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

Diagnosis: Anemia
 
Treatment: Inpatient Admission

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

This is a female patient who presented to the emergency department (ED) with complaints of chest pain, shortness of breath and dyspnea on exertion. It was reported that the patient had presented to the emergency department the day before with the same complaints and was found to have hemoglobin of 5.2 but eloped before medical management could be implemented. The patient stated his stool was black, but he denied any sightings of bright red blood. He had an electrocardiogram which was reported to be normal. A chest x-ray was performed which revealed pulmonary vascular congestion and an enlarged cardiomediastinal silhouette consistent with congestive heart failure or fluid overload. The patient received 2 units of packed red blood cells. The patient then left the hospital against medical advice.

The medical literature notes that admission for anemia is indicated for hemodynamic instability, active hemolysis, active bleeding that cannot be controlled (e.g. in emergency or observation care), altered mental status that is severe or persistent, recurrent syncope or near syncope, cardiac arrhythmias of immediate concern, acute peripheral ischemia, high risk low platelet count, acute renal failure, pulmonary artery catheter or other invasive monitoring or urgent inpatient surgery needed.
  
There was no indication that the patient had findings of hemodynamic instability or any of the above referenced conditions.

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

Diagnosis: Status Asthmaticus 

Treatment: Inpatient Admission

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

This patient is an obese female child who was brought to the Emergency Room (ER) for a treatment after having difficulty breathing at school. She has a one day history of coughing and shortness of breath; and a reported family history of asthma. In the ER she was noted to be in respiratory distress with biphasic wheezing and a pulse oximeter reading of 62%.  Oxygen supplementation was initiated and she was treated with 3 back to back DuoNeb inhalation treatments, prednisone and intravenous (IV) magnesium. Upon reexamination following the treatment the patient was noted to have decreased breath sounds on expiration and tested positive for influenza; started on Tamiflu. 

The patient was treated appropriately in the ER for an acute episode of asthma precipitated by influenza.  She continued to have an increase in her respiratory effort and with ongoing evidence of decreased breath sounds she could not have been discharged safely. The decision to admit for ongoing treatment with albuterol was consistent with the standard of care for status asthmaticus.

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

This is a patient with chronic alcohol and cannabis use disorders who was admitted to an inpatient detoxification unit.
The patient presented to the emergency room (ER) with a complaint of "detox". He endorsed drinking 2 liters (L) of alcohol daily and using $30 of cannabis daily. His blood alcohol level was 96 and his vital signs included a heart rate of 95 and a blood pressure of 144/93. He complained of multiple symptoms of withdrawal and was noted to be anxious and have tremors on the initial physical exam. His Clinical Institute Withdrawal Assessment (CIWA) was 17. The admission Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) indicated he was incapacitated by use, was at risk of moderate withdrawal and lacked support for early abstinence.
The health plan's determination is upheld. There is physician/NP documentation only at the time of admission and discharge. There are no interval progress notes or CIWA scores. The patient had no history of serious withdrawal, use in imminently hazardous situations, or serious psychiatric or medical comorbidities. The submitted documentation does not support that the inpatient level of detox for day 4 and 5 were medically necessary for this patient and why he could not have transitioned to an outpatient level of care. He was homeless but had access to housing through the shelter system.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low back and leg pain
Treatment: Inpatient hospital admission
The inpatient hospital admission was not medically necessary.

This is a female who was admitted through the ER for low back pain and leg pain, as well as tingling in the arms.   She has long history of chronic low back pain with recent fall and increased leg and back pain. She presented to the ED.

There were no neurological deficits. The patient's VS (vital signs) were stable, and she was ambulatory. There was immediate concern of psychological overtones.  There was some suspicion of myopathy due to the fall. This was easily resolved with hydration and blood work.  The MRI was not ordered as emergent, as there was no concern for myelopathy, infection, or possible emergent surgery.  She was seen by pain management and neurology.  Outpatient PT (physical therapy) and possible outpatient ESI (epidural steroid injection) were recommended. Given that there was no suspicion of infection, myelopathy, or immediate surgery, and that she was ambulatory and her VS were normal, the patient did not require inpatient management.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Metastatic colon cancer (liver, lung and brain), biliary drain displacement, pleural effusion, severe protein calorie malnutrition, ascites, cancer associated pain, fatigue, adjustment insomnia, and is status post left thoracentesis and left biliary catheter exchange
 
Treatment: Inpatient End of Life Hospital admission

The insurer denied the Inpatient Hospital admission. The denial was upheld. 

This is a male with metastatic colon cancer (liver, lung and brain), biliary drain displacement, pleural effusion, severe protein calorie malnutrition, ascites, cancer associated pain, fatigue, adjustment insomnia, and is status post left thoracentesis and left biliary catheter exchange, brain tumor excision in mid-2019.  His oral intake was extremely poor and was unable to tolerate oral medication/food.  He had progressively increasing somnolence and severe malnutrition, and worsening pain requiring a Fentanyl patch and optimizing of intravenous (IV) Dilaudid. Documentation in mid-2019 indicates that the patient was no longer able to receive chemotherapy, and his prognosis was poor.

Email communication between the insurance carrier and the hospital indicated that the hospital has advised the insurer that he had taken a turn for the worse and that he would be staying at hospital under Hospice until he passed. 
 
Based on the above, the medical necessity for the long term acute care hospital admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

The patient is a male with a past medical history significant for hypertension, gastroesophageal reflux disease (GERD), prostate cancer, and drug-induced liver injury secondary to Ciprofloxacin, which occurred approximately one year before the day of admission. He presented to the hospital with complaints of jaundice and abnormal liver enzymes. Apparently, in the last several days that preceded the day of admission, the patient had a low-grade fever, pruritus, dark urine, and clay-colored stools. He also reported one episode of non-bloody non-bilious vomiting. Two weeks before the day of admission the patient had a bout of acute diverticulitis, which was initially treated with oral antibiotics as an outpatient. Apparently, his symptoms did not improve and he was hospitalized for 2 days and received intravenous antibiotics. Upon discharge, the patient was treated with Augmentin. At the time of current admission, the patient was off antibiotics.

The patient was admitted to the hospital with abnormal liver function tests (LFTs). The differential diagnosis included choledocholithiasis versus drug-induced liver injury from recent antibiotics versus obstructing mass.

The health plan's determination is upheld.

This patient presented to the hospital with complaints of jaundice and abnormal liver enzymes. At the same time, the patient was afebrile, hemodynamically stable, and had an unremarkable abdominal exam.

The patient was able to tolerate his meals and had no signs of dehydration or active infection. There was no evidence that the patient was unable to tolerate oral intake. During the hospitalization, the patient did not require any diagnostic procedures or interventions necessitating admission at the acute inpatient level of care.

Taking into consideration all these circumstances, neither the severity of the patient's condition nor the complexity of the services provided justified admission at the inpatient level of care. The care could have been provided at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

The patient is a female who underwent a left hemithyroidectomy in 2016. She subsequently noticed a growing right neck nodule and complained that it "bothered" her. A fine needle aspiration was negative and in 2019, she underwent completion thyroidectomy. Surgery was uneventful. Postoperatively her vital signs were stable, she demonstrated no respiratory distress, stertor or stridor she was hemodynamically stable, the surgical incision was clean dry and intact, dysphagia was denied, and she demonstrated no nausea or vomiting. She moved all extremities and her neck was soft with no evidence of hematoma. A Chvostek sign was negative. She was admitted for observation and having had an uneventful night with mild pain and a stable surgical wound she was discharged.

The health plan's determination is upheld.

Clinically this is a patient who underwent a completion thyroidectomy that was uneventful. Postoperatively her vital signs were stable, she demonstrated no respiratory distress, stertor or stridor she was hemodynamically stable, the surgical incision was clean dry and intact, dysphagia was denied, and she demonstrated no nausea or vomiting. She moved all extremities and her neck was soft with no evidence of hematoma. A Chvostek sign was negative. The requested health service of an inpatient stay was not medically necessary for this patient.
According to the American Academy of Otolaryngology Head and Neck Surgery (2016) in a review of 2362 patients having gone inpatient or outpatient thyroid and parathyroid surgery, postoperative outcomes were assessed and included 30-day rates of complications, emergency department visits, all-cause hospital readmissions, and mortality. No statistically significant differences between inpatients and outpatients were found for complication rates or post-discharge utilization. The authors concluded that discharge within 8 hours after completion of thyroid and parathyroid surgery is as safe as inpatient surgery and according to Nelson (2016), outpatient claim management was successful. In summary, the patient could have been safely managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

This is a patient is a patient who has been diagnosed with attention deficit hyperactivity disorder (ADHD), behavioral problems and developmental delay. She has a history of a fractured left ankle and injured her knee . She has had orthopedic and physical therapy visits since the injuries. She sees a psychotherapist to address her behavioral problems. The patient's mother has had numerous surgeries and may have more surgeries. The health plan's determination of medical necessity is upheld.
The patient has been diagnosed with ADHD, behavioral problems and developmental delays. She does not have any documented physical health issues which would warrant the need for 21 hours per week of consumer direct care. Her Uniform Assessment System New York Comprehensive Pediatric 4-17 Assessment Report indicates that she requires limited assistance for bathing and taking medication. The health plan's approved 3.5 hours per week of consumer direct care is adequate to address these needs.

A detailed Task-Based Assessment Tool was administered. This indicated that the patient was independent but required set-up help for bathing, personal hygiene, and dressing her upper and lower body. She required supervision for managing medications. The total hours per week calculated for supervision of theses tasks was 3.1 hours. No other tasks were found to require supervision or assistance.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Panniculectomy
 
Treatment:  Inpatient Admission

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

This is a female patient, who presented to the hospital for a panniculectomy.  Her post-operative course included being treated in the Intensive Care Unit (ICU) for her hemodynamic instability.  Her blood pressure was monitored with an atrial line and she was treated with intravenous fluid resuscitation.  Her hematocrit was monitored closely. 

According to the Milliman Care Guidelines 22" edition: Ambulatory Surgery Exception Criteria GRG: CG-AEC (ISC GRG): Clinical Indications for Admission to Inpatient Care, a potentially ambulatory procedure or surgery warrants inpatient care due to one or more of the following: Postoperative event, condition, or finding that warrants inpatient stay, as indicated by 1 or more of the following:  1)  Hemodynamic instability, 2) Post-operative effects not resolved or adequately managed (e.g. pain or vomiting not appropriate for outpatient or next level of care).

The previous denial of coverage for the inpatient admission is reversed.  The medical necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

The class of drugs IL 17 has shown promise in managing patients with hidradenitis suppurativa. To date, there are case reports discussing the role that Cosentyx has in treating patients with hidradenitis suppurativa.  Therefore, peer-reviewed literature supports the use of Cosentyx for the patient's indication of hidradenitis suppurativa.

As reported by Maarouf M. et al, "TNF inhibitors (adalimumab, etanercept, and infliximab), IL-1 receptor antagonist (Anakinra), IL-17A inhibitor (secukinumab), IL-12/23 inhibitor (ustekinumab), and PDE4 inhibitor (apremilast) show promise due to statistically significant improvements in disease severity."

Per Pandey, K. et al. (2018), "Hidradenitis suppurativa (HS) is a chronic, inflammatory, recurrent, debilitating follicular disease, usually affecting the axillary, perineum and inframammary regions resulting in tender subcutaneous nodules, abscesses, fibrosis and sinus tract formation.  Recent studies have demonstrated role of various cytokines in HS pathogenesis including TNF-, IL-1, IL-17, IL-12, IL-23, and IL-10, therefore representing potential therapeutic targets."

Jorgensen, A. R. et al. (2018), "Furthermore, 12 months with secukinumab and a single CO2-laser treatment provided sustained and on-going therapeutic response, which expands upon results from previous reports that have shown only short term efficacy of secukinumab in HS."      

Cosentyx 300 mg Dose 2 pen is Food and Drug Administration (FDA) approved for plaque psoriasis and psoriatic arthritis.  In this case the use of Cosentyx will be an off-label indication.     
However, given the patient has a contraindication to standard therapies and has already failed antibiotics and antiandrogen medications, the off-label use of Cosentyx is likely to be more beneficial in treating her condition.  To date, there are case reports discussing the role that Cosentyx has in treating patients with hidradenitis suppurativa.                           

The carrier's denial of coverage for Cosentyx 300mg Dose - 2 pens should be reversed since this medication is likely to be more beneficial than any other existing standard health service.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Total Thyroidectomy
 
Treatment: Inpatient Admission

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

This is a young male patient who presented to the hospital for a total thyroidectomy. The patient had genetic testing performed that revealed positive for malignancy (99%). As scheduled, the patient underwent a total thyroidectomy, left central dissection, and left selective neck ll-lV. The patient was admitted for observation for possible hematoma at the surgical site. The patient's vital signs were monitored as well as his intake and output, including the Jackson-Pratt drainage. He received intravenous antibiotics and was treated for pain management. The patient was discharged home when medically stable.

The MCG indicates a thyroidectomy is generally performed on an ambulatory basis. The patient was not noted to have an otherwise remarkable medical history.  The patient's Jackson-Pratt drain, intake, output, and laboratory studies could have been monitored on a 23-hour observational basis. The patient was stable post-operatively. The records failed to support the necessity for inpatient admission. Therefore, the healthcare plan acted reasonably, and with sound medical judgment, and in the best interest of the patient.

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

Diagnosis: Severe Psoriasis

Treatment: Taltz 

The insurer denied Taltz. The denial was upheld.
 
This is patient is a male with a history of psoriasis with arthropathy, Type 2 diabetes, hypertension, hypercholesterolemia, and a family history of skin cancer. It is noted that the patient has psoriasis that effects over 15% of his body surface. The patient has had discussions regarding other treatments for his condition, however due to his other comorbidities this was the recommended drug of choice.
 
Taltz is not considered medically necessary for this patient.  In order to be approved for Taltz, the patient must try or be unable to try methotrexate for 3 months. The patient must try two of the preferred biologic drugs (Humira, Enbrel, or Cimzia.  The patient must also try or be unable to try (6) six months of Cosentyx.  The patient has not tried or failed any of the plan preferred medications nor does the patient have any contraindication to the plan preferred medications. The medical record does not show any contraindication to the patient utilizing the formulary options listed by the insurer.  

"Commonly used systemic agents include methotrexate, cyclosporine, acitretin (Soriatane, Connetics Corporation), and apremilast (Otezla, Celgene).3234 Biologic therapies are the next step if systemic agents fail to produce an adequate response.33 Established biologic treatments for adults with moderate-to-severe plaque psoriasis include adalimumab (Humira, AbbVie); etanercept (Enbrel, Amgen); infliximab (Remicade, Janssen); secukinumab (Cosentyx, Novartis); and ustekinumab (Stelara, Janssen) (Table 1).34 Adalimumab and etanercept are the top U.S. therapies for advanced plaque psoriasis, followed by ustekinumab.34" (Fellner C., 2016).    

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

Diagnosis: Epigastric and right-upper-quadrant abdominal pain, nausea, vomiting, and diarrhea
Treatment: Inpatient stay 

Summary:
The patient is a woman with a medical history of migraines. Her surgical history included Cesarean Sections. She presented to an emergency room with a history of epigastric and right-upper-quadrant abdominal pain, nausea, vomiting, and diarrhea. 
According to the Tokyo Guidelines (the international, gold-standard consensus statement on infections of the biliary tree), for a diagnosis of acute cholecystitis, a patient must demonstrate: 
"A. Local signs of inflammation, etc. [(1) Murphy's Sign, (2) RUQ mass/pain/tenderness]; 
B. Systemic signs of inflammation, etc. [(1) Fever, (2) elevated CRP, (3) elevated WBC count]; 
C. Imaging findings [Imaging findings characteristic of acute cholecystitis]." 
This patient did not meet all three criteria; she did not have imaging findings characteristic of acute cholecystitis. Therefore, she did not require admission at an acute inpatient level of care for treatment thereof. She could have been admitted for observation of abdominal pain at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Substance abuse
Issue under review:  Continued inpatient admission

Determination:
The Continued inpatient admission was not medically necessary.

The continued inpatient stay and detoxification treatment and other medical services noted in the clinical summary could have been safely and effectively provided at a lower level of care.  The treatment of this patient's substance use disorder did not require the continued structure of an inpatient setting or 24-hour monitoring.  The patient displayed no serious disturbance of mental status despite having a history of bipolar disorder and depression and despite ongoing substance use disorder with alcohol and cannabis.  Moreover, the patient did not show evidence of suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance that would have warranted continued inpatient level treatment for the time interval under review.  There were no severe symptoms of withdrawal or biomedical issues in this case, and the patient had no complications that required continued withdrawal management or general medical services, as noted in the clinical summary.  The patient had fair insight and control of impulses, and was cooperative and generally motivated to continue with substance use disorder treatment.  Thus, the continued inpatient admission was not medically necessary in this case scenario.

This answer is consistent with New York State LOCADTR 3.0 Criteria and with established practice guidelines, the scientific literature, and ASAM Criteria, as referenced below.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain, fever, aches
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient was admitted with acute onset of jaundice. On evaluation, he did not have any evidence of cholecystitis/cholelithiasis or choledocholithiasis requiring any endoscopic or surgical intervention. His hepatitis serology and autoimmune serologies were negative. His liver function tests continued to improve over the next 72 hours, and he did not require any pharmacological intervention such as use of IV steroids. His liver function tests were monitored on a daily basis. During his hospital stay, he tolerated diet well, and he did not experience any nausea or vomiting. Therefore, based on this clinical scenario, he could have safely and appropriately managed at the lower level of care. The acute level of care was not medically necessary.