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

Diagnosis: Chest pain
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

This patient presented for evaluation of chest pain. The diagnosis of an acute MI (myocardial infarction) was ruled out by cardiac enzymes, which were negative. The pain was felt to be atypical by the treating physicians, and no inpatient ischemic work-up was planned. There was no evidence of acute myocardial infarction, ACS, decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability. The patient improved clinically and was discharged with a plan for outpatient follow-up. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission. The care required could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

The patient is a male with a past medical history of diabetes, hyperlipidemia, anxiety, and left knee surgery, who presented to the emergency room (ER) with left knee redness, swelling, and pain for three days.  The patient was sent in from urgent care with fever.  The patient had a fall ten days prior to presentation.  He was noted to have swelling, warmth, and tenderness of the left lower extremity.

Bilateral lower extremity ultrasound was negative for deep vein thrombosis (DVT); chest x-ray (CXR) was without evidence of pneumonia.  Left knee x-ray showed prepatellar soft tissue swelling, with no acute fracture, dislocation, or knee joint effusion.

The patient was admitted for left leg cellulitis and bursitis.  He was given intravenous (IV) ceftriaxone and vancomycin.  Orthopedic surgery was consulted.  The patient improved and was discharged on oral doxycycline. 
The health plan's determination is upheld.

This patient's hospitalization was not medically necessary at an inpatient level of care.

The patient was admitted with left knee redness, swelling and pain. Left knee x-ray showed prepatellar soft tissue swelling, with no acute fracture, dislocation, or knee joint effusion. The patient was hemodynamically stable, without high grade fever, bacteremia, abscess associated with the cellulitis, acute fracture or dislocation. There was no major electrolyte abnormality. The patient had not had recent surgery. He was treated with IV antibiotics with improvement and discharged on oral antibiotics.
The patient could have appropriately been treated at a lower level of care status.
Appeal type: Medical necessity
Decision: Overturned

The patient was admitted for diagnostic evaluation and management after having been noted to have papilledema by an ophthalmologist. The patient had been experiencing frequent headaches for the preceding 2-3 months. The headache was described as affecting the left side of her head more than the right, and was also frontal and band-like. The patient had been taking Motrin twice a month. The headaches had been occurring daily in the week prior to admission, and had also experienced blurred vision. 

The health plan's determination is overturned. The patient had been experiencing increased frequency of headaches, with blurring of vision over the few days prior to admission. Appropriate diagnostic evaluation for such symptoms includes MRI brain to look for evidence of a mass lesion, venous sinus thrombosis, and for characteristic features of idiopathic intracranial hypertension, which comprise pituitary gland flattening, flattening of the posterior sclera, optic nerve sheath distention, and transverse venous sinus stenosis. The inpatient stay was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prostate Cancer
 
Treatment: Oncotype DX Prostate Cancer Assay

The insurer denied the Oncotype DX Prostate Cancer Assay. The denial was upheld. 

This is a male patient who is status post prostate biopsy in the later 2018 due to elevated PSA of 4.9; biopsy revealed Gleason 3+3 adenocarcinoma in 1 of 14 cores. The urologist ordered an OncotypeDx PCA test, which was performed shortly after initial biopsy; the GPS score was 20, indicating low risk prostate cancer. By his PSA/Gleason grade, this patient has very low risk prostate cancer. 

The NCCN guidelines state that men with low risk or favorable disease may consider the usage of Oncotype Dx PCA test for future risk stratification, but they note the absence of randomized prospective trials to show a true clinical benefit from usage of this test. American Urological Assocoation (AUA) guidelines in 2018 state regarding management of localized prostate cancer state: "tissue based genomic biomarkers (such as Oncotype Dx GPS) have not shown a clear role in Active surveillance for localized prostate cancer and are not necessary for follow up". The overall impact of tissue based gene expression tests (Oncotype DX PCA) on clinical practice and long-term patient outcomes remains to be empirically demonstrated. Prospective studies of Gene Expression tests yielding a true clinical benefit when implemented in clinical practice are still lacking. Low/very low risk prostate cancer diagnosed by elevated PSA, Gleason grade does not always need confirmation by tissue based Gene Expression testing. 
Expression tests yielding a true clinical benefit when implemented in clinical practice are still lacking. Low/very low risk prostate cancer diagnosed by elevated PSA, Gleason grade does not always need confirmation by tissue based Gene Expression testing. 

Based on the above, the medical necessity for the Oncotype DX Prostate Cancer Assay, is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic kidney disease, dizziness, cognitive impairment with hallucinations
Treatment: PCA services, level II, eight hours per day, seven days per week, 56 hours per week 
The PCA services, level II, eight hours per day, seven days per week, 56 hours per week is medically necessary.

The patient is a female with a complex medical history, including chronic kidney disease; dizziness/vertigo; hypertension; cognitive impairment with hallucinations; recurrent falls; long term use of anticoagulants; major depression; asthma; osteoarthritis; TIAs (transient ischemic attacks); and elevated cholesterol.  The patient lives at home alone.  The patient's mini mental status score 21.  Based upon most recent uniform assessment system, the patient requires moderate to extensive assist with most adult daily living task.  

Based upon medical records provided, the patient has medically necessary needs requiring care of eight hours per day seven days per week totaling 56 hours. 

The patient requires eight hours per day seven days per week for a total of 56 hours in order to meet the medically necessary needs described in the patient's most recent uniform assessment system.

Based upon the available documentation, the patient requires eight hours per day seven days per week for a total of 56 hours of PCA Level II care in order to provide the necessary unpreventable unscheduled care of urinary incontinence; medication administration; prevision of adequate nutritional intake; prevision of adequate hydration intake; fall recovery and fall prevention; and scheduling of safety parameters designed to enhance safe independent living. The health plan's currently approved PCA services, level II, for a total of 33 hours per week, are not sufficient to meet the patient's current needs.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with neurofibromatosis type 1 complicated by uncontrolled hypertension that is being treated with lisinopril. He has been evaluated for renal artery stenosis using Doppler ultrasonography of the kidneys that was unremarkable. An echocardiogram has not revealed left ventricular hypertrophy, but 24 hour ambulatory blood pressure monitoring has revealed severe ambulatory hypertension. More accurate assessment of the renal vasculature has been requested through a magnetic resonance imaging (MRI) scan of the abdomen. The health plan's determination is upheld.
The requested health service/treatment of magnetic resonance imaging (MRI) of the abdomen is not medically necessary for this patient as part of the evaluation for renal artery stenosis associated with neurofibromatosis. The focus of concern in this case is in the renal arteries.  An MRI of the abdomen is more traditionally associated with questions of adrenal masses or lesions, hematuria, renal mass (cyst or solid), and transitional cell carcinoma of kidney.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left knee pain
Treatment: Partial knee replacement.
The partial knee replacement was medically necessary.
The medical record demonstrates consistency of end stage medial compartment arthritis. The patient had ongoing subjective complaints with documented functional loss. He had difficulty with weight bearing and walking. He had physical findings of effusion, tenderness and decreased motion. He had imaging findings of bone on bone to the medial compartment. He had an established diagnosis of osteoarthritis. He had received a full course of conservative treatment (over 1.5 years) of medications, physical therapy, several cortisone injections, several viscosupplementation injections and activity restriction. The next course would be the unicompartmental arthroplasty. The patient had isolated disease to the medial compartment which would support the procedure versus TKR. 

Elective total knee arthroplasty may be considered medically necessary for either of the following indications:
1) Primary or metastatic tumor with limb salvage surgery.
2) Joint damage or destruction due to osteoarthritis, inflammatory disease or other chronic conditions when all of the following requirements have been met:
        1) Imaging evidence of significant joint destruction and cartilage loss, defined as modified Outerbridge grade III - IV or Kellgren-Lawrence grade 3 - 4, MET.
        2) Knee arc of motion greater than 50 degrees, MET.
        3) Failure of at least three (3) months of non-surgical conservative therapy, MET.
        4) Functional limitation secondary to knee pathology which interferes with the ability to carry out age-appropriate daily activities, MET.

Elective Unicompartmental Knee Arthroplasty (UKA)/Partial Knee Replacement (PKA) may be considered medically necessary when all of the following requirements are met:
1) Osteoarthritis isolated to the medial or lateral knee compartment with no degenerative changes in the opposite compartment, MET.
2) Intact anterior cruciate ligament (ACL),MET.
3) Less than 15 degrees of correctable varus deformity in both knees, MET.

The criteria had been met. The surgery was thus necessary and appropriate.
Appeal type: Medical necessity
Decision: Overturned

This case involves an adult admitted from the emergency department for acute inpatient psychiatric treatment. The patient was brought in by a family member due to erratic behavior and suicidal ideation with a plan to jump in front of a train. Patient had a recent inpatient stay and had stopped  lithium and was using substances of abuse. Patient has a history of bipolar disorder and co-occurring substance use disorder with past use of opioids, stimulants, cannabis and sedative-hypnotic-anxiolytic class substances of abuse and heavy tobacco use.
The patient has a history of comorbid attention deficit hyperactivity disorder. Patient was receiving outpatient psychiatric treatment with medications, but had been non-compliant with treatment and was actively using substances of abuse, as noted. There was a history of multiple past psychiatric hospitalizations with the last occurring in the month prior to presentation. The patient has a history of suicide attempt by overdose.
The patient had a stormy clinical course through approved DOS characterized by agitation, psychosis, and erratic behavior requiring staff intervention. After approved DOS Patient remained socially isolated with persistent symptoms of depression  including hopelessness, helplessness, and labile affect with tearfulness and depressive demeanor.  Wellbutrin was added with titration  with tolerability. Patient remained anxious and depressed with hopelessness, helplessness and social isolation with high risk for suicidality. Discharge diagnosis was schizoaffective disorder and ADHD with co-occurring substance-related disorders and severe psychosocial stressors involving primary support, housing, occupational and social environment domains, as well as the chronic back pain.
The continued Inpatient Mental Health stay was medically necessary. The HP determination is overturned in whole. The continued acute inpatient level care and the continued structure of an acute inpatient level setting was necessary in order to remain safe and to administer treatment for the psychiatric disturbance and co-occurring substance use disorder while conducting an evaluation, and while observing  functioning with the resumption/adjustment of clinically appropriate medications. Additionally, the inpatient stay during this time interval is medically necessary in order to monitor the response to medications, to insure that the patient will have a sustained response to treatment, and to continue to address the acute risk of suicidal behavior in the context of severe symptoms of bipolar mood disorder and/or schizoaffective disorder (anxiety and depression and suicidal risk) and co-occurring substance use disorder with active use of multiple substances of abuse.
Appeal type: Medical necessity
Decision: Overturned

The patient who presents to the dental office for evaluation and treatment of teeth # 7, 8, 9, 11, 20, 29. Provided for review are full mouth radiographic images and American Dental Association (ADA) claim forms.
Tooth #11 is clearly present in the radiograph. The teeth planned for treatment all have evidence of periodontal involvement involving only the coronal third of the tooth as well as decay, yet none have a non-restorable designation. The health plans determination is overturned in whole . The requested health service/treatment of scaling and root planning for UL, UR, LR, LL (4341), root canal therapy for #7, 8, 9, 11 (3310), root canal therapy for #20, 28 and 29 (3320), root canal therapy #19, 30 (3330)porcelain fused to metal crown for #8, 9, 11, 19, 20, 28, 29 and 30 (2751) is medically necessary for this patient. None of the teeth have decay too extensive to treat with a crown restoration nor do any have periodontal issues that would contra-indicate restorations or root canal therapy. The entire treatment plan is all medically necessary.
Appeal type: Medical necessity
Decision: Overturned

This is a patient  with atopic dermatitis, treated with topicals (steroids and topical calcineurin inhibitors), bleach baths, anti-histamines, phototherapy, systemic steroids, cyclosporine, and Dupixent. His provider is requesting continuation of Dupixent. The health plan's determination is overturned. This patient has severe eczema and has failed other standard of care therapies for atopic dermatitis. According to the clinic notes the patient has done phototherapy in the past which did not help, and was placed on cyclosporine. The safety and efficacy were supported in a recent meta-analysis of all published dupilumab paper. Dupixent in this patient is in accordance with Generally Accepted Standards of Medical Practice, clinically appropriate, in terms of type, frequency, extent, site of Service, duration, and considered effective, and can be considered more effective than other therapies as this patient has already failed other standard treatment options.
Appeal type: Medical necessity
Decision: Upheld

The patient was admitted  related to opioid use disorder, severe; amphetamine/stimulant use disorder, severe; cannabis use disorder, mild; sedative/hypnotic use disorder, moderate; and tobacco use, moderate. The patient was discharged from inpatient detoxification and then transferred to inpatient rehabilitation. The patient was assessed to also have depression, anxiety, and possible bipolar disorder. Treatment included a methadone taper. The patient was reported to have and opioid withdrawal scale score of eight.

The health plan's determination is upheld. There were no changes in the patient's status that required movement to a higher level of care. The patient did not have withdrawal symptoms that continue to required 24 hour medical oversight in a hospital setting due to serious and life-threatening complications. The patient did not require 24 hour medical supervision, stabilization, and regular vital sign monitoring.
Based on these responses, the patient did not meet criteria for continued inpatient detoxification level of care.
Appeal type: Step Therapy
Decision: Upheld

The patient has a diagnosis of 46 XY disorder of sexual development (pure gonadal dysgenesis). The patient has history of three ischemic strokes between 2018 and 2019. The evaluation showed elevated lipoprotein A (which is a known risk factor for stroke and coronary heart disease) and positive double stranded anti deoxyribonucleic acid (DNA) antibody. During the evaluation for genetic causes of strokes, the patient was found to have 46 XY karyotype and subsequent evaluation showed a mutation in the SRY gene (p.P125S).

The health plan's determination is upheld. The Vivelle-Dot .025 mg / 24 H Patch TDSW (Brand) is not medically necessary for this patient. The required prescription drug on formulary is not contraindicated nor likely to cause an adverse reaction or physical or mental harm to the patient.  There is no documentation provided that the patient has tried the plan's preferred drug or that the patient has a contraindication to it. The patient can get same amount of daily estradiol with either patch. Vivelle dot 0.025 mg patch and Climara 0.025 mg patch are both Estradiol transdermal system designed to release estradiol continuously upon application to intact skin. There is no medical reason why the patient cannot use the plan's preferred agent at this time.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of hypertension, hyperlipidemia, obesity, coronary artery disease, and congestive heart failure who presented to the hospital with a chief complaint of dizziness and weakness after  cardiac bypass surgery. He had just been discharged after his surgical procedure. He reported shortness of breath that was chronic. He denied fevers, chills, nausea and vomiting. He had been referred for rehabilitation but declined.  The health plan's determination of medical necessity is upheld. The patient did not have evidence of an acute CHF exacerbation that was clinically significant, did not have EKG or clinical evidence of recurrent acute ischemia, had no evidence of unstable cardiac arrhythmia, and had no other complications such as sepsis or wound infection related to his recent cardiac surgery. Overall, this was a mild presentation related to the patient's refusal to undergo rehabilitation after his surgery.
Appeal type: Medical necessity
Decision: Upheld

The patient has active problems including bilateral hand numbness, cervical pain, chronic low back pain without sciatica, chronic migraine, demyelinating disorder, history of depression, lower back pain, muscle fatigue, piriformis syndrome of the left side, radicular pain of the left lower extremity, thoracic back pain. The patient was involved in a motor vehicle accident in with resultant bilateral leg pain. The patient was found to be a good candidate for spinal cord stimulation. The patient was seen by for evaluation of a spinal cord stimulator. The patient has a longstanding history of pain. The patient has failed epidurals, trigger points, SI joint injections, RFA and physical therapy. The patient underwent a successful spinal cord stimulator trial. At the onset, the device was not helping until after programming, then the patient had profound improvements. Medication includes gabapentin, Flexeril and Effexor. The patient had quit smoking two months prior. Exam was normal. The plan was for permanent placement. The health plan's determination is upheld.

While the patient had a positive trial, it is not clear what the etiology of the back and leg pain is. The patient had pain after a motor vehicle accident. No imaging studies to show pathology. The patient has a normal exam and no indication of a radiculopathy or neuropathy. There are no therapy notes provided or injection notes with responses. Recently, the outcomes of SCS have improved significantly and have become a widely accepted form of therapy for chronic intractable neuropathic pain. SCS is particularly effective for relieving pain of the neuropathic origin. The most common indications include failed back surgery syndrome (FBSS) with radicular pain, complex regional pain syndrome (CRPS), peripheral neuropathy, phantom limb pain, angina, and ischemic limb pain.The patient has back and leg pain. Spinal cord stimulation is indicated for neuropathic pain. The spinal cord stimulator is not medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Detoxification 

Treatment: Inpatient substance detoxification

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

This is a male patient who was admitted to inpatient substance detoxification treatment in early 2019 for substance detoxification treatment.  He reportedly had withdrawal symptoms including tremors, sweats, joint pain, dilated pupils, nausea and vomiting, yawning, anxious mood. He had a history of using intravenous (IV) heroin and cocaine daily, and Xanax multiple times per day.  He reportedly had multiple past inpatient substance detoxification and rehabilitation treatments including a recent one. He reportedly had two detoxification medications including Librium and Methadone during this admission. He was discharged to inpatient substance rehabilitation treatment.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders report 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 use of multiple serious substances including heroin, cocaine, and Xanax and was at risk for death from overdose.

The carrier's denial of coverage for the continued inpatient hospital stay for detoxification level of care is reversed.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

The patient presented to the emergency department with a request for detoxification treatment prompted by health concerns, psychosocial stress, impairment of functioning and complaints related to alcohol withdrawal. The patient was admitted following medical screening to inpatient level services for monitoring and detoxification and withdrawal management of severe alcohol use disorder. The patient reported daily use of alcohol with up to one-fifth of vodka and beer. He had multiple past treatment episodes including rehabilitation services and detoxification treatments with relapses and inability to abstain due to intense craving and co-occurring psychiatric disorders and severe psychosocial stressors that were triggering use.

The health plan's determination is overturned. The presenting clinical features and risk for withdrawal seizures and other psychosocial complications of alcohol use disorder did warrant the admission and continued inpatient level services with medical monitoring in this case scenario. The patient's admission and continued inpatient stay with detoxification, withdrawal management, and other medical services through discharge could not have been effectively or safely provided at a lower level of care in this case scenario.