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

Appendicitis
Inpatient hospital

The patient is a male who presented to hospital with abdominal pain. The white blood cell (WBC) was mildly elevated at 12k. An ultrasound (U/S) was non diagnostic, and no appendix was visualized. Plain films were suggestive of possible bowel obstruction.
A computed tomography (CT) showed a 1-centimeter (cm) appendix consistent with appendicitis without features that suggested advanced disease or perforation. Pathology: acute appendicitis; no mention of gangrene or perforation No narrative documentation pertaining to the initial history and physical (H&P) nor operative note nor daily progress notes were provided. The inpatient stay is under review.

The health plan's determination is upheld. The inpatient stay was not medically necessary. There were no physician's notes provided that describe the clinical course either preoperatively nor postoperatively. An inpatient stay could be justified if there was some untoward perioperative event, intraoperative injury or complication, inadequate physiologic recovery, hemodynamic instability, acute organ injury, persistent altered mental status, fever or other signs of septic complications, surgical site complication, management of complex comorbid medical condition or a finding of an occult or new medical condition. No documentation of this was provided. Therefore, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic migraines.

Treatment: Ajovy 225 milligrams/1.5 milliliter autoinjector.

The insurer denied coverage for Ajovy 225 milligrams/1.5 milliliter autoinjector. The denial is overturned.

This patient is a female who has a history of chronic migraines.  The documentation indicated this patient was seen for neurological follow-up regarding her headaches.  The patient was being seen via telehealth.  The patient was unable to go through with Botox injections as there was severe anxiety about the procedure.  The migraine frequency has worsened, and she averages approximately 20 headaches per month.  The migraines are associated with nausea and vomiting.  She does utilize sumatriptan and ondansetron both of which work well.  The migraines are typically one-sided in the back of her head and can become severe.  She has previously trialed Topamax, Trokendi, and propanolol.  The physical examination is limited due to the nature of the visit.  The patient was recommended to utilize Ajovy and continue sumatriptan and ondansetron.

The patient has medically refractory migraine headaches with prior treatment failure with Topamax, Propranolol, and other agents, and was unable to undergo Botox injection due to anxiety. The treating physician wishes to proceed with Ajovy and continue with Imitrex.  The patient has a relevant neurological history of medically refractory migraine headaches with prior treatment failure with Topamax and Propranolol.  She was unable to undergo Botox injections due to a severe anxiety attack prior to the procedure.  Ajovy has been shown to help reduce the frequency and intensity of migraine headaches.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.
	
The carrier's denial of coverage for Ajovy 225 milligrams/1.5 milliliter autoinjector is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Other/dizziness.
Treatment: Inpatient hospital stay.
The insurer denied the medical necessity of the inpatient stay. The denial was upheld in whole.

The patient  presented to the emergency department (ED) with acute onset of dizziness and presyncope. The patient felt that "the room was spinning". In another note, it was mentioned that dizziness was worse on standing or walking. Prior to the presentation to the ED, the patient checked blood sugar (BS) in the morning and  administered self 7 units of insulin. After that patient felt dizzy, lightheaded, and felt like the patient was going to pass out, sat down and felt a little better, but then developed severe weakness and called Emergency Medical Services (EMS). The patient also was complaining of tingling and numbness in bilateral lower extremities.
The patient has a past medical history of diabetes mellitus II (DM type 2), hypertension and hyperlipidemia, and was not compliant with blood pressure (BP) treatment prior to admission. The patient was given intravenous fluids (IVF), 1 Liter normal saline (NS), and  labs were done.
A chest x-ray (CXR) was normal. The electrocardiogram (ECG) revealed nonspecific T wave abnormality. The orthostatic BP was negative (supine 169/91, standing 160/90.) During the hospital stay, the dizziness resolved, hypertension was managed with oral medications and was stable. The patient also was treated with Meclizine. Renal ultrasound revealed small left renal cyst, otherwise unremarkable renal ultrasound. The patient was discharged from the hospital.

The requested health service/treatment of inpatient stay were not medically necessary for this patient. The patient presented with persistent dizziness, which most likely was vertigo. The patient had elevated blood pressure, but that was chronic, and  was not takinganti-hypertensive medications at home. The patient did not have evidence of stroke, and head computed tomography (CT) scan was not even performed.
The cardiac work up was negative, troponin was normal, ECG was unremarkable, and echo was only abnormal for mild diastolic dysfunction. The patient was on cardiac telemetry and  was in sinus rhythm, Orthostatics were negative. From neurological and cardiac standpoints the patient did not have indications for inpatient admission.
The patient was consulted by endocrinologist and  insulin regimen was adjusted. However, that did not meet criteria for inpatient admission, Endocrinological evaluation could have been accomplished at a lower level of care.
Based on all above, inpatient admission was not medically necessary. A lower level of care would be more appropriate.
In addition, based on Milliman Care Guidelines (MCG) criteria for dizziness, inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest pain.
Treatment:  Inpatient admission.

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

The patient is a male with a past medical history significant for HTN (hypertension), COPD (chronic obstructive pulmonary disease), HIV (human immunodeficiency virus), remote history of endocarditis and latent TB (Tuberculosis) diagnosed, s/p (status post) treatment, and alcohol abuse. 

The patient presented to the ER with complaints of non-exertional, non-radiating chest pain and shortness of breath.  The patient had no fevers, chills, sore throat.  An ECG (echocardiogram) revealed no acute ischemic changes.  The patient's troponin was 0.05.  A urine screen revealed the presence of alcohol.  The patient was tachycardic, with stable blood pressure.  There was leg edema present bilaterally, with chronic venostasis changes.  The patient had normal oxygen saturation.  A lung exam revealed no rales or wheezing.  The patient's physical examination was unremarkable otherwise.  His BNP (brain natriuretic peptide) was not elevated.  The patient was admitted to telemetry to rule out ACS (acute coronary syndrome).  Echocardiogram was performed, revealing normal LV (left ventricle) function.  No inpatient ischemic work-up was planned.  The patient was treated for suspected COPD exacerbation and was discharged with a plan for outpatient follow-up.

No, the proposed Inpatient Admission is not "medically necessary".

This patient presented for evaluation of atypical chest pain and dyspnea.  The diagnosis of an acute MI (myocardial infarction) was ruled out by cardiac enzymes.  No ischemic work-up, such as stress test, CTA (computed tomography angiogram) or catheterization was planned by the treating physicians.  There was no evidence of acute myocardial infarction, ACS (acute coronary syndrome), decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability.  The symptoms were felt to be related to his underlying COPD, and he was treated with bronchodilators.  There was no evidence of acute alcohol withdrawal.  Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission, and the care required could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gastroenteritis.

Treatment: Inpatient admission.

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

This patient is a female with a past medical history of vasovagal syncope, anxiety, and an implantable loop recorder. The patient reported having nausea, vomiting and syncopal episodes, and also had a psychiatric history including depression, anxiety and conversion disorder. The patient was afebrile but she had a sinus tachycardia. On exam, there was no abdominal rebound or guarding. The renal function was normal. The patient had a diagnosis of postural orthostatic tachycardia syndrome and was receiving weekly saline infusion. The patient's nausea and vomiting was attributed to a viral syndrome. The patient was treated with intravenous (IV) fluids and antiemetic, Zofran. 

After a period of observation, the patient was still having nausea and vomiting for which Phenergen was added to the patient's medication regimen. The patient had recurrent episodes of tachycardia with heart rates fluctuating between 140 and 168. The plan was to give the patient intravenous (IV) boluses for sustained tachycardia.

Clinical indications for admission for gastroenteritis (M-170) include hemodynamic instability persistent vomiting and a requirement for IV fluid support after emergency department and observation care treatment. Based on the review of the medical record, this patient had persistent tachycardia and persistent symptoms of nausea, vomiting and intolerance to adequate oral intake beyond the length of observational care and treatment. In view of this patient's syncopal episodes and recurrent episodes of tachycardia, intravenous (IV) fluid support was needed. The patient met the MCG criteria for inpatient admission for gastroenteritis. The patient had postural orthostatic tachycardia syndrome and was having episodes of significant tachycardia. The patient had syncopal episodes and required IV fluid support. 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 is substantiated.  The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse.

Treatment: Continued substance abuse disorder services at the residential level of care.

The insurer denied coverage for continued substance abuse disorder services at the residential level of care. The denial is overturned.

This patient is a male who was admitted to this inpatient substance residential rehabilitation treatment as he was using multiple substances of use including alcohol, opiates, cannabis, and cocaine. He was drinking 2-6 beers per day, using 3 grams of heroin and 60 mg of pain pills daily, using up to 20 mg of Xanax, and using a couple of lines of cocaine when drinking. He was in pain daily which triggered his use as he had a past motorcycle accident. He had addiction issues for several years. He attended individual, group, and family therapy, as well as educational didactics. He was discharged. 

The APA Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that residential treatment is indicated primarily for individuals who do not meet clinical criteria for hospitalization but 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. Residential facilities provide a safe and substance-free environment in which residents learn individual and group living skills for preventing relapse. 

In this case this patient was considered in need of continued 24 hour residential treatment during the denial period as he needed more time in this 24  hour inpatient therapeutic structured and supervised setting to improve coping skills, relapse prevention skills, improve insight, better identify triggers, improve motivation, and he continued to have post-acute withdrawal symptoms during the denial period. 

According to the LOCADTR he met criteria for inpatient substance residential rehabilitation treatment as he continued to use multiple serious substances of use despite negative consequences of substance use and he could not stop using multiple substances without the 24 hour therapeutic supervised and structured programming of this therapeutic residential treatment setting.

Continued inpatient substance residential rehabilitation treatment was medically necessary. It did not appear that the health care plan acted reasonably, with good clinical judgment, or in the best interests of the individual then.

Based on the above, the medical necessity for the continued substance abuse disorder services at the residential level of care is substantiated.  The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pregnancy/Childbirth/other  
Treatment: Inpatient hospital 
The insurer denied the inpatient hospital stay. 
The denial is upheld in whole. 

Summary: 
This patient presented at 25-6/7 weeks' gestation as dated by second trimester ultrasound with a second episode of heavy vaginal bleeding. She was noted to be stable by vital signs and bleeding after examination. She had no coagulopathy. There was no fetal distress noted. There was no evidence of labor or rupture of membranes. Fetal growth was normal. There was no placenta previa noted on exam. The inpatient admission would not have been medically necessary at the acute inpatient level of care status for this patient given the diagnosis of second trimester vaginal bleeding that was stable without need for acute intervention. The patient did not have preterm premature rupture of membranes with non-reassuring fetal status, chorioamnionitis, fetal distress or demise, placental previa, vasa previa, placenta accreta, previa was excluded by ultrasound, there was no acute and ongoing bleeding requiring interventions, or continued fetal monitoring that requires inpatient care. A lower level of care such as observation or outpatient levels of care for the management of placenta previa have been studied and found to be safe alternatives to acute inpatient level of care. Based on review of the medical documentation and the MCG Health Guidelines, there was no
medical necessity for acute inpatient admission as the patient had no placenta pathology and did not have ongoing bleeding that indicated additional procedures such as delivery. In fact, the patient was deemed stable for transfer to another hospital. Thus, the care provided could have been accomplished at the lower level of care but would not have required acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Flu and difficulty walking
Treatment: Inpatient admission
The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a female child that presented to the ED because of leg pain and refusal to stand. She had three-day history of fever to 103 and cough, poor oral intake, and same-day history of refusing to bear weight with complaints of calf pain.

Vital signs included temperature 37.2, heart rate 97, respiratory rate 20, and blood pressure 92/58. Examination was significant for no acute distress, moist oral mucosa, regular heart rate and rhythm, clear lungs, tenderness to palpation over both calf and thigh muscles, unable to bear weight, and non-focal neurologic exam. Testing for influenza B was positive. Creatine kinase was elevated at 1236. She was treated with a normal saline bolus, acetaminophen, and ketorolac prior to admission that evening for further management of viral myositis secondary to influenza B. 

Admission orders included repeat labs the following morning, droplet precautions, IV fluids, and acetaminophen as needed. Her creatine kinase peaked at 3182. While in the hospital, she had no fevers, her pain had resolved, she was able to ambulate, and she was tolerating a regular diet for age. She was deemed stable for discharge to follow-up with her pediatrician. 

No, the Inpatient admission is not medically necessary.

While influenza is typically associated with pulmonary symptoms and sequelae it has also been associated with myocardial infarction, pericarditis, Guillain-Barre syndrome, encephalitis, and potentially severe rhabdomyolysis. Myalgia is a typical complaint for patients with influenza, but acute myositis and rhabdomyolysis occur as well, more often in children than in adults. Treatment of rhabdomyolysis in this circumstance is aimed at preventing acute renal failure.

This young female child presented to the ED with history of fevers and URI (upper respiratory infection) symptoms followed by acute onset lower extremity pain and refusal to walk. Testing in the ED was consistent with myositis secondary to influenza B infection. With poor fluid intake and mild dehydration, it was medically necessary to monitor her for adequate fluid intake alongside resolution of myositis symptoms. Because she was overall hemodynamically stable with no evidence of impending sepsis or renal failure, she did not require acute inpatient admission and could have been safely managed at a lower level of care such as observation.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male with a past medical history significant for HTN (hypertension), dyslipidemia, CAD (coronary artery disease), s/p CABG (status post coronary artery bypass graft), who presented for evaluation of chest pain, after exertion, radiating to bilateral neck, better with rest. The patient was hemodynamically stable. ECG revealed no acute ischemic changes. The cardiac enzymes were negative. The patient was admitted for cardiology evaluation to rule out ACS (acute coronary syndrome). The patient remained clinically stable. He was seen in consultation by cardiology with an impression of stable angina, no evidence of ACS. No ischemic work-up (stress test CTA or catheterization) was planned. Patient was continued on oral anti-anginal therapy and was discharged home with a plan for outpatient follow-up.

No, the proposed Inpatient admission is not "medically necessary".

This patient presented for evaluation of chest pain. The diagnosis of an acute MI (myocardial infarction) was ruled out by cardiac enzymes, which were negative. The patient was evaluated by cardiology and diagnosed with stable angina. No ischemic work-up was deemed to be necessary. There was no evidence of acute myocardial infarction, ACS, decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission and the care required could have been provided at an observational level of care.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis:  Hypertrophic cardiomyopathy (HCM).
Treatment:  Formulary Exception for Norpace CR 150 milligrams OR CP 12.

The insurer denied coverage for Formulary Exception for Norpace CR 150 milligrams OR CP 12.  The denial is upheld.

This patient is a female with hypertrophic cardiomyopathy (HCM), which was diagnosed in 2019 after she had experienced shortness of breath and an echocardiogram.  She experienced orthostatic dizziness and lightheadedness, as well as frequent palpitations lasting for seconds to minutes.  The patient had initially been treated with beta-blockers, which did not improve symptoms. She was prescribed Norpace CR 150 milligrams, which was denied by the insurance company, due to the fact that the patient could be prescribed the formulary alternative of disopyramide.  An appeal letter stated that sustained release disopyramide was the last line of medical management before aggressive therapy like open heart surgery for surgical septal myectomy.  The letter also noted that there was no conventional generic sustained release preparation of disopyramide sustained release.

The patient was prescribed Norpace 150 for treatment of symptoms related to hypertrophic cardiomyopathy.  There is no documentation that the formulary alternative of generic disopyramide had been tried and/or not tolerated.  There are no head-to-head comparisons demonstrating superiority or inferiority of brand-name Norpace compared with generic disopyramide. 

Based on the above, the need for Formulary Exception for Norpace CR 150 milligrams OR CP 12 is not substantiated.   The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Infectious disease/Bacterial infection
Treatment: Inpatient hospital  
The insurer denied the inpatient hospital stay
The denial is overturned in whole 

The patient  with a history of left breast cancer for which the patient underwent a left breast lumpectomy and radiation therapy then, underwent a bilateral mastectomy with sentinel lymph node biopsy. Post-operatively, did well until the Jackson-Pratt (JP) drains were removed. After this, the records indicate that the patient began experiencing pain at the operative site.

Yes, the inpatient stay was medically necessary for this patient.
The patient s/p left lumpectomy and radiation therapy followed by a bilateral mastectomy and sentinel lymph node biopsy. The  patient presented with subjective fevers and chills, redness and tenderness of the left mastectomy site and persistent purulent drainage from the JP site, all of which was refractory to outpatient management with two different antibiotic regimens. It should be noted that the  history of radiation therapy to the left chest wall puts the patient  at high risk for infection. Upon presentation to the Emergency Department, was afebrile and hemodynamically stable, but had a significant leukocytosis. The Emergency Department physician initiated serial examinations to rule out severe sepsis, and documented that inpatient admission was necessary for IV antibiotics for recurrent/refractory infection.

There are a number of factors that justify medical necessity for inpatient services, such as a high severity of illness, comorbid medical conditions that would be likely to increase the patient's need for medical services and the medical probability of a complication (1).
An inpatient hospital admission was medically necessary for the patient due to:
1. The  failure to respond to outpatient treatment with oral antibiotics.
2. The  increased risk of infection due to prior radiation therapy.
3. The need for an infectious disease consultation in an expeditious manner in order to treat her infection that did not respond to two different oral antibiotic regimens.
4. The need for frequent clinical reassessments to rule out severe sepsis.
5. The  additional diagnosis of C. Difficile colitis.