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

Diagnosis: Orthopedic/musculoskeletal.
Treatment: Inpatient Hospital.
The insurer denied: Inpatient stay.
The denial is: upheld in whole.

The patient is a female who had a history of chronic neck pain radiating into bilateral arms. Preoperative imaging apparently demonstrated multilevel cervical neural foraminal stenosis and kyphotic deformity. Her past medical history is significant for gastroesophageal reflux disease (GERD), hypertension (HTN) and current smoker status.  The patient underwent a 3 level anterior cervical discectomy and fusion (ACDF) C3 to C6 as part 1 of a planned staged deformity correction procedure. This was uncomplicated according to the operative note and excellent correction of the C4-5 kyphosis was also documented in the operative description. The patient was discharged to the floor when stable in the post-anesthesia care unit (PACU) and admitted to the inpatient service. The day after surgery she was noted to complain of incisional pain but was otherwise stable. Cervical imaging was performed with a computed tomography (CT) scan which demonstrated improved kyphosis compared with a preoperative CT scan. There is a progress note from the provider with the notation of "pre op for stage 2" under the assessment and plan portion of the note. Apparently, the plan to proceed with stage 2 was changed and the patient was discharged home in stable condition, reporting improved symptoms in her upper extremities and having been cleared by physical therapy (PT).
The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld, in whole.

It appears from the records that the initial plan was to perform the 3-level ACDF then 2 days later perform the second stage of a posterior decompression and instrumented fusion for further deformity correction. However, that second stage never took place for reasons that are not well-documented in the records. Therefore, the patient ultimately underwent an uncomplicated 3-level ACDF which is usually performed at a lower level of care status. There were no pre-operative morbidities nor any operative/postoperative complications that would have required an inpatient stay noted in any of the medical records provided for review. 
In summary, the inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Central nervous system/neuromuscular disorder/other.
Treatment:  Inpatient hospital.
 
The insurer denied  the inpatient hospital stay.  The denial is upheld in whole.

The patient was a restrained passenger involved in a motor vehicle collision presenting to the emergency department (ED) with head, neck, and chest pain.  The airbag deployed at the time of the collision (car was moving slowly, and the other car struck at the front passenger side) and the patient was wearing her seatbelt.  The patient was found walking around the scene when Emergency Medical Services (EMS) arrived, having been helped out of the car.  The patient remembered hitting her head, but was unsure where.

No, the inpatient stay is not medically necessary for this patient.

Mild traumatic brain injury, or concussion, can be defined as an alteration in consciousness as a result of non-penetrating trauma to the brain.  Common findings following concussion include the following: vacant or confused expression, delayed verbal and motor responses, easy distractibility, difficulty focusing attention, disorientation, speech alterations such as slurred or incoherent speech, incoordination, exaggerated emotional responses, memory deficits, and in some cases loss of consciousness.  Mild concussions typically involve no loss of consciousness, transient confusion, and rapid resolution of symptoms.  Moderate concussions may have longer duration of symptoms.  Severe concussions include any loss of consciousness.  Imaging is typically indicated for all severe concussions and for moderate concussions with progressively worsening or prolonged symptoms.  Hospitalization may be necessary for patients with moderate to severe concussions, if they have recurrent vomiting, persistent mental status changes, or abnormalities on neurologic examination.  

The patient did not require acute inpatient management for either the mild traumatic brain injury or the suspected and incidentally discovered pituitary adenoma.  The patient could have been monitored and undergone appropriate evaluations in a safe and timely manner at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tooth abscess and facial swelling.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

This is a male with no medical problems who developed the facial swelling from carious tooth #18. He was seen in a dental clinic for removal tooth #18 and an incision and drainage. He was then referred to the emergency room. 

The patient was admitted for intravenous (IV) antibiotics and pain control to the Oral and Maxillofacial Surgery service. His evaluation revealed no floor of mouth swelling and the uvula was in the midline. There was no computed tomography (CT) obtained. 

On admission, the patient was afebrile, his blood pressure was mildly elevated, and his white blood cell count was 14.8. The patient received IV fluids and antibiotics. His pain was controlled, and he was discharged the following day with a normal blood pressure and temperature and a decrease in his white blood cell count. 

There are no notes regarding any interventions for the patient's elevated international normalized ratio (INR) and platelets. An admission was denied as the criteria for admission were not met. The hospital is appealing. They state that the patient had a potential for decompensation, airway compromise and his INR and platelets were elevated.

No, inpatient admission was not medically necessary. 

The treatment received meets the definition of observation care.  Hospital admission criteria for odontogenic maxillofacial infections are threat to airways or other vital structures, need for general anesthesia, septic fever, marked swelling and a need for inpatient control of a concomitant systemic disease.

This patient had no threat to the airway, did not require a general anesthesia, was afebrile, the swelling was not a threat to the airway and the patient has no record of any medical problems. Oromaxillofacial infection can be expected to heal well initially by removing the infection source and performing proper drainage, which was performed prior to the admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Crossbite.
Treatment:  Braces.

The insurer denied the braces.  The denial is overturned. 

The patient is a male.  The request is for orthodontic benefits.

Yes, the proposed treatment with braces is medically necessary. 

The patient has an anterior tooth crossbite (tooth #23) with gingival (gum) attachment loss.  This is an automatic qualifier according to the handicapping index scale.  Braces are needed to properly align the teeth.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis:  Helicobacter pylori (H. pylori) infection.
Treatment:  Talicia (amoxicillin-rifabutin-omeprazole) 250-12.5-10 mg oral capsule.

The insurer denied coverage for Talicia (amoxicillin-rifabutin-omeprazole) 250-12.5-10 mg oral capsule.  The denial is upheld. 

This female patient suffers from drug-resistant Helicobacter pylori (H. pylori) infection.  The patient's symptoms include sharp epigastric pain and bloating.  An esphagogastroduodenoscopy (EGD) showed reflux esophagitis, chronic gastritis, duodenitis, and H. pylori.  The patient's urea breath tests also confirmed H. pylori after treatment with Prevpac, Pylera, and Levaquin.  The patient's gastroenterologist has prescribed the medication Talicia (amoxicillin-rifabutin-omeprazole) 250-12.5-10 mg oral capsule.

As per the UpToDate article titled "Treatment Regimens for Helicobacter Pylori", the article addresses salvage therapy for persistent H. Pylori infection.  One of the salvage options is to give Rifabutin, Omeprazole and Amoxicillin.  This regimen would be appropriate in this patient as the other regimens have already failed.  However, there is no recommendation that the patient has to take the brand name Talicia.  If the insurer is willing to provide the equivalent doses of amoxicillin, omeprazole, and rifabutin that would be acceptable.  The generic combination of amoxicillin, omeprazole, and rifabutin would not cause an adverse reaction as compared to Talicia.  The generic components have not been found to be ineffective.  Talicia would not be more effective than prescribing amoxicillin, omeprazole and rifabutin separately. 

The carrier's denial of formulary exception for Talicia (amoxicillin- rifabutin-omeprazole) 250-12.5-10 mg oral capsule should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Respiratory System Problems. 
Treatment:  Durable medical equipment - ventilator/noninvasive. 

The insurer denied durable medical equipment - ventilator/noninvasive.  The denial was overturned in whole.

The patient is a male with chronic obstructive pulmonary disease (COPD), bronchiectasis, pulmonary hypertension, and chronic respiratory failure on home oxygen (O2).  He is on inhaled corti-costeroids (ICS), long acting beta agonists (LABA), and long acting muscarinic antagonists (LAMA) therapy.  He was admitted with worsening respiratory failure.  Pulmonary Function Tests (PFTs) are consistent with severe obstructive lung disease (FEV1 0.89 Liters or 33% predicted; Forced expiratory volume (FEV1), Forced vital capacity/(FVC ) 0.55).  Despite bilevel positive airway pressure device (BiPAP), his partial pressure of carbon dioxide (PaCO2) remains elevated arterial blood gas (ABG) 7.42/74/99.  

The health plan's determination is overturned.  

Given his severe COPD and chronic hypoxemic and hypercarbic respiratory failure, this would be medically necessary, as it can improve quality of life and reduce mortality and hospitalizations.  For a patient with COPD and chronic hypoxemia and hypercarbic respiratory failure, non-invasive nocturnal ventilation with the device requested has proven benefit and is supported by a variety of professional societies, as cited below.  COPD with chronic respiratory failure is a condition with high morbidity and mortality.  The two most burdensome features are daily symptoms (with the most difficult component here being limited exertional tolerance) and frequent hospitalizations.  Nocturnal non-invasive ventilation, usually targeting a lower partial pressure of carbon dioxide (pCO2), has been shown to lead to clinically and statistically significant improvements on both fronts.  There are unfortunately few other helpful options, and this patient is already on all the data-proven alternatives (inhaled bronchodilators and anti-inflammatories).  For patients with persistent hypercapnia following an exacerbation, use of non invasive ventilation (NIV) prolonged time to re-admission or death over the next year.  Other studies have shown a sustained benefit with decrease in hospital days and mortality over 3 years.  As such, given the persistent symptoms, hospitalizations, and hypercarbia despite appropriate medical therapy and BPAP, a non-invasive ventilator is medically appropriate and necessary.
Appeal type: Medical necessity
Decision: Upheld

Cardiac/Circulatory Problems. 
Treatment: Diagnostic Testing Other than Radiology. 

Diagnosis: Chest Pain. 
Treatment: Myocardial Perfusion Imaging. 
The insurer denied the Myocardial Perfusion Imaging. The determination is upheld. 

The patient presented to his primary doctor with chest pain, described as pressure-like. His blood pressure (BP) was 118/90, pulse 85 beats per minute (bpm) and temperature 98.5 degrees Fahrenheit. An electrocardiogram (EKG) showed sinus rhythm at 73 beats per minute (bpm). There were no ST segment or T wave changes noted. 
He had further symptoms and was referred to the emergency room (ER) for evaluation of persistent chest pain and lightheadedness. He presented to the ER. He was discharged after an evaluation was negative for acute myocardial infarction and referred for outpatient evaluation. His provider recommended stress myocardial perfusion imaging and an echocardiogram (ECHO). At issue is the medical necessity of myocardial perfusion imaging. 

Myocardial perfusion imaging is not medically necessary for this patient. His baseline, resting EKG was interpretable for ischemia and he is able to exercise. Per current American College of Cardiology (ACC) and Milliman Guidelines, exercise stress testing with imaging is not appropriate as initial testing in this situation. This patient had an EKG which is interpretable for ischemia. Therefore, he meets guideline for stress testing without imaging (electrocardiogram (EKG) interpretable for ischemia and able to exercise to greater than or equal to (>/= 4) metabolic equivalents (METS ). He does not meet guidelines for stress testing with imaging, including nuclear imaging, as he does not have a high pretest probability for ischemia, known coronary artery disease (CAD), coronary calcium score > 100, poorly controlled hypertension (HTN), inability to exercise, or EKG uninterpretable for ischemia.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Influenza/Flu. 
Treatment:  Inpatient Hospital. 

The health plan denied the inpatient stay.  The health plan's determination is upheld. 

This is the case of a patient with a past medical history of anxiety, who presented to the emergency department with a sore throat, sinus pain, and a panic attack. 

On presentation she was febrile to 38.4C with a blood pressure of 116/72 millimeters of mercury (mmHg), a heart rate of 128 beats per minute (bpm), a respiratory rate of 24/minute and an oxygen saturation > 90%.  An exam otherwise noted lungs clear to auscultation.  Labs resulted with a white blood cell count (WBC) of 4.5, a hemoglobin (HGB) of 11.3, platelets of 208, a sodium of 136, a potassium of 3, a blood urea nitrogen (BUN) of 13.3, a creatinine of 0.72, a lactic acid of 5.7, a venous blood gas with a potential hydrogen (pH) of 7.55 and a partial pressure of carbon dioxide (pCO2) of 55.  Influenza A test was noted to be positive.  A urinalysis was unremarkable.  A chest x-ray showed no obvious cardiopulmonary process.  An electrocardiogram (EKG) showed sinus tachycardia without acute ischemia.  The patient was placed on a non-rebreather and the respiratory rate decreased to 20/minute and was otherwise given intravenous (IV) fluids.  The patient was subsequently brought into the hospital with concerns for hyperventilation and headache in the setting of influenza and with plans for IV fluids, Tamiflu and Tylenol as needed.  The patient was additionally given intranasal Midazolam and a paper bag to breath into, which helped the hyperventilation, and it was noted that the patient desaturated to 83% transiently while sleeping and fell asleep with a paper bag in place.

The patient was significantly improved with the aforementioned therapies and was subsequently deemed stable for discharge. 

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

This is a young patient with anxiety, who presented with influenza and hyperventilation in the setting of anxiety.  The patient was initially tachypneic in the setting of hyperventilation that improved with Midazolam and techniques to help anxiety and was not noted to be hypoxic, except when the patient fell asleep with the paper bag.  The patient otherwise did not have any abnormality on chest x-ray or other acute cardiopulmonary process such as asthma complication presentation.  This patient appears safe to have been treated at a lower level of care.  On presentation it would have been anticipated that this patient would improve rapidly.  Inpatient care was not medically necessary, and a lower level of care would have been appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Central nervous system neuro muscular disorder /other. 
Treatment:  Increase in Consumer Directed Personal Assistance Program (CDPAP) Services for 10.5 Hours per Day, 7 Days per Week (Total Amount of 73.5 Hours per Week). 
   
The insurer denied Increase in Consumer Directed Personal Assistance Program (CDPAP) Services for 10.5 Hours per Day, 7 Days per Week (Total Amount of 73.5 Hours per Week).  The denial is overturned in whole.

The patient has a past medical history of dementia, diabetes mellitus type 2, glaucoma, systolic heart failure, hyperlipidemia, gout, gastroesophageal reflux disease (GERD), cerebrovascular accident (CVA) with dysphagia, macular degeneration with legal blindness, incontinence of stool/urine and peripheral vascular disease with nonhealing ulcers and osteomyelitis and had been assigned Personal care aid (PCA) service hours at 6.5 hours/day, 7 days/week to total 45.5 hours/week based on recently performed assessment tool.

Yes, the requested services of the Consumer Directed Personal Assistance program services for 10.5 hours per day, 7 days per week for a total of 73.5 hours per week are medically necessary for this patient.

The patient has well-documented medical condition of left foot ulcer, non-healing and infected with placement on hospice, as goals of care were not to pursue further treatment, noting significant decline in functional abilities.  In addition, the patient had legal blindness making it difficult to successfully complete ADLs without maximum assistance.  The patient's medical providers, including his PCP, neurologist and surgeon all advocated that the patient required increased assistance with ADLs and IADLs, even recommending 24-hour PCA care. 

PCA /CDPAS services are not solely for supervision and safety for this patient but to assist him in successfully completing ADLs and IADLs.  Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in the patient's  own home.  Therefore, the requested services are medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Relapsing remitting multiple sclerosis (MS).

Treatment: Tecfidera

The insurer denied coverage for Tecfidera. The denial is reversed. 

This patient is a female who had a diagnosis of relapsing remitting multiple sclerosis (MS). The documentation indicated that the patient was previously treated with Rebif for over a decade but discontinued use due to nausea. The patient was recently hospitalized for multiple sclerosis flare with multiple complaints. The patient was treated on both occasions with 5-day course of high-dose steroid therapy. The patient had residual visual impairment as well as weakness. The patient was recommended Tecfidera to treat this patient's medical condition.

There are no head to head studies that would clearly define choice of medication in a patient who proves refractory to initial therapy. As per Up to Date, "There is no standard protocol for changing treatment in patients with either relapses or clinically silent MRI lesions. The overall goal is to balance the risks posed by the medications to the risks posed by the disease, though prognosticating long-term outcomes in MS is difficult. Consideration of the contribution of medication adherence and other factors to inadequate treatment response is also important."

Tecfidera is a medically appropriate and effective choice for the treatment of multiple sclerosis. Tecfidera is FDA approved in case of relapsing remitting multiple sclerosis (RRMS) and could be used in this case. As summarized in Up to Date "Fumarates may have neuroprotective and immunomodulatory properties. In two large trials, an oral formulation of dimethyl fumarate (BG-12) significantly reduced relapse rates and the development of new brain lesions on MRI in patients with active MS [104-106], and results from one of these trials suggest that BG-12 reduces the rate of disability progression."  

This reviewer's opinion is that treating this patient with Tecfidera for her multiple sclerosis is appropriate and medically necessary.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for Tecfidera should be reversed. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse
Treatment: Inpatient substance use rehabilitation treatment 
The insurer denied the inpatient substance use rehabilitation treatment. 
The denial is upheld.

The requested Inpatient substance use rehabilitation treatment is not medically necessary for this patient.

The patient presented with substance use disorders, diagnosed with alcohol and stimulant/cocaine and opioid and tobacco use disorders. He self-referred at the direction of his parole officer and briefly received inpatient level rehabilitation treatment. He readily engaged in treatment and had no biomedical or psychiatric treatment issues that warranted inpatient level care. During the time interval under review, the patient was noted to be in no apparent distress with reasonable functioning and active participation in treatment including positive interactions with staff and peers. Throughout his inpatient stay, there were no complicating treatment issues or biomedical or co-occurring psychiatric issues that would have warranted inpatient level of care, structure or 24-hour monitoring. The application of NY State OASAS LOCADTR 3.0 Criteria (referenced below) did indicate that the patient was clinically appropriate for treatment with lower level care in a less restrictive treatment setting, as the health plan asserts. Thus, medical necessity for the Inpatient substance use rehabilitation treatment is not met in this case scenario, also consistent with ASAM Criteria, the scientific literature and published guidelines, referenced below.

The patient in this case scenario is not clinically appropriate for an inpatient level of care during the time interval under review. The patient had presented with a level of stability and no co-occurring psychiatric disorders or safety concerns that would have warranted inpatient level care. He did not need the monitoring or the structure of an inpatient setting in order to receive effective substance use disorder treatment. He readily engaged with treatment and was involved with treatment interventions and peer-supported recovery groups that could have been provided in a less restrictive treatment setting with sober supports or living. Thus, the health plan's determination is reasonable in this case scenario. This answer is consistent with prevailing standards of medical practice for the conditions diagnosed and under treatment in this case, and consistent with the application of NY State OASAS LOCADTR 3.0 Guidelines.