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

Diagnosis: Questionable Sandhoff disease
 
Treatment: Genetic Testing 

The insurer denied the Genetic Testing. The denial was reversed.  

This is a female patient who at 11 6/7 weeks gestation underwent genetic counseling. It was reported that her husband underwent a carrier screening test for Tay-Sachs disease due to his French Canadian ancestry. His test results came back negative for Tay-Sachs disease but resulted positive for a carrier for Sandhoff disease. Based on his positive test results it was recommended that she have carrier screening.

According to the American College of Obstetricians and Gynecologists (ACOG), (2017), committee opinion on carrier screening, in regards to Tay-Sachs disease, "When one member of a couple is at high risk (ie, of Ashkenazi Jewish, French Canadian, or Cajun descent or has a family history consistent with TaySachs disease) but the other partner is not, the high-risk partner should be offered screening. If the high-risk partner is found to be a carrier, the other partner also should be offered screening." ACOG also stated, "Carrier screening is a term used to describe genetic testing that is performed on an individual who does not have any overt phenotype for a genetic disorder but may have one variant allele within a gene(s) associated with a diagnosis". And if an individual is found to be a carrier for a specific condition, the patient's reproductive partner should be offered testing in order to receive informed genetic counseling about potential reproductive outcomes. 

The provider of this patient followed this ACOG recommendation. Patient's husband (reproductive partner) screening showed >75% hexosaminidase activity but a decreased overall level; that was consistent with highly likelihood of a Sandhoff carrier. As result, patient was also offered carrier screening. 

Per literature review, Sandhoff disease is similar to Tay-Sachs disease. It is an autosomal recessive condition, in which both members of the couple need to be carriers in order for their child to be conceived with this genetic condition. And similar to Tay-Sachs disease, Sandhoff disease too is a rare inherited disorder that progressively destroys nerve cells (neurons) in the brain and spinal cord. The most common and severe form of Sandhoff disease becomes apparent in infancy. Infants with this disorder typically appear normal until the age of 3 to 6 months, when their development slows and muscles weaken. Affected infants lose motor skills such as turning over, sitting, and crawling; and as the disease progresses, these infants experience seizures, vision and hearing loss, intellectual disability, and paralysis. Given the severity of the condition soon after birth, it is important to know the genetic risk of the partners.  

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

Based on the above, the medical necessity for the prenatal genetic testing is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Pregnancy
Inpatient hospital

The patient is a female who was referred to the emergency department (ED) with suspicion of ectopic pregnancy.  The patient reported vaginal spotting.  She had used intrauterine device (IUD) in the past; removed 3 years prior.  Her medical history was significant for hypertension, off medications.  Beta HCG was 10.853.  Hemoglobin and hematocrit were 12.2 and 35.9. The LFTs (liver function tests), urinalysis, coagulation profile and electrolytes were normal.  The patient was hemodynamically stable with blood pressure (BP) 141 / 89.

The health plan's determination is upheld.  The Inpatient Hospital Admission was not medically necessary for this patient.  The patient underwent non - emergent laparoscopic salpingectomy / corneal resection for right unruptured cornual ectopic pregnancy.  The patient remained hemodynamically stable; had no evidence of acute abdomen and did not experience excessive blood loss.  The surgical procedure was uncomplicated and there was no excessive blood loss documented.

Therefore, based on the above discussion, the patient's clinical circumstances did not support acute inpatient level of care and the procedure could have been performed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Shortness of breath and coughing
Issue under review: Inpatient admission

Determination:
The Inpatient admission was medically necessary.

The patient is a male child with a history of complete AV (atrioventricular) block and sleep apnea.  He presented with worsening shortness of breath and coughing.  A pacemaker was recommended. He had persistent bradycardia with heart rates in the 40 bpm (beats per minute) range. 

The patient had complete heart block, and he required treatment for congestive heart failure.  The patient required admission and evaluation.  The patient was in congestive heart failure and at risk for serious complications of his disease (1-2). Treating the patient at a lower level of care would not have been medically prudent, and it would not have been consistent with the standard of care.
Appeal type: Medical necessity
Decision: Upheld

This is a pregnant patient who presented to the emergency room complaining of persistent nausea and vomiting. The patient had reported coffee ground emesis on presentation, but that was not observed in the hospital. Her electrolytes were normal on presentation. She was admitted  and then left the hospital against medical advice. The inpatient admission was denied by the health plan and is under review for medical necessity.
The health plan's determination is upheld.
An inpatient level of care for this patient was not medically necessary. Persistent vomiting is well-documented. However, the patient was prescribed antiemetics that did not appear to maximized. Zofran was given every four hours scheduled but the breakthrough Phenergan was only given twice. No other medications were required. Her electrolytes were normal on presentation, including a normal potassium and bicarbonate. There is no blood gas in the records. The patient's vital signs were never out of normal range. Potassium levels were mildly decreased after her fluid boluses, but that mild decrease can be normal in pregnancy and does not dictate admission (or necessarily treatment). The patient was treated with parenteral fluids and antiemetics, and then was able to drink less than 12 hours after admission. Her diet was able to be advanced the day after presentation with complete resolution of her emesis by 09:00. The care that was described in this case could have been provided at a lower level than inpatient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status post right quadriceps tendon repair and retinaculum repair
 
Treatment: Inpatient admission

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

This patient is a male who was status post right Total Knee Replacement (TKR), and fell. He was found to have a quadriceps tendon rupture.  He was admitted to the hospital for elective open repair. After the operation he was placed in a long hinged brace.  He was admitted for monitoring and "further treatment." He was found to be stable and discharged. 

Medical record indicates that the reason for admission was status post right quadriceps tendon repair and retinaculum repair. However, the procedure was uncomplicated by hematoma or infection. There was no evidence of postoperative or surgical site infection. Patient denied pain and was tolerating diet well. Patient was hemodynamically stable, and did not require intravenous hydration. Based on these negative findings, the MCG guidelines for "Knee: Patella Reconstruction or Realignment" do not recommend inpatient admission. According to MCG guidelines, this procedure is performed on an ambulatory basis. Since this patient meets MCG guidelines' discharge readiness milestones, the admission to inpatient status after the knee surgery was not medically necessary. 

The patient could have been placed in observation status. There was no evidence of hemodynamic, pulmonary, neurologic, or metabolic reason for acute level of care.  The records demonstrate a non-complicated direct repair was performed.  There were no problems with his previous knee replacement.  The procedure was of moderate duration.  The patient was able to tolerate oral pain medication. He did not require treatment for other underlying medical problems.  The records of a specified day show normal vital signs, pain level 2/10, satisfactory physical examination and "orthopedically stable for discharge."

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.  The inpatient admission is not considered medically necessary for this patient. The appropriate service would have been Observation.
 
The carrier's denial of coverage for the inpatient admission is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Genitourinary: other
Inpatient hospital

The patient was born at 39.1 weeks estimated gestational age. He was born to a mother who was A+, had negative serology testing and had received prenatal care. The infant was delivered by elective repeat Cesarean section and no complications were noted. He was discharged with the mother. The neonate had a circumcision performed at early morning and bleeding was noted at early afternoon . He was taken to the emergency department where he was noted to be lethargic, tachycardic (heart rate 190 beats/minute) with a history of emesis at home. 

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient presented to the ED after an episode of bleeding at the circumcision site. He was stabilized in the ED, had laboratory studies performed and a urology consult. The patient was hemodynamically stable after receiving a normal saline bolus in the ED. He was then observed, permitted to orally feed, and received a transfusion of packed red blood cells. He was discharged the following day. The patient's condition (severe hematologic abnormality) did not persist after appropriate care. The patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Early prostate cancer
Treatment:  Oncotype DX prostate
The Oncotype DX prostate is not medically necessary.

Per the American Urological Association (AUA) Guidelines, "14. Among most low-risk localized prostate cancer patients, tissue based genomic biomarkers have not shown a clear role in the selection of candidates for active surveillance. (Expert Opinion)"

This patient has a very low-risk prostate cancer.

Although results are promising, further validation is necessary to understand fully the potential clinical utility of this test.  The National Comprehensive Cancer Network (NCCN) Guidelines note that "Their clinical utility awaits evaluation by prospective, randomized clinical trials, which are unlikely to be done."

The NCCN Guidelines state that "In summary, although molecular test results can provide additional guidance to patients, only limited data of prostate cancer specific-survival are available, and whether patient outcomes are improved with use of these tests is unclear." ". . . any of these tests may be considered to aid management decisions, but they are not required for standard of care at this time."
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse
Treatment: Inpatient substance abuse treatment

The proposed treatment, inpatient substance abuse treatment, was not medically necessary for this patient.

The proposed detoxification treatment and other medical services noted in the clinical summary could have been safely and effectively provided at a lower level of care. The treatment of this patient's substance use disorder did not require the structure of an inpatient setting or 24-hour monitoring. The patient displayed no serious disturbance of mental status despite having a history of ongoing substance use disorder with alcohol and use of cocaine and cannabis and chronic general medical issues. Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance that would have warranted an inpatient level admission and treatment. There were no severe/objective symptoms of withdrawal or biomedical issues in this case, and the patient had received detoxification treatments recently with knowledge of substance use disorder treatment protocols, as noted in the clinical summary. The patient had fair insight and control of impulses, and a working knowledge of substance use disorder treatment with a past history of multiple treatment episodes, as noted. Thus, inpatient admission for detoxification treatment and 24-hour monitoring, and the requested inpatient level services were not medically necessary in this case scenario.

This answer is consistent with New York State OASAS LOCADTR 3.0 Criteria/Guidelines and with established practice guidelines, the scientific literature, and ASAM Criteria, as referenced below.

In this case scenario, the patient was amenable to treatment with lower level care in a less restrictive setting. The patient displayed no serious disturbance of mental status and no general medical complications or co-occurring disorders that would have warranted inpatient level services. Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance that would have warranted an inpatient level admission and treatment. There were no severe symptoms of withdrawal or biomedical issues in this case. The admission for detoxification treatment and 24-hour monitoring, and the requested inpatient level services were therefore not medically necessary in this case scenario, as the health plan asserts. And, NY State OASAS LOCADTR 3.0 Criteria/Guidelines are not met for the inpatient level of care, referenced below.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse 
 
Treatment: Inpatient Admission 

The insurer denied the inpatient admission. The denial was reversed. 

This is a male patient with a history of inpatient substance detoxification treatment. He presented to the hospital for detoxification treatment. He reported inhaling several grams of cocaine per day. He had presenting withdrawal symptoms that included yawning, teary eyes, nasal congestion, sleeping problems, irritable mood, anxiety, and had a Clinical Opiate Withdrawal Scale (COWS) of 15. He was treated with a Methadone protocol throughout his hospital stay. He was stabilized and discharged home. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) he did require 24 hour treatment as he could not safely and effectively be treated in a less restrictive detoxification setting as he continued to use large amounts of serious substances of use including heroin and cocaine recent past inpatient medical hospital detoxification treatment. He was at risk for severe withdrawal with his large amount of substance use and active withdrawal with COWS of 15 so he required medical hospital detoxification treatment. He also required and needed detoxification medication (Methadone) to modify withdrawal and prevent severe withdrawal. He needed 24 hour medical hospital detoxification treatment then as he was at risk for worsened withdrawal symptoms if not in this 24 hour setting then including severe withdrawal symptoms. 
It did not appear that the health care plan acted reasonably or in the best interests of the patient.  

The carrier's denial of coverage for the inpatient substance abuse admission is reversed. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Headache; Dizziness
Issue under review: Inpatient admission

Determination:
The denial was upheld.

The patient is an adult female with diabetes, coronary artery disease, and hypertension. She presented to the hospital with increasing blood pressures on an outpatient basis.  

The patient's blood pressure on presentation was 183/115, and the patient was without acute complaints.  Laboratory indices were unremarkable, and the chest x-ray and computed tomography of the brain showed no acute process.  Oral antihypertensive agents (nifedipine and valsartan) were provided, and serial blood pressure were monitored.  The patient's blood pressure normalized.


The patient's elevated blood pressures on presentation were asymptomatic.  There was no evidence of hypertensive emergency, as the patient did not have end organ damage, such as seizure activity, hypertensive encephalopathy, acute cerebrovascular accident, acute kidney injury, acute myocardial ischemia, or acute heart failure.  No intravenous antihypertensive agents were provided.  The blood pressure normalized with only oral antihypertensive agents.  In addition, glycemic control was acceptable.  

In summary, inpatient admission was not medically necessary.  The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient in making its determination.
Appeal type: Medical necessity
Decision: Upheld

Cardiac/Circulatory Problems - Chest Pain
Inpatient Hospital

The patient is a man with a history of chronic back pain and schizoaffective disorder, who presented to the hospital from inpatient psychiatric unit where he was placed for one day, for alcohol and opiate detoxification, with a chief complaint of chest pain. The patient described the chest pain as 5 out of 10, not aggravated or relieved by any factors. He denied associated nausea or diaphoresis. He experienced a fall the day before and was complaining of facial headache and pain. 

The patient was admitted with a principal diagnosis of precordial pain. He reported prior cocaine use. A second cardiac troponin was also negative. The patient was placed on telemetry, and an echocardiogram was ordered. He was given aspirin 81 mg and Lipitor. Beta-blockers were avoided due to urine tox screen positive for cocaine. Also, a urine tox screen was positive for opiates, and the patient had already been started on methadone taper by the psychiatric hospital. Surgery was consulted to evaluate the fracture of the nasal bones. Bacitracin ointment was applied to the wound.

The patient was seen by cardiology as well as psychiatry. The cardiologist agreed with the assessment with an echocardiogram, and a psychiatrist did not recommend any psychiatric medications at this time.

The health plan denied the inpatient admission as not medically necessary. 

The health plan's determination is upheld. He ruled out for an acute coronary syndrome with three sets of negative enzymes and had a normal EKG. An echocardiogram and a stress test were requested; however, there was a significant delay in testing, which should not account for a change to inpatient status. Ultimately, the stress test was not even done due to the malfunction of the in-hospital equipment, and the patient was scheduled for an outpatient stress test. There was no clear indication for admission to inpatient care at this time. The patient had no evidence of acute coronary syndrome, stroke, or aortic dissection. Vital signs were relatively normal during the entire hospitalization. This was a chest pain presentation that can be managed under a lower level of care, and that is the standard of care across the country. It was reasonable to monitor the patient at a lower level of care, to ensure that he did not develop coronary vasospasm related to cocaine use. He was started on a methadone taper to prevent withdrawal from opiates while awaiting the completion of cardiac workup. These interventions did not require inpatient hospitalization.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dizziness And Lightheadedness
Treatment: Inpatient admission 
The insurer denied the inpatient admission.
The denial is overturned.

The Inpatient admission was medically necessary.

The patient is a male whose inpatient admission is under review. The patient has a history of HIV (human immunodeficiency virus) (unknown CD4 count), who presented with vertigo. He has history of noncompliance with his medications.

In the ER, the patient's vitals were as follows:  T (temperature) - 98.0 P (pulse) - 74 RR (respiration rate) 16 BP (blood pressure) 101/51. On general examination, the patient was NAD (no acute distress). Examination of the patient's chest, CVS (cardiovascular system) and abdomen were normal.

The patient's labs were as follows:
WBC (white blood count) - 5.4
Hg (hemoglobin) - 15.0
Hct (hematocrit) - 45.2
Plt (platelets) - 166
Na (sodium) - 130 (low)
K (potassium) - 4.7
Cl (chloride) - 101
CO2 (carbon dioxide) - 23
BUN (blood urea nitrogen) - 15
Cr (creatinine) - 1.39

CT (computed tomography) of the head revealed encephalomalacia. 

The patient was admitted with vertigo in the setting of encephalomalacia and HIV. The patient had a cardiac and neurologic work-up, which did not reveal any new disorders. He was placed on antiseizure medication, and discharged.

This patient with HIV, who was not complaint with medications, presented with vertigo and pre-syncope. Because an HIV count was not known, and because of long-standing history of HIV, AIDS-related illnesses were on the differential diagnosis. In addition, because of lack of compliance, an outpatient work-up could not have been completed. Thus, standard of care would have required an inpatient work-up to look for acute, life-threatening diseases. This was done, and none were found. He was started on anti-seizure medications, and discharged. Thus, this admission was warranted, supported by standard of care. Failure to admit such as a patient can lead to loss of function, arrhythmia, or death.