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

Central Nervous System/Neuromuscular Disorder
Inpatient Hospital

The patient is a female with known history of diabetes mellitus (DM), hypertension (HTN), and vertigo who presented to the ED after an episode of passing out at work while standing. This was witnessed by coworkers who lowered her to the floor as she became weak. There was no trauma and no seizure. She regained consciousness in a few seconds. Premonitory symptoms of blurred vision with lightheadedness were noted. No other symptoms were reported. Reportedly, she felt the room spinning prior to the episode. No prior history of syncope was noted. She felt dizzy after the episode. No cardiac symptoms were reported including chest pain, and palpitations.

The health plan's determination is overturned in part. At the time of presentation for this patient, the patient could have been considered for observation at a lower level of care with no hx of congestive heart failure (CHF), low HGB (hemoglobin), shortness of breath (SOB), electrocardiogram (EKG) changes or systolic blood pressure (SBP)< 90 based on San Francisco syncope rule. There were no initial concerning relevant past medical history or findings during the emergency room (ER) evaluation prompting an inpatient hospital admission. Even if clinical judgement required monitoring and work up, it should have been completed at a lower level of care. Her initial testing was complete then Nuclear stress test showed reversible ischemia reported as small mild defect in apical wall. Based on this finding, the patient was planned for cardiac catheterization which required transfer to higher level of care. There was then a 3-day delay in cath for reasons that are unclear in the physician documentation. No intervention or hospital treatment was done between except waiting for transfer for cardiac catheterization. These days did not require an inpatient level of care. And when the Cardiac Cath was completed and this required an inpatient level of care based on the abnormal nuclear stress test.
Appeal type: Formulary Exception
Decision: Overturned

The patient is a female with past medical history significant of anxiety and insomnia as disorder. She has tried multiple different medications over the years and is currently taking Ativan, brand name for the treatment of anxiety disorder which is noted to be for at least 20 years duration. It was noted that she tried several different medications in the past and had intolerance. She is requesting approval for brand name Ativan 2 mg tablets 5 times a day.

The health plan's determination is overturned. The patient has tried several medications, formulary alternatives with intolerant side effects. The patient has been treated with this medicine for 20 years without complications. Based on documentation provided it is noted the patient has tried several formulary alternatives including lorazepam, alprazolam, on several different occasions dating back 20 years. Her physician's documentation states that the patient had worsening anxiety along with other somatic complaints when using lorazepam. The patient took Xanax with adverse reaction. She tried lorazepam again with adverse reactions.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

This is a male with a history of hypertension (HTN) who presented to the emergency room (ER) with syncope that occurred while on the beach drinking wine.  There were no associated symptoms.  

Vital signs (VS) included: 97.8, 85, 16, 126/78, and 100% room air (RA).  Exam was unremarkable.  Labs included: complete blood count (CBC) within normal limits (WNL), sodium (Na) 133, potassium (K) 4.5, blood urea nitrogen (BUN) / creatinine (Cr) 21 / 1.91, creatine and phosphokinase (CPK) 1027.  Troponin was less than (<) 0.03.  Electrocardiogram (EKG) revealed normal sinus rhythm (NSR).  Chest x-ray (CXR) showed no appreciable disease (NAD).  

The patient was admitted with syncope of unknown etiology.  Plan of care included intravenous (IV) antibiotics.  On the next day, vital signs were stable (VSS).  Creatinine (Cr) was 1.64.  CPK was 654.  Head computed tomography (CT) showed NAD.  Magnetic resonance image (MRI) of the brain was normal.  Magnetic resonance angiogram (MRA) of the head/neck was normal.  Echocardiogram revealed ejection fraction (EF) of 65%.  Rhabdomyolysis was resolving with IV.  On the following day, vital signs were stable (VSS).  Creatinine (Cr) was 1.46.  CPK was 652. Electroencephalography (EEG) showed temporal slowing.  On 07/17/20109, VSS.  The patient was cleared for discharge.

Most causes of syncope are benign.  Studies have not proven that inpatient admission of asymptomatic patients after syncope affects outcomes.  There are no standard criteria for diagnosing undifferentiated syncope. Inpatient admission should be reserved for patients identified to be at immediate risk, i.e. structural heart disease or history of ventricular arrhythmia. Outpatient management can be used for patients who are at low risk for a cardiac etiology.  Evaluation showed the patient to be hemodynamically stable.  The patient did not have fever or leukocytosis.  EKG was unremarkable for arrhythmia and no cardiac imaging was performed.  

Medically necessary services are those which are:
- safe 
- effective
- generally accepted national standard of medical practice 
- not provided primarily for convenience of the patient or the practitioner 
- the least intensive and/or most appropriate alternatives among diagnostic and treatment options

Based on the patient's presentation and findings in the ER, acute inpatient admission was not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Skin Disorders / Other
Pharmacy/Prescription Drugs

The patient is a male with a history of hypertension and proteinuria, and who is at risk for renal toxicity and damage.  The patient is homeless, lives in the woods, and has no transportation.  He is unable to return to the office for lab monitoring and is reportedly unable to use topical medication due to limited access to bathing facilities.  The patient has moderate to severe psoriasis (30% body surface area involvement) of the scalp, ears, torso, buttocks, and all four extremities.  The subject under review is the medical necessity for the requested Otezla.

The health plan's determination is upheld. 

Otezla is not medically necessary for this patient.  If renal insufficiency is a potential risk for this patient, who is homeless and without reliable access to facilities, then Otezla is a problematic medication for this patient no less than is the plan preferred Cyclosporine.  The need to monitor this patient for renal impairment and Otezla dosing is greater than with other medications which can be monitored with labs every few months and have very little issues relative to renal impairment.

The lack of lab results, topical treatment history, and access to patient care suggests problematic issues with all systemic therapies. 

Cyclosporine, Methotrexate, and Otezla are all inappropriate for a patient with significant renal issues, consistent with modern dermatology literature.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis

Treatment: Inpatient hospital admission 

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

This patient is a female who presented to the emergency department with epigastric abdominal pain that started early in the morning the day of the presentation to the emergency department. The patient reported associated nausea and multiple episodes of non-bilious vomiting.  The patient had a past medical history of diabetes mellitus, external hemorrhoids, hypertension, and migraines.  The physical examination revealed moderate tenderness to palpation in the right lower quadrant.  The patient underwent a CT scan that showed appendicitis without perforation.  The laboratory studies showed leukocytosis of 16.  The patient was given antibiotics in the emergency department.  The surgery team was consulted, and the patient was admitted.  The patient underwent an appendectomy and was subsequently discharged.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. The inpatient was not medically necessary for this patient. The Milliman Care Guidelines indicates that an appendectomy is generally performed on an ambulatory basis and that an inpatient stay is appropriate for patients with severe systemic illness (e.g. sepsis), poorly controlled comorbidities (e.g. COPD, chronic heart failure), or complications from procedure (e.g. infection, bleeding) that require more than 24 hours of postoperative care. An extended stay may be appropriate when the patient had a complication, such as postoperative bleeding. Admission may be needed when there is a pre-operative situation, condition or finding warranting an inpatient admission, such as the need for an emergent procedure, or a postoperative event, condition or findings that warrants an inpatient stay.  

The patient was admitted and underwent surgery the morning following admission, which would not support she had the need for an emergent procedure. The procedure was not performed immediately. The patient could have been observed and could have undergone the appendectomy on an ambulatory basis and could have been observed postoperatively for complications. There were no complications noted post-operatively to support the extended hospital stay. 

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

Diagnosis:  Myalgia; Fever

Treatment:  Inpatient admission

The insurer denied coverage for inpatient admission.  The denial reversed.

This patient is a male with a past medical history significant for obesity and depression who was referred to the emergency department with complaints of fever and myalgias. He sustained a tick bite two weeks previously.  Vitals on presentation included: Temperature. 99.2 F, blood pressure 140/95, pulse 105, respiratory rate 18, oxygen saturation was 100% on room air, pain score was 10 out of 10.  Laboratory values were notable for the following: WBC-6.9, Hgb-15.4, Hct-44.1, creatinine-0.9, glucose-113, troponin-162.8.  EKG showed no acute changes.  The patient was admitted for fever and myalgias.  He was empirically started on intravenous antibiotics (ceftriaxone and doxycycline) for a possible tick-borne related infection.  He complained of worsening back pain and developed fever to 103.1 F; he was given pain medications (tramadol and flexeril).  The patient refused a lumbar puncture; antibiotic coverage was upgraded to vancomycin, ceftriaxone, and acyclovir, as well as intravenous dexamethasone. Assessment was made to transfer patient to another facility to perform an urgent lumbar MRI. 

According to documentation, patient presented with fever and pain of unclear etiology.  He spiked to 103.1F, had tachycardia and reported pain 10 out of 10.  Laboratory results showed elevated cardiac troponins also of unclear cause.  The patient refused a diagnostic lumbar puncture, requiring empiric triple intravenous antibiotic therapy.  The patient eventually required transfer to another facility for additional diagnostic testing and management.  Based on above abnormal findings in a high-risk patient refusing diagnostic recommendations, hospital admission was medically necessary to rule out possible medical emergent infections.     

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

Based on the above, the medical necessity for the inpatient admission is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pelvic pain and endometriosis

Treatment: Inpatient admission

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

This patient is a female who was admitted and underwent a scheduled elective laparoscopic total hysterectomy and bilateral salpingo-oophorectomy and a sling procedure.  The procedure was reported as uncomplicated. Post-operatively, the patient was stable tolerating oral intake and ambulating.  She was discharged home.

There are many ways of performing a hysterectomy.  The trend has been towards less invasive procedures.  Conventional and robotic laparoscopy share similar advantages over laparotomy, including decreased morbidity, rapid recovery, and improved aesthetics of incisions. Laparoscopic hysterectomies are outpatient procedures unless a complication arises. Admission becomes necessary if the patient is febrile, hypotensive, bleeding, has difficulty breathing or the severity of the pain is such that admission is necessary.

According to the literature review, the current advances in surgery and anesthesia have allowed the feasibility and safety of outpatient total laparoscopic hysterectomy (TLH). Compared to laparotomy, laparoscopy is associated with fewer infections, less postoperative pain, and faster recovery time. As per Maheux-Lacroix, et al. increasing numbers of challenging cases of hysterectomies are now performed in the outpatient setting. For instance, TLH performed on a uterus weighing >500 grams was not associated with adverse outcomes when performed at outpatient setting. Studies have support the use of laparoscopic radical hysterectomy for severe endometriosis. And same-day discharge is feasible and safe option for carefully selected patients who undergone uncomplicated TLH. 

This case patient had a total laparoscopic hysterectomy for pelvic pain and endometriosis. Her uterus was at most 250 grams. Hospital course documents "patient admitted for TLH and BSO, as well as TOT with sling; uncomplicated procedure, routine post-op care."

According to Millman Care Guidelines (MCG), Inpatient and Surgical Care, Laparoscopic Hysterectomy, a laparoscopic hysterectomy is an ambulatory procedure, and an inpatient stay is only recommended for: Surgical complications (bladder ureter or bowel injury or hemorrhage); Conversion to abdominal hysterectomy; Complex surgery (staging of endometrial cancer); Wound complications; Comorbidities. This case patient's past medical history includes cardiovascular accident (CVA), pulmonary embolus, endometriosis, herniated cervical disc, spinal stenosis, and chronic back pain. However, none of these comorbidities were complicated and affected by the procedure. 
The patient's neurovascular and cardiovascular/respiratory exams were all normal. As per hospital record, patient was admitted for routine post-op care, which was not necessary for her uncomplicated procedure.  Based on above, the inpatient hospital admission was not medically necessary.

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

Diagnosis: Overbite
Issue under review: Braces

Determination:
The Braces are medically necessary.

The patient is a teen-aged female. The patient has a "deep impinging overbite with severe soft tissue damage."  This is an automatic qualifying condition according to the handicapping index. The patient needs to correct this problem with orthodontic treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, esophageal cancer
Treatment: Increase in consumer directed personal assistance services from 40 hours to 80 hours a week

The proposed treatment of an increase in consumer directed personal assistance services from 40 hours to 80 hours a week is deemed medically necessary.

The patient is a female with a history of dementia and recently diagnosed esophageal cancer. Due to impairments related to these conditions, she requires assistance with the majority of her activities of daily living (ADLs). 

Appeal review requested for potential approval of an increase in consumer directed personal assistance services from 40 hours to 80 hours a week to offer improved assistance with the patient's ADLs.

This is a female with a history of dementia and recently diagnosed esophageal cancer. Due to impairments related to these conditions, she requires assistance with the majority of her activities of daily living. Although the patient underwent a recent in home assessment of her functionality; she was diagnosed with esophageal cancer after the date of this assessment and will require intensive neoadjuvant chemo and radiation therapy which will result in worsening cognition, strength and balance. For these reasons, the currently approved plan of 40 personal care assistant (PCA) hours per week is not sufficient to meet the patient's needs. For these reasons, the proposed treatment of an increase in consumer directed personal assistance services from 40 hours to 80 hours a week to offer improved assistance with the patient's ADLs is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pregnancy-related nausea and vomiting

Treatment: Bonjesta 20-20 milligrams OR tablet controlled release (TBCR)

The insurer denied coverage for Bonjesta 20-20 milligrams OR tablet controlled release (TBCR). The denial upheld.

This patient is a pregnant female with a diagnosis of nausea and vomiting. The provider prescribed Bonjesta 20-20 milligrams. The patient has tried over-the-counter vitamin B6 and Unisom with no relief. The insurer has denied coverage for Bonjesta 20-20 milligrams OR tablet controlled release (TBCR) as not medically necessary.

Nausea with or without vomiting is common in early pregnancy. Management of affected women depends upon the impact of her symptoms on her health and quality of life, and the safety of maternal treatment for the fetus. Treatment approaches include dietary/lifestyle changes, oral or rectal medication, and hospitalization for parenteral fluids and therapies in women who fail to respond to outpatient management and continue to lose weight. Generally, treatment begins with advice about diet, avoidance of triggers, and non-pharmacologic interventions, such as acupressure; oral or rectal medications are added if symptoms do not improve. Pyridoxine (vitamin B6) improves mild to moderate nausea, but does not significantly reduce vomiting. Doxylamine succinate is an antihistamine that is usually taken with pyridoxine. The combination doxylamine-pyridoxine appears to improve efficacy and have been proven effective in placebo-controlled randomized trials. Formulations of doxylamine-pyridoxine are available under various names worldwide (Diclegis and Bonjesta in the United States).

Diclegis a combination of doxylamine-pyridoxine (10mg/10mg) was approved in the United States by the Food and Drug Administration (FDA) for treatment of nausea and vomiting of pregnancy in women who have not responded adequately to dietary and lifestyle modifications. Bonjesta a combination of doxylamine-pyridoxine (20mg/20mg) was approved in the United States by the FDA for treatment of nausea and vomiting of pregnancy in women who have not responded adequately to dietary and lifestyle modifications. In other words Bonjesta is a higher dose Diclegis: 1 tablet Bonjesta = 2 tablets Diclegis. The additional 10mg of pyridoxine and doxylamine in Bonjesta is in the extended release form. Note that, doxylamine is available in some over-the-counter sleeping pills (e.g., Unisom Sleep Tabs) and as a prescription antihistamine chewable tablet (Aldex AN). Since this patient had an inadequate response to generic doxylamine or generic pyridoxine Vitamin B6) or Diclegis (which contains exactly the same ingredients as Bonjesta), Bonjesta is not medically necessary. 

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. The medication Bonjesta 20-20 milligrams OR tablet controlled release (TBCR) is not medically necessary. Based on the above, the denial for a request for a Formulary Exception for Bonjesta 20-20 milligrams OR tablet controlled release (TBCR) is upheld.
Appeal type: Medical necessity
Decision: Overturned

Bladder Cancer 
Home Health Care

The patient is with a past medical history of bladder tumor, hematuria, anemia, urinary incontinence, osteoarthritis, frequent falls, congestive heart failure and dementia who resides in a one-story home. The patient had  falls . The patient was hospitalized in acute care with aspiration pneumonia, weakness, frequent falls and anemia. The  patient  was transferred to a sub-acute care  and remained there until discharge .  The  discharge plan included 24-hour care in split shifts and his primary physician supported such care as medically necessary. Overturn, in whole, the  health plans determination of medical necessity.   Yes. the requested service of the increased personal care aide service hours to 12 hours per day - 7 days a week (split shift) (168 hours per week) is medically necessary.
The patient has noted chronic medical problems of dementia, bladder tumor with frequent urination, intermittent incontinence, congestive heart failure requiring diuretic therapy, chronic lower extremity edema, pressure sores and frequent falls. The patient's medical conditions necessitate 24-hour personal care services. The patient's 24-hour care is not solely for safety, companionship or supervision as this patient requires the assistance of the personal care aide with bed transfer, toileting, locomotion, and incontinence care. Upon discharge from subacute rehabilitation 24-hour continuous care was recommended for the patient and the primary care physician continued to feel this care was medically necessary based on his 07/30/19 and 11/13/19 letters. The services are medically necessary, and it is felt that the patient's health and safety in the home can be maintained by the provision of these services.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with a history of polymyositis, arthritis, tachycardia, lung nodule, basilic vein thrombosis, and cervical and thoracic lymphadenopathy. A computed tomography (CT) scan of the chest performed several years prior for the evaluation of chest and arm pain revealed at least two pulmonary nodules, as well as mildly enlarged lymph nodes in the right hilum and mediastinum. Follow up in imaging in 4-6 weeks was recommended by the radiologist. No significant abnormalities were reported by the radiologist reading a chest x-ray performed for the evaluation of wheezing and coughing.

The patient was evaluated for multiple issues. Besides knee pain and hip pain, her review of systems was notable for shortness of breath and chest pain. A chest x-ray performed for the evaluation of shortness of breath and the history of lung nodules was again unremarkable, but the radiologist opined that a "CT exam could be considered." At issue is the medical necessity of the CT scan.

The health plan's determination is overturned. Based on the information provided, the chest CT scan was medically necessary. This is a complex patient with a systemic rheumatologic condition (polymyositis), complaints of shortness of breath, chest pain, and tachycardia at rest, as well as a prior CT scan showing potential worrisome findings that required CT imaging follow up. The normal chest x-rays are somewhat reassuring, but the chest x-ray is considerably insensitive for the evaluation of relatively small, but potentially clinically important pulmonary lesions. In addition, the diagnosis of sarcoidosis needs to be considered. The standard of care under these relatively complicated clinical circumstances would be to obtain a follow up chest CT scan. Therefore, the requested chest CT scan is medically necessary.