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

This is a patient with past medical history of CVA, craniotomy, seizures, diabetes, chronic cholecystitis, and status post cholecystectomy who presented with weakness and decreased oral intake. The patient was treated with IV fluids and potassium. A neurology consult was done. The health plan's determination was upheld. While the patient needed further care, it could have safely and effectively been provided at a lower level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Nocturia and Urinary Urgency
Treatment: 64590 Implanted Electrical Stimulator
Summary:  The implanted electrical stimulator is medically necessary.
The charge on the InterStim battery declines with time and does need periodic replacement, as in this case.  This patient had previously had an effective Interstim device, but the battery had become depleted.   There is sufficient documentation to determinate that medical necessity was met.
Appeal type: Medical necessity
Decision: Upheld

This patient was admitted to the hospital with ten days of fever, sore throat, fatigue, neck pain, headache and odynophagia.  She then developed joint pain and rash.  She had been exposed to a brother who was ill.  She had been seen in the Emergency Department (ED) six days earlier.  She started oral antibiotics one day prior to the current ED visit.  An exam showed a rash on the hand and swelling in the feet and small joints of the hands.  She had a temperature of 101.3 with a pulse of 102.  She was anemic with an elevated white blood cell (WBC) count with neutrophilia. The erythrocyte sedimentation rate and C-reactive protein were elevated.  An electrocardiogram and chest x-ray had no acute changes.  Considerations included viral syndrome, Still's Disease and Rheumatic Fever.  She was admitted and put on intravenous (IV) fluids, naproxen and IV antibiotics.  She is seen by Infectious Diseases and Rheumatology.  Her WBC count went up, hemoglobin and hematocrit dropped and her ferritin was high, consistent with Still's disease.  Work-up for other infections was negative.  She was placed on high-dose steroids.

The insurer denied coverage for the inpatient hospital services. The denial was upheld.

The hospital response notes that due to three ED visits in ten days and the severity of illness, acute inpatient care was needed.  Among the symptoms noted at the time of admission was lethargy.  Due to persistent symptoms, fever, and an elevated WBC count, outpatient care would not have been appropriate. The admission notes do not mention lethargy as a significant problem.  She had fever and mild tachycardia, but remained hemodynamically stable during the admission.  She rapidly responded to treatment.  Based on her status at the time of admission, care could have been provided at an Observation level.  The severity of illness did not meet guidelines for acute inpatient care.
Appeal type: Medical necessity
Decision: Overturned in Part

The patient had diagnoses of schizophrenia (SCZ) and Cannabis / synthetic cannabis or marijuana (K2) Use Disorder (CUD).  On admission to the hospital, he was noted to symptoms of disorganized behavior, loud speaking to self, making nonsensical comments, and showing poor insight and judgment.  The health plan's determination of medical necessity is overturned in part.  The patient on evaluation after being brought in by EMS was sufficiently disorganized and admission was necessary to do a diagnostic assessment as to what caused the patient's behaviors that had required police intervention on the day of admission.  Therefore, a partial inpatient hospital stay was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/ Circulatory Problems (Syncope)
Treatment: Inpatient Hospital

Summary: This patient was brought in by ambulance to the Emergency Department (ED) after a syncopal episode associated with a fall and loss of consciousness. He reported having similar episodes in the past without a full work-up. He was noted to have a lower lip laceration. The patient reports he may have hit his head on the sink. Computed tomography (CT) scan of the head was negative for acute pathology. He was admitted and impression was the syncopal episode was likely vasovagal. He was seen by oral surgery and lip laceration was sutured. The plan included echocardiogram and Holter monitor but the patient signed out against medical advice.

The insurer has denied coverage for the inpatient hospital admission as not medically necessary. The denial was upheld.

This patient had a history of hyperlipidemia and hypertension on aspirin, amlodipine and atorvastatin. At 03:00, while defecating, he felt hot and dizzy, followed by loss of consciousness, hitting his face on the sink. He presented to the ED later that morning, with initial vital signs at 10:04 blood pressure 131/78, heart rate 96, respiratory rate 16, temperature 98.20F, and oxygen saturation 100% on room air. Examination also revealed a 2 cm left lower outer lip laceration. Electrocardiogram at 10:16 was normal, as was a CT scan of the head. Laboratory test results from 10:37 included white blood count 9.3, hemoglobin 14.4, creatinine 1.4 and troponin <0.012. The lip laceration was repaired at 20:05 by a surgical consultant using local anesthesia. Evaluation for causes of his syncope was planned, including echocardiography, but he signed out against medical advice at 11:09. There is no evidence that this patient required an acute inpatient level of care to evaluate or treat his syncope or laceration of his lip. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders (Psoriasis)
Treatment: Pharmacy/Prescription Drugs (Otezla)

Summary: This patient has moderate to severe plaque type psoriasis. Her medical history is that of hypertension. The patient has tried and failed triamcinolone and calcipotriene. The psoriasis is primarily on the lower legs. The patient has been using Otezla samples, doing well with no adverse effects, and is requesting plan approval for continuation of therapy of Otezla.

The insurer has denied coverage for Otezla tablets as not medically necessary. The denial was upheld.

Review of the clinical note does not make mention of any gastrointestinal (GI) complaints. Of the insurer's approved therapies, cyclosporine would not be appropriate given her diagnosis of hypertension. However, it is unclear why either phototherapy or methotrexate could not be utilized. As per Up to Date "Severe psoriasis requires phototherapy or systemic therapies such as retinoids, methotrexate, cyclosporine, apremilast, or biologic immune modifying agents. Biologic agents used in the treatment of psoriasis include the anti-tumor necrosis factor [TNF] agents adalimumab, etanercept, and infliximab, the anti-interleukin (IL)-12/23 antibody ustekinumab, and the anti-IL-17 antibody secukinumab. Improvement usually occurs within weeks." The selection of an agent to treat severe psoriasis is somewhat limited by a lack of head to head trials particularly of the newer agents. That being said, several studies using the published data have provided guidance regarding their relative efficacy. Thus, while Otezla is Food and Drug Administration (FDA) approved for plaque psoriasis, the data do not support its benefit in comparison to agents available. Otezla tablets are not considered medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Trauma (Gunshot wound)
Treatment: Inpatient Hospital Admission

Summary: This patient presented to the Emergency Department (ED) following gunshot wounds to the chest. As noted in the ED note, the patient presented alert and oriented and in acute discomfort. He had tenderness around the subxiphoid and left flank. He had 2 penetrating wounds located subxiphoid and mid-axillary on left. The concern was for thoraco-abdominal trauma. Chest X Ray (CXR) revealed bullet fragments and subcutaneous emphysema overlying the anterolateral aspect of the lower left hemi-thorax. Computed tomography (CT) of the abdomen revealed subcutaneous emphysema in the anterior abdominal wall in the left upper quadrant. Shrapnel fragments were present in the subcutaneous soft tissue. A 1 cm hypodense indeterminate lesion in the right lobe of the liver was seen. The impression by trauma surgery was that there was no evidence of acute abdominal or pelvic organ injury. The patient was admitted to trauma surgery and kept NPO (nothing by mouth).

The insurer has denied coverage for the acute inpatient hospital services as not medically necessary. The denial was upheld.

Based upon the records provided, this reviewer agrees that the inpatient admission was not justified at the acute level of care as the patient presented with a gunshot wound to the chest with two penetrating wounds located in the subxiphoid and mid-axillary on the left. CT scan of the abdomen and chest were unremarkable for pathology. Echo was negative. Serial exams were unremarkable and the patient was discharged. As noted in the discharge summary the patient was observed with serial exams. He was stable for a 23 hour observation without an acute admission. According to MCG General Recovery care multiple trauma GRG: PG-MTR (ISC GRG) hospital admission is indicated when patients with significant multiple trauma require inpatient care for 1 or more of the following: Major surgical and post procedural care; Non-operative care of significant injury, such as observation. This patient did not have any indications above that would have required inpatient admission rather than just observation. He sustained Gun Shot Wound which proved to be superficial as the CXR, CT of the abdomen and pelvis, echocardiogram, and lab tests did not reveal any significant injury. The patient was stable for a 23 hour observation and did not need an acute inpatient hospital stay.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Infectious Disease (Panniculitis), Respiratory System (Asthma)
Treatment: Inpatient Hospital

Summary: This patient with a past medical history significant for hypertension, asthma, chronic infra-umbilical hernia, morbid obesity, and bipolar disorder presented to the emergency department (ED) with complaints of cough, shortness of breath, and abdominal pain. Vital signs on presentation included: Temperature 37.2 C, Blood Pressure 155/81, Pulse 90, Respiratory Rate 18, oxygen saturation 100%. Laboratory values were notable for the following: WBC-5.7, Hgb-8.4, Hct-27.5, creatinine-0.73, glucose-94. The patient was empirically started on intravenous antibiotics (Unasyn) for an abdominal wall cellulitis. A chest x-ray was negative. Computed Tomography (CT) scan of abdomen/pelvis showed only fatty liver infiltration and a left adnexal cyst. Their clinical diagnosis was panniculitis or inflammation. All cultures were negative. The patient remained afebrile, hemodynamically stable and improved clinically. The patient was discharged to continue oral antibiotics (Augmentin) as an outpatient.

The insurer has denied coverage for the inpatient hospital admission as not medically necessary. The denial was upheld.

According to the documentation, the patient presented with some non-specific upper respiratory symptoms believed to be an asthma exacerbation and panniculitis. Otherwise, she was afebrile, hemodynamically stable, with unremarkable laboratory results including WBC. The chest x-ray was negative and there was no evidence of a systemic infection. The patient was diagnosed with panniculitis - a non-specific inflammatory dermatologic finding. She had some chronic issues including an adnexal mass and infra-umbilical hernia - both appropriately recommended for follow-up as an outpatient. Based on above findings, patient was stable for outpatient management following evaluation in the emergency department. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with a history of Crohn's disease who was admitted to the hospital. He presented with abdominal pain and bloody bowel movements. He had a complicated history of poorly controlled Crohn's disease. He stated that he had been having bowel movements with blood for the past one week. He described the abdominal pain as occasionally being sharp and severe pain. The health plan's determination of medical necessity is overturned.  Inpatient medical care was medically necessary for this patient. Patients with an acute flare of inflammatory bowel disease are usually treated at the inpatient level because of the increased risk of complications including bowel perforation, need for surgical intervention or bowel resection, and infection. It was reasonable for the patient to be considered to be having an acute flare given his increased pain and blood bowel movements. These patients require a higher level of care because of the high risk of an adverse outcome during admissions for acute flares.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity history of morbid obesity (initial body mass index 41.2), gastroesophageal reflux disease, vitamin D deficiency and obstructive sleep apnea.  
Treatment: Surgical Services

The insurer has denied coverage for bariatric surgery. The denial was reversed.

This patient has morbid obesity (initial body mass index 41.2).  The patient has participated in an all-inclusive weight loss and metabolic center program, beginning January 2019.  Her weight on 01/31/19 was 251.6 pounds.  Notes indicate the patient received nutrition counselling and behavioral therapy.  Her weight on 04/03/19 was 241.4 pounds. 

The patient meets the standard criteria for bariatric surgery, determined in the 1990s with her body mass index (BMI) over 40 Kg/M2.  There are several operations which are recognized by national societies and the sleeve gastrectomy is one of those operations.  In question, in this case, is the fact that the patient did not complete the "insurance required" six-month weight loss program.  It is important to state that this is an insurance mandate.  

The concept of pre-operative "nutritional counseling" has been around for many years and embraced by most insurance companies.  Through the years the "need" for or the "effect" of or "benefit" of the counseling has been studied and reported on.  As far back as 2006, a study(1) showed there was no benefit from a mandated preoperative dietary counseling program and in fact there was an obstacle to patient access to care.  Other studies(2) documented that patients who were required to undergo a mandated preoperative weight loss program "fared no better in terms of weight change post surgically and, surprisingly, presurgical weight gain predicted better postsurgical weight loss outcome."
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive sleep apnea
Treatment: Surgical Services

Summary: Reviewer #3: This patient with a history of OSA, allergic rhinitis, chronic sinusitis, deviated septum, hypertrophy of nasal turbinates, and nasal valve collapse. Per the office visit note with the Otolaryngologist, the patient had a BMI of 26.45 and an AHI of 51 events/hour with desaturations to 64% on a sleep study evaluation. There was no evidence of complete concentric collapse at the nasopharynx, velopharynx or soft palate. There was anterior posterior collapse. The patient had CPAP, but was unable to tolerate it due to discomfort, and bloating and gas, even with trying a variety of masks.
 
The insurer has denied coverage for hypoglossal nerve stimulation or Inspire upper airway stimulation system as investigational. The denial was reversed because the requested procedure is likely to be more beneficial than any other existing standard health service.

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome. CPAP is a first-line treatment for OSA, but for patients that cannot tolerate a CPAP, the upper hypoglossal stimulator would be a second-line treatment. This patient has failed CPAP and the literature supports that this request would result in improvement in health outcome. The hypoglossal nerve stimulation or Inspire upper airway stimulation system has final approval from the appropriate regulatory bodies for this diagnosis (OSA). The carrier's denial of hypoglossal nerve stimulation or Inspire upper airway stimulation system for the patient's obstructive sleep apnea should be reversed.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive sleep apnea
Treatment: Surgical Services

Summary: Reviewer #2: This patient is diagnosed with OSA as well as other conditions such as chronic sinusitis, deviated septum, and hypertrophy of nasal turbinates. The letter of medical necessity indicated the patient has had a trial and failure of CPAP which is the gold standard of care therapy for patient with OSA. The patient was unable to tolerate the device and has trialed a variety of masks. The patient has a lot of discomfort in his nose. Given the severity of OSA he is not a viable candidate to utilize an oral appliance. The physician recommended the patient undergo surgical intervention for upper airway stimulation. The patient has also undergone a sleep endoscopy that confirms he does not have complete concentric collapse. The physician indicated the patient was an excellent candidate for stimulation of the upper airway. The patient did undergo a prior polysomnogram in 2017 which revealed the patient has severe OSA.

The insurer has denied coverage for hypoglossal nerve stimulation or Inspire upper airway stimulation system as investigational. The denial was reversed because the requested procedure is likely to be more beneficial than any other existing standard health service. 

Current US Food and Drug Administration (FDA) eligibility criteria for upper airway stimulator implantation includes age  >22 years, moderate or severe OSA (defined as AHI 20 to 65 events/hour), predominantly obstructive events (defined as central and mixed apneas =25 percent of AHI), CPAP failure (defined as AHI >20 on CPAP) or intolerance (defined as use <4 hours per night, five nights per week; or unwillingness to use), no complete concentric velopharyngeal collapse on screening sleep endoscopy, and no other anatomical findings that would compromise performance of the device (eg, tonsil size 3 or 4). Upper airway stimulator implantation is not recommended for patients with a BMI >32. Within the documentation it does appear this patient is an appropriate candidate to receive the requested device. The scientific evidence and peer reviewed literature does support a result of improvement in health outcome. The patient is noted to be a good candidate. Therefore, as the patient meets the above given the severity of disease as well as CPAP intolerance and evidence of new complete concentric and a low pharyngeal collapse on screening sleep endoscopy this would be considered the best available treatment for this patient at this time.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive sleep apnea
Treatment: Surgical Services

Summary: Reviewer #1: This patient has a history of obstructive sleep apnea (OSA) with history of allergic rhinitis, chronic sinusitis, deviated septum and hypertrophy of the nasal turbinates and nasal valve collapse. The patient had a Body Mass Index (BMI) of 26.45. The patient had a history of severe OSA with an Apnea Hypopnea Index (AHI) of 51 events per hour and a desaturation of 64% on sleep study 2017. The patient has tried Continuous Positive Airway Pressure (CPAP) but was unable to tolerate usage due to discomfort from the mask. The patient has tried a variety of mask interfaces. The patient also had a lot of difficulty with discomfort in the nose with positive pressure air and suffered with bloating and excessive gas. The patient had a favorable sleep endoscopy without circumferential collapse in the Velopharynx/retro-palatal space and wishes to proceed with a hypoglossal nerve stimulator placement. There are limited alternative treatments available. The patient is not a candidate for oral appliance therapy. 

The insurer has denied coverage for hypoglossal nerve stimulation or Inspire upper airway stimulation system as investigational. The denial was reversed because the requested procedure is likely to be more beneficial than any other existing standard health service.

The documentation indicates that the patient did have findings of obstructive sleep apnea. The patient has been intolerant to CPAP. The patient is not a candidate for oral appliance therapy. The sleep endoscopy did not show findings of complete concentric collapse.  The patient was over the age of 22.  The patient had a BMI of 26.45. The scientific evidence and peer-reviewed literature does support a result of improvement in health outcome. The hypoglossal nerve stimulation or inspire upper airway stimulation system does have final approval from the appropriate regulatory bodies for the diagnosis. The patient is a good candidate for hypoglossal nerve stimulation, or inspire upper airway stimulation. The hypoglossal nerve stimulation or inspire upper airway estimation system is the best available treatment for the patient at this time. Therefore, the requested hypoglossal nerve stimulation or inspire upper airway stimulation system is likely to be more beneficial than any other standard treatment/procedure for the patient at this time.
Appeal type: Medical necessity
Decision: Upheld

This patient had a history of diabetes, hypertension, and glaucoma. Home medications included metformin, glipizide, losartan, brimonidine tartrate, dorzolamide and bimatoprost eye drops. The patient noted elevated blood pressure for several days and awoke at 0100, took his blood pressure which was 200/104 and then presented to the emergency department at 0830 with complaints of chest pain since 0500, as well as persistently elevated blood pressure. Initial vital signs at 0840 included blood pressure 211/113, heart rate 70, and oxygen saturation 97%. Blood pressure at 1032 was 186/88 and 196/97 at 1845 and he received atenolol 50mg, amlodipine 10mg, and with subsequent blood pressure 156/87. The nurse note at 0053 indicates that systolic blood pressures were 120 to 130. Laboratory tests results from 0905 included white blood cell count 6.0, hemoglobin 15.9, creatinine 1.11, troponin 0.00 and brain natriuretic peptide less than 54. Chest x-ray was normal and echocardiography revealed left ventricular hypertrophy with normal left ventricular systolic function, no aortic dilation, and orate/diastolic dysfunction. 
The insurer has denied coverage for the inpatient hospital services. The denial was upheld.
There is no evidence that this patient required an acute inpatient level of care to evaluate his chest discomfort or to treat his hypertension. This should have been completed in the emergency department or an observation level of care, followed by outpatient management.