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

Cardiac/Circulatory Problems - Chest Pain
Inpatient Hospital

The patient is a female with a history of poorly controlled diabetes, hypertension, hyperlipidemia, and tachycardia. She presented to the emergency room with a one day history of chest pain. Her vital signs revealed a blood pressure of 186/72 and pulse of 115. She was afebrile and the oxygen saturation was 100% on room air. The physical exam was otherwise unremarkable. Labs were notable for an initial blood glucose of 582; the patient reporting skipping her insulin that morning. The electrocardiogram (EKG) showed sinus tachycardia but was negative of acute ischemia, and the chest x-ray was non-contributory. The patient was admitted for further treatment and evaluation.
Upon admission to a monitored bed, the patient was treated with a lidocaine patch, insulin, and oral medications. The computed tomography (CT) angiogram was negative for a pulmonary embolus. The blood glucose and pressure quickly resolved. EKG monitoring and serial markers were negative for an acute coronary syndrome. The inpatient stay was clinically uneventful, and she was discharged.

The health plan's determination is upheld.

Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or EKG of an imminently life-threatening cause of the patient's complaints. The elevated glucose was most likely related to poor compliance. The hyperglycemia and hypertension could have been easily managed in the emergency room while serial markers were checked. There was no evidence of severe metabolic disarray, and the chest CT angiogram could have been completed in the emergency room. The services provided - insulin, oral medications, CT angiogram - were not at the acute inpatient level. Based on the standard of care and peer reviewed literature, the acute inpatient level of care was not medically necessary, and the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Alcohol addiction
Treatment:  Substance abuse Inpatient

The patient entered treatment related to problematic use of alcohol and marijuana.  Patient reported drinking five bottles of brandy on a daily basis and smoking 1 to 2 joints approximately 1 to 2 times per week.  The patient had a history of multiple inpatient admissions in the past for rehabilitation or detoxification from substances or alcohol.  The patient was reported to have had an alcohol withdrawal score of 17 at the time of admission.  Scoring was for nausea, tremor, sweats, anxiety, mild tactile disturbances, mild auditory disturbance, mild sensitivity to light, very mild headache, some agitation, and inability to do serial additions.  Vital signs at the time of admission included a blood pressure of 117/67 with a pulse of 78.  Other vital signs were normal.  Diagnoses were alcohol dependence with withdrawal and cannabis dependence uncomplicated.  There was no documented history of alcohol withdrawal seizures or delirium tremens.  The patient did not have elevated blood pressure or pulse during the admission.
Social history was significant for being on parole due to possession and intent to sell controlled substances.  The patient reported having stable housing and being satisfied with living situation.
The patient was placed on admission on a Librium taper with standing, tapered doses.  The patient was apparently not on a symptom triggered withdrawal protocol.  The health plan's determination of medical necessity is upheld in whole.  The patient did not require immediate hospitalization for a life-threatening medical condition or severe psychiatric crisis.  Alcohol was the substance with the greatest potential for harm.  The patient clearly met criteria for alcohol use disorder.  The patient was not in full remission from a substance use disorder.  Alcohol does have a risk of medical complications with withdrawal.  Clinical records do not establish that the patient's medical symptoms required 24 hour inpatient medical management.  The risk of withdrawal was not limited to opioids.  The patient did not require medical supervision and stabilization in a 24 hour setting.  The patient had a safe environment that could support outpatient treatment.  Based on responses, the LOCADTR Level of Care is:  Stabilization Services in a Residential Setting.
This patient did not require inpatient level of care for his alcohol use disorder.  Medical records do not establish any history of seizures or delirium tremens.  Though the patient had some nonspecific withdrawal symptoms, the vital signs on admission were normal and stable.  Clinical records do not indicate consideration of lower levels of care for potential withdrawal symptoms.  The patient could have been safely and effectively treated in a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

This patient has a history of morbid obesity, status/post (s/p) sleeve gastrectomy, and gastroesophageal reflux disease (GERD) who presented to the emergency room (ER) with complaints of chest pain and nausea. The patient was ruled out for pulmonary embolism (PE) and cardiac etiology but was found to have elevated liver transaminases. An ultrasound revealed cholelithiasis with minimal pericholecystic fluid. The patient was made nothing by mouth (NPO), started on intravenous fluids (IVF) and intravenous (IV) antibiotics. A surgical consult was obtained. The patient was taken to the operating room (OR) for a laparoscopic cholecystectomy with intraoperative cholangiogram, which did not reveal any filling defects. An endoscopy was performed intraoperatively and was normal. The patient was transitioned to oral intake and oral pain medication and discharged home The pathology report returned as chronic cholecystitis. 
The requested health service/treatment of inpatient hospital admission was medically necessary for this patient. Although elective cholecystectomy is generally performed on an elective of ambulatory basis for symptomatic cholelithiasis or biliary colic, this patient presented with acute symptoms that initially mimicked cardiac or pulmonary etiology that required extensive work up. Patient was found to have abnormally elevated hepatic transaminases initiating a biliary work up.  A decision was made to proceed with a laparoscopic cholecystectomy, and an intraoperative cholangiogram instead of magnetic resonance cholangiopancreatography (MRCP) to rule out choledocholithiasis, and an intraoperative endoscopy to rule out peptic ulcer disease (PUD), given a history of sleeve gastrectomy and the location of pain. This could not have been accomplished at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left renal colic
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

An acute inpatient level of care was not medically necessary.  The patient's care could have been provided at a lower level of care.  She was afebrile and hemodynamically stable throughout the hospitalization. There was no significant evidence for sepsis.  Following admission, there were no unstable vital signs reported.  She did not have a documented infection or kidney failure, solitary kidney or a kidney transplant, or need for an open surgery. She did not have bilateral obstruction, acute renal failure, or severe vomiting.  Pain control and IVF followed by laser lithotripsy and stent placement in a non-toxic patient can be provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

The patient has an anterior crossbite on teeth 10 and 23 and presents with a skeletal Class I malocclusion and significant crowding. The patient is treatment planned for 24-30 months of orthodontics with extraction of teeth 5, 12, 21 and 28 to address the crowding and crossbite. 

The health plan's determination is overturned. This patient presents with an anterior crossbite on teeth 10 and 23, as well as severe crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rheumatoid arthritis 
Treatment: Cimzia
The Cimzia is not medically necessary.
Per attached documentation, this patient was pregnant and treated with Cimzia last year and possibly early this year.  She had an uncomplicated full term delivery this year, and there is no documentation provided indicating that she is currently pregnant.  Furthermore, there is no documentation of current treatment with Cimzia necessitating continuation of therapy, as her last dose of Cimzia was filled on late last year.  In the absence of current pregnancy or documentation that this patient is actively trying to conceive, treatment with any of the Plan-preferred biologic alternatives noted above may be clinically appropriate and in accordance with standard of care in the rheumatology community.  Therefore, the proposed Cimzia for the treatment of rheumatoid arthritis (RA) in this patient is not medically necessary over the health plan's preferred alternatives.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain,
 
Treatment: Inpatient Admission

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

This a male patient who presented to the ER in early 2019 with complaints of chest pain the past 3 days who's symptoms were worse with breathing or lying down. He has a past medical history notable for peripheral artery disease, an infectious disease, cocaine abuse, and tobacco abuse. EKG done in the ER suggested sinus rhythm with nonspecific repolarization abnormality. CT of the chest was negative for pulmonary embolism. Troponins were initially and subsequently negative. Vital signs and physical examination were unremarkable. Cardiology evaluated the patient, and it was felt his symptoms were gastrointestinal in nature. He remained clinically and hemodynamically stable throughout his hospital stay and was discharged home.

In the absence of elevated cardiac biomarkers and a diagnostic electrocardiogram, the patient's care could have been provided in the observational setting, allowing for additional cardiac testing prior to discharge. Further evaluation was warranted, however inpatient admission criteria was not met.  Although the patient had new onset symptoms, medical criteria were not met for any other additional extenuating circumstances. There were no other high-risk co-morbidities.

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

Diagnosis: Gait ataxia
Treatment: Increase in Personal Care Services, Level II from 24 hours/day, 7 days/week, Live-In, to 24 hours/day, 7 days/week Split Shift

The Increase in Personal Care Services, Level 2 from 24 hours/day, 7 days/week, Live-In, to 24 hours/day, 7 days/week Split Shift is deemed medically necessary. 

This is a male who requires assistance with the majority of his activities of daily living (ADLs). Recent documentation from the patient's Attending Physician indicates that the patient is up multiple times a night and requires the assistance of a Personal Care Aide for ambulation to the toilet due to gait ataxia and increased fall risk. For these reasons, the currently approved plan of Personal Care Services, Level 2 24 hours/day, 7 days/week, Live-In is not sufficient to meet the patient's needs. Hence, the proposed treatment of an increase in Personal Care Services, Level 2 from 24 hours/day, 7 days/week, Live-In, to 24 hours/day, 7 days/week Split Shift is deemed medically necessary for improved assistance with completion of the patient's ADLs.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back pain and urinary retention
Treatment: Inpatient admission
The inpatient admission is not deemed to have been medically necessary. 
This female presented to the ER for further evaluation/management of low back pain s/p trip and fall injury. 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 focal neurologic deficits. Laboratory and ECG testing was also within normal limits, with no significant abnormalities noted, including no evidence of acute end organ damage. Abdominal/CT was without significant abnormalities. 
The medical records indicate that this patient was admitted to the inpatient medical service in stable condition, where she received PRN analgesics and supportive care. 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 Inpatient admission is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
 
Treatment: Inpatient Admission

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

This is a male patient with medical history of coronary artery disease, hypertension, and substance abuse. He presented to the emergency room with complaints of left sided chest pain radiating to his left arm. He had an electrocardiogram that revealed pronounced T waves. Serial Troponin levels were done with negative results. He was evaluated and ruled out for a myocardial infarction.  When he was deemed medically stable he was discharged home.

The patient's care could have been provided in the observational setting, allowing for additional diagnostic testing. Further evaluation was warranted, however inpatient admission criteria was not met.  There was no hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions warranting acute inpatient level of care.

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Deep bite
Treatment: D8080 - Comprehensive orthodontic treatment of the Adolescent Dentition

The D8080 - comprehensive orthodontic treatment of the adolescent dentition is medically necessary.

The patient has a deep bite that is causing tissue damage to the palate. This is an "automatic qualifying" condition, according to the handicapping index. The patient needs orthodontic treatment to correct the problem.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Family history of cancer
Treatment: Molecular pathology testing 

The Molecular pathology testing was not medically necessary.

The MyRisk testing as it was recommended in this case is not supported by peer-reviewed data, it is not standard of care, and it is not supported by professional organizations. The test would be medically necessary and indicated in a patient not yet diagnosed with cancer, such as this patient, if the affected family members were not available for testing themselves.  There is no documentation that the family members already diagnosed with cancer are not available for BRCA testing, for example.  The testing, based on peer reviewed data, professional organization recommendations and standard of care, should be done in the affected family member with a personal history of cancer first, unless the unaffected individual has a family history of a known mutation, which has not been documented in this case.  Testing of an unaffected patient, as recommended in this case, is only appropriate and medically necessary if no affected family member is able to be tested, which has not been documented in this case either. Thus, as per the rationale above, the recommended testing is not medically necessary.  

Testing of an unaffected patient, as recommended in this case, is only appropriate and medically necessary if no affected family member is able to be tested, which has not been documented in this case either. Thus, as per the rationale above, the recommended testing is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient admission

The proposed inpatient admission was not medically necessary.

The patient presented with typical signs and symptoms of acute cholecystitis.  There were no signs of sepsis; he remained hemodynamically stable with a normal heart rate, and pancreatitis was ruled out with CT scan.  In addition, there was no elevation in white count with normal electrolytes. 

The optimal timing of surgery will depend upon the patient's overall medical condition and underlying diagnosis.

Acute cholecystitis - Patients with acute cholecystitis, who are surgical candidates, should undergo cholecystectomy as soon as they are fully resuscitated and the most qualified surgeon is available.  Early cholecystectomy has been associated with improved patient outcomes compared with interval cholecystectomy.

After an uncomplicated elective laparoscopic cholecystectomy, patients can drink clear liquids once awake from anesthesia, and their diet can be advanced as tolerated.

Most otherwise healthy, reliable patients with good home support can leave the hospital within six hours after surgery.  Cochrane reviews have found no significant differences for important clinical outcomes for patients discharged the same day versus admitted overnight following laparoscopic cholecystectomy.  A retrospective review of the American College of Surgeon's National Surgical Quality Improvement Program (NSQIP) database, which included 15,248 patients older than 65 years of age who underwent elective laparoscopic cholecystectomy, identified congestive heart failure, American Society of Anesthesiologists class IV, bleeding disorder, and renal failure requiring dialysis as significant independent predictors of inpatient admission and mortality.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes Mellitus
 
Treatment: Continuous Glucose Monitor Device and Supplies

The insurer denied the Continuous Glucose Monitor Device and Supplies. The denial was reversed.                       


This is a male patient with a history of diabetes, hyperlipidemia, hypertension, adrenal nodule, neuropathy, and erectile dysfunction. The patient reports that he monitors his blood sugar 4 times a day and utilizes NovoLog. It was documented that he can feel when his blood sugar drops to around 70; he takes a snack to alleviate further complications. He has a history of using a diagnostic continuous glucose monitor which helped him treat his low blood sugar before it dropped too low, however he did report episodes despite the continuous monitoring. A Dexcom unit was recommended.

Per the current recommendations of the American Diabetes Association, continuous glucose monitoring is a useful tool to reduce A1C levels in adults without increasing hypoglycemia and can reduce glycemic excursions. Glycemic improvements are correlated with frequency of continuous glucose monitoring use across all ages.  Many publications and the results from a series of meta-analyses support the clinical benefit of CGM. The device can help anyone who has diabetes mellitus gain a better understanding of their blood glucose patterns and help with insulin dose adjustments. The submitted documentation indicated the patient has utilized a diagnostic CGM in the patient with improvement in glucose levels.  The documentation indicated the patient was recommended to receive a unit for home use given prior benefit. Given the literature recommends use of this unit in a patient such as this, the requested unit is considered medically necessary as it will allow the patient better control of his diabetes.  

Based on the above, the medical necessity for continuous glucose monitor device and supplies is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Substance use
 
Treatment:  Inpatient admission, monitoring

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

This patient was admitted to inpatient substance residential treatment for rehabilitation of substance use.  He reportedly was smoking 2-3 blunts of cannabis per day.  He had a past inpatient substance detoxification and rehabilitation residential treatment and past substance outpatient treatment.  He lacked coping skills and a sober support, needed to have better motivation for change, needed to improve coping skills, relapse triggers, and relapse prevention skills.  He reportedly was unable to remain abstinent on his own, and his motivation was external due to being mandated by parole for positive toxicology.  He was discharged with referral to outpatient substance treatment.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that residential treatment is indicated for individuals who do not meet clinical criteria for hospitalization but whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting.  According to the Level of Care for Alcohol & Drug Treatment Referral (LOCADTR), he met criteria for substance residential treatment, as he continued to use substances despite a past inpatient substance detoxification and rehabilitation treatments and substance outpatient treatment.  He used substances despite negative consequences and could not stop on his own, so outpatient substance treatment was not considered to be safe and effective.  He was unable to stop substance use without being in a sober and supervised therapeutic inpatient substance residential setting.