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

Diagnosis: Substance Abuse

Treatment: Inpatient Substance Detoxification 

The insurer denied the Inpatient Substance Detoxification. The denial was reversed. 

This is a middle aged male who was admitted for inpatient substance detoxification treatment in late 2018 for heroin and crack/cocaine detoxification. He reportedly was using IV heroin and crack/cocaine use since a young age. He had withdrawal symptoms including nausea, sweats, yawning, tremors, anxiety, gooseflesh skin, and generalized body aches. He had a history of inpatient substance detoxification and rehabilitation treatments. During hospital admission he was placed on a Methadone taper and was then discharged home.

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 large amounts daily of heroin and crack/cocaine. According to the LOCADTR he did require 24 hour treatment as he could not safely and effectively be treated in outpatient detoxification settings as he continued to use multiple serious substances of abuse daily with a long history despite reports that he had multiple past inpatient substance detoxification and rehabilitation treatments. The patient also required and needed detoxification medication to modify withdrawal and needed 24 hour treatment then as he was at risk for worsened withdrawal symptoms including severe withdrawal and also was at high risk for overdose so he required this 24 hour inpatient detoxification setting then. Also, he likely would have relapsed again as evidenced by relapsing after past treatments so it was not likely that he could safely and effectively be treated for detoxification in an outpatient setting. It was unlikely that he would remain abstinent while having withdrawal symptoms which he reportedly had as he had reports of withdrawal symptoms including nausea, sweats, yawning, tremors, anxiety, gooseflesh skin, and generalized body aches.

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

Diagnosis: Dental Problems-edentulous spaces

Treatment: Dental implants placement

The insurer has denied coverage of dental implants placement. The denial was upheld.

This is a male patient who presented for dental evaluation and treatment and discussion regarding prosthetic rehabilitation for edentulous spaces in the anterior maxilla incisor area with missing teeth #7 and #10.  It appears that the patient completed orthodontic therapy and was wearing a removable prosthesis to replace the missing teeth. The orthodontist discussed treatment plans, which included no additional treatment, fixed or bonded bridges or endosteal implants (with grafts) and implant retained crowns. The patient chose endosteal implants to be placed at the sites after discussion of treatment plans.  

The insurer has denied the aforementioned services, stating that in their estimation, endosteal implants are not the only procedure or appropriate treatment. They further state that these services are exclusions from the patients' medical plan coverage, and the insurer will only cover certain dental services under the medical coverage with very specific criteria to be met. Therefore, the endosteal implants are considered not medically necessary, considered elective and therefore no benefit is available.  The patient is appealing the decision.

Upon review of the objective documentation, which primarily consists of the panoramic radiograph, it is evident that the patient exhibits edentulous spaces in the areas of #7, 10. As regards to endosteal implant placement, although implants are an acceptable treatment to restore edentulous spaces, an accepted standard of care in dentistry includes a fixed bridge of some type. Further, a functional impairment is not documented objectively and none appears to be present; therefore, no actual treatment is required and an option is to do nothing.  

Uphold denial of coverage of dental implant placement (21248) and bone graft (21210) as not medically necessary since there is no functional deficit documented. The insurer acted reasonably, with sound medical judgement, and in the patient's best interest.

Based on the above, the medical necessity for Dental Implant Placement (21248) and Bone Graft (21210) is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Infectious colitis
Treatment:  Inpatient stay 
The acute inpatient admission was not medically necessary.

Summary:
The patient was a female, who presented via ambulance to the ED with the complaints of nausea, vomiting and abdominal pain.

The patient was admitted to start treatment for infectious colitis.  The patient was maintained NPO (nothing by mouth) on intravenous (IV) fluids, IV antibiotics, Zofran and a proton pump inhibitor for acute management of acute infectious colitis.  The patient's tachycardia resolved when her pain was controlled and after getting fluids.  The patient had a repeat set of labs, which showed resolution of the leukocytosis, which lowered the suspicion for a systemic infection cause in this patient.  The patient was taken off antibiotics, and her cultures later returned confirming no bacteremia.  She symptomatically improved, and her vomiting stopped.

Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care.  The patient had infectious colitis; yet, she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for NPO (nothing by mouth) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission.  As such, the care could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Upheld

This patient presented to the emergency department with complaints of three days of intermittent shortness of breath and chest pain. His blood pressure was 119/80 millimeters of mercury (mmHg) with a heart rate of 61 beats/minute. His room air oxygen saturation was 96%. His cardiovascular exam was unremarkable. His electrocardiogram was normal. His serum troponin level was normal. His hemoglobin level was increased at 19.9 grams per deciliter (g/dl). A chest x-ray showed no acute disease. He was treated with nitroglycerin and intravenous hydration and admitted to the hospital to rule out acute coronary syndrome. The health plan's determination is upheld.  Observation until acute coronary syndrome (ACS) could be ruled out was a reasonable approach. A myocardial perfusion study was performed and was normal. He was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. There is no indication in the records provided that other potentially life-threatening causes of his chest pain were thought to be likely. He did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received did not require an inpatient admission and could have been provided at a lower level of care. This approach has been shown to be safe and is in accordance with the 2014 American Heart Association (AHA) / American College of Cardiology (ACC) Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.
Appeal type: Medical necessity
Decision: Upheld

The patient underwent upper and lower jaw surgery and went home the next day. There were no complications noted. The inpatient admission is under review. 

The health plan's determination is upheld. The inpatient stay was not medically necessary. Most patients with this surgery (orthognathic) are treated, observed and discharged the same day or the following day as long as discharge criteria is met. The surgery is accomplished in an operating room (OR) setting and the minimum required to accomplish the surgery. An inpatient setting would not be necessary unless discharge criteria is not met. In the United States, it has been reported that between 46% and 84% of patients go home the same day of surgery after an orthognathic procedure. It is rare for an orthognathic surgery patient stay to extend beyond the first postoperative day following a 3.5-hour bimaxillary surgery. A study of patients who underwent orthognathic surgery at Massachusetts General Hospital between January 1994 and July 2006 found that individual variables associated with duration of length of stay (LOS) are complexity of the orthognathic procedure and type of fixation used. In the multiple logistic regression model, LOS decreases significantly when rigid fixation, hypotensive anesthesia, and perioperative steroids are used in combination. In this patient's case, there were no postoperative complications, therefore the patient could have been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Attention Deficit Hyperactivity Disorder (ADHD), Oppositional Defiant Disorder, Disruptive Mood Dysregulation Disorder, Conduct Disorder, and Generalized Anxiety Disorder

Treatment:  Registered Nurse (RN) assessment for recertification of Consumer Directed Personal Assistance Services (CDPAS)

The insurer has denied Registered Nurse (RN) assessment for recertification of Consumer Directed Personal Assistance Services (CDPAS).  The denial was upheld.

The patient is a male child with diagnoses of ADHD, Oppositional Defiant Disorder, Disruptive Mood Dysregulation Disorder, Conduct Disorder, and Generalized Anxiety Disorder.  The patient is prescribed Seroquel, Clonidine, and Methylphenidate.  The request was for RN assessment for recertification of CDPAS.  It was reported that the patient could not self-administer medications, needed reminders and redirections to accomplish daily tasks and activities, did not cope well when frustrated or angry, had run away from the classroom, and had a history of throwing objects and pushing students.  It was stated that a personal aide could help manage behaviors.

The insurer denied coverage for RN assessment for recertification of CDPAS.  It was reported that he had this service for 41 1/2 hours from late 2018 to mid-2019.  

This reviewer agrees with the decision to deny coverage for RN assessment for recertification of CDPAS.  The Department of Health reports that personal care services (PCS) helps people with everyday tasks including activities of daily living or household tasks.  It also states that personal care attends to the physical needs of people disabled or otherwise unable to take care of themselves.  Such activities of daily living (ADLs) include bathing, showering, management of bodily fluids, toileting, feeding, ambulating, transferring from bed to chair or wheelchair, or in and out of the tub or shower, grooming, taking care of teeth or mouth, housekeeping, or meal preparation.

The American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameters for the Assessment and Treatment of Children, Adolescents, and Adults with Attention Deficit Hyperactivity Disorder does not mention personal care assistance services as a standard for treatment.  It mentions pharmacotherapy, and also behavioral therapy and parent training as standards of treatment.  This service is not indicated for reminders and redirections to accomplish daily tasks and activities; therefore, it is not medically necessary for this child. 

As a result, uphold the previous decision and deny coverage for RN assessment for recertification of CDPAS.  The health care plan acted reasonably and with sound medical judgment and in the best interests of the patient.

Based on the above, the medical necessity for the RN assessment for recertification of CDPAS is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

The patient  was admitted to the hospital and discharged the following day. The patient was admitted for diagnostic evaluation of episodes of jerking of the  body which had started 1 week prior to admission. The movements were initially left sided but had been bilateral for the previous 2 days. They decreased with activity and did not occur during sleep. There was no associated loss of consciousness, urinary incontinence, tongue biting or post-ictal confusion. The patient dropped items that they were  holding during an episode.The patient was admitted to the hospital for a diagnostic workup which included an magnetic resonance imaging (MRI) brain, video electroencephalogram (EEG) telemetry, lumbar puncture, blood and urine testing. The health plans determination of medical necessity is  overturned in whole. the requested health service/treatment of the inpatient hospital stay was medically necessary for this patient.
 The inpatient stay was medically necessary, and met the criteria for Inpatient Admission for Neurology under the Milliman Care Guidelines  Health Inpatient & Surgical Care,  which states:
"Hospital admission is needed for appropriate care of the patient because of 1 or more of the following: New onset severe neurologic finding requiring inpatient care indicated by 1 or more of the following: Involuntary movements. The differential diagnosis of the onset of involuntary movements , and included seizures, movement disorder which can be due to underlying infectious or autoimmune illness, or tics.,The  inpatient admission for video EEG telemetry and diagnostic workup including lumbar puncture with sedation was medically necessary in order to correctly diagnose the paroxysmal events that the patient was exhibiting. and prevent the patient  from being inappropriately treated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Abnormal pap smear
Treatment:  Inpatient admission
The inpatient admission was not medically necessary.
 
An outpatient observation bed is an alternate level of healthcare compromising of short stay encounters for patients who require close nursing observation or medical management.  It is an area where the patient is observed and assessed following surgery to determine a need to be admitted to the hospital as an inpatient.  
The patient in question was taken to the operating room and underwent an uncomplicated fractional dilation and curettage with hysteroscopy procedure for an abnormal pap smear of atypical glandular cells of undetermined significance.  After surgery she was not ready for discharge same day.  She required observation and nursing care to assist with her ambulation and medical management of her pain and nausea.   This could have been done in an observation status.  By post-operative day #1 the patient was ready for discharge, requiring less than a 24 hour stay.  Therefore, the patient did not require an acute inpatient stay, as the same care could have been provided under an observation status.
Appeal type: Medical necessity
Decision: Upheld

The patient with no significant past medical history who presented to the emergency department with complaints of nausea, vomiting, and abdominal discomfort that had been going on for 2-3 days. At the time of the initial evaluation, the patient denied fever, chills. The patient was evaluated by general surgery and was found to have no surgical cause of pain. the health plans determination of medical necessity is upheld in whole. The patient's clinical symptoms, including mild dehydration and mild electrolyte derangements, could have been handled at a lower level of care. The lower level of care was justified to ensure clinical stability and to ensure reliable oral intake. The inpatient level of care was not medically necessary for this patient, based on the severity of the patient's condition and the complexity of services.
Appeal type: Medical necessity
Decision: Overturned

The patient is a male who presented with vomiting and diarrhea.  He was well until the week prior to admission when he was traveling to New York after a visit to Peru.  At that time he began to have multiple episodes of emesis.  The emesis continued for 2 days before subsiding, and shortly after he developed diarrhea.  He described an average of 8 episodes of watery, non-bloody diarrhea with mucus every day.  This was accompanied by diffuse abdominal pain.
He was admitted for treatment of gastroenteritis with moderate dehydration.  He was given intravenous fluids as well as Zofran when necessary and bowel rest.  He continued to have diarrhea after admission and was started on a clear liquid diet.  His stool polymerase chain reaction (PCR) was found to be positive for rotavirus.  With hydration during the hospitalization, his electrolyte abnormalities resolved, and he was able to advance his diet.  His diarrhea had decreased, and he was stable for discharge to home.

The health plan's determination is overturned. 

This is a patient who presented with severe diarrhea after traveling out of the country. By the time of presentation he was having up to 12 episodes of diarrhea per day.  He had decreased urine output and had developed dehydration.  In the emergency department he was found to have orthostatic hypotension and abnormal laboratory values.  He required prompt initiation of intravenous hydration, as well as antiemetics as needed and close monitoring in an inpatient setting.
The decision-making at the time of admission was consistent with his young age, the presence of severe diarrhea in the setting of travel to different country, the presence of symptomatic dehydration, and the need for prompt initiation of treatment with close monitoring for potential deterioration of clinical status.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: ESRD, hyperphosphatemia, hypercalcemia
 
Treatment: Medication- Renvela

The insurer denied coverage for Renvela. The denial was upheld.

The patient has a history of end stage renal disease and hyperphosphatemia; also noted to have hypercalcemia and is not a candidate for PhosLo. Treating provider is requesting Renvela for her condition.

Renvela is not considered medically necessary for this patient. There is no current evidence-based literature that Renvela is safer or more effective than available preferred medications (Sevelamer carbonate, Fosrenol and Velphoro).  Based on documentation submitted, the patient has not tried and failed the preferred medications.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a past medical history of hyperlipidemia, osteoporosis, vertigo, who presented to the emergency room (ER) with vertigo, headache, nausea and vomiting. She had these symptoms on and off for two months, but she had worsening vertigo pulling to her left side, and a headache which localized to the right frontal area, for one hour prior to presentation. She had a National Institute of Health Stroke Scale (NIHSS) of 0 on admission.
The health plan's determination of medical necessity is upheld. She  was hemodynamically stable, without a major electrolyte abnormality, cardiac or respiratory issues, and without focal weakness, sensory changes, altered mental status, or slurred speech. The initial workup included a CT scan of the head and a CT angiogram of the head and neck was unrevealing. The neurologist's initial assessment was of a peripheral cause of the patient's symptoms as opposed to a central etiology.
According to an American Family Physician (AFP) review article on dizziness: "Evaluation focuses on determining whether the etiology is peripheral or central. Peripheral etiologies are usually benign. Central etiologies often require urgent treatment."
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Colitis and Campylobacter Infection

Treatment: Inpatient Admission

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

This is a young female patient who presented to the Emergency Department with complaints of worsening abdominal pain following a recent diagnosis and treatment for a Campylobacter infection. She reports a benign medical history. Vital signs on presentation included: a temperature of 37C, a blood pressure of 108/74, a pulse of 74, a respiratory rate of 18, and an oxygen saturation of 99% on room air.  The patient was given intravenous (IV) fluids and started on intravenous antibiotics (Azithromycin). She was kept nothing by mouth (NPO). A Computerized Tomography (CT) scan of the abdomen showed changes consistent with colitis. Gastroenterology consulted and recommended slowly advancing the diet as tolerated. Infectious Diseases was also consulted and recommended continuation of antibiotics. She underwent a colonoscopy. The patient remained afebrile and hemodynamically stable and was discharged to continue antibiotics as an outpatient.  
A Campylobacter infection is an important cause of acute diarrhea and may produce systemic illness, as well as other complications. Based on patient's documented failure of outpatient management, the need for IV fluids, maintaining NPO status, IV antibiotics, and a diagnostic procedure (colonoscopy), the hospital admission was medically necessary. 

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

Diagnosis: Obesity
Treatment: Saxenda
The treatment with Saxenda is medically necessary.

Saxenda is a GLP1 (glucagon-like peptide-1) agonist that is used in the treatment of obesity [1-3]. The FDA label is below [4]. 

-INDICATIONS AND USAGE
Saxenda is a glucagon-like peptide-1 (GLP-1) receptor agonist indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index (BMI) of 
- 30 kg/m2 or greater (obese) (1) or
- 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbid condition (e.g. hypertension, type 2 diabetes mellitus, or dyslipidemia) (1).
Limitations of Use: 
- Saxenda is not indicated for the treatment of type 2 diabetes (1). 
- Saxenda should not be used in combination with any other GLP-1 receptor agonist (1).
- Saxenda should not be used with insulin (1, 5.4).
- The effects of Saxenda on cardiovascular morbidity and mortality have not been established (1).
- The safety and efficacy of coadministration with other products for weight loss have not been established (1).
- Saxenda has not been studied in patients with a history of pancreatitis (1, 5.2). 

The patient meets accepted criteria for use of the requested medication. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.

The health plan's requirement of documentation of current and prior enrollment in a comprehensive weight management program like Weight Watchers or Curves Complete is not consistent with the FDA-approved indications for Saxenda.