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

Urological/GU

This is a patient with a long history of a bladder stone who underwent cystoscopy, open cystolithotomy, and was admitted to the hospital post-operatively overnight. The patient has complex co-morbidities such as coronary artery disease (CAD), uncontrolled diabetes mellitus (DM) II, essential hypertension/malignant, obesity, schizophrenia, benign prostatic hyperplasia (BPH), HX of methicillin-resistant staphylococcus aureus (MRSA) bacteremia, MRSA culture positive, sleep apnea, history of acute chest pain, and vitamin D deficiency. After the cystoscopy and open cystolithotomy which showed a massive bladder stone, the patient went home on the next day of the surgery with a foley catheter and leg bag. The post-operative course was unremarkable, and the patient was discharged day after the surgery. The health plan's determination of medical necessity is upheld in whole. 
Given the patient's health status, diagnosis, and condition, an acute inpatient level of care is not medically necessary. The patient did meet criteria for a lower level of care due to complex co-morbidities including CAD, uncontrolled DM II, essential hypertension/malignant, obesity, schizophrenia, BPH, hx of MRSA bacteremia, MRSA culture positive, sleep apnea, history of acute chest pain, and vitamin D deficiency, and bladder stone, requiring definite surgical intervention as outlined by the American Urological Association (AUA) stone management. However, there was no evidence of signs of sepsis or complications post operatively that meet inpatient criteria. The creatinine was within normal limits and the patient did not suffer from post-operative complications. The pain was well controlled, and the patient did not have risk for deep vein thrombosis (DVT). The level of service would be dependent on objective evidence of  severity of illness. There is no evidence that the patient met an inpatient level of service at any time throughout the hospital admission. It was appropriate to admit the patient for a lower level of care.
According to InterQual criteria, medical necessity for acute level of care has not been met. There was no documentation of post-operative complications such as bleeding or infection that require an acute level of care. However, the InterQual criteria does meet for a lower level of care, (ambulatory surgery with unable to void post op and needing catheter).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cough, shortness of breath
Treatment: Inpatient admission
The proposed treatment, inpatient admission, was not medically necessary.

The patient is a female child with medical history of umbilical hernia and an episode of wheezing that was taken to the ED for two-hour history of cough and shortness of breath. She had received Tylenol one hour prior to presentation for tactile fever. Additional symptoms included runny nose and congestion. 

Vital signs included temperature 38.7, heart rate 178, respiratory rate 30, and 97% saturation in room air. Examination was significant for non-toxic appearance, irritable but consolable, congestion, moist mucous membranes, tachycardia, tachypnea, belly breathing with intercostal retractions, good air movement with mild expiratory wheezing at the lower lobes bilaterally, no grunting, and non-focal neurologic exam. Interventions included ibuprofen, nebulized saline with option for albuterol, prednisolone, respiratory syncytial virus (RSV) swab, chest x-ray to rule out pneumonia, and pulse oximetry. Chest x-ray revealed bilateral perihilar peribronchial thickening consistent with reactive airway disease or bronchiolitis. RSV testing was negative, rapid strep and rapid influenza/RSV were negative. 

With treatment, the patient's respiratory rate improved and saturations were 97-100%, but she still had belly breathing and mild intercostal retractions. With sleep, saturations dipped to 90%. The decision was made to admit for further management of bronchiolitis. In total, the patient received one dose of albuterol and four saline nebulized treatments. Following admission, she was placed on the bronchiolitis pathway with frequent respiratory assessments and supportive care (saline nebulizer treatments, chest physiotherapy, suctioning). She had no oxygen requirement for the duration of her hospital stay. She did not require intravenous (IV) fluids, and maintained normal urine output. The family was given appropriate education and anticipatory guidance, and she was deemed stable for discharge home.

This young child with history of one prior wheezing episode presented to the ED with fever, congestion, wheezing, and increased work of breathing, consistent with bronchiolitis or viral infection with reactive airway disease. The patient responded to saline treatments in the ED, but had decreased oxygen saturation while sleeping and ongoing retractions. She had been monitored in the ED for a number of hours, but with ongoing concerns for increased work of breathing, it was reasonable to continue monitoring her in the hospital with saline treatments and albuterol as needed. However, she was hemodynamically stable with no oxygen requirement, no evidence of dehydration, and no impending respiratory failure. She did not require acute inpatient admission and could have been safely and appropriately managed at an observation level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Discomfort 
 Treatment: Inpatient Admission 

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

This is a male patient with a medical history of partial left nephrectomy for papillary renal cell carcinoma (status post left partial nephrectomy, chronic obstructive pulmonary disease (COPD), diabetes mellitus, hypertension, hyperlipidemia, obstructive sleep apnea, hepatic steatoses, and coronary artery disease. He presented to the emergency department with complaints of lower extremity swelling bilaterally, left leg numbness, right flank pain, dyspnea on exertion, rhinorrhea, and squeezing chest discomfort radiating to his back. His presenting vital signs were; blood pressure 107/83, heart rate 83, and temperature 97.8. He was consulted by Cardiology. An electrocardiogram was performed with normal results. A laboratory work up was performed with revealing  white blood cell (WBC) count 15.66, hemoglobin 14.1, creatinine 0.96, BNP <5, and high sensitivity troponin 8, with subsequent level earlier that day of 8 (range <6 - 14). He had a chest x-ray and a venous Doppler exam that were unremarkable. A computed tomography (CT) scan of the abdomen/pelvis and an ultrasound of the kidney and bladder revealed multiple bilateral renal cysts that remained unchanged from prior imaging. The patient was discharged with his home medications, which included proair, clopidogrel, amlodipine, atorvastatin, carvedilol, Lisinopril, montelukast, symbicort, aspirin, furosemide, metformin, and omeprazole. 

Based on the review of this patient's medical record and the clinical guidelines for the management of unstable angina/non-ST elevation myocardial infarction, there was no clinical evidence to support that this patient required an acute inpatient level of care to determine whether or not this patient's chest discomfort was related to acute coronary syndrome. 

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

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

Diagnosis: Suicidal Ideations
 
Treatment: Continued Inpatient Admission

The insurer denied the Continued Inpatient Admission. The denial was modified.   

This is a male patient with a history of bipolar disease, past suicidal attempts, alcohol and heroin usage, and liver disease. He was admitted to psychiatric facility with complaints of depressive symptoms including suicidal ideation with a plan to hang himself, hopelessness and helplessness, and decreased motivation. He was treated with Depakote, Quetiapine, and Trazodone, and was discharged home.

It was reported that a few days prior to discharge the patient denied suicidal or homicidal ideation or feelings of helplessness, and was less depressed, calmer, more hopeful, and had better insight and judgment, normal psychomotor activity, appropriate behavior, and organized thinking. The patient had no reports of acute medical instability or severe withdrawal that required further hospital treatment.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Bipolar Disorders reports that the least restrictive level of care for safe and effective treatment is appropriate and also that patients with aggression, homicidal or suicidal intent, plan, or behavior, psychotic symptoms, or severe agitation are candidates for inpatient hospitalization. 

The APA Practice Guidelines for the Treatment of Patients with Suicidal behaviors reports that patients with past suicide attempts are at high risk for suicide and that past suicide attempts are the most reliable predictors of suicide. It also reports that patients with bipolar disorder and substance use are at increased risk for suicide. 

The APA Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports also that patients may require more time in the hospital to better assess suicide because they sometimes do not tell the truth regarding their suicidal thoughts in order to leave the hospital, and that observation in the hospital is appropriate to better ensure their safety. This patient was considered a high risk patient for suicide due to his past history of suicide attempts and his suicidal plan to hang himself on admission, as well as his diagnoses of bipolar disorder and comorbid substance use

It appeared that the insurer acted reasonably and with sound medical judgment and in the best interests of the patient several days prior to discharge however they did not act in the best interests of the patient before then.

Based on the above, the medical necessity for continued inpatient hospital services is partially substantiated. The insurer's denial is modified.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Angina
Issue under review: Inpatient admission

Determination:
The Inpatient admission was medically necessary.

The patient is an adult male. He has a past medical history significant for HTN (hypertension), dyslipidemia, Type 2 diabetes mellitus on insulin, peripheral vascular disease, and toe amputation. He presented for cardiac catheterization for CCS Class III angina. 

The patient's ECG (electrocardiogram) revealed changes consistent with lateral ischemia. Laboratory data was significant for anemia, elevated serum creatinine and potassium. Cardiac catheterization revealed severe three vessel coronary artery disease, and the decision was made to refer the patient for urgent coronary artery bypass surgery (CABG). Repeat ECG revealed dynamic ECG changes, consistent with ischemia. The patient had experienced chest pain, requiring IV Morphine for control. He was transferred another hospital for urgent CABG.

The patient presented for evaluation of anginal chest pain, suggestive of unstable angina. The patient had multiple risk factors for CAD (coronary artery disease), including diabetes. Cardiac catheterization revealed severe multivessel CAD, requiring urgent surgical revascularization. Post procedure, the patient was documented to have chest pain at rest with dynamic ECG changes, consistent with ischemia and subendocardial injury. Given this presentation, consistent with an acute coronary syndrome, as well as risk factors and known CAD, results of catheterization and need for urgent CABG, 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: Pneumonia
 
Treatment: Inpatient Admission

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

This is a female patient with a recent medical history of asthma, and obstructive sleep apnea requiring continuous positive airway pressure (CPAP) support. He presented to the hospital with complaints of shortness of breath, fever and a productive cough for three days. The patient had been at another facility a few days prior to presentation with similar symptoms and had been discharged from the hospital on prednisone and inhalers. At presentation to the Emergency Department (ED), the patient was febrile to 101.4, the blood pressure was 164/91, the respiratory rate was 18, the heart rate was 88 and the oxygen saturation was 98% on room air.  Her lungs were clear, cardiovascular system (CVS) S1 S2 was normal, and the abdomen was soft.

The patient had a mildly elevated white blood cell count to 12 K.  Electrolytes and the blood urea nitrogen (BUN)/Creatinine were within normal limits. The patient had a chest x-ray which revealed some blunting of the costophrenic (CP) angle.  No definite infiltrate was noted. There were some premature ventricular contractions on EKG.  A D-Dimer showed mild elevation; therefore, a computed tomography angiography (CTA) was done.  No pulmonary embolism was noted.  There was some sub segmental atelectasis and possible air trapping.  Early pneumonia was noted in the differential diagnosis. The patient was placed on broad spectrum antibiotics, steroids and bronchodilators.  The patient remained stable after admission and defervesced rapidly.  She remained hemodynamically stable and was oxygenating appropriately.

There was no indication that this patient had a severe pneumonia.  Pneumonia if present was likely mild.  Asthma symptoms were also not severe. No use of accessory muscles was noted.  There was minimal wheezing.  The patient's pneumonia severity index (PSI) score was low and the CURB 65 score was Zero.

The patient was tolerating oral intake and could have been discharged home on oral antibiotics, steroids and bronchodilators with close follow-up after a period of observation which could be up to 48 hrs.  The prior denial of admission is upheld.

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: Recurrent acites (s/p paracentesis)
Treatment: Inpatient admission

The proposed acute care inpatient admission was not appropriate or medically necessary for this patient's condition. 

The patient is a male with history of (h/o) alcoholic cirrhosis, h/o hepatocellular carcinoma (HCC) status post (s/p) radiofrequency ablation, h/o ascites for which he had undergone large volume paracentesis previously, h/o esophageal varices for which he underwent banding of the varices in the past.  The patient was admitted with abdominal pain and distention secondary to ascites. 

In the emergency department (ED), the patient was hemodynamically stable and afebrile. He was admitted and underwent large volume paracentesis and approximately 8.4litres of fluid was removed without any complications.  The preliminary results of fluid did not show any evidence of spontaneous bacterial peritonitis. His complete blood count (CBC) and comprehensive panel were unremarkable and prothrombin time (PT) / international normalization ration (INR) was mildly elevated at 1.46.  Gastroenterology (GI) was consulted and the plan was to continue the patient on Aldactone and Lasix, as before, and follow up with his GI as an outpatient for further management.  The patient was discharged home the next day in fair and stable condition.

The patient presented with abdominal distention and discomfort secondary to ascites due to underlying cirrhosis. He was hemodynamically stable and afebrile and there were no clinical signs and symptoms of infection. He has prior h/o ascites for which he had undergone large volume paracentesis. His abdominal discomfort and distention improved significantly after large volume paracentesis and he was tolerating diet well without any symptoms of nausea and vomiting. Since he had no h/o GI bleeding or spontaneous bacterial peritonitis, and did not require any blood transfusion, endoscopic intervention, or intravenous (IV) antibiotics, the acute level care was not appropriate or medically necessary and the patient could have been safely managed under a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anxiety and depression
Treatment: Inpatient admission

The proposed treatment, inpatient admission, was not medically necessary for this patient.

The case involves a young adult female who self-referred to the emergency department and was admitted for acute inpatient psychiatric services. The patient provided a history of worsening symptoms of depression and anxiety with panic attacks and somatic anxiety. She has a past history of alcohol use disorder. She reported stress related to a romantic relationship and thought that she was overmedicated. Thus, she presented in the context of severe symptoms of anxiety and somatic complaints and stressors including the precipitating factor involving a relationship issue.

The proposed inpatient mental health stay is not medically necessary in this case. The intensive treatment of the patient's psychiatric disturbance did not require the structure, monitoring or intensity of an acute inpatient level of care. Moreover, the patient did not display evidence of violent intent or suicidal plan or intent during her hospital course, as noted in the clinical summary; other symptoms such as severe cognitive impairment (dementia or delirium), thought disorder, mania or psychosis were not present in this case, nor was there psychiatric co-morbidity or substance-related disorders that would warrant acute inpatient level care. The patient was cooperative with treatment; and medication adherent, and, the psychosocial stressors in this case were not so severe to require acute inpatient care or 24-hour monitoring. Additionally, the patient had an established treatment provider in the community and access to continued treatment and services at a lower level of care. Thus, medical necessity for the inpatient admission and acute inpatient level care was not met in this case scenario. 

The patient's treatment for her psychiatric disturbance and substance-related disorder could have been safely and effectively provided at a lower level of care. Specifically, the patient did not present with acute general medical complications or severe withdrawal symptoms from alcohol or complications of the co-occurring substance use disorder that was in remission. The patient's mood disturbance and associated symptoms of anxiety (generalized symptoms and panic) and functional impairments did not require the requested inpatient level structure or monitoring during the time interval under review. There was no imminent risk for suicidal behaviors or documented symptoms that would have necessitated the inpatient level of care or continued assessment, safety monitoring and treatment in an acute inpatient setting, as proposed. The psychosocial stressors in this case were not so severe to warrant inpatient level care, monitoring or structure. This answer is consistent with prevailing standards of care and with NY State instruction for this review including NY State OASAS LOCDTR 3.0 Guidelines, referenced below, or the scientific literature also referenced below.
Appeal type: Medical necessity
Decision: Upheld

Cardiac/Circulatory Problems - Chest pain
Inpatient Hospital

The patient is a female with a history of hypertension. While undergoing a cardiac stress test, she developed chest pain and lightheadedness. No associated arrhythmias were documented. No ST segment changes were noted. The stress test was stopped; her systolic blood pressure was 120-140 millimeters of mercury (mmHg). Her rhythm was sinus with a rate in the 90s. She was taken to the emergency department. She was alert and hemodynamically stable. There were no acute electrocardiographic changes. Her serum troponin level was normal. She complained of headache; brain computed tomography (CT) scan showed no acute pathology. She was admitted to the hospital to rule out acute coronary syndrome. Two repeat troponin levels were normal. The following day she was asymptomatic and hemodynamically stable. She was transferred to another facility for cardiac catheterization. An echocardiogram showed left ventricular hypertrophy with normal systolic function. There was mild mitral regurgitation, mild aortic stenosis, mild to moderate tricuspid regurgitation and mild pulmonary hypertension. Coronary angiography showed normal coronary arteries. She was discharged home. Medical necessity for an inpatient admission is at issue.

The health plan's determination is upheld.

Regarding the inpatient admission for cardiac catheterization, this patient was referred for cardiac catheterization after an episode of chest pain and near syncope during stress testing. She had no ischemic electrocardiographic changes and her cardiac biomarkers were normal. Angiography showed normal coronary arteries and the procedure was uncomplicated. The safety of outpatient cardiac catheterization, even when percutaneous intervention is required, has been well demonstrated. An inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Liver transplant.
Treatment:  Actigall 300mg PO BID. 

The insurer denied the Actigall 300mg PO BID.  The denial is overturned. 

The patient is a male.  He has history of ulcerative colitis and primary sclerosing cholangitis (PSC), s/p (status post) liver transplant.  He is currently on Tacrolimus 4mg PO (by mouth) BID (twice daily) and Cellcept 1000mg q12h (every 12 hours).  He is also maintained on low dose prednisone.  He has also been maintained on Actigall 300mg PO BID.

The liver biopsy done showed mild, nonspecific, degenerative bile duct changes, and no acute cellular rejection.  His PCP (primary care provider) switched him over from Actigall to generic ursodiol 300mg PO BID, on which he developed severe itching and rash.  The AP is requesting Actigall 300mg PO BID. 

Yes, the proposed use of brand name Actigall is medically necessary. 

The patient developed allergic rash after he was switched over to generic Ursodiol.  The risk of recurrent disease increases with time, but it does not correlate with the rate of graft loss.  Treatment is largely unproven, although in some studies, ursodeoxycholic acid has been shown to improve serology and may slow progression of recurrent PSC. 

Since this patient's allograft functions are well maintained on the combination of Tacrolimus, Cellcept, steroids and Actigall, it is appropriate and medically necessary to continue him on brand name Actigall.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis:  Central Nervous system/Neuro-muscular disorder - Multiple Sclerosis.
Treatment:  Pharmacy Prescription drugs (Vumerity).

The insurer denied  the medication Vumerity as a formulary exception.  The denial is upheld in whole.

This patient was seen by the neurology practitioner.  The patient had been on Tecfidera and was not receiving any multiple sclerosis disease-modifying therapy.  The patient had a relapse that was treated with high dose steroids.  A brain magnetic resonance imaging (MRI) at the time revealed new enhancing lesions. The patient returned to baseline subsequently.

The patient has not previously tried and failed or had adverse reactions to both Gilenya and Mayzent.  There is no evidence that Vumerity is superior in efficacy to Gilenya and Mayzent, as there have been no head-to-head clinical trials between Vumerity and either or both of these medications.  There is no evidence that the adverse effect profile of Vumerity is more severe than that of Gilenya and Mayzent.  Cardiac events can be eliminated by a change to a different antidepressant, as the patient was on Citalopram and had an increased risk of arrhythmia with Gilenya or Mayzent.