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

Diagnosis:  Status post cardiac catheterization 
Treatment:  Inpatient admission 

The patient is a male.  He was admitted for elective cardiac catheterization following intermittent episodes of palpitations and dyspnea that came on with exertion and relieved with rest.
 
This was an elective, uncomplicated catheterization that was scheduled after a positive nuclear test.  Significant lesion was successfully treated with one stent and no complications.  The patient was always hemodynamically stable with normal vital signs, normal EKG (electrocardiogram), normal LV (left ventricle) function, and no ectopy.  The only care that was given after the uncomplicated radial catheterization was monitoring, IVF, and routine medications.  This meets definition of outpatient care without any indication for a higher level. 

The denial was consistent with guidelines and usual community care.  Post-cardiac care, as described, is routinely performed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: s/p Vehicle collision
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

This patient is an adult, previously healthy, but intoxicated man who was involved in a car accident.  He was the unrestrained passenger of a car involved in collision.  Per report, the car was totaled and there was loss of consciousness at the scene of the accident.  

The patient presented to the ED by EMS.  The trauma service was consulted on.  Imaging with x-ray and CT scans did not identify acute intracranial, intrathoracic or intraabdominal injury or fracture.  Vital signs were normal, and Glasgow Coma Score was 15 at presentation.  He had fascial abrasions and lacerations.  

Following evaluation, the patient was monitored (observation due to mechanism and for alcohol withdrawal).  He was monitored overnight.  Ophthalmology consultation was requested with the recommendation of outpatient follow up.  Diet was advanced.  He was considered to be stable for discharge home two days after presentation.

An observation level of care would have satisfied the clinical needs of this patient.  This level of care would provide for monitoring with repetitive vital signs, neurologic signs or vascular checks, lab data, imaging, and overnight care.  An observation level of care would have also allowed for ophthalmology consultation.  An inpatient designation was not medically necessary or mandated by generally recognized standards of medical care.  This patient was clinically stable at the time of presentation and remained stable throughout the period of hospitalization. Imaging did not identify any acute intracranial, intrathoracic or intraabdominal injury or fracture that required inpatient care.
Appeal type: Medical necessity
Decision: Upheld

The patient  has a diagnosis of autism.  Available records for the therapy sessions under review include letters.  Available records from the treating clinician are multiple daily session notes for the dates of treatment in question, as well as the initial evaluation.
Goals outlined on the daily session note from the first date under review are verbatim in multiple to other treatment notes from the time period in question, including on an early 2019 daily session.  Thus the goals outlined included:  improve body and spatial awareness; improve visual fixation; improve attention, timing and organization; improve fine motor and visual motor skills; improve postural control and core strengthening; improve sensory modulation.  The "Reason for treatment/medical necessity" is documented as being in accordance with a comprehensive evaluation that was completed in 2017.  An updated comprehensive assessment is not documented.  At issue is the medical necessity of the requested occupational therapy services.
The health plan's determination is upheld.
The requested services are not medically necessary.  The patient received therapy.  The efficacy of ongoing care was not supported by the documentation submitted and, therefore, was not medically necessary.  Maximum Therapeutic Benefit had been reached.
Progress towards the outlined goals is not documented.  The goals and reason for medical necessity is documented as being the same at the beginning of the treatment period in question and the end of the treatment period in question.  Patients, such as this patient, who are not progressing in therapy by any standardized assessment would not warrant the level of care of skilled therapist intervention and should be discharged to a home exercise program.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Pressure in the vagina
Treatment:  Inpatient admission

The Inpatient admission was not medically necessary.

The patient is a G4P0 female.  She presented at 23 weeks five days complaining of pressure in her vagina.  There was no history of bleeding, leaking, or contractions.  Pregnancy was complicated by IVF (in vitro fertilization), mono-di twin gestation, gestational diabetes, short cervix on vaginal progesterone, diabetes, cerclage performed during this pregnancy, consanguinity, positive Quanti Feron, and abnormal MSAFP (Maternal Serum Alpha-Fetoprotein).  Membranes were noted to be prolapsing into the vaginal vault.  She was diagnosed as having cervical insufficiency and was transferred to another institution for higher level of care.  

The care given at this hospital was stabilization for transfer to another facility for higher level of care, and this was documented on the initial history and physical.  The diagnostic and therapeutic interventions that were performed (intravenous line, magnesium sulfate tocolysis/neuroprotection, antibiotics) are typically performed in the OB triage, an outpatient level of care, in preparation for transfer to a higher level of care when such transfer is anticipated at the initial presentation, as was the case for this patient.  The patient is then transferred from triage to the higher level of care without the need for inpatient level of care when the transport plan is implemented.  There was not a plan for definitive care at this facility addressing the medical complications.  Therefore, the admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Right humerus and proximal ulna fractures
 
Treatment:  Skilled nursing facility admission

The insurer denied coverage for skilled nursing facility from a specified date forward for a total of 7 days.  The denial is upheld. 

This patient is a morbidly obese female with multiple chronic medical problems including diabetes mellitus, atrial fibrillation, chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF).  She fell and sustained right humerus and proximal ulna fractures.  While hospitalized she underwent a left carotid endarterectomy due to a prior transient ischemic attack.  She was transferred to a SNF for subacute rehabilitation.  She was readmitted to the hospital, underwent an elective right carotid endarterectomy and transferred back to the SNF.  Currently under review is the medical necessity for skilled nursing facility (SNF) from a specified and forward for a total of 7 days.

The clinical records do not support the medical necessity of inpatient skilled nursing facility (SNF) rehabilitation from a specified date and forward for a total of 7 days.  The patient was appropriately admitted to the SNF for subacute rehabilitation.  However, there was a plateau in functional progress due to the non-weight bearing status of the right upper extremity.  She remained at the moderate to maximal assistance level for functional mobility (including transfers and ambulation).  Progress was unlikely to resume until her weight bearing status was advanced.  As a result, skilled services were not medically necessary during the time period under review.  There were no complicated nursing or acute medical needs that required skilled nursing or physician services, respectively.  The treatment provided from a specified date forward for a total of 7 days is best described as custodial and could have been provided at a lower level of care.  

The healthcare plan acted reasonably and with sound medical judgment and in the best interest of the patient.  From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, the continued stay at a skilled nursing facility (SNF) from a specified and forward for a total of 7 days was not medically necessary.

The carrier's denial of coverage for the continued stay at a skilled nursing facility from a specified date forward for a total of 7 days is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Chest pain
Issue under review:  Inpatient admission

Determination:  The Inpatient admission was medically necessary.

The patient is an elderly female.  At the time of admission to the hospital, she had a past medical history significant for hypertension (HTN), dyslipidemia, multivessel coronary artery disease (CAD) status post (s/p) recent catheterization and unsuccessful percutaneous coronary intervention (PCI) of the right coronary artery (RCA), deemed not to be a candidate for coronary artery bypass grafting (CABG) surgery, congestive heart failure (CHF), renal cell carcinoma s/p nephrectomy, and B-cell lymphoma s/p chemotherapy.  

The patient presented to the ER for new onset chest pain and dyspnea of three days duration.  The patient was hemodynamically stable.  Cardiac troponins were negative. Brain natriuretic peptide (BNP) was severely elevated at over 3000.  Basic metabolic panel (BMP) was significant for elevated creatinine, consistent with acute kidney injury.  The patient was admitted for management of acute on chronic CHF, acute kidney injury (AKI), CAD/angina, as well as suspected urinary tract infection (UTI) and upper respiratory infection.  The patient was diuresed with intravenous (IV) Lasix with close monitoring of urine output, renal function, and blood urea nitrogen (BUN) / creatinine.  Renal function gradually improved, and the patient was switched to oral diuretics.  She was discharged home with a plan for outpatient follow-up.

The patient presented with symptoms of acute CHF exacerbation, in the setting of acute kidney injury, with known severe CAD and chronic CHF.  Although usual course of hospitalized patients with CHF exacerbation is brief with expected discharge in 24 hours with adequate diuresis, there are certain subsets of patients that require extended periods of hospitalization for control of their symptoms.  This patient with multiple co-morbidities, who presented with CHF exacerbation, was appropriately treated with IV diuresis.  She required close monitoring of her CHF and renal function, given the underlying kidney disease, as well as single kidney due to prior surgery.  Given this presentation, acute on chronic CHF, as well as multiple risk factors, co-morbid conditions and known severe CAD, it would be consistent with the current standard of care that this patient be managed in an inpatient setting; therefore, the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse 
 
Treatment: Inpatient Admission for Substance Rehabilitation Treatment

The insurer denied the coverage. The denial was reversed.

This patient is a male was admitted to this inpatient substance rehabilitation treatment for substance rehabilitation treatment. He was using cocaine and cannabis and had a positive toxicology for tetrahydrocannabinol (THC) and cocaine. He was mandated to treatment by his parole officer. His longest reported period of abstinence was lasted for a few years when he was incarcerated. He had past inpatient substance rehabilitation treatments in mid-2018 and late 2018. He was in outpatient substance treatment and had a positive toxicology for THC and cocaine. He lived with family and attended group and individual therapy and was discharged in late 2018.

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), he met criteria for substance residential treatment as he continued to use multiple substances despite past inpatient residential treatment settings and outpatient substance treatment. He was in outpatient substance treatment and had a positive toxicology for THC and cocaine.  The patient had legal issues and was mandated to treatment by his parole officer. He was unable to stop substance use without being in this sober and supervised therapeutic residential inpatient setting. Without this structured and supervised therapeutic residential treatment, he likely would have quickly relapsed.
Appeal type: Medical necessity
Decision: Upheld

The patient entered treatment for problems with alcohol and marijuana use. The patient stated that the use of these substances had impacted the patient's ability to work. A positive urine drug screen for marijuana put the job in jeopardy. This admission was the patient's first episode of treatment for substance use disorders. Initial urine drug screen was positive for cannabis. Blood-alcohol level was zero. 

The health plan's determination is upheld. The Inpatient Rehabilitation Services are not medically necessary for this patient. The patient could have been cared for at a lower level of care. He did not have serious psychiatric symptoms that needed to be managed in an inpatient rehabilitation setting to be effective. The patient had used alcohol in settings that could be hazardous to others. The patient did not need to be managed in inpatient rehab in order to safely address cognitive or behavioral impairment.
Appeal type: Medical necessity
Decision: Upheld

The patient is a female with substance use disorders who was admitted to an inpatient detoxification unit for 6 days. The patient presented requesting treatment of multiple substance use disorders. The patient reported she was using two bags of heroin intravenously daily for about 10 weeks. Before that the patient was using her husband's prescription opiate (Dilaudid). She was also using cannabis and cocaine regularly. The patient reported the following symptoms: yawning, hot/cold sweats, joint pain, and rhinorrhea. The initial evaluation by the nurse practitioner stated, the patient appeared "with withdrawals" but no specifics are given on physical examination. Her Clinical Opiate Withdrawal Scale (COWS) score was 12 which is consistent with mild withdrawal. The COWS was repeated and was 14 consistent with moderate withdrawal (cutoff for moderate = 13). The patient's blood alcohol level was negative. Her urine was positive for opiates, cocaine and tetrahydrocannabinol (THC). The patient denied any psychiatric symptoms including suicidal ideation. The patient was previously approved 2 days. The health plan's determination is upheld. She was not using any substances that are associated directly with the possibility of life-threatening withdrawal. She had no diagnosed psychiatric comorbidity. She had no significant physical health conditions. She reported that she had stable and safe housing with a supportive significant other who did not use drugs. There were no COWS assessments during this time period under review and no notes from physicians or nurse practitioners. There were no notes that documented the medical decision making for continued inpatient stay. Using this information and the level of care for alcohol and drug treatment referral (LOCADTR) continuation of stay instrument was used; it resulted in the finding that the patient did not meet criteria for inpatient detoxification.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes mellitus, hypertension, peripheral neuropathy, gait ataxia
Treatment: Electric Stair Lift
The Electric Stair lift is deemed to be medically necessary. 

This is a female with a history of diabetes mellitus, hypertension, peripheral neuropathy and gait ataxia. For these reasons, she has significant difficulty with mobility and requires extensive assistance. Recent in home assessment of the patient's functionality indicated that the patient requires maximum assistance with support from other individuals for locomotion/ambulation. Furthermore, a clinic note revealed evidence of decreased sensation in the right head and bilateral lower extremities related to the patient's peripheral neuropathy. Her gait was noted to be slow, antalgic and ataxic. For these reasons, she is at a high risk for falling, especially when ambulating up or down stairs. Hence, the proposed treatment of Electric Stair lift is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: COPD, OSA, CAD
Treatment: Increase in PCA services to 24 hours/day, 7 days/week, split shift
The proposed treatment of an increase in PCA services to 24 hours/day, 7 days/week, split shift is not deemed medically necessary.

The patient is a male with a history of COPD (chronic obstructive pulmonary disease), obstructive sleep apnea, coronary artery disease, asthma, peripheral neuropathy and chronic skin ulcers. For these reasons, he requires assistance with the majority of his activities of daily living (ADLs). An appeal review requested for potential approval of an increase in PCA services to 24 hours/day, 7 days/week, split shift to offer increased assistance with the patient's ADLs.

The patient is a male with a history of COPD, obstructive sleep apnea (OSA), coronary artery disease (CAD), asthma, peripheral neuropathy and chronic skin ulcers. Per recent in home assessment of the patient's abilities to complete ADLs; the currently approved plan of PCA services 12 hours/day, 7 days/week was deemed to be sufficient to meet the patient's current needs. Although he was recently hospitalized with urosepsis, outpatient follow up documentation from his Primary Care Physician reveals that the patient is now back to his prior baseline. There is no recent documentation which demonstrates that the patient has sustained additional functional decline. For these reasons, the proposed treatment of an increase in PCA services to 24 hours/day, 7 days/week, split shift is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: ventricular fibrillation status post implantation of a cardioverter/defibrillator; 
 
Treatment: Nitrolingual 400MCG/SPR SPRAY

The insurer denied coverage for Nitrolingual 400MCG/SPR SPRAY. The denial is reversed. 

This patient is a man with a history of sleep apnea, obesity, ventricular fibrillation status post implantation of a cardioverter/defibrillator, hypertension, coronary artery disease status post coronary artery bypass graft (CABG), cardiomyopathy, cardiac arrest, chronic kidney disease, and diabetes mellitus.

He was evaluated by his doctor, who documented in the clinical record that the patient had been on the requested medication for almost 2 decades with good clinical efficacy, and that when he'd tried generic formulation of the requested medication, that there was insufficient clinical response. The patient suffered 2 heart attacks during the time when he was on generic nitroglycerin spray. 

The pharmacy allows for trials of preferred agents followed by authorization of non-preferred agents in the event of clinical intolerance. Due to prior trials of generic nitroglycerin spray, which resulted in ineffective control of angina, the use of the requested agent is appropriate and medically necessary. Moreover, given the suboptimal clinical response to generic formulation, resulting in 2 myocardial infarctions, use of generic formulation may confer further adverse health effects. Therefore, the use of brand name nitroglycerin spray is appropriate and medically necessary for this patient. 

The clinical documentation outlines that the patient has tried generic nitroglycerin spray, which resulted in ineffective clinical efficacy with respect to control of anginal symptoms, as well as 2 myocardial infarctions.  

Based on the above, the medical necessity for Nitrolingual 400MCG/SPR SPRAY is substantiated.  The insurer's denial is reversed
Appeal type: Medical necessity
Decision: Overturned

Respiratory System
DME

This is a male with obstructive sleep apnea. His apnea hypopnea index (AHI) was 17.5 on his sleep study. He has been intolerant of continuous positive airway pressure (CPAP) and was referred by his physician for an oral appliance. He was examined and there were no dental contraindications to an oral appliance. This treatment was previously denied due to lack of documentation.

The health plan's determination is overturned.

The oral sleep apnea appliance is medically necessary for this patient. 
According to the American Academy of Sleep Medicine: We recommend that sleep physicians consider prescription of oral appliances (OAs), rather than no treatment, for adult patients with obstructive sleep apnea (OSA) who are intolerant of CPAP therapy or prefer alternate therapy. OAs are equivalent to CPAP in reducing subjective daytime sleepiness in adult patients with OSA and improve quality of life. Mandibular advancement devices increase the area of the airway. They bring the soft palate, tongue, and hyoid bone forward and activate the masseter and submental muscles, preventing closure. All these effects reduce the AHI, increase the oxygen saturation, and improve the main symptoms of OSA. The patient has sleep apnea and has been intolerant of CPAP. The oral appliance is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Musculoskeletal
Inpatient stay

The patient is a pediatric patient who underwent surgery for a severe spinal deformity. The surgery was a "growing rod" procedure, in which two separate portions of the spine are exposed and instrumented, and then connected by a metal rod. Some correction of the curve takes place at the initial procedure, and later correction can be obtained by activating a mechanism to distract the hooks that are connected to the rod, lengthening and straightening the spine further. The health plan's determination of medical necessity is overturned in whole. A lengthy spinal surgery such as this requires a very substantial use of hospital resources for the surgery, spinal cord monitoring, monitoring of the patient after surgery, and early rehabilitation to allow the patient to be discharged to a home setting. It presents risks of blood loss, neurologic injury, ileus, and postoperative pain. Patients often require management in an Intensive Care Unit (ICU) for a day or two, and some will not be able to eat or drink for a few days after. Patients may not be able to stand or walk for a few days. Inpatient hospitalization is the standard of care and is medically necessary for this procedure.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Deep impinging bite 
Treatment:  Braces 

The proposed braces are medically necessary. 

The patient has a deep, impinging overbite with soft tissue damage to her palate.  This is an "automatic qualifier" according to the handicapping index scale.  The patient needs orthodontic treatment to correct this condition.