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

Diagnosis Allergic Reaction.
Treatment: Inpatient Stay.
The insurer denied the Inpatient Stay.
The determination is upheld.

The patient presented with concerns of an allergic reaction to his medication. He has a past history of T-cell acute lymphoblastic leukemia (ALL), methicillin-resistant staphylococcus aureus bacteremia, central line placement, on chemotherapy treatment at the time of presentation. He had been receiving a polyethylene glycol-conjugated (PEG)-asparaginase infusion as part of his chemotherapy treatment when he developed facial and lip swelling, abdominal pain, and throat and ear itching. He was given epinephrine, Benadryl, and hydrocortisone and was taken to the emergency department (ED) for further management. In the ED, he had persistent facial and lip swelling and was given intravenous (IV) famotidine, and he was admitted for further management of the anaphylaxis. At the time of admission, his heart rate was 143, his blood pressure was 103/63, his oxygen saturations were 99% on room air, he had strict monitoring of intake and output, intravenous (IV) fluids, IV SoluMedrol, IV and oral Benadryl and his home medications were continued. He continued with his chemotherapy treatments to include a lumbar puncture for intrathecal methotrexate. His anaphylaxis symptoms improved and he was discharged home the following day. The acute inpatient level of care is under review for medical necessity.

The inpatient stay was not medically necessary for this patient. This patient presented for further treatment and monitoring after experiencing an anaphylactic reaction to his PEG-asparaginase infusion. He received epinephrine, steroids, and Benadryl and was transferred to the ED for further treatment and monitoring. While in the ED he was given H2 blocker therapy with famotidine and the decision was to admit him to the hospital for further treatment and monitoring. While this patient was tachycardic at the time of admission with persistent facial swelling and continued to receive IV steroid therapy, the acute inpatient level of care was not necessary to deliver these services. The patient did not have clear persistent findings of airway edema, stridor, respiratory distress, bronchospasm or hemodynamic instability. His treatment needs could also have been safely met at a lower level of care, as this reaction was expected to be short-lived.In addition, while he was continued on chemotherapy treatments, these would typically have been provided in the outpatient setting and did not by themselves require admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Endocrine/Metabolic/Nutritional.
Treatment:  Pharmacy/Prescription Drugs (Humatrope).

The insurer denied the Humatrope.  The denial is upheld in whole.

The patient is a male receiving growth hormone (GH) therapy for treatment of short stature.  Height tracked at the 5-10th percentile prior to initiation of GH and growth velocity was 5-6 cm/year.  Longitudinal weight chart was not provided.  Insulin-like growth factor receptor one (IGF-1) level was 549 nanograms per milliliter (ng/mL); insulin-like growth factor binding protein-three (IGFBP-3) was 4604 micrograms per liter (ug/L).  Luteinizing hormone (LH) was 1.9 international units per liter (IU/L), follicle-stimulating hormone (FSH) 2.8 IU/L, testosterone 467 ng/dL.  Peak GH response to arginine was 0.21 ng/mL and peak response to arginine was 9.75 ng/mL.  Magnetic resonance imaging (MRI) of the brain was normal.  Short stature homeobox (SHOX) testing was negative.

The subject under review is the medical necessity for Humatrope in this patient.

The health plan's determination is upheld in whole. 

Based on the information provided, medical necessity of GH treatment has not been demonstrated.  The patient's growth chart demonstrates normal growth along the 5-10th percentile, and information about weight is not provided, nor is documentation provided that other causes of short stature, such as thyroid deficiency, malabsorption, celiac disease, and other systemic illness, have been ruled out.  The estimated final adult height prediction was calculated, and it is approximately 68 inches, normal.  The most likely causes of the patient's slow growth and delayed bone age is constitutional delay/delayed puberty, not GH deficiency.  Growth factors are normal, and there is no morphological abnormality of the pituitary gland on MRI.  The delayed bone age is not a specific finding and may indicate constitutional delay, not necessarily GH deficiency.  His puberty progressed and thus is expected to have a delayed pattern of growth and would not require GH therapy to achieve his height potential.
Appeal type: Formulary Exception
Decision: Upheld

Infectious Disease
Pharmacy/Prescription Drugs

Diagnosis: HIV
Treatment: Juluca
The insurer denied Juluca. The health plan's determination is upheld. 

The patient is a female with a history of human immunodeficiency virus (HIV) infection. Her Infectious Disease physician ordered Juluca (dolutegravir/rilpivirine) for treatment of her HIV, although the available clinical records do not indicate exactly when and why she was started on this particular regimen. Coverage for this medication was denied because it is considered non-formulary per the health plan.

In this case, one of the proposed formulary alternatives to Juluca is separately prescribing its components - dolutegravir (Tivicay) and rilpivirine (Edurant). There is no indication that the patient has had an adverse reaction to either dolutegravir or rilpivirine alone, and the same dosage provided in Juluca could be achieved with one tablet each of dolutegravir 50 milligrams (mg) and rilpivirine 25 mg. Furthermore, there is no indication that the patient would be adversely impacted by taking one additional tablet per day for her antiretroviral treatment. Thus, separate prescriptions for Tivicay and Edurant would be equally effective compared to Juluca without an increase in risk for adverse events. A formulary exception is not indicated in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis.
Treatment: Inpatient admission.
The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a woman. Her medical history included asthma and obesity. She re-presented to an emergency department with a one-day history of epigastric and right lower quadrant abdominal pain. She was diagnosed with acute appendicitis by history, physical, laboratories, and imaging (CT abdomen and pelvis). The patient elected to pursue non-operative management and was discharged home with oral antibiotics. However, her pain worsened, and she developed nausea and vomiting. Therefore, she re-presented to the emergency department. 

Her vitals were temperature 98.9, pulse 98, blood pressure 123/89, respirations 18, and oxygenation 100% on room air. On physical examination, she had tenderness to palpation of the right lower quadrant of the abdomen. Serum laboratories demonstrated leukocytosis to 15.6. 

The patient was admitted at an acute inpatient level of care for a diagnosis of acute appendicitis. She was made nil her os (nothing by mouth); and provided with intravenous fluids, antibiotics, analgesics, and anti-emetics. The patient underwent laparoscopic appendectomy; surgery and recovery were uncomplicated. Having returned to her baseline health and function, the patient was discharged home in good and stable condition with outpatient surgical follow-up. 

No, the proposed treatment admission at an acute inpatient level of care was not medically necessary. 

According to several studies, the majority of patients with uncomplicated appendicitis who undergo laparoscopic appendectomy can be treated effectively and safely at a lower level of care [Gilliam et al; Cross et al; Cosse et al]. In fact, most patients can be discharged from the post-anesthesia care unit (the recovery room) [Mitchell et al; Dubois et al; Cash et al]. Therefore, for this patient, there was no need for admission at an acute inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fever, chills, sore throat, tachycardia, cough, burning with urination
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned. 

The patient is a male whose inpatient admission date of service  is under review. The patient presented with fever and headache of one day duration, myalgia, dysuria, and sore throat.

In the ER, the patient was thought to have sepsis, started on IV fluids and antibiotics The ER physician determined that given this, the patient needed admission. The patient was admitted and treated with IV Zosyn. The patient improved over the next few days and was discharged home on PO (oral) antibiotics.

Yes, the proposed inpatient admission is medically necessary.

Although the qSOFA (quick sequential organ failure assessment) score is low (1), standard of care would require admitting such a patient. The patient did not respond to antibiotics or IV fluids, tachycardia persisted, and thus the tachycardia needed to be observed and treated under close observation. Failure to admit such as a patient can lead to loss of function, septic shock, or death.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Depression, suicidal ideation
Treatment: Continued inpatient admission
The insurer denied the continued inpatient admission.
The denial is overturned.

The Continued inpatient admission was medically necessary.

The patient represented an acutely elevated risk of dangerous behaviors, and there was no less-restrictive treatment environment appropriate.  The acute risk factors of depression and suicidality, with the chronic risk factors of potentially dangerous behaviors suggest that the patient would have been at an acute risk of aggressive or self-injurious behaviors (including but not limited to suicide) were they to have been discharged from the inpatient hospital setting.  She was discharged from the inpatient psychiatric hospital setting as soon as a less-restrictive treatment setting was appropriate.  

The patient represented an elevated risk of dangerous behaviors, including aggressive behaviors, self-injury, and suicide, and there was no less-restrictive treatment environment appropriate.  Therefore the treatment was medically necessary.  While the patient was not endorsing active suicidality or homicidality, the patient remained depressed.  The patient had multiple static risk factors for potentially dangerous behaviors, including prior history of aggression and suicidality and diagnosis with a severe mental illness.  Therefore the patient represented a chronic risk of potentially dangerous behaviors.  The fact that patient remained depressed with ongoing medication changes were acute risk factor for dangerous behaviors.  Furthermore, the fact that there was no less-restrictive environment of care appropriate suggests that ongoing inpatient psychiatric hospitalization was medically necessary and should be covered by the patient's health plan.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pain (sickle cell disease)
Treatment: Inpatient admission
The insurer denied the inpatient admission.  The denial is upheld.

The inpatient admission was not medically necessary.

The patient is a male with history of sickle cell disease and crisis, multiple blood transfusions, bilateral avascular necrosis of the hips, marijuana dependence, and cholecystectomy who presented to the emergency room with complaints of chest, back and leg pain.  He denied abdominal pain, nausea, vomiting, shortness of breath, fever, palpitations, or dizziness.

Vitals included: blood pressure 102/56, respiratory rate 18, temperature 98.8, and pulse oximetry 98%.   Physical examination was notable for pale conjunctiva, otherwise grossly unremarkable. Laboratory studies revealed: white cell count 11.7, hemoglobin 6.9, hematocrit 20.1, MCV 103.1, platelets 128, sodium 140, potassium 3.6, blood urea nitrogen (BUN) 7.8, and creatinine 0.72.  Chest x-ray was unremarkable.

Impression was vaso-occlusive crisis.  The patient was admitted to medical floor.  Plan included Dilaudid and Benadryl.  On 11/19/2019, the patient was deemed medically stable and discharged home.

The patient was admitted to the hospital for vaso-occlusive sickle cell crisis. However, he was hemodynamically stable.  Laboratory studies did not reveal any gross abnormalities that would support inpatient admission or management. Chest x-ray did not show evidence of acute cardiopulmonary process. Furthermore, there was no altered mental status, seizures, sepsis, acute chest syndrome, hypoxemia, deep vein thrombosis, stroke, myocardial infarction, acute renal infarction or anemia requiring blood transfusion.   

The inpatient admission was not medically necessary, because the care rendered could have been performed at a lower level of care without adversely affecting the patient's health.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fever

Treatment: inpatient hospital admission

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

This patient is a female with past medical history significant for hypertension, diabetes mellitus, renal cell carcinoma, deep venous thrombosis (DVT), pulmonary embolism (PE) status post inferior vena cava (IVC) filter, and recent hospitalization who returned to the Emergency Department (ED) with complaints of fever, abdominal cramps and urinary frequency. The patient's vitals on presentation included: Temperature maximum at 101.9 F, Blood pressure of 97/65, Pulse of 96, Respiratory rate of 20, Oxygen saturation of 98% on room air. The patient's laboratory results included the following: white blood cell (WBC) count of 16.5, hemoglobin of 9.2, hematocrit of 28.9, creatinine of 1.1, and glucose of 215. The patient was started empirically on intravenous (IV) antibiotics (ceftriaxone, metronidazole, ciprofloxacin) for possible urinary tract infection. The patient's chest x-ray was negative. The patient's urinalysis had epithelial cells. The patient had intermittent fevers and diarrhea. The patient's stool was sent for cultures and C. diff. The patient improved clinically, remained afebrile and hemodynamically stable. The patient was discharged to continue outpatient management.

According to documentation, patient returned to the hospital with reported fever of 103.1F, despite being discharged on oral antibiotics (Levaquin). In the ED, the patient was noted to have a fever, Tmax of 101.9 F. The patient also had multiple laboratory abnormalities including leukocytosis, anemia, and hyperglycemia. Based on these abnormal findings, in a high-risk patient with renal cell carcinoma, recent hospitalization form embolization, and failure of outpatient management, literature review supports that this patient's hospital admission was medical necessary for intravenous antibiotics and additional diagnostic evaluation. 

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 hospital admission is reversed. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Celiac Artery Stenosis
 
Treatment: Inpatient Admission

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

This is a female patient who presented to the hospital with complaints of epigastric pain and chest pain. It was reported that she was recently diagnosed with celiac artery stenosis. An electrocardiogram (EKG) was performed with negative results for ischemia and myocardial infarction (MI) was ruled out. She had a cardiac catheterization that revealed non-obstructive coronary artery disease. Vascular Surgery consulted on the patient and advised her against surgical intervention for her celiac artery stenosis.  

Clinical indications for admission for undiagnosed abdominal pain (M-05) include the need for surgery that cannot be performed on an ambulatory basis and peritoneal signs.  The patient did not have these conditions.  She also did not have hemodynamic instability, intestinal obstruction, bacteremia, a severe electrolyte abnormality, or an inability to maintain oral hydration.

This patient was having ongoing pains possibly related to her vascular stenosis.  However, no acute interventions were needed.  She did not have acute coronary syndrome (ACS).  Protonix and Carafate could have been given as an outpatient.  The vascular surgery consult could also have been done as an outpatient. She could have received outpatient pain management and undergo an outpatient work-up.  Intravenous (IV) hydration could have been given in the Emergency Room (ER).  She did not meet MCG criteria for admission for undiagnosed abdominal pain.  She could have been managed with observation status.  The healthcare plan acted reasonably and with sound medical judgment and in the patient's best interest.  An inpatient admission was not medically necessary.  The denial is upheld.

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

Diagnosis: Stroke, congestive heart failure, gait ataxia
Treatment: Increase in Personal Care Worker Services from five days/week, four hours/day to seven days/week, ten hours/day 

The patient is a female with a history of stroke, congestive heart failure, chronic obstructive pulmonary disease (COPD), aphasia and gait ataxia. Due to these conditions, she requires assistance with many of her activities of daily living (ADLs).

Appeal review requested for potential approval of an increase in personal care worker services from five days/week, four hours/day to seven days/week, ten hours/day for improved assistance with completion of the patient's ADLs.

This is a female with a history of stroke, congestive heart failure, COPD, aphasia and gait ataxia. Due to these conditions, she requires assistance with many of her activities of daily living (ADLs). However, based on the records provided, the currently approved plan of seven days/week, four hours/day personal care worker services is sufficient to meet the patient's current needs. The patient was noted to be able to ambulate up to 225 feet with a roller walker and set up assistance, able to transfer with set up help and only requires supervision with toileting. She is able to feed herself meals that are prepared in advance by her personal care worker and she is able to self-direct her care. Although she has shown some cognitive and physical decline in the records, the health plan did increase personal care worker services to seven days/week, four hours/day.  This is sufficient to meet the patient's needs.  For these reasons, the proposed treatment of an increase in personal care worker services to seven days/week, ten hours/day is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Abdominal pain, nausea and vomiting.
Treatment:  Inpatient admission.

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

The patient is a female who presented to the ER for further evaluation/management of abdominal pain, vomiting and diarrhea.  Intake vitals were notable for mild/moderate hypotension but normal heart rate and otherwise hemodynamically and neurologically stable.  Examination was non-focal with no significant abnormalities noted, including no evidence of acute cardiopulmonary abnormalities or findings consistent with acute/surgical abdomen.  Laboratory and electrocardiogram (ECG) testing were also within normal limits with no significant abnormalities noted, including no evidence of acute end organ damage. 

The medical records indicate that this patient was admitted to the inpatient medical service in stable condition where she received supportive care with intravenous (IV) fluids, antiemetics and continued cardiac monitoring.  She responded well to the prescribed therapies and was subsequently discharged in stable condition.  Appeal review requested for potential approval of Inpatient admission.

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

This female presented to the ER for further evaluation/management of abdominal pain, vomiting and diarrhea.  Intake vitals were notable for mild/moderate hypotension with blood pressure (BP) ranging 76-107/52-76 mmHg but normal heart rate and otherwise hemodynamically and neurologically stable.  Examination was non-focal with no significant abnormalities noted including no evidence of acute cardiopulmonary abnormalities or findings consistent with acute/surgical abdomen.  Laboratory and ECG testing was also within normal limits with no significant abnormalities noted, including no evidence of acute end organ damage. 

The medical records indicate that this patient was admitted to the inpatient medical service in stable condition where she received supportive care with IV fluids, antiemetics  and continued cardiac monitoring.  She responded well to the prescribed therapies and was subsequently discharged in stable condition.  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: Upheld

Diagnosis:  Asthma.
Treatment:  Inpatient admission.

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

The patient is a male with history of asthma who presented to emergency room with wheezing and shortness of breath (SOB).  The patient was found to be in mild asthma exacerbation.  The patient was recently discharged from the hospital after asthma exacerbation but reported he did not receive any asthma medications from the pharmacy. 

In the emergency room the patient was hemodynamically stable and was not in any respiratory distress.  The patient had wheezing despite multiple nebulization treatments.  With oral steroids and nebulization treatments, the patient's wheezing and SOB improved.  The patient was discharged home.

No, the proposed treatment, inpatient admission, was not medically necessary.

The patient's mild asthma exacerbation partially improved with emergency room care.  The patient was tolerating oral medications.  The patient was ambulating.  The patient required frequent nebulization.  The patient could have been safely and effectively treated at an observation level of care.  The acute in hospital level of care was not medically necessary.