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

Diagnosis: Duchenne muscular dystrophy 
Treatment: Vyondys 53
The insurer denied Vyondys 53.
The determination is overturned.

This is a male patient who was diagnosed with Duchenne muscular dystrophy (DMD), spastic quadriparetic cerebral palsy (thought to be due to placental insufficiency) and epilepsy . Notes by the nurse practitioner in the neuromuscular clinic, together with a letter by his treating physician indicate that he has cognitive impairment that impairs his ability to cooperate with formal testing of his pulmonary function and with timed walking tests.
He was diagnosed prenatally with Duchenne muscular dystrophy. His maternal uncle died of the disease. The patient has a deletion of exons 45-52 that is amenable to treatment with the exon 53-skipping drug Vyondys 53. He has been receiving infusions of this medication.
He remains ambulatory. At home he cruises around furniture. He uses a posterior walker. He is able to climb on the couch and to get out of bed on his own. He uses a manual wheelchair around 50 percent (%) of the time. He participates in Challenger baseball, and sings in a choir at school. He plays the harmonica.
His cardiac ejection fraction was 65 percent (%). A note by the pediatric pulmonologist described that he was doing well from a pulmonary standpoint. A sleep study showed mild obstructive sleep apnea, controlled with a nasal steroid. He was not using supplemental oxygen or assisted ventilation.
His medications include Vyondys 53 infusions every 7 days, clobazam, for epilepsy, Diastat as a seizure rescue medication, prednisone, vitamin D3, polyethylene glycol, cetirizine, enalapril and fluticasone nasal spray.
On examination, he walked holding his father's hand. His left foot was everted, and his left knee flexed. He was able to raise his hands above his head. His grip was strong. He has spasticity in both arms and legs. At issue in this review is the medical necessity of Vyondys 53.

Vyondys 53 is medically necessary for the patient.
He has been on Vyondys 53. He has a deletion of exons 45-52 that is amenable to treatment with the exon 53-skipping drug Vyondys 53. He appears to be doing well on the medication, and he is still ambulatory, with an ejection fraction of 65%. He does not require supplemental oxygen or assisted ventilation.
He has cognitive impairment (Intellectual disability is seen in at least 22% of boys with Duchenne muscular dystrophy [1]. In addition, he has cerebral palsy, and epilepsy, both of which may also be affecting his cognition.)
Vyondys 53 (golodiresen) was approved by the Food and Drug Administration (FDA) for the treatment of individuals with dystrophin mutations amenable to exon 53 skipping in December 2019 [2] The patient has a deletion of exons 45-52 that is amenable to treatment withe the exon 53-skipping drug Vyondys 53.. The health plan has added a stipulation that Vyondys 53 is only medically necessary for ambulatory patients. This restriction was not part of the FDA's approval for Vyondys 53.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: abdominal pain
Treatment: inpatient stay
The insurer denied the inpatient stay.
The health plan's determination is upheld. 

The patient is a male with medical history of asthma, chronic obstructive pulmonary disease, gastritis, and prior small bowel obstruction. He presented to the emergency department with severe diffuse abdominal pain, nausea, and vomiting. Vital signs were notable for elevated blood pressure of 141/82. Physical examination was notable for soft, tender abdomen. Labs showed low hemoglobin of 12.1 and hematocrit of 36.8% (percent), and unremarkable comprehensive metabolic panel. Chest x-ray showed increased right perihilar pulmonary opacity which may reflect atelectasis and/or consolidation secondary to pneumonia, a 0.8-centimeter (cm) nodule overlying the right anterior sixth rib, and emphysema. Abdominal x-ray showed nonspecific bowel gas, and evaluation was limited due to paucity of bowel gas. Computed tomography scan of the abdomen and pelvis showed mildly distended small bowel loops with air in the colon which may represent partial, early, or intermittent small bowel obstruction. 

The inpatient hospital admission was not medically necessary. The patient presented with abdominal pain, nausea, and vomiting; he quickly had improvement in symptoms with conservative therapy. Imaging did not show any definite complete small bowel obstruction. No other cause for the inpatient level of care, such as bowel perforation, peritonitis, toxic megacolon, sepsis, abscess, fistula, or other complication was documented. All of the measures that were undertaken, including monitoring, labs, imaging, and gradual advancement of diet, could have been performed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is upheld.

The patient is an adult male with asthma. He presented to the emergency room with shortness of breath. The patient was treated in the emergency room for asthma exacerbation. The patient was also found to have left pleural effusion and left lower lobe pneumonia and was admitted to acute hospitalization. The patient was treated with intravenous antibiotics and was started on hypertension medications. The patient was in the hospital for 3 days. The hospitalization was denied due to lack of medical necessity. This denial is being appealed.

The proposed treatment was not medically necessary.

The patient had shortness of breath due to pneumonia and mild asthma exacerbation. The patient was started on intravenous antibiotics and inhalers in the hospital. The patient remained hemodynamically stable. The patient was not on supplemental oxygen. The patient was tolerating oral diet and was ambulating. For the duration of the admission, the patient did not receive any treatment that could not have been safely and effectively be treated at a lower level of care. The acute hospitalization was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Occipital Headache
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient with a history of glomerulonephritis, kidney failure on hemodialysis, and hypertension. He presented to the emergency room with a 3-day history of a headache and generalized weakness. His vital signs were notable for a blood pressure of 155/104. He was alert and in no acute distress. The physical exam was non-contributory. 
There were no acute abnormalities on chest x-ray. There were no acute intracranial abnormalities on a head computed tomography (CT) scan. The electrocardiogram (EKG) showed peaked T-waves, but no arrhythmias. Insulin, dextrose, calcium, and intravenous fluids were administered. The patient was admitted for further treatment and evaluation.
Upon admission to a monitored bed, the patient was treated with a renal diet and oral medications. The nephrologist evaluated the patient and ordered hemodialysis for later that day. The following day, the patient was feeling well, the peak T-wave changes had essentially resolved, and the serum potassium was normal. The remainder of the stay was clinically uneventful and the patient was discharged.
At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient admission was not medically necessary for this patient.
Based on a review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or electrocardiogram (EKG) of an imminently life-threatening cause of the patient's complaints that required acute inpatient admission. Considering the end stage renal disease, the hyperkalemia was not entirely unexpected, and the patient responded quickly to straightforward treatment. The services provided, oral medication, dialysis, were not at the acute inpatient level of intensity.
Therefore, based on the standard of care, as well as the peer reviewed literature cited in the references, the acute inpatient level of care was not medically necessary and the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld.

 
The patient presented with abdominal pain. He was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. The White blood cell (WBC) count was 13. An abdominal computed tomography (CT) scan showed an acute appendicitis. There was no abscess present. There was a plan to do an appendectomy but there was no abdominal tenderness, and he left the hospital without any surgical intervention.

Medical necessity was determined based on Milliman Care Guidelines (MCG) M-05 for Undiagnosed Abdominal Pain. Clinical indications for admission include hemodynamic instability, peritonitis, bowel perforation or obstruction, bacteremia, and an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

This patient had abdominal pain that rapidly resolved, and he did not have evidence of an acute abdomen. There was a CT scan finding of acute appendicitis. However, if a laparoscopic appendectomy were to be done, it is listed by MCG guidelines as ambulatory care. In this case, there were no acute interventions needed. He could have been treated with observation status. He did not meet MCG criteria for Undiagnosed Abdominal Pain. The health care plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary. 

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 an inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcohol Abuse, Hypertension
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient with a past medical history (PMH) of alcohol abuse, major depressive disorder (MDD), generalized anxiety disorder (GAD), post-traumatic stress disorder (PTSD), and hypertension (HTN) who was admitted on with complaints of (c/o) alcohol withdrawal. The physical exam was notable for no apparent distress (NAD), Clinical Institute Withdrawal Assessment (CIWA) 10. Lab work was notable for alcohol greater than (>) 200. The patient was diagnosed with alcohol withdrawal and treated with multivitamin (MVI), intravenous fluids (IVF), CIWA, and benzodiazepines (BZDs). The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with complaints of (c/o) alcohol intoxication. The patient did not have an acute co-morbid illness requiring inpatient treatment, high risk for delirium tremens, history of withdrawal seizures, serious psychiatric condition (e.g., suicidal ideation, psychosis), or severe alcohol withdrawal symptoms. This patient was found to have mild alcohol withdrawal, treated with CIWA, BZDs, IVF, MVI, and telemetry. The patient was evaluated by mental health and they determined that the patient did not require inpatient mental health hospitalization and felt the patient was safe for discharge. Overall, these interventions could have been safely and appropriately provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gastroesophageal Reflux Disease

Treatment: Gastric procedure (procedure code 43245 - esophagogastroduodenoscopy [EGD]) in a hospital setting

The insurer denied coverage for gastric procedure (procedure code 43245 - esophagogastroduodenoscopy [EGD]) in a hospital setting

The denial is overturned

The patient had a previous gastric sleeve procedure and was having ongoing gastroesophageal reflux symptoms. The patient required having an endoscopy. The patient was diagnosed with a hiatus hernia. The patient tolerated the procedure well and no complications were reported. The insurance company has denied the procedure since it was done in a hospital setting. 

Milliman Care Guidelines (MCG) guideline ACG:A-0203 lists clinical indications for upper gastrointestinal (UGI) Endoscopy. Failure of medical therapy for gastroesophageal reflux disease is an indication as well as having symptoms after bariatric surgery. This procedure is listed as Ambulatory Care. This includes endoscopies performed in several places including ambulatory at the hospital, ambulatory surgery centers, and in doctors' offices. These all fall under the category of Ambulatory Care. 

In this case, the procedure was indicated and medically necessary. There does not seem to be a prior authorization for the procedure. In my experience, it is the common practice for the doctor's office to obtain the prior authorization based on the medical records and then the hospital checks on the validity of the authorization prior to the procedure being done. For some reason, it appears that this usual process did not take place. The patient went for an indicated procedure which they believed was covered by insurance.  Before the esophagogastroduodenoscopy (EGD) there was no notification of a problem prior to the procedure. Therefore, the coverage of the EGD as an ambulatory procedure at the hospital should be covered. 

Based on the above, the insurer's denial must be reversed. 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 a gastric procedure (procedure code 43245 - esophagogastroduodenoscopy [EGD]) in a hospital setting is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma Exacerbation
Treatment: Full Hospital Admission
The insurer denied the full hospital admission.
The health plan's determination is overturned.

The patient is a male who was admitted to the hospital for an asthma exacerbation. He has a medical history of asthma, hypertension, diabetes, coronary artery disease, and stent placement. On presentation the patient had worsening dyspnea, cough, and swelling. His vital signs were stable. 

The hospital admission is medically necessary for this patient. The chest x-ray noted a left basilar infiltrate. He was started on intravenous (IV) steroids, intravenous (IV) antibiotics, and bronchodilators. His blood pressure did go up to 181/103. His diabetes was treated with home Insulin. He was started on Nifedipine for hypertension.
The patient had both community acquired pneumonia and an asthma exacerbation with persisting symptoms during the admission. This would make the admission medically necessary at the acute inpatient level of care as the symptoms were not improved and were refractory to treatment initially especially in the setting of pneumonia which was noted on the x-ray. 

The health plan's determination of medical necessity is overturned in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Residual pulmonary embolism
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient with a past medical history (PMH) of cannabinoid hyperemesis and prior pulmonary embolism (PE) who was admitted with complaints of (c/o) chills, sweats, vomiting, and abdominal pain. His vital signs were unremarkable. The physical exam was notable for no apparent distress (NAD), awake, alert, oriented times three (AAOx3), cooperative, with a normal mood and affect. Lab work was notable for a negative troponin. Imaging studies included a computed tomography (CT) scan of the chest which showed partial but incomplete resolution of a left lower lobe (LLL) pulmonary embolism (PE); a computed tomography (CT) scan of the head which showed no acute pathology, an ultrasound (US) duplex which showed no deep vein thrombosis (DVT). An electrocardiogram (EKG) showed normal sinus rhythm (NSR) with incomplete right bundle branch block (RBBB). The patient was diagnosed with cannabis hyperemesis and residual pulmonary embolism and treated with intravenous fluids (IVF), anti-emetics, and expert consultations, who recommended transition from intravenous (IV) heparin to oral anticoagulation for three months. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with c/o chills, sweats, vomiting, and abdominal pain and was found to have a residual pulmonary embolism from a prior diagnosis. The patient had no history of cancer, heart failure, or chronic lung disease, there was no hypotension, tachycardia, tachypnea, fever, or hypoxia. The pulmonary embolism severity index (PESI) score was consistent with class I, which is very low risk, with a 0-1.6 percent (%) 30-day mortality. The simple pulmonary embolism severity index (sPESI) was also indicative of low risk. In addition, there was no respiratory distress, hemodynamic instability, recent bleeding, or serious comorbid conditions. Patients with a PESI score less than 65 are at very low risk for 30-day mortality (0%), and those with a score less than 85 are at low risk for 30-day mortality (1%); patients in these categories can be considered for outpatient management. For the cannabinoid hyperemesis, the patient was given IVF (intravenous fluids) and anti-emetics, and his diet was slowly advanced as tolerated. This patient was monitored and received anticoagulation, with transition to oral, which could have been provided safely at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abnormal uterine bleeding
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is upheld.
 
The patient is an adult with a history of abnormal uterine bleeding (AUB) and fibroids. The patient presented to the emergency room (ER) with complaints of a 6-day history of vaginal bleeding, passing large clots, lightheadedness, chest pain, and shortness of breath (SOB). Hemoglobin was 5.6.

The patient was given an intravenous (IV) fluid bolus and 2 units of packed red blood cells (PRBC) transfused. The patient was admitted with symptomatic anemia and AUB (abnormal uterine bleeding). The patient was given IV fluids, K-dur, ferrous sulfate, and medroxyprogesterone. 

This patient has symptomatic anemia. She fulfills the transfusion guidelines for use of blood components: her hemoglobin was less than 8. Transfusion was necessary. Transfusions are done routinely in outpatient settings (oncology clinics, infusion centers, even at home). So, the need for transfusion is not a reason for admission. The patient could have been transfused as an outpatient. Note that the submitted information does not document that the patient was actively bleeding.

Milliman Care Guidelines (MCG) lists the clinical indication for inpatient care for patients with anemia. These include: active massive hemorrhage, active hemolysis, cognitive impairment, heart failure, syncope. This patient was stable and did not have any of the above. The patient could have been transfused and discharged home ensuring that the patient was stable.

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 full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient with a history of cholecystectomy, gastric bypass, and recent Clostridium difficile infection who presented to the emergency department with abdominal pain, nonbloody, nonbilious vomiting, diarrhea, chills, generalized weakness, and a decreased appetite. The patient reported being recently prescribed treatment with oral Vancomycin due to a Clostridium difficile infection. 
The patient was admitted to the hospital, where she was evaluated by an infectious disease specialist. The specialist suggested that the symptoms leading to the hospital visit might not be related to the recent diagnosis of Clostridium difficile (C. diff)-induced diarrhea. The patient was also seen by a gastroenterologist who noted that the patient had completed a course of Vancomycin for the C. diff infection. The gastroenterologist considered the C. diff testing performed during this hospital stay equivocal and observed that the patient was afebrile without leukocytosis or acute kidney injury. Another reason for gastroenterology (GI) consultation was the elevation of liver enzymes, which was attributed to alcoholic fatty liver disease. During the hospital stay, the patient's clinical condition improved, and she was transitioned to outpatient care. At issue is the medical necessity of an inpatient stay.

This patient most likely had acute gastroenteritis. Her symptoms were unlikely related to the previously diagnosed Clostridium difficile infection. The review of the medical records clearly demonstrated that the patient unlikely had a severe infection due to the lack of systemic symptoms, or bladder diarrhea.
There was no evidence that the patient had severe abdominal pain, peritoneal signs on the exam, hemodynamic instability, profound dehydration, or severe electrolyte abnormalities that were not corrected within the observation period, or the inability to maintain oral hydration following the observation period.
Taking into consideration this information, a lower level of care seems to be most reasonable, given the clinical circumstances.
Neither the severity of the patient's condition nor the complexity of services provided rose to the acute inpatient level of care. This coincides with Milliman Care Guidelines (MCG) Health Inpatient & Surgical Care 26th Edition criteria for Gastroenteritis. These criteria were reviewed. There was no overwhelming evidence that the patient met those criteria in this clinical case to justify admission at the acute inpatient level of care.