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

Diagnosis: Opioid use disorder
Treatment: Suboxone 8MG-2MG FILM 

Summary:
The patient's substance use disorder treatment and treatment of co-occurring psychiatric disorders and chronic pain is clinically appropriate and in keeping with prevailing standards of medical practice for the conditions under treatment in this case with evidence-base treatments; the requested services/treatment with Brand Suboxone 8mg/2mg three times daily is clinically appropriate and backed by credible scientific evidence known to benefit patients with the conditions diagnosed in this case.  The trial of generic formulation of Suboxone failed to sustain a clinical response and resulted in adverse effects.  Thus, the requested benefit of Brand Suboxone Film Tab is reasonable in this case and does reflect sound medical judgment in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status asthmaticus 

Treatment: Inpatient admission 
The insurer denied Inpatient admission. The denial was reversed.
The patient is female child with a history of previous treatment with albuterol.  The child had been sick with an upper respiratory infection and a bad cough.  The child was noted to have a decrease in oral fluid intake and fever.  When the parent noted that the child was having difficulty breathing, the child was taken to the Emergency Room (ER).
In the ER she was noted to be in moderate respiratory distress with tachypnea, wheezing and increased work of breathing.  There was fever of 102; the pulse oximeter reading was low at 88% and she required treatment with 28% oxygen.  On physical exam the child was noted to have nasal flaring, grunting with retractions and there were bilateral crackles audible upon examination of the lungs.  She was treated with three doses of inhaled Combivent, prednisone, magnesium sulfate and a bolus of intravenous (IV) normal saline.  Following this treatment she was started on continuous albuterol administration.  A chest x-ray and blood testing were unremarkable.  Testing for influenza and Respiratory Syncytial Virus (RSV) were negative.  When the child continued to have evidence of respiratory distress and increased work of breathing following treatment in the ER, the decision was made to admit her to the hospital with a diagnosis of status asthmaticus for continued treatment with albuterol every two hours. 
The patient was treated appropriately in the ER and when her respiratory distress did not respond to vigorous treatment the decision to admit her to the hospital was appropriate and consistent with the standard of care for status asthmaticus.  The child had ongoing clinical evidence of respiratory distress and she could not have been safely discharged to the home.
The carrier's denial of coverage for the inpatient hospital services is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain

Treatment: Inpatient admission, diagnostic testing, medication management

The insurer denied inpatient admission. That denial was upheld

This patient presented to the emergency department with complaints of chest pain with shortness of breath on exertion. 

A chest pain observation unit is now commonly used, in many emergency departments, to evaluate patients with possible acute coronary syndrome. The goal is to arrive at a decision after a finite amount of time, which usually is between 6 and 12 hours but may extend up to 24 hours depending on the policies in individual hospitals. Typically, the patient undergoes a predetermined observation period with serial cardiac biomarkers and ECGs. (5)  

The patient's EKG was normal and showed no evidence of myocardial injury or ischemia. Her BNP, d-dimer and troponins were within normal limits. An echocardiogram showed no significant abnormalities which included no wall motion abnormalities. A nuclear stress test was positive for anterior wall ischemia which led to a coronary angiogram which showed a myocardial bridge over the mid LAD, which was thought to be the cause of her chest pain and abnormal nuclear stress test. She had no complaints and no abnormal vital signs or physical findings while in the hospital. She was placed on beta blockers and discharged home with arrangements made for outpatient follow-up.

Inpatient hospital admission was not medically necessary, since care could have been provided in a less acute setting such as an observation unit.
Appeal type: Medical necessity
Decision: Upheld

The patient has a a history of migraine headaches for about 3 years and presented to the emergency room 12/10/18 with sudden onset of left sided weakness at 2 PM with preceding headache. The patient also had a fall in the shower hitting her leg. The patient complained of left upper extremity and left lower extremity weakness with numbness and was treated as a stroke alert.

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient presented with a headache with unilateral weakness, and she was noted to be hemodynamically stable. A CT scan of the head in the emergency room ruled out an intracranial hemorrhage and also did not pick up on a stroke. With patient having weakness on examination, admission to the hospital was necessary for further work up but her work up was essentially unremarkable, she remained stable, and also had total resolvent of symptoms. For this reason, the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Redness and swelling of left knee
Treatment: Inpatient admission
The inpatient admission was medically necessary.
The patient meets the initial criteria for IV treatment and admission for cellulitis/abscess given by the Infectious Diseases Society of America (IDSA) (1), as she had evidence of systemic infection (elevated pulse, elevated WBC count) as well as a concern for deeper infection (septic arthritis). Thus, this admission was warranted, supported by IDSA guidelines. Failure to admit such as a patient can lead to loss of function, sepsis, deep abscess, or death.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol dependence
Treatment: Inpatient admission
The proposed treatment, inpatient admission, was medically necessary for this patient.

The requested benefit of inpatient admission 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 on a daily continuous basis together with crack cocaine, tobacco, and cannabis that did warrant inpatient level detoxification and withdrawal management and monitoring. Detoxification, as necessary, and other treatments pertinent to the detoxification treatment episode could not have been safely or effectively provided at a lower level of care following the comprehensive assessment that was provided at the time of admission. Moreover, the patient's social environment was not conducive to an effective detoxification, and the patient struggled with withdrawal symptoms (tremor, hallucinations, nausea, anxiety, restlessness and insomnia) in the context of limited insight, impaired judgment and poor control of impulses.

Thus, the adult inpatient stay and detoxification treatment of this patient's substance use disorders did necessitate the structure of an inpatient level setting with structure, supports, and 24-hour monitoring. The patient's history of substance abuse (frequency and quantity) together with the severe psychosocial stressors and functional impairments (disability) and co-occurring psychiatric disorders do reflect the seriousness of the substance use disorders, does support and 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 be 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, American Society of Addiction Medicine (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 OASAS LOCADTR 3.0 Criteria that requires that the patient default to the higher level of care-referenced below.

The requested benefit of the inpatient admission is clinically appropriate, medically necessary and warranted, and is therefore a covered benefit 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 requested benefit is not excluded under the plan, and should be covered in keeping with prevailing standards of care pertaining to substance use disorder services including ASAM Criteria and NY OASAS LOCADTR Criteria, referenced below.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle cell thalassemia 
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient was admitted for sickle cell thalassemia with crisis. However, his vital signs at the emergency room were noted to be stable. Laboratory studies did not reveal any gross abnormalities that would support inpatient admission, or management. Chest X-ray did not show evidence of lung infection. Further, there was no evidence of sepsis, acute chest syndrome, hypoxemia, deep vein thrombosis, stroke, myocardial infarction, acute renal infarction or anemia requiring blood transfusion.  

The inpatient admission was not medically necessary, because the care rendered could have been performed at a lower level of care without adversely affecting the patient's health.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis and Abscess
 
Treatment: Inpatient admission, I&D, medications, monitoring

The insurer denied the inpatient admission. The denial was reversed.

The patient is a child with right neck swelling that started about a week prior to presentation.  The patient saw the pediatrician the Friday prior to presentation who prescribed Augmentin.  The laboratory studies at that time were significant for white blood cell count of 18 (N70%) and a C-reactive protein of 64.  The swelling and redness increased over the prior few days, causing them to present to the emergency department. The patient had been eating and drinking well with baseline urine output and stooling.  The patient did not have fevers, chills, dyspnea, difficulty breathing, or vomiting.  In the emergency department, the patient had a 3 x 5 cm erythematous and tender area on the right side of her neck.  The laboratory studies were significant for a white blood cell count of 12.5, and a CRP of 13.  The ultrasound demonstrated a fluid collection, consistent with abscess.  An Ear, Nose, and Throat (ENT) Consultation was performed.  The patient was admitted for intravenous antibiotics and an incision and drainage.  The patient underwent an incision and drainage; 30 cc of fluid was drained, the site was irrigated, and a Penrose drain was placed. 
 
The MCG recommend inpatient admission for pediatric patients with cellulitis when there has been documented failure of outpatient treatment as indicated by insufficient improvement (or worsening) of signs or symptoms despite adherence to appropriate outpatient regimen of sufficient duration.  The patient had been treated on an outpatient basis with Augmentin.  If the patient was not admitted, there could have been dire consequences, such as airway compromise.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Issue under review: Inpatient admission

Determination:
Inpatient admission was not medically necessary.

This patient with a history of endometriosis presented to the ER for further evaluation/management of nausea/vomiting/abdominal pain. Her intake vitals were afebrile, hemodynamically stable with no evidence of febrile temperature, malignant hypertension, profound hypotension, severe tachycardia or hypoxemia on room air. Her examination was non-focal, with no significant abnormalities noted, including no evidence of acute cardiopulmonary abnormalities or findings consistent with acute/surgical abdomen. Laboratory and ECG testing were 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, analgesics and anti-emetics. 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. For these reasons, the proposed treatment of Inpatient admission is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

The patient with a history of diabetes and hypertension, presented to the hospital with shortness of breath and a feeling of lightheadedness and chest pain. Review of systems was negative for fevers and chills. Medical history was also notable for cocaine use. Vital signs showed temperature 97.7 Fahrenheit, blood pressure 196/125, heart rate 82, respiratory rate 16, and oxygen saturation 100%. On physical examination, neck was supple, heart was regular, breath sounds were normal, abdomen was soft, and the patient was alert and oriented.The patient was admitted for hypertensive urgency and non-ST elevation myocardial infarction (MI). The plan of care included calcium channel blocker, aspirin, atorvastatin, echocardiogram, urine toxicology screen because of history of cocaine use, monitor blood pressure, and continue other home medications. Cardiology was also consulted and recommended no further cardiac work up and attributed to the abnormal troponin to cocaine use and hypertension. 
The health plan's determination is upheld.

The requested service of inpatient hospital admission was not medically necessary for this patient. The reason is that the patient had hypertension and cocaine use with an associated troponin elevation but the EKG was not consistent with coronary plaque rupture, and the patient had no other hemodynamic abnormalities such as acute heart failure, acute kidney injury, or acute cerebral hemorrhage/hemorrhagic stroke. In addition, there was no evidence of pulmonary edema or a positive cardiac stress test. 

The patient needed further care for hypertensive urgency but had an early cardiology consultation that indicated that no further cardiac work up was needed, and blood pressure improved rapidly with antihypertensive therapy. The care the patient received could have been managed at a lower level.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with pelvic pain and an ovarian cyst. She was scheduled for and underwent a laparoscopic hysterectomy with salpingoophorectomy.  She was admitted as an inpatient and discharged the following day.  The health plan's determination of medical necessity is upheld.  The patient had a scheduled, uneventful laparoscopic hysterectomy.  The surgery was not long, blood loss was minimal and no complications were noted.  She had no comorbid conditions that would complicate recovery.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with multiple risk factors and ischemic cardiomyopathy (ejection fraction (EF) 15%) who was found to have severe 2 vessel disease on catheterization. A few weeks earlier, he underwent successful percutaneous coronary intervention (PCI) of the left anterior descending (LAD) and he returned for elective staged PCI of a right coronary artery (RCA) chronic total occlusion (CTO).

The health plan's determination of medical necessity is upheld. There were no procedural, postprocedural, hemodynamic, laboratory, electrical or other findings that warranted an inpatient level of care. He was  treated without complication, and he was discharged the following day without a significant event.
Appeal type: Medical necessity
Decision: Upheld

The patient in question has a Class II occlusion, no crossbites, excessive overjet and overbite, and mild maxillary/mandibular crowding. The patient is in the late mixed dentition. The patient has extensive untreated decay on teeth 8 and 10. The patient is treatment planned for 24-30 months comprehensive orthodontics to correct his malocclusion. 

The health plan's determination is upheld. The Orthodontic treatment (D8080) is not medically necessary in this patient. He already has major decay, and orthodontic treatment can dramatically increase the risk of tooth decay. The health of the patient's teeth must be addressed via tooth restorations before orthodontic treatment should be considered.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with a past medical history significant for endometriosis, migraine headaches, and uterine polyps who presented to the emergency department with complaints of left flank pain and fever.  She had a diagnosis of acute pyelonephritis.  She continued to receive treatment with intravenous fluids and intravenous antibiotics.  The health plan's determination of medical necessity is overturned in whole.  The patient was septic on admission.  During the hospital stay, the patient's tachycardia improved, but her blood pressure was low on several occasions.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with sickle cell disease who was admitted to the hospital from due to a pain crisis. The patient reported right upper and lower extremity pain as well as left lower extremity pain of 4 days duration not relieved with oxycodone or ibuprofen at home. In the emergency room (ER) she was given intravenous (IV) morphine, IV fluids and Tylenol. The health plan's determination is upheld. There was no mention of specific criteria that required an inpatient admission that could not be handled at a lower level of care. There was no mention of central nervous system (CNS) symptoms such as a stroke, seizure, confusion, headaches, or visual disturbance. There was no report of acute chest syndrome with absence of radiographic findings, normal SpO2 saturation, no tachypnea, or abnormal lung findings on exam. There was no mention of acute organ damage, such as acute kidney injury, aplastic crisis, splenic or liver sequestration nor infection. There was no need for a transfusion particularly an exchange transfusion.
Appeal type: Medical necessity
Decision: Overturned

The patient presents to dental provider for evaluation and treatment of missing teeth #2, 12, 13, 14, 29, 30, 31. In question is the medical necessity of the planned treatment of implant placement (6010) for #2, 12, 13, 14, 29, 30, 31, custom abutment for site #2, 12, 13, 14, 29, 30, 31, and abutment supported porcelain crown for implant #2, 12, 13, 14, 29, 30, 31 (6059). Previous denials of benefits have been on the basis that the patient requires more than one implant per arch while the patient requires more than one per arch. The patient has the medical diagnosis of epilepsy with complex seizures. The patient has the diagnosis of partial edentulism as well as diminished posterior support. The health plan's determination is overturned.

With the diagnosis of partial edentulism as well as diminished posterior support the only therapy capable of addressing both diagnosis is that of implant therapy as it is anchored within the bone offering complete support stability and retention for a tooth prosthesis. Fixed partial dentures do not offer additional support and actually depend on the residual dentition to replace the missing tooth simply putting additional load on the residual teeth without replacing the loss. Removable partial dentures are tissue supported prosthesis and do not offer any support to the dentition as they are designed to become passive upon load. After the implants have integrated, they will require restorations in the form of abutments and crowns in order to complete the tooth replacement. This is standard in tooth replacement involving implants. Further, as the patient has a medical diagnosis epilepsy with complex seizures there is increased risk aspiration of removable prosthesis which makes this mode of therapy absolutely contraindicated.
Hence, the entire treatment of implant placement (6010) for #2, 12, 13, 14, 29, 30, 31, custom abutment for site #2, 12, 13, 14, 29, 30, 31, and abutment supported porcelain crown for implant #2, 12, 13, 14, 29, 30, 31 (6059) medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: ADHD
Treatment: Assay codes 81225, 81226, 81291, 81231, 81230, 81227
The health plan should not cover the assay codes 81225, 81226, 81291, 81231, 81230, 81227.
The assay codes 81225, 81226, 81291, 81231, 81230, 81227 are not likely to be more beneficial.
The analytic validity of the assay cannot be determined due to a lack of information on the testing methods. The available evidence on clinical validity consists of genome-wide association studies and case-control studies that indicate a correlation between variants of these genes and clinical factors. This evidence shows low-strength associations with a variety of psychiatric and nonpsychiatric conditions. Often the evidence for an association is not consistently reported across all studies, and in many cases, there are correlations of the same genetic variants with other nonpsychiatric disorders. There are also a range of associations reported for response to certain medications and alterations in pharmacokinetics. Evidence on clinical utility is lacking. Management changes that occur as a result of this assay are ill-defined, with uncertain impact on clinical outcomes. In addition, it is not well understood how unexpected results or unknown variants are handled, and whether these type of results have an impact on diagnostic work-up, treatment decisions, and health outcomes.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: ADHD
Treatment: Assay codes 81225, 81226, 81291, 81231, 81230, 81227
The health plan should not cover the proposed treatment.
The assay is not likely to be more beneficial for the patient.
The symptoms described are complex behavioral symptoms requiring multi-modal approaches without being able to attribute the symptoms directly to medication. 
Standard of care is to follow treatment algorithms from peer literature and while genetic testing is a patient and provider preference, it does not have literature to support increased efficacy of treatment approaches that include genetic testing over empiric treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: ADHD
Treatment: Assay codes 81225, 81226, 81291, 81231, 81230, 81227
The health plan should not cover the proposed treatment.
The assay codes 81225, 81226, 81291, 81231, 81230, 81227 are not likely to be more beneficial for the patient.
Apparent poor clinical response to stimulant medication in patients with ADHD is multifactorial. Subjective parental evaluations, subjective school evaluations, confounding factors such as anxiety, class room size, intellectual disabilities, and various stressors, as well as differences in metabolism of the common medications used, all necessitate a careful clinical titration and evaluation of medication response. Possible genetic variations in susceptibility to these medications have not been scientifically shown to be of much clinical value. 
The literature submitted by the provider is general in nature.  While there is high-quality literature suggesting specific genetic susceptibilities to the condition ADHD, there is no high quality literature to date supporting the routine use of genetic testing in the treatment of ADHD. It is therefore considered to be investigational and experimental.