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

Diagnosis: Fibromyalgia, weakness
Treatment: Inpatient admission
The proposed treatment of inpatient admission is not deemed medically necessary. 
This female patient with a history of depression/anxiety and fibromyalgia presented to the ER for further evaluation/management of generalized body aches and weakness. Intake vitals were afebrile, hemodynamically stable with no evidence of febrile temperature, malignant hypertension, profound hypotension, severe tachycardia or hypoxemia on room air. Examination was non-focal with no significant abnormalities noted including no evidence of acute cardiopulmonary or neurologic abnormalities. Laboratory and ECG testing was also within normal limits with no significant abnormalities noted including no evidence of acute end organ damage. The medical records indicate that this patient was admitted to the inpatient medical service in stable condition where she received supportive care with IV fluids and PT/OT evaluations. She responded well to the prescribed therapies and was subsequently discharged in stable condition. There is no evidence of intensification of services throughout the course of this patient's hospital stay. Hence, the patient's care could have been safely furnished in a less intensive setting without adversely affecting patient's safety or outcome. Hence, the proposed treatment of Inpatient admission is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath, history of chronic obstructive pulmonary disease (COPD), diabetes mellitus, hypertension, pneumonia and schizophrenia

Treatment: Inpatient admission, diagnostic testing, and medication management.

The insurer has denied inpatient admission. That denial was upheld.

The patient was sent to the Emergency Department (ED) from the clinic with complaints of shortness of breath (SOB), weakness and dizziness.  The patient has history of COPD.  
At presentation to the Emergency Room (ER) the patient was afebrile and hemodynamically stable.  The patient was in no acute distress.  Her lungs were clear.  The cardiac exam was unremarkable.  There was no cyanosis, clubbing or edema.  The patient was alert and oriented x3. The neurological exam was non focal. Chest x-ray revealed some scarring/linear atelectasis.  There was no pneumonia or pleural effusion.  A CT angiogram was done which was negative for pulmonary embolism.  Some coronary calcification was noted. The patient was treated with Duo Nebs, and oral (PO) Prednisone. The patient improved with treatment.  She remained afebrile and hemodynamically stable.  White blood count (WBC) remained normal.  The patient was being treated with oral steroids and bronchodilators.  The patient was seen by Cardiology.  Myocardial infarction was ruled out.  They recommended a stress test as an outpatient.

This patient did not need acute hospitalization.  She could have been placed in observation status while diagnostic testing and treatment were initiated.  The patient remained stable after admission.  She was on oral steroids and bronchodilators.  The patient was in no acute distress (NAD).  Lungs were clear.  There was no pneumonia or pleural effusion noted.  Chest CT ruled out pulmonary embolism (PE).  The patient is not noted to be hypoxic.  The patient was tolerating oral intake.  The patient could have been discharged home on oral medications after a period in observation.
Appeal type: Medical necessity
Decision: Upheld

This is a a patient with hypertension (HTN) and alcohol dependency presented with lips swelling after lisinopril intake. on presentation no hemodynamic instability or respiratory distress or airways compromise documented. diagnosed with angiotensin-converting enzyme inhibitors (ACEI) induced angioedema and admitted to the intensive care unit (ICU). He was managed with systemic steroid, fresh frozen plasma (FFP), and antihistamines. He had a quick clinical response and was discharged the next day off all ACEI medications. Based on available information, there is no mention about any cardiopulmonary instability except for high blood pressure. The health plan's determination of medical necessity is upheld.

The presentation, based on the available record, was benign with no reported respiratory distress or airway compromise and no hemodynamic instability or anaphylaxis Therefore, the care could have been managed at a lower level of care than inpatient.
Appeal type: Medical necessity
Decision: Upheld

The patient  with a past medical history significant for hypertension, diabetes mellitus, hepatitis C virus (HCV), and cocaine abuse presented to the emergency department with complaints of chest pain which had been going on for 2-3 weeks. The patient reported an intermittent chest pain following the use of crack cocaine. Apparently, the patient had used crack cocaine consistently for 8-9 days. The patient was admitted to the hospital with a diagnosis of chest pain.  The patient had EKG changes that were present on the previous EKG. Patient was seen by a cardiologist who diagnosed the patient with atypical chest pain with no evidence of acute coronary syndrome. The cardiologist recommended no further cardiac workup as well as substance abuse counseling. The HP determination of medical necessity is upheld-inpatient hospital admission is not medically necessary. This patient was at risk for acute coronary syndrome. Patient was admitted to the hospital and ruled out for ACS. This is usually done at a lower level of care.  There was no evidence that the patient was hemodynamically unstable or required intravenous administration of antiplatelet agents or parenteral anticoagulation. There was no evidence that the patient had any of the potentially dangerous conditions such as a critical aortic aneurysm, aortic dissection, or pulmonary embolism.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: COPD
Treatment: Inpatient admission 

Inpatient acute care was not medically necessary.

This was an overnight observation with discharge home the next day. 

The patient is a cigarette smoker with COPD with a past history of being intubated. He also had the right lower extremity chronic ulcer. He was treated with Zithromax for both conditions. He was on home O2. In the ER he was also treated with steroids. He was in no distress. He did not have pneumonia. He improved overnight and was discharged home the next day. This was an overnight observation level of care; inpatient acute care was not medically necessary nor was it provided.
Appeal type: Medical necessity
Decision: Overturned

The patient has a history of hypertension, hyperlipidemia, coronary artery disease, ischemic cardiomyopathy, aortic and mitral valve replacement and human immunodeficiency virus (HIV) infection and presented to the emergency department complaining of chest pain, dyspnea, orthopnea, edema, blood-tinged sputum, nausea, vomiting and paroxysmal nocturnal dyspnea. 

Blood pressure was 157/96 millimeters of mercury (mmHg) with a heart rate of 85 beats/minute. Room air oxygen saturation was 95%. Physical exam was notable for pulmonary rales, jugular venous distension and a systolic murmur. Serum troponin level and liver function tests were mildly elevated; brain natriuretic peptide (BNP) level was markedly elevated. Chest x-ray showed cardiomegaly, pulmonary venous congestion and small bilateral pleural effusions. An electrocardiogram showed left ventricular hypertrophy with repolarization abnormalities. The patient was admitted for management of decompensated congestive heart failure.  His dyspnea was improved but the patient had persistent rales. An echocardiogram showed a left ventricular ejection fraction of less than 20%. The patient was started on Entresto. Blood pressure was 90/67 mmHg and spironolactone was held. Renal function remained stable. The patient was discharged home. The health plan's determination is overturned.

This patient presented with acute decompensated heart failure (ADHF). His serum troponin level was elevated. In patients with ADHF, elevated serum troponin is associated with an increased short- and long-term mortality. In-hospital mortality in this cohort has been shown to be nearly three times that of patients with normal troponin levels (8.0% vs. 2.7%). Moreover, the marked elevation in the BNP level was an additional high risk feature. In patients hospitalized with ADHF, BNP levels in the range this patient had are associated with substantial increases in in-hospital and one year mortality. Given this patient's poor prognostic features and high risk for morbidity and mortality, an inpatient level of care was medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive sleep apnea
Issue under review: Hypoglossal nerve stimulator

Determination:
The health plan should cover the Hypoglossal nerve stimulator.

Otolaryngology's academy's recommendations, as well as the literature, support that this procedure is the treatment of choice for OSA seen as seen in this patient (1-4). She has the appropriate diagnostic findings and has not tolerated CPAP.  The procedure is not E/I. It is accepted standard of care.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive sleep apnea
Issue under review: Hypoglossal nerve stimulator

Determination:
The health plan should cover the Hypoglossal nerve stimulator.

The patient is an adult female with a history of OSA.  AHI on sleep study was 20.2, with a BMI of 32.  The patient could not tolerate a CPAP trial, and underwent a sleep endoscopy, where there was no complete concentric collapse at the velum.  The provider is requesting placement of an Inspire hypoglossal nerve stimulator system to treat the patient's OSA.  

There is support in the literature for the efficacy of the Inspire hypoglossal nerve stimulator for the treatment of a subset of patients with OSA who have failed, or cannot tolerate, CPAP therapy.  A prospective multi-center study documented a reduction of AHI out to 12 months.  In addition, there was a randomized, controlled withdrawal arm of the study which reported AHI reduction out to 18 months.  Therefore, based on current scientific literature, scientific evidence would support the efficacy of upper airway stimulation therapy with a hypoglossal nerve stimulator for a subset of patients with OSA who meet FDA criteria for the procedure.  

In this particular case, the patient would meet FDA criteria for the device in terms of BMI, age, AHI and sleep endoscopy findings (there was no complete concentric collapse on sleep endoscopy).  The patient has had a previous reported failed CPAP trial.  There would be no contraindications to the procedure based on the information provided.  Therefore, based on the information provided, the requested service would be confirmed as a covered service, as the requested procedure is likely to be more beneficial than any standard treatment or treatments for the insured's condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive sleep apnea
Issue under review: Hypoglossal nerve stimulator

Determination:
The health plan should cover the Hypoglossal nerve stimulator.

It is a standard therapy. The procedure and device are FDA-approved, as referenced below, and recognized in the treating community as efficacious and safe for properly selected patients.  This patient with moderate desaturations and favorable anatomy is a good candidate for this intervention.  By virtue of review of the literature, it is neither experimental nor investigational.  This is particularly evident with the withdrawal study by Woodson referenced below, which showed the efficacy of the therapy and the reversal of efficacy by discontinuing the stimulation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Adrenal mass, headaches, dizziness
Treatment: Inpatient admission
The inpatient admission was not medically necessary.
The patient did not have a focal neurologic deficit, seizure activity, or change in level of consciousness. There was no evidence of severe pain or requirement for frequent or continuous administration of parenteral analgesics. Magnetic resonance imaging and angiography of the brain was negative. There was no evidence of vasculitis. Only oral antihypertensive agents were provided. There was no evidence of medication withdrawal headache.  There was no evidence of hypertensive emergency. Laboratory indices were unremarkable.  
In summary, the inpatient admission was not medically necessary. The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient in making its determination.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Food bolus impaction

Treatment: Endoscopic removal of bolus

The insurer has denied inpatient admission. That denial was upheld.

This patient is a male who presented to the Emergency Department on complaining of a meatball stuck in his throat. He has a history of gastroesophageal reflux disease (GERD) and eosinophilic esophagitis. Glucagon was administered in the ER without relief. The patient reported an inability to swallow his secretions. He was admitted and seen by gastroenterology, who removed the food bolus endoscopically. He was discharged.

Upon arrival, a physical exam of the patient revealed him to be in moderate distress, but with a patent airway and clear breath sounds. The recommendation was for IV fluids and additional diagnostics; including glucagon. This did not provide relief, and the patient was admitted for an endoscopic procedure to remove the food bolus. He underwent the procedure without complication and the food impaction was removed. Furthermore, the patient's diet was tolerated and he was discharged. Following the uncomplicated removal, the patient could be treated as an outpatient.

Based on the above, the medical necessity for the full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever and weakness
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

The patient presented to the hospital from a recent discharge where the pleural effusion had already been worked up and deemed transudative.  Therefore, most likely benign, the pleural effusion was discovered on a chest x-ray, but was not responsible for the patient's symptoms. The patient did not report any chest pain from the site of the pleural effusion, nor did the patient have any shortness of breath productive of sputum. The patient did not have any symptoms suggestive of sepsis with end-organ dysfunction.  The patient's blood pressure was elevated, which was due to his history of hypertension, and patient not taking his medication. As a consequence, his blood pressure was high, and pulse rate was high because of his fever.  His respiratory rate was normal, and oxygen saturation was normal on room air.  Other than pleural effusion, the rest of the laboratory data was unremarkable.  

Even though the patient's blood pressure was high upon presentation to the emergency room, he still ended up getting 2 L of saline. As a consequence, the blood pressure went high, and required IV medications to control it.  

Through looking at the hospital admission, the entire admission all the way to the discharge, the patient was unremarkable. The patient was ambulatory. He was on room air and hemodynamically stable. He did not require any oxygenation. There was no restriction with activity. His appetite was good.  The patient's clinical condition could have been managed at a lesser level of care such as observation or outpatient management.  As the patient's most recent thoracentesis data was available and suggested that it was a benign effusion, it was a transudative effusion, most likely not related to any infection such as pneumonia.
Appeal type: Medical necessity
Decision: Upheld

The patient has diabetes mellitus (DM) type 2, hypertension, hyperlipidemia, dementia, and PUD who presented with epigastric pain with non-bloody emesis. 

The health plan's determination is upheld. The inpatient stay was not medically necessary.The patient's care could have been done at a lower level of care. Based on the reviewed data, the patient did not look toxic or dehydrated and had normal electrolytes and renal function. The ED workup already ruled out any major acute process, though she merits monitoring to ensure oral tolerance given her age and comorbidities.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Flank pain and constipation

Treatment: Nephrostomy tube replacement and inpatient admission

The insurer denied inpatient hospital stay. That denial was upheld.

This patient was seen in the emergency department.  The patient stated that he needed his nephrostomy tubes changed.  The patient had complaints of back pain and constipation.  The patient was noted to have bilateral nephrostomy tubes which were last changed in two month prior.  The patient also reported chills and lightheadedness.  The patient had a blood pressure 146/81. The patient denied a change to nephrostomy tube output noting the tubes were draining clear yellow urine.  The patient complained of back pain, groin pain, and constipation since the previous Friday.  The last bowel movement was the previous day.  The patient was requesting a stool softener.  On examination, nephrostomy tubes were in place bilaterally.  Urine output appeared clear yellow.  The patient had a sodium of 141, chloride 111, BUN 40, potassium 5.5, HCO3 21, creatinine 4.3, calcium 9, troponin 7.6, albumin 4.5, T bilirubin 0.2, AST 13, ALT 7, white blood cell count 5.55, hemoglobin 10.7, hematocrit 34.4 platelets 195.  The patient was then admitted for nephrostomy tube replacement.  

The medical literature indicates that inpatient care may be indicated for patients with acute renal failure with threefold rise in serum creatinine from baseline, serum creatinine greater than 4 mg/DL with an acute rise greater than 0.5 mg/DL; reduction of more than 75% and estimated glomerular filtration rate from baseline; or oligoanuria.  Inpatient admission may be indicated for patients with significant uremic complications as indicated by outpatient therapy ineffective, cardiac arrhythmias of immediate concern, vomiting that is severe persistent, recurrent seizures, altered mental status that is severe persistent, bleeding abnormalities with active bleeding for dialysis indicated for long-term access or ambulatory arrangements can be made significant metabolic or electrolyte abnormalities such as severe acidosis or hyperkalemia.  

The patient had chronic kidney disease, stage IV.  The patient was requesting a nephrostomy tube exchange.  The patient did have findings of hyperkalemia.  However, the documentation did not demonstrate failure of appropriate treatment for hyperkalemia in the emergency department or in observational status.
Appeal type: Medical necessity
Decision: Upheld

The patient underwent primary right total knee arthroplasty. The records show that the patient recovered well after the operation with no complications. The patient was deemed stable for transfer to a skilled nursing facility. The health plan's determination is upheld.

The inpatient stay was not medically necessary for this patient. The provided medical records provide no justification for the inpatient hospital stay for the patient in question. In fact, the records state that the patient was stable for discharge, and the patient was awaiting acceptance to a skilled nursing facility. Therefore, this patient could have had care completed under a lower level of care status. Observation type admissions for elective total knee replacement surgery has been proven to be safe and effective in the current, peer-reviewed orthopedic literature by Yanik and colleagues.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nausea and vomiting
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

The care as provided was medically appropriate, but the level at which the service was provided was not medically necessary or appropriate.

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 an infection; yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, cardiac biomarkers, EKG changes, new renal abnormalities, need for prolonged NPO (nothing by mouth) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission.  As such, the care could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Major Depressive Disorder

Treatment: The medication Fluoxetine

The insurer has denied the medication Fluoxetine. The denial was reversed.

This patient had a diagnosis of Major Depressive Disorder-Severe-Recurrent and was taking Fluoxetine 60 mg tablets per day since 2016. Her depressive symptoms were successfully managed. The treating provider indicated the patient is unable to try the formulary options Fluoxetine capsules as she is unable to swallow capsules and that she was unable to tolerate the formulary option Fluoxetine solution as this has caused severe gastrointestinal (GI) discomfort.

The pharmacy records were reviewed and while they show use of capsules for various medications,  this was several years in the past and more recent use of capsules has been for short term use- e.g. for a course of treatment for an antibiotic. 

With regard to fluoxetine, the submitted records show use of 20 or 40mg capsules in 2014/2015 and fluoxetine solution in 2017/2018. The most recent noted in 2019 for 40mg caps - 30 day supply. There is an undated prescription requesting tablets due to difficulty with swallowing. The request states she has been on "this medication" since 2016 and to use tablets will help with compliance, as she does not tolerate the solution or capsules. 

Fluoxetine is available as a generic 60mg tablet. The submitted pharmacy records confirm that the patient has in the past used both capsules and solution.  The timing of the prescriptions also indicate inconsistency in the use of fluoxetine, since the pattern of refill would indicate periods where the patient was not compliant with use of the fluoxetine. As there is in fact a 60mg tablet available, and the patient has tried capsules and the solution, and the records do strongly suggest issues with compliance, there is no logic in denying the use of the 60mg tablet.