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

The patient presented for an evaluation and treatment of her entire mouth.  The patient has Hepatitis, Hypertension, Anxiety/Depression, a history of drug use, and is a smoker.  In question is the medical necessity of the planned treatment for extraction of teeth #6, 7, 8, 9, 10, 11, 13, 21, 22, 23, 24, 25, 26, 27, 29 (7140), bone graft (6104) at the time of implant placement for site #4, 6, 11, 13, 27, 22, a cone beam CT scan (0367) prior to implant surgery, implant placement (6010) for #4, 6, 11, 13, 22, 27, precision attachment for maxilla x4 (6052) and mandible x2 (6052), and implant supported maxillary (6110) and mandibular denture (6111).  From the documentation the patient has a history of drug use and is currently using methadone.  The patient is missing many teeth throughout the arch and has a non-restorable diagnosis for the remaining teeth.  The patient is reported as having minimal ridge to support dentures and a severe gag reflex preventing her from tolerating a palatal extension of the denture.  The patient currently also has the diagnosis of partial edentulism and diminished posterior support.  If therapy is delivered, the patient will be completely edentulous, and the patient will not have any posterior support.  The patient's medications and history of drug use have resulted in an increased risk for recurrent decay which supports the diagnosis of her remaining teeth being non restorable. The health plan's determination of medical necessity is overturned in whole.  As the remaining teeth in the dentition are non-restorable, they require extraction.  With the diagnosis of complete edentulism, as well as diminished posterior support, the only therapy capable of addressing both diagnoses is that of implant therapy, as it is anchored within the bone offering complete support stability and retention for a tooth prosthesis.  Complete dentures are tissue supported prosthesis and do not offer any support to the dentition as they are designed to become passive upon load.  The patient has been documented as not being able to support a denture due to ridge deficiency.  After the implants have integrated, they will require restorations in the form of abutments and crowns in order to complete the tooth replacement.  This is standard in tooth replacement involving implants.  Hence, the entire treatment plan is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope
 
Treatment: Inpatient admission 

The insurer denied inpatient admission. The denial was upheld.

This is a male patient with a history of hypertension, cerebrovascular accident, coronary artery disease, alcohol abuse, and hyperlipidemia. He presented to the Emergency Room (ER) and admitted with complaints of syncope. He was stable at the time of arrival and subsequently during his ER evaluation. Vital signs were stable. He was admitted for syncope. A CT of the head was normal. Telemetry showed a pause of up to 3 seconds in duration. Cardiology consultation was obtained and it was recommended to hold metoprolol and transfer the patient to another facility, should he have another pause. He was discharged home after having remained clinically stable throughout his hospital stay.

The acute inpatient admission was not medically necessary. The patient presented with a syncopal event; however, there were no signs or symptoms of hemodynamic instability, myocardial ischemia, arrhythmia, heart failure, cerebrovascular insufficiency or other organ dysfunction requiring inpatient admission status. The patient's clinical status was evaluated and deemed to be stable in the ER. The patient's care could have been provided under observational level of care with up to 23 hours of monitoring, or could have been administered solely the ER. 

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. 

Based on the above, the medical necessity for the inpatient hospital services at the acute level of care is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lactic acidosis
 
Treatment: inpatient hospital admission

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

This patient is a male who presented with abdominal pain, nausea, and vomiting. He had a blood pressure of 152/103 and a pulse of 109. There was no abdominal rebound or guarding. The white blood count (WBC) was 17.6. The lactate level was 4.4. The patient was reassessed and at that time, the abdominal pain had decreased and the lactate level was normal at 1.2. A CT scan was negative for acute disease. It was felt the patient had cannabis-induced vomiting. The WBC count came down to 12.1. The patient was also found to have poorly controlled diabetes and a hemoglobin A1C of 10. He signed out against medical advice.

According to Milliman Care Guidelines (MCG), clinical indications for admission for vomiting (M-370) include gastrointestinal obstruction, a significant metabolic derangement, severe electrolyte abnormalities, high fevers and acute renal failure. The patient did not have these conditions. He had hypertension and tachycardia on admission but they improved. The lactic acidosis resolved with intravenous (IV) hydration. He was hemodynamically stable. The diabetes was poorly controlled but the patient did not have diabetic ketoacidosis.

This patient had vomiting and lactic acidosis that was attributed to cannabis-induced vomiting. He responded rapidly to IV hydration and the lactic acidosis resolved. The leukocytosis was much improved. IV hydration, Reglan, and Pepcid could have been given with observation status. The patient responded well to the ER treatment. If antibiotics were felt to be needed, they could have been continued orally as an outpatient. He did not meet MCG guidelines for admission for vomiting. The healthcare plan acted reasonably and with sound medical judgment. Inpatient hospital services were not medically necessary.

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: Upheld

Diagnosis: Transient ischemic attack/cerebrovascular accident (TIA)/CVA)

Treatment: Livalo 2 milligrams OR tablets

The insurer denied Livalo 2 milligrams OR tablets. The denial was upheld. 

This is a female patient who was seen as an outpatient in her Cardiologist's office in spring of 2019. Two weeks prior to this, she had symptoms consistent with a transient ischemic attack/cerebrovascular accident (TIA)/CVA).  She was admitted to a hospital for a CVA workup, which was negative. The office notes stated that a carotid duplex showed no evidence of carotid artery stenosis.  A venous duplex revealed no evidence of deep vein thrombosis (DVT) and an EKG revealed no evidence of arrhythmia.   Medication history revealed that she was taking atorvastatin 40 mg daily and discontinued it due to leg cramps; she was subsequently started Livalo 2 milligrams daily. Further review of the patient's medications indicated that she discontinued taking Crestor 5 mg daily and Lipitor 40 mg daily due to leg cramps. The conclusion was that there was no hemodynamically significant stenosis of the bilateral lower extremities. 

All FDA-approved statins have been shown to reduce cardiovascular risk; the magnitude of the reduction is related to the magnitude of LDL-C lowering.  Atorvastatin and rosuvastatin at their highest approved doses are the most effective in lowering LDL-C levels and their beneficial effects on clinical outcomes are well-documented.  All of the statins except pitavastatin and pitavastatin magnesium are available generically.  Dosage adjustments are not required with atorvastatin or fluvastatin in patients with severe renal impairment.  Pravastatin, rosuvastatin, and pitavastatin are not metabolized by CYP isozymes and are less likely to interact with other drugs.

Oral pitavastatin (Livalo) is a competitive HMG-CoA reductase for the reduction of elevated total cholesterol and low-density lipoprotein cholesterol (LDL-C) levels in adults with primary hypercholesterolemia and combined (mixed) dyslipidemia. Pitavastatin is an effective treatment option in adults with primary hypercholesterolemia and combined (mixed) dyslipidemia, including those at risk of developing type 2 diabetes.

The carrier's denial of coverage for Livalo 2 milligrams OR tablets is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

The patient is a homeless and unemployed male who presented to the emergency department requesting detoxification from alcohol. The patient was using alcohol on a continuous daily basis with approximately five beers daily. He had a longstanding history of alcohol use beginning in adolescence.

The patient provided a history of withdrawal seizures including a seizure two days prior to presentation; he had no history of delirium tremens. Laboratory assessment revealed elevated glucose and evidence of an anemia and malnutrition. Electrocardiogram (EKG) revealed normal sinus rhythm and his chest x-ray revealed borderline cardiomegaly; vital signs were normal. There was no evidence for use of illicit drugs or other drugs of abuse though his urine drug screen was positive for benzodiazepine. The patient was tobacco dependent; he had a history of asthma.

The patient was admitted for inpatient detoxification and other medical services following evaluation and treatment in the emergency department including assessment for safety issues and medical clearance. He had received oral fluid replacement, vitamin replacement, and other supportive measures including resumption of treatment with his usual medication, Keppra.

The health plan's determination is upheld.

No, the requested health service/treatment of inpatient substance abuse treatment  is not medically necessary for this patient.

The proposed treatment and other inpatient medical services noted in the clinical summary could have been safely and effectively provided at a lower level of care. The acute inpatient treatment of this patient's alcohol use disorder did not require the structure of an inpatient setting or 24-hour monitoring. The patient displayed no serious disturbance of mental status despite having a history of ongoing substance use disorder with alcohol. Moreover, the patient had been evaluated and cleared with regard to safety concerns in the emergency department and did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance that would have warranted an inpatient level admission and treatment. Thus, admission for detoxification treatment and 24-hour monitoring, and the requested inpatient level services were not medically necessary in this case scenario. Any indicated treatment for alcohol use disorder in this case could have been provided, as clinically appropriate, at a lower level of care following the comprehensive assessment and stabilization in the emergency department.
Appeal type: Medical necessity
Decision: Overturned

This is a patient who was admitted following medical screening, to acute inpatient level services for detoxification and withdrawal management of severe alcohol use disorder. The patient was found in a park and brought to the emergency department; he had eloped and then returned indicating that he had drank all the alcohol he could find with a blood alcohol level of 196. He had laboratory abnormalities that included electrolyte and fluid imbalance and anemia and elevated liver function testing.
The patient reported drinking one pint or more of vodka daily. He presented with moderately severe alcohol withdrawal at the time of admission  including tremor, fatigue, nausea, sweats, headache, irritability, restlessness and anxiety with a Clinical Institute Withdrawal Assessment (CIWA) scale score of 13 despite having alcohol in his blood. The patient had relapsed after his last detoxification treatment which was one of four previous detoxifications with no past treatment with rehabilitation services and no involvement in recovery groups. He gave no history of withdrawal seizures or past episodes of delirium tremens. He denied use of illicit or prescription drugs, but has a history of cocaine dependence and is tobacco dependent at one-half pack per day.
The health plan's determination is overturned.
The proposed inpatient services and detoxification treatment and withdrawal management for severe alcohol use disorder and other services noted in the clinical summary could not have been safely and effectively provided at a lower level of care. The treatment of this patient's substance use disorders did require the admission and the continued structure of an inpatient level setting and 24-hour monitoring in view of the severity of the alcohol use disorder, and the presentation with moderately severe withdrawal symptoms and general medical conditions associated with laboratory abnormalities and high risk for withdrawal complications such as seizures. Withdraw symptoms were managed with an Ativan protocol requiring monitoring, as well as comfort medications and vitamin replacement therapy, and continuation of medications to manage his general medical illnesses. Thus, the patient did require a safe and effective detoxification with withdrawal management during the time frame under review, as it was reasonable that the patient would have been unable to abstain from the substances of abuse if detoxification and treatment were to be attempted at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

The patient is a female to male transgender who is requesting coverage of gender confirming mastectomies with free nipple grafting. He began hormone therapy in 2018. On physical examination there are grade 2 ptotic breasts. Coverage was denied for failure to meet age requirement of the coverage criteria.

The health plan's determination is overturned.

Yes, the bilateral mastectomy and nipple reconstruction are medically necessary for this patient.

The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, advocacy, public policy, and respect for transgender health. One of the main functions of WPATH is to promote the highest standards of health care for individuals through the articulation of Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People. The SOC are based on the best available science and expert professional consensus. The most recent standards published in 2011 are version 7 and are the current standards of care applied by physicians and surgeons worldwide. Prior to any treatment the criteria requirements are diagnostic and real life experience.
Their Criteria for mastectomy and creation of a male chest in female to male (FtM) patients are:
1) Persistent, well-documented gender dysphoria;
2) Capacity to make a fully informed decision and to consent for treatment;
3) Age of majority in a given country, (earlier preferably after ample time of living in the desired gender role and after one year of testosterone treatment).;
4) If significant medical or mental health concerns are present, they must be reasonably well controlled.
In this case their criteria have been met because he has lived as a male and been on hormone therapy for over a year, there are no other significant medical or mental health concerns, and the gender dysphoria is well documented and persistent.
Appeal type: Medical necessity
Decision: Upheld

The patient is a female with metastatic lung cancer who presented to the Emergency Department with a primary complaint of chest pain, with associated cough and vomiting. She is currently receiving chemotherapy and has a history of mycobacterium avium-intracellulare (MAI) infection as well. Workup in the emergency room (ER) showed abnormal chest imaging as well as new electrocardiogram (EKG) changes. Vital signs and physical examination were non-diagnostic. She was admitted for "chest pain likely as a consequence of cough secondary to irritation from lung cancer" with a plan for serial troponin measurement and pain control.
Following admission, her troponins were negative. Oncology and Interventional Radiology were consulted, and she underwent a therapeutic thoracentesis. On the day after admission, she was discharged home with a plan for follow-up with her oncologist.

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

No, the requested health service of inpatient stay was not medically necessary.
This admission does not meet criteria for inpatient acute medical admission based upon the standard Milliman Care Guidelines (MCG) guidelines for chest pain, which was both the chief complaint in the ER and the principal diagnosis by the admitting and discharging doctor. The hospital argued that there was concern the signs and symptoms may develop into a serious medical condition. Unfortunately, that is not backed up in any way by the medical documentation from the doctors involved in her care.
In fact, the actual documented assessment and plan of her condition was lacking and does not demonstrate that concern. In fact, it suggests that his belief was that her lung cancer was the cause of her chest pain (but there was no plan to address that). There was no explanation for the EKG abnormalities or how it potentially could represent something serious like acute coronary syndrome, nor does it have a treatment strategy for a serious condition. There were no high risk features of life-threatening acute disease, such as significantly abnormal vital signs or elevated troponin, and pretest probability for a condition requiring cardiac intervention was low (Penumetsa 2012). Her HEART score was only 2, which suggests a very low risk of major cardiac events (Backus 2013). Without supportive documentation, an inpatient stay was not medically necessary, and could have been managed at a lower level of care status, which is appropriate for most chest pain patients even if there is adequate documentation of concerning features.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who presented with a request for detoxification services.  The patient reported that he was using alcohol on a continuous daily basis together with the use of crack cocaine and Xanax.  He has a history of bipolar mood disorder and posttraumatic stress disorder with associated symptoms of anxiety.  He was taking Seroquel and Lexapro to address the mood, trauma and anxiety disorders.  He had received multiple past substance use disorder treatments including three recent detoxification treatment episodes.  He had also received multiple other detoxification treatments in the year prior to his presentation without significant follow up for aftercare or use of medication assisted treatment.
The patient provided no history of withdrawal seizures, delirium tremens or severe alcohol or drug withdrawal symptoms.  He had no acute general medical problems; he had a history of lower back pain and neuropathy.  He was tobacco dependent.
The health plan's determination is upheld.
The treatment of this patient's substance use disorder did not require the structure of an inpatient setting or 24-hour monitoring.  The patient displayed no serious disturbance of mental status, despite having a history of ongoing substance use disorder with alcohol and use of crack cocaine and Xanax.  Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance that would have warranted an inpatient level admission and treatment.  There were no severe symptoms of withdrawal or biomedical issues in this case, and the patient had received detoxification treatment recently.
Appeal type: Medical necessity
Decision: Overturned

The patient presented to the emergency department (ED) just before midnight with the complaint of coughing and breathing fast for two days. The patient has a history of asthma and did not improve following albuterol. The patient also also began vomiting. The Vital Signs on ED arrival were a temperature of 99.0F, heart rate (HR) 142, respiratory rate (RR) 48, blood pressure (BP) 114/76, and pulse oximetry 90%. The patient was started on supplemental oxygen and given nebulizer treatments and oral steroid
Patient was admitted with a diagnosis of status asthmaticus. After admission placed on albuterol every 2 hours, oxygen, and continued on PO steroid. Patient was also suspected to have a left lower lobe pneumonia and was started on intravenous (IV) ampicillin for this. Patient had initially a poor clinical response to treatment and was then given IV magnesium sulfate x1. The health plan determination is overturned in whole. The inpatient stay was medically necessary. This patient had respiratory distress as indicted by tachypnea and significant retractions and decreased oxygen saturations. Patient had vomiting secondary to increased work of breathing. The severity of his symptoms and poor response to initial treatment warranted inpatient medical care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ascending lymphangitis
 
Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial was upheld.

This patient is a female child with a history of intermittent asthma and allergy to peanut butter who presented to the Emergency Department (ED) with the chief complaint of left arm redness and pruritus. The parent clearly gave the history of this beginning as a small white dot on the dorsum of her finger (2nd metacarpophalangeal joint), which she thought was a bug bite, and reported that by the next morning she woke up with erythema and local itchiness. There was no pain or fever by history.

In the ED she had no fever and her vital signs were stable. On examination there was a tiny scab on the dorsal aspect of the left hand with surrounding erythema, and erythema and swelling tracking up the left forearm, but this was not tender to palpation. There were additional areas of redness and warmth on ventral aspect of the wrist with streaking up the forearm and another area of warmth and redness proximal to the elbow on the upper arm. There was no sign of fluctuance, abscess or drainage. This was a classic presentation of ascending lymphangitis. There was no lymphadenopathy.
The documentation shows that it was unlikely that the cause was infectious, that she had no signs of sepsis, and that she had normal laboratory values. She was admitted for IV antibiotics and observation, but the rationale for that is not documented. Although these areas of redness representing lymphangitis were extensive, the largest being 16.5 cm measured longitudinally, there was no evidence of deeper soft tissue involvement, (no evidence of tenosynovitis, joint involvement, muscle involvement, fasciitis, or compartment syndrome). The patient had no complaints of pain; she had itching and discomfort. Given her age, after receiving 1 dose of IV Clindamycin, the patient could safely have been treated and observed as an outpatient on oral antibiotics to cover both group A Strep and Staphylococcus aureus infection as possible bacterial causes of her cellulitis with lymphangitis secondary to the dorsum of hand lesion as the portal of entry.

Based on the above, the medical necessity for the inpatient admission for acute level of care is not substantiated. The insurer's denial is upheld.