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

Diagnosis: Abdominal pain 
Treatment: Inpatient admission
The proposed treatment, inpatient admission, was not medically necessary.
The patient had colon cancer with a tumor in the cecum (first part of the large bowel). He had several weeks of waxing/waning abdominal pain that was worsening the week prior to the admission under review. He was sent in from his primary care doctor to the emergency room for evaluation, for concern that he had cancer or bowel obstruction.
In the emergency room, the patient's vital signs were normal and he was declining any medicine for the pain. His pain had waned. He was seen by surgery, and did not have any clinical findings of bowel obstruction. He had a CT of the abdomen, but this did not have any clinical findings of bowel obstruction noted (1). The reading of the CT of the abdomen commented on an "obstructing cecal mass", but this may have been an over-read as CTs do not image the lumen of the intestine and the diagnosis of an obstructing mass requires that there be signs of bowel obstruction (principally dilated loops of bowel). The CT report makes no comment on clinical signs of bowel obstruction such as dilated loops of bowel. On colonoscopy two days later, the mass was not obstructing. The medical records document repeatedly that the patient was tolerating liquids, was not vomiting, was passing gas and was having bowel movements - he had no symptoms of ongoing bowel obstruction.
Stool is liquid in the right colon. Right sided tumors (the cecum is the start of the right colon) are less likely to cause bowel obstruction than distal, left sided tumors (2). 
The patient did not have uncontrolled pain, he had no severe bleeding from the mass, he did not bowel obstruction, he did not have renal failure, and he had stable vital signs. 
The workup of suspected colon cancer does not require acute inpatient hospital admission (3).
There was no clinical indication for admission.
On the subsequent days the patient had a prep for colonoscopy and had the colonoscopy. He was stable throughout this period. He had an MRI of the liver performed prior to discharge. These services are normally performed as an outpatient. The continued admission was for the convenience of the patient and/or treating providers, to expedite the diagnosis of his suspected cancer. This was not medically necessary.
There was no clinical indication documented justifying acute inpatient admission. The goal of the treatment of patients with advanced cancer is to provide them with as much time at home out of the hospital as possible. It was not in the best interest of the patient to be hospitalized when there were no clear indications for hospitalization.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who is requesting Xolair for bronchial asthma 225 milligrams (mg) every 4 weeks. The patient has been on Xolair from 1/2006 to the present. He had tried Singulair and Advair which caused adverse effects in the past. 
The health plan's determination is upheld. . The patient is not on a daily controller medication for asthma. The request is also not medically necessary per standard of care and practice guidelines. Xolair is intended for adjunct treatment of asthma. In this case, there is no evidence of a concurrent use of daily asthma medications for asthma.
Appeal type: Medical necessity
Decision: Upheld

The patient  presents with a loose crown on tooth #10 and requests a custom abutment and abutment supported porcelain/ceramic crown on tooth #10. The health plan has denied the procedures as not medically necessary. The health plan's determination is upheld. The custom abutment, tooth #10 and abutment supported porcelain/ceramic crown, tooth # 10 are not medically necessary. According to the radiographs provided, tooth #10 has about 15% bone loss from the cemento-enamel junction. Crown to root ratio is not ideal; however, the distance from the gingival and crown margin to the alveolar bone level indicates there is enough biological width that crown lengthening is not necessary. There is no radiographic evidence of a fracture or decay noted and the crown appears to be intact with no open margins.
Appeal type: Medical necessity
Decision: Upheld

The patient was brought by ambulance to the Emergency Department (ED) for an evaluation of moderate to severe chest pain and cough for the previous 3 days. Though the cough at times exacerbated the pain, the patient experienced the pain without coughing as well. Patient had sick contacts and had been feeling feverish, fatigued, and achy. The patient had a past history of coronary artery disease with previous left anterior descending (LAD) stenting, hypertension, chronic obstructive pulmonary disease (COPD), and diabetes mellitus.  The patient was admitted to rule out an acute coronary syndrome and for possible bronchitis. A myocardial infarction (MI) was ruled out by serial troponins. The HP determination of medical necessity was upheld, inpatient stay was not medically necessary. Ruling out myocardial ischemia in a low risk patient can be accomplished in less than 12-24 hours. When the risk of myocardial ischemia is low, as in this patient, safety monitoring  and evaluation can be performed on a lower level. Current guidelines specifically state the value of a "fast track" protocol in patients with low risk of myocardial ischemia such as this patient.  Thus after ruling out an MI, the patient could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Altered mental status, major depressive disorder, schizoaffective disorder
Treatment: Continued inpatient hospital admission
The proposed continued inpatient admission was medically necessary for this patient.
The health plan considered the continued stay was not medically necessary based upon plan guidelines. However, the continued inpatient mental health stay is medically necessary in this case scenario. The intensive treatment for depression and co-occurring complications of the cognitive disorder and mood disturbance did require the continued structure or monitoring of an acute inpatient psychiatric level of care. Moreover, the patient did continue to display high risk for suicidal behavior and inability to care for self and did require active treatment of the mood disturbance with safety monitoring and adjustment of medication and use of as needed (prn) medications during his hospital course; other symptoms such as worsening and intermittent cognitive impairment, and bouts of confusion associated with uncooperative behaviors were present in this case, with psychiatric co-morbidity (mood disturbance with suicidal ideation and dysphoria) that did warrant continued inpatient level mental health care. The functional impairment and the psychosocial stressors in this case were severe enough to require continued, acute inpatient psychiatric level care and 24-hour monitoring.
This answer is consistent with published practice guidelines and the scientific literature, referenced below, and, is consistent with prevailing standards of medical practice.
The patient in this case presented with severe symptoms of a depressive disorder with high risk for suicidal behavior in the context of severe substance use disorder and comorbid medical conditions including moderately severe cognitive impairment and a major neurocognitive disorder. The presenting clinical features of depression, suicidal ideation, cognitive disorder and co-occurring substance use disorders did warrant the transfer for an inpatient admission and the continued inpatient psychiatric level services. The patient remained a safety risk during his stay that did necessitate 24 hour monitoring and the structure and support of an inpatient level setting while achieving resumption of medication treatment for the mood disorder in a patient who has a history of medication non-adherence and a severe and persistent mental disorder complicated by a neurocognitive disorder and substance abuse. The patient's admission and continued inpatient stay could not have been safely or effectively provided at a lower level of care in this case scenario for the duration of treatment under review.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain, history of prediabetes, schizophrenia, and generalized anxiety disorder and tobacco abuse

Treatment: Inpatient admission, diagnostic testing, medication management

The insurer denied inpatient admission.  That denial was upheld.

The patient presented to the Emergency Department with a complaint of left-sided chest pain.  He had associated left shoulder pain as well.  Breathing increased the patient's discomfort.  The patient stated that the pain was 10/10 in intensity and lasted for hours at a time.  There was no history of similar discomfort in the past.  His review of systems was negative except for what it's been mentioned above.  An EKG was normal. There was no reported change from an earlier EKG.  Chest X-ray showed the lungs were unremarkable; there was no pleural effusion or pneumothorax.  The impression was no acute finding.  A nuclear stress test was negative.  Troponin X2 were negative.  EKG was not significant and was within normal limits.  The patient received aspirin and chest pain was improving.  He signed against medical advice (AMA). 

High-sensitivity cardiac troponin T (hs-cTnT) have been introduced as a highly sensitive and early biomarker of myocardial damage.(1) In two prospective cohorts of patients admitted to the hospital for chest pain, undetectable hs-cTnT was found to have a very high negative predictive value for MI.(2, 3) A chest pain observation unit is now commonly used, in many emergency departments, to evaluate patients with possible acute coronary syndrome (ACS).  The goal is to arrive at a decision after a finite amount of time, which usually is between 6 and 12 hours but may extend up to 24 hours depending on the policies in individual hospitals.  Typically, the patient undergoes a predetermined observation period with serial cardiac biomarkers and ECGs.(5)

This patient presented with chest and left shoulder discomfort, which was described as 10/10 in intensity and made worse with inspiration.  His workup included troponin X2 which were normal, an EKG that was within normal limits and unchanged from the previous EKG.  Chest x-ray, nuclear stress test and an echocardiogram showed no specific abnormalities.  This patient was placed in a telemetry unit at the time of his admission, which was not medically necessary.  The literature recognizes the use of an observation unit for this type of patient.  However, a monitored level of care or telemetry unit is not the same thing, and the literature cited show that a monitored level of care for this patient was not necessary, nor appropriate.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a medical history of traumatic brain injury, kidney stones, depression and past alcohol/polysubstance abuse. He presented with symptoms of a mild headache, unsteady gait and dizziness for three to four days prior to admission. He was found to have a left lung base pneumonia but without pleural effusions/empyema or necrotizing pneumonia. The health plan's determination of medical necessity is upheld.

Based upon the severity of illness and intensity of required therapy, the inpatient level of care was not medically necessary.  As per the clinical documentation, during all dates of service, the patient was hemodynamically stable, his oxygen saturation was reported greater than (>) 91% on room air and he was never in any respiratory distress or have a respiratory rate greater than or equal to () 30. The chest x-ray did not demonstrate evidence of a pleural effusion/empyema/abscess/necrotizing pneumonia. He was alert, awake and oriented throughout his stay and his CURB-65 score (which estimates mortality of community-acquired pneumonia) was 0 and Pneumonia severity index (PSI) score was class 2, putting him at low risk for adverse outcomes and outpatient treatment would be appropriate. In addition, he had not failed outpatient therapy and was able to take oral medications and feeds.
Appeal type: Medical necessity
Decision: Upheld

The patient is with a complaint of bilateral knee pain and known osteoarthritis of both knees who underwent cortisone injections in both knees followed by Gel One injections into both knees.
The subject under review is the medical necessity for Gel One injections.
The health plan's determination is upheld.

The rationale for this determination is based on the provided records and the current, peer-reviewed literature on the topic of viscosupplementation injections for knee osteoarthritis. A recent article published by Tammachote and colleagues in 2016 in the Journal of Bone and Joint Surgery was a prospective, randomized study of patients with knee osteoarthritis who received either a single shot of Hylan GF 20 or 1 milliliter (mL) of 40-milligrams (mg) triamcinolone acetonide and 5 mL of 1% lidocaine with epinephrine. The authors concluded that "Triamcinolone acetonide provided similar improvement in knee pain, function, and range of motion compared with Hylan GF 20 at the 6-month follow-up, with better pain control in the first week and better knee functional improvement in the second week."
A second article published by Jevesevar and associates in 2016 in the Journal of Bone and Joint Surgery was a meta-analysis. The authors concluded "Meta-analysis of only the double-blinded, sham-controlled trials with at least sixty patients did not show clinically important differences of hyaluronic acid treatment over placebo. When all literature was added to the analysis, the overall effect was greater but was biased toward stronger treatment effects because of the influence of nonblinded or improperly blinded trials."
These two studies published in the Journal of Bone and Joint Surgery demonstrated that viscosupplementation injections like the Gel One used in this case are not clinically effective and are not supported by the peer-reviewed literature. Recent articles published by Tammachote and colleagues and by Jevsevar and associates have shown that the effect of viscosupplementation injections for knee osteoarthritis are not better than placebo or a simple corticosteroid injection. Therefore, the medical necessity for Gel One injections is not established.
Appeal type: Medical necessity
Decision: Overturned

This patient with a complicated medical history significant for spina bifida, hydrocephalus status post ventriculoperitoneal (VP) shunt placement, neurogenic bowel, and neurogenic bladder, and an ischial decubitus ulcer for several years suffered multiple wound infection. Patient underwent multiple surgical procedures (debridement, revisions) and completed multiple courses of antibiotics. Patient was subsequently diagnosed with osteomyelitis. Patient again underwent surgical and medical treatments, but unfortunately had suffered significant and progressive destruction of bone and tissue. After an extensive debridement, she was admitted to inpatient rehabilitation for wound care and antibiotics.The health plan determination is overturned in whole. The inpatient rehabilitation is medically necessary. This patient, with complicated medical problems and need for complex wound care, requires the expertise of an institution like inpatient rehabilitation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes
Issue under review: Dexcom

Determination:
Dexcom is medically necessary.

The use of continuous glucose monitoring with Dexcom has been shown to reduce A1C in patients with type 2 diabetes on multiple daily injections, such as this patient [1]. This patient has had a worsening of his A1C off of continuous glucose monitoring, which puts him at risk of hyperglycemia-related complications, including retinopathy, neuropathy and nephropathy. Therefore, yes, the requested treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis
Treatment: Inpatient admission
The inpatient admission was medically necessary.
The patient meets the initial criteria for IV treatment and admission for cellulitis/abscess given by the Infectious Diseases Society of America (1) for a multitude of reasons that include having a cellulitis associated with deep structures (lacrimal glands, orbit, and brain). Furthermore, the fact that she was homeless meant that admission in such a case (even if it were a milder presentation) was necessary as outpatient treatment would have been difficult and potentially harmful. Finally, it is difficult to imagine how and why this patient could have been treated as an outpatient when she was transferred to a tertiary institution because the current hospital and its physicians clearly stated they themselves were not equipped to treat this case as an inpatient in their hospital. Failure to admit and treat this patient (or treating this patient as an outpatient) could lead to permanent neurological deficits, including blindness, or death.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back pain
Treatment: Inpatient admission
The inpatient admission was medically necessary.

1) The patient signed out AMA one day prior to admission. That means that the physicians in charge of him the day prior thought that his condition was serious enough that it warranted continued hospitalization. This incongruity was not addressed; however it is likely the patient would still meet admission criteria that next day.

2) Active endocarditis was being ruled out. This typically involves the use of IV antibiotics (as suggested by the Infectious Diseases team) while waiting for the results of the blood culture, as an inpatient.

3) The increasing back pain pointed to a potential complication of the paraspinal abscess, such as cord compression or spinal abscess (1). The symptoms of paresthesias were especially worrisome, and close monitoring with neurosurgical consultation and/or MRI were appropriately considered.

4) Even if the dangers of endocarditis and worsening abscess were ruled out (again, this was not done because the patient signed out AMA again), continuing admission would have been necessary to work out the details of how this patient were to received long-term antibiotics, especially with the history of substance abuse. Treating the patient at a lower level of care and discharging the patient could lead to catastrophic consequences such as paralysis, shock, or death.

5) The history of active intravenous drug use (IDU) and substance abuse also needed to be urgently evaluated and treatments attempted, as the consequences of continuing abuse are clearly seen in this case. While the patient may have been resistant to such treatment, the team is ethically obligated to act on the best interest of the patient. This includes arranging for and obtaining inpatient substance abuse, psychiatry evaluation, and social work evaluation, all of which would be impossible to address with this patient as an outpatient.

For the above reasons, to discharge such a patient would be going against both standard of care and ethical guidelines for treatment of vulnerable patients.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia 
Treatment: Attendant care hour seven days eight hours

The proposed treatment of an increase in attendant care hours to seven days/week, eight hours/day is not deemed medically indicated/necessary. 

This female patient has a history of mild dementia and requires minimum assistance with some of her activities of daily living.  She otherwise lives alone in an apartment with elevator access.  She can ambulate around home using a single point cane without any assistance needed.  She is independent with performing her exercises and eating her meals.  For these reasons, the requested treatment of an increase in Attendant care hours to 7 days a week, 8 hours per day is not deemed medically necessary/indicated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left lower quadrant pain
Treatment: Inpatient admission
The proposed treatment, inpatient admission, was not medically necessary.

The medical records and peer-reviewed medical literature were thoroughly reviewed.  A laparoscopic salpingo-oophorectomy is an invasive procedure, which could require inpatient admission depending upon the preoperative condition of the patient, intraoperative events and events during postoperative recovery.  This patient had no significant co-morbidities to support an immediate postoperative inpatient admission. She had an uncomplicated laparoscopic procedure with minimal blood loss and was admitted postoperatively as an inpatient.  The patient's postoperative recovery as an inpatient was uncomplicated.  There is no evidence in the submitted medical records that the patient's recovery was complicated or that there were existing, indicated co-morbidities to support inpatient admission. Laparoscopic salpingo-oophorectomy is an invasive procedure that requires immediate postoperative care in an acute care setting, and post anesthesia care unit (PACU) care is within the standard of care for this indication and management.  This procedure also requires postoperative care and observation which can include an overnight stay.  Therefore, the patient also required postoperative care after the PACU discharge.  However, postoperative care for this procedure does not necessarily require subsequent acute inpatient care, unless the postoperative course is complicated or the patient's co-morbidities are significant enough to indicate that level of care.  The patient is this case does not meet those standards.  Therefore, the patient could have been reliably discharged from the recovery room to a lesser level of care rather than as an acute inpatient admission.  Therefore, the treatment was within the standard of care to be provided in a lesser level of care setting, and not in an inpatient setting.  Therefore, the services were not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Senorineural hearing loss
Treatment: L8619

The proposed treatment with L8619 is medically necessary.

The provider and patient are asking for an upgraded external processor, not a new cochlear implant.  External processors need to be changed about every three to five years.   The necessity of this change is for battery life and overall CI performance.  The value of change is indicated in the literature (1, 2). 

The specific advantages of this external processor N7 has been studied and shown to be the most effective processor for those with a "Cochlear" internal device. (3)

The patient in question already has the implant and is asking for needed and standard upgrades of the external device.  Such requests are common at regular intervals and it is standard of care to do these upgrades; it is also standard for these upgrades to be covered by the health plan.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:chronic hypersensitivity pneumonitis 
Treatment: Non-Emergency Air Ambulance Transportation 
The non-emergency air ambulance transportation was not medically necessary.

The patient felt at the time that due to the traffic congestion, his time to arrival to the transplant center was going to be compromised.  Helicopter transportation was requested by patient and wife.  

Reviewing the medical records, the lung transplant offered to this patient was on at 4:00 PM.  The helicopter arrived at the scene at 6:01 PM; the flight was 44 minutes and arrived to the unit at 7:15 PM.

Reviewing the medical records from the Lung Transplant Coordinator, this patient received a back-up offer, not a primary offer.  The time for the donor surgery was schedule for 04:00 AM (this would be nine hours after his arrival to the hospital).  The lung transplant was not performed due to the fact that the lung donor was accepted for the primary lung recipient patient.  This patient could have been transported by ground transportation and not compromised the surgical time for the lung transplant.