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

Diagnosis: Substance Abuse

Treatment: Inpatient substance abuse treatment

The insurer denied coverage for inpatient substance abuse treatment. The denial is reversed. 

This patient is a male admitted to medically supervised inpatient detoxification treatment for alcohol and substance detoxification treatment. The patient reported drinking several beers per day with the last use on the day of admission and also using 2 mg Xanax bars several times per week with the last use prior to admission, and using tens of dollars' worth of cocaine per day with the last use on the day of admission. As inpatient, the patient was put on a Librium protocol for detoxification. The patient's past history was significant for past inpatient substance detoxification treatments.

The APA Practice Guidelines for the Treatment of Patients with Substance Use Disorders report that failure to achieve abstinence or patients who relapse frequently, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. In this case, this patient had been drinking large amounts of alcohol daily and taking Xanax 2 mg bars several times per week with tens of dollars' worth of cocaine use daily and was at risk for severe, complicated, and life threatening withdrawal symptoms and required 24 hour inpatient hospital detoxification treatment. The patient's polysubstance use was heavy. The patient drank large amounts of alcohol daily in addition to benzodiazepine use, which placed this patient at high risk for delirium tremens. Studies have shown that the risk of life complicated withdrawal such as delirium tremens can occur 4 days after alcohol use and even up to 1 week after Xanax use. Thus, the patient required the entire duration of the inpatient stay.

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient required 24 hour hospital treatment as the patient could not safely and effectively be treated in outpatient detoxification settings and had past recent inpatient detoxification treatments prior to this admission. The patient could not stop use of alcohol, Xanax, and cocaine as the patient's history indicated that this patient lacked the coping skills for abstinence. Also, the patient required and received detoxification medication, Librium, from inpatient stay to prevent life threatening withdrawals. This inpatient care was needed for this patient due to the large amount of alcohol use in conjunction with other high risk drugs, which were cocaine and benzodiazepines. Thus, the inpatient hospital detoxification treatment was medically necessary to treat this patient's medical condition.   

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

The carrier's denial of coverage for the inpatient substance abuse treatment is reversed. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Digestive System / Gastrointestinal - Abdominal pain
Inpatient Hospital

The patient is a woman with a past medical history significant for diabetes mellitus type 2 who presented to the emergency department with complaints of left-sided abdominal pain, nausea, and vomiting that started 2 days before the day of admission. It was reported that the patient had several emergency room visits because of the same complaints.
She described left-sided abdominal pain, colicky type, 4/10 in severity with associated nausea and vomiting. A review of systems was negative for fever, cold, diarrhea, constipation, and dysuria. The patient was admitted for evaluation and treatment of nausea and vomiting that was associated with abdominal pain. During the hospital stay, the patient's symptoms subsided and her diet was gradually advanced. The patient was seen by the surgical service and was recommended conservative management of her symptoms.

The health plan denied the inpatient admission as not medically necessary. The health plan's determination is upheld.

The patient's symptoms did not lead to severe dehydration, electrolyte abnormalities, or acute kidney failure. There were no serious medical conditions revealed on the diagnostic tests that would necessitate admission for treatment requiring acute inpatient level of care.
The patient's condition improved rather quickly and she was able to tolerate her diet. Even though the patient had diabetes mellitus, there was no evidence of any glycemic emergencies that would necessitate admission at the acute inpatient level of care.

Taking into consideration all these facts, neither the severity of the patient's condition nor the complexity of the services provided justified admission at the acute inpatient level of care. It was necessary to ensure the resolution of the patient's symptoms, to provide hydration with intravenous fluids, and to rule out infection but these could have been accomplished at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Pain

Treatment: Inpatient Admission

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

This is a female patient with a history of hypertension, anxiety disorder, lumpectomy and tubal ligation. She presented to the Emergency Department (ED) with complaints of mid-sternal chest pain that radiated to the nape of her neck with associated shortness of breath. Cardiology consulted the patient. An electrocardiogram (EKG) was performed that showed T-wave inversion in V4 and V5. The patient received aspirin, intravenous (IV) fluids, and enoxaparin injection. Nitroglycerin sublingual and Metoprolol were given. Laboratory work up was performed that revealed an elevated troponin from 0.2 to .11. The patient was admitted to the hospital and monitored on telemetry. After a period of medical stability the patient was discharged home.  

Based on the review of the medical record provided, this patient presented with chest pain, shortness of breath and mild elevations of Tn. In addition, there were T wave changes that although non-specific needed to be interpreted in light of the other findings. In sum, the increasing Tn levels were consistent with an acute ischemic event. 

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

The carrier's denial of coverage for the inpatient admission is reversed. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient stay
Decision: Upheld

Summary:
The patient is a gentleman with a history of hypertension, gastroesophageal reflux disease, and known coronary artery disease. He presented to the hospital complaining of chest pain for several hours.  

The patient presented with chest pain without ischemic ECG changes. Serum cardiac enzymes were not elevated. CT angiogram did not reveal any coronary occlusion and echocardiogram revealed no wall motion abnormalities. The cardiologist evaluating the patient noted that he did not believe that symptoms were due to a cardiac etiology, and chest pain was ultimately deemed to be musculoskeletal. This patient's pretest probability of coronary artery disease is high (Reference 1). Utilizing the HEART (History, ECG, Age, Risk factors, initial Troponin) score, he was considered low risk (Reference 2). 

Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati et al. (Reference 3). Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation. In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary. This patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  High blood sugar
Treatment:  Inpatient admission

The inpatient admission was medically necessary.

This patient is a female.  The patient presented with polyuria, polydipsia and unintentional weight loss of eight pounds.  She was found to have a glucose greater than 400.  The patient had intermittent blurry vision and headaches.  In emergency department her glucose was 276.  She received a normal saline intravenous bolus.  Blood glucose after the bolus was 216.  The patient was diagnosed with new onset diabetes and admitted for hyperglycemia management.  The patient has a brother with type I diabetes.  Hemoglobin A1C was 11.9%.  PH was 7.41.  Urine had no ketones.  The patient was started on Lantus 20 units nightly.  The patient was started on an insulin to carbohydrate ratio and an insulin sensitivity factor.  Blood glucoses were monitored before meals.  The patient received diabetes education on day #2. 

Diabetes education consists of several components, nutritional counseling, self-monitoring of blood glucose and treatment of hyper and hypoglycemia.  The standard of care is that all patients with diabetes should receive all these components [1, 2]. 

Practice patterns differ depending on the availability of educators, etc.  Whether a patient gets hospitalized for intensive insulin therapy initiation depends on the available program where the patient is seen.

The majority (75%) of medical centers in the US [3] that treat new onset type one diabetes admit their patients.  According to the American Diabetes Association (ADA) statement on treatment of type one diabetes [4], hospitalization is necessary regardless of severity if, "the center is not experienced in the outpatient management of newly diagnosed children with diabetes or is not adequately staffed to provide outpatient care because regional health care reimbursement is inadequate for initial outpatient care and education."   That is not the case for type two diabetes.  Indications for admission for new onset type two diabetes are more stringent and dependent upon the presence of symptoms such as ketosis, dehydration, hyperosmolarity, vomiting and inability to maintain hydration or severe metabolic/electrolyte abnormalities.  In type one diabetes, the initial hospitalization is to educate the patient and the family in self-injection, drawing up and mixing of insulins, checking blood sugar, recognizing and responding to hyper and hypoglycemia, and evaluating ketosis, as well as nutrition education on carbohydrate counting because there is only one treatment option (insulin).  Learning these skills is an overwhelming task for most patients and families and is the reason that this is done with a two to three day admission to the hospital. 

The standard of care is to admit patients for insulin initiation and diabetes education when they have new onset type one diabetes.  The patient has new onset type one diabetes and was admitted for insulin initiation and diabetes education.  The hospitalization is consistent with generally accepted standards of medical practice and is, therefore, medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastrointestinal
Treatment: Inpatient stay
The denial was upheld

This patient presented to the emergency department (ED) with an inguinal hernia. The hernia was able to be reduced in the ED. The patient had previously been diagnosed with a right inguinal hernia and had been scheduled for elective repair. However, he presented  with increasing groin/abdominal pain. The patient was clinically and hemodynamically stable at the time of presentation. Labs and vital signs were normal on.
Surgical consultation was obtained, and the patient was treated with laparoscopic bilateral inguinal hernia repair with mesh. The submitted nursing, surgical, ED and anesthetic records document hemodynamic stability during the perioperative period. The patient remained hemodynamically stable, post-surgical nausea was managed, diet was advanced and pain medications were converted to oral medications. Patient was discharged from the hospital on the following day. The health plan's determination of medical necessity is upheld in whole. The inpatient stay was not medically necessary for this patient. The patient underwent uncomplicated laparoscopic bilateral inguinal hernia repair and the period of monitoring was otherwise uncomplicated. This patient required prompt evaluation and surgical treatment for the inguinal hernia. However, the care and treatment provided could have reasonably been provided in a lower level of care setting This patient did not require inpatient admission as provision of intravenous (IV) fluid, pain medications, antiemetics, and surgery could have been appropriately provided in the lower level of care setting. This level of care would have provided for regular clinical assessment, follow up monitoring, surgical repair of the inguinal hernia and provision of the prescribed IV medications and fluid. The lower level of care would have also allowed for overnight observation.
Appeal type: Medical necessity
Decision: Overturned

Mental Health
Mental Health: Inpatient

Diagnosis: Depression/Substance Abuse
Treatment: Inpatient Mental Health. The insurer denied the inpatient stay. The health plan's determination is overturned. 

This case involves a male admitted for acute inpatient psychiatric treatment. The patient was brought to the emergency department by emergency services/ambulance with suicidal ideation and worsening symptoms of depression in the context of substance use and non-adherence with his medications. He presented with worsening symptoms of depression threatening suicide and displaying prominent symptoms of psychosis with paranoid thinking. He was medically cleared and admitted for inpatient psychiatric treatment. 

The patient required the admission and the continued acute inpatient level care and the structure and monitoring of an acute inpatient level setting in order to remain safe and to administer treatment for his psychiatric disturbance and co-occurring substance use disorder while conducting an evaluation, and while observing his functioning with the resumption/adjustment of clinically appropriate medications. The clinical course was complicated by severe substance use disorder with cocaine use and psychosocial stress being addressed during the time interval under review. Additionally, the treatment team was planning for a safe and clinically appropriate disposition with aftercare arrangements.
The medical necessity for the requested inpatient level structure and monitoring is in the patient's best interest in view of the patient's severe symptoms of mood disorder, risk for suicide, and co-occurring substance use disorder. And, in view of these clinical features and the complicated presentation with suicidal ideation and psychotic features, the patient's continued active treatment with safety monitoring was warranted in the context of the patient's deteriorated functioning and severe psychosocial stressors involving housing, occupational, social and economic domains. Additionally, the inpatient stay was medically necessary in order to monitor the response to medications, to insure that the patient will have a sustained response to treatment, and to continue to address the acute risk of suicidal behavior in the context of severe symptoms of the mood disorder and severe psychosocial stressors in a patient with impaired judgment and poor control of impulses. The necessity for continued inpatient level services reflects sound medical judgment in keeping with prevailing standards of professional practice, and with the published practice guidelines and criteria, as well as the NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Epilepsy
Treatment Epidiolex  The insurer denied Epidiolex.
The determination is overturned.

This is a patient with stiff person syndrome and temporal lobe epilepsy. The medical necessity of treatment with Epidiolex is the subject of this review. The patient has previously used phenobarbital, levetiracetam, oxcarbazepine, and lacosamide.

The Epidiolex is medically necessary. Although the use of Epidiolex is off-label for treatment of refractory epilepsy, the patient has a literature-supported indication. The patient has refractory temporal lobe epilepsy. Refractory epilepsy is defined as poor seizure control despite treatment with optimal doses of 2 or more anticonvulsant agents. Chart notes demonstrate that she has tried and failed multiple anticonvulsants including phenobarbital, levetiracetam, oxcarbazepine, and lacosamide. As such, the provider has demonstrated that the member has refractory epilepsy. Numerous open label and perspective studies have shown that Epidiolex is safe and effective for treatment of refractory seizures. In the studies, the use of Epidiolex was associated with an approximate 50% decrease in seizures. This finding was consistent for various seizure types and seizure etiologies. Patients did not have to be diagnosed with Lennox-Gastaut or Dravet syndrome. As such, treatment with Epidiolex is medically necessary in this clinical scenario. There are no other medications that or as likely to be as or more effective than the requested medication.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis Crohn's disease
Treatment Fecal Calprotectin test.   The health plan denied a Fecal Calprotectin test.
The health plan's determination is overturned.

This is a patient with a history of Crohn`s disease. She was experiencing symptoms of disease activity including bloody stools. Her treating physician requested fecal calprotectin to assess for bowel inflammation. 
At issue is the medical necessity of the fecal calprotectin test.
Fecal calprotectin stool test is medically necessary for this patient. It has been shown in numerous studies and peer reviewed reports to be a helpful tool in the management and monitoring of patients with inflammatory bowel disease. The use of this test is well supported by the clinical practice guidelines.
Per the Consensus guidelines of European Crohn's and Colitis Organization/European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ECCO / ESPGHAN) on the medical management of pediatric Crohn's disease: "Non-invasive biomarkers of mucosal healing such as fecal calprotectin are particularly useful for children as a way of monitoring resolution or recurrence of intestinal inflammation". (1)
Per the American College of Gastroenterology, clinical practice guidelines for the management of Crohn`s disease " FC (Fecal Calprotectin) may have an adjunctive role in monitoring disease activity " (Gary R. Lichtenstein et al). (2).
Per Catherine Reenaers et al, "FC is a valuable tool to optimize the care for inflammatory bowel disease (IBD) patients". Fecal calprotectin is a non-invasive and relatively easy to perform. It can provide valuable information regarding intestinal inflammation and disease activity and help the clinician avoid performing frequent endoscopic procedures". (3).
Finally, Foster, Alice Jane, et al published a study concluding that "Routine fecal calprotectin testing in children with Crohn's Disease (CD) in clinical remission is useful to predict relapse. Levels greater than (>) 250 micrograms per gram are a good predictor of relapse in the following 3 months. This information is important to guide monitoring standards used in this population." (4).
This patient has signs of an active disease which may require treatment changes. The use of fecal calprotectin can assist her doctor make the right treatment adjustments in order to improve her disease control. Using fecal calprotectin is well supported by scientific evidence and would be considered medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Skin Disorders
Pharmacy/prescription drugs

Diagnosis: atopic dermatitis and asthma
Treatment: Dupixent. The insurer denied Dupixent
The denial was overturned. 

The patient is a male with atopic dermatitis and asthma, treated with topical steroids. The provider is requesting Dupixent. This is the subject of this review.

Dupilumab (Dupixent) is medically necessary for this patient
According to the health plan, the patient is required to treat with phototherapy or a systemic immunosuppressant prior to use of Dupixent. This patient also has asthma, for which Dupixent is also Food and Drug Administration (FDA) approved. At the current time, use of systemic immunosuppressants is not an ideal therapy, and in a patient with concomitant asthma, risk of a more severe course of Coronavirus is possible. Therefore, given that Dupixent is FDA approved for both atopic dermatitis and asthma, and the risk associated with systemic immunosuppression during the Coronavirus pandemic, and limited access to phototherapy (requiring frequent office visits, which are also limited during this pandemic), Dupixent is medically necessary. Dupixent is known to be immuno-stimulating and not immunosuppressive.
According to the documentation, the patient has already tried Tacrolimus ointment (Protopic).  Cyclosporine, azathioprine, and methotrexate are all non-specific systemic immunosuppressants.  These are not ideal therapies in a patient at higher risk of COVID19 complications with asthma.
Appeal type: Medical necessity
Decision: Overturned in Part

Infectious disease
Inpatient hospital

Diagnosis: Knee injury. Treatment: Inpatient stay. The insurer denied the inpatient stay. The health plan's determination is overturned in part.

At the time of his admission, the patient was brought to an urgent care with a one day history of right knee swelling. The day before, he fell on the porch and abraded his right knee; the next day, the mom noticed the area was swollen so she brought him to the urgent care clinic, where the temperature was reportedly 101.6. Urgent care referred him to the emergency department (ED) for evaluation of possible septic arthritis. In the ED, the patient was afebrile with heart rate (HR) 132. He could bear weight on the right lower extremity and had normal range of motion of the knee joint and normal gait. His white blood cell (WBC) was 22.7 with 81% neutrophils. Erythrocyte sedimentation rate (ESR) was 28. C-reactive protein (CRP) 4.7. Plain film and computed tomography (CT) scan of the knee were normal. He was given intravenous (IV) clindamycin in the ED and hospitalized for further IV therapy. 

The Milliman Care Guidelines for Pediatric Cellulitis specifically state that a white cell count of greater than 15,000 is an indication for acute inpatient care. The WBC for this patient was 22.7, therefore the acute inpatient care was appropriate for 1 day.
By the second hospital day, however, the patient was clinically well and had remained afebrile and hemodynamically stable. The infection (the pus pocket below the right kneecap) was spontaneously draining, did not require a surgical drainage procedure, and there was substantial clinical response after the first two doses of IV antibiotics in terms of reduction of erythema and tenderness. The treating physicians had determined that the patient did not clinically have a septic arthritis or any other systemic/deep infection requiring surgical management, prolonged IV antibiotics, and continued measurement of serum inflammatory markers. There was no evidence of bacteremia, sepsis, or SIRS (Systemic inflammatory response syndrome). The patient no longer met acute inpatient criteria after the first hospital day.