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

Diagnosis: Alopecia areata universalis
 
Treatment: Xeljanz treatment

The insurer denied Xeljanz treatment. The denial was reversed.

This is a pediatric female with alopecia areata universalis for several years.  There is a family history of rheumatoid arthritis.  She has tried and failed topical, oral, and intralesional corticosteroids.  The family wanted to avoid immunosuppressants such as methotrexate.  The patient is socially isolated at school and is having emotional problems such as depression and anxiety.  The provider is requesting plan approval for Xeljanz.

There are no Food and Drug Administration (FDA) approved medications for the treatment of alopecia areata.  This is an orphan disease.  Xeljanz has been found to be safe, effective and durable for the treatment of alopecia areata.  The use of immunosuppressants in such a young person could have significant adverse effects causing organ damage and bone marrow damage which can have long-standing consequences. 

Xeljanz is medically necessary for this patient's clinical circumstance and has been found to be safe, effective, and durable in the treatment of alopecia areata. There has been no negative documentation of the use in the pediatric population.

The literature supports the use of Xeljanz in the pediatric population.  The carrier's denial of coverage for Xeljanz is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Genetic disorder
Issue under review:  Skilled shift nursing

Determination:
The Skilled shift nursing is medically necessary.

This infant has rare autosomal dominant genetic disorder characterized by moderate to severe cognitive delay, microcephaly, dysmorphic facies, broad thumbs and great toes, short stature, increased risk for tumors and blood cancers, and potential abnormalities in other organ systems.  In addition, she has severe gastroesophageal reflux with microaspiration, central and obstructive sleep apnea, hydronephrosis, and glaucoma.  She cannot tolerate bolus feeds, requiring feeds be run over two hours with an upright period after completion to prevent aspiration.  Because she is fed every three hours, there is little time in between feeds.  She is unable to tolerate bright lights.  With both obstructive and central sleep apnea, she is on continuous oxygen and must be monitored at all times for desaturations and breathing difficulties.  She has multiple subspecialist visits, and it is unsafe for the mother to transport her alone to these appointments. 

Overall, it is unsafe for any layperson caregiver to be responsible for all of these issues round-the-clock.  To further complicate matters, there is another young child for whom the mother is responsible.  The father is out of the house with work and is unable to assist in the day to day care of the children and is unable to provide the mother respite overnight by caring for the patient.  With the baby's airway and gastrointestinal problems, she is at significant risk for respiratory distress and infection.  She requires the skilled services of private duty nursing to maintain her safety and wellbeing.  The requested nursing is medically necessary and appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholecystitis
Treatment: Inpatient Hospitalization
The insurer denied the Inpatient Hospitalization. The denial was upheld. 

This is a middle age female who presented to the emergency department (ED) in late 2018 with complaints of epigastric pain for 2 days. The pain was described as pinching, radiating to back and not associated with eating. She had one episode of non-bloody/non-mucoid diarrhea. She has a past medical history of hypertension, atrial fibrillation on Xarelto, hyperlipidemia, gastroesophageal reflux disease (GERD) and questionable coronary artery disease (CAD). It was reported that the patient had a 20-30 years prior episode of gallbladder treatments which improved with medication. A computed tomography scan of the abdomen showed normal aorta, gallbladder sludge and gallstones. Laboratory studies revealed that she had elevated liver function tests. The patient was admitted for further management. Surgery was consulted and determined that a cholecystectomy was not necessary due to the patient's clinical presentation and diagnostic studies; no acute cholecystitis was noted. An endoscopic ultrasound was performed by gastroenterology which revealed multiple gallstones, gallbladder wall thickening, and pancreatic cyst. The patient was discharged with recommendations for outpatient follow up for evaluation of pancreatic cyst. 

Per MCG, clinical indications for admission for Gallbladder or Bile Duct Inflammation or Stone (M-555) includes the presence of acute cholecystitis as manifested by right upper quadrant pain with systemic signs of inflammation. In this case, the patient did not have fever or leukocytosis. She had biliary colic but did not have systemic signs of inflammation. She also did not have hemodynamic instability, severe vomiting, severe dehydration or bacteremia. The patient had gallbladder disease. However, the surgeon felt that she did not have acute cholecystitis. She did not require any surgical interventions. She did not meet MCG Criteria for admission for Gallbladder or Bile Duct Inflammation or Stone.

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

This is a patient with a history of hypertension, as well as a prior cerebrovascular accident (CVA), who presented to the emergency department with an acute onset of left upper extremity and left lower extremity weakness. Symptoms started 18 minutes prior to arrival in the emergency department. The patient was described with decreased sensation in the left lower extremity. The patient's prior CVA, was several years back, and reportedly the patient had no residual deficits. The patient reports an associated slurred speech, which prompted the call to emergency medical services. The patient was evaluated in the emergency department, had a blood pressure 139/61, pulse of 80, strength was 4 out of 5 in the left upper and left lower extremity, intact on the right side. A stat computed tomography (CT) scan of the brain was ordered. Subsequently, the patient experienced worsening of the weakness in the left upper and left lower extremity, with National Institute of Health (NIH) stroke score increasing to 5, and therefore the patient was evaluated with a computed tomography angiography (CTA) scan of the brain, per stroke protocol, and assessed for tissue plasminogen activator (TPA) administration. Based on the symptoms and elevated stroke scale, the decision was made to administer TPA on this patient. Critical care was consulted, for admission to the Intensive Care Unit (ICU) for post TPA care. The health plan's determination is upheld.

The hospital treatment during the dates under review primarily consisted of physical therapy evaluations and treatments. The medication regimen did not change. There was a delay in obtaining the brain MRI, which in any case, would not have changed the overall medical treatment for the patient.
Based on Milliman Care Guidelines (MCG) for ischemic stroke-83, discharge planning is appropriate, when the care team has developed a treatment plan, which was done by the third day. The patient was evaluated and preadmission functioning was assessed. Skilled services at the next level of care were identified as necessary, however there was a delay in initiating the established plan for rehabilitation services.
The patient did not need an extended or prolonged stay, because there was no clinical deterioration of status.
Appeal type: Medical necessity
Decision: Upheld

The patient has a medical history of cirrhosis complicated by portal hypertension, rectal varices, hemorrhoids, chronic Hepatitis C, pancreatitis, and prior alcohol use disorder. The patient was referred to the emergency department by Primary Care due to anemia on outpatient labs and anemia symptoms. The patient presented with abdominal distention, rectal bleeding, weakness, dyspnea on exertion, lower extremity edema, lightheadedness, dizziness, and mild abdominal pain. The patient had undergone a sigmoidoscopy with sclerotherapy injection 5 days prior and had previously required repeated paracentesis, the last two months prior. The patient was treated with intravenous fluids and pantoprazole and was transfused with 2 units of packed red blood cells. 

The health plan's determination is upheld. The inpatient stay was not medically necessary. In this case, the patient presented with lower gastrointestinal bleeding and anemia but did not have protracted hypotension or other signs of failure to respond to fluid resuscitation and blood transfusion. There was no ongoing active bleeding. The patient had monitoring of clinical status, vital signs, serial labs, imaging, and Gastroenterology consultation, which were warranted. However, no cause for inpatient status, such as severe intra-abdominal process, obstruction, perforation, ischemic colitis, or toxic megacolon, was suspected. No colonoscopy or other intervention was deemed necessary.
Acute kidney injury improved with intravenous hydration; there was no evidence of other complications of renal disease, and renal function quickly improved with hydration. As hemodynamic status remained stable, and there was no hypotension or hemodynamic decompensation, all of the measures that were undertaken in the first two days, including labs, monitoring, and specialist consultations, could have been performed at the observation level of care, with outpatient follow-up and without inpatient admission. There was no indication for abdominal pain caused by an etiology other than ascites, and no further workup was planned or performed for abdominal pain. The patient did have a paracentesis later in the hospital stay, which was warranted, but did not need to be performed in the inpatient setting. Renal function had normalized by the time paracentesis was performed. The patient had stabilized within two days, and no intervention was performed after the first two days of the hospital stay which could not have been performed without the inpatient level of care. Therefore, the inpatient level of care was not medically necessary
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope and fracture
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

This is a patient with a history of alcohol abuse and uncontrolled hypertension who presented to the ER for further evaluation s/p suspected syncopal episode with left shoulder/arm pain. Intake vitals were afebrile, hemodynamically stable with no evidence of febrile temperature, malignant hypertension, profound hypotension, severe tachycardia or hypoxemia on room air. Examination was notable for left upper extremity with decreased range of motion, swelling, tenderness and ecchymosis of the left shoulder, rest of examination was non focal with no significant abnormalities noted. Left shoulder x-rays were notable for fracture of the left humeral head. Laboratory and ECG testing were 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 was placed in a left shoulder immobilizing brace, treated with PRN analgesics, received supportive care with IV fluids and continued cardiac monitoring. 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. For these reasons, the proposed treatment of Inpatient admission is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

The patient is a male with past medical history significant for obesity who presented to the emergency department with chief complaint of fall and subsequent nose pain, headache, chest pain, and dizziness the following morning. He denied loss of consciousness with the fall, drug use, or other complaints.
On arrival to the emergency department, he was noted to be afebrile with blood pressure 126/78, heart rate 101, and to be maintaining an oxygen saturation of greater than (>) 90% on room air. Exam was otherwise notable for an abrasion and edema on the right side of his nasal septum. Electrocardiogram (EKG) revealed T wave inversions in leads II, III, avF as well as V4, V5, and V6. Bedside echocardiogram was performed which was suggestive of clot versus Chiari network. Request was subsequently made to admit the patient. The patient was subsequently admitted and seen by cardiology, the Intensive Care (IC), and hospitalist services. He underwent computed tomography (CT)-angiogram of the chest which revealed no evidence of clot. Formal echocardiogram confirmed Chiari network without evidence of clot. He was subsequently discharged home.
The health plan's determination is upheld, in whole.

No, acute inpatient admission was not medically necessary.
This patient presented with lightheadedness, nasal abrasion and edema, and chest pain after a fall. He was kept overnight because bedside echocardiogram was concerning for possible clot versus Chiari network and was subsequently discharged in the morning after formal echocardiogram revealed no clot and Chiari network only which is a normal variant. It is notable that suspicion for actual clot was low enough that per notes the IC physician suggested the patient did not need telemetry monitoring or initiation of anticoagulation while inpatient. Certainly, this patient was appropriate to keep for monitoring in the setting of fall with chest pain and concern for abnormal echocardiogram, but it is unclear why acute inpatient admission was needed in this patient with a normal heart variant in the absence of ongoing chest pain, process such as pulmonary embolism or dissection causing dizziness, and with symptoms that resolved very rapidly. Acute inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

The patient presented with right sided abdominal pain. The pain was occurring every 2-3 days. It started one month ago. The pain was 10/10. The patient had a recent urinary tract infection (UTI) and it was treated with antibiotics which were finished two days prior to this presentation. The patient also had left sided chest pain and shortness of breath. The shortness of breath was exertional. It radiated to left neck and left shoulder, associated with nausea. The patient was admitted to the hospital and underwent cardiac catheterization and it revealed minor irregularities in her left anterior descending (LAD). The patient was monitored after the procedure per protocol. She received intravenous (IV) hydration. The patient underwent an echocardiogram and it revealed an ejection fraction (EF) of 55-60%.

The health plan's determination is upheld. The inpatient admission was not medically necessary. This patient with borderline risk profile and atypical chest pain and abdominal pain presented to the hospital for evaluation. The patient was clinically stable with normal vital signs. The work up for CAD was negative, including troponin, ECG, CXR and echocardiogram. The coronary angiography was negative for obstructive CAD. The patient had PVCs, but they did not affect the clinical outcome. The chest pain was not caused by PVCs and the patient was started on b-blockers, but that would not justify an inpatient admission. A lower level of care would be more appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Viral Croup
 
Treatment: Gammagard

The insurer denied the Gammagard.  The denial was upheld.   

This patient is a young male with a history of autoimmune encephalitis. The patient had a prior viral infection presenting as croup. During that admission, he had mental status changes and weakness which was initially considered to be an encephalopathy or encephalitis. His mental status returned to normal by the time of discharge, but he developed pronounced behavioral and personality changes and had no neurologic deficits. His Magnetic Resonance Imaging (MRI) at that time could have suggested a demyelinating disorder. Over the ensuing months he continued to have episodes of mood changes, and emotional lability. Based on the patient records there is no clinical evidence of an organic disease process, inflammatory damage to the nervous system, or demyelination. Several months after discharge it was noticed that he was "positive" for anti-MOG antibodies (no titer is mentioned) and it was concluded that he had originally experienced, in retrospect, autoimmune encephalitis. The presence of anti-MOG does not confirm encephalitis. Detection of serum anti-MOG antibodies is associated with some patients with the demyelinating syndromes (acute disseminated encephalomyelitis (ADEM), multiphasic disseminated encephalomyelitis (MDEM), neuromyelitis optica spectrum disorders (NMOSD), and relapsing optic neuritis). Anti-MOG antibodies are not exclusively detected in patients with demyelinating syndromes, implying that anti-MOG antibodies can be present in other conditions.  
The detection of anti-MOG antibodies in the patient could be coincidental, and most likely is not playing a causative role in his neuropsychiatric condition.  Given this, intravenous immune globulin (IVIG) therapy would have no role in treatment of his syndrome, as the postulated mechanism of action of IVIG is anti-inflammatory, and there is no evidence the patient's condition is inflammatory, much less due to any antibody-mediated inflammation.

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

The patient presented to the hospital with a chief complaint of heroin overdose.  The patient had a history of hypertension, Opioid addiction, and methadone maintenance, and the patient was brought in by Emergency medical services for altered mental status.  The patient was believed to have overdosed on two bags of heroin.  Vital signs showed temperature 97.1 Fahrenheit, heart rate 71, blood pressure 129/72, and oxygen saturation 97%.  On physical examination, he was in no distress, neck was supple, breath sounds were clear, heart was regular, abdomen was soft, and the patient was diaphoretic, unresponsive to verbal stimuli, and covered in vomit.  The patient was admitted for altered mental status in the setting of heroin overdose.

The health plan's determination is overturned.  The inpatient admission was medically necessary.  The patient presented with overdose and required multiple doses of Narcan and continued to have persistent lethargy.  In addition, the patient had an elevated white blood cell count, and there was concern for acute infection, for which he was treated with broad-spectrum IV antibiotics.  The acuity of the presentation would be treated at the inpatient level of care because of the risk of recurrent overdose and the risk of infection/sepsis complicating his hospital course.  It was therefore reasonable to treat the patient at the inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rectal bleeding

Treatment: Inpatient hospital services

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

This patient is a male with a previous history of hemorrhoids and was having episodes of rectal bleeding. He was sent to the hospital after the hemoglobin was found to be 7.0. Upon presentation to the ER there was tachycardia. On exam the abdomen was soft and non-tender.  A rectal exam revealed brown guaiac negative stool. He was transfused 2 units of packed red blood cells (PRBC). The hemoglobin went up to 8.5 and the tachycardia resolved. There was a plan to do a colonoscopy but the patient left the hospital for outpatient follow-up.

Clinical indications for admission for anemia (M-35) include hemodynamic instability, active bleeding, altered mental status, cardiac arrhythmia, severe thrombocytopenia, acute renal failure, and cardiac ischemia. The patient did not have these conditions. There was an initial tachycardia which improved after the transfusion.

Clinical indications for admission for lower gastrointestinal bleeding (M-182) include ongoing active bleeding, failure to control bleeding after a colonoscopy, severe pain, internal obstruction or severe thrombocytopenia. The patient did not have these conditions.

This patient had a history of rectal bleeding but was not actively bleeding at this time. Transfusions were needed, but could have given in observation status. The colonoscopy could then have been scheduled on an outpatient basis. The patient did not meet MCG Criteria for admission for either anemia or lower GI bleeding. 

The healthcare plan acted reasonably and with sound medical judgment. Inpatient hospital services were not medically necessary. 

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

The patient presented to the hospital after a motor vehicle accident. Patient was sitting in the front seat on the passenger side with the seatbelt in place when the vehicle collided with another vehicle with air bag deployment and loss of consciousness. Patient reported neck pain, back pain, nasal pain, and mild lower extremity pain on the right side. after patient regained consciousness patient was confused and complained of blurry vision, vomiting, and nausea. A head computed tomography (CT) was negative for a bleed and bony fractures. A CT of the spine was negative for acute fractures. The patient was admitted for a concussion. The plan of care included monitor mental status, monitor for vomiting, fall precautions, dental consult, pain management, antibiotics, ear nose and throat surgery consult, and monitor blood pressure. The inpatient hospital stay was not medically necessary. There was no evidence of subdural or subarachnoid hemorrhage, patient did not have an unstable spinal fracture, had no acute neurologic deficit after the initial period of confusion, did not have acute blood loss or hemorrhage or fracture of a pelvic or long bone, and had no other complicating features such as intoxication or acute infection. The patient needed further care, but she could have been safely and effectively managed at a lower level. HP determination is upheld in whole.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who presented to the emergency department with epigastric abdominal pain and the inability to tolerate oral intake. The patient was found to have transaminitis thought to be related to herbal remedy use. The patient was admitted to the medical floor and treated with conservative management with intravenous fluid hydration and monitoring of liver chemistries. Gastroenterology service was consulted and the patient was taken for an upper endoscopy which was unrevealing. The health plan's determination of medical necessity is upheld.

On presentation, the patient was hemodynamically stable without fever, tachycardia or hypotension. Bloodwork was notable for transaminitis without evidence of leucocytosis or anemia. The patient remained hemodynamically stable throughout the hospital course and did not have any complications related to the abdominal pain in the way of abscess development, bowel obstruction, perforation or require surgical intervention.