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

Diagnosis: Central Nervous System / Neuromuscular Disorder
Treatment: Inpatient Hospital
Denied: Inpatient Hospital
Denial UPHELD

The patient is a generally health male who presented to the emergency department after he had a possible seizure that was reported by his girlfriend. Reportedly, the patient went to the bathroom and had two episodes of possible seizures. Two days later the patient came to the hospital.

At the time of the initial evaluation, the patient had an intermittent headache without nausea, vomiting, diarrhea. At the time of the initial evaluation, the patient denied any use of illicit drugs. He stated that he did not drink alcohol. When seen by the admitting physician the patient was afebrile, his respiratory rate was 16, blood pressure 111/72, heart rate 64 beats per minute (bpm), oxygen saturation 100%. The patient was awake and alert, in no distress. The cardiovascular exam was normal. The breath sounds were equal. The abdominal exam was unremarkable. The patient was awake, alert, and oriented times 4. There were no abnormalities elicited on the neuro exam. The rest of the physical exam was unremarkable. Laboratory evaluation revealed that sodium was 141, potassium 4.1, chloride 106, bicarbonate 31, blood urea nitrogen (BUN) 14, creatinine 1.1, glucose 95. creatine phosphokinase (CPK), creatine kinase (CK) MB, troponin were normal. White blood cell count was 9.74, hemoglobin 13.2, hematocrit 41.7, platelets 271. Computed tomography (CT) scan of the head showed no acute territorial infarct or hemorrhage. A chest x-ray showed no acute pathology.
The patient was admitted to the hospital with possible new onset of seizures.

During the short hospital stay, the patient remained seizure-free. It was mentioned in the records that the patient's symptoms could be attributed to stress due to his personal relationship. Magnetic resonance imaging (MRI) of the brain was performed and interpreted as normal.
The patient was discharged from the hospital with a recommendation to see a neurologist as an outpatient and consider electroencephalogram (EEG). It was determined that the patient did not require anti-seizure medications at the time of discharge. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld, in whole. 

The review of the medical records demonstrated that neither the severity of the patient's condition nor the complexity of the services provided justified admission at the acute inpatient level of care.
As mentioned in the previous section of this report, the patient had an unremarkable physical exam, including a neuro exam. The results of the laboratory studies and diagnostic tests were unremarkable.
The patient did not require any treatment or diagnostic tests performed in the hospital necessitating admission at the acute inpatient level of care. It is also important to mention that the patient came to the hospital two days after these episodes occurred, and during these two days the patient was symptom-free. The patient could have been treated at a lower level of care status.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Pre-Term Labor

Treatment: Inpatient Admission

The insurer denied the inpatient admission. The denial was modified.

This is a female patient with a history of a spontaneous abortion. This is a pregnant female patient who presented to the Emergency Department with complaints of possible contractions. A cervical ultrasound was performed that revealed cervical changes; cervical length of 1.6-1.8. The tocolysis (TOCO) transducer revealed irregular contractions and irritability. The patient was admitted to the hospital with pre-term labor. The patient was treated with Celestone and magnesium sulfate. Intravenous (IV) fluids and IV antibiotics were administered. The patient was medically stabilized and discharged home. 

According to literature review, preterm labor is an indication for admission and for tocolysis treatment. Preterm labor is defined as uterine contractions with cervical changes. 

Based on the review of the medical record, this patient had documented cervical changes by ultrasound that met the criteria for preterm labor. So, inpatient admission was medically necessary for this patient to be treated with tocolysis and steroids. However, the next day, progress note noted that the patient had no cervical changes. At this point, because there was no evidence of any cervical changes, the patient no longer met the criteria for preterm labor. The patient's vital signs were stable and the fetal heart rate was reassuring, and there was no adverse event, such as ruptured membranes that warranted continued inpatient stay. Once the provider ascertained that there were no additional cervical changes, the patient could have been safely discharged the next day.  

The health care plan acted reasonably with sound medical judgment in denying coverage for the last couple of days, but did not act in the best interest of the patient in denying coverage for the day of the inpatient admission.

The carrier's denial of coverage for the inpatient hospital services at the acute inpatient level of care from is modified. The medical necessity is substantiated for the day of admission but not substantiated for the following days. Reverse the day of admission, and uphold the last couple of days.
Appeal type: Medical necessity
Decision: Upheld

COPD
Inpatient hospital

This is a female with a history of chronic obstructive pulmonary disease and multiple intubations for laryngeal edema presumed to be secondary of specific food ingestion with a bilateral vocal fold paralysis. She underwent tracheostomy in the past and was decannulated. She presented with shortness of breath and labored breathing. Exam revealed bilateral true vocal fold paralysis with a firm posterior glottic stenosis, reducing the size of her airway. She was treated with steroids and with minimal improvement and underwent excision of this lesion and elective tracheostomy. She did well with no intraoperative complications and was weaned from ventilator support, demonstrating no respiratory distress and was admitted to critical care. 

The health plan's determination is upheld. The inpatient stay was not medically necessary. Clinically, this is a patient with a history of laryngeal edema secondary to specific food injections that resulted in multiple intubations, a previous tracheostomy and was decannulated, bilateral vocal fold paralysis, and posterior glottic stenosis. She presented with labored breathing and underwent an elective tracheostomy with excision of lesion. Based upon the records provided, an inpatient admission was not medically necessary. The patient tolerated the procedure well, with no intraoperative or postoperative complications. Postoperatively, she was tolerating oral intake with no nausea/vomiting, vital signs were stable, she demonstrated no respiratory distress, and was hemodynamically stable. There was no documentation of new onset neurologic signs and pain was managed by oral agents. The patient could have been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of left lower extremity deep vein thrombosis (DVT), hyperthyroidism, and recent delivery who presented to the emergency department with a chief complaint of difficulty breathing and back pain. She stated that she was walking her son to school and developed the symptoms along with nausea. She reported left-sided chest pain that was burning in nature and palpitations with associated tremors and dizziness. She had recently been admitted for hyperthyroidism and had been discharged on metoprolol. She was thought to have postpartum thyroiditis. However, she stated that she discontinued her medications that morning. Vital signs showed temperature 98 degrees Fahrenheit, heart rate 106, blood pressure 130/80, and oxygen saturation 97%. On physical examination, she was in no acute distress, her thyroid was enlarged, heart was regular and rapid, breath sounds were normal, abdomen was soft, and she had mild lower extremity edema. Lab results showed troponin negative, thyroid stimulating hormone (TSH) 0.01. Hemoglobin was 10.1. Chest computed tomography angiography (CTA) was negative for a pulmonary embolus. The patient was admitted for hyperthyroidism. At issue is the medical necessity of an inpatient stay.
The health plan's determination is upheld. The inpatient stay was not medically necessary. The plan of care included checking thyroid hormones, checking C-reactive protein (CRP), metoprolol, endocrinology consult, echocardiogram, ultrasound of the lower extremities, and checking iron studies to evaluate anemia. Endocrinology had an increased suspicion for Graves' Disease and recommended methimazole and continuing the beta blocker. She was discharged with a plan for outpatient follow-up with endocrinology.
This patient presented with stable Graves' disease symptoms, which does not routinely require inpatient level of care. Rather, she could have been started on metoprolol and methimazole with management at the outpatient level. This management plan would be more typical in a patient who is not hemodynamically unstable.
Appeal type: Medical necessity
Decision: Upheld

Knee Problem/Pain
Home Health Care

The patient is an elderly male with a past medical history significant for hypertension, hyperlipidemia, anxiety, anticoagulation secondary to pulmonary embolism, gastroesophageal reflux disease and benign prostatic hypertrophy. He requested an increase in personal care assistant (PCA) services from 15 hours a week to 40 hours a week. He currently receives 3 hours a day 5 days a week, Monday through Friday. The health plan has denied the increased hours as not medically necessary. The health plan's determination is upheld.

The services provided are adequate to meet the patient's needs in the allotted time. Additional hours are not medically necessary. The patient is independent with personal hygiene, bed mobility and eating. He needs limited assistance with personal hygiene such as dressing upper and lower body, walking, locomotion, toilet transfer and use. There are no other services that require extensive assistance for total dependency. The patient needs assistance with instrumental activities of daily living (IADLs) such as shopping and household chores, and meal preparation.

The majority of the patient's service hours include level 1 PCA hours for IADLs - mainly  meal preparation and housework, shopping and transportation. The patient did need help with certain ADLs which include showering, dressing upper and lower extremities and escorting to appointments. However, the services can be provided during the allotted time period. There are no noted services requested by the patient or his physician that cannot be performed during the 15 hours already provided during the week.
Appeal type: Medical necessity
Decision: Upheld

Cardiac/Circulatory Problems - Heart Attack
Inpatient Hospital

The patient is a male who suffered a cardiac arrest requiring intubation, and cardiac catheterization with stent placement. The hospital course was further complicated by pneumonia, trach placement and percutaneous endoscopic gastrostomy (PEG) placement.  He was transferred to another hospital for acute inpatient rehabilitation. He then required re-hospitalization and then was readmitted to for acute inpatient rehabilitation. Additional medical complexes included cortical blindness with associated Charles Bonnet Syndrome, encephalopathy, post anoxic mild clonus with moderate control, congestive heart failure with ejection fraction of 20% and recurrent urinary tract infections. He was decannulated. The patient had a final discharge from acute inpatient rehabilitation. The plan partially approved acute inpatient rehabilitation. 

The health plan's determination is upheld.

This is an unfortunate patient who suffered a cardiac arrest on with a multitude of complications. Despite the last covered day of rehab he continued with acute inpatient rehabilitation but even with the additional therapy, at time of discharge, the patient still required maximum assistance for feeding, grooming and upper body dressing. He was dependent for bathing and lower body dressing. He required maximum assistance with 2 persons for shower transfers. He could sit in a wheelchair with moderate assistance and he was unable to propel his wheelchair secondary to myoclonic movements and visual deficits. He required maximum assistance to ambulate the length of parallel bar with a wheelchair follow and with rolling walker maximum assistance of 2 with wheelchair follow. He also continued to "demonstrate severe cognitive/linguistic deficit in insight, awareness, and orientation and all aspects of attention and memory."
Continued acute inpatient rehabilitation had not resulted in functional improvement and, therefore, his needs could have been met at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Prostate Cancer
Lab Work/Blood tests

This patient has prostate cancer and had the Oncotype DX Prostate Cancer Assay performed. The original biopsy was positive and demonstrated a Gleason 3+3=6 adenocarcinoma in 5 of 14 cores. The clinical stage was T1c. The prostate-specific antigen (PSA) was 6.4.

The health plan determination of medical necessity is upheld in whole.

Per The American Urological Association (AUA) Guidelines, 14. "Among most low-risk localized prostate cancer patients, tissue based genomic biomarkers have not shown a clear role in the selection of candidates for active surveillance. (Expert Opinion)" Guideline Statement 32: "Tissue based genomic biomarkers have not shown a clear role in active surveillance for localized prostate cancer and are not necessary for follow up. (Expert Opinion)"

Although results are promising, further validation is necessary to understand fully the potential clinical utility of this test. National Comprehensive Cancer Network (NCCN) Guidelines state that "In summary, although molecular test results can provide additional guidance to patients, only limited data of prostate cancer specific-survival are available, and whether patient outcomes are improved with use of these tests is unclear." "Any of these tests may be considered to aid management decisions, but they are not required for standard of care at this time."
 
The 2017 NCCN Guidelines state that: "Although full assessment of their clinical utility requires prospective randomized clinical trials, which are unlikely to be done, the panel believes that men with clinically localized disease may consider the use of tumor-based molecular assays at this time. Future comparative effectiveness research may allow these tests and others like them to gain additional evidence regarding their utility for better risk stratification of men with prostate cancer." This patient has a low-risk prostate cancer. The prostate-specific antigen (PSA) was 6.4 and the clinical stage was T1c.
Appeal type: Medical necessity
Decision: Upheld

Cardiac/Circulatory Problems - Stroke/CVA
Home Health Care

The patient is a female with a past medical history significant for cerebrovascular disease, diabetes, hyperlipidemia, heart failure and chronic kidney disease. She has right hemiparesis secondary to a previous cerebrovascular accident. The patient has currently been approved for 81 hours a week of assistant care however, there is request for additional services, for a change in the patient's medical condition. The request is for 126 hours of personal care assistant services.

The health plan's determination is upheld.

The Uniform Assessment System (UAS) State of New York from 2 separate evaluations along with an appeal from the patient and her physician was reviewed. The patient's request for additional services noted a change in her medical condition. The patient requires care for almost all activities of daily living (ADLs) and many instrumental activities of daily living (IADLs). The patient is currently noted to have hemiparesis secondary to previous cerebrovascular accident (CVA) and she is currently bedbound, and wheelchair bound. 

The health plan denied services stating regulations do not require personal care assistant services for safety and supervision alone, such as may be clinically necessary for some with cognitive dysfunction. Personal care assistant hours for companion care or for safety supervision without the need for ADLs or IADLs is not required to be covered under the benefit of your plan. Safety supervision is included and covered as part of the total authorized personal care service hours one does during services such as ADLs. Cognitive prompting is included as part of another task and is not a specific standalone task required to be performed by a personal care assistant. It was noted that the patient's medical condition did change but that did not affect the amount of service hours necessary. 

The UAS State of New York noted that the patient required a total of 34 hours per week. The services included level 1 services and multiple level 2 services. The level 2 services include personal hygiene, bathing, dressing, toileting and transfers. There is no noted incontinence care. Bed mobility and positioning was not noted. She did need help with indoor locomotion and with eating. It was noted that the services could be provided with an average of 5 hours a day of services. The patient has been currently approved for 81 hours a week of services. 

The UAS State of New York noted that the patient required a total of 48 hours a week. There was not a significant change between the 2 evaluations. The second evaluation noted that no additional services were necessary due to the patient's medical condition change. 

Additionally, the Mini-Mental status exam was 28 out of 30, which improved from the previous evaluation. There is no noted additional services which were medically necessary which could not be provided during the allotted time.
Appeal type: Medical necessity
Decision: Upheld

Other
Inpatient Hospital

The patient is a male who had undergone placement of a cervical SCS (spinal cord stimulator) system 4 year prior. He no longer used the SCS and wished to have it removed so that he could have magnetic resonance imaging (MRI) to evaluate his chronic neck and lumbar issues. On the day of service, he underwent C3 and C4 laminectomies with removal of the SCS electrodes and pulse generator under an ambulatory patient status. The next morning, he was complaining of severe incisional pain and did not feel he was safe to go home. His status was changed to inpatient due to uncontrolled postoperative pain, and physical therapy (PT) and pain management was consulted. His neurological exam remained stable. At issue is the medical necessity of the acute inpatient admission. The health plan's determination of medical necessity is upheld in whole. The health plan did act reasonably with sound medical judgment and in the best interest of the patient in its determination of medical necessity. The patient did experience uncontrolled incision pain and muscle spasms in the posterior cervical region, which is not an uncommon occurrence when mobilizing paraspinal musculature in order to create the exposure needed for the 2-level laminectomy procedure. Therefore, it was medically necessary to delay his discharge, originally planned for one day earlier, in order to achieve reasonable pain control. However, this could have been done at a lower level of care as he did not require monitoring in an intensive care setting. By the next morning, following IV Toradol and oral muscle relaxant (Flexeril), he was ready for discharge.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: IVIG
Issue under review: Gamunex-C

Determination:
The Gamunex-C is medically necessary.

The patient is a teenaged female with pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) with sudden onset mood disorder.  She also had stridor and was found to have strep.  She was put on oral antibiotics with amoxicillin which did not help. 

PANDAS is a term used to describe a subset of children whose symptoms of obsessive compulsive disorder (OCD) or tic disorders are exacerbated by group A streptococcal (GAS) infection. It may be suspected in children with an abrupt onset of neuropsychiatric symptoms, recent group A streptococcal (GAS) infection, and remission of neuropsychiatric symptoms with antibiotic therapy. 

PANDAS can be considered rare because it is occurs too infrequently for a body of evidence to accumulate within a reasonable period of time. According to a review of evidence by the members of the Primary Immunodeficiency Committee of the American Academy of Allergy, Asthma and Immunology, IVIG might provide benefit for PANDAS. In another trial, the potential benefits of treatment with plasma exchange or IVIG compared with placebo were evaluated in 29 children who met PANDAS criteria and were severely affected. Symptom severity was rated at baseline, and at one and 12 months after treatment. Significant improvement in symptoms from baseline was noted in the treatment groups at one month; improvements were maintained at one year, although psychotropic medications were decreased or discontinued in only seven of 13 patients who required them at baseline. Adverse effects occurred in approximately two-thirds of patients in the treatment groups, including nausea, vomiting, headache, and dizziness. It is not likely that a robust body of clinical evidence about this treatment will accumulate within a reasonable period of time.

The physician notes that the patient has shown improvement with IVIG infusion. Given this, and that there is support in the literature for this treatment modality, as well as the above-described nature of the patient's condition, treatment should be continued. The medical community and standard of care would consider it to be medically necessary in this patient's clinical scenario.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overbite; impacted permanent canine.
Treatment: Braces

The braces are medically necessary.  

The patient exhibits two "automatic qualifying" conditions.  First, she has a deep impinging overbite with severe soft tissue damage.  And second, she has an impacted lower left permanent canine.  This is an anterior tooth that you do not want to extract, but rather help guide into position with orthodontic treatment.  Both of these conditions in their own right are enough to qualify for orthodontic treatment.  She has two of these qualifiers.
Appeal type: Medical necessity
Decision: Upheld

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

The patient presented with hypoglycemia (glucose 43 mg/dL) in the context of having diabetes on Glucophage and glimepiride after decreased intake since having a stroke. The patient's blood pressure (BP) was 163/131. She was treated with intravenous dextrose. The patient was admitted to the medical intensive care unit (ICU) and discharged home the next day. 

This patient presented with hypoglycemia. Her glucose improved to 69 mg/dL after oral treatment and then resolved after intravenous dextrose. Her hypoglycemia was caused by a sulfonylurea, and the offending drug was discontinued. She did not have a seizure or altered mental status. Her blood pressure was initially elevated but quickly improved. She did not fail observation. She did not have acute renal failure that would put her at risk for severe persistent hypoglycemia. Therefore, no, the proposed inpatient stay was not medically necessary.