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

Respiratory System
Inpatient Hospital

Diagnosis: COPD
Treatment: Inpatient hospital stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a male with a medical history of epilepsy, current smoker, alcohol abuse, heroin abuse on methadone treatment, adenocarcinoma of the lung (T4, N0, M0) and chronic obstructive pulmonary disease (COPD) who was admitted for an acute chronic obstructive pulmonary disease (COPD) exacerbation with symptoms of right sided chest pain, shortness of breath, productive cough, tremors and a frontal headache. 

The Inpatient Hospital Admission was not medically necessary for this patient. In the emergency room, he was afebrile, hemodynamically stable, noted to have a respiratory rate of 20 breaths per minute, had an oxygen saturation of 90% on room air, was not in any respiratory distress but had an increased work of breathing with bilateral inspiratory and expiratory wheezing on auscultation of the chest. He was treated with two albuterol-ipratropium nebulizers, one albuterol nebulizer, Solumedrol 125 milligrams (mg) intravenous once, magnesium sulfate 2 g once and prednisone 60 mg oral once. Per the emergency physician note, the patient was also treated with BiPAP (Bilevel Positive Airway Pressure) support but was weaned off prior to inpatient admission with an improvement in his condition with treatment rendered in the emergency room. His chest x-ray demonstrated no evidence for infiltrates, consolidations, pneumothorax, pleural effusions or fractures. On admission, he was not in any distress, laying comfortably in bed, had an oxygen saturation >90% on supplemental oxygen but had bilateral wheezing. He did not have documentation/evidence for hypercapnia, hypoxia or cyanosis, a sustained heart rate >=100 beats per minute, he was alert, awake and oriented, was able to protect his airway and did not require sustained non-invasive ventilator support. Although he was placed on supplemental oxygen, there is no documentation of hypoxia or hypoxemia. In addition, although there was a concern for possible alcohol withdrawal, the patient had a Clinical Institute Withdrawal Assessment (CIWA) score < 10 indicating minimal withdrawal severity. Therefore, the inpatient hospital admission was not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:Infectious disease
Treatment: Inpatient hospital stay

Diagnosis:Infectious disease-Other
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay as not medically necessary. 
The denial was upheld in whole.

The patient has a past medical history significant for diabetes mellitus and hypertension who presented to the emergency department with complaints of intermittent subjective fever that had been going on for 10 days. The fever was associated with fatigue, cough with sputum production, and occasional episodes of shortness of breath.
Two days before the presentation the patient went to an urgent care center and received Tylenol, intravenous fluids, and vaccines. The symptoms improved for 2 days but then the fever returned, and the patient went back to urgent care, and got Advil.
At the time of admission, the patient denied nausea or vomiting but endorsed occasional episodes of diarrhea every 3-4 days since  receiving medications for a urinary tract infection a few weeks before presentation.
In addition to intermittent fever, the patient had pain associated with urination. At the time of the initial evaluation in the emergency department, the patient had a temperature of 39.5F, heart rate 139 beats per minute (bpm), respiratory rate 24 breaths per minute, and an oxygen saturation 94% on room air. Following the administration of intravenous fluids, the serum lactate came down to 2.5 and vital signs stabilized. The patient became afebrile. A chest x-ray performed at the time of admission showed no evidence of acute disease. The urinalysis did not reveal evidence of urinary tract infection, so antibiotics were discontinued. Abdominal ultrasound was performed. It revealed fatty liver and small mass on the right renal pole suggestive of angiolipoma.
Since the patient's clinical condition significantly improved, the patient was discharged home.

This patient presented to the hospital with intermittent fever, and the sepsis syndrome was appropriately suspected. However, a thorough evaluation did not reveal any source of infection. The patient's temperature normalized very quickly. White blood cell count was completely normal. There was no evidence of infection based on the physical exam.
Taking into consideration all these facts, the admission at a lower level of care was appropriate to rule out infection and sepsis syndrome and look for the source of possible infection.
The patient remained hemodynamically stable throughout the entire hospitalization and the symptoms resolved fairly quickly. During the hospital stay the patient did not require administration of vasopressors, invasive blood pressure monitoring, long-term administration of intravenous antibiotics, or any other diagnostic studies or procedures necessitating admission at the acute inpatient level of care. Neither the severity of the patient's condition or complexity of the services provided rose to an acute inpatient level of care.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Respiratory system /Other.
Treatment:  Pharmacy Prescription /drugs.

The insurer denied Remicade.  The denial is overturned in whole.

The patient was diagnosed with cardiac sarcoidosis after presenting with heart block and recurrent non-sustained ventricular tachycardia (NSVT).  His cardiac ejection fraction (EF) of 35% led to placement of an implantable cardioverter defibrillator (ICD), and prednisone was initiated.

Yes, the Remicade is likely to be more beneficial for the patient's condition.  The patient has life threatening disease with reduced cardiac function and malignant arrhythmias.  The use of Methotrexate has failed to control his disease; he has been unable to wean corticosteroids to a tolerable level.  As prednisone was lowered, despite methotrexate, his EF dropped, and he continued to experience VT.

Infliximab has been shown to of benefit and, as in the literature cited below, is recommended in just such a case.  There is not a more suitable or standard of care.  The next group of treatments (cyclophosphamide, etc.) do not have any better efficacy data, generally have worse side effects, and are recommended as 4th line after infliximab.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Respiratory system /Other.
Treatment:  Pharmacy Prescription /drugs.

The insurer denied Remicade.  The denial is overturned in whole.

The patient has medical history of cardiac sarcoidosis with a history of ventricular tachycardia with reduced ejection fraction status post an internal defibrillator.  He is on high dose oral glucocorticoids (prednisone) but also requires Methotrexate, due to refractory disease on prednisone alone.  While on these previous medications, the patient had stabilization of disease; however, the patient now has developed worsening of his cardiac function with a significant reduction in ejection fraction from 55% to 44%.  

Yes, the proposed health service or treatment Remicade is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

Based on the clinical information, the patient has cardiac sarcoidosis with a history of ventricular tachycardia and reduced ejection fraction requiring placement of an internal defibrillator.  The patient is on high dose oral glucocorticoids (prednisone) but also requires methotrexate due to refractory disease on prednisone alone.  While on these previous medications, he had stabilization of disease, however, now has developed worsening of his cardiac function with a significant reduction in ejection fraction from 55% to 44%.

Tumor necrosis factor alpha (TNFa) is thought to accelerate the inflammatory process in sarcoidosis via its role in granuloma formation.  Infliximab is a chimeric, humanized monoclonal antibody that neutralizes TNFa.  Therefore, using therapy, such as Infliximab, that blocks the effect of TNFa may be beneficial in treating sarcoidosis.  However, these agents are reserved for patients who have persistent disease, despite treatment with glucocorticoids, and at least one second-line immunosuppressive agent.  Remicade has been studied in patients with pulmonary and extrapulmonary sarcoidosis refractory to glucocorticoid therapy and an additional immunosuppressive agent (eg. Methotrexate), such as in this patient.  Most recently, Harper et al. demonstrated the safety and efficacy of Infliximab in patients with cardiac sarcoidosis.  They found that Infliximab allowed a reduction in steroid dose without worsening of cardiac function and an improvement in arrhythmia control in a cohort of cardiac sarcoidosis patients refractory to other treatment regimens.  This member's sarcoidosis has progressed despite therapy with high dose oral glucocorticoids and methotrexate.  Therefore, the proposed health service or treatment, Remicade, is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Respiratory system /Other.
Treatment:  Pharmacy Prescription /drugs.

The insurer denied Remicade.  The denial is upheld in whole.

This is the case of a patient who suffers from cardiac sarcoidosis.  The provider is requesting the coverage of Infliximab.  The patient has been complaining of shortness of breath and occasional cough.  The patient has had a drop in the ejection fraction.  The patient was diagnosed with non-sustained ventricular tachycardia.  An automatic implantable cardioverter defibrillator (AICD) was placed on the patient.  The patient has been on Prednisone and Methotrexate.  The treating provider is requesting the coverage of Infliximab or Remicade.

No, based on current medical literature, the proposed health service or treatment Remicade is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.  

According to Milliman guidelines, for sarcoidosis, evidence regarding the role of Remicade is insufficient, conflicting, or poor and demonstrates an incomplete assessment of net benefit vs. harm; additional research is recommended.

Adler et al. reviewed the literature to characterize the efficacy and safety of anti-TNFs in sarcoidosis.  Sixty-five studies (five randomized controlled trials [RCTs]) were identified, comprising 1525 patients were reviewed.  For pulmonary sarcoidosis, while one RCT found infliximab (IFX) significantly improved vital capacity vs. placebo, a second study detected no difference.  In non-randomized studies of cutaneous, ocular, neurologic, and multisystem sarcoidosis, IFX improved 89%, 69%, 77%, and 71% of cases, respectively.

Hulten et al. (2016) stated that infliximab and adalimumab, as well as anti-CD20 antibody rituximab, have been reported to have efficacy in cardiac sarcoidosis in case series and small cohorts but are not considered standard therapy currently.

There are no adequate or well-conducted randomized controlled or cohort trials in the prevailing peer-reviewed published medical literature that established the long-term efficacy and safety of infliximab over steroid or methotrexate for the treatment of this patient medical condition.  There is no high-quality literature showing an improvement in health outcomes with the use of Infliximab/Remicade for this patient condition.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Cardiac /circulatory problems/other.  
Treatment:  Inpatient hospital.

The insurer denied the inpatient hospital stay.  The denial is overturned in whole.

The patient has a history of hypertension and coronary artery disease.  The patient   presented to the emergency department complaining of dyspnea.  The patient had just been discharged from the hospital earlier in the day after being admitted for congestive heart failure and new left ventricular systolic dysfunction.

Yes, an inpatient level of care was medically necessary.  This patient presented with persistent dyspnea hours after being discharged from the hospital where the patient  had been treated for decompensated heart failure.  The patient's chest was clear, BNP was only modestly elevated, and chest X-ray did not show evidence of pulmonary congestion.  Cardiac catheterization revealed severe two vessel disease and a normal left ventricular end diastolic pressure.  Thus, this patient's symptoms, as well as the  recent decline in left ventricular systolic function, could be attributed to ongoing ischemia.  Given her persistent symptoms and the decline in her left ventricular ejection fraction, she was at risk for adverse outcomes including myocardial infarction, malignant arrhythmias and death.  The inpatient level of care until revascularization could be performed was medically necessary in this case.

The Milliman Care Guideline for Heart Failure ORG: M-190, were considered and reviewed, the patient met the criteria for a precipitating cause for her acute decompensation, namely ischemia.in this particular case.  Therefore, the inpatient hospital stay was medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Duchenne Muscular Dystrophy.
Treatment: Emflaza.
The insurer denied the Emflaza.
The denial is overturned. 

The patient is a male with Duchenne muscular dystrophy (DMD). Genetic testing revealed a duplication of exon 53.  He also has obstructive sleep apnea. The patient has been on Emflaza but transitioned to prednisone due to the possibility of developing cataracts. However, once he was started on prednisone, he began with increased fatigue, worsening weakness, and weight gain.  He was then taken off of prednisone and restarted on Emflaza, and since then, he has been stable with continued ambulation and part-time use of a wheelchair.  As the patient has been maintained on Emflaza, and he tried and failed prednisone, his treating providers recommend he continue on Emflaza. Anticipated clinical benefits include prolonged independent ambulation, improving pulmonary function, reducing the incidence of scoliosis, and delaying wheelchair dependence. 

The patient was last seen in follow-up, at which time he was able to walk unassisted but was unable to climb stairs.  He was noted to be stable with no significant respiratory complications.  His parents had recently purchased a power wheelchair.  The patient was to be evaluated by otolaryngology (ENT) due to tonsil enlargement. 

Yes. The proposed Emflaza is medically necessary. 

The patient has Duchenne muscular dystrophy and has had intolerable side effects with prednisone. The side effects included fatigue, worsening weakness, and weight gain. 

According to the treatment guidelines published in Lancet in 2018, reference 3, as well as the practice parameter by the American Academy of Neurology, reference 4, deflazacort is indicated and is medically necessary in cases of Duchenne muscular dystrophy. Subsequent publications, references 1 and 2, indicate that deflazacort causes lesser weight gain comparing to prednisone, and preserves motor strength for longer. 

Therefore, in the patient's case the requested drug, deflazacort, is being used for a medically necessary indication as supported by the current medical literature and by treatment 

The patient has Duchenne muscular dystrophy and failed prednisone due to side effects. Deflazacort is considered to be the standard of care to prevent motor deterioration and to preserve pulmonary and cardiac function in patients with this diagnosis. Therefore, the best interest of the patient is to continue deflazacort/Emflaza.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Carotid Artery Stenosis.
Treatment:  Inpatient admission.

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

This is a male patient with a past medical history of hypertension, diabetes mellitus, multiple sclerosis, major depressive disorder, and osteoarthritis.  He presented to the emergency room for complaints of recurrent transient left arm weakness and facial droop 12 days prior to admission and a similar transient ischemic attack (TIA) episode 1 month prior that resolved spontaneously.  The initial exams showed an elevated blood pressure of 164/83, and an electrocardiogram with non-specific T abnormalities in the inferior leads, and minimal ST elevation in the anterior leads.  Computerized tomography angiogram (CTA) of the head and neck demonstrated 90-99% stenosis right Internal Cerebral Artery (ICA) and 100% occlusion left ICA.  The physical examination revealed a normal S1, S2, and no murmurs, rubs, or gallops.  The patient had normal speech, normal gait, 5/5 strength in the bilateral upper, and lower extremities.  The National Institutes of Health stroke scale (NIHSS) score on admission was 0.  The MRI of the brain revealed no acute infarct with severe small vessel disease.  There was a chronic pontine lacunar infarct and a 1.6 x 1.5 arachnoid cyst in the right cerebellar medullary junction.  The chest x-ray was normal.  

The patient was admitted to inpatient care due to blockages of blood vessels in the brain.  He underwent treatment by Neurology, Physical Therapy, and Occupational Therapy.  

The patient underwent a right carotid angioplasty and stent placement.  Echocardiogram showed mild dilated left atrium and mild to moderate concentric left ventricular hypertrophy.  The patient was stabilized and discharged in 3 days.

Given 100% occlusion of one carotid artery, and 90% occlusion of the other, and presenting symptoms of a TIA, the patient was at high risk for a stroke.  Management in such cases includes anticoagulation or antiplatelet therapy, serial neurologic exams, and correction of the anatomic/vascular abnormality.  Rapid correction of the carotid artery stenosis under hospital observation was appropriate.  To send the patient with multiple stroke risk factors home, without monitoring, would have placed the patient at risk for a stroke. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above information, the medical necessity for inpatient admission is substantiated.  The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lower back and leg pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned. 

The patient is a male. He presented to ED with low back and leg pain. The patient attempted steroids, muscle relaxants, oral and topic analgesics. MRI shows herniated disc with nerve impingement. The patient attempted NSAIDs (nonsteroidal antiinflammatory drugs), muscle relaxant, steroids IV, ketamine and opioids. 

The patient received IV Decadron 4mg every six hours. The patient remained in the hospital and received continued IV pain medications and IV steroids. The patient was discharged in stable condition without surgery.

Yes, the Inpatient admission was medically necessary.

The patient had significant back pain that was debilitating. The patient was maintained on IV pain medications and IV steroids throughout the hospitalization and was scheduled for surgery. This level of pain could not be monitored or treated in a lower level of care such as outpatient or SNF (skilled nursing facility), and with the abnormal MRI findings and the patient's significant pain level, the acute inpatient level of care was medically necessary. 

The patient had significant pain that was intractable to oral medications and required IV medications. Therefore, the acute inpatient stay is medically necessary and the denial should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal wound dehiscence

Treatment: inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

This is a female patient status post abdominal reconstructive surgery the prior month complicated by small bowel injury, who presented to the Emergency Department (ED) with complaints of umbilical wound opening with purulent discharge and abdominal soreness; pain rating 3/10. Based on the review of the medical record, this patient had an abdominal wound dehiscence with granulation tissue. She denied severe pain, fever or chills per the ED note. The patient's vital signs were in the normal range, and she was not septic. The patient was admitted for bedside debridement and intravenous (IV) antibiotics. However, this patient could have received debridement in an outpatient setting and could have received antibiotics via a PICC line at home. Inpatient admission was not required for wound debridement and antibiotics. 

According to the Milliman Care Guidelines, 24th Edition, "General Admission Criteria", inpatient admission is indicated for 1 or more of the following: (1) Hemodynamic instability; (2) Hypertension requiring inpatient treatment; (3) Acute cardiac or peripheral ischemia; (4) Cardiac arrhythmias of immediate concern; (5) Severe heart failure; (6) Respiratory abnormalities, such as severe airflow or ventilation abnormalities, impending or actual respiratory arrest; (7) Neurologic abnormalities, such as new-onset severe neurologic findings; (8) Suspected acute intra-abdominal process; (9) Severe physiologic disorder, such as abdominal abnormalities, acute renal failure, significant uremic complications, high fever or other high-risk infection situation, temperature less than 90 degrees F (32.2 degrees C) (rectal); (10) Severe nutritional abnormalities; (11) Severe electrolyte abnormalities; (12) Acute blood loss causing significant abnormality, such as severe anemia; (13) High-risk low platelet count; (14) Disseminated intravascular coagulation; (15) Severe adverse drug or systemic toxin reaction requiring inpatient treatment; (16) Severe pain requiring acute inpatient management; (17) Severe behavioral health issues; (18) Inpatient monitoring needed; or (19)  Treatment requiring inpatient care/Emergency procedures needed. In this case, this patient did not have any of these conditions that warranted inpatient admission. 

The patient had a wound that did not require operative debridement. The wound was debrided at the bedside, which indicated this procedure could have been safely done in the outpatient setting, i.e. office. Antibiotics could have been administered at home. There was no indication for inpatient admission for this patient. Thus, inpatient admission was not medically necessary for this patient.

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated.  The insurer's denial should be upheld.