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

Diagnosis: Subdural hematoma

Treatment: Continued care in a skilled nursing facility

The insurer denied coverage for continued care in a skilled nursing facility.  The denial is overturned.

This patient is a female who fell and sustained a subdural hematoma.  After the hospitalization she was admitted to the short term rehabilitation unit.  The clinical records demonstrate the patient continued to require and benefit from SNF level of care and rehabilitation.  According to the physical therapy notes, the patient continued to require stand by assistance for safe ambulation with a rolling walker for approximately 75 feet.  She also required stand by assistance for sit to stand transition tasks.  However, by the time of discharge the patient was at a safer supervision level for ambulating with a rolling walker and sit-to-stand transition activities.  A similar level of improvement was documented by the occupational therapist (supervision for ADL tasks such as dressing and toileting).  Given the patient's history of falls with disastrous consequences (subdural hematoma), the additional week of therapies provided further safety upon her return home.   

The healthcare plan did not act reasonably and with sound medical judgment and in the best interest of the patient.  Continued care in a skilled nursing facility (SNF) was medically necessary.

Based on the above, the medical necessity for continued care in a skilled nursing facility is substantiated.  The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute Biliary Pancreatitis.
Treatment: Inpatient hospital admission.
The insurer denied the inpatient hospital admission.
The denial was overturned.

This is a female patient with a past medical history of hypertension, asthma, and status post cholecystectomy. The patient presented to the Emergency Room (ER) with sharp right upper quadrant epigastric pain since that morning.  The patient stated it felt like "gallbladder pain".  The patient had no nausea or vomiting and no radiation. The patient's physical examination revealed no distention.  There was tenderness and there was no rebound or guarding.  The patient's blood pressure was 152/84 and her pulse was at 93. The patient's temperature was 97.4.  The patient's electrocardiogram (EKG) was normal.  The patient's laboratory studies revealed the white blood cell (WBC) count was 9.36, alkaline phosphatase 76, AST 163, ALT 70, Pro B type natriuretic peptide 55 and troponin less than 0.01.  The patient's lipase was 264.  The patient's computed tomography (CT) scan of the abdomen and pelvis revealed mild dilation of the common bile duct up to 1.2 cm, tapering distally, hepatomegaly, heterogeneous and enlarged uterus with questionable 1.3 cm cyst, and small amount of free pelvic fluid. Gastroenterology was consulted.  The patient's abdominal ultrasound showed echogenic hepatic parenchyma consistent with fatty infiltration. The patient was treated with intravenous fluids and pain medication. The patient was admitted for acute biliary pancreatitis. The patient underwent a magnetic resonance cholangiopancreatography (MRCP) which showed no intrahepatic or common bile duct dilatation and no choledocholithiasis or pancreatitis.  The patient was started on a clear liquid diet and was subsequently discharged in stable condition.

Based on the review of the medical record and literature, inpatient admission was medically necessary for this patient. The patient presented to the Emergency Room (ER) with abdominal pain suggestive of acute pancreatitis. The patient's lipase was elevated at 264, and the patient's computed tomography (CT) scan of the abdomen showed dilated common bile duct (CBD). The patient's liver transaminases were elevated. This constellation of features was suggestive of acute biliary pancreatitis. The fact that pancreas appeared normal on the patient's computed tomography (CT) scan does not exclude pancreatitis. The patient's clinical course and management were appropriate for this patient's clinical presentation.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

Based on the above, the medical necessity for the inpatient hospital admission is substantiated.  The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with a history of asthma and symptomatic PVCs (premature ventricular contractions), status/post (s/p) catheter ablation. She presented to the hospital with complaints of similar symptoms as prior to the PVC ablation. These symptoms became progressively more frequent. She was given Metoprolol as an outpatient and Holter monitoring was performed. The Holter monitoring showed frequent PVCs, with a PVC burden of 25% and 9 runs of ventricular tachycardia (VT), with the longest episode being 97 beats (34 seconds) duration, at 169 beats per minute (bpm). She was then referred to the emergency room (ER).
She presented and was admitted. She had a pulse of 84, a blood pressure (BP) of 140/96 millimeters of mercury (mm Hg), and respiratory rate of 19. She was asymptomatic on admission. She was evaluated by electrophysiology and underwent a cardiac catheterization which showed normal coronary arteries, a Left Ventricular End Diastolic Pressure (LVEDP) of 22 and an ejection fraction (EF) of 45-50%. She was felt to have a PVC-induced cardiomyopathy. A repeat PVC ablation was recommended and was to be done as an outpatient. The patient was discharged.
The health plan's determination is overturned. The inpatient hospital admission was medically necessary. Per the Milliman Guidelines, inpatient admission is indicated for "Newly recognized (eg, new diagnosis for patient) sustained (30 seconds or more of ventricular rhythm at more than 100 beats per minute) ventricular tachycardia." That is the situation for this patient.
Once admitted, she underwent prompt evaluation for myocardial ischemia/ obstructive coronary artery disease (CAD), which was negative. She also underwent an electrophysiology evaluation, medication adjustment and an appropriate plan for a catheter ablation was formulated. This one-day inpatient hospitalization was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lupus (mouth sores and body aches)
Treatment: Inpatient admission
The Inpatient admission was not medically necessary.

The patient is a female with systemic lupus erythematosus (SLE). She presented to the emergency department (ED) with painful oral ulcers ongoing for two months, but worsening over the prior two days.  Her symptoms were consistent with prior SLE flares.  She visited her rheumatologist two months prior, and her prednisone dose was decreased to 5 mg daily.  She was additionally treated with valacyclovir, and her primary doctor initiated treatment with penicillin one week prior. She had one episode of fever to 101 F and Raynaud's phenomenon, along with worsening of muscle and joint pains, and tingling/numbness in the hands.  She had shoulder and hip pain that was 10/10, sharp, constant, and worse with movement.  Tylenol, oxycodone, and muscle relaxants were not helping. 

On physical exam, the patient was in distress with 10/10 pain.  She had a butterfly rash, and two ulcers on the palate and under the tongue.  The patient's ED vital signs were as follows: BP (blood pressure) 111/78, HR (heart rate) 115, RR (respiration rate) 18, 97.2, oxygenation 100% on room air.  ED labs were notable for ESR (erythrocyte sedimentation rate) elevated to 90, CRP (C-reactive protein) elevated to 4.39, CPK (Creatine phosphokinase) 398.  

The patient was admitted as an inpatient for SLE flare, and treated with intravenous fluids, intravenous acetaminophen, one dose of intravenous Solumedrol 125 mg, and narcotic pain medications.  She was also treated with viscous lidocaine, mechanical soft diet, and continued Plaquenil 200 mg twice daily.  She was discharged with oral prednisone 30 mg daily, to taper as an outpatient, and tramadol as needed for pain management.

This patient with SLE presented with worsening oral ulcers what had been ongoing for two months, in addition to myalgias and arthralgias.  These symptoms were consistent with her prior SLE flares.  She was hemodynamically stable, and laboratory evaluations were consistent with inflammation.  She was admitted as an inpatient for SLE flare, and treated with intravenous fluids, intravenous acetaminophen, one dose of intravenous Solumedrol 125 mg, and narcotic pain medications. She was discharged with oral prednisone 30 mg daily, to taper as an outpatient, and tramadol as needed for pain management.  As there was no evidence of internal organ involvement concerning for a severe SLE flare, her acute symptoms could have been appropriately and safely managed in the hospital outpatient setting, and did not require inpatient admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal pain; nausea
Issue under review: Inpatient admission

Determination:
The Inpatient admission was medically necessary.

The patient is an adult male. He has a past medical history significant for chronic pancreatitis and alcohol abuse. He was admitted with complaints of abdominal pain, nausea, vomiting, inability to tolerate PO (oral) food or fluids. 

The patient was hemodynamically unstable, with sinus tachycardia to 130s. There was no hypotension. ECG (electrocardiogram) revealed sinus tachycardia with prolonged QT segment. Examination was significant for jaundice, abdominal tenderness, and persistent vomiting. The patient was treated with IV fluids and antiemetics in the ED, but his symptoms persisted, and he was admitted to inpatient service. His laboratory data was significant for increased anion gap acidosis, acute kidney injury, elevated bilirubin and severely elevated liver transaminases, consistent with acute hepatitis. Alcohol level was elevated. 

The patient was continued on IV hydration, antiemetics, H2-blockers, as well as alcohol withdrawal protocol. He was seen in consultation by gastroenterology, surgery and psychiatry services. His symptoms gradually improved, and his renal function normalized. He left against medical advice.

The patient presented with abdominal pain, nausea and vomiting in the setting of alcoholic intoxication, history of chronic gastritis and pancreatitis. His course was complicated by anion gap acidosis, acute kidney injury, acute hepatitis, and alcohol withdrawal. Given his comorbidities, failure to respond to initial treatment in the ER, as well as inability to take PO and need for alcohol withdrawal monitoring and treatment, he would not be an appropriate candidate for an ED 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: Overturned

Diagnosis:  Substance abuse
Treatment:  Inpatient detoxification treatment
The Inpatient detoxification treatment was medically necessary for this patient.

The requested benefit of Inpatient detoxification treatment could not have been safely or effectively provided at a lower level of care in this case scenario.  The patient in this case was using large quantities of alcohol together with benzodiazepines that did warrant inpatient level detoxification and withdrawal management and monitoring.  The patient's social environment was not conducive to an effective detoxification, and the patient struggled with withdrawal symptoms, as noted in the clinical summary.  There was a history or frequent blackouts and falls with injury and severe symptoms of withdrawal in the past.  The patient displayed limited insight, impaired judgment and poor control of impulses.

Thus, the adult inpatient stay for detoxification treatment of this patient's substance use disorders did necessitate the structure of an inpatient level setting with 24-hour monitoring.  The patient's history of substance abuse (frequency and quantity) together with the severe psychosocial stressors and functional impairments and co-occurring psychiatric disorder do reflect the seriousness of the substance use disorder and co-occurring disorder with persistent anxiety that served to trigger the patient's substance use.  Again, the clinical features and treatment dimensions in this case do warrant and support the need for a safe and effective detoxification with withdrawal management as the patient was at high risk for treatment failure or general medical complications such as seizures if detoxification and withdrawal management were to have been attempted at a lower level of care.  Therefore, medical necessity is met in this case, consistent with prevailing standards of professional practice, published practice guidelines, ASAM Criteria, and the scientific literature, referenced below, and consistent with New York State instruction for medical necessity reviews including the appropriate application of NY State OASAS LOCADTR 3.0 Criteria/Guidelines that requires that the patient default to the higher level of care in this case scenario-referenced below.

The requested benefit of Inpatient detoxification treatment is clinically appropriate, medically necessary and warranted, and should, therefore, be covered in this case scenario.  The Substance abuse detoxification and continued inpatient level treatment through discharge could not have been safely or effectively provided with lower level services, as noted above.  Thus, the Inpatient detoxification treatment should be covered in keeping with prevailing standards of care pertaining to substance use disorder services including ASAM Criteria and NY State OASAS LOCADTR 3.0 Criteria/Guidelines, referenced below.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Crossbite.
Treatment:  Braces.

The insurer denied the braces.  The denial is overturned. 

The patient is a male.  The request is for orthodontic benefits.

The patient has both anterior and posterior teeth in crossbite (reverse bite) on the right side.  This needs to be corrected to prevent trauma to the teeth, such as fracturing and/or loosening.  Also, the patients handicapping index scale was 27, above the threshold needed of 26.  This patient has a definite medical necessity for orthodontic treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Advanced Imaging. 
The insurer denied: MRI. 
The denial is: upheld in whole.

The patient is a male with a complaint of left knee pain. The patient was evaluated for his left knee pain. The patient stated that the pain began three years prior but became worse two weeks prior to presentation without a trauma, injury or fall. The patient was sent for a magnetic resonance imaging (MRI) scan of the left knee without contrast which was completed. The study confirmed mild quadriceps tendinosis with adjacent patellar marrow edema. No other internal derangement of the knee was identified. At issue in this case is the medical necessity of the left knee MRI scan.

The requested health service of magnetic resonance imaging of the knee was not medically necessary for this patient. The rationale for this determination is based upon the provided medial records which failed to document adequate and reasonable conservative treatment prior to the recommendation for an advanced imaging study. In addition, the patient reported no history of a traumatic incident related to his left knee and no plain radiographs were obtained to aid in the diagnostic work up. Thus, the provided records do not support the medial necessity of the left knee MRI scan. Furthermore, the current, peer-reviewed literature, including articles published by Subhas and colleagues in the Orthopedics Journal in 2014 and by Roberts and associates in the Journal of Bone and Joint Surgery in 2015 do not support the recommendation for an knee MRI based on the provided documentation in this patient's case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Central nervous system/neuromuscular disorder/other.  
Treatment:  Home health care.  

The insurer denied Personal care assistance services hours 7 hours per day, 7 days per week for a total of 49 hours per week.  The denial is overturned in whole.

The patient is a male with a past medical history of hypertension, diabetes mellitus (DM) type 2, human immunodeficiency virus (HIV), cerebrovascular accident (CVA) with right sided weakness, bladder incontinence, coronary artery disease, gout and chronic pain.  The patient had been assigned Personal Care Assistant (PCA) service hours 5 hours/day, 3 days/week and 3 hours/day, 2 days/week to total 21 hours/week.  Yes, the Personal care assistance service hours to 7 hours per day, 7 days a week for total of 49 hours per week is medically necessary.

The patient was documented to have chronic dizziness and increased risk of falls with a hospitalization related to a fall.  The plan denied increase in PCA hours stating the increase was for safety and supervision only.

The patient requires assistance with unscheduled needs, and that assistance is to safely perform Activities of daily living (ADL's).  The PCA service hour increase is not solely for supervision and safety.  The patient has increased assistance needs with tasks of transfer toilet, toilet use and personal hygiene as he does wear incontinence pads and has right sided weakness from previous stroke.  The goal of PCA services is to allow the patient to maintain independence in his community environment, and the increase in PCA hours for this patient would help the patient to reach this goal.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath 
Treatment: Inpatient admission 

The insurer denied the inpatient admission. The denial is upheld. 

The patient is a male. He has a history of hypertension, Type 2 diabetes mellitus and hyperlipidemia. The patient presented to the hospital for further evaluation/management of worsening dyspnea. Intake vitals were afebrile, hemodynamically stable. Examination was non-focal with no significant abnormalities noted. There was no evidence of acute cardiopulmonary abnormalities or findings consistent with acute/surgical abdomen. Laboratory and ECG (electrocardiogram) testing revealed no evidence of severe abnormalities or end organ damage. 

The medical records indicate that this patient was admitted to the inpatient medical service in stable condition where he received supportive care with IV (intravenous) fluids and continued cardiac monitoring. The patient responded well to the prescribed therapies and was subsequently discharged in stable condition. Appeal review requested for potential approval of inpatient admission. 

No, the proposed treatment of inpatient admission is not deemed medically necessary. 

The medical records indicate that this patient was admitted to the inpatient medical service in stable condition where he received supportive care with IV fluids and continued cardiac monitoring. He 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, patient's care could have been safely furnished in a less intensive setting without adversely affecting patient's safety or outcome. For these reasons, the proposed treatment of inpatient admission is not deemed medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Lyme disease
Treatment: Formulary exception for Bicillin L-A 1.2MMU/2ML syringe
The insurer denied the formulary exception for Bicillin L-A 1.2MMU/2ML syringe.
The denial is upheld. 

No, the health plan should not cover the formulary exception for Bicillin L-A 1.2MMU/2ML syringe.

The patient is a female with a history of Lyme disease. An appeal review was requested for potential approval of formulary exception for Bicillin L-A 1.2MMU/2ML syringe to treat this condition.

Although recent documentation from the patient's provider indicates that patient has demonstrated best response to Bicillin regarding improved cognitive functioning, myalgias, arthralgias and overall functionality; there are no further details of which other alternative treatments have been tried. This includes no mention of the recommended formulary alternative Cefuroxime which has been found to be equally efficacious.  For these reasons, the health plan should not cover the requested medication Bicillin L-A 1.2MMU/2ML syringe.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis:  Erosive esophagitis.
Treatment:  Omeprazole-Sodium Bicarbonate Pow. 
The insurer denied the Formulary exception for Omeprazole-Sodium Bicarbonate Pow.  The denial is overturned. 

The patient is a male with erosive esophagitis.  He has failed treatment with Dexilant, Pantoprazole, Omeprazole and Lansoprazole.  His MD is requesting treatment with Omeprazole-Sodium Bicarbonate Pow.

Omeprazole-Sodium Bicarbonate Powder has been found to be safe and effective for the treatment of GERD (gastroesophageal reflux disease) and erosive esophagitis. 

As the patient has failed the preferred formulary alternatives for the treatment
of GERD and erosive esophagitis, Dexilant, Pantoprazole, Omeprazole
and Lansoprazole, the health plan should cover the Omeprazole-Sodium Bicarbonate Powder.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis:  Chronic Cluster Headache.
Treatment:  Emgality (300 milligrams dose) 100 milligrams/milliliters SC SOSY.

The insurer is denied coverage for Emgality (300 milligrams dose) 100
milligrams/milliliters SC SOSY.  The denial is reversed. 

This is a male patient who has been diagnosed with cluster headache.  It was reported that the patient had suffered from headaches, since a young adult.  The patient was seen for a follow-up appointment regarding chronic cluster headache.  The patient reported not feeling better since the prior visit and did report a new cluster cycle that started several weeks prior to presentation.  The patient reported having a dozen headache cluster attacks in the last few weeks.  The patient was utilizing Imitrex and oxygen therapy with excellent relief and remained on verapamil for prevention.  A physical examination was performed; no significant abnormalities were noted.

The documentation indicated the patient was counseled on headache management, and it was recommended that he attempt Emgality for prevention of cluster headaches.  He was also recommended to continue verapamil and abortive therapy with Imitrex.

Emgality is FDA approved and literature supported for prevention of cluster headache.

Documentation indicates that the member uses sumatriptan.  Documentation does not indicate that the member has tried or failed DHE injection or nasal spray.  Both are for treatment of an acute episode and not for prevention.

The formulary alternatives are for treatment of an acute cluster headache.  However, Emgality is FDA approved and literature supported for prevention of cluster headache.  As such, the intent of therapy is different between the formulary alternatives and the requested medication.  The member is currently treated with the only know effective preventative agent for cluster headaches, which is verapamil.  Emgality is the only FDA approved treatment for prevention of cluster headache. (Up to Date)

Based on the above, Formulary Exception for Emgality (300 milligrams dose) 100
milligrams/milliliters SC SOSY is granted.  The insurer's denial is reversed.