Persius/hicric huggingface dataset:
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 an adult female who presented to the ER for further evaluation/management of abdominal pain. Her intake vitals were afebrile, hemodynamically stable with no evidence of febrile temperature, malignant hypertension, profound hypotension, severe tachycardia or hypoxemia on room air. Her examination was non-focal with no significant abnormalities noted including no evidence of acute cardiopulmonary abnormalities or findings consistent with acute/surgical abdomen. Laboratory and ECG testing was also within normal limits, with no significant abnormalities noted, including no evidence of acute end organ damage. 

The medical records indicate that this patient was admitted to the inpatient medical service in stable condition, where she received supportive care with IV fluids and PRN anti-emetics. She responded well to the prescribed therapies and was subsequently discharged in stable condition. There is no evidence of intensification of services throughout the course of this patient's hospital stay. Hence, the patient's care could have been safely furnished in a less intensive setting without adversely affecting patient's safety or outcome.
Appeal type: Medical necessity
Decision: Upheld

Breathing Problem
Inpatient hospital

The patient is a female with history of depressive disorder, OCP (Oral contraceptive pill) use, and paternal uncle with pulmonary embolism (PE), who presented to an urgent care center for one day of pleuritic chest pain and one month of an intermittent cough. The patient was found to have an elevated D dimer and was sent to the emergency room (ER) for further evaluation. She had been experiencing right sided chest pain that she attributed to worsening of an upper respiratory infection.

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient was not hemodynamically unstable nor hypoxic. Moreover, she did not have a massive PE, severely diminished cardiopulmonary reserve, right ventricular dysfunction, active bleeding, an extensive clot, acute cor pulmonale, or a need for thrombolysis. The patient was discharged in stable condition with no activity restrictions.
Based on the above, the patient could have been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Gynecological
Inpatient Hospital

The patient is a female who presented with pelvic organ prolapse for an emergency admission. The patient underwent robotic-assisted supracervical hysterectomy, sacral-colpopexy mid urethral sling. Surgery was uneventful. The patient's medical history was significant for diabetes. On postoperative day 1, the patient's Foley catheter as well as vaginal packing were removed and she passed voiding trial after which she was discharged home. During the hospital stay, her blood sugars were elevated above the normal limit of 106. This was treated with insulin. The patient was admitted to the hospital following the surgery.

The health plan's determination is overturned. The inpatient stay was medically necessary. This patient underwent extensive, very invasive surgery which by in itself would require hospital admission for close follow up for possible complications that can occur with invasive surgery such as this. The complications can include but are not limited to significant blood loss, ureter and or small bowel obstructions, uncontrolled diabetes due to patient's history of diabetes, injury two internal organs. With observation only, the patient would not have received intensive and level of service this type of operation would have required. Additionally, the patient had significantly elevated abnormality in her electrolytes, specifically elevated blood sugar which could be dangerous in diabetic patient requiring close monitoring. For all of these reasons, the inpatient hospital admission was standard of care and medically necessary.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with a diagnosis of anorexia nervosa, restricting type (ANR). Case notes document that the patient lost considerable weight by food restricting, decreasing from 91 pounds (lbs) to 76 pounds, with commensurate changes in physiology. She experienced distorted body image, fearing becoming fat even at her low weight. She also had passive suicidal ideation and urges to self-injury. She was very anxious. There is no dispute concerning the need to admit her to Inpatient Hospital Admission (IHA). Her treatment consisted of a multi-disciplinary program including: nutritional rehabilitation, cognitive behavioral therapy, psychoeducation concerning the need for weight restoration, and real-life practice in situations such as meals with parents. The health plan's determination is overturned. There is no dispute concerning her general psychological improvement. She was eating all of her meals, even though she was anxious. She was, however, only 84.3% of her target weight. She also had showed general psychological improvement, but here again, weight was below the accepted weight of at least 85% of goal weight. She was 84.8% of her target weight. Based on the trajectory of her weight restoration, she would be expected to meet the 85% of target weight and could be safely discharged to a lower level of care. Although a weight of 84.3% of target weight may appear to be close to the 85% goal, goal of 85% of target weight as a minimum goal for IHA is clinically accepted. 85% of target weight does not mean the patient is automatically ready for discharge to a lower level of care. Other factors including suicidality, medical instability, borderline or other personality disorder features may require a higher weight.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Perianal abscess 

Treatment: inpatient hospital admission

The insurer denied coverage for inpatient hospital admission. The denial was reversed.

This patient is a male with past medical history significant for hypertension, diabetes mellitus, hyperlipidemia, and asthma who presented to the emergency department with complaints of rectal pain. Vitals on presentation included: temperature 100.3 F, blood pressure 154/94, pulse 102, respiratory rate18, oxygen saturation 96% on room air. Laboratory results included the following; WBC-14.5, HGB-13.7, HCT-37.4, creatinine-1.4, glucose-684, sodium-125. The patient was started empirically on intravenous antibiotics (clindamycin and aztreonam) for possible perianal abscess. Surgery consulted and recommended imaging studies. CT scan of the pelvis showed a 2.5 cm perianal abscess. Colorectal surgery evaluated patient for a possible incision and drainage procedure. He continued to require insulin coverage and blood glucose monitoring. The patient remained uncooperative during his hospital course. He signed out against medical advice prior to completion of treatment.  

According to documentation, patient presented with worsening rectal pain, fever (100.3 F), hypertension (154/94), tachycardia (102), and multiple laboratory abnormalities including elevated WBC (14.5), hyperglycemia (684), and creatinine (1.4). Moreover, patient had a perianal abscess that required surgical intervention. Based on above findings in a high-risk patient with poorly controlled diabetes, hospital admission was medical necessary for intravenous antibiotics and surgical evaluation. 

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: Formulary Exception
Decision: Upheld

Diagnosis: Hypogonadism

Treatment: Formulary Exception for Testosterone 12.5 MG/ACT (1%) TD GEL

The insurer denied coverage for Formulary Exception for Testosterone 12.5 MG/ACT (1%) TD GEL. The denial was upheld.

This patient is a male who has been previously diagnosed with hypogonadism.  The patient's initial testosterone level, pretreatment, was 58.  After the initiation of treatment, the patient had labs drawn showing a level 444.  In mid-2019 this patient was seen for his annual exam.  The patient stated he was put on steroids for an ulnar nerve issue which helped 98%.  He stated he did not experience shoulder pain any longer and that he has been sleeping well.  There were no significant abnormalities noted.  The physician detailed that the patient should continue utilizing AndroGel.  The patient's prior colonoscopy was normal as well as his prior EKG.  Supportive care was also discussed.  Multiple laboratory studies were ordered, and the request was made for formulary exemption.

The formulary alternatives are testosterone transdermal 25 mg/2.5 g (1%), testosterone transdermal gel 10 mg/act (2%), testosterone cypionate, and testosterone enanthate.

The formulary drugs are unlikely to cause an adverse reaction. Review of the submitted documentation has not listed failure of the formulary alternatives or any rationale as to why the patient would have a less benefit from a formulary alternative. There are no documented adverse reactions or contraindications.

There is no evidence that the requested drug would be more effective than the formulary alternatives.

The carrier's denial of Request for Formulary Exception for Testosterone 12.5 MG/ACT (1%) TD GEL is upheld.
Appeal type: Medical necessity
Decision: Upheld

Prostate cancer 
Lab work /Blood tests

The patient who underwent a prostate biopsy for an elevated prostate-specific antigen.  The biopsy showed Gleason 6 adenocarcinoma in 8 out of 14 cores. The clinical stage was T1c. An OncotypeDx test was ordered on the biopsy specimens. The health plan's determination is upheld in whole.
No, the Oncotype Dx genetic testing is not medically necessary for this patient. The Oncotype DX Prostate Cancer Assay is a real time polymerase chain reaction assay designed for analysis of prostate core needle biopsies. The assay measures the expression of 17 genes to calculate a Genomic Prostate Score. A lower GPS score more favorable biology and less aggressive disease. This test may be utilized to counsel men regarding the best course of therapy (active surveillance vs. treatment) in newly diagnosed low or low-intermediate prostate cancer.
National Comprehensive Cancer Network guidelines for prostate cancer 2018 states, several tissue-based molecular assays have been developed in an effort to improve decision-making in newly diagnosed men considering active surveillance and in treated men considering adjuvant therapy or treatment for recurrence. Retrospective case cohort studies have shown that these assays provide prognostic information independent of NCCN risk groups, which include likelihood of death with conservative management, likelihood of biochemical recurrence after radical prostatectomy or radiotherapy, and likelihood of developing metastasis after operation or salvage radiotherapy. No randomized controlled trials have studied the utility of these tests. While Oncotype dx may eventually have a role in making treatment decision about patients with prostate cancer, there is limited data on clinical outcomes to currently support routine use. Hence, it is not considered a generally acceptable standard of care for management of patients with a diagnosis of prostate cancer.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Abdominal pain
Treatment:  Inpatient Hospital

The patient is a male with a history of parotid carcinoma, chronic kidney disease, congenital absence of pancreas and left kidney, gastroparesis and diabetes who was admitted to the hospital  for nausea and vomiting.  He reported acute onset of abdominal pain that was subsequently followed by nausea and vomiting starting five days prior to presentation.  He also reported constipation in the setting of starting opioids.  His last bowel movement was two days prior to presentation.  He stated that the abdominal pain improved after initiation of the vomiting.  Vital signs showed temperature 36.8 Celsius, heart rate 115, blood pressure 155/100, and respiratory rate 19.  On physical examination, heart rate was regular, breath sounds were normal, and the abdomen was soft and tender but distended.  Labs showed glucose 300, white blood cell (WBC) count 9.2, hemoglobin 15.0, platelets 217, sodium 140, potassium 4.2, and creatinine 3.0.  Aspartate aminotransferase (AST) was 54 and alanine aminotransferase (ALT) was 75.  Abdominal x-ray showed fecal loading throughout the colon.  The patient was admitted with nausea and vomiting thought to be secondary to constipation versus gastroparesis.  The plan of care included intravenous (IV) Zofran, bowel regimen, Reglan before meals, endocrine consult, monitor blood glucose, insulin sliding scale, antihypertensive therapy, pain management, and continue other home medications. Glucose improved with insulin therapy, and his symptoms of nausea and vomiting improved with Zofran and Reglan. 

The health plan's determination is upheld.

The patient was hemodynamically stable, had no evidence of bowel obstruction or bowel ischemia, had no evidence of acute gastrointestinal (GI) bleed, did not have significant electrolyte abnormalities, and had no evidence of sepsis.  There was no imaging evidence small bowel obstruction or bowel perforation, there was no imaging evidence of abscess, and there was no evidence of acute compromise of other organs or acute risk of compromise, such as acute kidney injury (AKI).  This was a stable case of likely constipation versus gastroparesis and, in the absence of complications, these patients do not need to be managed at the inpatient level of care.  The patient's abdominal pain and nausea/vomiting were concerning, and he needed further care, but he could have safely received diagnostic and therapeutic management at a lower level of care status.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Complete atrioventricular block of the heart
Treatment: Leadless pacemaker
The health plan should cover the Leadless pacemaker.

Insertion of a Leadless pacemaker is appropriate in this clinical circumstance.

The Leadless pacemaker is likely to be more beneficial. A leadless pacemaker has advantages over standard pacemaker systems in the patient's clinical condition.

Leadless pacemakers are appropriate in patients requiring a VVI pacer, but would be at risk for standard system with subcutaneous pocket and intravascular leads. 

In this case, patient has persistent atrial fibrillation, bradycardia, and documentation of complete heart block; thus documented need for a RV (right ventricle) VVI pacer.

Leadless was chosen, as the patient is at increased risk of pacemaker pocket infection with his insulin-dependent diabetes, and history of skin ulcer. An alternative choice would have required an antimicrobial pouch, which is bulky; or accept the increase risk of infection. In addition, his large BMI would be a factor to choose RV leadless unit.

The enclosed guidelines, CRID-11.1, stated that these units are considered experimental due to concerns about removal of a failed unit. This has not been an issue with the latest generation units, as retrieval has been successfully performed. In guidelines, CRID-11.1 it also states that they cannot be used for dual chamber pacing. However, there is no indication for dual chamber pacing in atrial fibrillation, nor for biventricular pacing with normal LV function. 

The FDA has approved this device, and CMS (Centers for Medicare and Medicaid Services) provides coverage. These devices are used routinely in community hospital for appropriately chosen patients.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Complete atrioventricular block of the heart
Treatment: Leadless pacemaker
The health plan should cover the Leadless pacemaker.

The Leadless pacemaker is likely to be more beneficial for the patient.

This patient meets standard criteria for permanent pacemaker therapy (Reference 1). He has a history of atrial fibrillation and ECG monitoring revealed periods of AV block with slow junctional escape.  Past history was significant for diabetes, skin ulcers and osteomyelitis.  Physician notes clearly describe an active unhealed skin ulcer and a concern for recurrent skin infections and bacteremia.  Leadless pacemakers are ideal for patients that only require single chamber pacing, such as those with atrial fibrillation. They have been shown to be safe and efficacious in multiple studies (Reference 2).  Moreover, such devices are thought to be superior to pacemakers with transvenous leads and subcutaneous pockets in patients that are prone to frequent infections and bacteremia (Reference 3, 4).

The patient is the ideal candidate for this type of device, and a leadless pacemaker is most likely to be more beneficial than any other standard treatment.  He has an active unhealed skin ulcer and a previous history of osteomyelitis.  

In conclusion, Leadless pacemaker is the optimal, most beneficial therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Complete atrioventricular block of the heart
Treatment: Leadless pacemaker
The health plan should cover the Leadless pacemaker.

The requested Leadless pacemaker is likely to be more beneficial than any standard treatment.

The patient has significant conduction disease, with episodes of complete heart block (3rd degree AVB) and bradycardia down to 30s, and thus placement of a permanent VVI pacemaker in the setting of permanent atrial fibrillation would be considered medically appropriate. As the patient has underling atrial fibrillation, there is no indication for an atrial lead placement, and therefore the plan is for RV (right ventricle) pacing. The patient has a history of insulin dependent diabetes mellitus and has a history of skin ulcer. The benefit of using the leadless device would be in avoidance the skin pocket creation, thus decreasing the risk of infection in this diabetic patient, as well as removing arm restrictions. 

The device has been approved by the FDA for use in patients who do not require atrial pacing, as in this patient's case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Epigastric pain
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient is an adult female. She presented with no significant past medical history and with two days of epigastric pain and body aches. This was associated with movement and walking. The pain is described as waxing and waning and crampy. 

The patient underwent uncomplicated Laparoscopic cholecystectomy. Postoperatively, there were no untoward events.

After an uncomplicated elective laparoscopic cholecystectomy, patients can drink clear liquids once awake from anesthesia, and their diet can be advanced as tolerated.

Most otherwise healthy, reliable patients with good home support can leave the hospital within six hours after surgery. Cochrane reviews have found no significant differences for important clinical outcomes for patients discharged the same day versus admitted overnight following laparoscopic cholecystectomy. A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database, which included 15,248 patients older than 65 years of age who underwent elective laparoscopic cholecystectomy, identified congestive heart failure, American Society of Anesthesiologists class 4, bleeding disorder, and renal failure requiring dialysis as significant independent predictors of inpatient admission and mortality.

There were no pre-op or post-op signs or symptoms of sepsis. The patient's operation was without any untoward events, and the patient had the expected postoperative recovery. This patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abominal pain
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient presented to the facility filing the appeal with the complaints of left lower quadrant abdominal pain and streaks of bright red blood on the toilet paper after a bowel movement.

Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had sigmoid diverticulitis, yet he did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for NPO (nothing by mouth) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission.  As such the care could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Overturned

Abdominal/Stomach Pain
Inpatient Hospital

The patient is a man with a history of metastatic pancreatic cancer who presented and was admitted to the hospital. He presented with severe abdominal pain that started that day. He had been recently admitted for similar symptoms. He reported pain radiating to the back and rated the pain as 10 out of 10 in severity. He was actively receiving chemotherapy. 

The health plan's determination is overturned. The Inpatient hospital admission was medically necessary for this patient. Based on the patient's pain management regimen during the hospital stay, which was intensive and combined both opioid therapy, muscle relaxers, and pain modulating anti-depressant agents, it was reasonable to manage the patient at an inpatient level of care. He required intensive evaluation, follow-up monitoring, and treatment for uncontrolled pain, in addition to the patient's nausea. Overall, the intensity of care was appropriate for the inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Breathing Problem
Inpatient Hospital

The patient presented to the emergency department (ED) with dyspnea. Her dyspnea was worse for last two days. The patient was previously hospitalized. The patient also had upper abdominal pain, 5/10. The patient has a past medical history of hypertension (HTN), diabetes mellitus (DM), coronary artery disease (CAD), congestive heart failure (CHF), hypersensitivity lung disease, anemia, and high cholesterol. She also has history of percutaneous coronary intervention (PCI) of her left anterior descending (LAD). She was admitted to the hospital. 

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient presented with worsening dyspnea and she was tachypneic and low oxygen saturation. There was evidence of congestive heart failure (CHF) exacerbation. The patient has known diastolic heart failure and was treated previously. There was very good response to one dose of IV diuretics and her respiratory status improved in first 24 hours. There is also superimposed pulmonary disease, which felt by pulmonology to be chronic, without pneumonia or tuberculosis (TB).
The patient had mild CHF exacerbation. Because she has pulmonary comorbidity, she was very short of breath, but as soon the acute component of CHF was treated, she improved. The patient's CHF did not meet criteria for inpatient admission. She improved and was discharged in stable condition in short period of time.
The patient underwent multiple imaging studies, but there was nothing acute found. She did not have pneumonia. The patient has coronary artery disease (CAD) with coronary stent placement, but her troponin was stable, she did not have ECG changes and no evidence of acute coronary syndrome (ACS).
A lower level of care would have been appropriate.