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

Diagnosis: Abdominal Pain, vomiting
Treatment: Inpatient evaluation, Radiologic evaluation and antibiotics

The insurer denied the inpatent admission. The insurer's denial was upheld.

This case involves a child who presented to the emergency department in 2019.  The patient complained of vomiting x1 hour with constant abdominal pain.  The abdomen was soft and tender to the right lower quadrant.  The patient had a blood pressure 112/81 with a heart rate of 85, respirations 20 and oxygen saturation 100%.  The patient stated that she had 4-5 episodes of vomiting.  The patient was tolerating oral fluids.  The last emesis was 30 minutes prior.  The patient had a sodium 136, potassium 4.6, chloride 101, carbon dioxide 21, BUN 11, creatinine 0.59, glucose 99, calcium 9.3, protein 7.9.  The patient had a white blood cell count of 9.5, red blood cell count 4.34, hemoglobin 12.9, hematocrit 39.5. A CT of the abdomen and pelvis revealed findings suspicious for early acute appendicitis with mildly dilated appendix not feeling with oral contrast, reactive ileocolic nodes and trace right pericolic gutter fluid.  An ultrasound of the appendix revealed findings that were somewhat indeterminate and early appendicitis was not excluded.  The patient was to be started on antibiotics.  The patient's abdominal pain and vomiting improved and the patient was able to tolerate a normal diet.  The patient was then discharged on 01/07/2019 home.

The medical literature indicates that inpatient admission is indicated for patient undergoing surgery that cannot be performed on an ambulatory basis.  It may also be indicated for patients with peritoneal signs present, evaluation requires the patient not to eat or drink for an extended period of more than 24 hours, hemodynamic instability, severe pain requiring acute inpatient management, identification of etiology or findings that require inpatient care, signs of intestinal obstruction, suspected toxic megacolon, bacteremia, severe electrolyte abnormalities, inability to maintain oral hydration, percutaneous or open drainage or parental nutrition regimen that must be implemented on inpatient basis.  However, none of the above were noted.  The presence of the fecalith was likely the cause of her pain (they often remove the appendix for pain with fecalith) but since she improved, they did not. The patient had a normal white blood cell count and the CT of the appendix revealed no inflammation.  The abdomen was soft and benign and the patient was given an oral challenge which she tolerated well.  The patient's condition was appropriate for the observational level of care rather than the inpatient level care.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who presented to the emergency department (ED) with vomiting after meals. She also had a cough, congestion, and rhinorrhea. There were multiple ill persons in the home. The health plan's determination is upheld.  Upon presentation to the ED, she was determined to be dehydrated and was treated with normal saline. By the time she reached the floor, she appeared well-hydrated and was able to tolerate fluids by mouth. She had no oxygen requirement and was hemodynamically stable. While it was not unreasonable to monitor her intake and voiding, she did not require acute inpatient admission and could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital

Summary: This patient was transferred from another facility with concern for appendicitis noted on ultrasound. The Emergency Department (ED) Triage Note assessment, noted the patient had abdominal pain, no vomiting, and a positive sonogram. The ED physician documentation included a physical examination demonstrating right lower quadrant abdominal tenderness without rebound, guarding, or masses. He was given Ceftriaxone and Flagyl (at the referring hospital). A sonogram (done at the receiving hospital) revealed a normally compressible appendix with fecalith at the tip. The patient was admitted for observation, was treated for constipation, and was released the next day. A surgical consultation note stated that the patient had no vomiting or diarrhea. The patient was pointing to his umbilicus when asked the location of his pain. The patient was crying during examination and was noted to have right lower quadrant tenderness. No surgical intervention was recommended. An oral fluid trial was recommended. 

The insurer has denied coverage for the inpatient hospital admission as not medically necessary. The denial was upheld.
 
This patient presented with complaints of right lower quadrant abdominal pain. Imaging done initially at the referring hospital was concerning for appendicitis. A followup right lower quadrant ultrasound however was normal, and the patient was cleared by pediatric surgery. Laboratory testing did not show cause for concern. Urinalysis was normal. Per the pediatric hospitalist note, the patient tolerated an oral fluid trial well and was sleeping comfortably upon assessment following admission at approximately 12:40 AM. Plans were made to administer an enema for persistent pain given the lack of a recent bowel movement, and/or to perform an abdominal sonogram or Computed Tomography (CT) to assess for intussusception. The following day, an enema was administered which led to relief in symptoms and the patient was discharged. Apart from abdominal pain, the patient did not have any worrisome symptoms. There was no bloody stool, vomiting, fever, or feeding intolerance. He was tolerating oral fluid. The working diagnoses of the inpatient team included mesenteric adenitis, intussusception, and constipation. Though there was some concern initially for an acute abdomen, he was cleared by surgery and had a normal sonogram. This child could have been placed on observation status rather than being admitted as the majority of children observed in this setting do not require surgical intervention. With normal imaging and good by mouth (PO) tolerance, there was no significant cause for concern regarding an acute abdomen. In terms of constipation, characteristics of children with constipation requiring inpatient management include chronicity of the disorder, overflow incontinence, and developmental delay, none of which describe the patient in question.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Small bowel obstruction
Treatment: Inpatient Hospital

Summary: This patient has a history of hypertension, anemia, breast cancer status post bilateral mastectomy with reconstruction in 2013, stage 4 colon cancer status post sigmoidectomy with hyperthermic intraperitoneal chemotherapy (HIPEC) in 2018, and resection of an adnexal mass and bilateral oophorectomy in 2018. The patient presented to the Emergency Department (ED) with complaints of abdominal pain, nausea and vomiting for one day with her last bowel movement two days prior to presentation. The ED provider note at 01:13 indicated that the patient had been previously seen at another hospital for similar symptoms was medically managed on a previous admission and was currently receiving chemotherapy for metastatic colon cancer. Her abdomen was soft and diffusely tender.  A Computed Tomography (CT) done at 20:32 revealed high grade small bowel obstruction (SBO) concerning for closed loop obstruction. The disposition was to admit the patient to surgery. The resident noted that he spoke with the surgical oncologist, and the patient wished no surgical intervention and just palliative care at this time. Medicine discussed goals with the patient and she expressed a desire to have everything done while she was in the hospital. The decision was made to admit her to surgery and to consult palliative care. A note at 08:32 indicated that the patient was agreeable to surgical intervention if conservative treatment did not work. If surgical intervention was needed, she would like her surgeon from another hospital who knows her to perform surgery. The patient was transferred for further care as per the note at 00:08. 

The insurer has denied coverage for the inpatient hospital admission as not medically necessary.  The denial was reversed.

Based upon the records provided, the inpatient acute care was clearly indicated and warranted as the patient had a SBO documented on CT with a high grade obstruction and concerns for closed loop obstruction. She could not have been placed on a lower level of care e.g. observation status and the acute admission were clearly warranted. It was not clear initially that the patient would be transferred to another facility. It is true that the patient had stable vital signs, but the patient did have a SBO as documented on the CT. Therefore, based upon the clinical information provided, the inpatient admission was justified at the acute care level. This patient had SBO presumably due to metastatic disease and the patient needed to be admitted and was placed on nothing by mouth (NPO) status and given intravenous fluids. It was only because the patient asked her surgeon from the other hospital to care for her that she needed to be transferred. Otherwise, she would have continued her care at the Hospital.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Endometriosis 

Treatment: Medication

The insurer denied the medication. The denial was upheld. 

This is a middle aged female with a diagnosis of pelvic pain and 3 small cystic structures on her ovaries suggestive of endometriomas. The patient has never been diagnosed with endometriosis (No history of a laparoscopy). The provider requested Orilissa.

It is not clear what this patient's diagnosis is. The patient has 3 cystic structures suggestive of endometriomas and the provider requested Orilissa.
Orilissa is not a treatment for endometriomas. The standard treatment is surgery. Ideally a patient would have a repeat ultrasound to see if those cysts have resolved and if not a laparoscopy with removal of the cyst (or ovary would be performed). Orilissa is not approved for management of cysts or endometriomas. 

"The treatment of endometriosis-related pain is based on the severity of symptoms. Other causes of pelvic pain should be excluded prior to treatment. 

1) For women with mild to moderate pain, nonsteroidal anti-inflammatory drugs (NSAIDs) and continuous hormonal contraceptives are recommended rather than either agent alone (Grade 2C). These therapies are low-risk, have few side effects, are low-cost, and are generally well-tolerated compared with other medical therapies. 
2) Women with adequate symptom improvement continue the hormonal therapy/NSAID regimen until pregnancy is desired or the average age of menopause is reached. Women whose symptoms do not improve continue NSAID treatment and are offered an alternate hormonal combination (eg, change to a different estrogen-progestin contraceptive or norethindrone acetate). 
3) For women with severe symptoms, symptoms that do not respond to the above therapies, or recurrent symptoms, a trial of gonadotropin-releasing hormone (GnRH) agonist with add-back hormonal therapy is recommended (Grade 2C). GnRH agonist treatment has demonstrated efficacy without the risks or negative impact on ovarian reserve of surgery. 

There are no studies comparing the efficacy, side effects, long term outcome between Lupron or Orilissa. This patient did not fail treatment with a formulary product (NSAID's oral contraceptives, progestins Danazol or Lupron, Lupaneta) nor does she have a contraindication to the formulary products. 

Based on the above, the insurer's denial of Formulary Exception for Orilissa 150 MG OR TABS is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nausea and vomiting
 
Treatment: Inpatient admission, hydration, medication, monitoring

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

The patient is a pregnant female, P2002, who presented at 12 weeks gestation with chief complaint of nausea and vomiting. The patient had been previously evaluated a week prior with a similar complaint. Her vitals were stable. She had a low potassium level and ketones in the urine. The plan was for fluid hydration, oral potassium replacement, Zofran, Diclegis and follow up in clinic. 

As per ACOG Practice Bulletin, when a woman cannot tolerate liquids without vomiting and has not responded to outpatient management, hospitalization for evaluation and treatment of dehydration and electrolyte imbalance is recommended. 

According to UpToDate literature findings, women who are unable to maintain adequate hydration, normal electrolyte levels, and acid-base balance with initial interventions should be admitted to the hospital. Women who have severe vomiting, weight loss, ketonuria, dry mucous membranes, poor skin turgor, dehydration, hypotension, alkalosis from hydrochloric acid loss, hypokalemia, or nutritional deficiencies are to be admitted. 

The above recommendations apply to patients with severe hyperemesis. This patient did not have severe hyperemesis. Her vitals were stable and her laboratory findings were normal except for mild hypokalemia that could be replaced orally. There was no report of any weight loss. This patient could have been hydrated in the emergency department (ED) and sent home. 

It is not clear why the patient was admitted and why she was kept in the hospital. Based on the above, the medical necessity for the inpatient hospital admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  ADHD
Treatment:  Adzenys XR-ODT 9.4mg OR TBED 
The Adzenys XR-ODT 9.4mg OR TBED is not medically necessary.

The patient is a male child.  He was prescribed Adzenys 18.8 milligrams (mg) daily, which is the maximum recommended daily dose for the patient's age.  The patient's provider writes, "This patient has clinically failed many other stimulants at high doses. Has tried short and long acting.  He has been proven to work on this medicine safely." 

The provider requests approval for an additional 9.4 mg daily, for a total dose of 28.2 mg daily, significantly exceeding the maximum recommended dose as per the United States Food and Drug Administration (FDA) product labeling. 
No chart information is available documenting the patient's specific symptoms, response to this medication, or other medications, at various doses, or rationale for increasing the dose.  For instance, there is no evidence that the patient is significantly large for his age, or that he has been shown historically to be a "fast metabolizer" of stimulants.  Therefore, the Adzenys XR-ODT 9.4mg OR TBED is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse
Treatment: Inpatient detox

Summary:
The requested benefit of Inpatient stay is medically necessary and clinically appropriate in this case scenario, and therefore should be a covered service in this case scenario. The patient's clinical features and treatment dimensions did warrant inpatient level detoxification services through discharge and did necessitate the monitoring that is provided with inpatient level treatment, including the use of comfort medications and continued treatment of his general medical conditions, together with counseling and educational sessions and peer support. Case management services were critical in this case to motivate the patient to proceed to rehabilitation treatment and formal substance use disorder treatment with a safe and clinically appropriate disposition with sober housing. Moreover, the admission and the continued substance abuse detoxification treatment through discharge could not have been safely or effectively provided with lower level services.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse
Treatment: Inpatient admission

The inpatient admission was medically necessary for this patient.

The requested benefit of the 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 opioid/heroin together with large quantity of alcohol on a daily continuous basis and daily use of a benzodiazepine anxiolytic (Xanax) and use of cocaine that did warrant inpatient level detoxification and withdrawal management and monitoring; detoxification, as necessary, and other treatments pertinent to the detoxification 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 presented with moderately severe withdrawal symptoms, and the patient's social environment was not conducive to detoxification, and the patient struggled with withdrawal symptoms during the time interval under review in the context of limited insight, impaired judgment and poor control of impulses.

Thus, the continued detoxification treatment of this patient's substance use disorder did necessitate the admission and continued structure of an inpatient level detoxification setting and monitoring.  The patient's history of substance abuse (frequency and quantity) and severe psychosocial stressors and functional impairments reflect the seriousness of the substance use disorder and the need for a safe and effective detoxification with withdrawal management, as the patient was at high risk for treatment failure if the continued detoxification and withdrawal management were to be 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, New York State instruction for medical necessity reviews including the LOCADTR Tool that requires the patient in this scenario default to the higher level of care.

The requested inpatient admission is medically necessary in this case scenario and, therefore, should be covered.  The patient's clinical features and treatment dimensions did warrant the admission and the continued inpatient level detoxification services through discharge and did necessitate the monitoring that is provided with inpatient level treatment including the use of comfort medications and seizure precautions. Moreover, the continued substance abuse detoxification 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 the appropriate application of New York State OASAS LOCADTR 3.0 Criteria, referenced below.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mediastinal B-Cell Non-Hodgkin's Lymphoma
 
Treatment: Inpatient admission, chemotherapy

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

This case involves a female who was diagnosed with primary mediastinal B-Cell (Non-Hodgkin's) Lymphoma. The patient had a history of left malignant pleural effusion with PleurX required for drainage; now resolved. The patient received Rituxan as an outpatient prior to admission. The patient presented for cycle #4 of chemotherapy. She had a blood pressure 131/79, pulse 111, respirations 18, oxygen saturation 97% on room air, and temperature 36.7 C. The patient tolerated the chemotherapy and was discharged.

The medical literature indicates inpatient admission is indicated for patients undergoing chemotherapy if the chemotherapy regimen requires aggressive or prolonged support as indicated by aggressive hydration needs that cannot be managed in infusion center or prolonged marrow suspension. The inpatient stay may also be indicated for hemodynamic instability, tumor lysis syndrome, significant chemotherapy infusion extravasation complications, acute renal failure, altered mental status is severe persistent, high risk febrile neutropenia, dehydration that is severe persistent, vomiting or diarrhea that is severe persistent, severe lateral abnormality, bacteremia, anemia requiring inpatient admission, high risk low platelet count, severe pain requiring acute inpatient management, parenteral nutrition regimen needed that must be documented on inpatient basis, or stricter protective isolation needed. 

The patient presented for cycle #4 da-R-EPO CH (etoposide, prednisone, vincristine (Oncovin), cyclophosphamide and doxorubicin hydrochloride (hydroxydaunorubicin hydrochloride).  There was no indication that the patient's chemotherapy regimen required aggressive or prolonged support as indicated by aggressive hydration needs that cannot be established at infusion center or prolonged marrow suppression. There was no indication that the patient had any of the issues noted above. 

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

Diagnosis: Osteoarthritis to her right hip
Treatment: Inpatient stay 

Summary:
The patient underwent a non-complicated arthroplasty. She was able to tolerate oral pain medication. She did not require treatment for other underlying medical problems. Her surgical wound site was satisfactory. The records denote initial hematocrit of 37 decreasing to 31. This is common after arthroplasty. There was no need or consideration of a transfusion. Her blood pressure was stable as compared to her baseline. 
There was a report of no adult in home but nevertheless, the services provided would be considered observation. It would be expected that she would continue to improve with independence and ability to perform her activities of daily living. There were no extenuating circumstances to substantiate acute inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

The patient is a female with sarcoidosis, bronchiectasis, with asthma exacerbation. She was treated at an acute in hospital level of care. The patient was treated with duonebs, prednisone, and magnesium sulfate.

The patient was treated for acute exacerbation of asthma and bronchiectasis. The patient's condition improved significantly with emergency room care. The patient did not require IV steroids and was tolerating oral medications.  Thus, the patient could have been safely and effectively treated as observation level of care followed by outpatient level of care.