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

This is a patient who sustained a trauma when hit in the face with a hockey stick and presented for care at a local emergency room (ER). He was treated for a laceration but not a concurrently sustained dentoalveolar trauma. It was suggested on discharge that he seek dental care.  He was diagnosed with a dentoalveolar fracture. The health plan's determination is overturned. The bone grafting and application of a splint on an emergency basis was medically necessary for this patient. It is considered standard of care that dental trauma and alveolar bone fracture be managed on an emergent basis. Dentoalveolar fractures are bone fractures that must be reduced (in this case there was displacement as #11 was not in alignment) and stabilized, which is performed via a splinting technique.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Lower Gastrointestinal Bleeding
 
Treatment:  Inpatient Admission

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

This is a female patient presented with rectal bleeding.  She was on aspirin and Plavix.  She was afebrile and the vital signs were stable.  The abdominal exam was benign.  The hemoglobin was 12.8.  The coagulation profile was normal.  A stool occult blood was negative.  A colonoscopy revealed diverticulosis, but no active bleeding.

Clinical indications for admission for lower gastrointestinal bleeding (M-182) include ongoing active bleeding, failure to control bleeding after a colonoscopy, coagulopathy, or severe anemia.  The patient did not have these conditions.  She also did not have hemodynamic instability, intestinal obstruction, severe thrombocytopenia, or an inability to maintain oral hydration.  She was stable to have had the colonoscopy on an outpatient basis.

The carrier's denial of coverage for the inpatient hospital services is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

The patient has complaint of left groin pain and left hip pain of several years duration and presented for evaluation. This pain limited the patient's ability to be active and was adversely affecting routine activities of daily living. The patient has been previously treated with rest, non-steroidal anti-inflammatory drugs (NSAIDs), steroid injection, and physical therapy without clinical improvement. He had undergone bilateral inguinal hernia repairs as an infant and left inguinal sports hernia repair. The patient consulted with an orthopedic surgeon and a physical therapist and was diagnosed with the condition of athletic pubalgia. The patient has also been evaluated by a general surgeon. The health plan's determination is overturned. 

The surgical repair of the left pelvic floor/groin is an appropriate treatment recommendation that is supported by published peer reviewed literature. The condition of athletic pubalgia is based upon symptoms of pubic/pelvic pain in the setting of confirmatory physical exam findings and abnormal imaging results. This patient has had such an evaluation including surgical evaluation and surgical follow up, orthopedic evaluation, and MRI, and physical therapy. The pelvic MRI has documented myofascial and bony abnormalities and the patient has failed conservative efforts with rest, NSAIDs, anesthetic/steroid injection, and physical therapy. This patient's history, physical, diagnostic work-up, and clinical course are all consistent with the diagnosis of athletic pubalgia and the surgical repair as proposed/performed is regarded by the medical community as a suitable treatment option in such a clinical circumstance. 
The medical records in this case do support the medical necessity of surgical therapy for the treatment of chronic groin pain secondary to the myofascial pathology noted on physical exam and MRI.  The patient has complaint of left groin pain and left hip pain of several years duration and presented for evaluation. This pain limited the patient's ability to be active and was adversely affecting routine activities of daily living. The patient has been previously treated with rest, non-steroidal anti-inflammatory drugs (NSAIDs), steroid injection, and physical therapy without clinical improvement. He had undergone bilateral inguinal hernia repairs as an infant and left inguinal sports hernia repair. The patient consulted with an orthopedic surgeon and a physical therapist and was diagnosed with the condition of athletic pubalgia. The patient has also been evaluated by a general surgeon. The health plan's determination is overturned. 

The surgical repair of the left pelvic floor/groin is an appropriate treatment recommendation that is supported by published peer reviewed literature. The condition of athletic pubalgia is based upon symptoms of pubic/pelvic pain in the setting of confirmatory physical exam findings and abnormal imaging results. This patient has had such an evaluation including surgical e
Appeal type: Medical necessity
Decision: Overturned

The patient presented for inpatient detoxification and substance-related treatment to address severe substance use disorder with opioid (Heroin), Cocaine and cannabis class substances of abuse. The patient has a longstanding history of severe substance use disorder beginning at age 12 years, with cannabis and subsequent use of cocaine at age 17 and heroin at age 29. He reported a past history of severe withdrawal symptoms when attempting to curtail his use. At the time of presentation for treatment he was using up to 15 bags of Heroin with intravenous (IV) administration on a daily basis and was using $20-$50 worth of Cocaine three to six times per week with IV administration. His self-referral was prompted by his desire to stop using substances with IV use, and health concerns. He has no prior history of substance use disorder treatment. The patient was admitted to detoxification treatment with comprehensive detoxification protocol with a Methadone taper, and medications as needed (prn) for comfort, including medications to address pain and aches, anxiety, insomnia and diarrhea/abdominal cramps. The patient initially had moderately severe symptoms of withdrawal that persisted throughout all of his inpatient stay but had diminished in intensity by the time of discharge. The patient reported chills, joint pain, body aches, and abdominal cramps and was restless with diaphoresis scoring 16 on the Clinical Opiate Withdrawal Scale (COWS). The health plan's determination of medical necessity is overturned. The patient in this case presented with continuous daily use of Heroin, cannabis and the frequent use of Cocaine in the context of chronic health issues that were drug related. His risk for withdrawal complications in the context of persistent symptoms of withdrawal and intense craving did warrant the continued inpatient level services and monitoring with withdrawal management. The inpatient treatment of this patient's substance use disorders with detoxification and withdrawal management did require the continued structure of an inpatient level setting and 24-hour monitoring, in view of the patient's clinical presentation and course of treatment. Withdrawal symptoms were appropriately managed with tapering dosages of Methadone requiring monitoring and supportive measures, including nicotine replacement therapy and comfort medications, as noted in the clinical summary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bilateral knee pain
Treatment: Total knee replacement and related inpatient admission 
The total knee replacement and related inpatient admission were medically necessary.
The medical records demonstrate consistency of diagnosis. The subjective complaints of pain were documented on several occasions. There was report of difficulty doing stairs and walking. The physical examination demonstrated crepitus and tenderness. There was guarding to motion. X rays reported severe osteoarthritis. The patient had received treatments of viscosupplementation on several occasions with medications. The patient had also utilized a brace. Due to documentation of a pain generator and poor response to conservative treatment, surgery was necessary. 
AIM criteria for TKR:
Indications and Criteria
Elective total knee arthroplasty may be considered medically necessary for EITHER of the following indications:
1) Bicompartmental or tricompartmental joint damage or destruction due to osteoarthritis, inflammatory disease or other chronic conditions when ALL of the following requirements have been met:
2) Imaging evidence of significant joint destruction and cartilage loss, defined as modified Outerbridge grade III-IV or Kellgren-Lawrence grade 3-4
(MET. The radiographic findings demonstrate evidence of severe OA.)
3) Knee arc of motion greater than 50 degrees
(MET. Reported greater than 90 degrees.)
4) Failure of at least three months of non-surgical conservative therapy
(MET. The patient has received medications and several injections of viscosupplementation. There was also report of brace use.)
5) Functional limitation secondary to knee pathology which interferes with the ability to carry out age-appropriate daily activities
(MET. There is a medical report stating she has difficulty bending the knee and walking. Walking stairs was quite difficult.) 
The procedure is complex and extensive. It requires hours to perform with medical monitoring after the operation. The services cannot be performed outside of a hospital. It is not an ambulatory surgical unit (ASU) or outpatient type procedure.  The inpatient stay 08/16/2018 through 08/20/2018 was medically necessary.  The inpatient stay was necessary due to the complexity and duration of procedure. The patient would require monitoring for blood loss and neuromuscular status. She would require intravenous analgesia and physical therapy (PT) services.
Appeal type: Medical necessity
Decision: Overturned

The patient has multiple diagnoses:  Pervasive Developmental Disorder; Schizoaffective Disorder, Bipolar Type; Bipolar Disorder, Unspecified; Autism Spectrum Disorder.  She has been receiving 45-minute psychotherapy sessions but has requested 60-minute psychotherapy sessions.  The health plan denied the increase as not medically necessary. 
The health plan's determination is overturned.  Sixty-minute sessions twice weekly are medically necessary.  The patient is severely impaired and continued, effective psychotherapy is necessary to process the daily unpredictable and negative social interactions with non-insightful individuals.  The preponderance of evidence supports a need for a twice weekly frequency and 60-minute sessions.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
 
Treatment: Inpatient Admission

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

This is a female patient presented to the Emergency Department with abdominal pain. She had a history of gastroparesis and has had similar pains several times in the past. She was afebrile and the vital signs were stable. The abdominal exam was benign. Vital signs included a blood pressure of 152/86, a heart rate of 89, a temperature of 98.5, a respiratory rate of 18, and a pulse oximetry of 99% on room air. A computerized tomography (CT) of the abdomen was negative. The patient was treated with Reglan, Famotidine and intravenous (IV) hydration. She was able to tolerate a diet.

Clinical indications for admission for undiagnosed abdominal pain (M-05) include the need for surgery that cannot be performed on an outpatient basis and peritoneal signs. The patient did not have these conditions. She also did not have hemodynamic instability, intestinal obstruction, severe electrolyte abnormalities or an inability to maintain oral hydration.

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

Diagnosis: Palpitations
Treatment: Inpatient admission

The proposed treatment, inpatient admission, was not medically necessary.

This patient presented with self-limited palpitations and hypertension.  Upon presentation to the emergency department, serum troponins were not elevated and electrocardiogram (ECG) tracings revealed no significant abnormality.  The patient was treated for hypertension and released the following day. Of note, the patient had recently initiated phenylephrine for nasal congestion, a substance that frequently causes hypertension and palpitations.  This agent was discontinued. 

This patient did not present with findings consistent with an acute coronary syndrome.  Based on history and presentation alone, this patient had a low short term risk of death and nonfatal cardiac ischemia. (Reference1)  

In conclusion, this patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain and nausea
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

According to the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), "patients undergoing uncomplicated laparoscopic cholecystectomy for symptomatic cholelithiasis may be discharged home on the day of surgery" [SAGES]. Indeed, insofar as the patient did not demonstrate significant co-morbidities or physiologic derangements, and insofar as surgery and recovery were uncomplicated, the patent could have been treated at a lower level of care, precluding the need for admission at an acute inpatient level of care.

Based on the provided medical documentation and in accordance with national guidelines, for this patient, admission at an acute inpatient level of care was not necessary. The patient could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain, left arm pain and nausea

Treatment: Aspirin, atorvastatin, telemetry and diagnostics

The insurer has denied inpatient admission. That denial was upheld.

This patient presented to the emergency department (ED) with complaints of chest pain/tightness, left arm discomfort, dizziness, nausea and indigestion over the past week. His blood pressure was 160/90 and his troponin was 0.083. His creatine kinase and D-dimer were normal. Cardiology was consulted and the patient was admitted. Labs, EKGs and telemetry were initiated.  He transferred to another facility.

The patient presented with chest pain; however, the initial evaluation in the ER was unremarkable, including non-diagnostic cardiac troponin and a non-diagnostic EKG. Inpatient admission was not medically necessary for this patient. In the absence of elevated cardiac biomarkers and a diagnostic electrocardiogram, the patient's care could have been provided in the observational setting. Further evaluation was warranted; however, inpatient admission criteria were not met. Although the patient had new onset symptoms, medical criteria were not met for any other additional extenuating circumstances. There were no other high-risk co-morbidities. The observational level of care would have been appropriate.

Based on the above, the medical necessity for the inpatient hospital stay from is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes
Issue under review: Jardiance

Determination:
Jardiance is medically necessary.

This patient has uncontrolled type 2 diabetes with hyperglycemia-related complications, as manifested by a history of a right first toe amputation. This patient has tried, and is currently on, insulin therapy, metformin, and dipeptidyl peptidase 4 inhibitor therapy. The use of Jardiance in this clinical situation is supported by the American Diabetes Association clinical guidelines. 

Steglatro is the formulary alternative. Steglatro is also in the class of sodium glucose co-transporter-2 inhibitors. Steglatro has not been shown in a randomized clinical trial to reduce the risk of cardiovascular events or risk of death from a cardiovascular event, whereas in a study of 7.020 patients, Jardiance reduced the primary composite outcome of death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke as compared to placebo [1]. 

This patient has uncontrolled type 2 diabetes, which is a significant risk factor for cardiovascular disease [2]. A cardiovascular event could be life-threatening. Therefore, yes, the proposed treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes
Issue under review: Toujeo Solostar

Determination:
The Toujeo Solostar is not medically necessary.,
Toujeo is an ultra-long acting basal insulin therapy. The documentation does not indicate that the patient has tried and failed Basaglar, which is a basal insulin that is FDA-approved for the treatment of type 2 diabetes. The documentation does not indicate that the patient has issues with nocturnal hypoglycemia, which would otherwise indicate that Toujeo should be used over Basaglar. The American Diabetes Association clinical guidelines do not recommend the use Toujeo over Basaglar in this clinical situation. Therefore, no, the proposed treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

The patient has a diagnosis of Major Depressive Disorder (MDD), recurrent, chronic. The question is whether the Inpatient Behavioral Health Services (IBHS) level of care are medically necessary. The admission under review was due to worsening depressive symptoms, in the context of noncompliance with medications and substance use (daily Cannabis Use Disorder (CUS), and other drugs intermittently, poly substance use disorder (PUD)).

The health plan's determination is upheld. The requested treatment of IBHS is not medically necessary for this patient. The patient appeared to have returned to a baseline state. She had no suicidal or homicidal ideation. The patient continued free of hallucinations or delusions. Poor social attachment is associated with increased suicide risk. This patient was lonely with no healthy social attachments. The patient was alert and oriented and was not agitated and showed no distress. The patient was compliant with treatment and had no adverse responses to medications. The patient interacted appropriately with the care team. The limited insight and poor judgment in addition to personality traits of impulsivity appear to be baseline conditions which could be treated at a lower level of intensity of care on an ongoing basis.
Appeal type: Medical necessity
Decision: Upheld

The patient is a male with a history of cerebrovascular accident (CVA), urinary incontinence, chronic obstructive pulmonary disease (COPD), peripheral vascular disease, and chronic wounds. He has requested personal care aide services for 7 days per week for (2) 12 hour split shifts. The documentation includes notes from his physician, a family member, and a formal assessment of his functional capacity from 2019. The physician states that the patient has had multiple hospitalizations over the past few years and has limited ambulation. The assessment from 2019 is based on the Uniform Assessment System-New York Comprehensive Community Assessment Report. It states that the patient has total dependence for multiple activities of daily living and maximal assistance needed for other activities of daily living. A medical note shows an order for wound care based on the patient's slowly healing chronic wounds/pressure ulcers. A cardiology note demonstrates a left ventricular ejection fraction of 44%, consistent with borderline heart failure. A note from the patient's son in law indicates that the patient's current service of 7 days per week for 12 hours per day is not sufficient because the patient is often found in the morning to have bed soiled by urine and bodily waste in the diaper. A concern is raised about the patient's pressure ulcers being exacerbated by these incontinence episodes. The plan documentation states that the request for increased personal care aide service was denied because a new assessment of functional status has not been obtained since early 2019.

The health plan's determination is upheld. 

No, the requested personal care aide 7 days x (2) 12 hour split shifts is not medically necessary. Based on the available documentation, there is no evidence of an objective assessment of functional status that indicates why a level of care of seven days per week for (2) 12 hour split shifts would be medically necessary. Based on the prior assessment from early 2019, the plan approved 12 hours daily for seven days per week. A change in this level of care would be predicated on an updated assessment, but this is not available in the documentation.
Appeal type: Medical necessity
Decision: Upheld

The patient is a female with past medical history significant for diabetes mellitus type 2, hypertension and hypothyroidism. The patient is requesting personal care assistant hours. The health plan's determination is upheld, in whole. The requested health service/treatment of personal care assistance is not medically necessary for this patient. The physical exam showed a relatively normal exam with exception of neurological exam showing slow gait. No distress was noted. The patient was denied personal-care services based upon the following rationale. Patient was able to toilet on their own, perform personal hygiene and ambulate independently. A form signed by the patient's physician states that the patient has chronic or other medical conditions that do not impact her ability to perform activities of daily living therefore the patient does not require personal-care assistant services. Uniform Assessment System (UAS) State of New York comprehensive community assessment report noted that the patient required a total of 13 hours a week. These hours were mainly noted for the following services, including meal preparation, housework and shopping. The patient was noted to be independent with walking, locomotion, toilet use and transfers. The patient was independent with eating. Based upon review of the documentation provided the patient does not require personal-care service hours because the patient can function independently, for most activities of daily living. No cognitive deficits are noted which would impair patient's ability to perform these activities.
Appeal type: Medical necessity
Decision: Overturned

The patient has gender dysphoria. She has been living as a female for over 10 years. She has requested breast augmentation that the health plan has denied as not medically necessary. The health plan's determination is overturned. The breast augmentation is medically necessary. The patient meets the WPATH (World Professional Association for Transgender Health) "Standards of Care for the Health of Transsexual, Transgender and Gender-Nonconforming People" guidelines for the breast augmentation in Male to Female patients.