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

Diagnosis: Fever, cough, nausea
 
Treatment: Inpatient admission, medication, monitoring

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

This case involves a female who presented to the emergency room with a history of a cough and nausea x1 week. The patient had a past medical history of hepatitis B carrier, polycystic kidney disease, status post renal transplant. She had fever up to 102 F and chills the morning of presentation, and took Tylenol. The patient reported cold/upper respiratory symptoms for the previous week with a productive cough with yellow sputum, rhinorrhea, and nasal congestion. The patient had nausea and one episode of non-bloody, non-bilious emesis. She had mild dyspnea and was dizzy, which was felt to be possibly position-related. The patient had poor oral intake in the prior few days and was having myalgias. The patient's temperature was 39.4 and her heart rate was 110. She had normal breath sounds bilaterally and no acute cardiopulmonary pathology. The patient was admitted. The admitting note indicated the patient had a history of recurrent pyelonephritis. The patient was treated with fluids, antibiotics, and Tylenol. 

Milliman Care Guidelines indicate admission would be appropriate for a patient with sepsis when they had bacteremia, hypoxemia, and altered mental status that was severe, persistent or the failure of outpatient treatment. The patient would also be appropriate for inpatient admission if they had tachypnea, not responsive to conservative treatment. Admission would be appropriate for temperature greater than 104.9 F (40.5 C).  

The records do not indicate that the patient had bacteremia, hypoxemia, or an altered mental status that was severe or persistent. The records do not support the patient had undergone and failed outpatient treatment. The records do not support the patient was not appropriate to be treated at an observation 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

The patient has a  history of diabetes mellitus, who had presented to the emergency department for evaluation of weakness and elevated blood glucose on ambulatory monitoring. The patient  was admitted for management of uncontrolled diabetes mellitus. Treatment included subcutaneous basal bolus insulin administration, intravenous fluid hydration, and monitoring of blood glucose. Hemoglobin A1c was 14.3%. Creatinine declined from 1.7 to 1.53. A history of chronic kidney disease was documented. An abdominal ultrasound done to evaluate abnormal liver function tests revealed cirrhosis, portal hypertension, and non-visualization within a segment of the right portal vein presumed to be secondary to slow flow though thrombosis could not be excluded. The patient has a history of chronic hepatitis C infection and outpatient follow up with a hematologist was recommended. Adequate glycemic control was achieved. The etiology of the hyperglycemia was determined to be noncompliance with insulin therapy due to poor health literacy and poor social circumstances. The patient was educated on diabetes self-management. She was discharged the following day. 

The health plan denied the inpatient admission as not medically necessary. The health plan's determination is overturned. The patient presented with uncontrolled diabetes mellitus with severe hyperglycemia. There was poor response to emergency department treatment prompting hospitalization. Though the patient  did not have life-threatening acute metabolic complications of diabetes mellitus such as diabetic ketoacidosis or hyperglycemic hyperosmolar state, the patient  required high doses of insulin and close blood glucose monitoring to achieve adequate glycemic control. HBA1c was 14% and etiology of uncontrolled diabetes was determined to be noncompliance with insulin therapy due to poor health literacy and poor social circumstances.The patient  and  caregiver required intensive education on diabetes self-management. ADA guidelines lists substantial and chronic poor metabolic control that necessitates close monitoring of the patient to determine the etiology of the control problem, with subsequent modification of therapy as an indication for inpatient care in the management of uncontrolled diabetes.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Refractory Multifocal Epilepsy
 
Treatment: Belviq 10mg tablet

The insurer denied Belviq 10mg tablet. The denial was upheld. 

This is a young female who presented to the Emergency Room (ER) mid- 2019 with complaints of right hand focal seizure. The patient has a history of cortical dysplasia, refractory epilepsy, a craniotomy and resection of left occipital focus. It was noted that the patient had a vagal nerve stimulator (VNS) and had no seizures since the last visit which was in late 2018. An ambulatory electroencephalogram (EEG) did show almost continuous epileptiform discharges. The plan was to target for a higher dose of phenytoin. While in the ER it was noted that the patient's seizures improved with 1 mg of Ativan and an increase in his felbatol dose. He was then discharged home.

Belviq 10 mg is not medically necessary for this patient. There are no clinical studies that show this medication is beneficial for epileptic patients. There was a small study on 5 children with Dravet Syndrome that showed promising results but the drug is not substantiated to be medically necessary in seizures. Griffin et al (2017) state, "Dravet syndrome is a catastrophic childhood epilepsy with early-onset seizures, delayed language and motor development, sleep disturbances, anxiety-like behavior, severe cognitive deficit.  It is primarily caused by de novo mutations of the SCN1A gene encoding a neuronal voltage-activated sodium channel. Zebrafish with a mutation in the SCN1A homologue recapitulate spontaneous seizure activity and mimic the convulsive behavioral movements observed in Dravet syndrome. Here, we show that phenotypic screening of drug libraries in zebrafish scn1 mutants rapidly and successfully identifies new therapeutics. We demonstrate that clemizole binds to serotonin receptors and its antiepileptic activity can be mimicked by drugs acting on serotonin signalling pathways e.g. trazodone and lorcaserin. Coincident with these zebrafish findings, we treated five medically intractable Dravet syndrome patients with a clinically-approved serotonin receptor agonist (lorcaserin, Belviq) and observed some promising results in terms of reductions in seizure frequency and/or severity. Our findings demonstrate a rapid path from preclinical discovery in zebrafish, through target identification, to potential clinical treatments for Dravet syndrome."     

The carrier's denial of coverage for Belviq 10mg tablet is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of sickle cell disease, avascular necrosis of the right hip, chronically anticoagulated with Lovenox secondary to pulmonary emboli, history of transient ischemic attack (TIA), and prior episode of acute chest crisis. She presented to the emergency department with a one-week history of upper respiratory symptoms, with nasal congestion cough and fatigue. The patient started to have back and leg pain 3 days prior to presentation, unrelieved with home dosing of Dilaudid. She was evaluated in the emergency department and was given 2 milligrams (mg) of intravenous (IV) Dilaudid as well as 4 mg of intramuscular (IM) Dilaudid, without relief, so she was admitted to the hospital.
The cardiovascular exam was unremarkable except for mild tachycardia. The patient had mild swelling of the right hand, with no erythema or warmth, and mild swelling of both feet. The patient had a right port, which looked clean dry and intact.  She was started on her home regiment of Dilaudid, and was given additional IV Dilaudid as well. IV fluids were started and the patient was encouraged to have increased oral hydration. Lovenox was continued at therapeutic doses. The patient did not have hypoxemia or pleuritic chest pain, therefore, no further imaging was performed. In regards to the sickle cell disease exacerbation, the admitting physician documents no red flags, the patient appeared comfortable during the exam, had only a mild elevation of the reticulocyte count, and the hemoglobin was at baseline.
On the following day, the pain specialist was consulted, to evaluate the patient. They went over her regimen of pain medications and discussed options. The health plan's determination is upheld. The patient does not satisfy inpatient criteria for admission. There is no evidence of severe adverse reaction to treatment, there is no severe underlying condition, that is exacerbated such as chronic obstructive pulmonary disease (COPD) or congestive heart failure (CHF). The patient has underlying sickle cell disease, that does not appear to be severely exacerbated, as evidenced by a stable hemoglobin and only slightly elevated reticulocyte count. Her symptoms are very subjective. There is no evidence of chest syndrome, there is no evidence of end-organ damage in this situation. There is no evidence of an infectious process, with normal white blood cell count, normal temperatures, no hemodynamic instability. The patient does not have severe electrolyte derangements, injuries, poisoning.  Care could have been provided at a lower level than inpatient.
Appeal type: Medical necessity
Decision: Overturned in Part

The patient is a female with a past medical history significant for coronary artery disease (CAD), Non-Stemi myocardial infarction (MI), diabetes, chronic kidney disease, anxiety, post-traumatic stress disorder (PTSD) and hypertension. The patient also suffers from urinary and bowel incontinence requiring the use of adult incontinence products. Currently, the patient receives 29 hours/week of personal-care assistance service hours.
At issue is the medical necessity of the increased personal care assistance hours from 29 hours per week to 40 hours per week. The health plans determination of medical necessity is overturned in part. The requested health service/treatment of Increased Personal Care Assistance from 29 to 40 hours per week is not medically necessary for this patient however, based on the documentation provided, an increase from 29 hours/week to 34 hours/week would be medically necessary. The recommendation is based upon the following rationale: the nursing evaluation of the patient's functional abilities according to the New York Uniform Assessment system (UAs) identifies the patient required a total of 34 hours per week. The patient's physician asked for an increase in personal care assistance service hours secondary to constant change in her medical condition. Noting that the patient has multiple pinched nerves causing her difficulty with balance leading to her being unable to do most activities herself. Hours were mainly for Instrumental activities of Daily Living (IADLs) and also Activities of daily living (ADLs) including personal hygiene for an average between 4-6 hours a day. The patient is currently receiving 29 hours per week. Based upon this determination of her abilities it is determined from the review that an additional 5 hours a week for assistance with her ADLs and IADLs would be medically necessary. Additional services beyond 34 hours a week are not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Right hip pain;osteoarthritis to the hip
Treatment:  Total Hip Arthroplasty 

This is a male with right hip pain.  The duration was several years (approximately 15). He had undergone hip arthroscopy seven years ago with no improvement.  He had several injections to the right hip.  He had chronic low back pain and had undergone a spinal fusion.  He had received courses of PT (physical therapy).  He had a hernia repair, which decreased his pain 50%.  The pain limited his life. 

The physical examination was significant for "SLR intact, normal gait pattern".  His physician opined osteoarthritis to the right hip.  A total hip replacement was recommended. 

He was evaluated by a second physician.  He was reported to have pain with activities of daily living and had received several courses of treatment.  His physical examination was remarkable for antalgic gait, mild pain with internal rotation and + Stinchfield test.  His recent imaging reported narrowing of joint space, near bone on bone arthritis. A total hip replacement was recommended. 

The medical record was consistent for the diagnosis of osteoarthritis to the hip.  The patient had ongoing high hip pain for several years. He was found to have progression.  There was loss of internal rotation and gradual development of abnormal gait.  His recent imaging demonstrated progressive osteoarthritis.  There was reported joint space narrowing and near "bone on bone".  He underwent arthroscopic surgery and was found to have grade 3 loss of articular cartilage.  This has progressed. 

The patient had received a full course of conservative treatments.  These included multiple courses of medications, injections and arthroscopic surgery.  A search for pain generator was made by several physicians (i.e. source of pain being back, SI, or hernia) with treatments provided.  No resolution to his condition has resulted. 

He has limitation to function and activities to daily living. 

His physician's opinion has credence and is in agreement with guidelines and Criteria. 

The total hip replacement would thus be necessary and appropriate at this time.
Appeal type: Medical necessity
Decision: Upheld

The patient underwent a robotic assisted hysterectomy, bilateral salpingo-oophorectomy and sentinel lymph node biopsy for endometrial cancer. The surgery was not complicated. The patient was admitted to the hospital. The inpatient stay is under review.

The health plan's determination is upheld. The inpatient stay was not medically necessary. The robotic assisted hysterectomy, bilateral salpingo-oophorectomy and sentinel lymph node biopsy is an outpatient procedure. In this case, there was no event that occurred to justify an inpatient level of care. The patient did not require conversion to an open procedure, she was stable after surgery, with stable vital signs, and a non-focal exam. In addition, the patient did not have any complications such as bowel, bladder, ureteral injury that would justify inpatient level of care. The patient was able to ambulate, void, and take oral medications and an oral diet after surgery. The patient could have been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

The patient is a male who presented to his dental provider's office for evaluation and treatment of tooth #22, 23, 24, 25, 26, and 27. Provided for review are previous letters of appeal and denial, one pages of American Dental Association (ADA) claim forms, patient education forms on tooth replacement, and an explanation of benefits.
In question is the medical necessity of the planned treatment of porcelain fused to high noble metal crown (6750) for #22, 23, 24, 26, 27, and pontic-porcelain/high noble on tooth # 25.

The health plan's determination of medical necessity is upheld.

No, the documentation does not support the service/treatment of retainer crown-porcelain/high noble on tooth numbers 22, 23, 24, 26, and 27, and pontic-porcelain/high noble on tooth number 25 as medically necessary for this patient. There are no records that show the presence of decay, disease, trauma, or anything to support the requested therapy. Therefore, the procedures are not medically necessary for the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cognitive impairment, depression
Issue under review: Personal care services

Determination:
The Personal care services are medically necessary.

This is a male with a history of cognitive impairment and severe depression. These conditions result in frequent short term memory loss, wandering behavior and numerous safety concerns. On one particular incident, the patient's family was forced to contact the police and file a missing person's report when the patient went missing for an extended period of time. For these reasons, Personal care services are deemed medically necessary to better assist with the patient's activities of daily living (ADLs) and help with increased overall safety for the patient. As evidenced by the incident in which the patient went missing, the full scope of the patient's needs is greater than what can reasonably be expected to be provided by the patient's informal caregivers.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute gastritis and Dehydration
 
Treatment: Inpatient Admission

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

This patient is a young child that presented to the emergency department (ED) with complaints of vomiting for 2 days associated with abdominal discomfort, low grade fever and upper respiratory symptoms. It was reported that the patient had between 15-25 episodes of vomiting the day of presentation. Her physical exam showed an active and alert child. Her lips and throat were dry, her skin turgor was poor, but her capillary refill was < 3 seconds. Lungs were clear. Her abdomen exam was soft and non-distension, rebound, or masses. It was noted that the patient's father and sibling were suffering with similar symptoms; her sibling had been hospitalized as a result of it. She had a laboratory work up and was treated with intravenous fluids for hydration. She was started on a clear diet and tolerated it well. She experienced no further vomiting during her hospital stay. She was safely discharged home with aftercare instructions. 

Volume depletion is most objectively measured as a change in weight from baseline. Acute loss of body weight reflects the loss of fluid, not lean body mass; thus, a 2 kg weight loss should reflect the loss of two liters of fluid.

In most cases, however, a previous recent weight is not available. As a result, a number of findings on physical examination coupled with the pertinent clinical history are used to help assess the severity of hypovolemia. These findings include the child's pulse, blood pressure, skin turgor, systemic signs such as increased thirst or lethargy, and changes in urine output.

Mild dehydration (3 to 5 percent volume loss) - A history of fluid losses may be the sole finding, as clinical signs may be absent or minimal. Such patients may have a reduction in urine output, but this may not be appreciated.

Moderate dehydration (6 to 9 percent volume loss) - Signs and symptoms are now apparent and can include the following: tachycardia, orthostatic falls in blood pressure, especially with orthostatic changes, decreased skin turgor, dry mucous membranes, irritability, decreased peripheral perfusion with a delay in capillary refill between two and three seconds, and deep respirations with or without an increase in respiratory rate. There may be a history of reduction in urine output and decreased tearing and, in infants, an open fontanelle will be sunken on physical examination.

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: Upheld

Diagnosis: COPD
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

The patient did not meet the criteria for acute inpatient hospital stay for her acute COPD exacerbation.

When the patient presented to the emergency room, she was not in acute respiratory failure requiring immediate assistance with noninvasive or invasive ventilation, her vital signs were stable including the respiratory rate which was 20 breaths per minute, blood pressure was normal, pulse was within normal range and saturations 93% on room air at rest.  She had no use of accessory muscles, she was not considered as impending respiratory failure, and she was not hemodynamically compromised.  In addition, laboratory data was also unremarkable, except for chronic anemia.  There was a chronic mass involving the left upper lobe which required outpatient workup, her cognitive status was intact, she was ambulatory, and there were no issues with the feeding. 

Therefore, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of chronic obstructive pulmonary disease (COPD), asthma, hypertension and a known pulmonary nodule. She was admitted for dizziness, weakness, chills, shortness of breath, pain in her throat and difficulty along with an ongoing cough with sputum production and complaint of melena the day prior to admission. On admission, she was hemodynamically stable, was not in respiratory distress, had an oxygen saturation greater than (>) 90% on room air but had wheezing on auscultation. After treatment with intravenous SoluMedrol, antibiotics and short-acting bronchodilator nebulizations, she was noted to have an improvement in her symptoms. She was also evaluated and treated for anemia with intravenous iron. The health plan's determination is upheld. In the emergency room, the patient was not in respiratory distress, was not using accessory muscles, noted to have a respiratory rate of 16 breaths per minute but had wheezing on auscultation of the chest. The patient was given intravenous corticosteroids, antibiotics and Duoneb nebulizers. On admission, the patient was afebrile, hemodynamically stable, had a respiratory rate of 16 breaths per minute, had an oxygen saturation 92% room air and although on auscultation of his chest she continued to have wheezing she was not in any respiratory distress. In addition, she did not have evidence for hypercapnia, hypoxemia or cyanosis, a sustained heart rate greater than or equal to () 100 beats per minute, she was alert, awake and oriented, was able to protect her airway and did not require ventilator support or supplemental oxygen. During the remainder of the hospitalization, the patient was hemodynamically stable, her oxygen saturation was reported >91% on room air and she was never in any respiratory distress nor have a respiratory rate 30. She was also evaluated for anemia for the initial complaint for melena the day prior to admission. She did not have active hemolysis or active bleeding, require invasive monitoring or emergent surgery, recurrent syncope or near syncope, cardiac arrhythmias, acute peripheral ischemia (eg, pulseless, cool, mottled, or cyanotic extremity), a low platelet count, acute renal failure or clinically significant signs or symptoms that are severe.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Shortness of breath
Treatment:  Inpatient admission

The inpatient hospital admission was not medically necessary.

This patient with a history of asthma and medical noncompliance was admitted with asthma exacerbation.  At time of admission, the patient was hemodynamically stable.  ABG showed normal oxygenation.  Diagnostic studies were remarkable for suspected pulmonary neoplasm.  The patient had not failed nebs x 3 in the ED prior to admission.  Her dyspnea rapidly improved.  The hospital course was remarkable for malignancy work up with studies and consultations that did not require an inpatient level of care.  The patient left AMA before biopsy could be performed.  The inpatient hospital admission was not medically necessary.