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

Endocrine/Adrenal Glands
Inpatient stay

This is the case of a patient with a past medical history of hypertension and known aldosterone-secreting left adrenal adenoma, who presented to the emergency department. The patient was called to the emergency department when the potassium level on an outpatient laboratory evaluation was noted to be 2.3. The patient had been on potassium supplementation as an outpatient but had run out of tablets two weeks prior. On presentation, patient was afebrile with a blood pressure of 171/111, heart rate of 84, respiratory rate of 20, and with an oxygen saturation of 98% on room air. The patient 's physical examination otherwise noted no clear abnormalities aside from ptosis of the right eyelid. The patient's electrocardiogram noted T wave abnormalities in I, II, aVL and V3-V6. The patient was brought into the hospital with the assessment of  hypokalemia and plans for telemetry, endocrinology consultation, and potassium repletion. It was only after 14 doses of IV potassium chloride (KCL) 10mEQ in addition to 40mEq KCL PO x 8 doses in addition to 3 doses of IV magnesium that the patient ultimately reached a potassium of 3.5. Ultimately, the patient was able to be weaned off IV potassium and discharged home on an oral regimen. The health plan's determination of medical necessity is overturned in whole. 
This patient presented with severe refractory hypokalemia associated with T wave changes on EKG that initially worsened from 2.4 to 2.3 overnight and then only normalized to 3.5 after 14 doses of IV KCL 10mEQ in addition to 40mEq KCL PO x 8 doses in addition to 3 doses of IV magnesium. It was not surprising that the hypokalemia was so refractory to therapy in the setting of an aldosterone-secreting tumor. This patient required aggressive IV and PO repletion, lab monitoring every 4-6 hours, in addition to telemetry, and was at risk of malignant cardiac arrhythmias in addition to muscle weakness and rhabdomyolysis. Inpatient care was medically necessary for this patient with severe refractory hypokalemia.  The patient could only be safely cared for at the inpatient level of care. Inpatient level of care was medically necessary and treating this patient at the lower level of care is grossly outside of the acceptable standard of practice.
Appeal type: Medical necessity
Decision: Overturned

Cardiac/Circulatory Problems
Inpatient Hospital

The patient is a male with classic features of idiopathic intracranial hypertension (IIH) consisting of headaches, papilledema, and tinnitus. Lumbar puncture showed elevated pressure of 44 centimeters of water (cmH2O). Magnetic resonance angiography (MRA) showed bilateral transverse sinus thrombosis. He was treated with acetazolamide for an unknown period of time. Prior to admission the patient had recent worsening dizziness and blurry vision.
The patient was admitted and had a right transverse sinus stenting performed without complication. He was monitored in the Medical Intensive Care Unit (MICU) for one day. Following the procedure, he complained of throat pain. The patient was seen by ear, nose, and throat (ENT) and found to have a throat lesion and was treated with antibiotics and magic mouth wash. He was  discharged with instructions for follow up.
The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is overturned.

Yes, the inpatient stay was medically necessary for this patient. 
Following the procedure, the patient should be monitored closely for at least 24 hours. In this case the patient was monitored in the MICU. After the stenting procedure, the patient is anticoagulated to prevent thrombosis of the stent. During this period of adjustment, there is the possibility of intracranial hemorrhage. Hemorrhage may occur if there is perforation of the sinus by the stent. Hemorrhage may also occur if there is thrombosis of the stent which would lead to a venous infarct which has a tendency to bleed. The close monitoring required is most appropriate for an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiomyopathy 

Treatment: inpatient hospital services

The insurer denied coverage for inpatient hospital services. The denial is upheld. 

This patient is a female with a history of cardiomyopathy, hypertension, hyperlipidemia, and stroke.  She presented to the hospital for elective cardiac catheterization.  She had experienced dyspnea on exertion and chest pain radiating to her left arm with ambulation.  She underwent cardiac catheterization and received a drug-eluting stent to the right coronary artery.  There was a dissection of the radial artery and manual pressure was applied.  The patient had a vagally-mediated episode of hypotension and promptly achieved medical stability.  She was tolerating oral intake.  The patient was subsequently discharged home after an uneventful, brief overnight hospital stay. 

Inpatient admission status was not medically necessary for this patient.  Per MCG Angioplasty, Percutaneous Coronary Intervention ORG: M-52 (ISC), this procedure is an outpatient one.  The clinical presentation and peri-procedural course were unremarkable and uneventful, and acute inpatient level monitoring was not medically necessary or appropriate.  There were no extenuating circumstances in this case which warranted inpatient admission status following elective cardiac catheterization and attempted angioplasty.  The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.  

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

Diagnosis: Altered mental status (AMS)
 
Treatment: inpatient hospital admission

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

This patient is a female with a past medical history of hypertension.  The patient presented to the Emergency Department(ED) with subjective complaints of lightheadedness, high blood pressure, abnormal menstruation, and lower back pain from a motor vehicle accident.  The patient complained of her menstruation getting worse and heavier.  The patient complained of general weakness and feeling lightheaded x1 day.  The patient had abdominal cramping and vaginal bleeding x 1 month.  The patient had passed some clots.  The patient denied recent travel, hemoptysis, chest pain, rectal bleeding, or dysuria.  The prior week she had developed random bruising on her upper and lower extremities without new trauma.  The patient was to undergo an electroencephalogram (EEG), a transvaginal ultrasound, and continue with valsartan.  The patient was to utilize Venodyne boots.  The transvaginal ultrasound revealed a uterine fibroid and a simple ovarian cyst.  The Neurologist was consulted for a possible seizure-like event.  A video EEG revealed no seizures.  There were no focal deficits.  There was no need for further neurological work-up.  The patient was discharged with instructions to follow-up in outpatient neurology clinic.

The health care plan acted reasonably, and with sound medical judgment, and in the best interest of the patient.  The inpatient hospital admission was not medically necessary for this patient.  The patient presented to the ED with complaints of lightheadedness with dizziness and generalized weakness.  The patient underwent a normal imaging study of the brain and EEG.  While blood pressure was elevated, the patient had a defined history of hypertension.  The care that was provided did not warrant or justify inpatient admission.  The patient could have been treated at an observation level of care.

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

Diagnosis: Systemic hypertension 

Treatment: inpatient admission

The insurer denied coverage for inpatient admission. The denial is modified. 

This patient is a female admitted to the hospital for systemic hypertension. She was referred by her Ear, Nose, Throat (ENT) physician to the Emergency Room (ER) for a blood pressure (BP) of 155/114 and 170/111 noted on a pre-operative clearance exam. Her pressure did not respond to an oral dose of Amlodipine and she needed treatment with intravenous (IV) Labetalol; therefore, she was admitted to the Pediatric Intensive Care Unit. After 2 doses of IV Labetalol, she was treated with Ativan due to her anxiety and her blood pressure improved. Therefore on day two she was placed on oral Amlodipine. She continued on that day to have further studies including a renal ultrasound. She continued to be stable and was discharged with some study results pending. The insurance company has denied coverage for the inpatient stay as it was not medically necessary.

MCG for Hypertension: Clinical indications for Admission to Inpatient Care States:

Hypertension in pediatric patient necessitating treatment with intravenous medication indicated by all of the following:

1)	Severe hypertension (blood pressure greater than 95th percentile for age, gender and height plus 30mmHg)

2)	 Intravenous treatment necessary indicated by 1 or more of the following.

A)	Acute or worsening target organ damage secondary to hypertension.

B)	Oral antihypertension treatment not feasible (e.g. patient not cooperative)

Based on normal blood pressure tables, the 95th% blood pressure recording for a girl at 95th% for height is 125/82. After oral Amlodipine, her blood pressure was 168/119, clearly meeting the above criteria for admission. In addition, the patient was extremely anxious and appropriately treated with IV medication. By the end of a specified date, the patient's blood pressure was well controlled on oral Amlodipine and the patient could have been discharged. Therefore, the denial is partially reversed (admission on specified dates was medically necessary). The insurer acted reasonably in their denial of coverage for the inpatient admission for specified dates, but not for other specified dates.

Based on the above, the insurer's denial of coverage for the inpatient admission is modified.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest pain
Issue under review:  Inpatient admission

Determination:  The Inpatient admission was not medically necessary.

The patient is an adult male with a past medical history significant for HTN (hypertension), dyslipidemia, CAD (coronary artery disease), s/p (status post) prior PCI (percutaneous coronary intervention) x  stents, DM (diabetes mellitus) type 2, schizophrenia and bipolar disorder, alcohol and drug abuse.  He presented to the ER for evaluation of chest pain of four days duration, URI (upper respiratory infection) symptoms and hearing voices.  The patient reported suicidal ideation, but no suicidal intent or plan. 

The patient was hemodynamically stable.  ECG (electrocardiogram) revealed no acute ischemic changes.  Troponin was negative.  The patient was admitted to telemetry to rule out ACS (acute coronary syndrome).  Repeat troponin level was negative.  Psychiatry evaluation was obtained.  The patient was cleared from psychiatry perspective for discharge.  Oral medications were adjusted.  No inpatient stress test was done, and outpatient follow-up was recommended.

This patient presented for evaluation of chest pain.  The diagnosis of an acute MI (myocardial infarction) was ruled out by cardiac enzymes, which were negative.  No inpatient stress test was planned.  There was no evidence of acute myocardial infarction, ACS, decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability.  His psychiatric symptoms were evaluated by psychiatry, and he was determined not to need inpatient psychiatric admission.  His medical therapy was continued, and he was discharged for outpatient follow-up.  Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission, and the care required could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma

Treatment: Dupixent 300 mg/2ml syringe quantity 4 every 14 days

The insurer denied Dupixent 300 mg/2ml syringe quantity 4 every 14 days. 
The denial was reversed.   

This is a female patient with a history of asthma. It was reported that her asthma had been difficult to control due to her reoccurring exacerbations despite taking optimal medication. She had been treated with repeat antibiotics and steroids, high dose inhaled corticosteroids with long-acting beta-agonist, and long-acting muscarinic antagonists; Singulair. She had diagnostic testing performed to rule out other causes for her symptoms such AAT levels with normal results, cystic fibrosis transmembrane regulator (CFTR) was negative and ruled out cystic fibrosis. She underwent fibreoptic bronchoscopy (FOB) twice. C/S grew Pseudomonas and Aspergillus. No evidence of invasive Aspergillosis was reported on Transbronchial lung biopsy. She had pulmonary function testing preformed that revealed restrictive pattern with reduced forced vital capacity and Forced Expiratory Volume in One Second with preserved ratio. The FEF 25-75 was reduced with 20% improvement post bronchodilator (BD) administration.

There is enough clinical and Spirometric data to suggest a diagnosis of asthma. A FeNo of 23 is borderline does not rule out diagnosis of asthma. It just indicates that there is no predominant eosinophilic inflammation of the airways. Though these values are truly borderline, the patient has required high doses of systemic steroids for up to 6 months during 2018 and 2019 per doctor's notes. The use of steroids for prolonged periods has caused lowering of immunity which has resulted in recurrent episodes of life threatening Pneumonias with Pseudomonas and Aspergillus species.

This patient has had adequate trial of systemic steroids, high dose inhaled corticosteroids, long-acting beta-agonist, long-acting muscarinic antagonists and Leukotriene Antagonists. Despite that patient's symptoms of asthma have not been controlled. The patient's pulmonary function tests' and FENo levels and clinical history and findings are not inconsistent with diagnosis of asthma. 

Dupixent trial is appropriate consideration in this patient to try and get her off systemic steroids and decrease her immunosuppression to hopefully decrease her recurrent bouts of pneumonia.

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

Based on the above, the medical necessity for Dupixent 300 mg/2ml syringe quantity 4 every 14 days is substantiated.  The insurer's denial is reversed.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Diabetes
Issue under review: Formulary exception for Janumet

Determination:
The health plan should not cover the Formulary exception for Janumet.

This patient is an adult male with type 2 diabetes and coronary artery disease. His A1C (glycated hemoglobin) was 7.2%.

The prior request for Janumet was denied as the patient does not have a documented trial of Jentadueto or Jentadueto XR. This patient does not have a documented contraindication to Jentadueto, which has the same mechanism of action as Janumet. Jentadueto and Janumet are expected to have equal efficacy and safety in this clinical situation. The American Diabetes Association clinical guidelines do not recommend Janumet over Jentadueto. Therefore, no, the health plan should not cover the proposed Formulary exception for Janumet.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Migraines

Treatment: Aimovig

The insurer denied coverage for Formulary Exception for Aimovig. The denial is reversed. 

This patient is a female who has diagnoses of depression and daily migraines.  The patient's current medications include Zoloft, Fioricet, and Ultram.  The patient was seen in the Emergency Department for headaches, depression and anxiety.  The patient was seen by a Neurologist on consultation for the headaches. The patient was seen for continued daily headaches that produced nausea, photophobia and phonophobia.  The patient was alert and oriented, but appeared to have a flat affect, was withdrawn and emotional.  The physical exam did not reveal any significant abnormalities. An MRI was done was normal.  According to the treating Neurologist, the patient cannot use propranolol, atenolol, Topiramate or divalproex due to anxiety and depression.   The patient has tried amitriptyline in the past, but it failed to decrease the frequency and intensity of the headaches.   

Each medication that is on the formulary is not in the same drug classification.  Atenolol and propranolol are beta blockers.  Topiramate and divalproex are anti-seizure medications. The current request is for Aimovig.  According the health plan formulary, the patient must have tried and failed propranolol, atenolol, Topiramate and divalproex prior to authorization of Aimovig.  As noted, this patient has a history of depression and is on medication for this diagnosis.  It would be clinically inappropriate in this scenario to treat with a drug(s) known to cause/exacerbate depression. Aimovig has been shown to be an effective drug for treatment of migraine.  

Based on the above, the denial for a request for a Formulary Exception for Aimovig is reversed.
Appeal type: Medical necessity
Decision: Upheld

Orthopedic/Musculoskeletal
Physical Therapy

This is a male patient who is noted to have a history of bilateral low back pain, bilateral groin pain and bilateral knee pain. The patient was seen for an initial evaluation stating that he had low back and groin pain that started two weeks prior as well as history of bilateral knee pain for the past two years. He reports having completed two courses of physical therapy and was doing physical therapy once a month. Under review is the medical necessity for additional physical therapy visits.

The health plan's determination is upheld. The additional PT is not medically necessary for this patient. Per The Official Disability Guidelines (ODG) Online Version, Low Back Chapter, Physical Therapy, "Allow for fading of treatment frequency (from up to 3 visits per week to 1 or less), plus active self-directed home physical therapy (PT)."
The records provided indicate that the patient has received extensive physical therapy for this condition of bilateral low back pain, bilateral groin pain and it is noted the patient was approved for six visits of physical therapy and prior to that the patient had undergone multiple rounds of therapy for the same condition. There was no documentation of any significant deficits on exam that would suggest the patient would require extensive ongoing skilled therapy services over that of transitioning into an independent home exercise program. The documentation lacked any objective measurements indicating significant progress made. The patient had been instructed in home exercises and it was noted the patient was able to perform these exercises. There would be no need for ongoing skilled/supervised therapy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient is a young female child with medical history significant for HbSS (sickle cell) status post splenectomy. She presented to the ED early in the morning with abdominal pain, one episode of watery stool, and back pain. She had been eating and drinking normally, but after the diarrhea stool refused to take anything except a small amount of ginger ale. The abdominal pain was described as generalized, unable to describe the quality. 

The patient's vital signs included temperature 37.1, heart rate 118, respiratory rate 30, and blood pressure 98.57. Examination was significant for no acute distress, non-toxic appearing, moist mucous membranes, regular heart rate and rhythm, clear lungs, non-distended abdomen full but soft and non-tender to palpation, no guarding or rebound, no tenderness to palpation of the back, and non-focal neurologic exam. Laboratory evaluation was significant for leukocytosis (17.7K). 

The patient was treated with a dose of Toradol for possible veno-occlusive crisis, a dose of Tylenol, and IV fluids. She remained in the ED overnight, awaking with abdominal pain. She had failed the oral challenge by taking very little by mouth overnight. She was diagnosed with probable food poisoning (sister developed similar symptoms) and admitted for further management to the Hematology service. 

Admission orders included Tylenol and Toradol round the clock for pain, treatment of constipation (Miralax, Colace, Fleet enema) resulting in a small bowel movement, and abdominal x-ray. The abdominal x-ray revealed large stool burden. The patient was treated with anther Fleet enema and a dose of lactulosis. She subsequently had a large bowel movement with resolution of her pain. She was deemed stable for discharge home the following day.

Functional constipation is a very common problem in childhood, with a worldwide prevalence of about 3%. In up to 40% of children, constipation begins in the first year of life. Constipation is typically associated with painful stooling, abdominal pain, stool incontinence, and infrequent stooling. Most children that present with this constellation of symptoms have no significant underlying medical etiology.

This young child with history of sickle cell disease presented to vomiting and abdominal pain after eating fast food and with sister already symptomatic. Her pain was initially thought to be secondary to veno-occlusive disease, and then following x-ray was determined to be due to constipation. She was treated aggressively, with production of a large stool and resolution of her pain. Given her underlying condition, it was reasonable and appropriate to monitor overnight pending stool evacuation and resolution of pain along with improved appetite. She was overall hemodynamically stable with no serious sickle cell complications, no evidence of necrotizing disease, and no persistent fevers. She did not require acute inpatient admission and could have been safely and appropriately treated at observation level of care.
Appeal type: Medical necessity
Decision: Overturned

Chest pain
Inpatient hospital

The patient is a woman who was admitted to the hospital with chest pain. She reported chest pain in the left upper quadrant. She stated that the pain started a few hours prior to presentation. She also reported radiation to the left arm, and she rated the chest pain as a nine out of 10 in severity. She stated that the left upper quadrant pain was a seven out of 10 in severity. In addition, she reported a headache and poor balance. Other review of systems included blood in the stool in the past week. Social history was notable for smoking and marijuana use. She was admitted to the hospital.

The health plan's determination is overturned. The inpatient stay was medically necessary. The reason is that the patient was being treated for alcohol withdrawal, had tachycardia at the time of presentation, and was documented as having delirium tremens. Alcohol withdrawal is associated with seizures, hemodynamic instability, sepsis, and respiratory failure, and has a high rate of morbidity. Delirium tremens is a major comorbidity that develops in some of these patients during withdrawal. This was a complicating factor that increased her risk of an adverse event.