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

This is a patient with a past medical history significant for uterine fibroids, goiter, and hemorrhoids who was referred to the emergency department by her primary care physician because of anemia. At the time of the initial evaluation, the patient denied any injury, overt bleeding, or blood in the stool or urine. She denied any excessive bleeding or bleeding between the menstrual cycles. The review of systems was positive for generalized weakness, otherwise negative.
At the time of the initial evaluation patient's temperature was 99.1 degrees Fahrenheit (F), pulse rate 105, respiratory rate 19, blood pressure 125/56, and oxygen saturation was 100% on room air. The rest of the physical exam was unremarkable. An EKG demonstrated normal sinus rhythm, no evidence of ischemia.
The health plan's determination is upheld. The inpatient admission was not medically necessary. A fecal occult blood test was negative. Anemia workup was initiated. The patient was ordered infusion of two units of packed red blood cells. During the hospital stay, the patient remained afebrile and hemodynamically stable. It was noted in the discharge summary that the patient's anemia was most likely due to iron deficiency. It was also noted that the etiology was still unknown at the time of discharge. The patient had no active massive hemorrhage, active hemolysis or rapidly progressive anemia, hemodynamic instability, cardiovascular symptoms such as dyspnea, chest pain. There was no evidence of heart failure, neurologic symptoms, cardiac arrhythmias of immediate concern, acute peripheral ischemia, high-risk low platelet count, or any other conditions necessitating admission at the inpatient level of care. There was no need for any procedures or diagnostic tests necessitating inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

The patient has a past medical history significant for recurrent diabetic foot ulcers with right toe amputation due to osteomyelitis, neuropathies, obesity, cerebrovascular accident (CVA) with left sided hemiparesis and non-ST elevation myocardial infarction (NSTEMI). Request is for a power wheelchair.  Power Wheelchair is not medically necessary for this patient. Provider notes that the patient is able to use a walker in the home. The use of an electric scooter/wheelchair outside of the home is not appropriate. If the patient is able to use a walker in the home patient should be capable of using a manual wheelchair outside of the home. Therefore, a customized manual wheelchair is more appropriate and within the generally accepted standards of medical care. The HP determination is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back and neck pain
Issue under review: Increase in consumer directed personal care assistance services

Determination:
The Increase in consumer directed personal care assistance services is medically necessary.

The patient has a history of chronic low back and neck pain. Due to these conditions, she has difficulty ambulating with associated gait ataxia, frequent falls and difficulty completing her activities of daily living (ADLs). Furthermore, her chronic musculoskeletal pain and decreased range of motion have rendered her chronically homebound, as she is unable to sit/stand/walk for prolonged periods of time longer than 20 to 30 minutes. In addition, she is restricted from bending/pushing/crouching/squatting/stooping and lifting/carrying greater than 10 lbs, per functional assessment statement. For these reasons, the proposed treatment of an increase in consumer directed personal care assistance services from 30 to 40 hours per week is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Liver Disease/Fatty Liver
Treatment: Magnetic Resonance Imaging, Abdomen

Summary:
No, the proposed MRI abdomen/MRCP is not appropriate and medically necessary for the evaluation and management of fatty liver and simple liver cyst. The patient has mild elevation of ALT due to underlying fatty liver disease. She had an MRI of the abdomen in December 2016, which revealed fatty liver disease and a small 3mm cyst in the right lobe of the liver. There was no evidence of biliary disease/obstruction/ or primary sclerosing cholangitis (PSC). Since there is no evidence of biliary obstruction or biochemical evidence of cholestasis (intra- or extra-hepatic cholestasis) based upon the liver function tests, no further evaluation is required.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Melanoma
 
Treatment: The DecisionDX-Melanoma Assay test

The insurer denied the  DecisionDX-Melanoma Assay test. The denial was upheld.

This is a male patient with a history of Melanoma. According to his surgical pathology report, he had a melanoma 2.3 millimeter thickness and a basal cell carcinoma on the left side of his forehead. As recommended, the patient underwent further testing for his diagnosis. The test revealed that the patient was a low risk for a reoccurrence.
 
The DecisionDx-Melanoma, a 31-gene panel assay, is stated to determine the risk of recurrence and metastases of the melanoma. However, the test is still investigational and is not the standard of care. According to the National Comprehensive Cancer Network (NCCN), routine genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study.  Given that the current recommendations at this time do not include the use of DecisionDX gene expression testing and the current peer-reviewed literature shows studies are needed to identify the clinical utility of such testing, the DecisionDX UM testing is not medically necessary.

Based on the above, the medical necessity for the Decision DX-Melanoma Assay test is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Syncope and Acute Renal Insufficiency 

Treatment:  Inpatient Admission

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

The patient is a middle aged male who presented to the ER with complaints of syncope.  The patient has a past medical history of diabetes mellitus.  The patient was given intravenous fluids and admitted for syncope and acute renal insufficiency.  Troponin level and EKG were unremarkable.  CT of the head showed no intracranial hemorrhage.  Cardiology consultation recommended CT angiography of the heart and echocardiography; both exams were unremarkable.  Carotid duplex ultrasound showed no significant stenosis.  He remained clinically and hemodynamically stable and was discharged home.  

The patient presented with a syncopal event; however there were no signs or symptoms of hemodynamic instability, myocardial ischemia, arrhythmia, heart failure, cerebrovascular insufficiency or other organ dysfunction requiring inpatient admission status.  The patient's clinical status was evaluated and deemed to be stable in the emergency department.  The care provided could have been administered under observational level of care with up to 23 hours of monitoring, or solely the emergency department. 

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: Upheld

The patient who presented to the emergency department (ED) with chest pain described chest pain as aching, squeezing chest pain in the  left chest and left arm when walking. The pain resolved with rest. Also, occasionally the pain happened at night. Two days prior to presentation the  patient had nausea with episode of chest pain.
The patient has history of coronary artery disease (CAD), and coronary stent placement in the past. The  health plans determination of medical necessity is upheld in whole .The  ECG did not reveal ischemia the  troponin was normal. The  nuclear stress test did not reveal evidence of ischemia. The  echocardiogram was abnormal with evidence of left ventricular hypertrophy (LVH), but there were no wall motion abnormalities.
The patient remained stable on medical management. The patient was evaluated and treated however, the level of care for this patient did not meet criteria for inpatient admission. The care could have been provided at a lower level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope
 
Treatment: Inpatient admission, telemetry monitoring, diagnostic testing

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

The patient is a male who presented to the Emergency Department (ED) for evaluation of syncope. The patient was walking in the morning and had a sudden episode of syncope. The patient recovered and showed no evidence of injury and is now asymptomatic. The patient had no post-episode confusion or incontinence. There was no known relieving or aggravating factors. The patient has a history of similar episodes in the past. There was no pre-or post-episode chest pain, headache, shortness of breath, abdominal or back pain, palpitations, weakness or tingling sensations. The patient's vital signs include blood pressure 110/62, pulse 77, temperature 97.8 F., respiratory rate 16, oxygen saturation 100% on room air. 

His physical and neurologic exam described no abnormalities. The patient had a history of anemia, diabetes mellitus, gastroparesis, hypertension and pancreatitis. Bloodwork results include glucose 321, blood urea nitrogen (BUN) 12, creatinine 1.4, sodium 131, potassium 6.4- hemolyzed (repeat was 5.0). His hemoglobin A1C was greater than 15 and troponin series were within normal limits. A CT of the brain showed no acute abnormality. A chest x-ray was normal. His EKG showed no change from previous. The patient was admitted to telemetry for cardiac monitoring. An ultrasound study of the extra cranial vessels showed less than 20% left and right internal carotid stenosis. An echocardiogram was normal. The patient left Against Medical Advice (AMA).

This patient presented to the ED after an episode of syncope. His troponins were normal and his EKG showed no change from previous studies and no evidence suggesting myocardial injury or ischemia. An echocardiogram showed no evidence of valve disease or hypertrophic cardiomyopathy. Other studies showed no significant abnormalities. The workup this patient required could have been done in a less acute setting such as an observation unit or a syncope unit.

 The medical necessity for Inpatient Hospital Services is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Emesis, abdominal pain, end stage renal disease
Treatment:  Inpatient admission
The inpatient admission was not medically necessary.

The patient had emesis and abdominal pain which were referable to chronic pancreatitis. There was no evidence of acute pancreatitis or acute pancreatic pseudocyst. Computed tomography of the abdomen/pelvis demonstrated no acute process. The diet was advanced successfully and symptoms improved promptly with conservative therapy.  The patient remained hemodynamically stable and afebrile. The white blood cell count was normal. The patient did not have uremia, acidosis, volume overload, or hyperkalemia. Hemodialysis was performed without complication.  

In summary, inpatient admission was not medically necessary. The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient in making its determination.
Appeal type: Medical necessity
Decision: Overturned

The patient is a man with a history of diabetes. He presented to the emergency department complaining of cough, chest pain and dyspnea. He was diagnosed with right lower lobe pneumonia and sepsis. The following day an echocardiogram showed a markedly decreased left ventricular ejection fraction (LVEF) of 10%. A cardiac catheterization showed a chronic total occlusion of the left anterior descending coronary artery; the distal vessel filled via collaterals. There was a 95% proximal right coronary artery occlusion. Myocardial perfusion imaging showed diffusely viable myocardium. The patient then underwent coronary artery bypass graft surgery. Postoperatively, a LifeVest wearable cardioverter defibrillator (WCD) was prescribed. The health plan denied the LifeVest as not medically necessary. The health plan's determination is overturned. 

Depressed left ventricular systolic function is a risk factor for, and powerful predictor of, sudden arrhythmic death. Consequently, implantation of an implantable cardioverter defibrillator (ICD) for the primary prevention of sudden cardiac death is a widespread practice, proven to be beneficial to heart failure patients with a variety of cardiac diagnoses. Current guidelines support ICD implantation in patients, such as this man, with ischemic cardiomyopathy, and left ventricular ejection fractions of 35% or less. 

However, due to the possibility that left ventricular function may improve with revascularization, it is recommended that device implantation be delayed for at least 90 days following coronary artery bypass graft surgery or percutaneous coronary intervention. If, 90 days post-revascularization, the LVEF remains less than or equal to 35%, ICD implantation is then recommended. However, the degree to which revascularization mitigates the risk for serious ventricular arrhythmias during this 90 day period is unclear. Accordingly, many physicians prescribe the LifeVest wearable cardioverter defibrillator (WCD) as a "bridge" to potential ICD implantation in these patients. The efficacy of the WCD in terminating serious ventricular arrhythmias compares favorably to that of the implanted device. In one large retrospective study of patients with left ventricular ejection fractions of 35% or less after coronary artery bypass graft surgery (CABG) or percutaneous coronary intervention (PCI), the WCD was associated with a lower 90-day mortality in patients after CABG (no WCD: 7% vs WCD: 3%) and after PCI (no WCD: 10% vs WCD: 2%). Per the 2016 Science Advisory from the American Heart Association, use of the WCD in cases such as this one is a reasonable approach.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope versus seizure
 
Treatment: Brain magnetic resonance angiography

The insurer denied the brain magnetic resonance angiography. The denial was upheld.

This is a female with a past medical history of cervical pain, migraines, fibromyalgia, syncope and anxiety.  She had mild migraines until several years ago; not recently an issue.  The patient had previous fainting spells which she felt were due to dehydration. She reported 3 episodes of feeling like she was going to pass out, followed by headache, right-sided numbness/paresthesia, and loss of consciousness.  There was no seizure activity, urinary incontinence or tongue biting.  A magnetic resonance imaging (MRI) of the brain was normal. Given the patient's clinical history and MRI of the brain, further imaging including a MR angiography (MRA) of the head and neck was felt to be medically necessary.

Medical literature indicates head MRA may be indicated if aneurysm or arteriovenous malformation is known or suspected, as indicated by follow-up monitoring for a patient with a history of subarachnoid hemorrhage, aneurysm or arteriovenous malformation, initial evaluation of suspected aneurysm or arteriovenous malformation, or re-evaluation after surgical or endovascular therapy for cerebral artery aneurysm or arteriovenous malformation.  The physician had concern for syncope versus seizure.  An electroencephalogram (EEG) was ordered.  MRI of the brain did not reveal evidence of infarct, mass lesion or hydrocephalus. The patient was to undergo an MRA of the head/neck to exclude the presence of an underlying vascular lesion or dissection.  The patient did not require follow-up monitoring for a history of subarachnoid hemorrhage, a known aneurysm or arteriovenous malformation, and did not require a head MR angiography for initial evaluation of a suspected aneurysm or arteriovenous malformation, such as an acute severe headache.  There was no other indication as to why an MRA of the brain would be appropriate.  

The carrier's denial of coverage for the brain magnetic resonance angiography (MRA) is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

The patient has cocaine, alcohol, opiate and cannabis dependence and was admitted to an inpatient detox service. Patient endorsed typically using alcohol, heroin and cocaine daily. The reported  last use of cocaine and heroin was the day prior, but had drunk two 24 ounce beers earlier that day. Blood alcohol level was zero and urine was positive for cocaine, opiates and tetrahydrocannabinol (THC). Complained to nursing of hot/cold sweats, tremors, diarrhea, headache, abdominal pain, and joint pain. Initial vital signs included a mildly tachycardic pulse of 105 and a normal blood pressure of 128/72. To the nurse practitioner patient complained of the same symptoms; in addition,  nausea, anxiety, irritability, diarrhea, and teary eyes. The physical exam did document tremors and a flushed appearance. The initial Clinical Institute Withdrawal Assessment (CIWA) score was 16 and Clinical Opiate Withdrawal Scale (COWS) was 15.
The patient reported a psychiatric history of anxiety, depression, and post-traumatic stress disorder (PTSD). Denied current suicidal thoughts and denied current outpatient treatment. Has a history of suicide attempt while intoxicated on alcohol. Patient reported over 100 past treatment episodes and has serious legal and personal consequences from use. Patient was admitted to the detox unit and placed on methadone and Ativan withdrawal protocols. The service of inpatient detoxification treatment was medically necessary The patient has a documented history of chemical dependence on multiple substances (opiates, alcohol, cocaine, and cannabis). Patient has a shelter bed but does not have a sober support network. The CIWA, COWS and physical exam on admission all are consistent with clinically significant withdrawal. Of the substances used, the potential for alcohol withdrawal is the most clinically serious given that alcohol withdrawal can be fatal. Patient does not have a known history of serious withdrawal, but serious withdrawal can manifest at any time in the illness course. The chronicity and amount of  use also places patient at increased risk for withdrawal. The combination of alcohol withdrawal with opiate withdrawal does increase risk of medical complication. An admission LOCADTR  resulted in a recommendation for inpatient services. The HP determination is overturned in whole.
Appeal type: Medical necessity
Decision: Upheld

This is a patient a past medical history significant for hypertension and gastroesophageal reflux disease (GERD) who presented to the emergency department (ED) with complaints of high blood pressure. Apparently, the patient did not take her blood pressure medications on the day of the presentation to the ED. While in the emergency department, the patient started to have left-sided chest pain that radiated to the left arm. She described the pain as throbbing, non-exertional. The patient also complained of epigastric abdominal pain and nausea. It was associated with sweating and palpitations.
During the hospital stay, the patient was ruled out for acute coronary The health plan's determination of medical necessity is upheld. The patient presented with atypical chest pain. Considering her risk factors, which included hypertension and hyperlipidemia, it was appropriate to rule out acute coronary syndrome and this was ruled out. The patient was seen by the cardiology service and was found to have atypical chest pain. No intervention was needed.
Even though the patient came to the hospital with elevated blood pressure, there was no evidence that she had a hypertensive emergency or any other complications that would require management of the blood pressure in inpatient settings.
Appeal type: Medical necessity
Decision: Overturned

The patient presented to the hospital in early 2019. The patient had a history of chronic lymphedema, recurrent lower extremity cellulitis, and scrotal cellulitis. The patient presented complaining of lower extremity edema, warmth, and scrotal pain. The patient's symptoms were worse on the left side. He also reported fever, sore throat, and nausea. The patient denied chest pain, shortness of breath and diarrhea. The plan of care included intravenous (IV) antibiotics, IV fluids, blood cultures, lower extremity ultrasound, ultrasound of the scrotum, and consider iron supplementation. 

The health plan's determination is overturned. The inpatient stay is medically necessary. The patient presented with sepsis and cellulitis and had some evidence of hemodynamic instability with tachycardia. He required IV antibiotics and there was concern for toxic shock initially as a possible complication of the patient's presentation. In addition, the white blood cell count was markedly elevated and he had a relatively high fever. The patient was it increased risk of having an adverse outcome because of these factors and it would not have been appropriate to manage at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

The patient was referred from the High Risk OB clinic for admission for glycemic control. The obstetrical history was significant for 1 cesarean section. The patient had history of 2 prior admissions for glycemic control. On presentation, the patient's blood glucose was 61. There were no obstetrical complaints. Fetal heart rate tracing was reassuring. The inpatient admission is under review.

The health plan's determination is upheld. The inpatient stay was not medically necessary. Based on provided clinical information, the records did not indicate any evidence of hyper/hypoglycemia; fetal heart rate tracing and ultrasound examination were normal; the patient was hemodynamically stable. there was no evidence of ketoacidosis; there was no abnormal bleeding, PPROM (Preterm premature rupture of the membranes) or preterm labor. Insulin regimen (each dose) was increased only by 2 units; the initial and subsequent FS assessments were all normal.
Appeal type: Medical necessity
Decision: Upheld

The patient is a previously healthy female, whose family has limited English proficiency, who presented to the emergency department (ED) with fevers, vomiting and diarrhea. Symptoms began approximately 1 month prior with waxing and waning course. There were no associated respiratory symptoms or recent travel. Of note, ED records indicate that this child was still nearly exclusively breast fed.

Labs showed white blood cell (WBC) count of 12 with 44 segs and 43 lymphs, hematocrit (Hct) 32, and platelets (Plt) 562. Sodium (Na) 136, potassium (K) 4.0, chloride (Cl) 105, carbon dioxide (CO2) 15, blood urea nitrogen (BUN) 10, creatinine (Cr) 0.45, and glucose (66). Liver function tests (LFTs) and bilirubin were normal. Initial urinalysis (UA) showed specific gravity (SG) 1.020 and small ketones. The patient received intravenous fluids (IVF) bolus x 2 and intravenous (IV) Zofran. She was admitted to the pediatric ward where she continued to receive IVF and advance diet as tolerated. Her diarrhea and other symptoms improved, and she was able to be discharged home two days later.

The health plan's determination is upheld.

The requested inpatient stay was not medically necessary for this patient.
This patient was hemodynamically stable with mild dehydration secondary to acute gastroenteritis. She received 2 IVF boluses in the ED, but reportedly failed an oral challenge so was admitted to the hospital. Hospital notes indicate continued diarrhea, but do not indicate continued vomiting or other complications. Therefore, based on patient condition her care could have been managed at a lower level of care status.