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

Diagnosis:  Abdominal pain.
Treatment: Inpatient stay.

The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a male who initially presented to the emergency department with concerns of abdominal pain. Pertinent history included systemic lupus erythematosus, terminal ileitis and cecal colitis. Initial vital signs revealed a temperature of 97.3oF, heart rate (HR) 78, blood pressure (BP) 100/66, respiratory rate (RR) 22, and peripheral capillary oxygen saturation (SpO2) 100% on room air. Initial examination revealed the patient to be alert with periumbilical tenderness. Initial laboratory testing revealed a white blood cell count (WBC) 17.7, Hemoglobin (HGB) 13.5, platelets (Plt) 409, Na (sodium) 136, K (potassium) 3.6, blood urea nitrogen (BUN) 17, Creatinine 1.0, Glucose 148, Tbil (total bilirubin) 1.5, aspartate aminotransferase (AST) 18, alanine aminotransferase (ALT) 7, alkaline phosphatase (ALP) 93, and Lipase 10. A computed tomography (CT) abdomen/pelvis revealed findings concerning for active Crohn's disease with small bowel and colonic involvement and findings suggestive of associated small bowel obstruction.

Based on the clinical documentation provided, evidence based literature and standards of care, the acute inpatient level of care was not medically necessary. Evaluation and management could have been performed at a lower level of care. In this particular situation, the patient presented with periumbilical abdominal pain, vomiting, and diarrhea. Initial evaluation was concerning for possible inflammatory bowel disease with an associated small bowel obstruction. General surgery consultation was obtained whom documented low concern for complete obstruction due to ongoing bowel movements. Gastroenterology consultation was obtained whom recommended an outpatient diagnostic colonoscopy. Treatment plan included intravenous fluids, empiric antibiotics and supportive care. Following observation care, presenting symptoms were resolved and oral intake was tolerated. No other issues or complications requiring an acute inpatient level of care were documented.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned

The patient has a history of left breast cancer status/post (s/p) mastectomy, axillary lymph node dissection, and reconstruction, lumpectomy, right partial mastectomy and left mastectomy with deep inferior epigastric perforators (DIEP) flap. She has left upper extremity (LUE) lymphedema and has had multiple episodes of cellulitis but they have been less frequent in the past several years. The last episode did not require hospitalization.
She presented to the hospital with left arm pain and erythema times (x) 1 day associated with chills, nausea/vomiting (N/V) and fever to 101 degrees Fahrenheit. She received one dose of ampicillin-sulbactam in the emergency room (ER). She reported pain in the left arm and axilla. She had a mosquito bite in the arm 1 week prior to her admission and was scratching it. She was admitted to the hospital and treated with intravenous (IV) antibiotics and elevation. An infectious disease consultation was provided. A progress note documents no improvement on Cefazolin. Vancomycin was initiated. A progress note from 8/15/21 documents improvement in cellulitis with IV Vancomycin. A progress note documents improved cellulitis with plan to transition to oral antibiotics. She was discharged on oral antibiotics.
At issue is the medical necessity of an inpatient admission.

The inpatient stay was medically necessary. The patient had an extensive area of cellulitis. Although failure of outpatient therapy is not documented, the patient did fail 48 hours of IV therapy with ampicillin-sulbactam and Cefazolin. The patient clearly would not have responded to outpatient oral antibiotics if the initial treatment period of IV antibiotics failed. Moreover, the emergency department (ED) and consult notes document an extensive area of cellulitis for the left upper extremity with a fever and elevated white blood count. The patient's physicians were appropriately concerned about worsening sepsis, and hospital monitoring was medically necessary due to her condition of early sepsis. Per the Milliman Care Guidelines (MCG), 26th Edition, cellulitis, admission is warranted if clinical presentation indicates that immediate IV antibiotics are warranted and sepsis is a risk. The patient had both of these conditions on admission. The clinical judgment to admit was correct on retrospective analysis because the patient did not improve on IV antibiotics until Vancomycin was started.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a female with morbid obesity whose inpatient Hospital Admission is under review. The patient was diagnosed with facial cellulitis one week prior to admission and was treated with PO (per os - oral) bactrim. Symptoms did not improve, and erythema worsened, so patient presented to the ER (emergency room). The patient had a fever and was compliant with bactrim.

In the ER (emergency room), the patient's vital signs were as follows: T (temperature) 98.5, P (pulse) 92, BP (blood pressure) 131/82, RR (respiration rate) 16. On general examination, the patient was revealed to be in no acute distress. Examination of the patient's HEENT (head, eyes, ears, nose, throat) revealed 5cm (centimeter) facial erythema. Examination of the patient's chest, CVS (cardiovascular system), and abdomen were normal.

The patient's labs were as follows:
WBC (white blood count): 7.1
Hg (hemoglobin): 13.9
Hct (hematocrit): 42.9
Plt (platelets): 226
Na (sodium): 141
K (potassium): 4.9
Cl (chloride): 106
HCO3 (bicarbonate): 27
BUN (blood urea nitrogen): 12
Cr (creatinine): 0.75

The patent was thought to have facial cellulitis that failed outpatient treatment. The patient was admitted and started on IV (intravenous) vacomycin, flagyl, and ceftriaxone, which was later changed to vancomycin only. The patient improved and was discharged on oral antibiotics.

Yes, the Inpatient admission was medically necessary.
The treatment was medically necessary. According to the Infectious Diseases Society of America (IDSA), inpatient treatment and IV antibiotics are an indication for cellulitis that fails outpatient treatment (1), as was the case here. Failure to do so could lead to complications such as sepsis, brain abscess, or death.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Closed fracture of the phalanx of the left foot

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

This patient has a history of anemia, chronic obstructive pulmonary disease (COPD), hyperlipidemia, bipolar disorder, seizures, and an ankle fracture. She presented to the emergency room (ER) with complaints of left foot pain. She fell and had ankle pain since that time. A left foot x-ray revealed multiple fractures involving the distal shafts of the proximal phalanges of the second and third toes. She was evaluated by physical therapy (PT) and provided with crutch training. The patient was transferred to a subacute rehabilitation (SAR) facility. 

The facts were the patient sustained an injury one month prior. She had been walking on her affected foot and had previous visits to the emergency department (ED). Her main complaint was swelling and lack of progress. 

The treatments provided were repeat x rays, PT, consultation, and Podiatry consultation. Recommendations were limited weight bearing and crutches. 

The records show the mechanism of injury was low energy which occurred weeks ago.

Her vital signs were stable. There were no open wounds. There was no bleeding. There were no problems with managing her pain. There were no special imaging studies nor procedures required. She did not receive treatment for an underlying medical problem. 
The reported necessity for placement and consultations all could have been completed at a lower level of care. There were no extenuating circumstances to substantiate the admission. 

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

The inpatient hospital admission is not considered medically necessary for this patient.

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

Diagnosis: Cirrhosis

Treatment inpatient admission  

The insurer denied coverage for inpatient admission 

The denial is upheld

The patient had a history of alcohol abuse and a cerebral vascular accident (CVA) and presented with dizziness, vomiting, and dark stool. He had a recent hospitalization and a workup for anemia and cirrhosis. He was advised to go to rehab, but he refused and was discharged home. He was afebrile and the vital signs were stable, although there was an initial mild tachycardia. There was no abdominal rebound or guarding. The stool was noted to be heme positive, but the impression was that he did not have evidence of
of overt bleeding. The hemoglobin was 9.5 but dropped to 7.5. He was treated with a proton pump inhibitor (PPI). An endoscopy was negative for active bleeding.

Clinical indications for admission for Upper gastrointestinal (Gl) Bleeding (MCG [Milliman Care Guidelines] M-180) include hemodynamic instability, ongoing active bleeding, a peptic ulcer with high-risk endoscopic features, bleeding varices, severe coagulopathy that is not reversible, anemia with signs of cardiac ischemia, gastric outlet obstruction, and peritoneal signs. The patient did not have these indications.

This patient had alcoholic cirrhosis and presented with black stool. The impression was that although the stool was heme positive, he was not having active bleeding. The endoscopy was also negative for active bleeding. He was stable to have had the endoscopy performed and been treated with a PPI with observation status.  Intravenous (IV) hydration could have been given in the emergency room (ER) as an outpatient. The cirrhosis was a chronic condition and was amenable to outpatient management. He did not meet MCG criteria for admission for Upper Gastrointestinal Bleeding. 

The health care plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary.

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

Diagnosis: Heartburn.
Treatment: Scope test EGD (esophagogastroduodenoscopy).
The insurer denied the scope test EGD (esophagogastroduodenoscopy).
The denial is upheld.

The patient is a male with chronic GERD (gastroesophageal reflux disease). He had not failed treatment with H2 (histamine H2-receptor) blocker or proton pump inhibitors. There were no alarm symptoms of dysphagia, weight loss, vomiting or GI (gastrointestinal) bleeding. The patient's provider requested an EGD (esophagogastroduodenoscopy).

No, the requested esophagogastroduodenoscopy is not medically necessary.
Medical literature supports EGD (esophagogastroduodenoscopy) in patients with chronic heartburn refractory to acid suppression therapy, or associated with alarm symptoms of dysphagia, weight loss, vomiting or GI (gastrointestinal) bleeding. The patient had not failed acid suppression therapy and had no alarm symptoms. Therefore, the requested EGD (esophagogastroduodenoscopy) is not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient, as the requested esophagogastroduodenoscopy is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder - Seizure Disorder. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Vimpat. 
The denial is upheld.

The patient is a male with a seizure disorder. The subject under review is the medical necessity for Vimpat. This was denied by the plan on the basis that the patient has not tried and failed generic Vimpat (lacosamide). The patient's physician indicates that the patient is stable on the brand formulation and that change could lead to destabilization of the patient's seizure disorder.

The health plan's determination is upheld.

The requested Vimpat is not medically necessary. The health plan denied brand Vimpat as the patient had not tried and failed or has a contraindication to the generic drug lacosamide. The generic and brand drugs both have the same active ingredient.
A 2016 position statement by the American Epilepsy Society notes that drug formulation substitution with Food and Drug Administration (FDA)-approved generic products reduces cost without compromising efficacy. The society also notes that there are data showing that tablet or capsule color or shape and that statements about drug products impact patient adherence and drug response. Therefore, healthcare professionals should exercise the highest standards of care when substituting generic product.
In this instance, there are no records to suggest that the patient has tried and failed the generic product or that he cannot use the generic product due to some filer or drug excipient that would cause an allergy. Furthermore, the provider has obtained lacosamide levels and these levels can be compared when the patient is on the generic product if titration is needed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain
Treatment: Inpatient admission 
The insurer denied coverage for an inpatient admission 
The denial is overturned

This is a patient with a past medical history of hypertension and diabetes mellitus that presented to the hospital complaining of chest pain and lightheaded. Upon arrival to the hospital, vital signs were BP (blood pressure) 210/130 mmHg (millimeters of mercury) and pulse of 80bpm (beats per minute). No positive findings were noted on physical examination. A 12-lead electrocardiogram (ECG) revealed normal sinus rhythm with T wave (interval on an ECG) inversions. Serum blood testing revealed no elevation in serum troponin (peak 0.07). Creatinine was elevated (1.4mg (milligrams)/dl (deciliter)) and B (brain) type natriuretic peptide was elevated (202). The patient was admitted to the hospital for treatment of a hypertensive emergency. Following admission, the patient was treated with antihypertensive therapy and stress testing was performed. The patient signed out AMA (against medical advice).

Hypertensive emergency is defined as BP>180/120 with target organ damage. (Reference 1) In this patient, BNP (brain natriuretic peptide) was elevated and consistent with left ventricular dysfunction and target organ damage. Acute renal insufficiency was also noted. The goals of treatment of hypertensive emergency are to minimize progressive or additional target organ damage while preventing consequence of rapid BP correction. (Reference 2) Given this patient's failure to respond to initial medical therapy, admission to the hospital for aggressive blood pressure management was necessary. In fact, American Heart Association guidelines recommend admission to the ICU (intensive care unit) for management of hypertensive emergencies (Reference 1). In conclusion this patient should have been managed at a higher level of care. Acute inpatient admission was medically necessary. 

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

The insurer's denial of coverage for the inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma

Treatment: Inpatient admission 

The insurer denied coverage for an inpatient admission 
The denial is upheld

The patient is an adult female with a history of asthma, obstructive sleep apnea (OSA) and obesity. She presented to the emergency department (ED) with complaints of cough, wheezing and shortness of breath (SOB) which started after using tobacco and cocaine. The patient had been recently hospitalized for asthma and anemia.

The patient was given Duo Nebs by Emergency Medical Systems (EMS) and placed on continuous positive airway pressure (CPAP). Vital signs in the ED revealed respiratory rate 23 and heart rate 117. She had bilateral rales and wheezes on exam. The patient was treated with intravenous (IV) steroids, bronchodilators (BD) and antibiotics.

Initial labs included a white blood count (WBC) of 9.7, hemoglobin (Hb) 8.3 and hematocrit (Hct) 29.8. Electrolytes and BUN (blood urea nitrogen) / Cr (creatinine) were all within normal limits. The BNP (Brain natriuretic peptide) was normal, the D dimer (protein fragment) was negative and procalcitonin was also negative. The patient was admitted to the hospital for further treatment of asthma exacerbation.

The patient reported feeling claustrophobic after bilevel positive airway pressure (BIPAP), so she was switched to nasal cannula (NC). As per the history and physical (H&P), the patient was in no apparent distress (NAD), conversing in full sentences, and awake and alert. Bilateral wheezes were heard on the lung exam and the patient was saturating well on 2 to 3 liters (L) of oxygen via NC (nasal canula). Vital signs were as follows: temperature 97.9, respiratory rate 20, heart rate 105 and blood pressure 150/63. Her peak expiratory flow (PEF) had improved from 150 to 225 (baseline). The patient was continued on present prescriptions, was stabilized and discharged home.

This patient did not need acute inpatient hospitalization. She was suitable to be placed in observation status. An observation period could be for up to 48 hours. The patient was in NAD (no apparent distress). She had started improving after treatment in the ED, was tolerating an oral (PO) intake and maintaining good saturations on low flow NC. She was stable enough by the following day to be placed on PO steroids and continued on BD (bronchodilators) and other maintenance medications. Her PEF (peak expiratory flow) had improved from 175 to 225. There was no evidence of pneumonia, pulmonary embolism, or congestive heart failure. The WBC (white blood cell count) increased mildly to 13.6, likely from steroids.

This patient was stable enough to be admitted to observation; treatment and diagnostic testing could be done, and the patient could have been discharged home on PO meds after a period in observation with close follow up after discharge. Inpatient admission was not medically necessary.

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

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

Diagnosis: Gastroesophageal reflux disease (GERD)

Treatment: diagnostic esophagogastroduodenoscopy (EGD), procedure code 43239

The insurer denied coverage for diagnostic EGD, procedure code 43239.

The denial is upheld.

The patient was complaining of epigastric pain, nausea, and bloating. An office visit noted that pantoprazole was started, and the endoscopy was scheduled. The biopsies were read as chronic gastritis. 

Milliman Care Guideline (MCG) ACG: A-0203 lists indications for doing an Upper Gastrointestinal (GI) Endoscopy. Among the indications is dyspepsia if it is associated with another risk factor. These risk factors include age 60 years old or older, dysphagia, failure of medical therapy, iron deficient anemia, persistent symptoms for greater than 3 months, vomiting, and weight loss. GERD is also an indication if there is anemia, dysphagia, failure of medical therapy after 4-8 weeks, vomiting, and weight loss.

This patient was having upper GI symptoms. However, at the time of the office visit note, he was both started on a proton pump inhibitor (PPI) and scheduled for an endoscopy. He did not have a 4-8-week trial of a PPI and it is not documented that he failed medical therapy. He did not meet MCG criteria for Upper GI Endoscopy for either dyspepsia or reflux disease since his age did not meet the noted risk factors and did not have a documented trial and failure of medical therapy. 

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

The insurer's denial of coverage for diagnostic esophagogastroduodenoscopy (EGD), procedure code 43239 is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Septic embolism

Treatment: Acute inpatient rehabilitation services

The insurer denied coverage for acute inpatient rehabilitation services
The denial is upheld

This is a patient who was found unresponsive and was taken to the emergency room (ER). Imaging of the head revealed multiple small hemorrhages involving the corpus callosum with local edema and mass effect. Under review is the medical necessity of continued acute inpatient rehabilitation services.

The patient was at a reasonably high functional level when admitted to the acute rehabilitation facility. Over the subsequent week, he continued to improve.  According to the occupational therapy note, the patient required only supervision for upper/lower body dressing, grooming and general self-care. He did not require an assistive device for (supervised) ambulation.  A similar level of function was noted by the physical therapist. According to the treatment note, the patient was (modified) independent for bed mobility and transfers as well as ambulatory without a device. Continued acute inpatient rehabilitation services was not medically necessary as subsequent care could have been provided at a lower level (e.g., home with therapy or as an outpatient). In addition, there were no acute medical or complicated nursing issues that necessitated continued acute inpatient rehabilitation.

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient in this particular case. Considerations include the clinical standards of the plan, the information provided concerning the patient, the attending physician's recommendations and applicable generally accepted practice guidelines developed by the federal government, national or professional medical societies, boards and/or associations. All decisions are evidence-based.    

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, continued acute inpatient rehabilitation services were not medically necessary.

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

The insurer's denial of coverage for continued acute inpatient rehabilitation services is upheld. Medical Necessity is not substantiated.