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

The patient is a male with cirrhosis complicated by ascites. He is reported to have hepatic failure. He has had abdominal pain, nausea, and ascites. Labs were notable for elevated aspartate aminotransferase of 82 international units per liter (IU/L), alanine aminotransferase of 58 IU/L, and elevated alkaline phosphatase of 222 IU/L.
The subject under review is the medical necessity for dronabinol 10 milligrams (mg) twice daily for the treatment of abdominal pain, nausea, and ascites.

The health plan's determination is upheld.

The request for dronabinol 10mg is not medically necessary.  Dronabinol is indicated for the treatment of anorexia in patients with acquired immunodeficiency syndrome (AIDS) and chemotherapy-induced nausea and vomiting, but not for abdominal pain, nausea, or ascites, as requested. [1,2] The plan's preferred alternatives metoclopramide, prochlorperazine, promethazine are effective for the treatment of nausea, and may require dosage adjustment but are not contraindicated in patients with hepatic impairment. [3,4] For these reasons, the request for dronabinol is not supported as medically necessary over the plan's preferred alternatives in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse
Treatment: Inpatient admission

The Inpatient admission was not medically necessary for this patient.

The proposed inpatient stay and detoxification treatment and other medical services noted in the clinical summary could have been safely and effectively provided at a lower level of care. The treatment of this patient's substance use disorder did not require the structure of an inpatient setting or 24-hour monitoring in a medically monitored treatment setting. The patient displayed no serious disturbance of mental status despite having a history of PTSD and depressive disorder and the ongoing substance use disorder with alcohol and intermittent use of cocaine and cannabis. Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance that would have warranted an inpatient level admission and treatment. There were no severe/objective symptoms of withdrawal or biomedical issues in this case, and the patient had received detoxification treatments recently with knowledge of substance use disorder treatment protocols, as noted in the clinical summary. The patient had fair insight and control of impulses, and a working knowledge of substance use disorder treatment with a past history of multiple treatment episodes, as noted. Thus, inpatient admission for detoxification treatment and 24-hour monitoring, and the requested inpatient level services were not medically necessary in this case scenario.

This answer is consistent with New York State OASAS LOCADTR 3.0 Criteria/Guidelines and with established practice guidelines, the scientific literature, and ASAM Criteria, as referenced below.

In this case scenario, the patient was amenable to treatment with lower level care in a less restrictive setting. The patient displayed no serious disturbance of mental status and no general medical complications or co-occurring psychiatric disorders that would have warranted inpatient level services. Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance that would have warranted an inpatient level admission and treatment. There were no severe symptoms of withdrawal or biomedical issues in this case. The admission for detoxification treatment and 24-hour monitoring, and the requested inpatient level services were therefore not medically necessary in this case scenario, as the health plan asserts. NY State OASAS LOCADTR 3.0 Criteria/Guidelines are not met, referenced below.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right upper quadrant pain
Treatment: Inpatient hospital admission

The inpatient admission was not medically necessary for this particular patient.

The patient presented with typical signs and symptoms of acute cholecystitis without any systemic infection. Both the heart rate and laboratory data were normal without any fever. The surgery was performed in a timely fashion without any untoward event, and recovery was as expected with same day discharge after having met discharge criteria. 

After an uncomplicated elective laparoscopic cholecystectomy, patients can drink clear liquids once awake from anesthesia, and their diet can be advanced as tolerated.

Most otherwise healthy, reliable patients with good home support can leave the hospital within six hours after surgery. Cochrane reviews have found no significant differences for important clinical outcomes for patients discharged the same day versus admitted overnight following laparoscopic cholecystectomy. A retrospective review of the American College of Surgeon's National Surgical Quality Improvement Program (NSQIP) database, which included 15,248 patients older than 65 years of age who underwent elective laparoscopic cholecystectomy, identified congestive heart failure, American Society of Anesthesiologists class-4, bleeding disorder, and renal failure requiring dialysis as significant independent predictors of inpatient admission and mortality

In conclusion, given the above, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic hepatitis
Treatment: Harvoni
The proposed Harvoni is medically necessary.

The physician in this case acted reasonably, with sound medical judgment and in the best interest of the patient. 

According to the American Association for the Study of Liver Disease (AASLD) guidelines for HCV treatment: "Glecaprevir/pibrentasvir should not be used with ...efavirenz" (1).   Glecaprevir/pibrentasvir also causes an interaction with the oxycodone the patient is taking. 

Harvoni treatment could also have the potential for adverse effects on the kidney, and the AASLD guidelines say that: "In patients with an eGFR <60 mL/min who are taking tenofovir disoproxil fumarate with ledipasvir/sofosbuvir, renal parameters should be checked at baseline and at the end of treatment" (1).  

Thus, although there is an interaction, it can be used with close supervision, unlike the recommendation for Glecaprevir/pibrentasvir. In short, the treatment with Glecaprevir/pibrentasvir is not medically necessary, while the treatment for Harvoni is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

The patient is a male with end-stage renal disease on hemodialysis, heart failure, human immunodeficiency virus (HIV), and hypertension. He presented to the emergency room with pain, swelling, and bleeding at the arteriovenous (AV) fistula site, along with numbness and tingling in the right 4th and 5th fingers, while being dialyzed. He was afebrile and the physical exam revealed that he was in no distress. There was some tenderness to palpation of the right arm AV fistula, a palpable thrill, an intact radial pulse, and no bleeding. Motor and sensor were intact. The vascular surgical consultant evaluated the patient and found no evidence of steal syndrome. Inpatient dialysis and observation were recommended.
Upon admission the patient was treated with intravenous acetaminophen and warm compresses. Apparently, an ultrasound guided access procedure was planned, but the patient left against medical advice.

The health plan's determination is upheld. 

Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam or labs an imminently life- or limb- threatening cause of the patient's complaints. The AV fistula had a palpable thrill, there was no bleeding, the radial pulse was present, and there were no neurologic findings. The patient was afebrile. Therefore, the signs and symptoms did not objectively support the need for acute inpatient care.
Appeal type: Medical necessity
Decision: Upheld

The patient is a male with a past medical history significant for malignant anaplastic oligodendroglioma. This review is for the medical necessity of personal care aide level 2, 14 hours per day 7 days a week for a total 98 hours per week.  The plan approved 7.5 hours a day 7 days a week for total 52.5 hours per week. The patient requested additional hours. The plan approved 8.5 hours per day 7 days a week for a total 59.5 hours per week.  The subject under review is the medical necessity of the requested 98 hours per week.

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

No, the requested health service/treatment of Personal Care Aide Level 2, 14 hours/days 7 days per week total of 98 hours per week is not medically necessary for this patient.
The patient has a malignant brain tumor status post chemotherapy along with primary resection. He has progressive left-sided weakness prompting a repeat resection of tumor. Evaluation for services was dated prior to the surgery.  Due to the patient's progression of the tumor and symptomatology including left-sided hemiparesis and focal seizures, the patient would benefit from additional hours of service, however, 98 hours per week is not medically necessary. Given that there has been a significant change in symptoms, a reevaluation secondary to the change in his medical status may be of consideration.

The prior Uniform Assessment (UA) noted a total of 52.5 hours per week of level 2 aide hours. That was sufficient for his care needs at that time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain
Treatment: Inpatient admission
The proposed treatment, inpatient admission, was medically necessary.

The patient presented with new onset chest pain, suggestive of unstable angina. The patient had multiple risk factors. The ECG was unrevealing for acute coronary syndrome (ACS), but was abnormal, with findings suggestive of myocardial ischemia. The patient failed prior management in ER in an outside hospital. Stress test was markedly abnormal with evidence of severe ischemia, wall motion abnormality and ventricular tachycardia with exercise. His presentation was consistent with unstable angina/ACS. Subsequently there was troponin release, consistent with non-ST elevation myocardial infarction (NSTEMI). There was a high index of suspicion for an ACS, and a cardiac catheterization was performed. The patient underwent percutaneous coronary intervention (PCI) of proximal LAD lesion. Given the presentation, as well as clinical suspicion for an acute coronary syndrome/unstable angina, he would not be an appropriate candidate for an ED chest pain observation unit, and it would be consistent with the current standard of care that this patient be managed in an inpatient setting, and therefore the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Upheld

This patient has a past medical history (PMH) of hypertension (HTN) and right inguinal hernia status/post (s/p) repair who presented to the emergency room with complaints of left groin pain. The patient had complained of left inguinal mass for the past year but had generally been reducible. In the emergency room (ER), the hernia was unable to be reduced. Vital signs were normal. Labs were normal. A computed tomography (CT) scan revealed a high grade small bowel obstruction secondary to the left inguinal hernia. The patient was taken to the operating room for left inguinal hernia repair with mesh for incarcerated inguinal hernia. No complications were noted. No bowel resection was required. The patient was transitioned to an oral diet after surgery and pain controlled with oral meds, minimal pain, stable vital signs, ambulating and voiding. The patient was discharged home on postoperative day (POD)#1.

The health plan's determination is upheld. The inpatient stay was not medically necessary. This patient presented with an incarcerated inguinal hernia but had stable vital signs and all labs were normal. A decision to proceed to the operating room was made based on the findings of a secondary SBO (small bowel obstruction) secondary to the acute herniation. The patient underwent an open left inguinal hernia repair with mesh which was uncomplicated and did not require any bowel resection. The patient was advanced to an oral diet which was tolerated, had minimal pain, continued to have stable vital signs, ambulating and voiding and was discharged home within a 23hour observation period. There were no unusual clinical circumstances or complications that required extended care or an inpatient level of care. The patient could have been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse

Treatment: Inpatient Rehabilitation Services

The insurer denied the Inpatient Rehabilitation Services. The denial was reversed. 
This is a male patient who presented to a rehabilitation facility for rehabilitation treatment after being referred by his parole officer. It was reported that he had a positive toxicology for cocaine and opiates.  The patient reported that he used multiple bags of intravenous heroin per day, and spent tens of dollars for daily use of crack/cocaine. He had several past inpatient substance detoxification treatment and a couple of outpatient substance detoxifications. He also had a history of legal issues. While in treatment it was reported that he attended individual and group therapy to facilitate better coping skills, to better identify the relapse triggers, and learn prevention skills. He was discharged after a couple weeks of treatment with aftercare plans that included a long term residential treatment facility and a methadone program.
According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) he met criteria for inpatient substance rehabilitation treatment as he continued to use heroin and crack/cocaine daily despite multiple past inpatient substance treatments, recent outpatient substance treatments, and substance inpatient detoxification treatments. He last had inpatient substance detoxification in late 2018. He was still was unable to remain abstinent and relapsed. Also, he continued to use despite negative consequences, including legal issues. He was referred to this treatment by his law enforcement after a positive toxicology as he tested positive for cocaine and opiates. He reportedly lacked sober supports to maintain abstinence outside of this 24 hour substance rehabilitation treatment. He lacked coping skills, needed to better identify relapse triggers, and needed to learn relapse prevention skills. He was unemployed. He was unable to stop substance use without being in a sober and supervised therapeutic inpatient substance residential setting then. Without this structured and supervised therapeutic residential treatment he likely would have relapsed quickly. Furthermore, the plan was for him to go to long term residential substance treatment after this. 

Based on the above, the medical necessity for the inpatient rehabilitation services is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male child. He presented to the ED with four-day history of diarrhea and two-day history of vomiting and fever. He had been taken to a different ED earlier and was diagnosed with acute gastroenteritis. He was taken back to the ED because of worsening diarrhea and development of cough and runny nose. 

The patient's vital signs included temperature 98.7 spiking to 102.5, heart rate 121, respiratory rate 30, and 99% saturation in room air. Examination was significant for fatigued appearance with pallor but non-toxic, positive tears, flat anterior fontanelle, nasal discharge, moist oral mucosa, benign abdomen, clear lung, and non-focal neurologic exam. He continued having watery stools in the ED, about one an hour. Lab studies were obtained, significant for normal bedside glucose, unremarkable CBC (complete blood count), metabolic panel with metabolic acidosis (CO2 [carbon dioxide] 16), and negative influenza/RSV (respiratory syncytial virus) screen. 

The patient was treated with Zofran, ibuprofen, and two normal saline boluses followed by 1.5 maintenance IV fluids. He was subsequently admitted because of persistent diarrhea and inability to keep up with fluid losses despite resolution of vomiting. Admission orders included Pedialyte as tolerated and maintenance IV fluids. Following admission, he was taking good fluids by mouth but continued having copious diarrhea. 

By the last day under review, the patient's diarrhea had resolved, his activity level had returned to baseline, and he had no episodes of fever or vomiting. He was deemed stable for discharge home with close outpatient follow-up.

Acute gastroenteritis is a major problem worldwide, representing one of the leading causes of morbidity and mortality in children. There are an estimated 2.5 million deaths each year attributable to gastroenteritis in children under the age of five years. Most cases are caused by viruses, are self-limited, and require supportive treatment. According to the World Health Organization, oral rehydration therapy is the treatment of choice, particularly where diarrhea is the prominent feature and dehydration is mild to moderate. Intravenous rehydration is indicated when oral rehydration fails or when output is excessive. Vomiting limits the success of oral rehydration, prompting use of anti-emetic medications.

This male infant presented to the ED for the second time with profuse watery diarrhea and fevers. The vomiting had resolved, but he was not able to keep up with stool losses, as evidenced by metabolic acidosis on laboratory interrogation. He was treated aggressively with fluids in the ED, but continued to have frequent watery stools. It was reasonable and appropriate to continue IV fluids in the hospital setting. However, he was hemodynamically stable with no evidence of sepsis or other complications. He did not required acute inpatient admission, and he could have been safely managed at a lower level of care, such as observation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain
Issue under review: Inpatient admission

Determination:
The Inpatient admission was medically necessary.

The patient presented with new onset chest pain. His ECG was abnormal, with LBBB (left bundle branch block), and his troponin was elevated. The patient had a prior stress test and was recommended to undergo a cardiac catheterization. There was a high index of suspicion for an ACS. Also, he presented with a syncopal episode, suspicious for ventricular arrhythmia. Given the presentation, as well as clinical suspicion for an acute coronary syndrome/unstable angina, he 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 patient be managed in an inpatient setting. Therefore, the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Altered Mental Status
 
Treatment:  Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld

This is a male patient who presented to the emergency department with complaints of altered mental status (AMS).  He has a medical history of diabetes, hypertension, cerebrovascular accident, chronic obstructive pulmonary disease, progressive supranuclear palsy (PSP) and schizophrenia.  The patient is bed bound and non-verbal; his baseline level of consciousness is confused.  He had a computerized tomography (CT) of the head and a chest x-ray which were both normal.  He was treated with bolus intravenous (IV) fluids.  He had elevated blood pressures while in the ED 170/115, 191/118, 189/121; he was started on Nicardipine IV.  The patient was discharged the assisted living facility when medically stable.

The patient did not need acute medical admission.  He could have been placed in observation status while diagnostic testing and treatment were initiated.  The patient remained stable after admission.  The patient was on oral medications.  He was stable to be discharged to an assisted living facility with close follow-up in an outpatient setting.  The patient's WBC and labs were stable.  Serum Osmolality improved.  Mental status was back to baseline.  

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

Diagnosis: Chest pain and tooth pain
Treatment: Inpatient admission
The proposed treatment, inpatient admission, was not medically necessary.

This patient presented for evaluation of chest pain. The diagnosis of an acute myocardial infarct (MI) was ruled out by cardiac enzymes, which were negative, and the patient was referred for a nuclear stress test, which was not completed, as the patient eloped. 

There was no evidence of acute myocardial infarction, acute coronary syndrome (ACS), decompensated congestive heart failure (CHF), malignant arrhythmia or hemodynamic instability. The standard of care, which is in concert with ACC/AHA clinical guidelines, for patients presenting with chest discomfort, in whom the diagnosis of acute coronary syndrome is unclear, is observation in ED or chest pain unit with serial cardiomarker measurements to rule out an acute myocardial infarction, followed by a non-invasive ischemic work-up (stress test, CT angiogram). Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission and the care required could have been provided at an observational level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prostate Cancer

Treatment: Radiation Therapy 

The insurer denied the Radiation Therapy. The denial was upheld. 

This is a middle aged male who was diagnosed with prostate cancer in 2016. The patient documentation states that he has been under watchful waiting and that his prostate-specific antigen (PSA) had increased to 7.3 by mid- 2018.  The patient elected to proceed with definitive therapy. He did not want to undergo a radical prostatectomy and sought proton beam therapy as a definitive treatment of choice to minimize dosing to critical structures and to decrease the risk for secondary cancers in his lifetime.

The National Comprehensive Cancer Network (NCCN) recommends that highly conformal radiation therapy [RT] techniques should be utilized to treat localized prostate cancer. The NCCN also indicates that proton beam therapy for primary treatment of prostate cancer should only be performed within the context of a prospective clinical trial or registry.  The NCCN panel believes that no clear evidence supports a benefit or decrement to proton therapy over intensity-modulated radiation therapy [IMRT] for either treatment efficacy or long-term toxicity.
Based on the above, the medical necessity for the requested radiation therapy for prostate adenocarcinoma is not substantiated.  The insurer's denial is upheld.