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

Cellulitis
Inpatient hospital

The patient was a male brought to the emergency department (ED) with fever and lower extremity swelling. He sustained a laceration to his right heel area while playing baseball about a week previously and had progressive worsening pain and swelling. The day before and the day of presentation to the ED, the mother said he had a fever. At triage, his vital signs were normal and he looked generally well. The ED physician described a healing laceration over his right heel area, below Achilles tendon, with surrounding swelling and erythema that progressed over the internal malleolar area and below the internal aspect of the foot. The entire area was noted to be very tender and warm to the touch, with decreased range of motion. He could not bear weight on that extremity. The white blood cell (WBC) count was normal, erythrocyte sedimentation rate (ESR) 43, and C-reactive protein (CRP) 5.1. X-rays were normal except for soft tissue swelling. 

The health plan's determination is overturned. The inpatient stay was medically necessary. The patient presented with a large and spreading cellulitis of the foot along with systemic symptoms and signs: fever, elevated ESR, and elevated CRP. It was described as extremely painful. Septic arthritis was in the differential diagnosis, although cellulitis was the leading diagnosis. In either case, initial treatment with IV antibiotics was medically necessary, and it was appropriate to discharge him the next day on oral antibiotics because of the clinical improvement and lack of continuing evidence of possible septic arthritis. The one day inpatient hospitalization was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:Back pain, syncope, and dizziness. 
Treatment: Inpatient stay

Summary:
The patient is a female with depression, bipolar disorder, asthma/COPD (chronic obstructive pulmonary disease), hypothyroidism, and anxiety. She presented with back pain, syncope, and dizziness. 

This patient presented after syncopal episode that was deemed to be likely a vasovagal syncopal episode, which did not require inpatient admission. This patient was found to be significantly hypothyroid, but she was not bradycardic and she was hemodynamically stable. Her mental status was not altered. The documentation does not support a diagnosis of myxedema coma. She was treated with oral levothyroxine. The documentation does not support that she failed observation. Therefore, no, the proposed inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Schizoaffective Disorder

Treatment: Continued Inpatient Mental Health Treatment

The insurer denied the continued inpatient mental health treatment. The denial was upheld.   

This is a male patient with a history of Schizoaffective Disorder-depressive type, and multiple psychiatric hospitalizations. He was admitted to a mental health facility with complaints of psychotic and depressive symptoms including auditory hallucinations, paranoid thinking, thought blocking, slowness in responding to others, depressed mood, suicidal statements, feelings of hopelessness, helplessness, worthlessness, and social isolation. His treatment course included intramuscular Risperidone, Clozapine, Duloxetine, Haldol, and Ativan. 
 
According to the American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Schizophrenia, patients with hallucinations, delusional thinking, disorganized behavior, suicidal or homicidal plan or intent, agitation, or aggressive behavior are candidates for inpatient treatment.  In this case there were no reports that this patient was exhibiting serious psychotic symptoms such as delusions, hallucinations, or disorganized behavior, suicidal or homicidal ideation, intent, or plan, manic symptoms, aggressive, threatening, self-injurious, or agitated behavior, withdrawal symptoms or acute medical instability.  In the later part of his admission the patient did not exhibit any acute or severe mental health or behavioral symptoms that required 24-hour acute hospital treatment, and there were no reports of specific identifiable or quantifiable treatment goals or objectives that could only be achieved in a 24-hour acute psychiatric hospital treatment setting, or that could not have been achieved in a less restrictive level of care. 

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

The carrier denial of coverage for the 31 units of continued Inpatient Mental Health Treatment is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Major Depressive Disorder

Treatment: Residential Mental Health Treatment

The insurer denied the residential mental health treatment. The denial was reversed. 

This is a young male patient with a history of polysubstance use and several psychiatric hospitalizations due to suicidal ideations in the past month. He was admitted to a residential treatment program due to his significant mood and behavioral symptoms. It was reported that he was on probation and had a history of arrest for robbery. He had been suspended from school due to bringing illicit substances to school. It was noted that the patient had poor decision making, poor communication, and coping skills.  The patient remained inpatient under mental health treatment.

The American Academy of Child and Adolescent Psychiatry's Practice Parameter for the Assessment and Treatment of Children and Adolescents with Depressive Disorders provides that the decision for level of care depends primarily on level of function and safety to self and others and that the least restrictive level of care for safe and effective treatment is appropriate. Also, the MCG Inpatient Residential Behavioral Health Level of Care-Child and Adolescent medical necessity guidelines report that if the patient has moderately or severe psychiatric or behavioral symptoms requiring 24-hour daily treatment or serious dysfunction in daily living then the patient meets criteria for residential treatment. It also states that for discharge there needs to be sufficient support at a lower level of care, absence of suicidal or homicidal thoughts or thoughts of harm to self or others. 

Despite the inpatient care received from a specified date forward, clinical guidelines support that this patient's persistent pattern of abusive behavior and mood instability indicates that this patient's inpatient 24-hour care from a specified date forward and continuous inpatient stay are medically necessary for this patient to make further, clinical progress to prevent harm to the patient and to others.

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

The carrier denial of coverage for the Residential Mental Health Treatment is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with a lump on the right side of the mid-back. This mass grew over the next two weeks. The patient presented for care with a large (3.7 x 6.1 x 9 centimeter (cm)) irregular heterogeneous right-sided paraspinal mass with extension through the neural foramina, concerning for neuroblastoma. The patient had homovanillic acid (HVA) and vanillylmandelic acid (VMA) levels that were elevated and a tissue biopsy was performed which confirmed the disease as well as bone marrow biopsies and insertion of a central venous access catheter. A bone scan was performed that showed abnormal uptake within the tumor in the paraspinal region and a separate focus of uptake either in the tumor itself or in the 10th rib. Once the diagnosis was finalized, the patient was started on treatment per the Children's Oncology Group (COG) protocol ANBL0531. The patient started cycle 1 with Carboplatin and Etoposide and was discharged with plans for a meta-iodobenzylguanidine (MIBG) study. At issue is the medical necessity of the inpatient stay. 

The health plan's determination is overturned in whole. This patient presented with a spinal mass with concerns for possible cord compression and a new malignancy which required the evaluation and initiation of treatment. Imaging was performed to determine the extent of the mass, and a plan of care for a surgical biopsy, bone marrow biopsy and central line placement occurred during the admission. The patient had a bone scan evaluation and monitoring while awaiting the final pathology results in the hospital as it was not safe to discharge the patient with the concerns for possible cord compression, and treatment was started the day after the results were given. The chemotherapy treatment itself also required a hospital stay (continuous intravenous (IV) fluid treatment, 3 days of chemotherapy medications) and the patient was discharged on the 3rd and final day of the chemotherapy treatment.

Malignant spinal cord tumors are considered oncologic emergencies and can lead to paralysis if treatment is delayed. As per the current standards of care, whether or not neurologic symptoms are present, this condition warrants a multidisciplinary approach and close monitoring and prompt treatment. In this case, the chemotherapy treatment for the underlying malignant condition was most likely to result in improvement in the patient's status and was the safest method of treatment.

Therefore, based on the clinical information provided for review, the peer-reviewed literature and the standards of care in the field, the requested inpatient stay was medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hepatitis C

Treatment: Epclusa 

The insurer denied coverage for Epclusa. The denial was upheld.

This patient is a female with chronic disease of the liver, hypothyroidism, and asthma. The patient presented for follow-up. She denied symptoms at the time and decided to start management of the disease in early-2019. The provider discussed the possibility of starting medication management sooner.

The American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of American (IDSA) has issued guidelines for the treatment of hepatitis C genotype 1a without cirrhosis. Both Epclusa and Mavyret are recommended regimens.  Mavyret is only recommended for 8 weeks of treatment while the duration of Epclusa treatment is 12 weeks.  The SVR [Sustained Virologic Response] rate for Mavyret was 99%. The preferred product offered by the insurance company was Mavyret.  It has a success rate of 99% and an excellent safety profile.  It is considered appropriate treatment for this patient.  Therefore, Epclusa is not medically necessary.  There are no contraindications to the patient taking Mavyret.  There is no record of intolerance to Mavyret.  The healthcare plan acted reasonably and with sound medical judgment and in the best interest of the patient.  The denial of Epclusa is upheld.

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

Diagnosis: Toe wound
Treatment: Inpatient admission
The inpatient admission was medically necessary.

The patient is a male with a history of insulin-dependent diabetes who presented to the emergency room with a toe wound that he had for one week.  

X-rays suggested osteomyelitis. The patient was febrile to 100.2.  He was admitted for IV antibiotics and possible amputation.  A transmetatarsal amputation was performed. The patient was discharged on oral antibiotics.  Surgical pathology showed abscess with acute osteomyelitis.

This is one of the more obvious indications for inpatient care.  This is rarely treated in an outpatient setting, as this requires monitoring (for response to treatment and the development of such findings as gangrene, necrotizing fasciitis, which would require more aggressive treatment such as more proximal amputation), treatment and evaluation.  The patient ultimately required aggressive surgical treatment, also providing evidence that the initial decision to admit the patient for inpatient care was the correct one.

Admission for diabetic foot infection that ultimately resulted in transmetatarsal amputation is most certainly a justified inpatient admission.  To deny such a medical admission would have left the patient at risk for sepsis and death.  The patient's presentation as described in the clinical notes is rarely if ever treated as an outpatient, and it is one of the more obvious clear-cut indications for inpatient care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Purpuric rash of the lower extremities and buttocks, bilateral lower extremity swelling, severe ankle pain 
Treatment: Inpatient stay

Summary:
The patient is a young male child. He was referred to the ED by his pediatrician because of refusal to walk, right foot swelling and pain, and rash. He had fallen a week prior and hurt his left ankle. He was taken to an orthopedic surgeon where x-rays were done and he was diagnosed with left ankle sprain. The day prior to presentation, he was noted after school to have developed pain, swelling, and rash to the right ankle. The swelling worsening, involving the left lower extremity to a lesser degree. His pediatrician was concerned about septic arthritis or Henoch-Schonlein purpura (HSP). 

Henoch-Schonlein Purpura is an acute systemic immune-complex mediated vasculitis that occurs most commonly in children. It results from IgA (Immunoglobulin A) deposition in small vessels, causing petechiae and purpura. Gastrointestinal hemorrhage may occur when immune complexes are deposited in the small blood vessels in the gut wall. Glomerulonephritis may occur when immune complexes affect the renal mesangium. 

HSP typically follows an upper respiratory tract infection, with characteristic features including purpura, abdominal pain, and arthritis. Symptoms may also include fever and fatigue. Diagnosis is based on clinical features following guidelines established by the American College of Rheumatology and the International Consensus Conference, and biopsy shows characteristic lesions. Gastrointestinal complications include the following: bowel infarction, bowel perforation, duodenal obstruction, gastrointestinal hemorrhage, intestinal stricture, and intussusception. 

Hospitalization is indicated when outpatient monitoring is unavailable, or if inpatient management is necessary for dehydration, pain control, or hemorrhage. In order to reduce unnecessary hospitalization, there has recently been an effort to identify specific clinical criteria that are indicative of need for admission: orchitis, moderate or severe abdominal pain, arthritis involving more than two joints, proteinuria, clear evidence of gastrointestinal bleeding, and/or inability to ambulate. 

This male child presented to the ED with purpuric rash of the lower extremities and buttocks, bilateral lower extremity swelling, severe ankle pain worse on the right, and inability to bear weight or walk. His exam and rash were consistent with Henoch-Schonlein purpura. Based on clinical examination and current criteria for admission, acute inpatient admission was indicated for hydration, rest, and pain management.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: TIA (transient ischemic attack) 
Treatment: Inpatient admission 

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

The patient is a male with a history of diabetes. He presented to the emergency ward with the complaint of slurred speech, nausea and vertigo.  At presentation, his blood pressure was elevated, but otherwise, his examination was normal. CT brain at presentation was normal. He was admitted for TIA (transient ischemic attack), and his subsequent MRI was negative. 

No, the inpatient admission was not medically necessary. 

The patient had a normal neurological evaluation and CT brain at presentation, and his subsequent MRI was negative for stroke. Based on his presenting symptoms and examination, current TIA risk stratification guidelines do not support acute inpatient admission here. The diagnostic studies, monitoring and treatment could have been safely and effectively provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory system/Asthma 
Treatment: Inpatient hospital  
The insurer denied  the inpatient hospital stay
The denial is upheld in whole 

This patient  who was brought to the emergency department (ED) on  with a chief complaint of shortness of breath. The patient  also had chest pain and wheezing noted. The patient  has a medical history significant for asthma. The patient  has no previous episodes of respiratory failure requiring intubation, or Intensive Care Unit (ICU) stays related to asthma.
Based on the provided documentation, and standard of care, the requested service and treatment is not medically necessary at an acute inpatient level of care. This patient was admitted with an acute exacerbation of asthma. In this case the patient was not noted to have evidence of hemodynamic compromise, "silent chest", need for invasive or noninvasive ventilation, symptoms that were persistent beyond a lower level of care, severe hypoxemia at a level that could not be provided at an alternate level of care, progressive decline in mentation, Glasgow coma scale of < 10, pneumothorax, chest tube, encephalopathy or respiratory arrest.
Therefore, the inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis Right Ureteral Stone
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient presented to the emergency department (ED) with complaints of flank pain. He was diagnosed with a 3 millimeter (mm) right ureteral stone 3 days ago. He was afebrile and hemodynamically stable on presentation. Lab results were grossly normal. he was admitted to the inpatient service and his pain was managed. He was discharged the next day with outpatient follow-up. The medical necessity for an inpatient stay is under review.
The inpatient stay was not medically necessary. This patient's hospital course was essentially normal without any significant complications or major issues with pain control. There was no procedure performed. The information provided and the patient's clinical status do not support the need for acute inpatient care. The patient did not present with hemodynamic instability, renal failure, severe obstruction, sepsis or unstable medical problems requiring inpatient management. A lower level of care for this patient's clinical presentation and hospital course was the safe, effective, generally accepted standard and the most appropriate treatment option. The majority of patients who present with renal colic can be discharged within 24 hours of the presentation.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Crohn's disease 

Treatment: Cimzia 400 milligrams/2 milliliter (400 MG/2 ML) every 2 weeks

The insurer denied coverage the medication Cimzia 400 milligrams/2 milliliter (400 MG/2 ML) every 2 weeks

The denial is overturned.

The patient is a female diagnosed with ileocolonic Crohn's disease (duodenal involvement with extraintestinal manifestations) status post left colectomy with end colostomy and colostomy revision with 15 cm of bowel removed.  The patient had failed infliximab, adalimumab, vedolizumab, and ustekinumab.  The patient was maintained on Cimzia 200 mg every 2 weeks and the external appeal requests for increase her dosing to 400 mg every 2 weeks was in process.  The patient was also on azathioprine 25 mg daily, and allopurinol 100 mg daily previously, but this was stopped due to her continued symptoms despite dose optimization of azathioprine.  The request for drug evaluation form noted that the patient had failed Remicade, Humira, Entyvio, Stelara, azathioprine, mercaptopurine (6-MP), and methotrexate.  The patient was noted to have severe Crohn's disease.  The request was for a dose increase to 400 mg subcutaneously every 2 weeks.

The literature is supportive of dose escalation for biologics in patients with Crohn's disease. In patients who respond, the literature recommends continuation with Cimzia for maintenance therapy even including dose escalation and therefore, additional drug quantities are medically necessary outside of the prior authorization criteria. 

Cimzia 400 milligrams/2 milliliter (400 MG/2 ML) every 2 weeks does not have final approval from the appropriate regulatory bodies for this diagnosis. However, since the patient had relapsed while on the standard dosing of every 4 weeks, more frequent administration should be considered for this patient. This patient is considered a good candidate for Cimzia 400 milligrams/2 milliliter (400 MG/2 ML) every 2 weeks because this patient's disease relapsed on standard dosing. The patient had tried and failed Remicade, Humira, Entyvio, Stelara, azathioprine, Mercaptopurine (6-MP), and methotrexate.

The requested treatment is likely to be more beneficial than any of the standard treatments for this patient. 

The carrier's denial of Cimzia 400 milligrams/2 milliliter (400 MG/2 ML) every 2 weeks should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Crohn's disease 

Treatment: Cimzia 400 milligrams/2 milliliter (400 MG/2 ML) every 2 weeks

The insurer denied coverage the medication Cimzia 400 milligrams/2 milliliter (400 MG/2 ML) every 2 weeks

The denial is upheld.

This female patient has been diagnosed with severe Crohn's disease and failed multiple biologic agents. The patient was on Cimzia 200mg every 2 weeks, and her physician wanted to increase the dose to 400 mg every 2 weeks. A colonoscopy revealed persistent bowel inflammation. As per Sandborn et al (2010), patients with moderate to severe Crohn's disease refractory to infliximab treatment was found to show good response to certolizumab treatment. However, there was similar efficacy with giving this drug every 4 weeks or every 2 weeks. This is also supported by Sandborn et al (2010) article on "Reinduction with certolizumab pegol in patients with relapsed Crohn's disease... that states that maintenance was given every 4 weeks, not every 2 weeks as requested by this patient's provider. 

Based on the review of the medical record and literature, Cimzia (certolizumab pegol) 400 mg every 2 weeks is not supported by the scientific literature to result in improved health outcome compared to every 4 weeks schedule. It is not the recommended dose by the FDA. Giving Cimzia 400 mg every 2 weeks has not been shown to be superior to the every 4 week dosing.

The requested treatment is not likely to be more beneficial than any of the standard treatments for this patient.

The carrier's denial of Cimzia 400 milligrams/2milliliter (400 MG/2 ML) every 2 weeks should be upheld.