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

Diagnosis: Diaphragmatic hernia with obstruction; vomiting, Gastrointestinal discomfort
 
Treatment: Stomach and Intestine Surgery

The insurer denied the Stomach and Intestine Surgery. The denial was reversed 

This is a female patient with a history of sleeve gastrectomy, hiatal hernia, gastroesophageal reflux disease (GERD), cholecystectomy, bladder lift and knee surgery.  In mid-2019, she consulted with general surgeon for hiatal hernia repair and possible gastric bypass surgery.  She had a diaphragmatic hernia with obstruction and was taking Omeprazole 40 mg capsule, delayed release, 1 capsule twice a day.  The patient reported severe discomfort and vomiting from GERD despite medication, and that her symptoms were exacerbated since her gastric sleeve surgery over five years ago.  A gastrointestinal (GI) series in mid-2019 showed status post gastric sleeve without evidence of leak; moderate hiatal hernia with incomplete emptying into the stomach and reflux level of the proximal esophagus; contrast remained present in the esophagus on post examination radiographs.  A conversion to bypass for treatment and alleviation of her worsening GERD symptoms is requested, and journal articles have been submitted for review.  Bariatric Surgery is proven and medically necessary when due to a technical failure or major complication from the initial bariatric procedure.  
As this patient has a bariatric surgery complication, the procedure to manage the complication is medically necessary.  

Based on the above, the medical necessity for the requested stomach and intestine surgery to treat the reverse flow of stomach juice that backs up into the esophagus is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

The patient is a male with a history of alcohol abuse. He presented to the emergency department requesting admission for alcohol withdrawal. He had a shoulder fracture that had occurred two weeks prior; he was unable to say whether or not this occurred in the setting of a seizure. He complained of tremors and mild nausea.
In the emergency department, his blood pressure was 129/90 millimeters of mercury (mmHg). His heart rate ranged from 101 to 123 beats/minute. On physical exam he was mildly tremulous with tongue fasciculations. His Clinical Institute Withdrawal Assessment (CIWA) score was 8. He was treated with lorazepam and admitted to the hospital. The following day his blood pressure was 159/105 mmHg with a heart rate of 98-103 beats/minute. On exam he was tremulous. His CIWA score was 3-5.  On the third day he was hypertensive with a blood pressure of 172/120 mmHg with a heart rate of 89 beats/minute, He had bilateral upper extremity tremors with a CIWA score of 5. His lorazepam was slowly tapered. The following day his CIWA score was 3. Lorazepam taper was continued. On the day of discharge, his tremor had resolved. 

The health plan's determination is overturned.

The inpatient stay was medically necessary for this patient.
While most patients with acute alcohol withdrawal do not need inpatient admission, given the risk for delirium tremens, which can be fatal, a minority do require inpatient care. The decision regarding inpatient admission should be based on the Clinical Institute Withdrawal Assessment Scale for Alcohol (CIWA), which includes such factors as nausea, vomiting, tremor, diaphoresis, anxiety, agitation, itching, hallucinations, visual disturbances, headache and disorientation. According to current recommendations, patients with mild symptoms (CIWA score of less than 8) can be monitored on an outpatient basis and may not require medication. Patients with a CIWA score of 15 or higher or a history of alcoholic withdrawal seizure, suicidal ideation, or other comorbid conditions should be admitted to the hospital. The decision regarding admission versus outpatient care of patients with scores from 8 to 14 should be individualized. This patient's initial score was 8. While medication and careful outpatient monitoring is often acceptable in this situation, the possible history of a recent alcohol withdrawal seizure and shoulder fracture placed this patient in a higher risk group. Inpatient admission with careful monitoring and serial assessment was reasonable and prudent and supported by the medical literature.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis
Treatment: Inpatient admission

The inpatient admission was medically necessary.
This patient had signs of systemic infection, including tachycardia and leukocytosis, which are indications for admission according to the Infectious Diseases Society of America (IDSA) guidelines (1). Thus, this admission was supported by IDSA guidelines. Failure to admit such as a patient can lead to loss of function, sepsis, deep abscess, or death.
Appeal type: Formulary Exception
Decision: Upheld

Diagosis:  Psoriasis
Issue under review:  Formulary exception for Tremfya

Determination:
The health plan should not cover the Formulary exception for Tremfya.

The patient has a longtime history of successful therapy with Humira, and there is no indication that it is not working for her any longer.  Additionally, the formulary alternatives, Stelara and Taltz, are medically appropriate for her diagnosis and would be suitable alternatives to Humira, should that not work for her any longer.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Issue conceiving
Treatment:  IUI
The proposed treatment was not medically necessary.

According to the American Society of Reproductive Medicine (ASRM), Infertility is a disease, defined by the failure to achieve a successful pregnancy after 12 months or more of appropriate, timed unprotected intercourse or therapeutic donor insemination. Earlier evaluation and treatment may be justified based on medical history and physical findings and is warranted after six months for women over age 35 years.

This patient was able to conceive following donor insemination but had a miscarriage.  In other words, she did not fail to conceive after six therapeutic donor inseminations, and, therefore, she does not have a diagnosis of infertility.  In the absence of such a diagnosis, treatment for infertility including the intrauterine insemination was not medically necessary.

The requested IUI is not medically necessary, since this patient did not have an illness, injury or disease:  She has inability to conceive due to non-exposure to sperm and due to aging a normal, natural physiological process.  The standard of care is for this patient to fail six inseminations (i.e. fail to get pregnant) before she is considered infertile and eligible for coverage of infertility services.

In summary, this patient's inability to conceive is due to natural aging and non-exposure to sperm.  She does not have a diagnosis of infertility, and the requested IUI was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse
Treatment: Continued inpatient admission 
The continued inpatient admission was medically necessary for this patient.

The requested benefit of continued inpatient admission could not have been safely or effectively provided at a lower level of care in this case scenario. The patient in this case was using large quantities of alcohol on a daily continuous basis together with frequent use of cocaine that did warrant inpatient level detoxification and withdrawal management and monitoring. Detoxification, as necessary, and other treatments pertinent to the substance use disorder treatment episode, could not have been safely or effectively provided at a lower level of care following the comprehensive assessment that was provided at the time of admission. Moreover, the patient's social environment was not conducive to an effective detoxification, and the patient struggled initially with withdrawal symptoms in the context of limited insight, impaired judgment and poor control of impulses.

Thus, the adult inpatient stay and detoxification treatment of this patient's substance use disorders did warrant the continued structure of an inpatient level setting with structure, supports, and 24-hour monitoring. The patient's history of substance abuse (frequency and quantity) together with the severe psychosocial stressors and functional impairments do clearly reflect the seriousness of the substance use disorders, and does support the need for a safe and effective detoxification with withdrawal management as the patient was at high risk for treatment failure or general medical complications such as seizures if detoxification and withdrawal management were to have been attempted at a lower level of care. Therefore, medical necessity is met in this case, consistent with prevailing standards of professional practice, published practice guidelines, ASAM Criteria, and the scientific literature, referenced below, and consistent with New York State instruction for medical necessity reviews including the appropriate application of NY OASAS LOCADTR 3.0 Criteria.

The requested benefit of the continued inpatient admission is clinically appropriate, medically necessary and warranted/necessary for this patient, and therefore should be covered in this case scenario. The Substance abuse detoxification for alcohol and continued inpatient level treatment through discharge could not have been safely or effectively provided with lower level services, as noted above. Thus, the requested benefit is not excluded under the plan, and should be covered in keeping with prevailing standards of care pertaining to substance use disorder services including ASAM Criteria and NY OASAS LOCADTR 3.0 Criteria/Guidelines, referenced below.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Appendicitis 

Treatment:  Inpatient Hospital Admission 

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

This is a young female patient who presented to the emergency department (ED) in 2019 with complaints of right lower quadrant pain associated with nausea and vomiting.  The patient did not have a significant past medical history.  The physical examination revealed the patient had abdominal tenderness in the right lower quadrant.  The patient had a Computer Tomogram scan of the abdomen and pelvis, which showed acute appendicitis.  The patient was admitted, and underwent a laparoscopic appendectomy without complications.  She was treated postoperatively with intravenous fluids and was discharged when she was deemed medically stable.

The Milliman Care Guidelines (MCG) indicates that an appendectomy is generally performed on an ambulatory basis and that an inpatient stay is appropriate for patients with severe systemic illness (e.g., sepsis), poorly controlled comorbidities (e.g., COPD, CHF) chronic obstructive pulmonary disease or chronic heart failure, or complications from procedure (e.g., infection, bleeding) that require more than 24 hours of postoperative care.  The patient did not met inpatient (MCG) criteria for acute care inpatient admission, as this was an otherwise healthy female that presented to the ED.  The patient was found to have appendicitis.  The patient subsequently underwent a laparoscopic appendectomy after admission.  This surgical intervention is generally performed on an ambulatory basis.  The records failed to support the patient could not have been treated at a lower level of care, such as observation status.  There were no exceptional factors to support the necessity for an inpatient level of care.

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

The patient is a female who presented to the emergency department (ED) with a history of progressively worsening abdominal pain and vomiting of 3-hours duration. Past medical history is significant for diabetes and asthma. Her evaluation included physical exam, labs, and computed tomography (CT) scan. This yielded the diagnosis of acute appendicitis. Lab data identified an elevated white blood cell (WBC) count of 12.1 thousand (K). Treatment was initiated with intravenous (IV) fluid and antibiotics. Surgical consultation was obtained on the day of presentation.

The patient underwent laparoscopic appendectomy. The clinical notes and the anesthetic record indicate an uncomplicated appendectomy. The operative note describes an acute, non-perforated appendicitis. The patient was provided IV fluid and perioperative antibiotics. Vital signs remained normal throughout the hospitalization. She was discharged home.

The health plan's determination is upheld, in whole.

Inpatient stay was not medically necessary for this patient.This patient presented with abdominal pain. Evaluation with examination, lab data, and CT scan confirmed the diagnosis of appendicitis. Initial treatment appropriately included nothing by mouth (NPO) status, IV fluid, IV antibiotics and appendectomy. The early post-surgical course was uncomplicated and the patient was clinically stable for discharge from the hospital.

The submitted clinical documentation does not support the need for inpatient admission for this patient. The patient required urgent surgical intervention for acute appendicitis, however, a lower level of care would have satisfactorily provided for the care provided and would have been consistent with the accepted standard of medical care. The patient was clinically stable at the time of presentation and remained so during the course of care. The medical records include no documentation of hemodynamic instability, sepsis or toxicity, significant electrolyte imbalance, bleeding, GI obstruction or surgical complications. The patient tolerated oral hydration, diet and medication. Pain was well controlled. 

Inpatient designation was not medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned in Part

The patient has a history of nephrolithiasis and presented to the emergency department (ED) on 5/5/19 with complaints of (c/o) of palpitations x 3 days. The patient reports associated shortness of breath, blood tinged emesis and generalized weakness and noted subjective fevers, dysuria and suprapubic pain. The patient was admitted to the hospital. 

The health plan's determination is overturned in part. The inpatient stay was medically necessary for 2 days. However, as of day 3, the patient no longer required an inpatient level of care. Urinary tract infection with known urologic obstruction in setting of vomiting and unable to take PO would warrant inpatient monitoring to ensure patient tolerating antibiotics and does not have rapid progression of infection with sepsis and renal damage. As of day 3, the patient had been seen by urology who felt the obstruction did not need inpatient intervention was no longer vomiting and culture results showed pan sensitive E. Coli. Therefore, the patient was medically stable for discharge.
Appeal type: Medical necessity
Decision: Upheld

The patient has prior history of prostate cancer treated with radiation and chemotherapy, 2 years prior to this presentation. The patient presented to the emergency department with a 3-week history of right upper quadrant pain with associated nausea and some vomiting as well as low-grade fevers. The patient was in Haiti, when the symptoms started, and reportedly was hospitalized there for 3 days, evaluated with an esophagogastroduodenoscopy (EGD), which showed reported inflammation and infection of the intestines. Reportedly, the patient was treated with Cipro and Flagyl. Upon discharge, the patient returned to the US, and came to the emergency department to be evaluated. The patient reported feeling nauseated, but had experienced no vomiting. The patient did not experience diarrhea. The pain in the right upper quadrant described as heaviness, persisted, but is relieved with applying direct pressure. The patient had a right upper quadrant ultrasound done in the emergency department which was negative. A computed tomography (CT) scan was also done, which showed no evidence of pancreatitis. The patient was admitted to the hospital, with concerns for an infectious etiology causing the right upper quadrant pain.

The health plan's determination is upheld. The inpatient stay was not medically necessary. According to the Milliman Care Guidelines (MCG) criteria for gastroenterology, gallbladder or bile duct inflammation or stone M-555, the patient does not meet criteria for inpatient admission. There is no evidence of acute cholecystitis, there is no evidence of acute cholangitis as the patient lacked objective fever, there is no documentation of elevated CRP greater than 10, or elevation in the white blood cell count. There is no radiologic evidence of common bile duct disease. There is no evidence of common bile obstruction, vomiting that is severe or persistent, there is no clinical evidence of dehydration with normal creatinine and electrolytes, there is no evidence of hemodynamic instability. The patient does not have bacteremia and did not require an interventional procedure to relieve his condition. As a result, a lower level of care is more appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Skull Fracture (left parietal) and Subdural Hematoma

Treatment:  Inpatient Stay

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

This is a female baby who was transferred from another hospital mid-2019.  The mother stated, that 2 days prior to presentation while changing her on the bed the patient fell to the ground.  The mother stated she had asked the older sister watch the patient while she walked away to wash her hands.  The mother was unsure as to how the patient landed; it was reported that the sister immediately picked the patient up off of the hardwood floor.  The mother reported that there was no loss of consciousness, vomiting, or altered mental status.  She added that the patient was playful and was acting normal.  The mother noted that it wasn't until the next day that she noticed the patient had been rubbing her head.  She assessed the baby's head and felt a hematoma.  It was reported that she felt like the patient was more cranky than usual, but was consolable.  She immediately brought the patient to the hospital.  A computerized tomography was performed, which revealed a skull fracture (left parietal) and subdural hematoma.  She had a Magnetic Resonance Imaging of the brain, which revealed evidence of soft tissue swelling around the left frontoparietal calvaria and no discrete evidence of intracranial hemorrhage.  The patient was eating and drinking normally.  There were no gross neurologic deficits.  The physical examination was normal with the exception of a left parietal boggy hematoma.  A Social Worker was consulted and agreed the injuries were consistent with the mother's reporting.  The patient was stabilized and discharged. 

The Milliman Care Guidelines (MCG) note that inpatient admission for a closed head injury, for a pediatric patient would be supported if the patient had a skull fracture that was basilar, open, or depressed, or for suspicion of abusive head trauma.  Admission will also be appropriate for patients who have focal signs on neurologic examination or new signs or symptoms that are severe or persist despite observation care treatment, or who have altered mental status that is severe persistent.  There was no documented suspicion of abusive head trauma. The patient had a skull fracture that was not noted to be basilar, open, or depressed.  The patient did not have focal signs on neurologic examination or new signs or symptoms that were severe or persistent despite observation treatment.  The patient did not have an altered mental status.  The records supported the patient was appropriate for age.  The patient could have undergone observation care, instead of acute admission.

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

Diagnosis: Guttate psoriatric lesions
Treatment: Inpatient stay 
The acute inpatient admission  was medically necessary.

Summary:
The patient has a history of psoriasis, and presented with increased leg swelling, and pain. 

In the ER, the patient's vitals were as follows:  Temperature-36.9, Pulse-155, Respiration Rate-18, Blood Pressure-123/80. On general examination, the patient was NAD (no acute distress). Examination of the patient's CVS (cardiovascular system), chest, and abdomen were normal. Examination of the patient revealed widespread guttate psoriatric lesions, erythematous lesions with circumferential scaling, tender to touch, leg lesions are more coalesced with scaling with yellowish thin discharge from both calves, foul smelling.

This patient should have had inpatient admission and for the following reasons:
1)	She had systemic signs of infection (high WBC count and tachycardia), which is indication for admission according to the Infectious Diseases Society of America guidelines (1).
2)	The patient failed outpatient therapy and MRSA infection was suspected. Again, these are indications for admission according to the Infectious Diseases Society of America guidelines (1).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right toe infection
Treatment: Inpatient admission
The inpatient admission was medically necessary.

The patient has a history of right (R) foot bunionectomy and hammertoe, status post (s/p) right leg bone marrow aspiration from tibia, s/p right leg Baumann procedure, right superficial peroneal anastomosis to deep peroneal nerve, lateral transposition of peroneus brevis muscle with graft, s/p right medial tibia removal of neuroma, and resection of soleus muscle.

The patient presented with R great toe infection. The patient noted an ulcer one week prior, saw an MD who prescribed oral (PO) Augmentin (could not complete course secondary to side effects). There was no fever and no chills. 

In the ER, the patient was thought to have infection of the R first toe. She was started on intravenous (IV) Unasyn and was admitted. Psychiatry, gastroenterology (GI), gynecology (Gyn), pain management and infectious disease (ID) services were consulted. The patient then signed out against medical advice (AMA).

This patient meets initial criteria for IV treatment and admission for cellulitis/abscess given by the Infectious Diseases Society of America (IDSA) (1), as she failed outpatient therapy. Failure to admit such as a patient can lead to loss of function, sepsis, deep abscess, or death.