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

The patient has a past medical history significant for hypertension, gastroesophageal reflux disease, cataract, hypercholesterolemia, anxiety disorder and polyarthritis. She requests personal care service hours. These services were denied as not medically necessary. The health plan's determination is upheld. The personal care hours are not medically necessary. The patient can perform many of the tasks independently - at least 50% of the task. She is able to ambulate, toilet, and eat independently. There are no noted additional services that were noted to be medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prostate Cancer
 
Treatment: Positron Emission Tomography (PET) Scan Skull Base to Mid-Thigh (78815)

The insurer denied the Positron Emission Tomography (PET) Scan Skull Base to Mid-Thigh (78815). The denial was upheld. 

This is a male patient with a medical history of hypertension, hyperlipidemia, coronary artery disease (CAD), a myocardial infarction (MI); status post cardiac stent, renal colic with stent placement, prostate cancer status post prostatectomy. Due to the patient's rising PSA of 0.06 several years ago to 0.32 in early 2019, a positron emission tomography (PET) Flucicovine Axumin scan was performed. The test revealed no evidence of metastatic disease or local reoccurrence.  

Axumin PET scans were FDA approved in 2016 for biochemical recurrence of prostate cancer, namely a rising PSA noted after definitive local therapy, such as radical prostatectomy or radiation therapy. FDA approval of Axumin included a trial showing it to perform as well, if not better, than C11 Choline scans in patients with median PSA value of 1.44. The optimal utilization of Axumin PET scans has yet to be fully delineated by NCCN or American Urological Association (AUA) guidelines. NCCN also notes it is unclear what to do when such imaging is positive in setting of negative conventional imaging. However, imaging with this modality is felt to be most useful early in the course of a suspected biochemical recurrence.  

The patient's PSA had shown an increase over several years. In any event, in the setting of BCR (biochemical recurrence) for previously treated prostate cancer, CT scan and bone scan remain first line imaging, despite their limitations in limited volume disease recurrence. As noted, the role of Axumin PET remains unclear. In this case, in fact, the patient had radiation therapy after the negative PET Scan. This is consistent with the lack of clarity of how this test affects therapy in setting of suspected recurrence.  

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

The carrier's denial of coverage for the Positron Emission Tomography (PET) scan skull base to mid-thigh (78815) performed is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Substance abuse
Treatment:  Inpatient rehabilitation
The inpatient rehabilitation substance use disorder treatment was not medically necessary for this patient.

The patient presented with substance use disorders, diagnosed with alcohol and stimulant/cocaine use.  He self-referred and received inpatient level rehabilitation treatment.  He readily engaged in treatment and had no biomedical or psychiatric treatment issues.  During the time interval under review, the patient was noted to be in no apparent distress with reasonable functioning and active participation in treatment including positive interactions with staff and peers.  Throughout his inpatient stay, there were no complicating treatment issues or biomedical or co-occurring psychiatric issues that would have warranted inpatient level of care, structure or 24-hour monitoring.  The application of NY State OASAS LOCADTR 3.0 Criteria (referenced below) did indicate that the patient was clinically appropriate for treatment with lower level care in a less restrictive treatment setting, as the health plan asserts.  Thus, medical necessity for the inpatient rehabilitation substance use disorder treatment is not met in this case scenario, also consistent with ASAM Criteria, the scientific literature and published guidelines, referenced below.

The patient in this case scenario is not clinically appropriate for an inpatient level of care during the time interval under review.  The patient had presented with a level of stability and no co-occurring psychiatric disorders or safety concerns that would have warranted inpatient level care.  He did not need 24-hour monitoring or the structure of an inpatient setting in order to receive effective substance use disorder treatment.  He readily engaged with treatment and was involved with peer supported recovery groups that could have been provided in a less restrictive treatment setting with sober supports or living.  Thus, the health plan's determination is reasonable in this case scenario.  This answer is consistent with prevailing standards of medical practice for the conditions diagnosed and under treatment in this case, and consistent with the application of NY State OASAS LOCADTR 3.0 Guidelines.
Appeal type: Medical necessity
Decision: Upheld

Abdominal pain
Inpatient hospital

The patient is a female with medical history of gastroesophageal reflux disease (GERD), Helicobacter pylori infection, and colitis treated with antibiotics 2 months prior. She presented to the emergency department with left lower quadrant abdominal pain, nausea, vomiting, and diarrhea with scant red blood since the night before, as well as weakness and a feeling of dehydration. Vital signs were unremarkable. Physical examination was notable for tenderness in the left lower quadrant of the abdomen. She was admitted to the hospital.

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient had abdominal pain, nausea, and diarrhea consistent with acute gastroenteritis or colitis. Computed tomography scan of the abdomen and pelvis showed enteritis and possible colitis but was not consistent with pathology such as gastrointestinal perforation, pancreatitis, abscess, toxic megacolon, or bowel obstruction. Although uncomplicated gastroenteritis and/or colitis may have been present, the patient did not have peritonitis, sepsis, ongoing gastrointestinal bleeding, or other complications warranting inpatient level of care. She was appropriately treated with intravenous fluids and antibiotics. The measures which were undertaken, such as observation, monitoring, labs, antibiotic administration, intravenous fluid administration, and sitter monitoring could have been performed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental-deep impinging overbite
Treatment: Dental/Orthodontic Procedure

Summary: This patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to deep impinging overbite. The orthodontist has completed the Handicapping Labio-Lingual Deviation Index Report (HLD) as required and has chosen the automatically qualifying condition of deep impinging overbite with signs of soft tissue damage.
 
The insurer has denied coverage for orthodontic treatment-service codes D8080 (braces) and D8670 (monthly visit x4) as not medically necessary. The denial was reversed.

Upon review of the submitted documentation, it is evident that the patient exhibits a significant malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires, as of September 1, 2012, the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after the HLD Index. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care, a total score of 26 points is necessary. In this case, the treating orthodontist claims an automatic qualifying condition of deep impinging overbite. This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: pain
Issue under review: inpatient admission

Determination:
Inpatient admission was not medically necessary.

The patient presented with lower abdominal pain off and on for three days, associated with vaginal discharge. On presentation in the ED, she was hemodynamically stable and afebrile, and her abdominal examination was remarkable for mild to moderate right lower quadrant tenderness with no signs of peritonitis. Her CBC, UA, CMP (comprehensive metabolic panel), and ABG were normal. The CT scan of the abdomen/pelvis and US pelvis were unremarkable except for appendicolith and small ovarian cyst. Her abdominal pain resolved with IV fluids and pain medication, and in the afternoon of 11/08/2018, her abdominal pain was better and she was able to tolerate diet. She slept well overnight and discharged home next day. Since she had no evidence of infection, dehydration bowel obstruction, peritonitis, and did not need any surgical or endoscopic intervention, and she felt better within 24 hours of hydration and pain management, she could have been safely managed at the lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System (Asthma)
Treatment: Inpatient Hospital

Summary: This patient presented to the Emergency Department (ED) for asthma exacerbation. Oxygen saturations in the field were in the 80's. He was placed on oxygen and given intravenous (IV) steroids and magnesium. He also was treated with bronchodilators. He denied cough, fever, chills or chest pain. Past medical history included asthma, history of multiple intubations, hypertension and morbid obesity. Vital signs at triage were temperature 97.7, blood pressure 169/87 mm Hg, heart rate 79, and respiratory rate 20. Oxygen saturation was 100%. The patient was alert and oriented x 3 and in no apparent distress. There was no distension of the jugular vein. There was diffuse wheezing on auscultation. Abdomen was soft. He could move all extremities. White blood count was 11.5 and hemoglobin 11.8. Lactate was normal. Electrolytes were within normal limits. Brain natriuretic peptide was 29. Troponin was < 0.015. Urine toxicology was negative. Cannabinoids was positive. Arterial blood gases were 7.392/41/106. Oxygen saturation was 98%. Chest X Ray showed no infiltrates, effusions or pneumothorax.

The insurer has denied coverage for the inpatient hospital admission as not medically necessary. The denial was upheld.

As per the history and physical, vital signs were temperature 98.3F, blood pressure 177/89 mm Hg, heart rate 95, respiratory rate 16, oxygen saturation 98 % on room air. The patient was in no apparent distress. He was speaking in full sentences. No use of accessory muscles was noted. Lungs had a bilateral mild end expiratory wheeze. The patient's admission diagnoses were acute asthma exacerbation likely secondary to weather change and marijuana use. Based on review of the medical record, acute hospitalization was not medically necessary. The patient could have been placed in observation status. He was improving after treatment in ED. He was afebrile and hemodynamically stable as per history and physical. He was not hypoxic. Chest x-ray showed no infiltrate. This patient could have been treated with IV steroids, bronchodilators and inhaled corticosteroid combination inhalers and long acting beta agonist inhalers while under observation. The patient remained stable overnight and was discharged the next day. He could have been placed on observation status while diagnostic testing and treatment was initiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: CAD
Issue under review: Inpatient admission

Determination:
The inpatient admission was not medically necessary.

This was an elective, scheduled, uncomplicated percutaneous intervention on a patient with known anatomy. Both guidelines and standard community practice would recommend that it is safely performed in an outpatient setting. In this case, there was never any hemodynamic instability, angina, ischemic changes, or an unstable situation. While the patient did complain of a brief episode of dyspnea, his CXR was negative, his ABG was normal, O2 saturation was 98%. The only treatment that was recommended was an inhaler. 

Determination of level of care is primarily dependent on the actual care a patient receives, and whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results. It is highlighted in the orders for care. 
  
The letter of appeal was carefully considered, but it offered no evidence to support an inpatient level of care. The only cardiac care post-PCI that was provided was telemetry, which is frequently performed in a lower level of care. The patient was admitted for monitoring, and the subsequent tests and therapy did not require an inpatient level of care. There was no complex care that required inpatient care. This patient had no evidence of ischemia post procedure.  While there was always a potential for an adverse event (and in this case a very low probability), one did not happen, and no actual treatment was added. The procedure was electively scheduled and performed without complication, and the recovery essentially uneventful. The patient's SOB was brief, reversible and did not require significant intervention. There was no requirement in any part of this admission that required acute level of care.

Milliman criteria requirements were not fulfilled, as there was never any evidence of ACS (acute coronary syndrome) present. Neither triple vessel CAD nor being a smoker requires an inpatient level of care. There was no evidence of "inadequate physiologic recovery." There is no evidence to support that the patient's potential for a complication required an inpatient level of care. Since all testing and therapy that were provided would have been appropriate, safe and guidelines consistent in a lower level of care, the inpatient level of care was thus not medically necessary.

The denial explanation was consistent with guidelines and usual community care.
Appeal type: Medical necessity
Decision: Overturned

The patient is a male with systemic juvenile idiopathic arthritis who is prescribed Kineret. The health plan denied it as not medically necessary as he did not try the preferred medications, Ilaris and Actemra. The health plan's determination is overturned.  The Kineret is medically necessary for the patient.

Anakinra, along with Ilaris and Actemra are considered standard of care treatments for SJIA however, the American College of Rheumatology, in its most recent guidelines, recommends anakinra as initial therapy or for continued disease activity following NSAIDs as in this patient's case.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Suicide attempt, hallucinations.

Treatment: Inpatient admission, evaluation, and medication management

The insurer has denied inpatient mental health. That denial was modified.

The patient was admitted to inpatient mental health treatment due to a suicide attempt by overdose of Mirtazapine. She had reports of command auditory hallucinations suicidal in nature, persecutory delusional thinking, depressed mood, feelings of hopelessness, helplessness, and worthlessness, psychomotor retardation, irritable mood, poor activities of daily living (ADLs), and she had a past reported suicide attempt. She was initially admitted to telemetry after the suicide attempt.  She had diagnoses of Schizoaffective Disorder and Major Depressive Disorder.  She took Abilify.

The insurer denied coverage for continued inpatient mental health treatment in this hospital as not medically necessary.  They stated that she was stable with no self-harm or suicidal thoughts, had no mention of active psychiatric issues, was responsive to treatment, and they recommended a less restrictive level of care.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports that patients with past suicide attempts are at high risk for suicide and past suicide attempts are the single most reliable indicator of suicide.  It also states that patients may require more time in the hospital to better assess suicide because they sometimes do not tell the truth regarding their suicidal thoughts in order to leave the hospital.  This patient was considered a high risk patient and required continued inpatient acute hospital treatment in the hospital as she had three reported suicide attempts in 2018 and was considered a high risk for suicide.  She also continued with psychotic and depressive symptoms during part of the denial period.  

The documentation supports the need for approval in part.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Benign prostatic hyperplasia
Treatment: Acute Inpatient Hospital Admission

Summary:
Care after an uncomplicated TURP can be provided at a lower level of care.  Because there were no signs of complications, infection, excessive bleeding, or instability an acute inpatient level of care was not necessary.  The care of his co-morbid conditions was routine.  An observation level of care was appropriate
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Endocrine/Metabolic/Nutritional (Morbid obesity), Digestive System/ Gastrointestinal (GERD), Respiratory System (Sleep apnea)
Treatment:  Surgical Services (Stomach surgery for weight loss)

Summary: This patient has a history of morbid obesity, migraine, asthma, gastroesophageal reflux disease (GERD) without esophagitis, sleep apnea, and diabetes mellitus. Per the office note with the Bariatric Surgeon, the patient has completed all preop evaluation for bariatric surgery and is ready to proceed. The patient's body mass index (BMI) was 38.8. Per the note for the initial bariatric evaluation, the patient had a BMI of 38 and had diabetes diagnosed two to three years ago. She has had numerous weight loss attempts. The Pulmonologist/ Sleep Medicine specialist noted in a letter that the patient has morbid obesity and symptoms suggestive of obstructive sleep apnea (OSA). Her exam is significant for morbid obesity and a crowded oropharynx. The Home Sleep Apnea Testing (HSAT) showed mild OSA with an apnea hypopnea index (AHI) of 7/hr. She was not contraindicated for surgery, although deep extubation should be avoided and anesthesia consultation prior to surgery should be done. The Dietitian saw the patient for nutrition consultation and found that the patient has made significant attempts at non-surgical weight loss using a variety of methods. The patient was counseled regarding preop diet, as well as the progression of food after surgery. It was noted that the patient is required to follow up with the dietician or nutritionist both pre and post-surgery for further dietary guidance and behavioral change counseling, and it was also recommended that the patient attend support groups and educational workshops when available. Labs showed that the HbA1c was 6.2, which is considered pre diabetic. The patient was seen by the Cardiologist for preop evaluation for coronary artery disease (CAD) and was found to have no contraindication for surgery.

The insurer has denied coverage for stomach surgery for weight loss. The denial was upheld.

Based upon the records provided, the patient does not meet the criteria and indications for bariatric surgery. At the most recent visit, the patient had a BMI of 39.2 and has never had a BMI greater than 40. She does not have severe sleep apnea/OSA but rather very mild OSA with an AHI of only 7/hour. In fact, the Pulmonologist did not confirm that she had sleep apnea, but only that she has symptoms that are suggestive of OSA and an exam significant for a crowded oropharynx. She does not have diabetes as her HbA1C is only 6.2, which is considered pre-diabetic. Although she has undergone appropriate evaluation including psychiatric and nutrition, and has followed a medically supervised program, she does not meet the BMI criteria and she does not have significant co-morbidities. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Attention and concentration deficit; major depressive disorder
Treatment: Methylphenidate HCI 5MG
The proposed treatment is medically necessary.
The patient has a diagnosis of major depressive disorder, moderately severe and recurrent without psychotic features. He has a history of treatment refractory depression failing trials with six antidepressants: Lexapro, Zoloft, Wellbutrin, Cymbalta, Fetzima and Viibryd. He has experienced worsening episodes of depression over a ten year time interval associated with general medical illness. He is currently prescribed Luvox and Seroquel together with Xarelto, Losartan, atenolol-chlorthalidone and alprazolam. 
The patient's current mental status examination reflects depressed mood with associated symptoms of anxiety, low interest and motivation, decreased concentration and fatigue, and, motor retardation. He is well groomed with clear speech and no evidence for mood cycling or mania, thought disorder, psychosis or severe cognitive impairment. Insight and judgment are fair. He has sleep disturbance with low energy and volition associated with social withdrawal. PHQ-9 is at 14 reflecting moderate symptoms of depression.
Methylphenidate 5 mg bid is prescribed for augmentation of his major depression with the treatment goal of improvement in functioning and symptoms of the major depressive disorder. Coverage for methylphenidate (Ritalin) to address the treatment-resistant depression is requested to address these target symptoms of low energy, motivation and mood, and to augment any other antidepressant medications. There are no other documented diagnoses of substance use disorder; or, co-morbid psychiatric diagnoses.
The use of stimulant medications including methylphenidate (Ritalin) is considered a clinically appropriate and effective augmentation strategy for the treatment of major depressive disorder in patients who are refractory/resistant to treatment with antidepressant medications. Moreover, the patient in this case has a likelihood of demonstrating a response to the current regimen that includes the starting dose of 5 mg bid with regard to symptoms of fatigue, low interest and motivation, and decreased concentration or focus, as well as the core symptoms of major depressive disorder.  The requested treatment has a reasonable expectation for improvement and/or maintenance treatment of major depressive disorder in a patient with treatment refractory depressive disorder and comorbid general medical illness associated with symptoms of low energy, fatigue, mood and motivation in keeping with the scientific literature concerning treatment refractory depression and medication augmentation strategies. the requested benefit of methylphenidate to address symptoms of moderately severe and recurrent major depressive disorder and/or to augment the antidepressant medication regimen is considered medically necessary in this case scenario, in keeping with prevailing standards of professional practice.
Appeal type: Medical necessity
Decision: Upheld

The patient was admitted from the emergency department for anemia and worsening renal failure with a plan to initiate dialysis. At issue is the medical necessity of the inpatient stay. The health plan's determination is upheld. The patient did not have evidence of an acute process contributing to the progression of the renal disease that required inpatient treatment.