Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive Sleep Apnea
 
Treatment: Incision for implantation of cranial nerve neurostimulator electrode array and pulse generator and Insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator 
The insurer denied coverage for Incision for implantation of cranial nerve neurostimulator electrode array and pulse generator and Insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator. The denial was reversed as two out of three panelists determined that the treatment is more likely to be beneficial than any of the standard treatments/procedures for this patient.
This case involves a male patient diagnosed with obstructive sleep apnea.  The patient has been recommended for implantation of an upper airway stimulation device.  The letter of medical necessity does detail the patient has previously undergone a polysomnogram eliminating the possibility of central sleep apnea.  The patient has had a trial and failure of a continuous positive airway pressure (CPAP) machine and many masks.  The patient has also undergone a sleep endoscopy with confirmation that he does not have complete concentric collapse of the upper airway. Additional documentation details the patient's apnea-hypopnea index (AHI) is 24.6 with a body mass index of 31.9.
According to literature, the recommended device was initially approved in 2014 for treatment of moderate to severe obstructive sleep apnea.  While CPAP is a first-line treatment long-term use for many patients is suboptimal.  The selection criteria for the use of the nerve stimulator may include a body mass index of less than 32 as well as a lack of central apnea and a favorable pattern of palatal collapse during drug-induced sleep endoscopy.  Therefore, given the submitted documentation details the patient has had a trial and failure of a CPAP device with multiple masks as well as a body mass index of less than 32 and a diagnosis of obstructive sleep apnea he would be an appropriate candidate. Given the above, the requested service is more likely to be beneficial than any of the standard treatments/procedures for this patient.
The carrier's denial of coverage for Incision for implantation of cranial nerve (e.g., vagus nerve) neurostimulator electrode array and pulse generator and Insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator should be reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Fractured Buccal Cusp Tooth, #4  

Treatment:  Crown-Porcelain Fused to High Noble Metal Tooth 4, and Endodontic Therapy, Bicuspid Tooth (excluding final restoration), Tooth 4

The insurer denied the Crown-Porcelain Fused to High Noble Metal Tooth 4, and Endodontic Therapy, Bicuspid Tooth (excluding final restoration), Tooth 4. 
The denial was upheld.   

This is a middle aged male patient who was seen by his dentist for a fractured buccal cusp tooth, #4, with no pain in early 2019.  Initial treatment plan for #4 was extraction and addition of this tooth to a partial denture.  Upon review of his information, particularly the radiographic examination, #4 exhibits significant decay /caries markedly undermining and compromising tooth integrity and tooth structure, and involving the root structure.  This decay radiographically extends below the alveolar bone height. Effectively this tooth will remain a retained root tip.  The extent of coronal destruction and caries renders this tooth a poor support for full coverage restoration despite the recommended endodontic therapy.  This tooth would be prosthetically poor support for a crown restoration.  It seems that this was the consideration of the dentist, as well, as the initial treatment plan was for extraction of #4.

Based on the above, the medical necessity for Crown-porcelain fused to high noble metal Tooth 4, and Endodontic therapy, bicuspid tooth (excluding final restoration), Tooth 4 is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Knee pain
Treatment:  Right total knee arthroplasty and full hospital admission 
The right total knee arthroplasty and full hospital admission are medically necessary.

The patient demonstrated consistency of subjective complaints, objective findings and imaging for her diagnosis.  She has end stage osteoarthritis to both knees. 

She has significant limitations to her activities of daily living.  She has positive physical findings of deformity, loss of motion and deformity. 

She has had extensive nonoperative treatment.  This included multiple injections, medications and therapies. 

There are limited treatment alternatives left beside TKR.  The standard of care would be providing the TKR. 

In addition, an inpatient stay of three days would be standard for this procedure; the patient will need to recover from anesthesia, engage in physical therapy, and have pain controlled.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of hypertension, obesity status post gastric bypass, gastroesophageal reflux disease (GERD), depression/anxiety who presented to the emergency department with nausea and diarrhea. On presentation, the patient had a temperature of 98.4 degrees Fahrenheit, pulse rate of 115, blood pressure of 182/112, respiratory rate 20, and oxygen saturation 100% on room air. Blood work was notable for a white blood cell count (WBC) of 5.5, hemoglobin 11.7, and hematocrit 35.9, platelet count 58,000, sodium 130, chloride 93, and bicarbonate 19. The patient was admitted to the medical floor and treated with conservative management with intravenous fluid hydration and antiemetic therapy. The health plan's determination is upheld.

This is a patient who presented with nausea and diarrhea. On presentation, she was hemodynamically stable without a fever, or persistent tachycardia or hypotension. Blood work was notable for electrolyte abnormalities. She was admitted to the medical floor and treated with conservative management with intravenous fluid hydration and antiemetic therapy. Stool studies did return positive for Campylobacter. The patient has a history of alcohol abuse and was monitored for alcohol withdrawal using Clinical Institute Withdrawal Assessment (CIWA) protocol with benzodiazepine therapy. The patient did develop pancytopenia and the Hematology service was consulted. It was felt that the pancytopenia resulted in myelosuppression related to alcohol use. The patient remained hemodynamically stable throughout the hospital course.
Appeal type: Medical necessity
Decision: Upheld

The patient was admitted to inpatient mental health diagnosed with anxiety disorder and avoidant personality. Prior to admission, the patient was highly isolate, not attending school or socializing. The patient would watch TV, lift weight or place computer games all day. This was the patient's first hospitalization.The patient had no active suicidal ideation with plan, homicidal ideation with plan or command hallucinations. The patient was not physically aggressive, acutely manic or sexually inappropriate. The patient was not catatonic. No indication the patient is at risk for life threatening withdrawal. The patient had no required emergency medications, restraints or seclusions in the previous 24 hours. The patient has been diagnosed with Generalized anxiety disorder, social anxiety disorder and rule out (r/o) obsessive-compulsive disorder (OCD). The plan is to refer the patient to an intensive day treatment service. The patient had been participating in school and groups. Family was also involved in care. The health plan's determination is upheld.

For the dates of service in question, the patient is medically stable. The patient had no active suicidal ideation with plan, homicidal ideation with plan or command hallucinations. The patient was not physically aggressive, acutely manic or sexually inappropriate. The patient was not catatonic. No indication the patient is at risk for life threatening withdrawal. The patient had no required emergency medications, restraints or seclusions in the previous 24 hours. There was no indication for around the clock monitoring. MH inpatient level of care was not medically necessary for the patient.
Appeal type: Medical necessity
Decision: Upheld

The patient has a history of diabetes, hypertension, cigarette smoking and pulmonary emboli. The patient presented to the emergency department complaining of one week of intermittent left-sided chest pain; this was a recurring problem over several years. Prior workup for this included myocardial perfusion imaging that showed no evidence of ischemia. An electrocardiogram showed sinus rhythm without ischemic changes; it was a normal tracing. Chest computed tomography (CT) angiography showed no evidence of pulmonary embolism. Serum troponin level was normal. The patient was treated with aspirin and admitted to the hospital. Myocardial perfusion imaging performed showed a fixed apical defect suggestive of prior infarction; there was no evidence of stress-induced ischemia. The patient declined cardiac catheterization and was discharged home. The health plan's determination is upheld.

An inpatient level of care was not medically necessary. The care this patient received did not require an inpatient admission and could have been provided under lower level of care status. This approach has been shown to be both safe and cost-effective and is in accordance with the American Heart Association recommendations on the management of patients who present to the emergency department with acute chest pain and who, like this patient, are at low risk for acute coronary syndrome. Given the normal electrocardiogram and cardiac biomarkers, it is also supported by the American Heart Association (AHA)/American College of Cardiology (ACC) Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of hyperlipidemia, metastatic prostate cancer and cigarette smoking. He presented to the emergency department complaining of two months of intermittent, stabbing, left-sided chest pain that had worsened over the prior three days. His blood pressure was 120/78 millimeters of mercury (mmHg) with a heart rate of 73 beats/minute. His respiratory rate was 18/minute with a room air oxygen saturation of 99%. His cardiovascular and respiratory exams were unremarkable. His serum creatinine was 2.0 milligrams per deciliter (mg/dl), which was his baseline. His brain (or B-type) natriuretic peptide (BNP) level was mildly elevated. A chest x-ray showed no acute pathology. His serum troponin level was mildly elevated, in the indeterminate range, at .04 ng/ml. His electrocardiogram showed sinus rhythm without acute changes. He was treated with aspirin and admitted to the hospital for further evaluation of his chest pain. A repeat troponin level was .05 ng/ml. Overnight monitoring showed sinus rhythm with premature atrial beats. The health plan's determination is upheld.
This patient presented with atypical chest pain. He was hemodynamically stable. There were no acute electrocardiographic changes. While his serum troponin level was mildly elevated, this was in the indeterminate range and did not necessarily represent acute coronary syndrome (ACS); it was thought to possibly be a result of his decreased renal function. Other than aspirin, no specific therapy for acute coronary syndrome (ACS) was instituted. While monitoring until ACS could be ruled out was a reasonable approach, this did not require an inpatient admission. A lower level of care has been shown to be safe in low risk patients and is in accordance with the 2014 American Heart Association (AHA)/American College of Cardiology (ACC) Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.
Appeal type: Medical necessity
Decision: Upheld

Cardiac/Circulatory Problems - Chest Pain
Inpatient Hospital

The patient is a female with a history of hypertension, chronic kidney disease, coronary artery disease (CAD) myocardial infarction (MI), cardiomegaly (CM) with ejection fraction (EF) of 20%, implantable cardioverter defibrillator (ICD), and chronic obstructive pulmonary disease (COPD) who presented with chest pain and shortness of breath. 
The electrocardiogram (ECG) in the emergency room (ER) revealed normal sinus with LBBB, left ventricular hypertrophy (LVH) and T wave inversions in the lateral leads. The chest x-ray revealed enlarged cardiac silhouette and the cardiac enzymes were normal despite a mildly elevated Creatinine. 

The patient was admitted with an initial blood pressure of 159/110, respiratory rate of 20, and a pulse ox of 100%. The patient had serial enzymes and increase in the blood pressure medication. There was no documentation to confirm the patient was in heart failure despite the low EF. The patient was in no distress but with a few expiratory wheezes on exam despite the improved blood pressure of 127-154/90's. The patient was given fluid restriction with a continuation of by mouth (PO) diuretics. The medical necessity for the inpatient stay is the subject under review.

The health plan's determination is upheld.

The patient had chest pain with an overall risk profile of intermediate-risk based on age and clinical presentation. There was no evidence of heart failure, myocardial ischemia/injury or acute on chronic renal dysfunction nor abnormalities on the ECG. Although the patient had elevated blood pressure there was no significant evidence of respiratory compromise based on respiratory rate and oxygen saturation. The patient could have been monitored with adjustment of blood pressure with ongoing serial enzymes prior to re-evaluating to determine if the patient was stable and safe to be discharged with outpatient cardiac evaluation pending the serial enzymes, ECG, and response to blood pressure medication. There is no medical literature that without acute ischemia, injury, hemodynamic compromise, arrhythmias, laboratory abnormalities, heart failure or other high-risk markers that a patient presenting to the ER with chest pain would have to be admitted for an inpatient stay. The patient could have been treated at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient admission
The inpatient admission was not medically necessary.  
The proposed treatment was medically appropriate; however, the level at which the care was provided was not medically necessary.
Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had abdominal pain; yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for nothing by mouth (NPO) status, need for invasive surgery, need for invasive monitoring, severe electrolyte dyscrasias or any other indication for an acute admission.  As such the care could have been rendered at a lesser level. The endoscopy could have been performed while the patient was at a lower level of care as well.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient admission

The inpatient admission was not medically necessary.

The patient is a female. She admitted to the emergency room with complaints of right lower quadrant pain. 

The patient's vital signs were normal and she was afebrile. Right lower quadrant tenderness was noted and a right adnexal mass found on pelvic examination. A transvaginal ultrasound revealed a 12 cm (centimeter) cystic mass and an ovarian torsion was suspected. 

The patient was admitted to the inpatient service and underwent a laparoscopic right salpingo-oophorectomy. She was transferred to the recovery room and recovered without incident. She was transferred to the inpatient floor with normal vital signs and was afebrile. 

The next day, the patient continued with normal vital signs, was ambulating and tolerating a normal diet, and was afebrile. She was discharged that day.

The medical records and peer-reviewed medical literature were thoroughly reviewed. The patient had an uncomplicated laparoscopic procedure and was admitted postoperatively as an inpatient. There is no evidence to support an inpatient admission based on her intraoperative and immediate postoperative conditions. A review of the physician progress notes and associated inpatient records does not reveal any evidence that the patient's postoperative condition required acute inpatient admission. The patient did not have co-morbidities indicating the need for an inpatient postoperative admission. There is no evidence that her pain was uncontrolled, or that she did not tolerate PO (oral) intake overnight and through the first postoperative day. It is within the standard of care for a laparoscopic salpingo-oophorectomy to be an ambulatory procedure. 

The patient required postoperative care in the recovery room. However, given her intraoperative condition and uncomplicated postoperative recovery she could have been reliably discharged from the recovery room to a lesser level of care, rather than as an acute inpatient admission. Therefore the treatment was within the standard of care to be provided in a less than acute level of care setting, and not in an inpatient setting. Therefore, the services were not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Post Hysterectomy Abscess
 
Treatment: Inpatient Services

The insurer denied the Inpatient Services. The denial was reversed.

The patient is a middle aged female status post robotic hysterectomy and bilateral salpingectomy in early 2019. She patient presented to the ER from her physician's office a few days after her hysterectomy with fever abdominal pain tachycardia and elevated White Blood Cells (WBCs). Her WBC count was 18.6. CT scan was consistent with abscess formation. She was admitted and started on IV antibiotics. The plan was for possible drainage of the abscess but this was not radiologically feasible. Documentation from her admission states that the patient was afebrile with significant improvement in her pain. The patient remained stable with improvement in her symptoms. She was shifted to oral antibiotics and later discharged home.

The patient presented a few days after a hysterectomy with fever abdominal pain tachycardia and elevated White Blood Cells (WBCs). The typical presentation of post hysterectomy abscess is fever, tachycardia, tachypnea, and lower abdominal pain, days to weeks after hysterectomy. This patient presented a few days after a hysterectomy with fever abdominal pain tachycardia and elevated White Blood Cells (WBCs).
Once the patient's condition improved she was shifted to oral antibiotics and discharged home as per standard of care.

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

The patient presented for care after having a 2-cm malignant soft tissue tumor (sarcoma) removed from the right mid-face via a sub-labial approach. The infant initially presented one-month prior with an enlarging, firm bump on the nose. The initial ultrasound suggested a fibroma or hemangioma and computed tomography (CT) and magnetic resonance imaging (MRI) showed a 16 millimeter (mm) soft tissue mass in the right nasal labial fold causing erosion of the right pre-maxillary area concerning for tumor. 

The health plan's determination is overturned. The inpatient stay was medically necessary. This was a young infant who had a malignant tumor of the face that required surgical resection and close postoperative monitoring. Given the age of the patient and the location of the mass, close attention had to be paid to the child's nutritional intake (this age can be fed by bottle or breast only, and the surgical site might affect the ability of the child to suck and obtain nutrition). The provider noted that the infant was at risk for bleeding and wound issues, complicated by the fact that a malignant tumor was removed. There were concerns that the child would have significant post-operative pain requiring intravenous (IV) management.
Appeal type: Medical necessity
Decision: Overturned

The patient is a female who is requesting Dupixent for atopic dermatitis. She has tried triamcinolone, hydrocortisone, eucrisa and tacrolimus and systemic steroids, elidel and protopic. The health plan has denied Dupixent as not medically necessary, stating that the patient has not tried and failed or cannot take one topical calcineurin inhibitor. The health plan's determination is overturned. 

The patient is at least age 12, has chronic atopic dermatitis and has tried triamcinolone, hydrocrtisone, eucrisa and tacrolimus and systemic steroids, Elidel and Protopic.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a past medical history significant for Parkinson's disease, gait abnormality and hypertension.  She has been approved for a total of 89 hours per week of personal-care services.  An additional 20 hours a week for a total of 109 hours per week is requested for safety concerns and supervision.  This was denied based upon medical necessity.  The issue for review is the medical necessity of the services - 109 hours per week.

The health plan's determination is upheld.  Based upon the records provided, the patient requires a total of 89 hours per week of personal-care services.  The time allotted is sufficient to meet the patient's medical needs.  An additional 20 hours a week is not medically necessary.  Additional service hours for patient supervision and monitoring are not considered medically necessary unless they take place during the time which patient requires help with an ADL or IADL.  All of her ADLs and IADLs can be met within the allotted time.
Appeal type: Medical necessity
Decision: Upheld

The patient has a history of alcohol dependence and was admitted to medically supervised withdrawal services.  The patient was receiving treatment for alcohol use disorder with a recommended level of care of medically supervised withdrawal.  The patient was reported to have an initial Clinical Institute Withdrawal Assessment (CIWA) score of 17.  The health plan's determination is upheld.

The current module of Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) was used with medically managed or medically supervised detoxification as the current level of care.  There had not been changes in the patient's status that would require a higher level of care.  There was no evidence that withdrawal symptoms continued to require 24-hour medical oversight in a hospital setting due to serious or life-threatening complications.  Clinical documentation does not establish that the withdrawal continued to require 24-hour medical supervision, stabilization, and regular vital sign monitoring that should have been managed in a supervised setting.  Based on the answers to these questions, the patient did not meet criteria for continued inpatient care.
The patient had experienced improvement in withdrawal symptoms during the authorized days.  By the dates of service and question, the patient did not have any distressing withdrawal symptoms, and the clinical documentation does not establish that the inpatient level of care continued to be necessary.
The patient could have been safely and effectively treated at a lower level of care.