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

Diagnosis: Chest Pain 
Treatment: Inpatient stay

Summary:
The patient is a female. She has a past medical history significant for HIV/AIDS, HTN (hypertension), dyslipidemia, diabetes, CAD (coronary artery disease), s/p (status post) CABG (coronary artery bypass graft), mitral valve disease, s/p surgical repair, CVA (cerebrovascular accident), COPD (chronic obstructive pulmonary disease), nephrolithiasis, s/p prior stent placement, DVT/PE (deep venous thrombosis/pulmonary embolism), diverticulosis, ovarian cyst, migraine, and bipolar disorder. She presented for evaluation of left sided chest pain, abdominal pain, nausea and vomiting. The pain was rated 9 out of 10, radiating to the left arm. 

The patient presented with new onset chest pain, and presentation suspicious of unstable angina. The patient had multiple risk factors for CAD, including diabetes, as well as a known history of coronary artery disease, s/p CABG and mitral valve surgery. She had multiple co-morbid conditions. Given this presentation, suspicion for an acute coronary syndrome, as well as risk factors and known CAD, she would not be an appropriate candidate for an ED chest pain observation unit. It would be consistent with the current standard of care that this high risk patient be managed in an inpatient setting. Therefore, the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Overturned

Eye Pain
Inpatient hospital

This is the case of male with history of eosinophilic esophagitis (on Prevacid) who presented to the emergency department (ED) with a 3 day history of left eye pain. There was reported redness and swelling; he was previously seen at urgent care and given erythromycin for blepharitis but the symptoms worsened to include blurred vision and facial pain. There was no known trauma or foreign body. A review of symptoms (ROS) was negative for fevers, chills, headache, neck pain, gastrointestinal (GI) or genitourinary (GU) symptoms.

The health plan's determination is overturned. The inpatient hospital stay was medically necessary for this patient. This patient presented to the ED with worsening pain and redness in the left eye, that was not responding to antibiotic eye ointment that was previously prescribed. The physical exam and laboratory findings indicated infection, and the orbital CT was concerning for lacrimal abscess. Given the severity and progression of symptoms, this patient's hospitalization was medically necessary to treat with IV antibiotics and monitor closely for worsening.
Appeal type: Medical necessity
Decision: Overturned

This is  patient, at the time of admission, who presented with cough and nasal congestion x 3 days and increased work of breathing x 1 day. Per the parents, they were performing supportive care at home with mild improvement to her symptoms. On the day of presentation, the patient woke up with belly breathing, gasping but no cyanosis or facial color change. The  patient did have subjective fevers, decreased by mouth (PO) and decreased urine output.The health plan's determination is overturned in whole.

The requested health service/treatment of inpatient stay was medically necessary for this patient. This patient presented with complaints of worsening respiratory status and decreased urine output as well as decreased PO intake. In the ER the patient  was assessed to be in significant respiratory distress with belly breathing, retractions and wheezing. The patient  did show improvement after ER management but had an episode of hypoxia that required supplemental oxygen. Laboratory studies also revealed elevated WBC as well as low CO2 which would support the history of poor PO intake and decreased urine output as significant. At the time of admission, the patient was requiring oxygen and continued to have intermittent belly breathing. It would then be in the best interest of the patient to admit to inpatient level of care to continue supplemental oxygen with continuous pulse oximetry and supportive respiratory care
It has been noted that oxygen saturation is the most consistent clinical predictor of deterioration. Continuous pulse oximetry and frequent respiratory assessment would be needed to monitor the patient's clinical status especially given the fact that the patient  required supplemental O2 to maintain  saturations and continued intermittently with signs of respiratory distress. Surveillance as an inpatient was reasonable and medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma Exacerbation 

Treatment: Inpatient hospital admission

The insurer denied coverage for Inpatient hospital admission.  The denial was upheld.

This patient is a female with history of asthma, hyperlipidemia, diabetes mellitus, who presented to the Emergency Department (ED) with complaint of shortness of breath.  The patient had not obtained relief from use of nebulizers so came to the ED.  The patient was also reportedly taking steroids at home.  The patient also complained of productive cough with yellow sputum for the past three days along with sore throat.  The patient denied fever, chest pain, nausea, and vomiting.  The patient was on home oxygen 4 liters by nasal cannula.

The patient's vital signs at presentation were: Temperature (T) 98.4F, respiratory rate (RR) 24, heart rate (HR) 82, blood pressure (BP) 122/77 mm Hg and oxygen saturations 97%.  Lung exam revealed bilateral wheezing.  The patient was treated with nebulizers and steroids.  The patient improved after treatment and felt much better.  Lung exam had improved.  White blood cell (WBC) count was 9.5 K.  Hemoglobin (HB) 9.7 g, electrolytes were within normal limits (WNL).  Chest x-ray was unremarkable.  Flu test was negative.  The patient was admitted with diagnosis of Asthma Exacerbation.  The patient was continued on Duo Nebs every 6 hours, and Albuterol when necessary (PRN).  The patient was continued on intravenous (IV) Steroids.  The patient was also continued on Breo Ellipta.  The patient was also receiving Montelukast 10 mg daily.  The patient was subsequently discharged.

This patient did not need acute hospitalization.  The patient had improved after treatment in the Emergency Department.  As per History & Physical the patient was alert and oriented.  She was speaking in full sentences.  There was no use of accessory muscles.  The patient was afebrile and hemodynamically stable.  She was not hypoxic.  Oxygen saturations were 97% on nasal cannula (the patient was already on home oxygen).  Respirations were non-labored.  There was wheezing present.  Breath sounds were equal.  Cardiovascular system was normal.  The patient was awake and alert.  Neurological exam was non focal.  There was no leukocytosis.  Chest x-ray was within normal limits.  Peak expiratory flow (PEF) had improved to 71% of baseline after Emergency Department treatment.  Oxygen saturations were 96% off oxygen noted.  The patient was tolerating oral intake.  The patient remained afebrile and hemodynamically stable after admission.  She could have been discharged after evaluation and treatment in the Emergency Department.  The patient was stable enough to be discharged on oral steroids and bronchodilators and other maintenance medications.  The patient could have been followed up closely in an outpatient setting.  

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital admission at the acute inpatient level of care is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain; shortness of breath (SOB)

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission. The denial was upheld.

This patient is a male with history of asthma, obesity, cocaine and marijuana use who presented to the Emergency Department (ED) with complaint of shortness of breath (SOB) for one day.  The patient had used cocaine the previous night, following which her shortness of breath worsened, and the patient presented to the Emergency Room (ER).  The patient also complained of some numbness, blurry vision and headache.  Vital signs at presentation were temperature (T) 99.2 F, heart rate (HR) 110, respiratory rate (RR) 18 and blood pressure (BP) 123/88 mm Hg.  The patient's physical exam was unremarkable.  Lungs were clear.  There was some decreased breath sounds.  Cardiovascular system - S1, S2 were normal.  The patient was awake and alert. Chest x-ray showed no acute infiltrates.  Head CT showed no acute pathology.  The patient was treated with Duo Nebs, oxygen (O2), Magnesium and Solu-Medrol.  The patient was admitted to Telemetry for serial EKGs and troponins.

The patient remained stable after admission; the patient was afebrile.  He was hemodynamically stable.  Respiratory rate (RR) was 20.  There was no jugular venous distention (JVD).  Lungs were clear.  Follow-up troponins were 0.046 and a third troponin was 0.018.  Myocardial infarction (MI) was ruled out.  He was tolerating oral intake.  Lungs were clear.  He was not hypoxic.  White blood cell count was 9.3K. It appears that this patient did not need acute inpatient hospitalization.  He could have been placed in observation status and diagnostic studies and treatment done.  By specified date MI had been ruled out.  The patient was afebrile and hemodynamically stable.  Lungs were clear.  He was tolerating oral intake.  The patient could have been switched to oral steroids, bronchodilator and discharged home with close follow-up in an outpatient setting.    

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial was upheld.

This patient is a female who presented to the emergency room (ER) with complaints of syncope. She suffered a laceration on her right temple. Vital signs noted blood pressure 186/89. EKG showed normal sinus rhythm with poor R-wave progression and prolonged QT interval. Cardiology recommended admission for telemetry. CT of the head was negative for any acute pathology. Troponins remained negative throughout her stay. She was evaluated by psychiatry and discharged home for follow-up with her primary care provider and recommendations for medication compliance. 

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. 

The patient presented with a single 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 care could have been rendered under observational level of care with up to 23 hours of monitoring, or could have been administered solely the emergency department with administration of IV fluids.

Based on the above, the medical necessity for the inpatient admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned in Part

Chronic Obstructive Lung Disease/COPD
Nursing Services (including Private Duty Nursing)

The patient is a female with multiple medical problems including kyphosis, chronic obstructive pulmonary disease (COPD), diabetes and generalized debility. This review is for the medical necessity of increased personal care assistant hours to 42 hours a week. The patient requests an increase of personal care service hours from 7 hours per day 5 days a week to 7 hours a day 6 days a week for a total of 42 hours per week. The plan approved 35 hours a week.

The health plan's determination is overturned in part. Personal Care Assistance 6 days a week 6 hours per day for a total of 36 hours per week is medically necessary. The patient requires medical services daily. In the past, her husband was able to function to help her with some of the services on weekends however according to documentation provided he can no longer do so. The patient does have help for 1 day a week. Therefore, her needs would still be necessary every day of the week except Sunday because she has alternative help from another family member. However, service hours noted according to Uniform Assessment System (UAS) are in excess of the patient's needs. Therefore, 6 days a week 6 hours per day for a total of 36 hours per week is indicated. According to the UAS, this level of support is sufficient to meet the patient's needs. The hours were denied as the patient had a change in social circumstances since last assessment. However, the change has not impacted the patient's personal care assistance needs. After review of the assessment and plan of CARE, the recommendation is to continue current level of care. It is noted that the patient does require assistance with toileting, bathing, dressing, housekeeping as well as ambulation and transferring. It was noted that the patient was wheelchair bound and is only able to walk short distances. The Uniform Assessment System (UAS) noted that the patient required assistance with IADLs (Instrumental Activities of Daily Living) including meal preparation and housework and other level 1 services. The patient also required personal care aide services level 2 including showering, dressing, toilet transfer and incontinence care. It is noted that the patient ambulates with a walker. She does use oxygen. There is no noted hospitalizations. The patient is able to walk 150-299 feet at one time without sitting down to rest. The patient is not able to cook due to pain in joint and using oxygen. The personal care worker prepares all meals and spouse can reheat for member. In conclusion, a total of 36 hours per week are indicated.
Appeal type: Medical necessity
Decision: Upheld

Chest Pain
Inpatient hospital

The patient is a man with hypertension and type 2 diabetes who presented to the emergency room with complaints of chest pain, foreign body sensation on the right side of his throat and right sided abdominal pain. Blood pressure (BP) was 163/82 and pulse 65 beats per minute (bpm). Oxygen saturation was 100% on room air. Troponin T was elevated at 24 but decreased to 21 on serial testing. Creatine kinase (CK) was normal at 136 and CK MB was also normal at 4.23. Electrocardiogram (EKG) showed sinus rhythm at 81 bpm. He was admitted to telemetry.

The health plan's determination is upheld. The inpatient admission is not medically necessary. The patient was hemodynamically stable, had no respiratory distress or acute CHF symptoms, and did not meet criteria for acute myocardial infarction (troponin levels mildly increased, but flat, not indicating acute myocardial injury). There was no evidence of another critical cardiac or pulmonary diagnosis, such as aortic dissection or pulmonary embolus. Hospitalization could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Prostate Cancer
Cancer Screening

The patient is a male who underwent a prostate biopsy for an elevated prostate-specific antigen (PSA). The biopsy showed Gleason 6 adenocarcinoma in 5 out of 12 cores. The clinical stage was T1c. An OncotypeDx test was ordered on the biopsy specimens. Medical necessity of the test is under review.

The health plan's determination is upheld. The OncotypeDx testing is not medically necessary. While OncotypeDx may eventually have a role in making treatment decision about patients with prostate cancer, there is limited data on clinical outcomes to currently support routine use. Hence, it is not considered a generally acceptable standard of care for management of patients with a diagnosis of prostate cancer. It is not medically necessary in this case. The American Urological Association (AUA) Guidelines on Clinically Localized Prostate Cancer, 2017 states, "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. Tissue based genomic biomarkers have not shown a clear role in active surveillance for localized prostate cancer and are not necessary for follow up."
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism Spectrum Disorder (ASD)

Treatment: 30 Day Feeding Program Sessions

The insurer denied coverage for 30 Day Feeding Program Sessions. The denial was reversed.

This patient is a young child with Autism Spectrum Disorder (ASD) who was referred because he received all of his nutrition by drinking liquids solely from a baby bottle.  This is considered to be a very severe feeding delay.

The health plan denial stated that the patient received services from a speech therapist, but had not made any progress.  

This reviewer has read the reports. This is a case of extreme food sensitivity, which is not uncommon in children with ASD.  According to the reports, this child is not receiving intervention from a Speech-Language Pathologist alone, but appropriately, rather from a multidisciplinary team consisting of several relevant professionals.  This reviewer finds that this child has actually made quite substantial progress within the first ten sessions.  This child entered the program drinking only liquids from a baby bottle.  As noted in his mother's note he is now able to eat solid foods in a pureed consistency, and is able to accept the introduction of a spoon with the pureed solid foods.  He has also shown improvement in accepting a straw into his mouth rather than the bottle, which represents considerable progress.  The use of a straw requires a completely different lip and tongue configuration (retracted tongue) from the suckle pattern used in bottle drinking (tongue in a forward and flattened position).  The child has also overcome his sensory aversions enough to be able to tolerate a spoon and a straw intra-orally.  This would be considered considerable improvement within ten sessions for a child of his age and diagnoses. The reviewer agrees that this child has actually made "tremendous gains" and needs to continue his therapy program.

Sensory aversions and motor-planning deficits in young children with ASD, leading to severe delays in feeding skills, are complex medical issues that are best addressed through a professional team approach. This reviewer finds that the health care plan did not act reasonably or with sound medical judgment or in the best interests of the patient.

This reviewer finds that the requested 30 Day Feeding Program Sessions are considered medically necessary for this patient.

The carrier's denial of coverage for 30 Day Feeding Program Sessions is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

The patient in this case is a female with a history of chronic kidney disease and anemia.  She was sent to the emergency department (ED) by the outpatient clinic for evaluation and treatment of worsening anemia.  Her only symptom was weakness.   Hemoglobin was 6.0 grams per deciliter (g/dl).  

Physical examination was notable for pallor.  There was no documentation of significant hypotension or tachycardia.  She was admitted and treated with blood transfusion.  On the next day, the patient was seen by gastroenterology and gynecology.  Hemoglobin was improved to 7.3 g/dl.  She had no complaints and had not noted any significant vaginal or gastrointestinal bleeding.  She had been diagnosed with iron deficiency anemia.  Both gynecology and gastroenterology recommended outpatient follow up after hospital discharge.  The patient was discharged to home.

This patient had anemia with fatigue/weakness.  She did not have significant shortness of breath, hemodynamic instability or hypoxia.  She also did not have a history of active bleeding.  She was treated with transfusion and discharged the following day.  Given lack of ongoing blood loss and lack of hemodynamic instability, hypoxia or significant pulmonary symptoms, she did not require acute care hospital admission.  She could have been managed at a lower level of care such as outpatient.
Appeal type: Medical necessity
Decision: Overturned

The patient is a male without significant past medical history who presented to the emergency department with a 5-day history of pain, tearing, and partial vision loss in the right eye, as well as occasional headaches. The patient came to the emergency department according to the recommendation of his ophthalmologist, who examined the patient and suspected that he could have optic neuritis. Reportedly, the patient had a recent viral illness approximately 2-4 weeks before the day of admission.
At the time of admission, the patient denied any fever, chills, nausea, vomiting, shortness of breath, cough, sputum production, abdominal pain, changes in bowel habits, muscle weakness, or altered mental status.

The health plan's determination is overturned. The inpatient hospital stay was medically necessary for this patient because of the severity of the patient's condition determined by the presence of optic neuritis, and the need for administration of very high doses of intravenous corticosteroids, which might cause severe and potentially dangerous side effects. It is a standard of care to provide treatment with high doses of corticosteroids in inpatient settings, considering the high risk of side effects associated with treatment.