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

The patient with a history of hyperlipidemia, diabetes, gastroesophageal reflux disease and neuropathy, presented to the emergency department with epigastric abdominal pain, nausea, vomiting and diarrhea.The patient was admitted to the medical floor and treated with conservative management. The health plan's determination is upheld.

On presentation, the patient was hemodynamically stable. Blood work was notable for leucocytosis without anemia or significant electrolyte derangements. CT of the abdomen/pelvis was unremarkable. The patient was admitted to the medical floor and treated with conservative management with intravenous fluid hydration, antiemetic therapy and Protonix therapy.The patient did not develop sepsis related to the infectious process, abscess formation, bowel obstruction or require invasive percutaneous drainage or surgical intervention. 

Based on the Milliman Care Guidelines (MCG) criteria, the patient did not have suspected severe infection, severe abdominal tenderness, toxic megacolon, hemodynamic instability, severe or persistent vomiting or dehydration, hemolytic uremic syndrome, absent bowel sounds, signs of intestinal obstruction, or require parenteral nutrition and therefore an acute level of care and inpatient admission was not medically necessary. The patient's care could have been safely and appropriately managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: s/p T4-Pelvis posterior fusion 
Issue under review:  Continued SNF admission

Determination:
The continued SNF admission was medically necessary.

As of date under review, the patient was ambulating 50-60 feet with rolling walker with contact-guard assistance, propelling wheel-chair 20 feet with moderate assistance and requiring minimum assistance for most ADLs.  Her safe ambulation and improved balance, along with improved functionality towards independence or modified independence with ADLs, required continued stay in SNF rehabilitation.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lipedema stage 2
Treatment:Water-jet assisted lipectomy

Summary:
Based on the clinical documentation provided, and review of the medical literature, the proposed procedure, water-jet suction assisted lipectomy is not considered the standard of care for this condition. In addition, it is not considered restorative in nature for treatment of lipedema as per review of the medical literature. Suction-assisted lipectomy for the treatment of lipedema, as proposed by the treating physician, has not been proven based on current clinical evidence reported in peer-reviewed medical literature as an effective means of therapy that is as effective or supersedes current treatment modalities.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lipedema stage 2
Treatment:Water-jet assisted lipectomy

Summary:
Suction assisted lipectomy of the lower extremity for the treatment of lymphedema and lipedema has not been established as a safe, appropriate, and essential treatment, based on widely recognize standards of healthcare established by the relevant medical community. There is no clinical evidence that the requested procedure will definitely improve the patient's overall outcome and welfare given the clinical scenario presented. Failure to provide this treatment would not adversely affect the patient's well-being. This recommendation is reflective of the standard of care for the treatment of lymphedema and lipedema established by the relevant medical community. The recommendation is to deny the requested service as being not medically appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lipedema stage 2
Treatment:Water-jet assisted lipectomy

Summary:
Liposuction has been proposed as a treatment for lipedema, but the records do not confirm that the patient actually has this diagnosis.  According to a review by Rieche-Schupke et al, "Due to its increased presence in the press and on television, the diagnosis of lipedema is on the way to becoming a trendy diagnosis for those with thick legs. Despite this, one must recognize that lipedema is a very rare disease. It is characterized by disproportional obesity of the extremities, especially in the region of the hip and the legs, hematoma development after minimal trauma, and increased pressure-induced or spontaneous pain. Aids for making the correct diagnosis are (duplex) sonography, the waist-hip index or the waist-height index and lymphoscintigraphy. Important differential diagnoses are constitutional variability of the legs, lipohypertrophy in obesity, edema in immobility, edema in chronic venous insufficiency and rheumatic diseases." 
The Water-jet assisted lipectomy is not appropriate for the patient's diagnosis of morbid obesity.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with hypogonadism. Associated symptoms include decreased libido and muscle. The subject under review is the medical necessity for Aveed. The health plan's determination is overturned. The patient has hypogonadism as noted by clinical symptoms and two low morning testosterone levels. The use of the drug is considered the standard of care for management of this patient's medical condition.
Appeal type: Medical necessity
Decision: Upheld

The patient has a history of hyperlipidemia who is requesting coverage for Vascepa capsules. The patient writes that the provider recommended fish oil to treat his cholesterol levels, and that multiple over-the-counter (OTC) fish oil brands caused heartburn and upset stomach.

The health plan's determination is upheld. Vascepa Capsules 1GM was not medically necessary for this patient. Vascepa (Icosapent ethyl) is Food and Drug Administration (FDA) approved for the treatment of severe hypertriglyceridemia (blood triglyceride levels greater than 500 mg/dl. There is no evidence that the patient met either of these criteria. In addition, clinical trials have not demonstrated the benefit of these agents for the treatment of other conditions.
Appeal type: Medical necessity
Decision: Upheld

The patient has a h/o hypertension, hyperlipidemia, and coronary artery disease, with previous myocardial infarction in 2006. The patient had coronary stents placed, most recently in 4/2018. At that time, an echocardiogram (ECHO) showed an ejection fraction (EF) of 54%. The patient presented to the physician's office for an appointment (records not provided) and was reported to have an electrocardiogram (EKG) showing sinus rhythm at 70 beats per minute (bpm) with a wide complex rhythm (rate not reported), overtaking sinus rhythm. The patient was referred for electrophysiology testing.

The health plan's determination is upheld. The inpatient stay was not medically necessary. For patients who are electively admitted for electrophysiologic (EP) testing and ICD placement, the usual length of stay is ambulatory to one day. Observation is appropriate for this patient who underwent elective, uncomplicated EP testing and ICD placement. The patient had comorbidities, but these did not require active treatment during the hospitalization and the patient could have been cared for at a lower level of care.
Appeal type: Experimental/Investigational
Decision: Overturned

This is a patient  with sickle cell disease (HgbS-Bthal) who has experienced numerous and severe complications of her disease, including chronic leg ulcerations requiring chronic transfusions, hip replacements, osteomyelitis and most recently life threatening hepatic sequestration/vaso-occlusive crisis. Her physician is requesting coverage for a haploidentical donor stem cell transplant. The patient does not have a matched sibling donor.  The health plan's determination is overturned. While the risks of transplant are potentially significant, this is the only known cure for sickle cell disease. Standard treatments, including hydroxyurea and chronic transfusions, help to manage or prevent complications, but do not cure the patient. She has developed worsening complications despite these standard therapies.
Appeal type: Experimental/Investigational
Decision: Overturned

This is a patient with severe sickle cell anemia (sickle beta zero thalassemia) who has had complications with non-healing leg ulcers, bilateral hip replacements, contracture, chronic pain and complications. She does not have a sibling match to be a donor for stem cell transplant, so the provider has recommended a haploidentical allogeneic stem cell transplant (SCT) to treat her condition.  The health plan's determination is overturned.Yes, the allogeneic haploidentical stem cell transplant (SCT) is likely to be more beneficial than any standard treatment or treatments for this patient's sickle cell disease. This patient has severe sickle cell disease that has resulted in chronic pain issues, joint damage, non-healing skin ulcers and other health concerns. She has limited treatment options that are expected to give her improved survival, and the only curative option for her disease is SCT.
Appeal type: Experimental/Investigational
Decision: Overturned

This is a patient with a history of severe sickle cell disease. She has hemoglobin S/beta-thalassemia, a more serious and severe form of classic sickle cell disease. She has had multiple severe complications and medical conditions as a result of her sickle beta thal asemia disease. 
The treating physician has recommended and requested a haploidentical bone marrow transplant for this patient as she has no siblings and no donor has been identified in the National Marrow Registry.  The health plan's determination is overturned.  This patient does not have any siblings and no identified unrelated matched donor in the Marrow Registry. Haploidentical transplants have been performed in patients with sickle cell disease when there are no matched donors. Outcomes have been excellent with excellent engraftment and a low incidence of complications including graft versus host disease. Modifications were made in the preparative transplant regimen to improve engraftment while reducing side effects including graft versus host disease and infections.
Appeal type: Medical necessity
Decision: Upheld

The patient presented after a fall while being carried down the stairs. The notes indicate that the patient fell backwards in the wheelchair while being carried down the stairs and hit her neck on a single step. The entire event was witnessed by the patient's daughter, who reported that there was neither loss of consciousness nor trauma to the patient's head, although the patient reported to the emergency room (ER) doctor that the patient had hit her head and initially had occipital pain. 

The health plan's determination is upheld. This patient's condition did not warrant an inpatient stay. The patient had no documented injuries. The patient did not have any abnormal vital signs or evidence of bleeding. The patient had no new neurologic deficits. A lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Upheld

The patient has a lymphatic malformation of the tongue and neck. The patient underwent an ultrasound guided neck and oral cavity bleomycin injection on 12/19/18. Per the operative note, the patient had previous bleomycin treatment. There were no operative or perioperative complications. The patient was admitted overnight.

The health plan's determination is upheld. The inpatient admission was not medically necessary. The patient could have been cared for at a lower level of care. There were no pre-operative airway concerns. There were no intra-operative complications noted. Bleomycin sclerotherapy can cause localized swelling thus it is reasonable to allow for a period of overnight observation, but acute admission was not needed as there was no immediate documentation of airway swelling, abnormal vital signs, bleeding or any other significant concerns.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder (Seizure)
Treatment: Inpatient Hospital

Summary: This patient was seen in the emergency department (ED) for syncope and a seizure. He had a temperature of 98.8, heart rate 118, respirations 24, oxygen saturation 90% and a blood pressure 131/89. Pain was a 4/10. The patient did have a fall with bruising, pain and swelling. He was at swim practice when the lifeguard saw the patient fall to the floor. The lifeguard did not report convulsions but stated the patient's eyes rolled back. The patient was alert upon Emergency Medical Services (EMS) arrival. There was an abrasion and swelling noted to the nose. The patient was alert and oriented x4 with pupils 4 mm equal and reactive. He had an abrasion to the face. A computed tomography (CT) scan of the head was negative for intracranial hemorrhage. There were findings of acute displaced left nasal bone fracture. The patient was admitted. An electroencephalogram (EEG) was negative and electrocardiogram (EKG) was normal. It was recommended that the patient undergo a 24-hour Holter monitor. The patient was then discharged home.

The insurer has denied coverage for the inpatient hospital admission as not medically necessary. The denial was upheld.

The medical literature indicates that inpatient admission for pediatric seizures is indicated for patients with hemodynamic instability, complex febrile seizures, status epilepticus or repetitive seizures not controlled with emergent treatment, brain disorder that requires monitoring or intervention available only at the inpatient level care, etiology that requires monitoring or intervention available only at the inpatient level care, cardiac arrhythmia's of immediate concern, altered mental status that is severe persistent, new focal neurological deficit, metabolic disorder, recurrent seizure during emergency department observational care, outpatient anti-seizure regimen cannot be established, cerebral bleeding, hydrocephalus or vasospasm monitoring required. The documentation indicated the patient did have a seizure while at swimming practice. He did have a moment of unconsciousness and also fell and hit his face and fractured his nose. However, following the seizure, the patient was alert and oriented. There was no evidence of hemodynamic instability, complex febrile seizure, status epilepticus or repetitive seizures, brain disorder that requires monitoring or intervention, cardiac arrhythmia's of immediate concern, altered mental status that is severe persistent, new focal neurological deficit, metabolic disorder that persist, recurrent seizure in the emergency department observational care, cerebral bleeding, hydrocephalus or vasospasm monitoring. Therefore, the inpatient hospital service is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This patient has a complaint of right knee pain and known right knee osteoarthritis. His records show that previous viscosupplementation injections were performed previously for the right knee. 

The health plan's determination is upheld. The Supartz (Hyaluronan) Injection [J7321-RT x 5] is not medically necessary for this patient. Two recent articles have been published in the Journal of Bone and Joint Surgery which have highlighted the limited effect these injections have for patient with pain from knee osteoarthritis.
Appeal type: Medical necessity
Decision: Upheld

This is a patientwith a past medical history significant for polysubstance abuse and hepatitis C who presented to the emergency department after he consumed several bags of intravenous heroin before falling onto his face. In the emergency department, the patient underwent a computed tomography (CT) scan of the head and neck, which did not show any acute pathology.
The patient expressed a desire to be detoxed from opiates, and this prompted admission to the hospital. The review of systems that was obtained at the time of admission was positive for falls and loss of consciousness as well as substance abuse. The rest of the review of systems was negative.
The health plan's determination of medical necessity is upheld. Overall, despite the presence of withdrawal symptoms, the patient remained in stable clinical condition. According to the Merck Manual Professional Version, "The opioid withdrawal syndrome is self-limited and, although severely uncomfortable, is not life-threatening. Minor metabolic and physical withdrawal effects may persist up to 6 months. Withdrawal is typically managed in outpatient settings unless patients require hospitalization for concurrent medical or mental health problems." A detailed review of the medical records demonstrated that the patient had no concurrent medical or mental health problems requiring admission at the acute inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

The patient has a history of hypertension, diabetes and gastroparesis who has recently been admitted for the treatment of the perianal abscess requiring incision and drainage (I&D) with a subsequent initiation of intravenous (IV) antibiotics.

The health plan's determination is overturned. The inpatient stay was medically necessary. Yes, the Inpatient Hospital Setting is medically necessary. The patient presented with DKA. Diabetic ketoacidosis is a life-threatening condition that if not treated promptly can lead to death. DKA requires admission to the medical intensive care unit with administration an IV insulin drip and close monitoring and supplementation of the electrolytes.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma
 
Treatment:  Inpatient admission, diagnostic testing, medications

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

The patient has a history of Asthma; presented to Emergency Department (ED) with complaint of asthma exacerbation for three days, upper respiratory tract infection (URTI) symptoms, subjective fever and cough which was productive of sputum.  Vital signs at triage were temperature (T) 100.1, blood pressure (BP) 104/65, heart rate (HR) 122 and respiratory rate (RR) 17.  Oxygen (O2) saturations on room air were 94%

The patient was in no acute distress; lung exam revealed bilateral wheezing.  Peak expiratory flow (PEF) was 150.  The patient was treated with intravenous (IV) steroids, bronchodilators, antibiotics, and Magnesium.  The patient had white blood count (WBC) of 13.7K. Chest x-ray showed no acute infiltrates.

The decision was made to admit the patient.  O2 saturations were 96% on 2L nasal cannula.  Lung exam revealed bilateral wheeze; no rales.  The patient was speaking full sentences; no use of accessory muscles.  The patient was treated with IV fluids, IV steroids, bronchodilator, antibiotics.  This patient remained stable after admission.    

This patient did not need acute hospitalization.  She could have been placed in observation status while diagnostic testing and treatment were initiated.  The patient responded to treatment in the ED.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with diabetes and hypertension who presented to the emergency room (ER) on 12/14/18 with a perianal abscess. At that time she met systemic inflammatory response syndrome (SIRS) criteria with tachycardia (123 beats per minute (bpm)), fever (102.8 degrees Fahrenheit), and an elevated white blood cell count (WBC). The health plan's determination of medical necessity is overturned.
This patient was suffering from sepsis due to an abscess. She had signs of a systemic infection based on her vital signs and serology. Her infection was in the perineum. She also met inpatient criteria based on her hyperglycemia. She required pain control, IV antibiotics, source control via surgery, and wound care thereafter given the abscess' complex location.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Nasal Mass
Treatment: Inpatient admission, diagnostic testing and medication administration.

The insurer has denied inpatient hospital admission. The denial was upheld.

The patient was seen in the Emergency Department at 1933 hours. He complained of swelling on the left side of his nose, pain, bloody discharge from his nose, and blurred vision. Physical examination confirmed that there was a 3 x 3 cm swelling on the left side of his nares and blood clots were seen within his nasal cavity. It is noted that he had been previously seen at the hospital where a nasal septal perforation was noted. His pain was intense and on admission was 9/10 in intensity. 

Differential diagnosis included phlegmon versus a neoplastic process. Other chronic and postsurgical changes as noted above."

During the hospital stay, the patient's pain decreased from 9 to 8 /10 and this was controlled with multiple doses of oxycodone. The pain scale at time of discharge was zero.

Three peer-reviewed literature 1-3 and textbook chapter4 note the potential seriousness of a facial abscess including life-threatening cavernous sinus thrombosis2. The patient was noted to have increased facial swelling on the left side, confirmed by MRI and CT, and had pain, blurred vision, and had nasal bloody nasal discharge which was confirmed by direct observation. All of these physical findings indicate a potential serious facial nasal infection, which according to the peer-reviewed literature, warrants hospital stay to insure no further complications.1

The patient had an expanding mass on the left side of his nose with bloody nasal discharge and pain. All of the signs and symptoms are indications for a possible infectious process which could lead to serious central nervous system complications. Not to have admitted him would have been contrary to the interest of the patient according to the peer-reviewed literature.

The inpatient hospital admission was medically necessary for this patient with a possible expanding facial abscess. A diagnosis needed to be made. The sequelae of untreated or a delayed treatment of such a condition can result in cavernous sinus thrombosis. This is amply confirmed by the peer-reviewed literature 1-3 and book chapter2.