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

Diagnosis: Stroke

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld. 

This male patient has a history of hyperlipidemia and premature family history of stroke disease. The patient presented to the Emergency Department (ED) with complaints of right arm pain and tingling that started the previous night and lasted approximately 5 minutes. The patient described heaviness in the right arm and shoulder associated with tingling sensation. The patient indicated that he was informed by his provider a year ago to have a stroke work-up, but did not due to COVID (coronavirus). Findings included heart rate of 47, anion gap of 3, troponin I level of less than 0.015, triglycerides of 167, non-high-density lipoprotein of 155, low-density lipoprotein of 212, and chloride of 109. Inpatient admission was recommended given right arm symptoms, bradycardia, nystagmus, and concern for stroke requiring neurology evaluation. The patient was given normal saline bolus, heparin, and recommended for telemetry monitoring.

Milliman Care Guidelines (MCG) recommends inpatient admission for stroke when there are neurologic findings that warrant inpatient care or there is hemodynamic instability, cardiac arrhythmias of immediate concern, clinically significant cardiac or vascular disorder identified that requires inpatient care, respiratory abnormalities, severe hypertension, prolonged cardiac telemetry monitoring needed, suspected vasculitis, or pregnancy. There was a lack of neurological deficits noted. A heart rate of 47 would not be sufficient for inpatient admission versus monitoring and work up under observational level of care. As such, the denial of coverage for the inpatient admission is upheld.

The health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.

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

Diagnosis: Abdominal pain and Vomiting

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

The patient presented with abdominal pain and vomiting. He had multiple previous visits for the same symptoms which were felt to be related to cannabinoid use. The initial vital signs showed a blood pressure of 162/100 and a pulse of 100. There was no abdominal rebound or guarding. The white blood cell (WBC) count was 18.3. The BUN [blood urea nitrogen] was 22 and the creatinine was 1.44. A previous computed tomography scan of the abdomen was negative. Intravenous (IV) hydration, Pepcid, and antiemetics were given. His symptoms improved and he was able to tolerate a diet.

Clinical indications for admission for Vomiting (M-370) include gastrointestinal obstruction, a significant metabolic derangement, hemodynamic instability, severe electrolyte abnormalities, acute renal failure as manifested by a 3-fold rise in serum creatinine, and an inability to maintain oral hydration after observation care. The patient did not have these conditions.

Clinical indications for admission for Gastroenteritis (M-170) include having a suspected severe infection such as bloody diarrhea, severe abdominal pain, peritoneal signs, severe dehydration, or a severe electrolyte abnormality. The patient did not have these conditions.

This patient had recurrent episodes of vomiting that were felt to be related to cannabinoid use. IV hydration, Pepcid, and antiemetics could have been given in the emergency room (ER) with observations status. He responded to the treatment. He did not meet Milliman Care Guidelines (MCG) criteria for admission for either Vomiting or Gastroenteritis. The health care plan acted reasonably and with sound medical judgement an inpatient admission was not medically necessary.

The insurer's denial of coverage for the inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma, Depression. 
Treatment: Inpatient Admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a male with asthma and depression with medical non-compliance.  He presented to the emergency department (ED) with agitation and confusion and was noted to have an elevated creatine kinase (CK) value of 3592. The patient was treated with intravenous fluids and seen by Psychiatry Service for transfer to inpatient psychiatry. The creatine kinase (CK) values were trending down and the patient was subsequently transferred to Psychiatry Service. 

No, the proposed treatment was not medically necessary. 

Inpatient level of care for dates of service for rhabdomyolysis is not considered medically necessary.  Based on available data, it is not generally accepted national standard of medical practice, provided primarily for convenience of the patient or the practitioner nor the least intensive and/or most appropriate alternative among diagnostic and treatment options. Based on the available data, the patient could have safely and effectively been managed at a lower level of care. 

Based on the available data, there was no documentation of hemodynamic instability, hypertension requiring inpatient treatment, cardiac arrhythmias or findings of immediate concern or respiratory abnormalities requiring inpatient level of care.  There was no documented need for intravenous hydration after emergency or observation level care (as appropriate), inability to maintain oral hydration, altered mental status that is severe or persistent, or electrolyte abnormality that remains after emergency or observation level care. 

Based on the available data, the patient was able to take good oral intake with stabilizing creatine kinase (CK) values and there were no specific treatments or therapies that required inpatient level of care; therefore, the denial is upheld.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Cancer. 
Treatment: Pharmacy/Prescription Drugs. 

The insurer denied posaconazole. 
The health plan's determination is upheld in whole. 

The patient is a female who has undergone a hallo-identical allogenic stem cell transplant for myelofibrosis. Non-formulary posaconazole has been recommended for anti-fungal prophylaxis and is under review to determine if this drug would be more effective than the formulary alternatives. 

The health plan's determination is upheld in whole. 

In patients receiving myeloablative allogeneic stem cell transplants, antifungal prophylaxis is reasonable and appropriate. Posaconazole is, as the provider stated, a category 1 National Comprehensive Cancer Network (NCCN) recommendation for patients with significant graft versus host disease (GVHD); but this patient is documented to have no evidence of acute or chronic GVHD. Fluconazole is a category 1 recommendation in the allogeneic, neutropenic population (non-GVHD) and is on formulary. Voriconazole and posaconazole are both category 2B in this clinical scenario and the former is on formulary. 

In addition to the NCCN, these recommendations are generally in keeping with those of the authors of UpToDate, the 2018 American Society of Clinical Oncology and Infectious Diseases Society of America (IDSA) antimicrobial prophylaxis guidelines for patients with cancer-related immunosuppression, the 2016 IDSA guidelines for the diagnosis and management of aspergillosis, and the 2009 international guidelines for preventing infectious complications in hematopoietic cell transplantation (HCT) recipients.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: gender dysphoria

Treatment: Estradiol Valerate

The insurer denied coverage for Estradiol Valerate

The denial is upheld. 

This female patient has a history of gender dysphoria

There is no evidence in the records that the requested drug is more effective for this patient than the formulary drug.  The attending physician states that removal of the Estradiol Valerate would reverse feminizing changes. This is true if Estradiol Valerate is removed without starting a different feminizing hormone medication but is not inevitable or even likely that the feminizing changes will be reversed if the patient transitions to a new feminizing hormone medication that is formulary approved.

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.

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

Diagnosis: Alcohol Withdrawal and COPD. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a male with a history of COPD (chronic obstructive pulmonary disease). He presented to the ED (emergency department) requesting alcohol detox.  He reported drinking 2 pints of vodka and a 6 pack of 24 ounce beer daily. 

The patient's vital signs were as follows: Temperature 98.1, pulse 120, respiration rate 18, blood pressure 135/90. His exam was remarkable for a breast lump. The patient's labs were as follows: WBC (white blood count) 4.6, H/H (hemoglobin/hematocrit) 12.5/37.2, Plt (platelets) 178, Na (sodium) 139, K (potassium) 4.2, BUN/Cr (blood urea nitrogen/creatinine) 6.8/.76.  His alcohol level was 225.  His EKG (electrocardiogram) revealed sinus tachycardia.  His chest x-ray revealed NAD (no active disease). 

The patient was cleared for admission to detoxification unit.  While awaiting transfer to psych, the patient was found to have wheezing, tachycardia and O2 (oxygen) saturation of 94-95%.  The patient was admitted to the medical service for COPD (chronic obstructive pulmonary disease) exacerbation.  Plan of care included solumedrol, Atrovent, PO (oral) antibiotics, and lorazepam.  Chest CT (computed tomography) revealed lower lobe atelectasis and emphysema. 

No, the Inpatient admission was not medically necessary. 

This patient was admitted to an inpatient level of care for COPD (chronic obstructive pulmonary disease) exacerbation after presenting requesting detox.  The patient was hemodynamically stable.  The patient had tachycardia.  He had normal oxygenation.  Criteria for hospitalization of patient's with exacerbations of Chronic Obstructive Pulmonary Disease (COPD) include high risk comorbidities, such as pneumonia, arrhythmia and congestive heart failure; inadequate response of symptoms to outpatient management; marked increase in dyspnea; inability to eat or sleep due to symptoms; worsening hypoxemia or hypercapnia; and altered mental status. 

This patient presented to the ER (emergency room) requesting detox.  During evaluation, he developed wheezing associated with tachycardia. He did not have tachypnea.  He had normal oxygenation.  He did not have altered mental status.  Diagnostic did not show pneumonia or evidence of CHF (congestive heart failure).  His EKG (electrocardiogram) was normal.  Labs were remarkable for alcohol intoxication.  He did not have persistent vomiting, delirium, seizures, or gross tremor.  The patient remained hemodynamically stable during hospital stay.  He did not have signs of severe alcohol withdrawal.  The patient had not failed a lesser level of care.  He was not receiving intervention that required an acute inpatient level of care.  The inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Appendicitis

Treatment inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

This case involves a patient who presented to the emergency department complaining of abdominal pain. The documentation indicated he also had complaints of emesis twice. The documentation indicated he had 100% (percent) oxygen saturation on room air. His blood pressure was 129/78 and heart rate was 95 beats per minute (bpm). Respiration was 22. He was recommended to undergo laboratory diagnostic studies. The documentation detailed he did undergo an ultrasound which was positive for appendicitis. The admitting diagnosis was acute appendicitis with localized peritonitis without perforation or gangrene. It was recommended that he be admitted for surgical services. The documentation also indicated he had a white blood cell count of 18. He was admitted and underwent a laparoscopic appendectomy without complication. The documentation indicated he was discharged later that day due to continued improvement.

According to current literature a patient may be admitted when there is a need for an emergency inpatient surgery or there is evidence of hemodynamic instability that is not correctable in a lower level of care.  Additionally, if there is evidence of peritoneal signs the patient may be admitted.  The documentation submitted does not detail the above.  The patient was seen and it was recommended he undergo multiple laboratory and diagnostic studies.  An ultrasound showed appendicitis.  He was admitted and underwent laparoscopic surgery.  The documentation indicated the surgery did not have any complications noted.  Therefore, while observation care was needed, the full inpatient admission was not necessary.  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 inpatient admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain, Nausea and Vomiting
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female who had presented to the emergency department of the facility with the complaint of epigastric pain with emesis for 24 hours prior to presentation. The patient had a prior history of drug and alcohol abuse, migraines, pancreatitis, and hypertension as well as morbid obesity.

The patient had epigastric pain on evaluation and an anion gap acidosis. The provider perceived the patient was having dehydration. The white count was elevated at 23,000. Stranding around the kidney was felt to be consistent with acute pyelonephritis. The patient received IV (intravenous) fluids, IV (intravenous) antibiotics and supportive care. The patient was discharged in improved condition.

No, the inpatient admission was not medically necessary.

The care was appropriate as provided, but not medically necessary at the level at which it was provided.

Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had a kidney infection, yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for NPO (nothing by mouth) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission. As such, the care could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic obstructive pulmonary disease (COPD). 
Treatment: Inpatient hospital admission. 

The insurer is denied coverage for inpatient hospital admission. 
The denial is overturned. 

This male patient has a history of diabetes mellitus (DM), chronic obstructive pulmonary disease (COPD), hypertension (HTN), coronary artery disease (CAD), benign prostate hyperplasia (BPH), morbid obesity, Parkinson's disease, hypothyroidism, bipolar disorder, arthritis, substance abuse including daily alcohol/tobacco use, and medication noncompliance. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. It also states that patients with past complicated or life-threatening withdrawal symptoms including withdrawal seizures or delirium tremens are in need of inpatient hospital treatment for the management of withdrawal and reports that patients with comorbid medical condition that complicate the management of withdrawal are also candidates for inpatient detoxification. 

This patient could not safely be treated in a less restrictive setting as he reportedly had multiple comorbid medical issues. These issues included shortness of breath, tachycardia, bilateral wheezing with cough with white sputum, leg swelling, joint pain, hypoxia, high Carbon Dioxide (CO2) of 58.8, high glucose of 226, anion gap with potassium K of 18.1, and White blood cells (WBC) of 13.8. The patient also had medical issues including COPD, coronary artery disease, Parkinson's disease, hypothyroidism, hypertension, and diabetes that complicated the management of detoxification and thus required hospital detoxification. He was considered a risk for overdose due to daily alcohol and cocaine use and also at risk for severe, complicated, and life-threatening withdrawal. 

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient. 

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

Diagnosis: Tonic-Clonic seizure.
Treatment hospital admission.
The insurer denied coverage for hospital admission.
The denial is upheld.

This case involves an infant who was taken to the emergency department due to a generalized tonic-clonic seizure.  The documentation indicated he does have a history of febrile seizures an early age.  According to the parents, he had a seizure lasting approximately 4 minutes.  The documentation indicated he was taken to a different facility and a partial sepsis work-up was obtained.  The infant received a dose of ceftriaxone due to the findings of fever.  The infant was transferred for additional treatment.  The documentation indicated laboratory studies ordered at the presenting facility did include a chest x-ray with a blood culture and a basic panel.  The infant was also administered Tylenol and an IV [intravenous] bolus at the transferring facility.  It was recommended upon transfer that the infant be admitted to the pediatric services for further management.  The physician in the emergency department indicated the physical examination was within normal limits.  The documentation indicated the temperature was 101.1 with a heart rate of 148.  Oxygen saturation was 97% [percent].  The documentation detailed the laboratory studies did not reveal any significant findings.  The infant continued to be monitored without any significant adverse events overnight.  The infant was discharged the following day due to continued improvement.  It was recommended that the parents continue with additional diagnostics that include an outpatient electroencephalogram.

Regarding the requested inpatient admission, current literature indicates a full admission may be appropriate for patients when there is documentation detailing significant hemodynamic instability that is not corrected in a lower level of care.  Furthermore, the patient may be admitted when there is evidence of a febrile seizure in greater than 15 minutes of seizure activity or there is a suspicion for meningitis.  If the patient is status epilepticus or there is evidence of cardiac arrhythmias of immediate concern they may also be admitted.  The submitted documentation does not detail any the above.  The documentation does not indicate any significant abnormalities on examination that would warrant inpatient admission.  There is no indication why patient could not have been treated at a lower level and therefore the prior determination is upheld.

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 hospital admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Metabolic syndrome

Treatment Saxenda 3 milligram (mg)/0.5 milliliter (mL) pen injectors

The insurer denied coverage for Saxenda 3 milligram (mg)/0.5 milliliter (mL) pen injectors.

The denial is upheld.

This is a female with medical history of metabolic syndrome, hyperlipidemia, hypothyroidism, asthma and GERD (gastroesophageal reflux disease). The patient was seen by her Gynecology specialist for supervised weight loss. The patient was 214 pounds (BMI [body mass index] 34). The patient was put on weight loss program with caloric restriction. Her weight came down to 164 pounds [lb].  Later, the patient was put on Phentermine and her weight decreased to 146lb. Phentermine was discontinued when her weight was 185 lb. She was put on Qsymia, but patient had side effect of decrease mental acuity, her weight went up to 201lb. When she was started on Saxenda she lost only 7lb. Her doctor wants to continue her on Saxenda, but her insurance denied the request indicating that the patient has not demonstrated at least 5% (percent) weight loss in 5 months of therapy.

Based on above data, the patient had clear benefit from low caloric diet, she lost 50lb (214 down to 164lb) approximately 23% weight loss, and then on Phentermine 10.9%, reduction in weight, while 6 months on saxenda only 3% weight loss. Studies showing that 5% to 10% reduction in weight have important health benefits (Reference 1), of patient not losing at least 5% of body weight after 3 to 6 months of therapy, the treatment should be switched to another anti-obesity medication. (Reference 1) Saxenda (liraglutide) 3mg (milligram) can be used in non-diabetics for weight loss (reference 2, 3), but it appears that this patient has not achieved the expected 5 % weight loss in 5 months.

 The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for Saxenda 3 milligram (mg)/0.5 milliliter (mL) pen injectors is upheld. Medical Necessity is not substantiated.