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

Diagnosis: Obstructive Sleep Apnea
 
Treatment: Continuous Positive Airway Pressure (CPAP) titration Sleep Study

The insurer denied the CPAP titration Sleep Study. The denial was reversed. 

This case involves an adolescent male with a past medical history of snoring, recurrent pneumonia and possible asthma.  In late 2018, the patient was noted to have loud nightly snoring for several seasons, mouth breathing, rapid breathing, enuresis, some inattention and some impulsivity.  There were no observed apneas.  The patient had sleep talking.  The patient had a family history of obstructive sleep apnea (the father).  The father used continuous positive airway pressure.  The patient's body mass index was 32.60 kg/m2.  The patient yawned several times during the visit.  The patient underwent an overnight polysomnogram in the sleep lab in late 2018, which revealed the patient had an apnea hypopnea index of 5.1.  The recommendation was to see a provider for a tonsillectomy and adenoidectomy.  Additionally, if surgery was not pursued, the recommendation was for a repeat polysomnogram for continuous positive airway pressure (CPAP) initiation. In early 2019 the patient had seen an ear nose and throat provider and was found to have large tonsils and adenoids.  The provider recommended for the patient to lose weight. The provider stated that the patient met the American Academy of sleep medicine's criteria for pediatric obstructive sleep apnea and that a polysomnogram was indicated for positive airway pressure titration in the pediatric patient with obstructive sleep apnea syndrome.  It further stated that home sleep studies and the use of AutoPap may be appropriate for adults, but not for pediatric patients.  Therefore, the request was made for a Pap titration polysomnogram.

The MCG recommend a facility sleep study for pediatric patients who have daytime sleepiness, mouth breathing or snoring, and indicate that for a child, infant, or neonate with obstructive sleep apnea, evidence demonstrates at least moderate certainty of at least moderate net benefit. (RG A1).  The criteria for interpreting pediatric polysomnograms typically define mild obstructive sleep apnea as an apnea-hypopnea index of 1 to 4, moderate as 5 to 10, and severe as greater than 10.
Per UpToDate, "The fitting of equipment, titration of pressure settings, and monitoring of positive airway pressure therapy should be performed in a sleep laboratory with expertise in managing pediatric patients [6,27].  Proper technique and family support are essential to optimize adherence to therapy.  The pressure level should be periodically rechecked with repeat polysomnography, especially if there are changes in the child's clinical status (eg, recurrence of snoring despite using CPAP, recurrent daytime symptoms) or substantial changes in the child's weight or body mass index (BMI) percentiles".

Based on the above, the medical necessity for the CPAP titration sleep study is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Achalasia 
Treatment: Peroral Endscopic Myotomy (POEM)

Summary:
POEM is considered a standard of care option for the patient's indication. Further, the durability of benefit and safety of the technique versus other treatment options define POEM as medically necessary (with greater likelihood of benefit than available standard approaches) for treatment of the patient's condition.
Appeal type: Medical necessity
Decision: Overturned

The patient was being prepared for a hysterectomy due to abnormal menstrual bleeding, and the family history triggered the physician to order the Myriad My Risk cancer test.  The test was ordered due to paternal relatives with cancer that raised suspicion for Lynch syndrome, including a paternal grandmother with ovarian cancer, a paternal aunt with colon cancer, and a paternal grandmother with uterine cancer - all diagnosed in their 40's. 

The health plan's determination is overturned.  The requested testing is indicated.  The My Risk test in this case was medically necessary.  Most importantly, the test results would have a very direct effect on clinical management.  The patient was planning hysterectomy for unrelated reasons, but the decision to conserve or remove the ovaries rests on the future risk for ovarian cancer.  Incidental oophorectomy during her hysterectomy would increase the future risks of cardiovascular disease and osteoporosis.  Therefore, the decision to remove the ovaries in such a young patient requires careful consideration.  A genetic syndrome predisposing her to ovarian cancer (a deadly cancer without a screening test) would be a clear indication to remove the ovaries.  The physician is using the family history as he should to assess for future risks. The test result was going to affect clinical management (the decision to conserve or remove ovaries), and, therefore, was absolutely indicated.
Appeal type: Medical necessity
Decision: Overturned

The patient presented to the hospital with fever to 102.8 Fahrenheit, decreased appetite, chills, and fatigue for the past three days.  He also reported right flank pain and painful urination.  He denied headache, dizziness, vision changes, chest pain and shortness of breath.  Vital signs showed temperature 39.3 Celsius, heart rate 80, respiratory rate 18, and blood pressure 99/66.  The patient was admitted with suspected aseptic meningitis.  The plan of care included gram stain and culture of spinal fluid, intravenous (IV) antibiotics, acyclovir, infectious disease consult, droplet precautions, IV fluids, blood cultures, viral studies, encephalitis panel testing, and varicella testing.

The health plan's determination is overturned.  The inpatient stay was medically necessary.  The patient presented with suspected meningitis and high fevers along with a suppressed white blood cell count, all of which are consistent with sepsis.  In addition, the lumbar puncture in the emergency department demonstrated an elevated protein count.  The patient at least required IV acyclovir while awaiting the results of herpes simplex virus testing on spinal fluid.  Patients with sepsis in the setting of meningitis are not usually managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Loss of Consciousness/Head Trauma
Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld.    

This case involves a young male who presented to the emergency room by Emergency Medical Services (EMS) for a head trauma with loss of consciousness. The patient stated the incident occurred after running and accidentally bumped into someone pushing his head into the wall. The patient stated his vision became blurry and he fainted. He stated he only had pain to the back of his head.  On examination, the patient was cooperating, and answering all questions appropriately.  The physical examination revealed a Glasgow Coma Scale (GCS) score of 15.  His pupils were equal and reactive to light; he had tenderness to palpation of the posterior scalp with a small hematoma.  There were no lacerations/ abrasions/ecchymosis, and no gross motor deficits noted.  The Computerized Tomography (CT) scan of the head without contrast was negative. The treatment plan was admission to pediatric medicine for close observation, included maintaining a clear liquid diet. His vital signs and examinations were within normal limits.  The patient was discharged.
The Milliman Care Guidelines (MCG) recommends observation care for patients who have had a temporary loss of consciousness at the time of injury.  The guidelines also support admission for patients who have worsening of neurologic functioning post presentation, new focal signs on neurologic examination or new signs or symptoms.  The records indicated that the patient had a GCS score of 15.  The patient's physical examination and vital signs were noted to be normal.  The CT scan of the head without contrast was negative.  The patient was able to answer questions appropriately.  The patient could have been observed, instead of being treated with acute admission. 


Based on the above, the medical necessity for the inpatient hospital services at the acute level of care is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned in Part

The patient is pregnant and presented to the emergency department (ED) with complaints of nausea / vomiting / epigastric pain and chest pain (pain localized to the area under right breast). The patient reported cold symptoms " on and off " and was previously advised by her primary medical doctor (PMD) to use Tylenol cold. The patient was given intravenous (IV) hydration, IV Zofran, and IV Pepcid. In view of suspicion for preeclampsia and preterm labor with advanced cervical dilatation, the patient was admitted to L&D (Labor and Delivery); started on magnesium sulfate; and received steroids for fetal lung maturity.

The health plan's determination is overturned in part. The Inpatient Hospital Admission was medically necessary for the patient for 2 days. Based on provided clinical information, the patient presented with chest pain, nausea and was noted to have proteinuria and elevated transaminases. In the setting of proteinuria and elevated transaminases, the suspicion for preeclampsia (particularly - partial HELLP syndrome) was reasonable, consistent with literature (as 25 % of cases of HELLP or partial HELLP syndrome occur in normotensive patients) and with generally accepted standards of practice. The patient's symptoms were at no point suspicious for hyperemesis gravidarum. By the third day, the patient's transaminases normalized, there was no further suspicion for HELLP / partial HELLP syndrome, and therefore, continued acute inpatient stay beyond the 2nd day was not medically necessary as the 24 h urine collection could have been performed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vaginal Spotting
Treatment: Inpatient stay

Summary:
The inpatient admission was not medically necessary.
The patient had demonstration of an intrauterine pregnancy on ultrasound and was completely asymptomatic, with no abdominal or adnexal tenderness on multiple examinations, and normal vital signs. The concern for abnormal pregnancy location
was limited to the possibility that the pregnancy might be cornual. Based on the presentation, the patient had no signs of ruptured ectopic pregnancy, which would be highly unlikely if in fact the pregnancy was cornual at this gestational age,
particularly given this ultrasound appearance. Therefore, there was no surgical emergency. Therefore, given the above, the admission was not medically necessary, as it would not contribute to making the diagnosis of cornual ectopic
pregnancy that would point to definitive treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right hand laceration
Treatment: Inpatient admission
The inpatient admission was not medically necessary. 

The patient is a healthy male with no medical problems. He required flexor tendon repairs to his right long finger. Circulation to his long finger was normal. His postoperative course was unremarkable. Finger flexor tendon repair is an outpatient procedure. There was no indication for hospitalization in this healthy male with finger flexor tendon lacerations.  According to MCG Musculoskeletal Surgery or Procedure GRG 23rd edition, "Plastic operations on tendon or joints" can be performed on an ambulatory basis. The records do not provide any documentation of extenuating circumstances to support admission in this case. 
This procedure could have been performed on an ambulatory basis. Admission was not required.
Appeal type: Medical necessity
Decision: Upheld

The patient is a female who was admitted to inpatient rehabilitation substance use disorder treatment of severe opioid use disorder and moderately severe alcohol, stimulant (cocaine) and cannabis use disorders. The patient was using up to twenty 10 milligram (mg) pills of oxycontin while receiving methadone maintenance with 30 mg of methadone daily. She was frequently using alcohol with up to two drinks at three to six times per week, one gram of cocaine up to twice per week with intranasal administration and intermittent use of cannabis (marijuana/hashish). Her use of these substances was causing significant risk to health and impairing her ability to function socially or occupationally. The patient has a history of poly-substance with progression of the disease and escalating use of substances. She was also tobacco dependent with use of three cigarettes per day. There are co-occurring psychiatric disorders in this case diagnosed as major depressive disorder and an unspecified personality disorder as well as trauma history and symptoms which are best characterized as chronic posttraumatic stress disorder (PTSD) related to childhood emotional, physical and sexual abuse, as well as rape at age 18 years and subsequent sexual assault and domestic violence.

The health plan's determination is upheld.

The inpatient substance treatment in this case was amenable to treatment at a lower level of care, as noted in the answer to question 1. The patient was motivated and following detoxification treatment was capable of effectively continuing in substance use disorder treatment in a less restrictive treatment setting with sober supports and/or housing. The patient did not need the structure of an inpatient setting in order to effectively participate in rehabilitation substance abuse treatment, or to receive effective treatment for the mood and trauma related disturbances.

Again, there were no biomedical or psychiatric complications, or severe psychiatric symptoms/disorders in this case that would have warranted the transfer/admission and the inpatient level services and treatment. Thus, the requested benefit of inpatient substance use disorder rehabilitation treatment for the DOS in question is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

The patient is a female that presented to the emergency department (ED) for the fourth time in four days with week-long history of abdominal pain and vomiting. She had no fevers, diarrhea, trauma, or urinary symptoms. The pain was located in the epigastric and left sided regions and was non-radiating. Lab studies had been done previously, with leukocytosis and elevated inflammatory marker. Urinalysis was positive, but culture grew less than 10000 colony forming unit (CFU). Abdominal x-ray was unremarkable. She had been given a dose of ceftriaxone for possible urinary tract infection and discharged home on Omnicef. She was not able to tolerate the antibiotic, with ongoing vomiting. She had no current report of dysuria. She was seen by her pediatrician in follow-up and referred back to the ED this day. The health plan's determination is overturned.
 Acute inpatient hospital admission was medically necessary for this patient. She was admitted for evaluation and while hospitalized, her symptoms evolved necessitating additional testing and further diagnostic considerations. Hospitalization is indicated when outpatient monitoring is unavailable, or if inpatient management is necessary for dehydration, pain control, or hemorrhage. In this case, the diagnosis was not immediately clear because it took several days for the rash to appear. Her initial diagnosis was based on CT findings of mesenteric adenitis, likely part of the HSP/IgA vasculitis diagnosis. She had failed outpatient management with three prior ED visits and outpatient treatment of a presumed urinary tract infection. With persistent abdominal pain and vomiting, she required hospitalization and acute inpatient management.
Appeal type: Medical necessity
Decision: Upheld

The patient presented to the emergency department (ED) with a constant, left sided pressure type chest discomfort extending low-mid sternum to the throat. There was a pleuritic component to her chest pain (CP). A slight headache was present which later improved. The patient reported lower extremity edema which related to her salt intake. The vital signs were unremarkable as was the physical examination (though with a body mass index (BMI) of 30.2) without evidence for an elevated jugular venous pressure (JVP), rales, a cardiac friction rub, organomegaly, peripheral edema, rash or focal neurologic deficit.

The health plan's determination is upheld. The inpatient hospital admission was not medically necessary. The patient could have been just as safely and effectively treated at a lower level of care. While the patient's clinical background presented several concerning issues in the differential diagnosis, the appropriate studies and consultations could have been obtained at a lower level. There was no evidence of hemodynamic instability, persistent chest pain or significant cardiac dysrhythmia. Only routine laboratory studies were obtained. There were no invasive or interventional cardiac studies performed. Management in an observational setting would have been appropriate. Based on the orders and level of care delivered, the acute inpatient hospitalization was not indicated.
Appeal type: Experimental/Investigational
Decision: Overturned

This is a patient with a history of occipital neuralgia.  She previously underwent occipital nerve simulator and generator placement with two revisions since initial placement.  The patient now presents with persistent symptoms pertaining to occipital neuralgia and has a low battery occipital nerve generator.  The health plan's determination is upheld.  It is unlikely that the proposed treatment of replacement of occipital nerve simulator generator will be more beneficial than standard treatment.  Both revisions were done within one year of placement of the occipital nerve stimulator and generator.  The literature provided does note promising results for occipital nerve simulator and generator for intractable occipital neuralgia, and it can be an option, but systematic review of the literature by the Congress of Neurological Surgeons, considers it at best a level III recommendation.
Appeal type: Experimental/Investigational
Decision: Overturned

This is a patient with a significant past medical history (PMH) of Sjogren's disease with neuromyelitis, ON (occipital neuralgia), GN (glossopharyngeal neuralgia), subcortical cognitive impairment, and myelopathy with tremors according to her neurologist's notes.  She was first seen by the neurosurgery provider for a year's history of sharp ice-pick like intermittent right occipital region pain, associated with scalp tenderness and difficulty with activities of daily living (ADLs).  She had had benefit from 3 right ON (occipital nerve) blocks but these did not last.  Multiple neural-mediated medications were tried without relief and with significant side-effects.  The health plan's determination is overturned.  Replacing an already functioning end of life battery for an already indwelling system that appears to be functioning well for this patient is a minor outpatient procedure with the potential benefit to extend her pain control and continue to enhance her quality of life (QOL), as occipital nerve stimulation for ON shows continued efficacy with long-term follow-up.
Appeal type: Experimental/Investigational
Decision: Overturned

This is a patient requesting replacement insertion of a pulse generator for occipital neuralgia.  The battery is approaching end-of-life.
The patient was seen status post occipital nerve trial and permanent placement.  She reports greater than 90% reduction in occipital pain.
She has neuro-Sjogrens and is currently under therapy with medications. 
The health plan's determination is overturned.  The patient has had a stimulator for years providing 90% improvement in her pain and it improves her quality of life.  She has already failed prior non-stimulator treatment, so there would be no other standard treatment that would produce the same effect for the patient's pain and disability.
Appeal type: Medical necessity
Decision: Upheld

The patient  with a past medical history significant for hypertension, iron deficiency anemia, gastroesophageal reflux disease (GERD), bladder cancer, esophageal cancer, and schizoaffective disorder presented to the emergency department after sustaining an unwitnessed fall. Since the patient was a poor medical historian, patient  was not unable to provide the details of the fall.
Apparently, at the time of admission, the patient complained of being sweaty and dehydrated. He hit his head, but it was unclear if he lost consciousness.
At the time the patient was seen by the admitting physician patient was complaining of a headache, feeling dizzy, but denied any pain, including chest pain or abdominal pain. Patient also denied shortness of breath, fever, chills, sore throat. Laboratory evaluation revealed that the patient's sodium was 130, potassium 3.4, bicarbonate 23, BUN 27, creatinine 2.1. wide blood cell count was 11.6, hemoglobin 8.3, hematocrit 25, platelets 169.
During the hospital stay the patient underwent treatment with intravenous fluids with fast resolution of his acute kidney failure and normalization of the blood pressure. For evaluation of anemia, the patient was seen by a gastrointestinal (GI) specialist and underwent esophagogastroduodenoscopy (EGD), which demonstrated no focal point of bleeding.  The inpatient stay was not medically necessary. Even though the patient was anemic, there were no signs of active gastrointestinal bleeding necessitating any intervention. The EGD performed during the hospital stay did not reveal any evidence of bleeding. Patient's acute respiratory failure was transient and was most likely related to a viral upper respiratory tract infection. It was indicated in the notes that the diagnosis of pneumonia was unlikely.
Taking into consideration all of these facts, an admission at a lower level of care was the most appropriate to ensure a response to initial treatment.
Neither the severity of the patient's condition nor the complexity of services provided justified admission at the acute inpatient level of care.
The health plan determination of medical necessity is upheld.