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

Diagnosis: Dementia
Issue under review: Increased personal care aide services

Determination:
The Increased personal care aide services are medically necessary.

This is an elderly female with a history of vascular dementia and anxiety. Due to these conditions, she requires assistance with the majority of her activities of daily living (ADLs). Per recent evaluation the patient requires 24/7 caregiver services for assistance with all of her major activities of daily living (bed mobility, transfers, ambulation, toileting, showering, feeding, dressing). For these reasons, the proposed treatment, personal care aide service 7 days 2 X 12 hours per day Split shift is deemed medically necessary to better assist with the patient's activities of daily living (ADLs). The patient's current level of service, personal care aide, 7 days 10 hours a week, is not adequate to provide for the patient's medical needs.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: MS
Issue under review: Increased PCA services

Determination:
The Increased PCA services are not medically necessary.

This is a female who is homebound due to moderate/severe multiple sclerosis. Due to impairments related to her condition, she requires assistance with the majority of her activities of daily living (ADLs). In the appeal request for review, the patient's representative reports that the patient requires increased PCA hours due to split-day care for all needs, history of incontinence and inability to stand requires changing every two hours. Food preparation/shopping assistance required. Repositioning while lying down and bathing assistance required. The patient cannot be left alone, is at risk of falls and possibility of developing UTI (urinary tract infection) from urine/feces.

However, the medical records indicate that the patient recently underwent a face to face clinical assessment, which determined that the currently approved plan of PCA service is sufficient to meet the patient's needs and ADLs. There is no additional documentation that demonstrates evidence of further clinical decline since this assessment. For these reasons, the proposed treatment of an increase in PCA services is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Alzheimer's disease
Treatment:  Increase PCA hours to 42 hours per week 

The proposed treatment of an increase in PCA hours to 42 hours per week is deemed medically necessary. 

This is a female with a history of advanced Alzheimer's disease.  For these reasons, she requires assistance with the majority of her activities of daily living (ADLs).  Per documentation from her Neurologist - the patient has been demonstrating progressively worsening memory, difficulties managing her medications and increased difficulties performing her ADLs.  The currently approved schedule of 25 PCA hours per week is no longer sufficient to meet the patient's needs.  For these reasons, an increase PCA hours to 42 hours per week is deemed medically necessary to better assist with completion of the patient's ADLs.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure
 
Treatment: inpatient admission

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

This patient is a female with a past medical history of asthma, benign essential tremor, bipolar disorder, factor V deficiency, migraine, mixed incontinence, urge and stress, thyroid disease, urinary tract infection, and a history of seizures. The patient presented to the emergency department. The patient noted she had seizure activity 1 year prior to presentation.  The patient had opioid abuse and was currently on Suboxone.  Upon presentation, the patient had complaints of multiple seizures since 1 PM.  The patient reported sitting on the couch in front of the television and the partner noted the patient suddenly appeared to gaze off into the distance, then fell to her side and began shaking.  The partner reported the patient had continued seizures, 6 in total, and it would take several minutes for the patient to regain consciousness.  The patient reported in between seizures she had blurry vision and felt "off." The patient was to undergo a brain CT and MRI and EEG as an outpatient.  The patient was admitted for observation.  The patient left Against Medical Advice.

The Milliman Care Guidelines recommend admission for patients with seizures who have a new focal deficit or those who have a recurrent seizure during observation. They also recommend inpatient admission for patients who have hemodynamic instability not corrected by appropriate treatment within 12 - 24 hours.

The patient had presented to the Emergency Department (ED) and had a 1-minute seizure while in the ED. The patient was treated with Ativan, which broke the seizure. The patient underwent a neurologic consultation and was found to have no abnormalities on examination. The documentation failed to support the patient who had an inadequate response to pharmacotherapy in the emergency department or that she was not appropriate for observation. The CT scan and MRI could have been performed on an outpatient basis, as recommended per the neurology consultation.  Therefore, the healthcare 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.

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

The patient is a male with short stature, poor weight gain, and delayed puberty, receiving growth hormone (GH) therapy since 2019. Complete blood count (CBC)/differential, electrolytes, and liver function tests (LFTs) were normal in 2018. Provocative GH testing with glucagon and L-dopa revealed a peak GH response of 13 nanograms per milliliter (ng/mL) in 2018. Magnetic resonance imaging (MRI) of the brain was normal in mid-2018. GH therapy was initiated in 2019.
The patient was noted to have had weight loss in 2019 on follow-up. 
The subject under review is the medical necessity for Nutropin.

The health plan's determination is upheld.

No, Nutropin is not medically necessary for this patient.
The patient's height is not more than 2 standard deviations (SDs) below the mean for age and gender, he had a normal response to provocative GH testing, normal morphology of the pituitary gland and midline structures, and a normal adult height prediction.
Based on the pre-treatment bone age  in 2018 and height measurement of 150 cm at that time, the estimated final adult height prediction is 68.5 to 69 inches, using the Bayley-Pinneau method. The patient experienced a more notable fall-off in weight than height and he has delayed pubertal development. Thus, the most likely cause of the fall-off in height is undernutrition or malabsorption coupled with delayed pubertal development, rather than GH deficiency.
Appeal type: Medical necessity
Decision: Upheld

The patient has gastroesophageal reflux disease. Brand-name Nexium is being requested. The appeal letter states that a recent endoscopy showed achalasia. She had failed generic Nexium, pantoprazole, omeprazole, and ranitidine. Despite one month of generic Nexium, the patient still has symptoms of reflux. By switching to the brand name, the symptoms have been controlled. A progress note describes a negative screening colonoscopy. The patient complains of ongoing reflux symptoms on generic Nexium. A barium swallow showed mild esophagitis, no delayed emptying. A esophagogastroduodenoscopy (EGD) showed a normal esophagus. The patient had surgery for achalasia in the past. Body mass index (BMI) is 29.3.

The health plan's determination is upheld. Brand name Nexium is not medically necessary. Since there are alternative proton pump inhibitors available on the formulary such as omeprazole, pantoprazole, lansoprazole, the brand-name Nexium is not considered medically necessary for the treatment of gastroesophageal reflux disease. Although the progress note mentions trials of other proton pump inhibitors, there was no objective documentation of trial, failure, proper dosage and duration of alternative available proton pump inhibitors. No doctors notes or paid pharmacy claims show trials of other generic available PPI's. The doses of various PPIs that would be considered pharmacologically equivalent have not been well established, and thus it is possible that all the various PPIs could be equivalent when administered at certain doses.

The Updated Guidelines for the Diagnosis and Treatment of GERD from the American College of Gastroenterology state: "All of these agents (omeprazole, lansoprazole, rabeprazole, pantoprazole, and esomeprazole) have been demonstrated to control GERD symptoms and heal esophagitis when used at prescription doses. An 8-week course of PPIs is the therapy of choice for symptom relief and healing of erosive esophagitis. There are no major differences in efficacy between the different PPIs."
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebral vascular accident; progressive dementia
Treatment: Increase Customer Directed Personal Assistance Service Hours from Seven Days 12 Hours per week to two days per week two 12 hours shifts per day (split-shift)

The increase in customer directed personal assistance service hours from seven days 12 hours per week, to two days per week two 12 hour shifts per day (split-shift) is medically necessary.

The patient is a male with history significant for cerebral vascular accident (CVA) with left sided weakness complicated by progressive dementia and incontinence requiring garment changes.  The patient also requires maximum assistance with bathing, dressing, locomotion, toileting, household chores, finances, shopping, transportation, and personal hygiene.  

Note: the doctor's letter requests seven days per week, two 12 hour shifts per day (split shift) for a total of 168 hours per week.  However, this request/letter of medical necessity is dated after the final denial letter which denies two days per week, two 12 hours shifts per day (split-shift).

Based upon the additional recent documentation by Dr. Walfish dated 08/22/2019, the proposed treatment of two days per week two 12 hour split shifts is medically necessary to provide the wound care required to heal the patient's stage III decubitus ulcer.  The care is necessary to prevent this wound from becoming a stage IV ulcer.  Based on the patient's current status, more hours may be appropriate.

Based upon the additional recent information provided by Dr. Walfish, the proposed treatment of two days per week two 12 hour split shifts is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with no significant past medical history.  He had otitis media and conjunctivitis with an upper respiratory infection (URI), which had been treated as an outpatient for six days.  He was brought to emergency department (ED) because of left eyelid swelling x 2 days.
He was admitted with a diagnosis of periorbital cellulitis.  He was started on intravenous (IV) cefuroxime and IV clindamycin.  The following day he had mild swelling of the upper eyelid only and was much improved.  He was discharged home on oral Augmentin.
The health plan's determination is upheld.  The periorbital swelling documented in the record involved the left upper eyelid.  Typical periorbital cellulitis involves significant swelling below the eye and extending downward rather than the upper eyelid.  Given that this patient had documented otitis media and conjunctivitis, swelling of the upper eyelid was more likely to be a reaction to bacterial conjunctivitis rather than true periorbital cellulitis.  The normal WBC and vital signs do not support a diagnosis of periorbital cellulitis.  Care could have been provided at a lower level to watch for the onset of infraorbital swelling, toxic appearance, or proptosis.
Appeal type: Medical necessity
Decision: Upheld

The patient presented requesting "I want detox and rehab" and was admitted. Patient endorsed a daily pattern of drinking half a pint of liquor, inhaling 10 bags of heroin, smoking $50 of cocaine and $10 of marijuana. The day of admission used all four substances but only two shots of brandy and seven bags of heroin. Blood alcohol level was 54 and urine was positive for cocaine and opiates. On admission  pulse was 81 and blood pressure was 135/88. The initial Clinical Institute Withdrawal Assessment (CIWA) was 8 and  Clinical Opiate Withdrawal Scale (COWS) was 13. Patient reportedly complained of insomnia, anxiety and irritability, did not complain of tremors. Patient was given a primary diagnosis of opiate dependence with withdrawal and admitted to the detox unit. The Admission Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) completed by the facility indicated the patient was incapacitated by use, at risk for moderate withdrawal and had a "lack of support for early abstinence". It also indicated that patient had continued use after withdrawal services at a lower level of care and was not appropriate for outpatient detox. The patient reported a history of depression, schizophrenia, post-traumatic stress disorder (PTSD) and anxiety but was prescribed only fluoxetine and clonidine and denied a history of hallucinations. Patient has a history of multiple past detox and rehab stays. Patient was admitted and placed on a five day methadone and Librium taper and was discharged home after declining rehab referral. On the day of discharge patient disclosed that patient had been in a methadone maintenance treatment program (MMTP) prior to admission; not disclosed that on admission. The inpatient stay on the last 2 dates of service were not medically necessary. Opiate withdrawal is uncomfortable but not in of itself dangerous. Per established guidelines and the medical literature, inpatient detoxification may be indicated when other comorbid conditions or circumstances elevate the level of risk to the patient. However this patient does not meet those criteria. It is not clear from the research literature that inpatient detoxification in this patient would be expected to be clinically helpful, i.e. unlikely it would make chance of recovery any more likely than in the outpatient setting.  Furthermore, the patient's available clinical information was entered in the NY state LOCADTR "Concurrent Review" tool which resulted in a recommendation that inpatient detox was no longer the recommended level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Hemiparesis
Treatment:  Increase in consumer directed personal care assistance from 24 to 42 hours per week

The proposed treatment of an increase in consumer directed personal care assistance from 24 to 42 hours per week is not deemed medically necessary. 

The patient is a male with a history of CVA with residual hemiparesis.  For these reasons, he requires assistance with performing the majority of his activities of daily living (ADLs).  However, his currently approved plan of consumer directed personal care assistance 24 hours/week is sufficient to meet all of the patient's needs and ADLs.  Furthermore, there is no medical documentation which demonstrates additional functional decline or worsening medical status to support an increase in hours.  For these reasons, the proposed treatment of an Increase in consumer directed personal care assistance from 24 to 42 hours per week to better assist with completion of the patient's ADLs is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: s/p Accident
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

This preteen male patient was taken to the ED after sustaining injuries from having been struck by a car while crossing the street. He hit his head, with no loss of consciousness, no reported headache, and no vomiting. His cervical spine was cleared by Trauma. X-rays were all unremarkable. He had a forehead abrasion with some swelling, and several hours after presentation, complained of left knee pain and difficulty extending. Further evaluation, including PM&R consultation, PT evaluation, and x-rays were completed. He remained stable in room air, tolerating a regular diet, with no alterations in his neurologic status, and no significant issues with pain. While it was reasonable and appropriate to monitor this patient in the hospital, he did not require acute inpatient admission. He could have been safely and appropriately managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Alcohol Abuse/Addiction 
Inpatient Hospital   

The patient who  was admitted  following medical screening to acute inpatient level services for detoxification and withdrawal management of severe alcohol use disorder. The patient presented to the emergency department requesting detoxification treatment; he reported using up to five pints of liquor daily. He had a recent fall with laceration of his left eyebrow and reported dizziness and fatigue with prominent gait disturbance. The health plan determination is overturned .
The proposed inpatient services and detoxification treatment and withdrawal management for severe alcohol use disorder and other services noted in the clinical summary could not have been safely and effectively provided at a lower level of care. The adult inpatient treatment of this patient's substance use disorder did require the admission and the continued structure of an inpatient level setting and 24-hour monitoring in view of the severity of the alcohol use disorder, and the presentation with withdrawal symptoms and high risk for falls, seizures and other medical complications. Withdraw symptoms were managed with tapering dosages of benzodiazepine/Librium requiring monitoring, as well as comfort medications and vitamin replacement therapy. Thus, the patient did require a safe and effective detoxification with withdrawal management during the time frame under review, as it was reasonable that the patient would have been unable to abstain from the substances of abuse if detoxification and treatment were to be attempted at a lower level of care.
Medical necessity for the admission and the continued inpatient services, is met in this case, and is consistent with prevailing standards of medical practice, published practice guidelines, and ASAM Criteria, referenced below. This answer is also consistent with the application of NY State OASAS LOCADTR  Criteria/Guidelines, referenced below.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
 
Treatment: Inpatient hospital stay 

The insurer denied coverage for inpatient hospital stay. The denial was upheld.

This patient is a man who was sent from his doctor's office to the emergency room (ER) for chest pain. The pain localized to his left arm. Vital signs were stable. CT angiography of the chest showed no pulmonary embolism. He was admitted with atrial fibrillation. He ruled out for myocardial infarction with negative cardiac enzymes. He had an echocardiogram which showed ejection fraction 55-60%. A nuclear stress test was performed, which was normal. The patient was deemed stable for discharge.

The patient presented with chest pain, however the initial evaluation in the ER was unremarkable, including negative cardiac troponin and a non-diagnostic EKG. Inpatient admission was not medically necessary for this patient. In the absence of elevated cardiac biomarkers and a diagnostic electrocardiogram, the patient's care could have been provided in the observational setting, allowing for additional cardiac testing. Further evaluation was warranted, however inpatient admission criteria was not met.  Although the patient had new onset symptoms, medical criteria were not met for any other additional extenuating circumstances. There were no other high-risk co-morbidities. The observational level of care would have been appropriate. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

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

The patient is a female with morbid obesity, obstructive sleep apnea, on continuous positive airway pressure (CPAP), chronic obstructive pulmonary disease (COPD), on chronic home oxygen, diabetes, hypertension and hyperlipidemia who was referred to the emergency room (ER) by her cardiologist for evaluation of chest pain. She had chest pain and dyspnea over 2 days prior to admission. Electrocardiogram (EKG) showed sinus rhythm and left anterior hemiblock. No acute ischemic ST-T changes were noted. Chest x-ray (CXR) showed clear lungs.
A previous cardiac catheterization on had been normal. Blood pressure (BP) was 146/78, pulse was 78 beats per minute (bpm), respiratory rate was 20 and oxygen saturation was 96%.
She was admitted and ruled out for myocardial infarction with negative serial troponin levels. The following day symptoms were reported to have improved. Right and left heart catheterization was recommended but declined by the patient. She was discharged.

The health plan's determination is upheld. 

No, inpatient admission is not medically necessary for this patient. The patient has multiple comorbidities, as noted above, and presented with chest pain, which was present over the 2 days prior to admission. She was hemodynamically stable. She did not have evidence for acute coronary syndrome, however, as initial troponin and EKG were negative. Inpatient admission is not indicated.
Based on Milliman Guidelines, inpatient admission for chest pain is recommended if there is hemodynamic instability, respiratory distress, acute myocardial infarction or chest pain indicative of another serious cardiac or pulmonary diagnosis, such as aortic dissection or pneumonia, for example.
In this case, the patient did not have objective evidence for an acute coronary syndrome (negative EKG and troponins, as well as recent normal coronary angiogram, by report), or another critical cardiac or pulmonary diagnosis requiring admission.
The patient was admitted with chest pain, but hemodynamically stable and without objective evidence for an acute coronary syndrome, treatment could have been carried out at a lower level of care status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Lower Back Pain
 
Treatment:  Inpatient Admission

The insurer denied the Inpatient Admission.  The denial was reversed. 

This is a male patient who presented to the emergency department (ED) with complains of lower back pain.  The patient described the pain to be rated a 7/10 in intensity.  It was reported that the patient was unable to ambulate due to the severity of his pain.  He had a history of hypertension.  The patient had presented to the ED the day before for similar symptom.  He had been treated with non-steroidal anti-inflammatory medication and a muscle relaxant, with no relief.  On physical exam the patient was noted to be hypertensive; 203/103.  He was treated with several medications including intravenous (IV) morphine for his pain.  The patient's urine toxicology tested positive for opioids.  He had completed several imaging tests that had no positive results.  He was safely discharged home.

The medical record denoted inability to ambulate on several occasions despite pain medications.  He required the attention and adjustment for pain medications and the efficacy to obtain sufficient relief.  He required a number of imaging studies to assist in diagnosis.  Based upon complexity of his clinical presentation and concern for possible the development of a so called "red flag" the admission and length of stay would be considered necessary.

Based on the above, the medical necessity for the inpatient hospital admission was substantiated.  The insurer's denial is reversed.