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

This patient presented to the hospital with the complaint of epigastric abdominal pain and nausea of one-day duration.  Lab data showed an elevated white blood cell count (WBC) count of 16 K.  He was tender in the right upper abdomen.  A computed tomography (CT) scan identified findings consistent with cholecystitis.  Abdominal ultrasound showed gallstones.  The patient was started on intravenous (IV) fluid, antibiotics, and antiemetics.  Patient underwent laparoscopic cholecystectomy.  The operative dictation describes an acutely inflamed and gangrenous gallbladder.  A surgical drain was placed.  Patient was admitted to the hospital with the diagnosis of acute cholecystitis and was treated with IV antibiotics in the post-operative period.  Patient was kept nothing by mouth (NPO) for 2 days then the patient was started on a liquid diet.  The WBC count was still elevated (11.2 K).  The pathology report confirmed the diagnosis of acute cholecystitis.Once the patient tolerated a diet and pain was controlled with oral medications, patient was discharged from the hospital on 2/16/19. The surgical drain was kept in place to be removed in the outpatient setting.  Inpatient care was medically necessary.  Patient had upper abdominal pain and tenderness at the time of presentation to the ED on and had an elevated WBC count of 16.2 K.  The clinical condition was consistent with acute cholecystitis.  Imaging data also identified findings consistent with acute cholecystitis.  At the time of surgery this diagnosis was confirmed with direct inspection of the gallbladder, and the pathology report corroborated this condition.  During this period of inpatient admission, the patient required provision of IV fluid, antibiotics, and pain medications.  Patient also had a surgical drain in place.  The records indicate that the patient was appropriately cared for over a period of time that spanned > 2-nights.  This care and treatment was most appropriately carried out in the inpatient setting, as there was need for regular clinical assessment by the treating surgical service, follow up lab assessment, and provision of parenteral medications that spanned >2-nights for the diagnosis of acute cholecystitis.  Milliman Care Guidelines (MCG) also support that inpatient care was appropriate, as this patient had acute cholecystitis with upper abdominal pain and tenderness and a WBC count of 16.2 K.  The health plan determination of medical necessity is overturned in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Difficulty with Ambulation and Tremors
 
Treatment: Inpatient Admission

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

This is a male patient who was seen in the Emergency Department in early 2019 for difficulty with ambulation and tremors. The patient reported difficulty with speech. The physical exam revealed normal vital signs with tremors in both hands. The patient was able to make a modest grip.  There was no facial asymmetry. A Computerized Tomography (CT) scan revealed no acute intracranial findings. A chest x-ray was also normal. A CT angiography (CTA) of the head and neck was normal and laboratory studies revealed no significant abnormalities. It was recommended that the patient be admitted. Further documentation detailed that the patient was evaluated and noted to have a colectomy and J-pouch. The patient stated that he had recently taken 2 Percocet. The physician detailed that it was likely that the patient had erratic absorption causing a medication spike in the setting of Percocet dosing that resulted in symptoms. The patient had returned to baseline during an additional consultation, and it was recommended that the patient be discharged later that afternoon. The patient was discharged after continued stability with instructions to follow-up.

According to current literature, the patient may be admitted to inpatient services when there is evidence of a severe central nervous system (CNS) infection, vasculitis, a new onset of severe neurologic finding that may require inpatient care such as Guillian-Barre syndrome, myasthenia gravis, multiple sclerosis, Parkinson's, annular atrophic lateral sclerosis, severe myopathy, complications of congenital or degenerative disease, neurologic trauma, or suspected or confirmed nerve or muscle toxic injury. 
Within the documentation, none of the above was present.

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: Loss of consciousness 
Treatment: EEG
The three hour extended EEG was not medically necessary.

The current standard of care after a possible seizure is routine EEG with 20 to 30 minute recording time. There are no standard of care guidelines supporting the use of any extended EEG monitoring as an initial work-up after a single episode of loss of consciousness. Similarly, there are no high quality clinical trials supporting the preferential use of any extended EEG monitoring after a single episode of loss of consciousness without first doing a routine EEG or that doing an extended study, without first doing a routine study improves outcomes for persons in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Overturned

This is a male patient with depression and hyperlipidemia. He has longstanding obstructive sleep apnea diagnosed over 20 years ago when he presented with symptoms of sleepiness, snoring and gasping at night while sleeping. He has attempted Continuous Positive Airway Pressure (CPAP) off and on for several years, but records indicate that his last attempt at CPAP usage was a few years ago. He reports pressure intolerance, mask issues and removing the mask as reasons he has been unable to tolerate CPAP. He notes that he has been unable to sleep overnight with his wife for many years due to his snoring. A compliance download from a few years ago showed usage on 14/30 nights with 40% of the nights usage for > 4 hours. His average nightly usage on the nights he attempted usage was 4 hours 48 minutes. His autotitrating CPAP was set at +8 to +15 cm H2O and the pressure required to relieve sleep apnea 90% of the time was 11 cm H2O.  His residual Apnea Hypopnea Index (AHI) was elevated at 11.2 events/hour. His most recent sleep study is a home sleep test from mid-2016 that showed an AHI of 27.4 events/hour, consistent with moderate obstructive sleep apnea. His time in bed on the night of home sleep testing was short at 6.7 hours, and his sleep time was likewise short at 4.7 hours. He has a body mass index of 25 kg/m2. He underwent drug induced sleep endoscopy in early 2019 that showed anterior-posterior collapse at the level of the base of the tongue. Coverage for implantation of a hypoglossal nerve stimulator is being requested. 
The patient's device was initially approved in 2014 for treatment of moderate to severe obstructive sleep apnea. While CPAP is a first-line treatment, long-term use for many patients is suboptimal. The selection criteria for the use of the nerve stimulator may include a body mass index of less than 32, as well as a lack of central apnea and a favorable pattern of palatal collapse during drug-induced sleep endoscopy. The patient has had a trial and failure of a CPAP device with multiple masks. He has as a body mass index of less than 32 and a diagnosis of obstructive sleep apnea. He would be an appropriate candidate.  In addition, the requested CPT codes 64568 and 0466T would be the most appropriate treatment for this patient and it has final approval from the appropriate regulatory bodies. Scientific evidence does support a result of improvement in health outcomes. The requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient and the prior denial is overturned.

The carrier's denial of procedure code 64568 (Incision for implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator) and 0466T (insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator) should be reversed.
Appeal type: Experimental/Investigational
Decision: Overturned

This is a male patient currently diagnosed with obstructive sleep apnea. The patient had an apnea-hypopnea index (AHI) of 27.4.  The patient's body mass index (BMI) was 25 kg/m2.  The Predetermination of medical benefits for the surgical implantation of an upper airway stimulation (AUS) device for the hypoglossal nerve (12th cranial nerve) due to obstructive sleep apnea letter indicated that the patient had undergone a polysomnogram which eliminated the possibility of central sleep apnea or complex sleep apnea.  The physician opined there was no other appropriate beneficial treatment available for the patient.  The patient had failed and was intolerant to continuous positive airway pressure (CPAP)-the gold standard of care therapy for patients with obstructive sleep apnea syndrome.  The patient had been unable to achieve benefit from CPAP therapy due to pressure intolerance, mask issues, and trouble keeping the mask in place.  In addition, the patient struggled with depression.  The provider opined there were limited options available and that in their medical judgment, upper airway stimulation offered the best clinical option for the patient, given his medical condition.  After performing the sleep endoscopy, the provider further stated that there was confirmation the patient did not have complete concentric collapse of the upper airway.  The provider stated that the combination of indicators supported the patient as being an excellent candidate for stimulation of the upper airway via Inspire therapy.

Continuous positive airway pressure (CPAP) is a first line of treatment for obstructive sleep apnea; however, long-term use for many patients is suboptimal.  The hypoglossal nerve stimulator was US Food and Drug Administration (FDA)-approved in 2014 for the treatment of moderate and severe obstructive sleep apnea.  A five-year study indicated that the treatment was effective and improved sleepiness, quality of life and respiratory outcomes.

The carrier's denial of procedure code 64568 (Incision for implantation of cranial nerve (e.g., vagus nerve) neurostimulator electrode array and pulse generator) and 0466T (insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator) should be reversed.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Severe Obstructive Sleep Apnea (OSA)
 
Treatment: Diagnostic Procedure

The insurer denied the diagnostic procedure. The denial was reversed as all three panelists determined that the diagnostic procedures would be much more beneficial than any other standard treatment or procedure for this patient at this time.

This is male patient with severe obstructive sleep apnea (OSA). The OSA was documented by a polysomnography study which found an apnea hypopnea index (AHI) = 43. The patient had a body mass index (BMI) = 25. He failed the use of continuous positive airway pressure (CPAP). A sleep endoscopy performed in early 2019 observed that there was no circumferential collapse level of the soft palate and that the tongue base was noted to be completely prolapsed back against the posterior oropharyngeal wall.
The peer reviewed literature is abundantly clear concerning the efficacy for patients with a high AHI, and the inability to utilize some form of CPAP without concentric collapse of the upper airway. This is the case with this patient. The use hypoglossal nerve stimulation for the treatment of OSA has been approved by the American Academy of Otolaryngology Head and Neck Surgery and the International Sleep Society. The Food and Drug Administration (FDA) of United States Department of Health and Human Services has initially approved the use of the hypoglossal stimulation for patients with the characteristics of this patient. More recently, the FDA has expanded the clinical criteria for the use of the hypoglossal stimulation for which this patient qualifies. This is additionally substantiated by the statement in the Blue Cross Blue Shield Association Surgical Treatment for Snoring and Obstructive Sleep Apnea Syndrome Evidence Summary which stated that:
The patient is an excellent candidate for the procedure and it is the best available treatment for this patient at this time.The use of the implantable hypoglossal nerve stimulation will be much more beneficial than any other standard treatment or procedure for this patient at this time. This has been demonstrated through numerous peer review articles.

The carrier's denial of procedure code 64568 (Incision for implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator) and 0466T (insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator) should be reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Headache; Hyponatremia.
 
Treatment: Inpatient Admission

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

This is an elderly female who presented to the Emergency Department (ED) in early 2019 with complaints of headache, neck, and chest pain for 3 days. Her past medical history included hyperlipidemia, essential tremor, vertigo, and myofascial pain syndrome. Vital signs at presentation were stable temperature 98.6F, a blood pressure 138/79, a heart rate 74, a respiratory rate 16 and an oxygen saturation of 100%.  Left neck and shoulder tenderness was noted on palpation as well as left anterior chest wall and lateral chest wall. Patient was noted to have a sodium level of 129; a repeat sodium level a few hours later was 142. Cardiac enzyme results were < 0.01 and an erythrocyte sedimentation rate (ESR) was 39. She had a head CT scan was negative and a chest CT scan revealed a small sub centimeter pleural nodule some basal atelectasis and a small left loculated effusion, no pulmonary embolism; a follow-up CT scan in six months was indicated. Upon history and physical exam the patient was in no acute distress and hemodynamically stable. The patient remained hemodynamically. 
The patient did not need acute hospitalization. She could have been placed in Observation status while diagnostic testing and treatment were initiated. She remained stable after admission and was on oral medications.  Labs were essentially normal. There was no evidence of an acute myocardial infarction (MI), cerebrovascular accident or temporal arteritis. The patient was stable for discharge on oral medications after initial evaluation and treatment done in the ED/ Observation status.

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

Diagnosis: Suicidal ideation
Treatment: Continued inpatient admission 
The continued inpatient admission was medically necessary. 
Three days of inpatient observation is not sufficient to adequately assess the safety of an adolescent who presented with suicidal ideation and specific plans after the breakup of a two-year relationship and expulsion from school.  Adolescents frequently present a "flight into health" during the initial days of hospitalization, without actually addressing their underlying problems. Hospital staff acted reasonably in keeping this patient in order to be better assured of his stability and safety in the community.
Appeal type: Medical necessity
Decision: Upheld

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

The treatment as provided was medically appropriate for the patient's complaints; however, the level at which the care was provided was not medically necessary. The care could have been provided at a lower level safely and effectively.

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 varied constellation of findings including CT diagnosed colitis, nausea with emesis, diabetes and hyperglycemia; yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for prolonged NPO status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission. The dehydration was managed effectively and the patient did respond to the antinausea medication as provided.  As such the care could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Upheld

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

The patient had a hand infection, and her physicians were concerned about possible tenosynovitis. She was treated with elevation of her hand, IV fluids, observation, NPO (nothing by mouth) and IV antibiotics. She could have received hand elevation, IV fluids, observation, NPO and IV antibiotics at a lower level of care. She did not require inpatient acute care nursing for the management of her hand infection.  She had a history of asthma, but her asthma was stable. She did not have any acute physiologic compromise that required management with inpatient admission.  Treatment of her infection with IV antibiotics and observation could have been performed at a lower level of care.
Treatment of the patient's infection with IV antibiotics and observation could have been performed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath
Treatment: Inpatient admission
The proposed treatment was not medically necessary.

This is a male patient with history of chronic obstructive pulmonary disease (COPD) that presented to emergency room with worsening shortness of breath. The patient was seen in the emergency room a few days prior for similar symptoms. The patient did not pick up the prescriptions when discharged from the emergency room a few days prior.  

In the emergency room, the patient was mildly hypoxic on room air and was not in any respiratory distress. The patient had bilateral wheezing. The chest x-ray did not reveal any infiltrates or effusion. The patient was started on intravenous (IV) steroids, oral steroids and nebulizations for COPD exacerbation. The patient's COPD exacerbation improved significantly in one day length of stay. The patient was discharged home with COPD home medications and pulmonary follow up.

Since patient's condition improved significantly with emergency room care and patient was discharged after one day length of stay, the acute inpatient level of care does not meet medical necessity. A lower level of care would be as effective in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial Fibrillation
 
Treatment: Inpatient Admission

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

This was a male patient who presented to the Emergency Room (ER) in early 2019 with complaints of chest palpitations and dizziness. He has a past medical history of atrial fibrillation and hypertrophic obstructive cardiomyopathy. He was found in the ER to be in atrial fibrillation with heart rate in the 130s. He was given a saline infusion and intravenous metoprolol and diltiazem. His heart rate improved while in the ER to a rate in the 80s-90s. He was admitted for further evaluation. The remainder of his cardiac workup was unremarkable, including his cardiac troponins. Gastroenterology saw him for transaminitis. The patient remained clinically and hemodynamically stable throughout his hospital stay. He was discharged home.

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: Overturned

Diagnosis: Substance Abuse
 
Treatment: Inpatient substance detoxification treatment

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

This is a male was admitted to inpatient substance detoxification treatment in early 2019 for alcohol and heroin. He reportedly had withdrawal symptoms including tremors, sweats, nausea, teary eyes, restlessness, runny nose, irritable mood and anxiety. He reportedly was drinking alcohol, using heroin intravenously (IV), and smoking cannabis daily. He reportedly was homeless and unemployed. His history included blackouts, nonprescription Methadone use, and inpatient substance detoxification treatment; patient reports he was unable to maintain abstinence. Librium and Methadone protocols were implemented during admission and Clonidine for withdrawal modification. He was discharged when stable and agreed to go to substance rehabilitation treatment at a later date.

The 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. This was the case with this patient. This patient had past substance detoxification treatment and was still using heroin and cannabis and drinking alcohol. It was reported that he needed better coping and relapse prevention skills and needed better identification of relapse triggers.  It was not likely that he could attend an outpatient substance detoxification treatment due to his continued use despite past inpatient substance treatment so he required only inpatient substance detoxification treatment then. He also was at risk for accidental overdose.

According to the LOCADTR he did require 24 hour treatment from as he needed 3 detoxification medications to modify withdrawal including Librium, Methadone, and Clonidine, and had a long history of large amounts of IV heroin use putting him at high risk for overdose, so outpatient treatment for detoxification was not considered enough or safe. He was also homeless and unemployed so he lacked sober supports and could not safely and effectively have outpatient substance detoxification treatment. 

Based on the above, the medical necessity for the Medically Supervised Withdrawal Service level of care is substantiated. The insurer's denial is reversed.