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

Diagnosis: Chest pain; Diaphoresis
Issue under review: Inpatient admission

Determination:
The Inpatient admission was medically necessary.

The patient is an adult male with multiple medical problems. He presented to the hospital with chest pain and diaphoresis. He noted that chest pain varied with position accompanied by diaphoresis.  His relevant past medical history included ischemic cardiomyopathy status post coronary artery bypass surgery with preserved left ventricular ejection fraction, sick sinus syndrome status post dual chamber pacemaker implantation, hypertension and chronic kidney disease. Additional past medical history included previous heroin addiction treated with methadone and anxiety disorder.  

Upon arrival, the patient's BP (blood pressure) was 180/100 and pulse was 60bpm.  No other abnormalities were noted on physical examination. ECG (electrocardiogram) revealed sinus rhythm with right bundle branch block and diffuse T wave abnormalities without changes from baseline.  Patient's chest pain resolved spontaneously and serum high sensitivity troponin was in the indeterminate range.  The patient was discharged the following day with cardiology follow up.

This patient presented with chest pain and diaphoresis.  His pretest probability of coronary artery disease is high, given his history of CABG (coronary artery bypass graft) and T wave abnormalities on electrocardiogram (Reference 1).  Utilizing the HEART (History, EKG, Age, Risk factors, initial Troponin) score, he was considered high risk (Reference 2). 

Risk assessment of patients presenting with chest pain was reviewed by Hedayati et al (Reference 3).  Using the HEART score risk stratification schema, this patient would have a high risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation. These findings are concerning and warrant management and evaluation at a higher level of care. High sensitivity troponin levels were mildly elevated and in the "indeterminate" range. Observation on telemetry with serial ECGs and serum blood testings were warranted prior to discharge.    

In conclusion, admission to the hospital to treat an acute cardiac event was medically necessary. In conclusion, given the patient's presentation and multiple cardiac risk factors, inpatient hospital admission was appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath
Treatment: Inpatient admission

The Inpatient admission was not medically necessary; inpatient level of care was neither indicated nor provided.

The patient is a female. She presented to the ED with shortness of breath. She was chest pain-free in her initial evaluation. 

The patient's exam was normal except for hypertension. CXR (chest x-ray) was negative. CT chest was negative. EKG (electrocardiogram) was normal. Nuclear stress test showed no evidence of ischemia. Echocardiogram showed normal LV (left ventricle) function without any wall motion abnormalities (WMA). Enzymes were negative. Abdominal ultrasound was negative. The patient was treated with IV and ASA (aspirin). The patient was discharged to home.

The appeal letter referenced Milliman's section on angina to justify the admission; however there is no evidence of angina in the presentation, tests results, and treatment. The EKG and enzymes were normal. Echo and nuclear stress test showed normal LV function, no evidence of ischemia, and no wall motion abnormality. 

The letter of appeal was carefully considered, but it offered no evidence to support an inpatient level of care. The only cardiac care that was provided was telemetry, which is frequently performed in a lower level of care. The patient was admitted for monitoring, and the subsequent tests and therapy did not require an inpatient level of care. There was no "complex" care that required inpatient level of care. This patient had no evidence of CAD (coronary artery disease). In fact, all tests showed absence of ischemia.  While there was always a potential for an adverse event, one did not happen, and no actual treatment was added.

Milliman criteria requirements were not fulfilled, as there was never any evidence of ACS (acute coronary syndrome) present.
 
Determination of level of care is primarily dependent on the actual care a patient receives, and whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results. It is highlighted in the orders for care. 

In this case, the patient's symptoms were atypical and unlikely to be representative of acute coronary syndrome. Her symptoms had resolved before admission, and no justification for the diagnosis of angina was present. Her exam (BP [blood pressure] normalized) and cardiac findings were normal. Biomarkers and EKG showed no evidence of acute ischemia. CXR was normal. Echocardiogram showed no wall motion abnormality.  Nuclear scan was negative for CAD. The physicians' treatment did not reflect any serious concern about the patient's cardiac condition.  Orders did not include medical therapy for ACS, such as IV heparin, dual antiplatelet inhibitors, high dose beta blockers or IV NTG (nitroglycerin).  

All of the testing and therapy that were provided would have been appropriate, safe and guidelines-consistent in a lower level of care. Thus, inpatient level of care was not medically necessary.

The denial explanation was consistent with guidelines and usual community care.
Appeal type: Experimental/Investigational
Decision: Upheld

Cardiac/Circulatory Problems
Radiology Services (including Ultrasound)

The patient is a male with past medical history of headaches which are managed with amitriptyline who was admitted for acute pericarditis. The criteria he met for the diagnosis was the chest pain and the electrocardiogram (EKG) changes showing ST elevations and PR depression. He had a negative troponin ruling out a myocardial process. Additionally, his echocardiogram was normal showing normal biventricular systolic function and no evidence of pericardial effusion. He had incidental findings of mildly dilated aortic root and ascending aorta which were concerning for connective tissue disorder. He was discharged home with ibuprofen and colchicine. He followed up in Pediatric Cardiology clinic 1 week after discharge where he reported that his pain resolved completely 3 days ago. He has been asked to follow up in Pediatric Cardiology clinic in 3 months to follow up on this incidental findings with the working diagnosis of connective tissue disorder.
The use of Myocardial Strain Imaging is under review.

The health plan's determination is overturned. The Myocardial Strain Imaging is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. 
He did have incidental echocardiogram findings of aortic root and ascending aorta dilation which could be secondary to a connective tissue disorder. Per Mavrogeni et al, "Despite etiology, symptoms of cardiovascular disease (CVD) in ARD patients are usually subtle and are often underestimated or dismissed as constitutional symptoms of the underlying systemic disease. Clinically. overt cardiovascular signs and symptoms present late in the course of CVD in patients with ARDs and carry a poor prognosis because they indicate advanced stages of cardiovascular damage and/or decompensation." Hence, evaluation of myocardial tissue through myocardial strain imaging can provide crucial data for patients in whom connective tissue disorders are suspected.
Appeal type: Experimental/Investigational
Decision: Upheld

Cardiac/Circulatory Problems
Radiology Services (including Ultrasound)

The patient is a male who presented to the emergency department with a 2-3 day history of mild chest discomfort following a viral like illness the week prior. His physical examination in the emergency department was considered unremarkable and laboratory blood work demonstrated a slight elevation of inflammatory markers, a negative troponin, ST segment elevation on electrocardiography and a normal echocardiogram with normal biventricular systolic function and no evidence of a pericardial effusion. Under review is the use of Myocardial Strain Imaging.

The health plan's determination is upheld. The Myocardial Strain Imaging is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. Based on the information submitted including a normal transthoracic echocardiogram and negative troponin on the day of presentation, there was no indication to perform myocardial strain imaging as a superior imaging modality. In fact, no additional echocardiograms were performed during the patient's hospital stay also consistent with the patients underlying diagnosis. The patient demonstrated historical and clinical evidence of pericarditis without a pericardial effusion or myocardial involvement on two consecutive echocardiograms and therefore the use of myocardial strain imaging was of no value. Although myocardial strain imaging is an approved non-invasive imaging modality in patients with ventricular dysfunction, it was not indicated in this particular patient based on the diagnostic information obtained.
Appeal type: Experimental/Investigational
Decision: Upheld

Cardiac/Circulatory Problems
Radiology Services (including Ultrasound)

The patient is a previously healthy male with a history of two days of acute chest pain. He was seen in the Emergency Department where he was found to have a normal physical exam, electrocardiogram (ECG) with ST segment changes and mild PR depression, normal troponin levels, and a echocardiogram with normal systolic ventricular function and no pericardial effusion. He was diagnosed with uncomplicated pericarditis and discharged home the next day on ibuprofen and colchicine therapy. He was seen in clinic one week later and his ECG had normalized. His systolic function was normal without effusion. He was told to continue his ibuprofen and colchicine therapy and to follow up in 3 months. During one of his echocardiograms, he had myocardial strain imaging, which is a relatively new method to assess ventricular function and predict heart disease. This is under review.

The health plan's determination is upheld. The Myocardial Strain Imaging is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. Myocardial strain imaging has been shown to be of benefit in patients with constrictive pericarditis. However, that is a chronic condition and this patient had uncomplicated, acute pericarditis. The recommendations are that these patients have a transthoracic echocardiogram with assessment of systolic function, which he had.
There is no indication for strain imaging in this situation. Further, if constrictive pericarditis were a concern, cardiac magnetic resonance imaging (MRI) or computed tomography (CT) imaging would have been a better option than strain imaging.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who presented to the emergency department (ED) with signs and symptoms of early acute appendicitis. An ultrasound (US) confirmed the clinical impression. He was admitted overnight and went for an uncomplicated laparoscopic appendectomy the following day. Postoperatively, he recovered and was discharged home from the recovery room doing well tolerating a diet with good pain relief. At issue is the medical necessity of an inpatient stay. 

The health plan's determination is upheld. An inpatient stay was not medically necessary based on the documentation provided. The patient could have been safely and appropriately managed at a lower level of care. Moreover, patients with acute non-perforated appendicitis like this child had can often be discharged home the same day from the hospital, without an overnight stay. He underwent an uncomplicated laparoscopic appendectomy. An inpatient stay could be justified if there was some diagnostic dilemma (eg., complicated appendicitis when ultrasound had been read as uncomplicated), an untoward perioperative event, intraoperative injury or complication, inadequate physiologic recovery, hemodynamic instability, acute organ injury, persistent altered mental status, fever or other signs of septic complications, surgical site complication, management of complex comorbid medical condition or a finding of an occult or new medical condition. Surgical treatment of otherwise healthy pediatric patients with acute nonperforated appendicitis is usually provided at a lower level of care. 

In one study authored by Aguayo et.al., in over 500 cases, approximately 28% (number [n]=128) were discharged on the day of surgery. Of the remaining patients, 12.9% (n=59) stayed overnight for medical reasons, 0.4% (n=2) stayed for social reasons, 3.9% (n=18) stayed because the operation ended late in the evening, and 82.8% (n=381) stayed because of clinical care habits. Compared with patients who stayed overnight, there was no statistically significant difference in readmission rates (0.7% versus 1.9%, P=0.6%), follow-up before scheduled appointment (5.4% versus 5.4%, P=1.0), and complication rate (0.7% versus 2.6%, P=0.3). Patients whose operation ended later in the day had a longer hospital stay. Thus same day discharge is safe for children undergoing laparoscopic appendectomy for nonperforated appendicitis. These data strongly suggest that for most patients with acute, nonperforated appendicitis who undergo an uncomplicated appendectomy, a lower level of care is appropriate since their needs are low acuity and the recovery is generally smooth and uneventful. Based on the literature and widespread experience with modern treatment of pediatric acute appendicitis, an inpatient acute level of care is not justified for acute, uncomplicated appendicitis.
Appeal type: Medical necessity
Decision: Overturned

This patient has a history of  reactive airways disease, eczema, and occasional nocturnal dyspnea . The patient presented  with cough, fever, decreased intake and increased work of breathing. The patient was treated multiple times with albuterol nebulizers with minimal improvement.  The health plan's determination of medical necessity is overturned in whole.The inpatient hospital stay was medically necessary. For patients with moderate to severe exacerbations that do not respond to such intensive therapy in the Emergency Department, admission is necessary.  The patient did meet standard of care criteria for acute inpatient admission to the PICU, and the patient also met the national guideline criteria for management of status asthmaticus or acute asthma exacerbation. The hospital stay was medically necessary as an acute inpatient stay.
Appeal type: Medical necessity
Decision: Upheld

This patient has a history of rheumatoid arthritis.  The Rheumatologist ordered the Vectra Disease Activity Test for the patient in 2018.  The test requisition form notes that the test is medically necessary for the treatment and management of the patient.  Results of the test indicate the patient's Vectra Disease Activity Test Score was 32 (moderate).  The insurer has denied coverage for CPT Code 81490, Autoimmune (rheumatoid arthritis) analysis of 12 biomarkers using immunoassays, utilizing serum, prognostic algorithm reported as a disease activity score.  The denial was upheld.  The only clinical information provided for review is that the patient had a Vectra Disease Activity Test done in 2018 that was mildly elevated at 32.  No other information about disease extent, duration, treatment, response to treatment and reason for ordering the test or what the response was to the result is given.  In a letter a representative of the test manufacturer notes that the assay helps predict long-term joint damage and can be used to manage and alter therapy, including in situations where methotrexate has not worked.  In the www.uptodate.com chapter "Biologic markers in the diagnosis and assessment of rheumatoid arthritis" section "Multi-protein biomarker algorithms" it is noted risk of long-term joint damage can be assessed using an assay such as Vectra Disease Activity.  It is, however, also noted that "Whether multi-biomarker disease activity [e.g. Vectra Disease Activity] has a useful role in informing a clinical management decision has been more controversial...".  As already noted above, there is no clinical information provided for review.  The provider was contacted on multiple occasions to obtain records.  This reviewer cannot assess what clinical issues were being addressed when the test was ordered, what treatment decisions if any were being considered, and how the test was being used.  The documentation submitted does not support the need for the requested service.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse
Issue under review: Inpatient rehabilitation

Determination:
The Inpatient rehabilitation was not medically necessary.

The inpatient substance abuse rehabilitation treatment, in this case scenario, was amenable to treatment at a lower level of care. The patient was motivated and able to effectively engage in rehabilitation services, and the patient did not need the structure or 24-hour monitoring of an inpatient setting in order to safely and effectively participate in rehabilitation substance abuse treatment. There were no biomedical or psychiatric complications, or severe psychiatric symptoms/disorders in this case that would have warranted inpatient level services and treatment. Moreover, the patient had family support for the substance use disorder treatment with fair insight, as noted in the clinical summary. Thus, the requested benefit of Inpatient rehabilitation was not medically necessary for this patient 

This answer is consistent with prevailing standards of professional practice, ASAM Criteria, and the scientific literature, referenced below, as well as New York State instruction for medical necessity reviews together with the NY State OASAS LOCADTR 3.0 Criteria applicable in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness, severe headache, blurry vision, tinnitus, nausea, vomiting 

Treatment: Inpatient admission

Based on records sent, the inpatient admission was not medically necessary.
The available medical records provided for review do not include actual progress notes or documentation of the medical evaluations and/or treatment that was provided in reference to the dates of care.  As such, the available medical information provided for review does not support a determination that the patient met inpatient hospitalization requirements.  The available medical records do not document electrolyte disturbance or other electrolyte abnormalities.  There is no indication of cardiopulmonary instability and no indication that the patient could not be managed with alternative care including outpatient management for the noted time interval.
Therefore, based on the records available, the inpatient admission is not supported as medically necessary.
Appeal type: Medical necessity
Decision: Overturned

The patient was admitted to acute inpatient level services for detoxification of opioid (heroin), sedative-hypnotic-anxiolytic, and stimulant (cocaine) class substances. He was referred following an inadvertent overdose complicated by aspiration pneumonia. The patient was admitted to acute inpatient level care and was placed on a detoxification regimen with benzodiazepine (Ativan) and buprenorphine with medical monitoring. The health plan's determination of medical necessity is overturned. The patient was at high risk for complications such as seizures, or overdose with continued use, and he had initially required emergency medical care and stabilization prior to his referral for the inpatient stay including necessary treatment for pneumonia that had complicated his overdose. Thus, the patient did require a safe and effective detoxification with withdrawal management during the time frame under review, as it was foreseeable that the patient was unable to abstain from substances of abuse if detoxification were to be attempted at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Genitourinary / Kidney Disorder
Treatment:  Surgical Services

The patient is a male with a diagnosis of benign prostatic hyperplasia (BPH) with obstruction.  He has failed medical therapy.  He underwent an aqua ablation procedure.  The prostate volume was measured at 110 grams (g).  The subject under review is the medical necessity for the procedure.

The health plan's determination is upheld.

No, transurethral waterjet ablation is not medically necessary for this patient.  Aquablation is a novel procedure for management of BPH.  The aquablation procedure uses a targeted high velocity saline stream to ablate prostatic tissue without generation of thermal energy under real-time ultrasound guidance.  Current medical literature is limited with a few studies with limited long term outcomes.  As such, use of aquablation is not considered a clinically appropriate and generally acceptable standard of care for managing patients with BPH.  Therefore, it would be considered not the standard of care and not medically necessary.
American Urological Association (AUA) guidelines on BPH states "Aquablation may be offered to patients with lower urinary tract symptoms (LUTS) attributed to BPH provided prostate volume is more than 30 g and less than 80 g, however, patient should be informed in long-term evidence of efficacy and retreatment rates, remain limited."  European Association of Urology (EAU) guidelines on management of nonneurogenic male urinary tract symptoms states, "The first clinical experience provides encouraging results, with a low risk of sexual dysfunction, but further modifications of the aqua beam cystoscopy may be necessary.  Long-term follow-up will help us assess the clinical value of Aquablation."
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Depression 
Treatment: Nursing Services (including Private Duty Nursing) 

The patient is a female who lives alone with past medical history of osteoarthritis, spinal stenosis, peripheral neuropathy, history of retinal detachment with vision loss, Alzheimer's dementia, diabetes mellitus type 2, fibromyalgia, constipation, urinary incontinence, hypertension, aortic stenosis, angina, ataxia with falls, cirrhosis and obesity. She has personal care aide services 8 hours/day, 7 days a week to total 56 hours per with last assessment tool. In a letter, the provider requested an increase in personal care aide service due to "multiple medical problems" as well as depression/anxiety. This request was denied. The patient developed more difficulty with her memory and increased dizziness and imbalance resulting in frequent falls per provider documentation. The patient was seen for office visit reporting worsening tremor, dizziness and headache with frequent falls. The provider is requesting an increase in personal care aide (pca) level 2 services: total of 84 hours per week (12 hours per day/7 days per week) due to worsening ataxia, vision, memory requiring an increase in scheduled and unscheduled needs. 

The health plan's determination is overturned. The Increase in Personal Care Aide (PCA) Level 2 Services: Total of 84 Hours per Week (12 Hours per Day/7 Days per Week) is medically necessary for this patient. Since the patient's last assessment tool, she had a decline in her ADL's (activities of daily living) due to worsening osteoarthritis, vision loss, ataxia/dizziness and memory loss. The patient had frequent falls over the last year since her last assessment. The patient's provider felt it was medically necessary for the patient to have an increase in personal care aide service hours due to the change in her condition since the last assessment. Therefore, the requested services are medically necessary.