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

This is a patient with a past medical history significant for hypertension, diabetes mellitus, generalized anxiety disorder, and tobacco abuse who presented to the emergency department with complaints of chest pain, palpitations, and dyspnea. The patient reported sharp intermittent chest pain, which had been going on for 1 week. The health plan's determination of medical necessity is upheld.  Considering the patient's risk factors, it was appropriate to suspect that the patient's chest pain could have been related to an acute coronary syndrome. At the same time, the patient remained hemodynamically stable, there were no laboratory signs that the patient, had an acute coronary syndrome or any other dangerous medical condition that would require further evaluation and treatment at the inpatient level of care. The patient was evaluated by the cardiology service and was found to have atypical chest pain. She was able to tolerate a diet without difficulties.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abscess
Issue under review: Inpatient admission

Determination:
The inpatient admission was not medically necessary.

The patient's care could have been provided at a lower level of care than acute inpatient.  Bedside incision and drainage of a scrotal abscess does not require inpatient care.  The oral antibiotics and observation of clinical status did not require an acute inpatient level of care, because care could have been provided at an observation level of care.  After admission, he was afebrile and hemodynamically stable.  Complicating features were not present.
Appeal type: Medical necessity
Decision: Upheld

The patient presented with  right lower quadrant pain with nausea and vomiting. The patient had previously taken clomid. The patient was admitted to the hospital .The health plan's determination  of medical necessity is upheld in whole.The inpatient stay was not medically necessary the patient could have been monitored at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

The patient with a history of hypertension, abdominal aortic aneurysm and cigarette smoking, presented to the emergency department complaining of chest pain that radiated to both arms. Blood pressure was 142/92 millimeters of mercury (mmHg) with a heart rate of 76 beats/minute. There were no acute electrocardiographic changes. There was no evidence of aortic dissection by computed tomography (CT) angiography. Cardiac biomarkers, including creatine kinase and troponin, were elevated. The patient was treated with aspirin, heparin and Plavix and admitted with a diagnosis of non-ST segment elevation myocardial infarction. The patient was transferred to another institution for cardiac catheterization.  Coronary arteries were normal, and the patient was discharged home. The health plan's determination is upheld.

An inpatient level of care following cardiac catheterization was not medically necessary. This patient was sent for cardiac catheterization due to an episode of chest pain. While his cardiac enzymes were elevated, he was hemodynamically stable, without evidence of ischemia by electrocardiogram and his coronary arteries were normal. There were no procedural complications. The care this patient received, before, during and after his cardiac catheterization did not require an inpatient admission. The safety of same-day discharge after coronary angiography, even when percutaneous interventions are necessary, have been well established.
Per Milliman Care Guideline for Cardiovascular Surgery or Procedure, cardiac catheterization is typically performed under ambulatory status. The ambulatory exception criteria were not provided.
The patient could have been appropriately managed at a lower level of care status; inpatient was not medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Plaque psoriasis
Issue under review: Formulary exception for Cimzia

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

The patient has moderate to severe psoriasis that has only been treated with topical medications in the past. His provider states the member cannot take Otezla due to GI issues and other, non-specific medications because he is planning pregnancy with his partner in the near future. Cimzia is a non-formulary medication, and there are no documented circumstances that would justify medical necessity over the formulary products, Humira and Stelara. Additionally, there is no documentation of contraindications or intolerance to Humira or Stelara.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastritis
Treatment: inpatient admission, evaluation, and medication management
The insurer denied inpatient hospital services. The denial was upheld.
The patient presented with complaints of abdominal pain and vomiting.  He had a history of gastritis.  He was afebrile and his vital signs were stable.  There were no peritoneal signs.  The patient was diagnosed with gastritis and cyclic vomiting syndrome.  He was treated with Protonix.  He gradually improved.

MCG clinical indications for admission for Vomiting (M-370) include gastrointestinal obstruction, a severe metabolic derangement, severe electrolyte abnormalities, high fevers and acute renal failure.  The patient did not have these conditions.  Inability to maintain oral hydration after observation care is an indication for admission.  However, by the next day he was feeling better although he still had an episode of vomiting.  When he was discharged he was tolerating a diet.

MCG clinical indications for admission for Gastritis (M-560) include gastric outlet obstruction, perforation, peritoneal signs, and ongoing bleeding.  The patient did not have these conditions.

This patient had gastritis and cyclic vomiting syndrome.  He required proton pump inhibitor (PPI) therapy, Maalox, and Reglan.  He responded to treatment and gradually the diet was able to be re-started.  This treatment could have been given with observation care.  He did not meet MCG criteria for admission for either vomiting or gastritis.  He could have been managed with observation status.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who was admitted to acute inpatient mental health treatment for worsening symptoms of a psychotic disorder in the context of medication non-adherence and severe substance use disorder with crack cocaine, alcohol and cannabis. She exhibited paranoid thought content and auditory hallucinations that resulted in erratic behavior and severe symptoms of anxiety. The health plan's determination of medical necessity is upheld. The patient no longer required the structure or the 24 hour monitoring of an acute inpatient level of care in order to remain safe or to administer continued treatment for the psychiatric disturbance including support of daily activities and safety monitoring. It was not medically necessary for this patient to have acute inpatient level services in view of her improved functioning and better control of the psychotic symptoms, and lack of impulsive behaviors, as well as improved insight and cooperation with staff with regard to daily functioning. There were no general medical issues or co-occurring symptoms of the substance use disorders complicating this case that would have required the continued acute inpatient level services.
Appeal type: Medical necessity
Decision: Upheld

The patient with no pertinent past medical history who presented to the emergency department with complaints of fever, chills, nausea, and back pain that the patient had experienced for six days. In addition, the patient also complained of foul-smelling urine, which was red in color, as well as some dysuria. The patient was admitted  for management of pyelonephritis. The treatment included administration of intravenous fluids and intravenous antibiotics. The health plan's determination of medical necessity is upheld in whole .The inpatient Hospital Admission was not medically necessary.The admission at a lower level of care was the best alternative to ensure clinical stability.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: achalasia
Treatment: Per Oral Endoscopic Myotomy (POEM)
The proposed POEM procedure is medically necessary for the management of this patient's condition (achalasia).
The POEM procedure allows for performing a myotomy of the lower esophageal sphincter (LES) using endoscopy rather than laparoscopy (as with laparoscopic Heller myotomy [LHM]). Obvious technical advantages of POEM over LHM include lack of abdominal incisions, more rapid recovery, and the option of avoiding general anesthesia with airway intubation. For the management of type I (minimal esophageal contractility) and type II (panesophageal pressurization) achalasia, POEM is associated with an efficacy of approximately 85% to 95%. 
This patient has type II achalasia, and therefore, POEM should be approved for the management of achalasia.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Schizophrenia, Cannabis Use Disorder, and Cocaine Use Disorder 

Treatment: inpatient Admission

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

This is a male patient admitted to inpatient psychiatric hospital in late 2018 for acute psychosis. He had been involved with a community outreach psychiatric team prior to his hospitalization.  He was had a history of threatening behavior He had a long psychiatric history with previous psychiatric hospitalizations and involvement with outpatient commitment.  He was on long-acting injectable antipsychotic medication (Invega Sustenna); however, he was refusing oral medications.  Following involuntary admission, he was less agitated, but he was withdrawn, isolative and irritable.  He continued to have paranoid delusions about his neighbors.  Patient documentation indicated that the disposition plan was for the patient to return to his home with follow-up by the Assertive Community Treatment (ACT) team.  Multiple attempts were made by the social worker to contact the residential case worker, during this admission. It was learned that the patient had a long history of issues at his residence. He received active psychiatric treatment such that at the later time of his admission he was psychiatrically stable.  He was no longer dangerous.  He was accepting medication treatment. 
This finding is consistent with the general standards of psychiatric care, American Psychiatric Association (APA) Guidelines for the Treatment of Patients with Schizophrenia.  The patient could have received safe and effective ongoing treatment outside of a hospital setting.

Based on the above, the medical necessity for inpatient hospital services at the inpatient level is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neck pain/Cervical disc disease

Treatment: Four level total disc arthroplasty C3-4-5-6-7 and associated inpatient stay

The insurer denied  cervical disc surgery procedure code 22856 (Total disc arthroplasty [artificial disc], anterior approach, including discectomy with end plate preparation [includes osteophytectomy for nerve root or spinal cord decompression and microdissection]; single interspace, cervical). That denial was upheld

This patient presented for evaluation complaining of neck pain as well as numbness and paresthesia's radiating down the upper extremities.  The patient also complained of lightheadedness as well as pectoral pain.  The imaging showed multilevel cervical degenerative disc disease most significant at the 3-4 level and then to a greater extent at the 5-6 and 6-7 level on the left side with moderate to severe foraminal narrowing bilaterally.  The patient on objective examination had decreased range of motion to the cervical spine.  

Artificial disc replacement is indicated for treatment of severe radiculopathy permitting neural decompression and maintenance of motion. The proposed indications for surgery include patients with unremitting cervical radiculopathy despite 6 to 8 weeks of conservative treatment. There needs to be evidence of cervical nerve root compression by MRI as well as signs of cervical radiculopathy on the physical examination. The Prodisc-C device for cervical artificial disc replacement is a safe option for patients providing excellent clinical outcomes, satisfactory return to work rates, and maintenance of segmental motion. Total disc arthroplasty with Prodisc-C is a safe and effective surgical treatment of single level symptomatic cervical degenerative disc disease. 

The patient had complaints of neck pain with intermittent radiation.  The clinical notes are however contradictory.  In some the physical examination reveals multiple neurologic deficits; however, other notes do not detail the same deficits.  It was also documented that the patient had electrodiagnostic evidence of carpal tunnel.  While the documentation detailed the patient had a trial and failure of conservative measures the treatment rendered was not the most appropriate treatment.  The objective examination must corroborate the diagnosis.  The submitted contradictory information as well as indication the patient also has pathology at the wrist and the current literature does not support the requested procedure. While there are follow-up data for 1and 2 level arthroplasty, no data could be found for 4 level arthroplasty The cervical disc surgery as well as the hospitalization were not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Croup/respiratory distress

Treatment: Inpatient admission, monitoring, oxygen, medication management

The insurer denied the inpatient admission. The denial was reversed

This was an infant with respiratory distress/ croup that was initially treated as an outpatient with nebulized saline at the doctor's office and then, home.  There was documentation of apneic episodes at home. The patient was transported to the emergency department (ED) by EMS who reported oxygen destauration between 89-83%. EMS administered Duoneb en route. In the ED, the patient had a weak cry, appeared distressed, and was tachycardic (heart rate - 182) and tachypneic (respiratory rate -  50) with retractions. She was RSV positive. She was placed on 1 liter of oxygen and admitted. Following admission, she was weaned to room air. Due to a coughing fit, she was kept an additional day for monitoring and pulmonary toilet, as needed.

As per Up to Date, "Severe bronchiolitis is indicated by persistently increased respiratory effort (tachypnea; nasal flaring; intercostal, subcostal, or suprasternal retractions; accessory muscle use; grunting), hypoxemia, apnea, or acute respiratory failure [107]. Repeated observations are necessary to adequately assess disease severity because examination findings may vary substantially over time [3]. Infants and young children with severe disease usually require hospitalization for frequent observation as well as respiratory and/or fluid support."
Appeal type: Medical necessity
Decision: Upheld

Diaagnosis: Depression and Anxiety
Treatment: Residential mental health treatment 
The proposed treatment was not medically necessary
This patient's clinical presentation is suggestive of an Axis II diagnosis in addition to her stated diagnoses of autism spectrum disorder and major depressive disorder. Her chronic acting out behaviors waxed and waned throughout her stay, but by the period under review her behaviors were generally oppositional and attention seeking, without such severity as to require 24-hour daily observation and treatment. By the time period in question, ongoing treatment in a less restrictive setting would have been safe and appropriate.
Appeal type: Medical necessity
Decision: Upheld

The patient was diagnosed with Stage IV small cell lung cancer with extensive bony metastases. Clinical notes indicate the patient was directly admitted to the hospital for cycle 2 of cisplatin/etoposide because transportation issues prevented him from receiving this as an outpatient.He tolerated chemotherapy well with minimal nausea and no vomiting, and was discharged when treatment was completed.

The health plan's determination is upheld. The inpatient admission was not medically necessary. The patient was clinically stable and received chemotherapy, port placement, labs, and imaging, all of which could have been performed at a lower level of care. The patient does not meet any of the criteria for acute inpatient level of care according to Milliman Care Guidelines, Oncology GRG, W0074.
Appeal type: Medical necessity
Decision: Upheld

The patient with history of hypertension, stroke, asthma, depression, diabetes, and seizures was brought to the ER with altered mental status after three witnessed seizures. The patient was supposed to be on Keppra, however the patient's medication compliance was questionable. The patient was admitted and given a loading dose of Keppra. Computed tomography of the head showed old lacunar infarct. The health plan's determination is upheld.
There was no objective evidence on physical exam, or imaging of an imminently life-threatening cause of the patient's complaints. It is very likely that the seizures were due to poor medication compliance. The services provided could have been easily and safely completed at a lower level of care status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left lower extremity swelling and erythema; lymphedema

Treatment: Inpatient hospital stay 

Summary:
The patient had lymphedema that had never been worked up and it was unclear how it was contributing to the current problem (and whether she needed urgent treatment for that specific entity). Also, with the recent history of C-section, a wound infection or deeper infection was also on the differential diagnosis. These conditions could not safely (and in a timely manner) be evaluated as an outpatient. Thus, this admission was warranted, supported by standard of care. Failure to admit such as a patient can lead to loss of function, sepsis, deep abscess, or death.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness and vomiting
Treatment: Inpatient admission
The acute inpatient admission was not medically necessary.
The patient presented with recurrent vertigo over a two week period. She did not have any abnormalities on examination to suggest stroke and her report of position dependent symptoms was incompatible with stroke. The diagnostic studies, monitoring and treatment could have been safely and effectively completed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Perianal cellulitis
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The infection had four days prodrome, the abscess was already draining, and there were no signs or symptoms of systemic toxicity. 

This patient could have been managed at a lower level of care. The abscess was draining and the treatment was appropriate with antibiotics.

The primary treatment of anorectal abscess is surgical drainage. Once diagnosed, all perianal and perirectal abscesses should be drained promptly; lack of fluctuance should not be a reason to delay treatment. Any undrained anorectal abscess can continue to expand into adjacent spaces as well as progress to generalized systemic infection.

The abscess in this patient was already draining hence further therapy was not indicated as detailed by the pediatric surgery consultation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bipolar disorder
Treatment: Continued inpatient admission
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 depressed mood with the chronic risk factors of potentially dangerous behaviors suggest that the patient would have been at an acute risk of self-injurious behaviors (including but not limited to suicide) were he to have been discharged from the inpatient hospital setting.  The patient 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 self-injury, and suicide, and there was no less-restrictive treatment environment that wold have been 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 suicidality, medication non-adherence, and diagnosis with a severe mental illness.  Therefore, the patient represented a chronic risk of potentially dangerous behaviors.  The fact that patient remained depressed and medication non-adherent were acute risk factors for dangerous behaviors.  Furthermore, the fact that there was no appropriate less-restrictive environment of care suggests that ongoing inpatient psychiatric hospitalization was medically necessary and should be covered by the patient's health plan.
Appeal type: Medical necessity
Decision: Overturned

The patient has right buccal ulcerated melanoma status/post (s/p) wide local excision. Adjuvant treatment planning included the Decision Dx gene assay to help assist in formulating treatment plan. 

The health plan's determination is overturned. The Decision Dx melanoma assay is medically necessary. Gene assays allow the physician to formulate the most effective treatment plan based on biology of the tumor. Gene assays are being utilized not just for melanoma but also for breast cancer on a routine basis. The data clearly identifies the utility of the clinical impact of gene assay in early stage melanoma.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status Asthmaticus, Bronchiolitis

Treatment: Inpatient admission, diagnostic testing, and medication management

The insurer denied inpatient admission. That denial was reversed.

This infant had a history of 3 previous hospitalizations for bronchiolitis. The child was prescribed pulmicort and albuterol. The child has had to use albuterol every 2 - 3 weeks. The child is also noted to have coughing with exertion. The child had been coughing for 2 weeks and the mother had been administering the albuterol at home with no improvement. She took the child to the Emergency Room (ER) at another hospital because of the child being irritable and not allowing the mother to touch the left ear. The child was discharged from that ER without any medical treatment. Since the symptoms were not improving the mother decided to bring him to this hospital ER for an evaluation.

In the ER, he was diagnosed with an otitis media and he was also noted to be wheezing with increased work of breathing. He was treated with 3 doses of inhaled bronchodilators, prednisone and ceftriaxone. A chest x-ray did not show evidence of pneumonia. When his increased respiratory effort and wheezing did not improve with treatment in the ER the decision was made to admit him to the hospital with a diagnosis of status asthmaticus for continued treatment with albuterol every 2 hours. During his hospitalization he was begun on anti-inflammatory therapy to prevent recurrence of wheezing.

The patient was treated appropriately in the ER and when his respiratory distress and wheezing did not respond to vigorous treatment the decision to admit him to the hospital for continued treatment with albuterol every 2 hours was appropriate and consistent with the standard of care for status asthmaticus.