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

Diagnosis:Sinus tachycardia
Treatment: Inpatient stay

Summary:
The patient is a male. He had no past medical history. He was admitted for evaluation of sinus tachycardia. The patient reported taking two energy drinks prior to admission. 

The patient presented for evaluation of sinus tachycardia. The diagnosis of an acute MI (myocardial infarction) was ruled out by cardiac enzymes, which were negative. There was no evidence of pulmonary embolism, pneumothorax or aortic dissection. There was no evidence of sepsis or septic shock. There was no evidence of acute myocardial infarction, ACS (acute coronary syndrome), decompensated CHF (congestive heart failure), or malignant arrhythmia.  Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission. The care required could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient admission 

The Inpatient admission was not medically necessary, as inpatient level of care was neither indicated nor provided.

Summary:
The patient is a female. She presented with atypical chest pain, and dyspnea. The pain was described as sharp and present for months. A lower leg edema was seen for one month. On day of this admission, she had left another hospital AMA (against medical advice) with reportedly elevated enzymes. 

The patient was prescribed ASA (aspirin) and statin and admitted to telemetry.  Her exam was normal, as were her vital signs. Her EKG (electrocardiogram) was normal, with NSR (normal sinus rhythm) and incomplete right BBB (bundle branch block). Her CXR (chest x-ray) was negative. Her CT scan was unremarkable, and there was also no coronary calcium.  An echocardiogram was ordered. Her CBC (complete blood count), BMP (basic metabolic panel), and BNP (brain natriuretic peptide) were all unremarkable. Her highly sensitive troponin was normal.

Determination of level of care is primarily dependent on the actual care a patient receives, and whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results. It is highlighted in the orders for care. 

In this case, the patient's symptoms were atypical and unlikely to be representative of acute coronary syndrome (ACS). These symptoms had been present for a significant amount of time. Her exam and cardiac findings were normal. Her biomarkers and EKG showed no evidence of acute ischemia. In particular, the troponin HS (high-sensitivity) assay is particularly sensitive to diagnosing ischemia. Her CXR was normal. The physicians' treatment did not reflect any serious concern about the patient's cardiac condition.  Orders did not include medical therapy for ACS, such as IV heparin, dual antiplatelet inhibitors, high dose beta blockers or IV NTG (nitroglycerin).
Appeal type: Medical necessity
Decision: Upheld

Home Health Care 

The patient  with diabetes, dementia, and hemiplegia.
The consumer directed personal assistance services were reduced from 168 hours per week to 38 hours per week.
The subject under review is the medical necessity of the requested hours of the Consumer Directed Personal Assistance Services. Uphold, in whole the health plans determination of medical necessity.
No, the requested health service hours of 168 hours per week are not medically necessary for this patient. The reduction to 38 hours per week is medically necessary for this patient.
The Consumer Directed Personal Assistance (CDPA) services of 38 hours per week are sufficient to meet the patient's medical needs. Additional service hours are not medically necessary. Patient is able to walk in home with a cane. Patient is able to wash face and upper body, brushes teeth and toilet independently. During the most recent patient evaluation it was noted that the functional capacity did improve. Noting that the patient required less CDPA hours. Based upon review of the documentation provided, including the UAS State of New York, and medical documentation the hours provided are adequate to meet the patient's needs. There has not been shown to be any additional medical needs noted which would require additional services above and beyond 38 hours per week.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis:  Headache
Treatment:  Pharmacy/Prescription Drugs

The patient is a female with "persistent headache" and "intractable migraine with aura without status migrainous."  She has tried and failed the preventative medications of topiramate, amitriptyline, and atenolol.  Treatment with Aimovig is requested.

The health plan's determination is overturned. 

The formulary drugs are not likely to be as effective as the non-formulary drug, Aimovig.  The documentation provided indicates that the patient has tried and failed 3 drug classes for prevention of migraine including anticonvulsants, antidepressants, and beta-blockers.  The remaining formulary alternatives are anticonvulsants and beta-blockers. As such, these are not appropriate options to try because similar drugs have already been attempted and failed.  Additionally, one of the remaining formulary alternatives of divalproex sodium extended release is inappropriate for use in women of childbearing age due to risk of birth defects.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Attention-Deficit Hyperactivity Disorder (ADHD) Combined Type
 
Treatment: Vyvanse 50 mg Capsule (40/50/60/70 MG)

The insurer denied coverage for Vyvanse 50 mg Capsule (40/50/60/70 MG). The denial reversed. 

This patient is a male with a history of Attention-Deficit Hyperactivity Disorder (ADHD) Combined Type. The provider stated that the patient has been receiving intensive psychopharmacological treatment for many years. The patient started taking Vyvanse several years ago. He has had many unsuccessful trials of other medications, which have caused negative side effects. He has had the best response to Vyvanse 40 mg and Vyvanse 50 mg in the morning. As the medication does not come in a 90 mg pill, the provider is requesting the quantity that covers the recommended dose. Vyvanse 50 mg Capsule (40/50/60/70 MG) at the requested quantity is considered medically necessary for this patient. The patient has tried and failed other medications having no success. The patient has been on the current regimen of 40+50 in the morning for years with good results. It would be medically necessary to stay on the same regimen.

"The superior efficacy of lisdexamfetamine dimesylate [LDX] over atomoxetine [ATX] was maintained irrespective of the criteria used to determine a clinically relevant response to treatment" (Dittmann, R. W., et al. 2014). "Capsules: 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg, 70 mg VYVANSE is a central nervous system (CNS) stimulant indicated for the treatment of: Attention Deficit Hyperactivity Disorder (ADHD), Moderate to Severe Binge Eating Disorder (BED) Limitation of Use: VYVANSE is not indicated for weight loss. Use of other sympathomimetic drugs for weight loss has been associated with serious cardiovascular adverse events. The safety and effectiveness of VYVANSE for the treatment of obesity have not been established" (FDA Highlights of Prescribing Information 2015). 
"This post hoc analysis showed that, at the doses tested, patients treated with lisdexamfetamine showed statistically significantly greater improvement in symptoms of ADHD than those receiving OROS-MPH, as assessed using the ADHD-RS-IV and CGI-I. The safety profiles of lisdexamfetamine and OROS-MPH were consistent with the known effects of stimulant medications"(Soutullo et al 2013).

This patient has been on this dosage of Vynase for several years. While the dose would be considered off label, it has proven effective and without serious side effects. In addition, there is literature showing its superiority to other standard medications.                                                   

Thus, the health care plan did not act reasonably or with sound medical judgment or in the best interest of the patient.      

Based on the above, the medical necessity for Vyvanse 50 mg Capsule (40/50/60/70 MG) at the requested quantity is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyperkalemia
 
Treatment: Lokelma Pak

The insurer denied coverage for Lokelma Pak. The denial is upheld. 

This patient is a female with a past medical history of hyperkalemia and a hair loss.  The phone documentation indicated the patient described her hair loss was accelerated since stopping Aldactone secondary to hyperkalemia.  The cause of the hyperkalemia was unclear.  The patient had been taking a potassium supplement and her diet was potassium rich.  The patient's renal function was normal with no evidence for tubular dysfunction.  A review of the current electrolytes showed that the patient's potassium was in the upper limit of normal, 4.7 mEq/L.  The treatment plan included restarting Aldactone at full dose and the patient was to begin Lokelma 5 g daily.  The patient was given samples.

This request was previously denied by the insurer as they state the physician should consider other medications that lower potassium, including diuretics.  
Mount, D. (2019) notes that "In general, the following patients should be considered to have a hyperkalemic emergency and should therefore be treated with rapidly acting therapies (ie, intravenous calcium, insulin, and glucose) in addition to therapies that remove potassium from the body (such as hemodialysis, gastrointestinal potassium binders, or diuretics)" and " Some patients without a hyperkalemic emergency should, nonetheless, have their potassium lowered promptly (i.e., within 6 to 12 hours). Such patients include hemodialysis patients who present outside of regular dialysis hours, patients with marginal renal function and/or marginal urine output, or hyperkalemic patients who need to be optimized for surgery. Measures such as isotonic bicarbonate infusion, intravenous 5 percent dextrose in water infusion overnight (to stimulate insulin in a fasting patient), or hemodialysis may be appropriate in these settings. Additional measures can include oral potassium binders or kaliuresis induced by intravenous saline with diuretic therapy". 

In this patient, she had hyperkalemia secondary to Aldactone use, was taking potassium supplements and had a diet rich in potassium. The patient's renal function was normal and her potassium was in the upper limit of normal, 4.7, which would not support the need for the use of Lokelma to lower her potassium level. There was no explanation if the patient's use of potassium supplements and her diet that was high in potassium were discussed as they contribute to hyperkalemia. 

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. The Lokelma Pak is not medically necessary for this patient.

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

Respiratory System - Breathing Problem
Inpatient Hospital

The patient has a history of chronic obstructive pulmonary disease (COPD), hypertension, tobacco abuse, schizoaffective disorder, opioid dependence, and alcohol dependence. He presented to the emergency room with a one-day history of shortness of breath. The vital signs were unremarkable, including a normal respiratory rate, but the physical exam was notable for labored breathing and diffuse wheezes. His lab work was notable for arterial blood gases documenting minimal carbon dioxide (CO2) retention but there was also an elevated serum bicarbonate. The electrocardiogram (EKG) and chest x-ray were non-contributory. The cardiology consultant evaluated the patient and concluded that the patient was suffering from an exacerbation of COPD, with an element of noncompliance. Nebulizer treatments were administered in the emergency room. The patient was admitted for further treatment and evaluation. Upon admission, the patient was treated with his usual home regimen, intravenous corticosteroids, intravenous antibiotics, and nebulizer treatments. The clinical course was uneventful, and the patient signed out against medical advice.

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

The health plan, in its determination of medical necessity, has acted reasonably, with sound medical judgment, and in the best interest of the patient. The requested health service/treatment of inpatient stay was not medically necessary for this patient. Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or EKG of an imminently life-threatening cause of the patient's complaints. There is no evidence that he required intravenous corticosteroids or intravenous antibiotics. The services provided could have easily and safely provided in the emergency room or an observation stay. Based on the standard of care and peer reviewed literature, the inpatient level of care was not medically necessary, and the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Dizziness/Vertigo
Inpatient hospital

The patient is a female with a medical history of hypertension, diabetes mellitus, hypothyroidism, chronic kidney disease stage 3 with nephrotic syndrome and recent diagnosis of vertigo who was admitted with spinning and dizziness similar to her vertigo symptoms. She was alert, awake and oriented without neurological abnormalities. She was not in any distress, and she was hemodynamically stable without arrhythmias. She did not require any intravenous medications, or monitoring. The inpatient level of care is under review.

The health plan's determination is upheld. The inpatient hospital admission was not medically necessary for this patient.
Based upon the severity of illness and intensity of required therapy, the inpatient hospital admission was not medically necessary. This patient with a medical history of hypertension, diabetes mellitus, hypothyroidism, chronic kidney disease stage 3 with nephrotic syndrome and recent diagnosis of vertigo was admitted spinning and dizziness similar to her vertigo symptoms. On initial evaluation in the emergency room, she was hemodynamically stable with a blood pressure of 127/73 mmHg and heart rate of 80 beats per minute, had an oxygen saturation 99% on room air, was not in any distress, she was alert/awake/oriented without documentation of any focal neurological abnormalities, she did not have any arrhythmias or severe electrolyte abnormalities. She was noted to have a slightly elevated serum creatinine of 2.89 mg/dl from a baseline of 2.3 mg/dl.
In the emergency room she was treated with intravenous fluids, meclizine and Reglan with an improvement in her spinning and dizziness. In addition, with intravenous fluid hydration her serum creatinine was noted to be improved to 2.56 mg/dl and the renal consultant felt the acute kidney injury was pre-renal in nature. They recommended continuing oral intake and was medically stable to discharge from a nephrology standpoint. Although the patient had an acute kidney injury with a serum creatinine of 2.89 mg/dl, it was improving with 1 liter of intravenous hydration, she did not have a urine output < 0.5 mL/kg/h and there was no documentation that her glomerular filtration rate (GFR) was decreased >50% from baseline. In addition, the patient was able to take oral medications and feeds, she did not require continued volume expansion in the from of intravenous fluids, diuretic therapy or hemodialysis. Therefore, based on the clinical information provided, the patient did not have the clinical risk factors indicated for an inpatient hospital admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left hand pain (at stitches)
Treatment: ER visit

The ER visit was not medically necessary.

The patient is a right-handed female smoker with a history of obesity, hypertension, lap band procedure and varicose veins who presented to the emergency department (ED)  with a chief complaint of pain in the left hand for one week, concerned that stitches may not have resolved and that she may have an infection. The patient originally sustained a laceration approximately one month prior, repaired by an orthopedic hand specialist in the emergency room (ER) and had a subsequent follow up appointment on approximately one week later with the hand specialist. The patient reported that the skin around the laceration site was peeling and was sore with varying movements. She denied fever, redness, drainage, or other signs of infection. 

The patient's vital signs were essentially normal. The ED provider's physical exam revealed a healing six centimeter (cm) laceration with intact granulation tissue, with no signs of infection, and no evidence of retained sutures. The ED provider reviewed the surgical notes from the repair and documented that "absorbable sutures were used." The telephone record from the orthopedic hand surgeon documents that the patient called one to two days prior to admission because of reported "discoloration and pain in her left hand, she believes it may be an infection," after which the office staff called her back and documented the they "spoke to patient and informed her she should go to the ER if she thinks she may have an infection in her finger. Suggested going to an urgent care for some antibiotics and a check up patient refused."

There was nothing in the history or exam to suggest an emergency condition requiring the unique resources of an Emergency Room. The care could have easily and appropriately been provided in an urgent care of outpatient office setting. The key points that point to a non-emergency condition are the following: 1) there was no fever, swelling, redness, drainage, streaking or other signs of post-op infection, 2) the symptoms of new soreness had already been going on for one week, so the thinking that an ongoing condition that has been present for a week now suddenly needs the ER strains credulity, 3) although post-op infections do occur, they are typically within the first three to five days of the procedure; this issue was one month after the original injury and repair, so the likelihood of a new post-op infection was low, 4) although the hand surgeon's staff did tell the patient the standard response of "go to the ER if you think you have an infection," the staff did also recommend going to an urgent care and documented that the "patient refused."
Appeal type: Medical necessity
Decision: Overturned

Preventive Care
Dental/Orthodontic Procedure

The patient  who presents for evaluation and treatment of tooth #12. In question is the medical necessity of the treatment of root canal therapy (3320) for tooth #12.
From the radiographic documentation the patient did have evidence of decay as well as periapical periodontitis on tooth #12 indicating pulpal pathology.
The subject under review is the medical necessity for the root canal.

The health plan's determination is overturned. The root canal for tooth #12 is medically necessary for this patient. The presence of pulpal infection necessitates pulpal therapy, not extraction. Root canal therapy is a standard therapy in caring for patients with pulpal pathology when there is enough residual tooth structure for the tooth to support a prosthesis and remain in function after the treatments have been delivered. From the radiographic documentation the patient did have evidence of decay as well as periapical periodontitis on tooth #12 indicating pulpal pathology. Based on the documentation provided and the rationale above, the root canal therapy for tooth #12 is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of asthma who presented with fever of increased work of breathing for 3 days. His mother had been administering albuterol every 4 hours while he was ill in addition to his daily budesonide. He then presented to the Emergency Department (ED) with decreased wet diapers and tachypnea. In the ED, he was febrile, tachypneic, and having sternal retractions. In the ED, he received several inhaled treatments with albuterol/atrovent as well as oral prednisolone and ceftriaxone. He had testing showing a bicarbonate level of 16. No complete blood count (CBC) was obtained. A chest x-ray was performed and was read as bilateral pneumonia with superimposed bronchitis/reactive airway disease. The child was noted to have an oxygen saturation, in the ED, of 95% on room air, approximately 2.5 hours after arrival. The only oxygen supplementation occurred in the first few hours in the ED and was blow-by and was discontinued after admission. For the majority of the admission, the child had normal oxygen saturation without supplemental oxygen and was afebrile. His respiratory rate was in the 30's for the majority of the admission. The health plan's determination is upheld.
The need for hospital admission for asthma exacerbation has been examined in detail in the literature. Several asthma severity scoring systems have been devised to assist providers in determining which patients should be admitted rather than observed. An asthma exacerbation can still be fatal and it is important to be judicious in deciding who to admit and who to observe at a lower level of care. The most important reason to admit an asthmatic for inpatient care is if they do not respond to interventions in the ED or if in fact they worsen in this setting. Children, who still have significant wheezing, retractions, need for supplemental oxygen, poor aeration, or altered mental status despite use of beta-agonist therapy and/or systemic steroids will require admission to prevent further morbidity.
In this case, the child did not require supplemental oxygenation during the admission. He did not have any alteration of his mental state. Any wheezing or breathing difficulties were improving by the time that he arrived at the on the inpatient pediatric floor. This child was responding to the intervention in the ED including decreased respiratory rate, resolution of fever, and increased oxygenation. He was also given a regular diet and oral medications which would not be appropriate for a child who was truly in respiratory distress.
Appeal type: Medical necessity
Decision: Upheld

The patient presented for evaluation and treatment of tooth number (#) 29. Provided for review are previous letters of appeal and denial, patient narratives, full mouth radiographic images, panoramic radiographs, multiple pages of American Dental Association (ADA) claim forms, and health plan language. Previous denials have been on the basis that the crown could not be allowed in events where there is either excessive decay or poor bone support. At issue is the medical necessity of the planned treatment of porcelain ceramic crown for tooth #29 (2740).
The health plan's determination is upheld. There is nothing in the provided documentation to support the medical necessity of the desired treatment of porcelain ceramic crown for tooth #29 (2740). From the provided documentation, there are not any clinical findings or diagnosis to support the medical necessity of the planned procedure. From the radiographic documentation, there is no evidence of decay within the tooth to support the need removal of the current restoration and replacement with a full coverage restoration. Therefore, the requested service/treatment is not medically necessary.