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

Diagnosis: Status asthmaticus. 
Treatment: Inpatient hospital admission. 

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

This patient is a female child with a history of severe persistent asthma. The patient was receiving intramuscular (IM) omalizumab injection therapy twice a month. The patient had been ill for 3 - 4 days with coughing and post-tussive vomiting which did not improve with albuterol at home. There were 4 episodes of post-tussive emesis on the day of admission and she had not produced urine for the past 24 hours. When there was no improvement in her symptoms with treatment at home, the patient's parent brought the patient to the Emergency Department (ED) for further treatment. In the ED, the patient was noted to have severe respiratory distress and dehydration. The patient was treated with intravenous (IV) fluids, multiple doses of DuoNeb, ranitidine and methylprednisolone. The patient's peak flow was 250, which was a significant reduction from her baseline 450. The patient's white blood cell (WBC) count was elevated at 19,000 with a shift to the left which was concerning for a bacterial infection. On physical exam, the patient was noted to have decreased breath sound at the lung bases and wheezing. Based on this patient's history of severe persistent asthma, failure to respond to treatment in the ED and dehydration, the decision was made to admit the patient with a diagnosis of status asthmaticus for ongoing treatment with albuterol every 2 hours. 
 
Based on the review of the medical record and literature, inpatient hospital admission was medically necessary for this patient. The patient was treated appropriately in the Emergency Room (ER) for a cough, wheezing and respiratory distress. The patient has a history of severe persistent asthma requiring twice a month intramuscular (IM) omalizumab and intubation in the past. The patient failed to respond to treatment in the home and was experiencing frequent post-tussive vomiting which resulted in no urine production in the previous 24 hours. The admission for ongoing intravenous (IV) fluid therapy and DuoNeb nebulization every 2 hours was appropriate and consistent with the standard of care to admit the patient to the hospital with a diagnosis of status asthmaticus for ongoing treatment with DuoNeb every 2 hours. The patient had failed outpatient management of her asthma and was unable to urinate for 24 hours. 

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

The medical necessity for the inpatient hospital admission is substantiated.  The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Redo femoro-tibial bypass graft. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is overturned. 

The patient is a male. He underwent a redo femoro-tibial bypass graft. His history is notable for severe peripheral vascular disease with critical limb ischemia. He had a non-healing toe amputation site. He had already suffered occlusion of a femoro-tibial bypass. Angiography showed anatomy suitable for a redo bypass. The admission after the procedure is under review. 

Yes, the Inpatient admission was medically necessary. 

The patient underwent a major vascular bypass procedure of the lower extremity, namely a femoro-tibial bypass. It is standard of care to admit such a patient to the hospital. It is not even an option to do otherwise. 

The reasons for the inpatient stay are as follows: 

1) Control of pain 2) Frequent need for intravenous medications, including pain medications; intravenous fluids because patients cannot generally take oral fluids and food for several hours after surgery; intravenous anticoagulants 3) Significant possibility of surgical site complications, such as graft occlusion or bleeding 4) Significant possibility of systemic complications, such as myocardial ischemia or pulmonary compromise. 

Noteworthy is that the complications in (3) and (4) do not have to occur to warrant admission. Hospital admission is necessary to monitor for and prevent the complications. 

The procedure always requires an inpatient hospital stay. It would be outside of normal practice to consider doing the procedure on an outpatient basis. In fact, the average length of stay for this surgery is four to five days [1]. This case is exceptional in that the patient was discharged in one day. The fact that he went home in one day does not change the fact that inpatient admission was medically necessary. 

Under CMS (Centers for Medicare and Medicaid Services) rules prevalent [2], the procedure (CPT [Current Procedural Terminology] 35666) is inpatient-only. This classification is an acknowledgement of the standard of care for the procedure.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Preterm Labor. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for inpatient hospital admission. 

The denial is upheld.  

The patient is a female at 23.6 weeks gestation who presented with complaints of abdominal pain. The examination revealed a cervical examination unchanged from month prior. The patient was admitted to labor and delivery to rule out preterm labor.  The patient was reevaluated and since she was stable, the patient was discharged home. 

As per literature, preterm labor is an indication for admission and tocolysis. Preterm labor is defined as uterine contractions with cervical changes. However, in this case, during this patient's admission, there was no documentation of any cervical changes for this patient; the patient was not in preterm labor.  Thus, rather than being admitted, this patient should have been observed in labor and delivery, received intravenous (IV) fluid and then reevaluated a few hours later.  If upon reevaluation, no cervical changes occurred then the patient would be sent home.  If cervical changes did occur then the patient could have been admitted for tocolysis and further management. 

In this case, neither the patient nor the fetus was in any jeopardy. There was no vaginal bleeding, and vital signs were stable. The fetal heart rate was reassuring. There was no evidence of ruptured membranes.  The management that this patient received during her admission could have been easily done in a less acute setting. Once the provider ascertained that there was no evidence of preterm labor (i.e., no change in cervical status after few hours of observation), the patient could have been discharged home after being hydrated. 

According to the Millman Care Guidelines (MCG), admission is indicated for one or more of the following: (1) Condition requiring premature delivery; (2) Fetal distress or demise; (3) Preterm prelabor rupture of membranes; (4) Significant maternal disease; (5) Vaginal bleeding; (6) Complications of tocolytic treatment; (7) Continued fetal monitoring that require inpatient care; (8) Tocolytic therapy needed that requires inpatient care; (9) Inability to stop preterm labor. 

Observation care is appropriate for patients with one or more of the following: (1) Condition requiring premature delivery suspected; (2) Preterm premature rupture of membranes suspected; (3) Suspected maternal infection; (4) Ongoing uterine contractions (tocolytic therapy needed, monitoring of cervical changes needed); (5) Fetal distress suspected; (6) Suspected placenta previa, vasa previa or placenta accreta. 

Based on above, admission to the hospital was not medically necessary. This is in accordance with standard of care and the Milliman guidelines. 

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

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

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

Diagnosis: Anemia.

Treatment: Inpatient Hospital Admission.

The insurer denied coverage for the Inpatient Hospital Admission.

The denial is upheld. 

This is a female patient with a history of anemia who presented to the Emergency Room (ER) with anemia in the setting of heavy menses. On the previous day, the patient's hemoglobin level was 5.5, and was then 5.4 on arrival to the ER. The patient had stopped taking her iron supplements.  The patient's primary care physician (PCP) had sent her to the ER. The patient's physical exam was unremarkable, and her vital signs were stable. The patient had no active bleeding. The patient's orthostatic vital signs were not performed. The patient was stated to be short of breath, and her electrocardiogram (EKG) was normal; no chest X-ray (CXR) was performed. The patient was admitted to the hospital.

As per Auerbach et al. (2016), "Oral iron is considered front line therapy except for conditions such as gastric bypass, heavy uterine bleeding, inflammatory bowel disease, and hereditary hemorrhagic telangiectasia. Oral iron has many unpleasant side effects, resulting in low patient adherence. For patients intolerant of, or unresponsive to, oral iron, intravenous (IV) administration is the preferred route. While early formulations were associated with a high incidence of serious adverse events (SAEs), newer formulations are much safer with SAEs occurring very infrequently. Full replacement doses can be administered in a matter of minutes to a few hours. IV iron is safe and effective in all clinical circumstances including pregnancy. The preponderance of published evidence suggests IV iron therapy is underutilized and we believe that IV iron should be moved forward in the treatment of...iron deficiency anemia (IDA)." 

Based on the review of the medical record and literature, inpatient admission was not medically necessary for this patient. This patient could have been managed in an alternative level of care for her anemia induced by her recent heavy menses and noncompliance to her iron supplementation. Though the patient was short of breath, the patient was otherwise hemodynamically stable, and was responsive to blood transfusion. The patient did not have active bleeding and did not require acute level hospitalization for management. As this patient had a condition that could reasonably be expected to be stabilized within 24 hours, observational status would have been appropriate setting of care for this patient. 

The Inpatient Hospital Admission is not considered medically necessary for this patient.

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

The medical necessity for the Inpatient Hospital Admission is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: alopecia areata

Treatment: Xeljanz

The insurer is denied coverage for Xeljanz

The denial is upheld. 

This male patient has a history of alopecia areata affecting his scalp and beard. The patient had a Video Visit with Dermatology for follow-up on alopecia areata. Per the progress notes, the patient had lost over 60% of the hair on his scalp, and has had intralesional Kenalog and oral steroids without improvement. The patient reportedly lost facial hair as well. Xeljanz was prescribed for the patient. Progress notes stated the patient experienced regrowth over most of the scalp. The physician is requesting coverage of Xeljanz for the patient.

The patient has not failed or shown to have a contraindication to numerous non-systemic therapies known to possibly improve alopecia areata, including light therapy, squaric acid, diphenylcyclopropenone (DPCP), calcipotriene, and anthralin. (1-11) Although case reports have demonstrated possible efficacy of Xeljanz for alopecia areata, further studies are needed to demonstrate the long term efficacy and safety of Xeljanz. It is noted that the Food and Drug Administration (FDA) released a statement in early 2019 finding increased risk of deep vein thrombosis and pulmonary embolism in patients enrolled in a phase 4 clinical trial of Xeljanz at a dosing of 10 milligrams twice per day. (1) Xeljanz is not medically necessary for the patient's condition, alopecia areata.

The standard of care for treatment of alopecia areata would necessitate an attempt to use the above mentioned non-systemic options for the treatment of alopecia areata. The patient has not failed or shown to have a contraindication to numerous non-systemic therapies known to possible improve alopecia areata, including light therapy, squaric acid, DPCP, and anthralin. (9-11)   

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

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

Diagnosis: new-onset psychotic symptoms and chronic headache, history of major depressive disorder
Treatment: Continued Inpatient Admission 
The insurer denied the Continued Inpatient Admission.
The denial is upheld. 

This was the first psychiatric admission for this patient with a history of major depressive disorder who was referred for admission due to new-onset psychotic symptoms and chronic headache. She had initially been evaluated in the emergency department and discharged home.  For the previous two or three months the patient complained of worsening fatigue, dizziness, headaches, memory problems and "no longer being allowed to take care of the kids." She complained of trouble concentrating and remembering things. She admitted that she at times forgot if she took her medications or that she left the stove on. She spent most of her time sitting in a chair or in her room. 

The patient had multiple psychosocial stressors including financial problems, joblessness, and the responsibility of caring for her husband who had a history of strokes. She had difficulty sleeping and reported being able to sleep only three or four hours a night. She reported nightmares of choking and of snakes trying to catch her. She was alert and oriented, but when asked if she could name the current president, she asked the psychiatrist if she passed her citizenship test. She denied suicidal intent but admitted to passive suicidal ideation. She did however admit to auditory hallucinations with multiple voices calling her nicknames and telling her to hit herself. Her outpatient psychiatrist told her to discontinue her medications the day before admission. They had included Lexapro 10 milligrams (MG) daily, omeprazole 40MG daily, sumatriptan 50MG as needed, and topiramate 25MG twice daily.

The patient was provided reassurance, support and pharmacotherapy. Over the course of her stay she showed improvement in mood and anxiety. A psychiatry progress note reported that the patient was cooperative and appropriate. There was no further evidence of psychotic symptoms such as hallucinations or delusions. Her mood remained depressed and her affect was constricted.

No, the proposed continued inpatient admission was not medically necessary. 

The patient's mood had improved significantly. She described her mood as being good and staff described her affect as bright. There was never any question of suicidal plan or intent or behavioral dyscontrol. She had no further psychotic symptoms. She tolerated her medications without difficulties. Nothing in the documentation reviewed indicates that treatment could not have continued equally safely and effectively in a less restrictive setting.
Appeal type: Medical necessity
Decision: Overturned

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

Yes, the Inpatient admission was medically necessary.

The patient is male with a past medical history significant for hypertension, diabetes mellitus type 2, dyslipidemia, CAD (coronary artery disease), s/p (status post) prior bypass surgery, CHF (congestive heart failure), atrial fibrillation, elevated CHADS-VASC (congestive heart failure, hypertension, age >= 75, diabetes mellitus, prior stroke or TIA or thromboembolism, vascular disease, age 65-74, sex category) and HAS-BLED Score (hypertension, abnormal renal and liver function, stroke, bleeding, labile INR, elderly, drugs or alcohol). He was admitted to hospital for a percutaneous implantation of a Watchman left atrial occlusion device. 

The patient underwent implantation of Watchman via trans-septal approach and was admitted for monitoring post procedure. The patient tolerated the procedure well and was discharged with a plan for outpatient follow-up.

The patient presented for a percutaneous implantation of a Watchman left atrial occlusion device. Watchman LAA (left atrial appendage) occlusion device has been shown to be non-inferior to Warfarin in clinical trials in terms of ischemic CVA (cerebrovascular acciden) prevention, and is considered a reasonable alternative in patients with non-valvular atrial fibrillation, who are not candidates for anticoagulation. Percutaneous implantation is performed via femoral vein and requires trans-septal puncture for access to the left atrium. This technique is associated with a higher incidence of procedural and post-procedural complications, including arrhythmia, MI (myocardial infarction), atrial perforation, pericardial tamponade, device embolization, embolic stroke (CVA [cerebrovascular accident]), access site bleeding and AV (arteriovenous) fistula. 

Due to the complex nature of this procedure, it would be consistent with the current standard of care that this patient be managed in an inpatient setting. Therefore, the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:Central nervous system/Neuromuscular disorder.   
Treatment:Inpatient Hospital.
The insurer denied a portion of the hospital stay.
The denial is upheld in whole.

The patient is  with a past medical history of chronic anemia who initially presented to the hospital with a 1.5-month history of progressive ascending symmetric weakness and sensory loss, 3-month history of weight loss, hypokalemia, and a fall in the setting of upper respiratory infection. Reportedly, the patient had no reflexes.
No, the inpatient stay for the dates in question was not medically necessary at the acute inpatient hospital level of care.
 According to the medical records, the patient underwent a very thorough workup, which was finished long before earlier this year. The patient had ambulatory dysfunction related to her neurological problems. The ambulatory dysfunction started long before the day when the patient sustained the fall. The fall resulted in a relatively small fracture, which did not require any surgical intervention. There was no need for pain control in an inpatient setting. This fracture did not contribute to additional neurological compromise. This fracture was managed conservatively. Otherwise, the patient was afebrile and hemodynamically stable and was waiting for acute rehabilitation placement.
Taking into consideration all these facts, there was no evidence that either the severity of the patient's condition or the complexity of the services provided justified admission at the acute inpatient level of care The fall and the minor fracture did not alter the course of the hospitalization.
There was no overwhelming evidence that any events that occurred   altered the course of the hospitalization or substantially increased the severity of the patient's condition, to the point that the admission at the acute inpatient level of care was justified.
The patient was very sick, with significant medical problems. However, by the date in question , those medical problems were worked up very thoroughly, and in general, the patient did not require continued stay at the acute inpatient level of care on that day. The patient  was waiting for acute rehabilitation placement. The events that occurred on that day, including the fall and minor fracture in the toe phalanx, did not add to the severity of the patient's condition to the point that the admission at the acute inpatient level of care was justified.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular/ Alzheimer's disease
Treatment: Home Health Care  
The insurer denied increase in the consumer directed personal care assistance program hours to 12 hours/day, 7 days/week to total 84 hours/week. 
The denial is overturned in whole. 

The patient with a past medical history of diabetes mellitus type 2, hypertension, hyperlipidemia, fecal urgency, urinary incontinence, gastroesophageal reflux disease (Gerd), anxiety, depression, gait abnormalities, osteoarthritis of multiple joints and Alzheimer's dementia.
Yes, the requested treatment of increase in the consumer directed personal care assistance program to 12 hours per day, 7 days per week 84 hours per week is medically necessary.
The patient's primary care provider has requested an increase in Personal Care Assistant (PCA) service hours due to the patient's worsening mobility and worsening dementia. The patient's assessment was fairly comparable for seven months; however, it is felt that this is an underestimate of the patient's assistance needs.
This assessment specifically noted the patient was totally dependent with tasks of meal preparation, ordinary housework, managing finances and shopping while maximum assistance was deemed necessary for managing medication, phone use, stairs, transportation, bathing, dressing lower extremity, walking, locomotion and transfer toilet. The patient was assessed to need extensive assistance for tasks of personal hygiene, dressing upper extremity, toilet use and bed mobility.
The patient has the need for assistance with toilet use, incontinence cares and transfer toilet which are unscheduled needs. The patient would need assistance with ambulation for these unscheduled toileting needs. There is documentation by the PCP  that the patient had multiple falls over the last year which was not reflected on the assessment. The patient's personal care aide services would not just be for supervision and safety but for assistance with ADLs and Instrumental activities of daily living (IADLs.) The patient also has diabetes and requires assistance with glucose monitoring which was not considered in the most recent assessment tool. In summary, an increase in PCA services hours is medically necessary for this patient.