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

Diagnosis:  Immunologic disorders/Arthritis.
Treatment:  Radiology Services.
The insurer denied the Radiology Services.  The denial was overturned.

The patient is a female with obesity and well controlled psoriatic arthritis.  The patient  has had a very elevated erythrocyte sedimentation rate (ESR) for 2 years.  Recently the patient's ESR was 94.  The patient's psoriatic arthritis (PsA) is well controlled on Cosentyx and Arava.

The issue in this case under review is the medical necessity of a computed tomography (CT) of the abdomen/pelvis (A/P) without contrast to rule out occult malignancy.  The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of CT scan of the abdomen is medically necessary for this patient.  The patient has an elevated ESR without explanation x 2 years.  Her PsA is well controlled at this time on Cosentyx and Arava, so this would not explain the elevated ESR.  Other causes for an elevated ESR include, but are not limited to, malignancy and infection.  The provider has recommended a CT A/P to rule out occult malignancy and has also ordered a CT chest, as well as recommended age appropriate malignancy screening with mammogram, pap smear and colonoscopy.  This is consistent with the standard of care and a reasonable next step in further working up the elevated ESR.  The patient  did have an abdominal ultrasound (U/S) that showed hernia, so a CT A/P would be the next step, as the U/S was unrevealing other than a hernia.  Infection seems less likely given the persistently elevated ESR x 2 years, lack of fevers/chills/night sweats and the normal white blood cell count (WBC) (from the late 2019 labs).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Altered Mental Status.
Treatment: Inpatient hospital stay.  
The insurer denied the inpatient hospital stay.  The health plan's determination is upheld. 

The patient is a woman who was admitted to the hospital.  She had a history of coronary artery disease (CAD), hypertension, diabetes, recent robotic hernia repair complicated by acute kidney injury, abscess formation status post wound vac placement, and abdominal exploration followed by small bowel resection.  She had previously been discharged to an acute rehab facility after the abdominal complications and presented with fever and altered mental status for the past two days.  According to her grandson, she had expressed concerns consistent with paranoia at the subacute rehab. 

The inpatient hospital admission was not medically necessary.  During the patient's hospital stay, she underwent a consultative evaluation by surgery and an evaluation for suicidal ideation by psychiatry.  Surgery had low suspicion for any abdominal complication or sepsis, and psychiatry's impression was that the patient had resolving delirium.  Her evaluations were not consistent with acute illness requiring inpatient management.  She did receive blood transfusion but did not have acute G.I. (gastrointestinal) bleed or any other evidence of acute blood loss anemia that would have required inpatient management.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment Inpatient stay
The insurer denied an inpatient stay.
The determination is upheld.

The patient presented to emergency department (ED) with chest pain. He stated that he woke up with chest pain and cramping to the left hand. The chest pain lasted for 3 hours, based on the ED encounter. It also was non-radiating. The pain was achy in quality. When seen in the ED, the chest pain resolved. There were no associated symptoms.
The patient has history of hypertension. There is no history of cardiac disease. His blood pressure (BP) was 227/100 and heart rate was 58 beats per minute (BPM). The oxygen saturation (O2 sat) was 100%. His physical examination was unremarkable.
His lab results were unremarkable, troponin was normal. His electrocardiogram (ECG) revealed left ventricular hypertrophy (LVH) with global T wave inversion. A chest x-ray (CXR) was normal.
In the ED, the patient was given oral Amlodipine and his BP went down to 170/90.
He was admitted to the hospital to the telemetry unit for a chest pain work up.
Cardiology was consulted. He underwent an echocardiogram. It revealed hyperdynamic left ventricular (LV) function. There were no wall motion abnormalities. The ejection fraction (EF) was 70-75%. There was mild left ventricular hypertrophy (LVH). There was intracavitary gradient 22 millimeters of mercury (mmHg) at rest and 55 mmHg with Valsalva maneuver. There was no obvious left ventricular outflow tract (LVOT) obstruction. The rest of the echocardiogram was normal.
The patient also underwent a computed tomography (CT) angiogram. It revealed normal size, wall thickness and function. EF was 82%. His coronary arteries were patent.
The patient felt better, his BP normalized. Metoprolol was added to his lisinopril. His cardiac enzymes in series were normal.
The patient was discharged home. At issue is the medical necessity of an inpatient stay.
The Inpatient Hospital Stay was not medically necessary for this patient.
The patient presented with resting chest pain. The pain was present for 3 hours prior to presentation. His troponin was negative. His CT coronary angiogram revealed patent coronary arteries without significant disease. The patient was treated with oral medications. The patient presented with a very high BP, however, he did not have symptoms of encephalopathy or pulmonary edema. His BP was managed with oral medications and resolved to normal range.
The level of care for this patient did not meet inpatient admission criteria; he could have been managed at a lower level.
Appeal type: Medical necessity
Decision: Upheld

Digestive System/Gastrointestinal - Abdominal/Stomach Pain
Lab Work/Blood Tests

The patient is a female who was evaluated by a physician secondary to the presence of cough and right upper quadrant abdominal pain. Medical history includes osteoarthritis. As part of the diagnostic evaluation, she underwent laboratory testing for hepatitis B and C viruses. The specific laboratory data was not provided. The subject under review is the medical necessity for the hepatitis B testing.

The health plan's determination is upheld.

Based on the materials provided, the requested health service (i.e. hepatitis B virus testing) was not medically necessary for this patient.
Based on expert guidelines, hepatitis B virus (HBV) screening (i.e. hepatitis B surface antigen, antibody to hepatitis B core antigen, and antibody to hepatitis B surface antigen) should be performed in high-risk persons, including persons born in countries with 2% or higher HBV prevalence, men who have sex with men, persons who inject drugs, human immunodeficiency virus (HIV)-positive persons, household and sexual contacts of HBV-infected persons, persons requiring immunosuppressive therapy, persons with end-stage renal disease (including hemodialysis patients), blood and tissue donors, persons infected with hepatitis C virus, persons with elevated alanine aminotransferase levels (greater than or equal to [>=] 19 IU/L for women and >=30 IU/L for men), incarcerated persons, pregnant women, and infants born to HBV-infected mothers.
Based on the information provided, this patient does not have the clinical, behavioral, or demographic risk factors which would make her at high risk for having acquired HBV infection. The published expert guidelines would not recommend HBV screening for this patient. Based on this scenario, the requested service (i.e. HBV testing) cannot be considered medically necessary or clinically appropriate for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetic foot ulcer
Issue under review: Increase in personal care assistance services

Determination:
The increase in personal care assistance services is medically necessary.

This is an elderly female who is wheelchair bound with a history of complex diabetic foot ulcer. For these reasons, she requires assistance with many of her activities of daily living (ADLs). Documentation from the patient's podiatrist indicates that the patient is incapacitated and handicapped due to a large foot abscess on her right foot which has remained refractory to a long course of wound care and various treatments. She is unable to ambulate on that foot and requires extensive assistance with the majority of her ADLs. For these reasons, the currently approved plan of personal care assistance services is insufficient to meet the patient's needs. Hence, the proposed treatment of an increase in personal care assistance services is deemed medically necessary to offer increased assistance with completion of the patient's ADLs.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Suspected preterm labor

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission. The denial upheld.

This patient is a pregnant female G1 P1 with a prior full-term normal vaginal delivery who presented at 23.3 weeks gestation to a hospital with complaint of painful uterine contractions. Fetal movements were present and the patient denied leakage of fluid or vaginal bleeding. Vital signs were stable.  The fetal heart rate was reassuring. The cervix was dilated 0.5 centimeters. She was admitted with the diagnosis of suspected preterm labor for observation. She received 2 doses of betamethasone. The Progress Note on the day after presentation stated that there were no contractions. The Progress Note on the following day stated no preterm labor and patient will be discharged. 

This patient was complaining of abdominal pain and had no history of a prior preterm delivery. Preterm labor is an indication for admission and tocolysis. Preterm labor is defined as uterine contractions with cervical changes. Did this patient have preterm labor? During this admission, there was no documentation of any cervical changes. So the patient was not in preterm labor. Ideally, this patient would have been observed in labor and delivery, received IV fluid and then re-evaluated few hours later.  If upon re-evaluation, no cervical changes occurred then she would be sent home.  If cervical changes did occur then she would be admitted for tocolysis and further management.

Please note that neither the patient nor the fetus were in any jeopardy. There was no bleeding, and vital signs were stable. 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, (no change in cervical status after few hours of observation) the patient could have been sent home after being hydrated. 

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

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. 

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Refractory headaches
 
Treatment: Botox injections 

The insurer denied coverage for Botox injections. The denial is reversed. 

This patient is a male child with refractory headaches in the setting of severe post-concussive syndrome.  He is home schooled in large part because of headaches and requires ER visits multiple times per month.  He has tried multiple medications and other therapies for his headaches.  Medications have included valproic acid, imitrex, propranolol, amitryptiline, cyproheptadine and Topamax.  Therapies have included behavioral therapies, nerve blocks and physical therapy.  His local Neurologist was unable to control his headaches.  The patient has been traveling several hours to receive botox for headaches.  His local neurologist cannot administer botox and is in agreement with this, as is his primary care physician. The patient is much improved on botox.  

The insurer has denied coverage for Botox injections as not medically necessary. Most of the reasons for the denial are inaccurate or have been addressed: 

1)	Botox is clearly used to "treat the patient's medical condition, [is] required for direct treatment or management of the patient's condition, and if the patient would get worse if [it was] not provided."
2)	The muscle groups to be treated are noted to be: corrugator, frontalis, temporalis, occipitalis and cervical paraspinus, as noted in a letter from NY HA Center dated 11/12/2019.
3)	Preventive medications tried and failed have included valproic acid, propranolol, amitryptiline, cyproheptadine and Topamax. 
 
Another reason for the denial is that botox is not FDA approved for patients under 18 years old.  However, the patient is adult-sized and there is abundant evidence that botox is safe and effective in children.1-3 

Botox is medically necessary for this patient. The health plan did not act in the best interest of this patient.

Based on the above, the medical necessity for Botox injections is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Multiple Sclerosis (MS) Exacerbation
 
Treatment:  Inpatient Admission

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

This is a patient who has a history of multiple sclerosis (MS).  She presented to the Emergency Room (ER) with new onset symptoms that included vertigo, difficulty walking and change in speech.  The plan was to administer steroids; however, before doing so she improved on her own.  It is standard practice to admit MS patients with MS exacerbations unless they are minor e.g. limited to sensory changes.  The patient reported that it was becoming more difficult for her to walk and her speech was shaky. Initial vital signs included a blood pressure of 136/85, a pulse of 88, respirations of 18, and a temperature of 37.0C.  She stated that she has had rhinorrhea, mild headache, neck pain, and an episode of dysarthria.  The patient reported her symptoms were typical of her MS flares.  This patient's symptoms were not minor and resulted in increased disability (decreased walking ability.) 

According to UpToDate: "For patients with an acute multiple sclerosis (MS) exacerbation that results in neurologic symptoms and increased disability or impairments in vision, strength, or cerebellar function, we recommend treatment with glucocorticoids (Grade 1B)."  Hospital admission was appropriate and medically necessary.  The denial is reversed.

The insurer did not act reasonably, or with sound medical judgment, or in the patient's best interest.

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

Alcohol abuse
Substance abuse: inpatient

On presentation to the emergency department, the patient reported past history of acquired immunodeficiency syndrome (AIDS) / human immunodeficiency virus (HIV), high cholesterol, substance abuse, bipolar disorder, diabetes. Vital signs were initially within normal limits with a heart rate of 78. The patient reported  drinking "3 pints with some beer." It was unclear from the initial documentation what type of alcoholic drink was quantified by the phrase "3 pints." Patient stated that her last drink had been a few hours prior to coming to the hospital. Patient reported alcohol withdrawal with detoxification some months ago. Patient reported having seizures in the past. There were no initial medical complaints.
Subsequent documentation indicated that the patient was drinking "3-4 pints of liquor daily." Patient reported that her maximum period of sobriety had been 4 months in the past. Also reported a history of seizures and delirium tremens during prior detoxification admissions. Patient also reported a history of heroin, cocaine, and marijuana abuse. Patient reported being sober for more than 20 years, though was unclear from documentation to which substance this referred. Medications included Seroquel, Lexapro, Ambien, Klonopin/Ativan, Truvada, Isentress.
Initial Clinical Institute Withdrawal Assessment (CIWA) score was 13. Patient was admitted for detoxification on an Ativan protocol. 
The health plan's determination of medical necessity is overturned in whole. The patient was drinking heavily prior to admission, had a significantly elevated alcohol withdrawal score, and had a history of alcohol withdrawal seizures and delirium tremens and needed inpatient detoxification. The patient did not require immediate hospitalization for life-threatening medical conditions or for a severe psychiatric crisis. Alcohol was the substance most likely to cause harm. The patient clearly met criteria for an alcohol use disorder. The patient was not in full remission from the substance use disorder. The patient was using a substance with the risk of medical complications from withdrawal. The patient did have serious medical symptoms of withdrawal that would require medical management and a hospital setting. Vital signs would need to be monitored at least every 6 hours and likely more. Detoxification medications were needed to prevent or modify withdrawal and the client's needs needed to be monitored to adjust medication. The patient had a history of seizures and delirium tremens and there was a long term history of substance abuse that would eventually lead to serious medical problems.
LOCADTR Level of Care is: Hospital Based Inpatient Detoxification
The patient could not have been safely and effectively treated for  withdrawal symptoms at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Entero-rhinovirus
 
Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was reversed.  
This is a female infant who was born premature. She presented to the Emergency Department by her parent with fever, rhinorrhea, cough and 1 episode of vomiting. It was reported that she had poor oral intake for 2 days; resulting in a decrease in her wet diapers. Laboratory work up, blood, and urine cultures were obtained. Influenza and respiratory syncytial virus (RSV) tests were negative. A respiratory virus panel (RVP) was sent with was positive for entero-rhinovirus. Intravenous (IV) fluids, IV antibiotics, and Tylenol were given.  A lumbar puncture was suggested, but refused by the infant's parents. The patient was medically stabilized and discharged home. 
The patient falls into the category of "young febrile infant" i.e. who needs to be assessed for risk of serious bacterial infection (SBI). SBI includes bacterial sepsis and bacteremia, bacterial meningitis, and urinary tract infection. Although there is no universal (such as a national) febrile infant guideline, all pediatric protocols are similar in their use of risk stratification to classify a febrile infant into Low Risk or High Risk for SBI. This stratification determines whether the infant should undergo a lumbar puncture, be admitted, be treated with antibiotics pending culture results, or any combination of these 3 interventions.   Low Risk is: Not Ill Appearing, Full Term (>37 wks GA), No previous systemic antibiotics within 1-week, negative urinalysis, WBC > 5,000 and < 15,000/mm3, and Band count < 1500 (if available). If even one of these criteria is not met, the baby should be classified as High Risk. 

This patient was High Risk due to being born premature, so it was appropriate to begin empiric treatment with ceftriaxone and observe as inpatient, pending culture results for about 48 hours, especially because a lumbar puncture had not been performed. Not doing so would entail a risk of her returning with evidence of untreated SBI.  

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

Based on the above, the medical necessity for the inpatient hospital admission is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Kidney calculus
 
Treatment: Inpatient Admission

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

This is a male patient with a medical history of nephrolithiasis. The patient presented to the emergency department (ED) with complaints of right flank pain and intermittent hematuria. ED triage revealed a temperature of 98.8F and a blood pressure of 134/72. Labs in the ED were stable A computed tomography was performed that revealed right hydronephrosis due to a proximal obstructing right ureter calculus and a left renal calculi was also present. He received 2 liters of intravenous (IV) fluids, IV Levaquin, and Ketorolac intramuscular (IM). Urology consulted on the patient. Despite the medical intervention the patient was taken to the Operating Room (OR) for a cystourethroscopy, right retrograde pyelogram (RPG)/ right ureteroscopy (URS) with laser lithotripsy/stent placement. The patient's symptoms improved and the foley was removed prior to discharge. 

Per MCG Health (23rd Edition) Renal Colic + Kidney Stones, the patient fails to meet clinical indications for admission to inpatient care.  In addition, per MCG Health (23rd Edition) Urologic Surgery or Procedure GRG, the patient is noted to have met the General Recovery Course discharge parameter within 23 hours postoperative.  As per the guidelines, this procedure is normally performed in the ambulatory surgery setting.  Some hematuria is expected after cystourethroscopy and laser lithotripsy/stent placement for a large, obstructing upper ureteral calculus.  

The healthcare plan acted reasonably and with sound medical judgment and in the best interests of the patient.

The carrier's denial of coverage for the inpatient hospital services at the acute medical surgical level is upheld.  The medical necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Endocrine/Metabolic/Nutritional
Treatment: Pharmacy/Prescription Drugs
The insurer denied: Nutropin
The denial is: Upheld, in whole

The patient is a male diagnosed with growth hormone deficiency (GHD). This request is for Nutropin. As reported in the records, he is on growth hormone (GH) therapy with Humatrope. He is at point where he must divide injecting due to his high dosage of 6.2 milligrams (mg) daily, 0.54 mg per kilogram per week. Humatrope only dials up to 6 mg. the other preferred Genotropin dials up to 4 mg. He is currently on Tanner 4. His weight was 80.4 kilograms (kg). He is on Anastrozole. His testes are 28 cubic centimeter (cc) at left and 29 cc at right and pubic hair is at Tanner 4. His height on therapy on in January was 166.3 centimeter (cm) (-1.09 standard deviation score [SDS]). His mother's height is 160.02 cm and father's height is 180.34 cm and so mid parental height is 176.68 cm (0 SDS). According to the doctor's letter, the preferred formulary options are Humatrope and Genotropin. And the request is for Nutropin.

The health plan's determination is upheld, in whole. 

The formulary drugs Genotropin, and Humatrope have not and will not be less effective as the non-formulary drug Nutropin. The formulary drugs would not have adverse effects. There are no studies showing the superiority of one form of growth hormone over another.