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

Diagnosis:  Cholecystitis.
Treatment:  Inpatient Hospital stay.

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

The patient had a history of gallstones and presented with abdominal pain, nausea, and vomiting. The patient was afebrile (without fever), and the vital signs were stable. The history and physical exam states that there was diffuse tenderness including the epigastric area, slightly in the right upper quadrant (RUQ), and also focal tenderness in the left lower quadrant (LLQ). There was no abdominal rebound or guarding. An abdominal ultrasound showed gallstones, but the gallbladder was not distended or thickened. There was no pericholecystic fluid or sonographic Murphy's sign. The white blood cell (WBC) count was 12.6. The patient was diagnosed with chronic cholecystitis. The patient was advised to have a laparoscopic cholecystectomy but refused it. Intravenous (IV) antibiotics were started, but the patient was discharged the next day on oral Levaquin. 

Medical necessity was determined using Milliman Care Guidelines (MCG) guideline M-555 for Gallbladder or Bile Duct Inflammation or Obstruction. Clinical indications for admission include having acute cholecystitis, as manifested by RUQ pain, systemic signs of inflammation, and when a cholecystectomy is not planned, such as when there is a high surgical risk. In this case, the pain was diffuse. There was only slight RUQ tenderness but there was also LLQ tenderness. The patient did not have a fever although the WBC count was 12.6. A cholecystectomy was planned, but the patient refused it and then left the next day on an oral antibiotic. The patient also did not have hemodynamic instability, common bile duct obstruction, severe vomiting, severe pain, or bacteremia. 

This patient had chronic gallbladder disease. The patient required a laparoscopic cholecystectomy but refused it at this time. The ultrasound did not show evidence of acute cholecystitis. The patient was stable to have had a laparoscopic cholecystectomy performed on an ambulatory basis or to be discharged on a course of an oral antibiotic. The patient did not meet MCG criteria for admission for Gallbladder or Bile Duct Inflammation or Obstruction. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for hospital stay is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal/Stomach Pain
Treatment: Inpatient Hospital Stay
The health plan denied: Inpatient Hospital Stay
The determination is: Upheld

The patient is a male with medical history of recurrent pancreatitis, intestinal intussusception, hypertension, hyperlipidemia, and alcohol use disorder. He presented to the emergency department with 3-4 days of abdominal pain, nausea, and vomiting. His last drink was two days prior. His vital signs were notable for elevated blood pressure of 147/93 millimeters of mercury (mmHg) and a rapid pulse of 122 beats per minute (bpm). The physical examination was notable for soft abdomen with diffuse abdominal tenderness and normal bowel sounds. The labs showed an unremarkable complete blood count (CBC), elevated aspartate aminotransferase of 60, and elevated lipase of 456. A computed tomography (CT) scan of the abdomen and pelvis showed peripancreatic fat infiltration compatible with acute pancreatitis without complications, and lack of bowel obstruction. He was treated with intravenous (IV) fluids, ondansetron, famotidine, morphine, and ketorolac. He was made nothing by mouth (NPO) status. He was placed on a Clinical Institute Withdrawal Assessment (CIWA) protocol. The next day, he had mild nausea without vomiting, diaphoresis, and anxiety. His labs showed low a hemoglobin of 13.2 with normal hematocrit, and a low potassium of 3.4. The following day, he had no acute events overnight. His labs showed an unremarkable CBC and comprehensive metabolic panel. The next day, he was comfortable, tolerating a diet, and had mild intermittent abdominal and back pain. The final day, he had no acute events overnight. His labs showed an unremarkable CBC and a low potassium of 3.3. He left against medical advice, with a plan for Primary Care follow-up.
At issue is the medical necessity of the inpatient level of care.
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of inpatient hospital services is not medically necessary for this patient. The patient presented with symptoms, labs, and imaging consistent with acute pancreatitis [1]. He was appropriately treated, with intravenous fluid administration, and gradual advancement of diet [1-5]. However, there was no hemodynamic instability or other complications such as pseudocyst, pancreatic necrosis, thrombosis, ascending cholangitis, abscess, active gastrointestinal bleeding, peritonitis, or sepsis, which would require a higher level of care [4-5]. There was concern for alcohol withdrawal, but no complicated or severe acute alcohol withdrawal was documented; he was appropriately maintained on a CIWA protocol [6,7]. All of the measures that were undertaken, including labs, intravenous fluids, monitoring, imaging, and CIWA protocol, could have been performed without the inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: abdominal discomfort

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 


The patient is an adult female, with a history of hypertension, gastroesophageal reflux disease (GERD), liver abscess, and a recent cholecystectomy. The patient presented to the emergency room with complaints of abdominal discomfort. The patient had significant transaminitis as well. The patient was given an intravenous (IV) fluid bolus and IV famotidine. The patient was admitted for care. Her liver function tests (LFT's) were trended. The patient was given 40 milligrams (mg) of intravenous (IV) Pantoprazole per day (QD). Symptoms improved and she was discharged.  

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 elevation of liver enzymes and abdominal pain; yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for nothing by mouth (NPO) 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.

"Initial management of acute transaminitis includes fluid resuscitation, pain management, and nausea management. Generally, the cause of transaminitis will determine treatment and disposition. Transaminase values alone do not determine disposition. Admission is recommended for higher-risk (elderly and pregnant) patients or when there is no response or poor response to supportive care. It is also recommended for bilirubin >=20 mg/dL, PT >50% above normal, hypoglycemia, spontaneous bacterial peritonitis, new or worsening hepatic encephalopathy, hepatorenal syndrome, or coagulopathy with bleeding. Additionally, the patient should be admitted if he or she cannot ambulate safely or if there is an unsafe home condition. Any patient with acetaminophen toxicity (using the Rumack-Matthew nomogram) should be admitted, even if the transaminases and coagulation factors are normal" (Hieger M. A. 2018).                                                         

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: New onset diabetes
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is overturned.

This is a teenager with a history of intermittent asthma who presented with new onset diabetes with an glycated hemoglobin (A1c) of 10.8% (percent) having failed metformin as an outpatient due to nausea and vomiting. She was admitted for initiation of insulin and diabetes education. Glucose was elevated to 294 and lactate was 2.8. She was treated with a basal bolus regimen and educated on carbohydrate counting and sliding scale insulin giving herself 4 injections of insulin per day.

Diabetes education consists of several components, nutritional counseling, self-monitoring of blood glucose and treatment of hyper and hypoglycemia. The standard of care is that all patients with diabetes should receive all these components (1, 2). 

Practice patterns differ depending on the availability of educators, et cetera ("and other similar things"). Whether a patient gets hospitalized for intensive insulin therapy initiation depends on the available program where the patient is seen.

The majority (75%) of medical centers in the United States (3) that treat new onset type 1 diabetes admit their patients. According to the American Diabetic Association (ADA) statement on treatment of type 1 diabetes (4), hospitalization is necessary regardless of severity if, "the center is not experienced in the outpatient management of newly diagnosed children with diabetes or is not adequately staffed to provide outpatient care because regional health care reimbursement is inadequate for initial outpatient care and education."  

The standard of care for patients with new onset diabetes whether suspected of having type I or type 2 diabetes according to the Pediatric Endocrine Society is to admit them to the hospital if the hemoglobin A1c is 9% or higher (5-8). The patient had a hemoglobin A1c of 10.8% and had already failed metformin therapy as an outpatient. The patient was admitted to the hospital for insulin initiation and diabetes education. Admission to the hospital for diabetes education and insulin initiation is consistent with generally accepted standards of medical practice and is therefore medically necessary.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. 

The medical necessity for inpatient hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diverticulitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld
 

The patient had a history of diverticulitis and presented with abdominal pain. He was afebrile and the vital signs were stable. He did not have peritoneal signs. A computed tomography (CT) scan showed diverticulitis but there was no fluid collection. It was decided not to proceed with a sigmoid resection during this admission. He was treated with antibiotics. He was able to tolerate a diet. 

Milliman Care Guidelines (MCG) clinical indications for admission for Acute Diverticulitis (MCG M-150) include hemodynamic instability, peritoneal sign, persistent gross bleeding, need for a drainage procedure, and a significant abnormality on an imaging study. This abnormality can be a fistula, obstruction, or free perforation. The patient did not have these conditions. He also did not have bacteremia, severe vomiting, or an inability to maintain oral rehydration after observation care. 

This patient had recurrent diverticulitis. At this time, the CT scan was read as a mild diverticulitis. This could have been treated with observation care followed by a course of oral antibiotics. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes, knee osteoarthritis, lumbar disc disorder
Treatment: Increase Personal Care Aide (PCA) Services for a Total Amount of 30 Hours per Week
The insurer denied: Increase Personal Care Aide (PCA) Services for a Total Amount of 30 Hours per Week
The denial is overturned.

This elderly female patient has conditions including hypertension, diabetes, knee osteoarthritis, lumbar disc disorder, asthma, chronic pain, and vertigo. The denial of an increase in personal care aide (PCA) services for a total of 30 hours per week is being appealed. The health plan approved personal care aide 4.5 hours per day, 5 days a week, for a total of 22.5 hours per week.

The patient's Uniform Assessment System evaluation completed 10 months ago showed modified independent cognition and functional status: maximal assistance with meal preparation, housework, and managing medications; extensive assistance with bathing, dressing, and toileting; limited assistance with personal hygiene, walking, and locomotion; and independent with managing finances, phone use, bed mobility, and eating.

An appeal statement from New York State notes the patient lives alone. The patient no longer has informal support of her husband who died 5 months ago. The patient is unable to complete activities of daily living (ADLs). The patient has frequent and unpredictable needs for assistance with activities of daily living. She had a fall last year while trying to shower independently. Her needs cannot be met with adaptive equipment. A letter from one of the patient's physicians notes the patient's physical heath is poor. She has an unsteady gait and has had a recent fall. She lives alone and needs assistance with activities of daily living.

The proposed treatment is medically necessary. 

Personal Assistance Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. This patient has several chronic conditions. The denial of an increase in personal care aide (PCA) services for a total of 30 hours per week is being appealed. The health plan approved personal care aide 4.5 hours per day, 5 days a week, a total of 22.5 hours per week. Uniform Assessment System (UAS) evaluation performed 10 months ago shows the patient requires assistance with all activities of daily living, except managing finances, phone use, bed mobility, and eating. Appeal statements support the need for assistance with activities of daily living. She 
lives alone, and no longer has informal support since the recent death of her husband. Based on the patient's impairments and loss of informal support, the currently approved personal care aide 22.5 hours per week is insufficient to meet her needs for assistance with activities of daily living. The proposed increase in personal care aide to 30 hours per week is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's disease

Treatment: Stelara 90MG/ML SC SOSY every four weeks

The insurer denied coverage for Stelara 90MG/ML SC SOSY every four weeks

The denial is overturned

 
The patient has Crohn's disease and was on Stelara every 8 weeks. She was having abdominal pain and diarrhea. At the 6 week point after her injection, she was getting increased symptoms. She was found to have a low level of ustekinumab and did not have antibodies. Her physician is now requesting to increase the Stelara dose to every 6 weeks. 

Clinical Gastroenterology and Hepatology 2021 Jan 19 (1 ): 104-11 O has an article titled "Effectiveness of Ustekinumab Dose Escalation in Patients with Crohn's Disease." Data was studied from patients who initially received ustekinumab every 8 weeks and then had their interval shortened to every 4 weeks. The conclusion was that shortening the ustekinumab dose to every 4 weeks, in patients who did not respond to dosing every 8 weeks, improved clinical and biological indices of disease activity. It was noted that dose interval shortening was effective and safe. 

This patient has Crohn's disease that was not adequately controlled on the standard every 8-week Stelara dose. Dose escalation of Stelara is well supported in the scientific literature. It is both effective and safe. The increased dose of Stelara is medically necessary up to a frequency of every four weeks. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Stelara 90MG/ML SC SOSY as frequently as every 4 weeks is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Hypogonadism
Treatment: Testosterone Gel
Health plan denied Testosterone Gel
The health plan's determination is upheld

The patient is a male with hypogonadism. He has been treated with Testim Gel (Testosterone Gel). The provider stated that the patient is stable on this treatment.
At issue is whether the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.

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

The patient has not failed or been intolerant to and has no contraindication to formulary alternatives Testosterone Gel (Androgel 1.62% [percent]), Testosterone solution, and Androderm. None of these agents has been shown in published literature to be less efficacious than or less safe than the requested agent. A change in testosterone formulation would not be likely to cause a decompensation in the patient's medical condition. In summary, the formulary drugs have not been ineffective, would be as effective as the nonformulary medication, and would not have adverse effects.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

This adult patient with a history of anemia, presented to the emergency room (ER) with complaints of dizziness, shortness of breath (SOB), and a three-day history of vaginal bleeding. Hemoglobin (hgb) and hematocrit (hct) levels were 7.2/26.2. The patient was given one unit of packed red blood cells. The patient was admitted to the Medicine service with anemia. Gynecology was consulted over the case. Changes in bleeding pattern were most likely related to perimenopausal years. Gastroenterology (GI) consulted over the case for rectal bleeding. No intervention was needed. The patient was discharged after a period of hemodynamic stability. 

This patient has symptomatic anemia. The patient fulfilled the transfusion guidelines for use of blood components, the hemoglobin was less than 8 grams per deciliter (g/dl). A transfusion was necessary. Transfusions are done routinely in outpatient settings (oncology clinics, infusion centers, even at home). An admission is not required in order to transfuse a patient. The patient could have been transfused as an outpatient. 

Milliman Care Guidelines (MCG) lists the clinical indication for inpatient care for patients with anemia. These include having an active massive hemorrhage, active hemolysis, cognitive impairment, heart failure, chest pain, syncope. This patient was stable and did not have any of the above. The patient could have been transfused and discharged home after ensuring that the patient was stable. A hospital admission is not required for the patient to be evaluated by consulting services (Gynecology, and Gastroenterology). 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: vomiting
treatment: inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is overturned. 

This is a young patient with XYY syndrome, autism, and developmental delay, who presented with decreased oral intake and decreased urine output.
He was well until a week prior to presentation when he developed fevers and vomiting. He had been seen previously in the emergency department for vomiting and diarrhea, but was able to drink at that time and was discharged to home. He then developed watery diarrhea. The diarrhea resolved, but he then developed congestion and cough. He was making fewer diapers than usual and continued to have decreased oral intake and also had decreased energy. He was therefore brought back to the emergency department for care.

Inpatient Hospital Admission was medically necessary for this patient.
This is a young boy with a complex medical history who presented with a prolonged course of illness that included vomiting, diarrhea, and reduced oral intake. He also had fever and cough, thus increasing insensible fluid losses. At the time of the emergency visit he was diagnosed with otitis media and was felt to be dehydrated. He received appropriate treatment including a bolus of normal saline and breathing treatments, but he continued to refuse to drink. He therefore required hospital admission for continued intravenous fluids to maintain his hydration status, along with close monitoring with additional treatments as needed.
The decision making at the time of admission for this patient was consistent with his young age, the presence of dehydration with refusal to drink orally, and the need for continued intravenous fluids to maintain his hydration status in the context of fever, along with close monitoring for potential deterioration of clinical status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Chronic Idiopathic Urticaria.
Treatment:  Dupixent.

The insurer denied Dupixent.  The denial is overturned.

The patient is a young adult female with chronic idiopathic urticaria, treated with antihistamines, cyclosporine and Xolair. The provider is requesting Dupixent as patient has failed Xolair.

The proposed treatment is medically necessary.

Current literature does support use of Dupixent in antihistamine-resistant urticaria. According to the review by Kolkhir et al., the off-label use of dupilumab, reslizumab, mepolizumab, and benralizumab can be effective in chronic urticaria (CU). Ligelizumab and UB-221, two novel anti-immunoglobulin E (IgE) monoclonal antibodies, are in clinical trials for chronic urticaria (CU). Other promising drugs that are currently under development for chronic urticaria are a chemoattractant receptor-homologous molecule expressed on TH2 cell antagonist, a monoclonal antibody to Siglec-8 (AK002), Bruton tyrosine kinase inhibitors (fenebrutinib and Lou064), a spleen tyrosine kinase inhibitor, and dupilumab.