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

Diagnosis: Digestive System / Gastrointestinal 
Treatment: Inpatient Hospital
The insurer denied: Inpatient stay
The denial is: Upheld, in whole

The patient is a male with medical history of hypertension, diabetes mellitus type 2, obstructive sleep apnea, hyperlipidemia, and chronic obstructive pulmonary disease. He presented to the emergency department with nausea, vomiting, diarrhea for two weeks with 5-6 bowel movements per day, and unintentional weight loss. Vital signs were unremarkable. Physical examination was notable for frailty, appearance of distress, and left-sided abdominal tenderness. Complete blood count and chemistry were unremarkable. Urine testing was positive for opiates. Chest x-ray showed no acute findings. Computed tomography scan of the abdomen and pelvis showed no acute findings. He was treated with intravenous ketorolac, ciprofloxacin, and metronidazole, as well as oral pantoprazole and Imodium. The following day, he reported ongoing diarrhea. Labs showed normal blood count and chemistry. He was treated with Toradol. The next day, he reported no diarrhea, nausea, vomiting, or abdominal pain. He was discharged with a plan for Primary Care follow-up. The subject under review is the medical necessity for the inpatient stay.

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

The inpatient stay is not supported as medically necessary.
The patient had symptoms including nausea, vomiting, and diarrhea consistent with gastroenteritis.  The standard of care for the treatment of gastroenteritis and the evaluation of diarrhea was appropriately performed, including intravenous fluids, empiric antibiotics, and supportive care, and symptoms improved [1-5].  The patient improved on intravenous antibiotics; there was no protracted fever or hypotension to suggest that antibiotics were ineffective.  Mild hypokalemia improved within a day.  No other cause for the inpatient level of care, such as peritonitis, toxic megacolon, bowel obstruction, sepsis, abscess, fistula, or other complication was documented. The care, which was undertaken, including observation, monitoring, labs, and antibiotic administration, could have been performed without the inpatient stay.  For these reasons, the inpatient level of care is not supported in this case. The patient could have been treated at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pressure, Shortness of Breath

Treatment: Inpatient admission
 
The insurer denied the inpatient admission.

The denial was upheld.

The is a male patient who has a history of coronary artery disease, Type II diabetes, diabetic nephropathy, chronic kidney disease, seizure disorder, pulmonary embolism, former tobacco abuse, atrial fibrillation, three myocardial infarctions, hypertension, hyperlipidemia, morbid obesity, obstructive sleep apnea (OSA) on continuous positive airway pressure (CPAP), substance abuse, eight cardiac stents, Lithium use, and strokes. He presented to the Emergency Department with complaints of worsening left-sided chest pressure that radiated to the left arm and was accompanied by shortness breath. Vital signs were stable.  An EKG revealed normal sinus rhythm with nonspecific T-wave abnormality and a chest x-ray showed mild cardiomegaly. The patient was admitted to the telemetry unit. He ruled out for myocardial infarction with negative cardiac biomarkers. The patient was seen by a Nephrologist and a Cardiologist. Once the patient was medically stable, he was discharged with outpatient follow-up.  

The patient presented with chest pain.  The initial evaluation in the Emergency Room was unremarkable, including a non-diagnostic EKG and cardiac biomarkers. Inpatient admission was not medically necessary for this patient. The patient's care could have been provided in the observational setting, allowing for additional diagnostic testing. Further evaluation was warranted; however, inpatient admission criteria were not met.  There was no hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions warranting the acute inpatient level of care. 

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 admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Neck pain
Issue under review:  MRI

Determination:
The MRI is not medically necessary.

The patient is an adult male patient with history of prior cervical fusion.  He presented multiple times with neck pain radiating to head and weakness in both hands.  Physical exam reveals decreased neck range of motion and decreased sensation in the right second and third digits.  X-rays show prior fusion at C4-5.  The attending physician (AP) recommends magnetic resonance image (MRI) of the cervical spine.

The patient has neck pain and some sensory loss, but there is no evidence of a sufficient course of conservative care including physical therapy and non-steroidal anti-inflammatory drugs (NSAIDs). 

A trial of conservative care should be tried before ordering a MRI, as the MRI will not change the treatment plan.  Physical therapy and NSAIDs would be appropriate no matter what the MRI reveals.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:Dental problems
Secondary: overbite
Treatment: Dental/Orthodontic treatment

The patient has a Class II malocclusion. Moderate maxillary crowding and mild mandibular crowding. Mild overbite and overjet. The health plan's determination is upheld, in whole. Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 15 with no auto qualifiers. Auto qualifiers include cleft palate deformity or cranio-facial anomaly, severe traumatic deviation, impacted permanent anteriors where extraction is not indicated, deep impinging overbite, anterior crossbite causing clinical attachment loss and recession of the gingival margin, overjet 9mm or greater and underbite 3.5mm or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary. Thus, braces and periodic orthodontic treatment visits are not medically necessary for this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Neuromuscular Pain
 
Treatment:  Physical Therapy Services

The insurer denied the Physical Therapy Services.  The denial was upheld.

This is a male patient who presented to the doctor with complaints of generalized musculoskeletal pain including his shoulder, head, neck, and right knee.  He was treated with injections and physical therapy. 

The physical therapy treatment notes provide insufficient objective clinical information to support the medical necessity of the services provided for the treatment dates under review.  The physical therapy treatment notes also fail to provide evidence of specific impairment or significant improvement that supports the medical necessity of continuing a structured physical therapy program.  The physical therapy treatment provided without evidence of significant improvement was consistent with maintenance therapy and, thus, was not medically necessary.  

The health 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 physical therapy services is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest pain 
Treatment:  Inpatient hospital 

The patient is a woman with hypertension, chronic ETOH abuse, alcoholic gastritis and acute pancreatitis, and tobacco abuse, who presented to the emergency department (ED) with new onset chest pain.  The chest pain was severe, persistent, with retrosternal tightness.  The patient rated this pain as 10/10.  She also mentioned a fluttering feeling in the chest.  The patient also reported nausea, vomiting, diaphoresis and palpitations. 

The health plan's determination is upheld.  The inpatient stay was not medically necessary.  The patient presented with chest pain, which was atypical in nature.  The patient had coronary risk factors, including elevated BP and hyperlipidemia.  Her BP in ED was elevated, but after oral medications, her BP normalized.  Her troponin, echocardiogram and ECG did not reveal evidence of acute coronary syndrome.  Cardiology consult did not recommend any additional tests beside echocardiogram.  The patient did not have indications for inpatient admission from cardiac standpoint. 
The patient also had evidence of alcoholic gastritis.  Her vomiting improved.  There was no evidence of withdrawal symptoms.  Her electrolytes were abnormal and were replaced in the ED. 

The patient did not have any serious complications of alcohol abuse which would justify an inpatient admission.  She had chronic changes and electrolyte abnormalities due to alcohol abuse which could have managed at a lower level of care. 

The inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Respiratory System
Inpatient Hospital

Diagnosis: Asthma
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a male child with previous episodes of wheezing and family history of asthma who presented to the emergency department (ED) with three-day history of fever to 103, cough, and nasal congestion, one-day history of crying, fussiness, and increased work of breathing. He was seen by his pediatrician with recommendations to use Tylenol for fever and albuterol every four hours for cough. He was seen a second time with the same recommendations. He was treated with albuterol within half hour prior to presentation to the ED. His appetite was decreased, but he had no vomiting or diarrhea. Vital signs included temperature 102.4 to 102.7, heart rate 170, respiratory rate 42 with 92% saturation in room air. Examination was significant for intermittent fussiness, non-toxic appearance, nasal discharge, moist oral mucosa, inflamed pharynx, poor air entry with diffuse crackles and rhonchi, belly breathing with grunting, no nasal flaring, benign abdomen, and non-focal neurologic exam. 

The acute inpatient admission was not medically necessary. He could have been safely managed at a lower level of care. This young male child with some atopic history (prior episodes of wheezing) and family history of asthma developed an upper respiratory infection that presented to the ED with increased work of breathing. He was diagnosed with bronchiolitis and admitted for ongoing management of bronchiolitis and reactive airway disease. While it was reasonable to monitor him in the hospital as he was weaned from albuterol and supplemental oxygen, he was overall hemodynamically stable, with no evidence of dehydration or impending respiratory failure. He did not require acute inpatient admission and could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  CVA with right sided weakness.
Treatment:  Increase in Consumer Directed Personal Assistance Program (CDPAP) to 48 Hours/Week.

The insurer denied the Increase in Consumer Directed Personal Assistance Program (CDPAP) to 48 Hours/Week.  The denial is upheld.

Based upon the available medical records and Uniform Assessment System Evaluation, the proposed treatment is not medically necessary.

The patient is a female with significant past medical history of cerebral vascular accident (CVA) with right sided weakness requiring walker and wheelchair use, depression and related cognitive impairment.  The patient lives alone and has supportive family.
			
The last Uniform Assessment was performed and showed that the currently approved hours are sufficient to meet the patient's daily needs.  The patient's daughter reports progressive changes in her mother's medical condition not documented in the Uniform Assessment System Evaluation.  

Based on the Uniform Assessment System Evaluation dated, the patient's needs can be met with the current approved hours.  While the daughter's concerns are acknowledged, there is no medical documentation, or updated Uniform Assessment System Evaluation, to support her request for more hours.  Therefore, based on the last assessment, the currently approved hours are sufficient to meet the patient's needs, and the request for an increase in hours is not medically necessary at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Subdural Hematoma, Subarachnoid Hemorrhage

Treatment: Inpatient hospital admission

The insurer denied the inpatient hospital admission.

The denial was upheld.   

This is a female patient with a history of hyperlipidemia, migraines, hypothyroidism, and oropharyngeal cancer.  She presented to the emergency department with complaints of syncope with no loss of consciousness.  She was very confused about the events and was found by a family member. The physical examination revealed she was alert and oriented and answers questions appropriately. She had 5/5 muscle strength. The patient has a computed tomography (CT) scan of the head that revealed a thin right frontoparietal subdural hematoma with a right parietal scalp laceration and hematoma; suture repair was performed on the laceration. There was increased density along the left medial temporal lobe adjacent to the hippocampus which may represent a small hemorrhagic contusion or possibly represent a small amount of subarachnoid hemorrhage. There was a small amount of subarachnoid hemorrhage in the left frontal lobe. A CT scan of the cervical spine did not reveal any significant abnormalities. Neurosurgery was consulted with recommendation for no surgical intervention. She underwent an echocardiogram revealing an ejection fraction of 56-60%.  A carotid duplex also showed no significant stenosis.  She did have repletion of electrolytes given some minor noted deficits. She did not any further significant adverse events.  She was discharged.  It was recommended she continue medication use and follow-up.

There is no medical necessity for the requested inpatient stay given that observation level of care in this case is more appropriate.  On all days, this patient remained hemodynamically and neurologically stable, no infection or bleeding was noted, no drips were noted, no urgent surgery was necessary, pain was under control, and the patient was ambulatory and tolerating oral intake.  Therefore, the health plan acted reasonably with sound medical judgment in the best interest of the patient.

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

Diagnosis:  Melanoma.
Treatment:  Molecular Oncology Testing.

The insurer denied the Molecular Oncology Testing.  The denial was upheld.    

This is a male patient with a history of cutaneous melanoma of the abdomen; 0.5 mm in greatest depth, and stage t1a.  The requested test is Decision Dx testing.

The National Comprehensive Cancer Network (NCCN) guidelines do not recommend any additional workup for T1 melanomas, outside of an excision with 1 cm margins.  Decision Dx is a gene expression profile test that is used to stratify risk of metastasis in patients with melanoma.  Gene expression profiling like that undertaken by this provider has not yet been accepted as standard of care in treating cutaneous melanoma patients. 

The American Joint Committee on Cancer (AJCC) and National Comprehensive Cancer Network (NCCN) guidelines for clinical decision-making and follow-up for patients with cutaneous melanoma do not currently incorporate gene expression profiling.  Given that these assays are not recommended in clinical guidelines, the data pertaining to this assay's use is not yet accepted.  The 2019 melanoma guidelines from the American Academy of Dermatology state that information gleaned from the assay itself should not affect the treatment or follow-up approach for cutaneous melanoma.

"Gene expression based prognostic signatures offer promise, but the studies to date have been characterized by heterogeneous sample sizes of high-risk, event-rich cohorts that do not necessarily represent the spectrum of patients who may benefit from the test, as well as by questionable applicability to clinical practice.  Importantly, changes to clinical practice (eg, SLNB, intensity of surveillance/imaging, and/or therapeutic choice) based on GEP results should be avoided until more data from the requisite clinical trials and an assessment of clinical utility are available.  In addition, the impact of a high-risk prognostic GEP classification on patient quality of life and anxiety over disease recurrence has not been adequately addressed....  Current evidence does not support increased surveillance imaging as a result of available prognostic GEP tests, particularly in node-negative patients who are not yet eligible for newer, more effective adjuvant therapies.  Similarly, the frequency of clinical follow-up and indications for imaging in patients with CM are unlikely to be modified by a prognostic GEP result until prospective studies have confirmed a benefit and adjuvant therapy has demonstrated a meaningful impact in earlier-stage disease." (Swetter 2019)

The health care plan acted reasonably, with sound medical judgement and in the best interest of the patient.  DecisionDx Melanoma Test, code 81599 performed is not considered to be medically necessary.  For stage 1 melanoma there is no additional testing that needs to be done.  The risk of metastasis for this thin melanoma is small. 

Based on the above, the medical necessity for the laboratory services (Decision DX Melanoma Test, code 81599) performed is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory distress; Croup
Treatment: Inpatient hospital admission
The insurer denied coverage for inpatient hospital admission.
The denial is overturned.

The patient is a male child with 2 days of fever, stridor, and a barking cough. He had a sick sibling in his home. He was seen in the emergency department (ED) the day before admission with retractions and respiratory distress. He was discharged after treatment in the ED for croup with Decadron and racemic epinephrine.  The father called for an ambulance to take him back to the ED when his respiratory distress and stridor recurred. He was administered another dose of racemic epinephrine during the ambulance ride to the hospital.

In the ED, the child was noted to be pale and ill appearing with rapid breathing with stridor. He was treated with several additional doses of racemic epinephrine, Decadron and 2 fluid boluses of intravenous normal saline. Following treatment in the ED he continued to have stridor at rest and tachypnea. He was also noted to have a significant elevation of blood sugar which was thought to be a complication of the frequent doses of Decadron. Because he had failed outpatient management and did not improve with treatment in the ED, the decision was made to admit him to the hospital for ongoing treatment with intravenous (IV) fluids and he required 2 additional treatments with racemic epinephrine during the admission in the hospital with a diagnosis of croup.

The patient was treated appropriately in the ED for a second acute episode of croup. He had been treated in the ED the day prior to the admission and when his symptoms recurred the father appropriately sought additional treatment. He appeared dehydrated, pale and ill appearing and had a significant complication of hyperglycemia because he had required multiple treatments with Decadron for his difficult to control symptoms. The medical record does support the need for admission to the hospital and the admission was consistent with the standard of care for a child in respiratory distress which did not improve in the ED.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The inpatient services are considered medically necessary for this patient.

Based on the above, the medical necessity for the inpatient admission is substantiated.  The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anxiety, Depression. 
Treatment: Trintellix 5 mg. 

The insurer denied Trintellix 5 mg. 

The denial was upheld. 

This is a male patient who has a history of anxiety, depression and cerebrovascular accident (CVA). He presented to his provider for evaluation of anxiety and depressive symptoms related to stressors. The patient reported depressed and irritable mood, anxiety including excessive worrying and nervousness. The patient's symptoms were not adequately controlled with maximal doses of Lexapro at 20 mg per day. The patient has tried Duloxetine in the past but could not continue treatment due to side-effects. The patient was currently taking Wellbutrin samples and was doing well. It was reported that due to his history of cerebrovascular accident (CVA), it was not advisable to take selective serotonin reuptake inhibitors (SSRI) such as paroxetine or citalopram. It was reported that the patient was given samples of Trintellix 5 mg per day and was doing well with that medication. 

Based on the review of the medical record, this patient did not have a diagnosis of Major Depressive Disorder but rather Adjustment Disorder with Mixed Anxiety and Depressed Mood and not Major Depressive Disorder. While Trintellix is FDA-approved for major depressive disorder, it is not FDA-approved for Adjustment Disorder. According to literature review, Trintellix, which is also known as Vortioxetine, is a serotonin modulator as it is a serotonin reuptake inhibitor, norepinephrine transporter blocker, and a 5HT1A and 5HTIB partial agonist, and 5HT1D, 5HT3A and 5HT7 receptor antagonist with a half-life of 66 hours. It is FDA-approved for adults with Major Depressive Disorder with a maximum FDA-approved dosage of 20 mg per day. As per the medical record submitted for review, the patient had reported failed trials of SSRI's including Lexapro at 20 mg per day and also had side effects to Duloxetine. It also was reported that the patient could not take Paroxetine or Citalopram due to his CVA. Based on the patient's diagnosis of Adjustment Disorder with Mixed Anxiety and Depressed Mood, this requested medication, Trintellix is not supported by FDA and literature to be medically necessary for this patient. The literature supports that the standard of treatment for Adjustment Disorder is psychotherapy since this patient's anxiety and depressive symptoms are thought to be in response to a stressor. Psychiatrists sometimes prescribe antidepressant and anti-anxiety medication to target depressive and anxiety symptoms but this patient has not tried and failed other anti-anxiety and antidepressant medications that are generic medications prior to requesting a non-formulary medication, such as Trintellix. Thus, Trintellix is not considered medically necessary for this patient. 

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

Based on the above, the medical necessity for Trintellix 5 mg OR Tablets is not substantiated. The insurer's denial should be upheld.