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

This is a patient who sustained an acute injury to her knee after a slip and fall. The patient was examined by an orthopedic provider and the exam was suggestive of a meniscal tear. The patient was referred for a magnetic resonance imaging (MRI) scan of the affected left knee. The MRI was subsequently completed and confirmed a partial tear of the medial collateral ligament in the left knee. The health plan's determination is overturned. Based on the office progress note from the orthopedic provider documented an acute injury to this patient's left knee after she sustained an acute injury. The examination documented tenderness along the medial joint line and significantly diminished active range of motion in this healthy, active patient. The provided notes document an exam highly suggestive of an internal derangement of the left knee. Thus, the documentation in this case supports the medical necessity of the left knee MRI scan to determine treatment. The current, peer-reviewed orthopedic literature also supports the need for a knee MRI scan in this clinical scenario.
Appeal type: Medical necessity
Decision: Upheld

The patient presented to the emergency department (ED) with complaints of abdominal pain and concurrent fever. The patient has a medical history of sclerosing cholangitis as well as having had stents. The patient was imaged on admission for abdominal complaints and, while no abnormalities were noted within the abdomen, there was notation that the patient had infiltrate/atelectasis in the right lower lobe. The patient did not have nausea, vomiting or hematemesis and did not have cough. The patient did not have dyspnea and did not have dysuria. The patient is documented as having a fever of 105.3 on admission and had a lactate of 2.4 but remained hemodynamically stable. The inpatient stay is under review.

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient presented with abdominal pain and had incidentally noted RLL (right lower lobe) changes that could have been atelectasis or pneumonia. The patient did not have nausea, vomiting or hematemesis and did not have cough. The patient did not have dyspnea and did not have dysuria. The patient did have an elevated temperature at 105.3 as well as an increase in the lactate which does justify the diagnosis of sepsis. However, the patient did not have evidence of end organ damage and responded to measures enacted upon admission. The fever rapidly improved within hours of admission. I do not see a reason for an inpatient level of care based on the provided documentation. The patient could have been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Neuropathic Pain
 
Treatment: Monthly Quantity of 120 Oxycodone ER 80 mg tablets

The insurer denied the Monthly Quantity of 120 Oxycodone ER 80 mg tablets. The denial was reversed. 

This is a female patient who has a history of cervical herniated disk (C5-C6), chronic neuropathic pain likely due to metronidazole neuropathy, migraines, mitral valve prolapse, adrenal insufficiency, Hashimoto thyroiditis, gastroesophageal reflux disease (GERD), rectal bleeding, vertigo, anal stenosis and spasm, and opioid dependence. Due to the patient's condition she suffers from chronic pain that requires 24 hour pain management. She has tried morphine and hydromorphone in the past; she was allergic. She has also tried non-steroidal anti-inflammatory (NSAIDS) which caused hematuria. It was noted that the patient has had good pain management on the current regimen; OxyContin ER 160mg and Fentanyl patch. 

The patient has chronic pain due to neuropathy and cervical radiculopathy.  She is able to work and function with round-the-clock pain medication, which she has taken for many years.  The patient's neurologist notes that she has never abused or diverted medication. Suddenly discontinuing her pain medication is definitely not in the best interest of the patient. This patient has severe pain and pain control is medically necessary.  Despite the current focus on curbing opiate abuse, there are many patients, including this one, who need opiates and do not abuse them.  A JAMA editorial notes "The general philosophy regarding the level of attention that should be paid to pain, as well as its treatment, has changed dramatically during the past 30 years, swinging wildly between extremes, and remains a moving target.... Currently, most articles in the lay and even professional press highlight the problems associated with these drugs, as opposed to the significant benefits that may accrue from their appropriate use."1 This is a patient who would benefit significantly from appropriate use.  She should be allowed to continue.

Based on the above, the medical necessity for the monthly quantity of 120 Oxycodone ER 80 mg tablets is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who presented to the hospital for an elective cardiac catheterization. He had had progressive fatigue and dyspnea for one year prior to the procedure. Four months prior to the catheterization, he had had a one hour episode of chest pain. The patient had a history of hypertension, cardiomyopathy with an ejection fraction of 20%  and chronic obstructive pulmonary disease (COPD). The health plan's determination is upheld. The patient had an elective coronary intervention. It is reasonable and appropriate to monitor the patient for several hours after the procedure. However, it was very likely that the patient would be ready for discharge within 8-23 hours after the procedure. Thus, the patient could have been observed without the need for a full admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  End Stage Renal Disease, Hyperkalemia

Treatment:  Inpatient Admission

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

This is a female patient who presented to the emergency department (ED) after refusing her hemodialysis for 1 week.  She has a history of end stage renal disease, diabetes, and blindness.  The patient potassium on arrival was 7.4, blood urea nitrogen level was 90 and creatinine was 13.  Her blood pressure was 202/91.  She was admitted to telemetry, and underwent a hemodialysis treatment.  She was treated for her elevated potassium.  She tolerated the treatment well.  Her post dialysis blood pressure was 140/61, her potassium was 3.7, and her creatinine was 5.0.  It was recommended that the patient undergo dialysis the following day; she refused.  The patient was discharged back to the nursing home where she agreed to participate in dialysis in the nursing home. 

According to current literature, a patient may be admitted to inpatient services when there is evidence of cardiac arrhythmias of immediate concern, hemodynamic instability or clinically significant electrolyte abnormalities requiring inpatient care.  Within the documentation, it was noted that the patient did have hyperkalemia and ECG changes; however, the documentation detailed that this was readily corrected.  The documentation detailed that the patient also underwent hemodialysis the night of admission which normalized her vital signs.  Therefore, the inpatient level of service was not the most appropriate level of care as the patient could have been treated at a lower level such as observation.  The documentation does not detail why the patient could not have been treated at an observation level.

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

Diagnosis:  Cellulitis
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 (1), as he had systemic signs of infection (tachycardia).  In addition, there was confusion as to his diagnosis (cellulitis versus gout).  Thus, admission was warranted under standard of care, as the two diseases have very different treatment regimens.  Thus, this admission was warranted, supported by IDSA guidelines, as well as standard of care.  Failure to admit such as a patient can lead to loss of function, sepsis, deep abscess, or death.  Observation level of care would not have been adequate to provide for the care that was required for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
 
Treatment: Inpatient Admission

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

This is a female patient who presented to a rehabilitation facility seeking inpatient substance abuse treatment. It was reported that her symptoms included tremors, yawning, joint pain, and mood irritability. Her drug usage includes intravenous (IV) heroin, cocaine, and cannabis.  Her Clinical Opiate Withdrawal Scale (COWS) score was 11 and her Clinical Institute Withdrawal Assessment (CIWA) score was 10. 
She reported that she had past inpatient substance detoxification treatment. During her admission she was treated with a 5-day Methadone protocol and then discharged. 

The APA Practice Guidelines for the Treatment of Patients with Substance Use Disorders indicates that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. 

According to the LOCADTR she did require 24-hour treatment as she still needed and took detoxification medication to modify withdrawal and had a long history of heavy IV heroin use putting her at high risk for overdose and at risk for severe withdrawal. She was at risk for worsened withdrawal if she left prematurely.

Based on the above, the medical necessity for the inpatient hospital services at the medically supervised withdrawal service level of care is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The records do not support that inpatient admission was medically necessary.  The care and treatment provided to this patient could have reasonably been administered with an outpatient or observational level of care (rather than acute inpatient admission).

This patient is an adult male who presented to the ED with abdominal pain and was diagnosed with cholelithiasis/cholecystitis. The patient was clinically stable at the time of presentation, and he remained stable throughout the hospitalization.  The initial vital signs were normal.  Liver enzymes were normal.  The patient underwent an uncomplicated cholecystectomy procedure, and he was discharged from the hospital the next day.

Based on the available medical record, the medical necessity of inpatient admission is not established.  The records support the health plan contention that this care and treatment provided could have been completed in the outpatient (ambulatory) or observational setting. This level of care would have allowed for provision of the medical treatment that was rendered in this case (including overnight observation).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrophic disorder of skin
Treatment:  Surgery (abdominoplasty)
The abdominoplasty is not medically necessary.  

The abdominoplasty is cosmetic because the records do not document any functional problems related to the abdominal pannus and rectus diastasis.  According to the American Society of Plastic Surgeons Position Paper "Abdominoplasty", abdominoplasty is considered reconstructive when performed to correct or relieve structural defects of the abdominal wall (ICD-9: 701.8/708.9) and/or chronic low back pain (ICD-9: 724.1) due to functional incompetence of the anterior abdominal wall. The Position Paper also indicates that panniculectomy is considered medically necessary when performed to relieve uncontrolled intertriginous dermatitis, difficulty in walking and occasionally actual skin necrosis.  The records do not document chronic low back pain, uncontrolled intertriginous dermatitis, difficulty in walking or skin necrosis.  The medical records do not provide any documentation in the form of primary care provider (PCP) or dermatology progress notes that describe ongoing clinically significant dermatologic problems that have either 1) never responded to physician directed topical therapy or 2) despite initial response, have recurred and caused significant functional impairment. Supervised medical management for rashes is not documented in any of the progress notes. The patient is not sick from her excess skin, and has not had ulcerations, panniculitis or sepsis from her infections.  A dermatologist has not evaluated the rashes.  The patient has not required hospitalization or treatment with intravenous (IV) or oral antifungal or antibiotic medications.  The excess skin has not jeopardized health.  Physician supervised treatment is the simplest, safest and most cost-effective method of managing this patient's problems, and conservative treatment with appropriate hygiene and topical medications has a reasonable likelihood of correcting the condition. 

In a multiple regression analysis of postoperative complications after body-contouring surgery written by Parvizi et al. the authors found that the overall rate for major complications that required operative revision and/or antibiotics was 10.2%. In addition, 41% had minor complications, such as seromas, hematomas, wound healing problems, and wound dehiscences. Therefore, conservative, non-operative treatment would be recommended, such as improved hygiene, topical creams or powders, and watchful waiting.  Surgical lipectomy should be reserved for patients that have failed optimal medical management for intertrigo, which is not documented to be the case for this patient. Summary treatment letters and patient appeal testimonies in the absence of physician office note documentation of specific dates of treatments and medications prescribed do not provide sufficient documentation to confirm the failure of medically supervised care.
Appeal type: Medical necessity
Decision: Overturned

The patient has a history of psoriatic arthritis (PsA) and chronic bronchiectasis and ILD (Interstitial lung disease). Prior tx: Otezla (stopped due to HA's (headaches) and diarrhea), Enbrel (effective but stopped due to reports of tumor necrosis factor (TNF) inhibitors causing ILD) and Cosentyx (not effective). Methotrexate (MTX) is not an option due to history of lung disease. The patient is getting Xeljanz samples and is doing fairly well.
The use of Xeljanz XR is under review. 

The health plan's determination is overturned. The health plan denied the use of Xeljanz as it is not being used in conjunction with a non-biologic disease modifying anti-rheumatic drug (DMARD) (e.g. MTX, SSz or Arava). Of these agents, only MTX would be appropriate for PsA. However, given this patient's lung disease, MTX is contraindicated in this case. The patient has PsA as well as chronic bronchiectasis and ILD. The patient's PsA is controlled on Xeljanz.
Appeal type: Medical necessity
Decision: Upheld

The patient is a female with a listed diagnosis of multiple sclerosis. She is reported to have paraparesis, chronic pain and fatigue, as well as intermittent seizures.
Evaluation for personal care assistance reveals good cognition, occasional incontinence. It also indicates that she lives with relatives, has adequate current pain control, and uses wheelchair and scooter for locomotion. Fatigue is reported as a limiting factor.
Documentation indicates no recent changes in functional status, and does not document upper extremity difficulties.
The patient is currently receiving 63 hours a week and is requesting 70 hours per week, which is the subject under review.

The health plan's determination is upheld. 

An increase in personal care assistance service hours is not medically necessary for this patient. The patient is currently receiving 63 hours a week. There is no submitted documentation to support a recent change in status that would require increased hours of care for this patient with paraparesis, occasional incontinence, intact cognition and mood, adequate pain control. There is no evidence to support need for increased hours for any essential activities that could not be handled otherwise by the current level of care or by the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Osteoarthritis
Treatment:  Nursing Services (including Private Duty Nursing)

The patient is a female with multiple past medical problems.  Most notably, these include ambulatory dysfunction secondary to osteoarthritis and leg weakness.  The patient requests personal care level 2 aid hours 12 hours per day 7 days a week for a total of 84 hours per week.  This is under review.

The health plan's determination is upheld.  The Personal Care Aide Level 2: 12 hours per day/7 days week for a total of 84 Hours per Week is not medically necessary for this patient.  The allotted time provided by the plan is sufficient to meet the patient's medical needs.  Of note, there were no medical records provided by her physician for review.  The patient currently lives in a 1-bedroom apartment with her husband.  She has been approved for personal care 8 hours level 2, 8.5 hours per day  7 days per week for a total of 59.5 hours per week.  The assessment noted the patient required a total of 8.5 hours per day  7 days per week.  These medical services include dressing upper and lower body, personal hygiene, bed mobility, walking, bathing, toilet transfer, toilet use, continence care, meal preparation and medication.
There are no noted documentation/medical records which note skin breakdown.  There was an assessment by the nurse that noted that the patient should receive treatment; however, there were no physician records provided which noted a sacral ulcer.  There was no noted documentation provided by her physician that would necessitate frequent turning in the middle of the night.  There is evidence based upon this assessment showing that the patient does have frequent incontinence of bowel and bladder.  There is no noted rationale why the patient's husband could not help her during the time that the aid was not available, such as changing adult diapers, toileting or mobility in the middle of night.  The requested services are not medically necessary, and the services approved by the plan are adequate to meet the needs of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse

Treatment: inpatient substance detoxification

 The insurer denied coverage for inpatient substance detoxification. The denial was reversed.

This patient is a male who was admitted to this inpatient substance detoxification treatment due to alcohol and substance detoxification treatment. He had withdrawal symptoms including tremors, sweats, agitation, anxiety, irritable mood, nausea, and had a Clinical Institute Withdrawal Assessment (CIWA) of 8 and Clinical Opioid Withdrawal Score (COWS) as high as 8 during his treatment stay. He was drinking alcohol, using heroin, crack, and methamphetamine. He reportedly had past inpatient substance detoxification treatment more than a decade ago and had past inpatient substance rehabilitation treatment. He was put on a 5 day Ativan protocol and was discharged to a substance inpatient rehabilitation treatment for further treatment.

The insurer denied coverage for continued inpatient substance detoxification treatment as not medically necessary. They stated that he had no history of withdrawal seizures or delirium. They stated that he did not require 24 hour inpatient substance detoxification treatment as of then, and they recommended a less restrictive level of care then.

This reviewer disagrees with the decision to deny coverage for continued inpatient substance detoxification treatment. He was discharged to an inpatient substance rehabilitation treatment for further treatment. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. In this case this patient had been using multiple serious substances of use including heroin, crack, and methamphetamine and drinking alcohol.

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) he did require continued 24 hour treatment as he could not safely and effectively be treated in outpatient detoxification settings as he continued to use alcohol and multiple substances despite reports that he had a past inpatient substance detoxification treatment and inpatient substance rehabilitation treatment. He also required and needed detoxification medication to modify withdrawal and prevent severe, complicated, or life threatening withdrawal. The risk of life complicated withdrawal such as delirium tremens can occur 4 days after alcohol use so he required the entire time.

Based on the above, the medical necessity for the Inpatient substance detoxification is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of chronic kidney disease stage III-IV, diabetes mellitus type 2 and hypertension, who presented on to the emergency department, complaining of exertional dyspnea, after ambulating up 11 steps, as well as intermittent back pain, which started 3 days prior, radiating to the bilateral chest and up to the head. Last time that the patient experienced chest discomfort was 2 days prior to the admission. The primary cause for the visit, was the dyspnea on exertion. There was no associated nausea or vomiting or diarrhea, there were no chills or diaphoresis.
On the cardiac exam, the documentation notes a regular rate and rhythm with no rub. Laboratory studies revealed a high-sensitivity troponin of 16, with a subsequent high-sensitivity troponin of 15, normal delta change. A chest x-ray was clear. The patient was admitted to the hospital, for dyspnea on exertion as well as chest pain, rule out acute coronary syndrome.
The health plan's determination is upheld.
The patient presented to the emergency department, with symptoms of dyspnea on exertion after climbing 11 steps. There is a mention of chest pain, that appears somewhat unrelated to exertional dyspnea, and separated by at least 48 hours. The symptoms are atypical for unstable angina. The patient had inverted T waves, in the anterior leads, but negative cardiac enzymes. This type of presentation is typically managed in an observation unit or outpatient. This patient has a heart score of 3, indicating a risk of 0.7 to 1.7%. In the HEART [History, EKG, Age, Risk factors, and Troponin] score study, these patients were discharged to home, and not admitted to the hospital. Generally, a follow-up appointment with cardiology was arranged, within 14 days, with outpatient testing.