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

Diagnosis: Abdominal pain rule out abdominal pathology

Treatment: Inpatient services

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

This patient is a female with a benign past medical history who presented to the Emergency Department with complaints of fever, nausea, diarrhea, vomiting, and abdominal pain. Vital signs on presentation included a temperature of 102.7F, a blood pressure of 117/57, a pulse of 100, a respiratory rate of 20, an oxygen saturation of 99%, and pain that was 5 out of 10 in severity. Laboratory values were notable for the following: a white blood cell count of 4.02, hemoglobin of 11.1, a hematocrit of 34.8, a creatinine of 0.6, a glucose of 102, and a lactate of 0.6.

The patient received some intravenous fluids and a dose of empiric antibiotics (ceftriaxone) while in the Emergency Department. A CT of the abdomen/pelvis showed an enlarged fibroid uterus and was otherwise negative. A chest x-ray showed no evidence of active pulmonary disease. Blood cultures were negative.
The patient remained afebrile and hemodynamically and clinically stable. She requested to be discharged to follow-up as an outpatient.

According to documentation, the patient presented with gastrointestinal symptoms. Otherwise, she was febrile, but hemodynamically stable. Laboratory results were unremarkable, including a normal white blood cell count and lactate. There was no evidence for a systemic infection and the patient had no significant comorbid conditions. Based on above findings, the patient met criteria for observation level of care. 

The prior determination of denial of coverage for inpatient services has been upheld. The insurer acted reasonably, with sound medical judgment, and in the patient's best interest.

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

Primary Diagnosis:Endocrine/Metabolic/Nutritional/short stature
Primary treatment:pharmacy/prescription drugs 

 This is patient diagnosed with idiopathic short stature (ISS). The request is for the medication Nutropin. The patient  started Arimidex in 02/2019.
The patient's growth hormone (GH) stimulation test in 2/2019 peaked at 27. The health plans determination is upheld in whole . The peer reviewed literature including consensus clinical guidelines, and randomized controlled trials are summarized below:
 The Classic growth hormone (GH) deficiency criteria are outlined in the consensus guidelines for the diagnosis and treatment of GH deficiency published by the GH research society(1), the Lawson Wilkins Pediatric Endocrinology Society(2, 3), and the medical guidelines for GH use provided by the American Association of Clinical Endocrinologists(4). The above referenced guidelines are the latest available guidelines from these respective societies.
The diagnosis is based on auxological, biochemical and sometimes radiological findings. The auxological criteria based on consensus guidelines upon which a biochemical evaluation is to be initiated are 1) severe short stature, defined as a height more than 3 SD below the mean; 2) height more than 1.5 SD below the midparental height; 3) height more than 2 SD below the mean and a height velocity over 1 yr. more than 1 SD below the mean for chronological age, or a decrease in height SD of more than 0.5 over 1 yr. in children over 2 yr. of age; 4) in the absence of short stature, a height velocity more than 2 SD below the mean over 1 yr. or more than 1.5 SD sustained over 2 yr. The biochemical criteria include low IGF1 or IGFBP3 or GH stimulation testing with a peak GH less than 10ng/ml.The patient did not meet biochemical criteria. Growth hormone stimulation testing peaked at greater than 10.
The request does not meet any nationally accepted criteria for use of growth hormone. The request is therefore not medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

The patient is a female with moderate to severe psoriasis. The patient has tried and failed topical Mometasone, Calcipotriene, Triamcinolone, and Clobetasol, as well as the biologic agent Stelara. The patient does not consume significant amounts of alcohol as per the clinic records. The subject under review is whether the formulary drug(s) will be or has been ineffective or would not be as effective as the requested non-formulary drug Cosentyx.

The health plan's determination is upheld.

No. The patient has no documented treatment failure with, or true medical contraindication to, either Humira, Otezla, or Taltz, the formulary drugs. All of these are appropriate for this patient's particular clinical diagnosis. The patient has already tried and failed Stelara.
Modern dermatology literature supports use of the formulary medications as similarly efficacious to the requested Cosentyx, particularly in that they have either similar mechanisms of action (Taltz) and/or have different mechanisms of action than previously-failed treatments (Stelara). The same literature recommends use of these preferred agents as appropriate for this patient's clinical diagnosis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Weakness, headache, left arm pain
Treatment: Inpatient admission
The Inpatient admission was not medically necessary.

The patient is a female. She was admitted with weakness and headache. She also endorsed left arm pain. 

The patient's physical exam was normal. Her lab was normal. She underwent an unremarkable and well-tolerated nuclear stress test, which was normal. Echocardiogram showed normal function without wall motion abnormality (WMA). Her EKG (electrocardiogram) was normal. Her enzymes were negative. 

The patient was given antibiotics for sinusitis. She was discharged on antibiotics and home medications.


The patient presented with atypical symptoms including left arm pain/numbness, sinusitis, weakness and headache. Multiple tests were performed, and there was no evidence of ischemia. Her exam was normal. Her nuclear stress test was normal. Echo was normal. She was discharged with primary diagnosis of migraine. 

Determination of level of care is primarily dependent on the actual care a patient receives, and whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results. It is highlighted in the orders for care. In this case, the patient's symptoms were atypical and unlikely to be representative of acute coronary syndrome. Her exam and cardiac findings were normal. Biomarkers and EKG showed no evidence of acute ischemia. CXR (chest x-ray) was normal. Echocardiogram showed no wall motion abnormality.  Nuclear scan was negative for CAD (coronary artery disease). The physicians' treatment did not reflect any serious concern about patient's cardiac condition.  Orders did not include medical therapy for ACS (acute coronary syndrome) such as IV heparin, dual antiplatelet inhibitors, high dose beta blockers or IV NTG (nitroglycerin).  The final diagnosis was migraine.
 
The letter of appeal was carefully considered, but it offered no evidence to support inpatient level of care. The only cardiac care that was provided was telemetry, which is frequently performed in a lower level of care. The patient was admitted for monitoring, and the subsequent tests and therapy did not require an inpatient level of care. There was no complex care that required inpatient care. This patient had no evidence of CAD. In fact, all tests showed absence of ischemia.  While there was always a potential for an adverse event (and in this case a very low probability), one did not happen, and no actual treatment was added.

Milliman criteria requirements were not fulfilled, as there was never any evidence of ACS present. All of the testing and therapy that were provided would have been appropriate, safe and guidelines consistent in a lower level of care. Thus, inpatient level of care was not medically necessary.

The denial explanation was consistent with guidelines and usual community care.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with bipolar affective disorder (BPAD) admitted to Inpatient Hospital Admission (IHA). Case notes document that the patient had been chronically ill with BPAD, with worsening of depression. He developed suicidal ideation with a plan to hang himself. He felt helpless and hopeless. He experienced insomnia. He had been experiencing several high stressors in his life, including the death of his mother before admission, arrest of his wife for opiate use disorder, care of his children, and loss of his job. On admission to the emergency room, he was noted to be sad, depressed, with a constricted affect, feeling hopeless and helpless. He had a history of self-cutting. He had been treated as an outpatient with Prozac, lithium, Wellbutrin, oxycodone, and Xanax. It is not known if he was compliant or not with his medications. He had a strong family history of affective disorders, including BPAD, depressive disorders, and suicides. On admission, he was treated with Wellbutrin, Lithium, Prozac, trazodone and Xanax. He also received psychotherapy and discharge planning. His psychotropic medications were adjusted according to his clinical progress. For example, Pamelor was later added. In addition, he was evaluated and treated for his multiple medical conditions. The health plan's determination is overturned. The patient was depressed, anxious, with a constricted mood, isolate, feeling hopeless and helpless, but with improved reality testing. He was deemed not safe for discharge. He was anxious, sleeping better and partially improved in depressive symptoms. He was highly stressed by his wife's imprisonment, feeling anxious, with impaired concentration and attention.  The patient suffered from a severe, chronic, life-threatening mental disorder, BPAD, with a suicidal plan. He faced overwhelming stressors including loss of his wife to prison, the care of three children and the loss of his job. Partial improvement was not an adequate standard for discharge.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Idiopathic short stature 
Treatment: Nutropin AQ

The proposed Nutropin AQ is medically necessary.

The peer reviewed literature including consensus clinical guidelines, randomized controlled trials are summarized below:

Classic GH deficiency
Classic GH deficiency criteria are outlined in the consensus guidelines for the diagnosis and treatment of GH deficiency published by the GH research society[1], the Lawson Wilkins Pediatric Endocrinology Society[2, 3], and the medical guidelines for GH use provided by the American Association of Clinical Endocrinologists [4]. The above referenced guidelines are the latest available guidelines from these respective societies. The diagnosis is based on auxological, biochemical and sometimes radiological findings. The auxological criteria based on consensus guidelines upon which a biochemical evaluation is to be initiated are 1) severe short stature, defined as a height more than 3.0 SD below the mean; 2) height more than 1.5 SD below the midparental height; 3) height more than 2.0 SD below the mean and a height velocity over one year more than 1.0 SD below the mean for chronological age, or a decrease in height SD of more than 0.5 over one year in children over two years of age; 4) in the absence of short stature, a height velocity more than 2.0 SD below the mean over one year or more than 1.5 SD sustained over two years. The biochemical criteria include low insulin-like growth factor one (IGF1) or IGFBP3 or GH stimulation testing with a peak GH less than ten nanograms per milliliter (ng/ml).

The patient did not meet biochemical criteria. Growth hormone stimulation testing peaked at greater than ten.

Idiopathic Short stature
Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines [4-9]. FDA approval for this indication is for "non-growth hormone-deficient short stature, defined by height SDS less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means."

The patient has a pretreatment height less than or equal to -2.25 SD. The height velocity would not allow a height in the normal range. The patient therefore met idiopathic short stature criteria. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of Brugada syndrome.  He has an implantable cardioverter defibrillator (ICD). He received seven appropriate implantable cardioverter defibrillator (ICD) shocks for ventricular tachycardia.  He presented to the hospital for scheduled a ventricular tachycardia ablation.  Three morphologies of ventricular tachycardia were induced.  Both endocardial and epicardial ablations were performed.  Vascular access was achieved via both femoral veins and the right femoral artery.  Epicardial access was achieved via a subxiphoid approach.  At the end of the procedure no ventricular tachycardia was inducible.  The procedure was uncomplicated.  The patient was admitted to the coronary care unit for overnight monitoring.  He remained stable and was discharged home.
The health plan's determination is upheld.  This patient with Brugada Syndrome presented for an elective catheter ablation approximately four weeks after experiencing multiple ICD shocks for ventricular tachyarrhythmias.  He was stable at the time of presentation.  While the ablation was a complex ablation, with both endocardial and epicardial ablation sites, the procedure was uncomplicated and was successful.  Post-ablation, no ventricular tachycardia was inducible.  Overnight monitoring for arrhythmias and access site complications was medically necessary.  However, no specific treatment was required, and the patient was discharged home the next day.  This did not require an inpatient level of care.  Monitoring at a lower level of care would have been appropriate.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a new onset of left sided pressure associated with shortness of breath and fatigue when climbing one flight of stairs. The chest pain resolves with rest.
The patient has history of coronary artery disease (CAD), with prior coronary stent placement. He also has hyperlipidemia and diabetes.
The patient underwent a stress nuclear perfusion scan as outpatient, and it was positive, with chest pain reproduced, 2 millimeter (mm) ST depression and ejection fraction (EF) 57%.
The patient was scheduled for coronary angiography. He presented to pre-procedural assessment. He was given oral aspirin and Clopidogrel. He was started on intravenous fluids (IVF). The patient underwent coronary angiography and it revealed 90% stenosis of right posterior descending artery. The patient underwent coronary intervention with stent placement. His left anterior descending (LAD) stent was patent. The rest of the arteries were with mild irregularities. The procedure went as planned, and the patient remained stable. There were no complications.
His left ventricle (LV) had normal function, EF 55%. His left ventricular end-diastolic pressure (LVEDP) was 7. His vital signs were stable. His post procedural physical examination was unremarkable.
The patient was observed in a monitored bed overnight.
The health plan's determination is upheld. The patient's symptoms were consistent with exertional angina. The symptoms were classified as New York Heart Association (NYHA) III. The patient was clinically stable. He did not have resting angina. His stress test done as an outpatient was abnormal. The patient was scheduled for cardiac catheterization electively and came for the procedure from home, as an outpatient. The procedure revealed severe single vessel disease, but there was no acute vessel occlusion, thrombus or other acute changes. The patient had severe symptomatic, but stable coronary lesion. He appropriately underwent coronary intervention. His condition through the whole hospital stay was stable. He was discharged the next day, after overnight observation in a monitored bed, by routine protocol. This does not meet criteria for an inpatient admission. A lower level of care would be more appropriate.
Appeal type: Medical necessity
Decision: Upheld

Peripheral Vascular Disease/PVD
Inpatient Hospital

The patient is an undomiciled female with a history of asthma and deep vein thrombosis (DVT) who was brought to the emergency department (ED) for complaints of leg swelling and pain as per history and physical (H&P). She was also noted to be intoxicated. Her alcohol level was 246 mg/dl; otherwise all other lab work was unremarkable. Emergency Medical Services (EMS) records state that patient was found sitting on her walker because she could not move due to left hip pain (status/post (s/p) left hip surgery approximately a week ago as per patient). Subsequently, the patient was brought to the emergency department (ED) for further evaluation. A duplex ultrasound of the bilateral lower extremities revealed a DVT in the "right common femoral and proximal femoral veins." The patient was started on Xarelto for acute DVT treatment. The discharge note stated, "Patient admitted as she cannot readily obtain NOAC if discharged straight from ED overnight. Started on Xarelto in ED. When the Xarelto was approved from the pharmacy she was discharged." The inpatient stay is under review.

The health plan's determination is upheld. The inpatient stay was not medically necessary. A lower level of care was appropriate. Indications for inpatient treatment of the DVT and PE would be a patient with "active or high risk of bleeding"- i.e. recent surgery within seven days, cardio-pulmonary instability, thrombocytopenia with platelets less than 50,000, unstable renal function, or poor hepatic function with an INR greater than 1.4. This was not the case for this patient. 
There was no documentation of concern of immobilization for greater than or equal to seven days. Moreover, the IMPROVE risk assessment noted in the H&P does not appear to be applicable to this particular clinical case. Improve venous thromboembolism (VTE) risk calculator is a screening tool to improve clinical venous thromboembolism prophylaxis after a pulmonary embolism. This particular patient does not have any documentation of the patient having a pulmonary embolism.
Overall, the patient would have been better served at a lower level of care. She was hemodynamically stable with no pulmonary, neurological or metabolic reasons for inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Colitis 

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial was upheld.

This patient is a female with a history of hypertension, hyperlipidemia, diabetes, diabetic neuropathy, and colonic and gastric polyps, who presented to the Emergency Department with complaints of fever, chills, abdominal pain, and diarrhea for four days. A computed tomography scan revealed evidence of colitis. The patient was admitted with colitis. Gastroenterology consulted and recommended obtaining stool studies including ova and parasite testing and Clostridium Difficile testing. The patient did not have significant diarrhea and the Clostridium Difficile test was cancelled. The stool culture revealed normal flora. The treatment plan included keeping the patient on nothing by mouth, administering intravenous fluids, continuing prehospital medications, administering daily intravenous Protonix, administering intravenous Zosyn every eight hours, administering Flagyl every eight hours, checking blood sugars with coverage administration, administering Lovenox, and applying compression stockings. The patient's diet was advanced to Carbohydrate Controlled Medium. Upon discharge the patient was instructed to complete five more days of Flagyl and Amoxicillin. The patient was discharged after a period of medical stability. 

The insurer has denied coverage for the inpatient admission as not deemed medically necessary.

According to the literature the evaluation of patients with diarrhea should include a careful history to determine the duration of symptoms and the frequency and characteristics of the stool. The focus is in extracellular volume depletion (e.g., decreased skin turgor, orthostatic hypotension), fever and peritoneal signs may be clues to infection with an invasive enteric pathogen. Severe illness (this was not the case in this clinical setting), can be, suggested by one or more of the following, but is not limited to: 1) Profuse watery diarrhea with signs of hypovolemia 2) Passage of many small volume stools containing blood and mucus 3) Bloody diarrhea 4) Temperature greater than or equal to 38.5oC (101.3oF) 5) Passage of greater than or equal to 6 unformed stools per 24 hours or duration of illness >48 hours 6) Severe abdominal pain
7) Hospitalized patients or recent use of antibiotics 8) Diarrhea in the elderly (greater than or equal to 70 years of age) or the immunocompromised 9) Systemic illness with diarrhea, especially in pregnant women (in which case listeriosis should be suspected)

The admission was not medically necessary at the acute inpatient level of care. The patient could have been safely and effectively managed at an observational level of care. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the acute admission is not substantiated.  The insurer's denial is upheld.