98%, resulting in what they conclude was an acceptably low false-negative rate[2]

Analysis of a database including 199,008 hospitalized patients discharged with a principal diagnosis of nonvariceal upper GI bleeding found, for patients who underwent endoscopy within 24 hours, a median length of stay of 2.5 days.  In the same study, analysis of 3251 patients discharged with a principal diagnosis of variceal upper GI bleeding found, among patients who received endoscopy within 24 hours, that 25% of patients had a length of stay of 2 days or less.[3]

Analysis of 12,501 adults (mean age 58.5 years) admitted for upper GI bleed who were not receiving home oral anticoagulation reported a 2.6-day mean length of stay.(26) (EG 2) Analysis of national hospital discharge data shows 32% of hospitalized adult patients with upper GI bleeding as the principal diagnosis discharged in 2 days or less.[4]

When taking into account the patient's exam, imaging, and lab findings as well as her lack of need for diagnostic testing beyond what was done under observation care and the availability of any additional diagnostic testing as an outpatient, she had no requirements for inpatient level of care.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient hospital services is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: vomiting
treatment: inpatient stay
The insurer denied an inpatient stay. The health plan's determination is overturned. 

The patient is a girl with mild persistent asthma who presented with emesis, diarrhea, and upper respiratory symptoms.
She had presented to the emergency department (ED) the day prior to presentation and was diagnosed with viral gastroenteritis. She was discharged from the ED after receiving intravenous fluids, Zofran, and an oral challenge. Her electrolytes were within normal limits at that time. However, that evening, she had additional emesis and diarrhea. She subsequently had a near syncopal episode in the bathroom. Emergency services were called and her fingerstick glucose was 68. She was given some juice and then brought to the emergency department for evaluation.

Inpatient Hospital Stay was medically necessary for this patient, in order to provide treatment with intravenous fluids, assessment and evaluation for failure to thrive, and specialist consultation. According to the Milliman Care Guidelines (MCG) Health, Inpatient and Surgical Care Guidelines 26th edition, Syncope; hospital admission is indicated for patients with dehydration that is severe or persistent, which was the case for this patient.
This is a young girl who presented with near syncope, in the setting of multiple days of vomiting, diarrhea, and decreased oral intake. She was found to have low blood glucose at the time of presentation and was felt to be dehydrated and ill-appearing. She therefore required hospital admission for ongoing treatment with intravenous fluids, as well as assessment and evaluation for failure to thrive. She required consultation from a nutritionist, and ongoing intravenous fluids until she could fully support her hydration with oral intake.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cannabis hyperemesis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld.

 
The patient had the diagnosis of cannabis hyperemesis. She has a history of gastroesophageal reflux disease (GERD), alcohol use, and marijuana use. The patient presented to the Emergency Department (ED). She reported nausea and vomiting. The patient was given an intravenous (IV) fluid bolus, IV Pepcid, and IV Zofran. She was diagnosed with acute kidney injury (AKI) and admitted with the diagnosis of cyclical vomiting syndrome. The patient also tested positive for COVID 19. The patient received IV fluids, IV proton pump inhibitors (PPI), and IV antiemetics before discharge. 

Despite the member's presentation the care as provided could have been rendered in its entirety at a lower level of care. The member had an infection; yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for prolonged 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.  

"Generally a person is considered to be in inpatient status if officially admitted as an inpatient with the expectation that he or she will remain at least overnight. The severity of the patient's illness and the intensity of services to be provided should justify the need for an acute level of care. An inpatient admission solely because the patient has been kept in observation status over 23 hours would not be considered medically necessary." (American Health Information Management Association, 2018).

"Cannabis hyperemesis syndrome (CHS) is a form of functional gut-brain axis disorder characterized by bouts of episodic nausea and vomiting worsened by cannabis intake. It is considered as a variant of cyclical vomiting syndrome seen in cannabis users especially characterized by compulsive hot bathing/showers to relieve the symptoms."

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma Exacerbation
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is upheld. 

According to the documentation submitted, this is an adult with a history of cerebrovascular accident (CVA), hypertension, hyperlipidemia, coronary artery disease (CAD), diabetes, asthma, gout, and renal stones. The patient presented to the emergency room (ER) with complaints of shortness of breath. A chest x-ray (CXR) revealed no acute findings. The patient was admitted for an asthma exacerbation. Infectious Disease (ID) consulted over the case. A computed tomography angiogram (CTA) revealed pneumonitis versus congestive changes. The patient met systemic infectious response system (SIRS) criteria. The patient was given intravenous (IV) fluids and IV antibiotics.

The insurer has denied coverage for the inpatient as not medically necessary. In a Final Adverse Determination letter, they stated that the patient presented to the ER (emergency room) with complaints of trouble breathing. There were no unstable vital signs that did not improve or other findings warranting an inpatient admission. The requested admission is denied based on Milliman Care Guidelines 26th Edition using the guideline of Asthma. 

The patient has a past medical history significant for cerebrovascular accident, hypertension, hyperlipidemia, coronary artery disease, diabetes, asthma, gout, and renal stones who presented to the emergency room (ER) with complaints of shortness of breath.

Vitals on presentation included: temperature 98.4 (degrees) Fahrenheit (F), blood pressure (BP) 109/57, pulse 109, respiratory rate 22, oxygen saturation 95% (percent) on room air. Laboratory results included the following: white blood cell (WBC) count 12.73, hemoglobin (HGB) 14.4, creatinine 0.73, lactic acid 2.3, and glucose 191. Viral panel showed human rhinovirus. 

The patient was started empirically on intravenous antibiotics for possible pneumonia. Infectious Diseases (ID) consulted and recommended continuation of antibiotics. Chest X-ray (CXR) was negative. Chest computed tomography (CT) showed right upper lobe pneumonitis versus congestive changes. The patient remained afebrile, clinically, and hemodynamically stable. Patient was discharged to continue outpatient management.
 
According to documentation, patient presented with respiratory symptoms. Otherwise, patient remained afebrile, hemodynamically stable. Laboratory results were unremarkable except for a mildly elevated WBC (white blood cell). Patient had no evidence of a disseminated infection. The documented clinical impression was "common cold." Their recommendation included "supportive care." Based on above findings, patient did met criteria for observation level of management. The patient did not fulfill criteria for acute hospital admission. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: End stage renal disease. 
Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

According to the documentation submitted, this is an adult with a history of end stage renal disease (ESRD), hypertension, diabetes, chronic venous stasis ulcer, and schizophrenia. The patient presented to the emergency room (ER) with complaints of generalized aching and fatigue. The patient reported missing two dialysis sessions. Blood pressure was 192/112. The patient was admitted to Telemetry with hypertensive urgency. Blood urea nitrogen (BUN) and creatinine were stable at baseline. Home medications were continued. The patient underwent hemodialysis. The patient was discharged. 

The insurer has denied coverage for the inpatient admission as not medically necessary. In a Final Adverse Determination letter, they stated that the patient could have been placed in observation under monitoring. There was no hemodynamic, pulmonary, metabolic, or neurological reason to treat the patient at an acute level of care. 

The patient was admitted for missing routine dialysis treatment as an outpatient. During this admission, the patient was evaluated by nephrology service and underwent routine dialysis. The patient was discharged in stable condition.  The patient's condition could have been treated safely under lower level of care. 

The patient was admitted for hypertension and volume overload, and was treated with hemodialysis and intravenous blood pressure medication on admission. 

The patient's condition responded to daily dialysis. The patient did not have persistent severe hyperkalemia, no signs of severe volume overload or hypoxia, no documentation of severe uremia such as encephalopathy or uremic bleeding.  The patient had established dialysis access and did not require emergent vascular intervention.  When taking into account the member's exam, imaging, and lab findings as well as the lack of need for diagnostic testing beyond what was done under observation care and the availability of any additional diagnostic testing as an outpatient, the patient had no requirements for inpatient level of care. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Digestive system
inpatient hospital

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

The patient is a male with medical history of Crohn's disease complicated by colonic perforation status post colectomy with end-ileostomy, deep venous thrombosis and pulmonary embolism, Factor V Leiden post inferior vena cava filter, anxiety, depression, and polysubstance abuse. He presented to the emergency department with nausea, vomiting, and abdominal pain consistent with prior Crohn's disease flares. He has had intermittent disease flares since stopping Remicade. Vital signs were unremarkable. Physical examination was notable for soft, non-distended abdomen with diffuse tenderness, and ostomy bag with stool. Labs showed low hemoglobin of 11.0 and an unremarkable basic metabolic panel. 

inpatient hospital admission was not medically necessary. The care provided could have been provided at the observation level of care. The patient presented with symptoms (nausea, vomiting, abdominal pain) and imaging suggestive of Crohn's disease flare. However, there was no complication such as small bowel obstruction, intra-abdominal abscess, bowel perforation, toxic megacolon, peritonitis, fistula, or sepsis, which would require the inpatient level of care. The interventions performed during the brief stay, including labs, imaging, and intravenous fluids, could have been performed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Migraine
Treatment: Qulipta 60 mg Tablet
The health plan denied: Qulipta 60 mg Tablet
The determination is: Overturned

The patient is a female who is diagnosed with episodic migraine. The drug Qulipta has been prescribed by the treating provider. This was denied because there was documentation lacking to show that the member had tried and failed both oral and injectable Calcitonin gene-related peptide (CGRP) migraine treatments.
At issue is the medical necessity of Qulipta 60 milligram (mg) tablets.
The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of Qulipta 60 mg tablets is medically necessary for this patient. The health plan denied treatment with this because there was no evidence that the patient had used oral migraine preventative therapies or injectable CGRP inhibitors. However, an office note submitted for review indicates that the member has tried and failed amitriptyline, topiramate, and propranolol. Thus, the member has used three oral preventative therapies, all with different mechanisms of action. Additionally, the member has tried and failed Ajovy and Emgality. Together, the patient meets the criteria as set forth by the plan. Moreover, the patient meets the standard of care for use of Qulipta. This drug is an appropriate preventative therapy for episodic migraine after a patient has tried and failed oral migraine preventative therapies. There are no requirements in the peer reviewed literature or any treatment guidelines that require a patient to have used certain oral or injectable medications prior to this drug. Additionally, the Food and Drug Administration (FDA) has recently approved the drug for prevention of chronic migraine. Thus, the drug is approved for prevention of all migraine disorders.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: maxillary hypoplasia

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

 
This patient is an adult patient under the care of an Oral and maxillofacial surgeons (OMS) and orthodontist. The patient is diagnosed with Maxillary and Mandibular Hypoplasia and a class two malocclusion. The patient underwent a Lefort 1 and Bilateral sagittal split ramus osteotomy (BSSRO) and genioplasty. The surgery was performed under general anesthesia. Botox was also injected into the facial muscles at the time of surgery. This patient had multiple jaw surgeries. This is an appeal for inpatient stay.

The prolonged surgery includes maintaining blood pressure at certain levels to minimize blood loss. The longer the anesthesia the greater the chance of nausea and vomiting. The surgery itself is very painful. Prior to discharge the patient is closely followed for post op nausea and vomiting, hemostasis, pain control, airway maintenance, swelling, nutrition status, fluid status, all prior to discharge. The applicable guidelines and literature recommend inpatient status for orthognathic surgery patients who undergo multiple jaw surgeries like this patient. This patient meets the criteria for inpatient stay due to the extent of the surgery.

Chang, F. S., Burrows, S. A., & Gebauer, D. P. (2019), "Randomization resulted in approximately equal proportions of male patients (45% vs 50%) and median ages (18.5 years vs 20 years) for the patient controlled analgesia (PCA) group versus the non-PCA group; however, the PCA group was noted to have a higher proportion of double-jaw surgery (65% vs 40%). The median length of stay (LOS) was 2 days for both the PCA and non-PCA groups (probability (P) = .06). No statistically significant difference in pain scores was found between the 2 groups either at rest (P = .27) or on movement (P = .13)."

Bahmanyar, S., Namin, A. W., Weiss, R. O., 2nd, Vincent, A. G., Read-Fuller, A. M., & Reddy, L. V. (2021), "Orthognathic surgery performed in conjunction with orthodontic treatment is commonly performed to correct skeletal irregularities and realign the maxillomandibular relationship to improve occlusal function and facial esthetics. A thorough understanding of soft tissue esthetics, skeletal and occlusal relationships, and surgical techniques is required to obtain successful results. Surgical techniques have evolved greatly throughout history, as technological advances such as virtual surgical planning have become available and widely used to obtain predictable movements with minimized complications. The aim of this article is to review the orthognathic surgical procedures of the mandible, with particular attention to the indications, contraindications, preoperative assessment, surgical technique, and possible complications encountered." 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis. 
Treatment: Total hip replacement (arthroplasty). 
The insurer denied coverage for total hip replacement (arthroplasty). 
The denial is upheld. 

This is an adult with a history of osteoarthritis. The patient had procedure code 27130-RT (arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft and assistant surgeon (procedure code: 27130-AS-RT: arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft). 

Procedure code 27130-RT (arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft and assistant surgeon (procedure code: 27130-AS-RT: arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft) is not considered medically necessary for this patient. 

The medical records provided showed a single visit. (See X ray report) The "fellow" completed a consultation under the direction of a Physical Medicine and Rehabilitation / Sports Medicine physician. The pertinent facts were no previous treatment, limited motion and an x ray report of moderate to severe osteoarthritis. The next record was an operative report for right total hip replacement performed by an Orthopedic Surgeon. 

There is a lack of documentation to support necessity. The Clinical Criteria have not been fulfilled. 

There was no report of limits to activities of daily living. The patient was able to work. There was no report of gait abnormality nor need for ambulatory aid. 

Several treatment recommendations were made including physical therapy, medications and injections. There were no reports of these services being completed. 

Surgical indications require evidence of functional disability and failure to improve with conservative treatment. These findings were not present. Based upon the above, the surgery would not be indicated. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for procedure code 27130-RT (arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft and assistant surgeon (procedure code: 27130-AS-RT: arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft) is not substantiated.