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

This patient presented for evaluation and treatment in the area of tooth #4 which was deemed non-maintainable due to periapical pathology and periodontal involvement.  Upon extraction an oroantral/sinus communication was identified.  The dentist recommended sinus augmentation and graft procedure for ridge preservation to address the defect and sinus communication.
  
The insurer has denied coverage for Sinus augmentation (D7951) and Bone replacement graft for ridge preservation per site (D7953). The denial was reversed.

Based on the radiographic images it is noted that tooth #4 is non-maintainable due to periapical pathology extending into the sinus as well as periodontal bone loss.  To address the documented sinus communication and in addition to maintain ridge height for future prosthetic rehabilitation of the area, the dentist has recommended the aforementioned grafting procedures.  Sinus augmentation and ridge preservation procedures with bone grafting are an accepted standard of care service in dental practice for these clinical circumstances and substantiated by peer reviewed literature.  As this is a standard treatment the graft procedures for sinus augmentation and ridge preservation are deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal (Abdominal pain, Chronic pancreatitis)
Treatment: Inpatient Hospital

Summary:  This patient with a history of diabetes and chronic pancreatitis presented to the Emergency Department (ED) with abdominal pain and vomiting. She had a glucose of 573, was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. There was no leukocytosis. Acute Coronary Syndrome (ACS) was ruled out. Insulin was given and the glucose levels were controlled. Gastritis was treated with Protonix and Metoclopramide. Intravenous (IV) hydration was given. The lipase was normal. A Computerized Axial Tomography (CAT) scan was consistent with chronic pancreatitis, but there was no evidence of acute pancreatitis. Oral pancreatic enzymes were given. An endoscopy revealed gastritis. There was a plan for an outpatient endoscopic retrograde cholangiopancreatography (ERCP). 

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

Clinical indications for admission for pancreatitis (M-250) include having pancreatic enzymes greater than 3 times the upper limit of normal and characteristic abdominal imaging for acute pancreatitis. This patient did not have an elevated lipase and the CAT scan was consistent with chronic pancreatitis, not acute pancreatitis. The patient also did not have hemodynamic instability, hypoxemia, a 3-fold rise in serum creatinine, or a severe electrolyte abnormality. Clinical indications for admission for undiagnosed abdominal pain (M-05) include the need for surgery that cannot be performed on an outpatient basis and peritoneal signs. The patient did not have these conditions. She also did not have intestinal obstruction, bacteremia, or a severe electrolyte abnormality. This patient had abdominal pain and vomiting. ACS could have been excluded in the ED with serial troponins and IV hydration, proton pump inhibitor therapy and antiemetics could have been given in the ED. The hyperglycemia responded to insulin treatment. The patient was stable for an outpatient working, including the endoscopy. The chronic pancreatitis could have been treated with pain medications and pancreatic enzymes as an outpatient. She did not meet MCG criteria for admission for either pancreatic disease or undiagnosed abdominal pain. She could have been managed with observation status.
Appeal type: Medical necessity
Decision: Overturned in Part

This patient was admitted to inpatient mental health treatment after going to the emergency department for syncope as she had reported bizarre behavior, auditory hallucinations, mumbling to self, paranoid delusional thinking, disorganized thinking, non-compliance, suicidal ideation, self-injurious behavior including cutting self, agitation, restlessness, poor impulse control, judgment, and insight. She had a diagnosis of Schizophrenia. She had past reported psychiatric hospitalizations. She took Risperidone, Prolixin, Depakote, and Klonopin.

The insurer denied coverage for continued inpatient mental health treatment. The decision was modified.

The American Psychiatric Association Practice Guidelines for the Treatment of Patients with Schizophrenia reports that the least restrictive level of care for safe and effective treatment is appropriate and also reports that patients with hallucinations, delusional or disorganized thinking or behavior, suicidal or homicidal intent or plan, or severe agitation or aggression are candidates for inpatient treatment. The denial was partially approved because the patient still had reports of disorganized thought process and illogical thought process as well as poor judgment and insight so she still had psychotic symptoms which required continued inpatient psychiatric hospitalization. The subsequent days of the admission were denied because there were no notes reporting hallucinations, delusional thinking, illogical or disorganized thought process, suicidal or homicidal ideation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: pyelonephritis with sepsis
Issue under review: inpatient admission
Summary: Yes, the proposed treatment, inpatient admission, was medically necessary.
The patient does not fit the profile of a patient with simple urinary tract infection (UTI) or pyelonephritis that can be treated as an outpatient as given by the Infectious Diseases Society of America (1).  The patient had signs of sepsis (fever, tachycardia, tachypnea), requiring IV fluids, making this a more complicated case.  Furthermore, the patient had multiple bouts of vomiting, necessitating multiple doses of IV Zofran. Patients who cannot tolerate oral (PO) intake are not good candidates for outpatient therapy (vomiting medications, leads to subtherapeutic doses, and potential worsening of disease).  Thus, this admission was warranted, supported by IDSA guidelines, as well as standard of care.  Failure to admit such a patient can lead to loss of function, sepsis, deep abscess, or death.
Appeal type: Medical necessity
Decision: Upheld

The patient has a history of hypertension high cholesterol, coronary artery disease (CAD) and gastroesophageal reflux disease (GERD). The patient presented to the hospital after being found down with abrasions and swelling on the face with post syncope confusion. 

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient presented with syncope and work up was concerning for a seizure due to the post syncope clinical findings. There was no documentation to confirm that the patient had a heart attack, abnormal rhythms or unstable hemodynamic status at the time of presentation that would have required an inpatient acute admission. The initial blood tests, consultations and testing with completion of the work up could have been done at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Acute Myeloblastic Leukemia (AML)
Issue under review:  Mylotarg dosed every four weeks 

Determination:
The Mylotarg dosed every four weeks  is not medically necessary.

The patient in this case was diagnosed with acute myeloid leukemia (AML).  He was found to have FLT3-ITD and was treated with daunorubicin, cytarabine and midostaurin.  Day 21 bone marrow revealed persistent disease.  He was enrolled on a clinical trial testing a novel FLT3 inhibitor and eventually transitioned to salvage therapy on another clinical trial.  This was complicated by severe infusion reaction.  Following that he started on azacitidine and sorafenib, following which he was treated with additional chemotherapy.  Despite those treatments he has had persistent refractory AML with partial response to decitabine and sorafenib.  His physician has now recommended changing to decitabine and gemtuzumab ozogamicin (Mylotarg).

The combination of Mylotarg and decitabine is not a standard treatment for relapsed/refractory AML based on the National Comprehensive Cancer Network (NCCN) guidelines.  This agent is also not FDA approved for use in combination with decitabine, but rather is FDA approved as a single agent.  There is only limited experience using Mylotarg in combination with decitabine.  In a phase II trial this combination was found to have some degree of efficacy in patients with relapsed/refractory AML.  However, there is no evidence that adding Mylotarg after prior treatment with decitabine can further improve outcomes compared to those with decitabine alone.  Given lack of sufficient supporting evidence and given lack of NCCN endorsement, this treatment cannot be considered medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who has been assigned a diagnosis of psoriatic arthritis . Although he has a skin rash, it is not clear it is psoriasis as opposed to eczema or another papulosquamous eruption He does use topical Clobetasol on the rash. His pattern of joint involvement is also described as "not typical for psoriatic arthritis" and he has not had synovitis or dactylitis. 
The health plan's determination of medical necessity is upheld.
It is not clear that the patient has psoriatic arthritis. He has dysesthesia of the hands and no synovitis; no synovitis has ever been reported. It is also not clear that the patient has current liver issues His last several transaminase studies were normal despite the use of nonsteroidal anti-inflammatory drugs (NSAIDS). There is no documentation that the patient has actually tried and failed full dose Sulfasalazine as the progress notes do not document such a trial nor does the prior authorization form.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Obstructive Pulmonary Disease
 
Treatment: Advair Diskus 100-50 microgram (mcg) Blister Inhalation Device

The insurer denied the Advair Diskus 100-50 microgram (mcg) Blister Inhalation Device.  The denial was upheld.   

This is a female patient with a medical history of chronic obstructive pulmonary disease (COPD)/asthma, gastroesophageal reflux disease (GERD), obesity, hypertension and hypothyroidism.  The patient presented to her treating pulmonologist with complaints of a dry cough.  A physical exam was performed that revealed her lungs were clear, her oxygen saturation was 96%, and she was hemodynamically stable.  Advair and Albuterol were prescribed.

As per insurance company, the preferred Generic Brand of the same medication (Advair) or long-acting beta agonist inhaled corticosteroid (LABA ICS) combination which was on their formulary.  The patient was recommended Generic Fluticasone and Salmeterol which was available through several manufacturers.  This combination / formulation is exactly the same as in brand name Advair.  They are biologically equivalent and exactly the same pharmacologically.

The other LABA/ ICS Combinations on Fidelis Formulary are:

1) Wixela - Fluticasone + Salmeterol 2) Breo - Fluticasone + Vilanterol 3) Dulera - Mometasone + Formoterol

Any of these are also equivalent and could be used.

It has not been documented that this patent cannot tolerate these drugs or that she is allergic to them.  There are no contraindications to the use of the suggested formulary medication.  The prior denial of Advair (Brand Name) coverage is upheld.

The insurer acted reasonably, with sound medical judgment and in the patient's best interest. 

The carrier's denial of coverage for Advair Diskus 100-50 microgram (mcg) blister inhalation device is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

This is a patient who was admitted to Inpatient Services (IS) on with diagnoses of Major Depressive Disorder (MDD), severe without psychosis, Alcohol Use Disorder (AUD) and Generalized Anxiety Disorder (GAD).  The question is whether the requested treatment was medically necessary for this patient.  Case notes document that the patient became increasingly depressed and overwhelmed in the months prior to admission.  She experienced numerous stressors including marital strain, household disarray, self-isolating, and the challenge of parenting a 5-year old and an infant.  She experienced daily suicidal ideation, anergia, lack of motivation, poor appetite, excessive sleeping, avoidance of social and other activities, rumination, and poor activities of daily living (ADLs).  She felt helpless and hopeless.  She had been self-treating with alcohol and promiscuity.  She has struggled with depression since her teen age years.  She required one prior psychiatric admission.  Upon admission her admitting medications were reviewed, and she was placed on Prozac, Abilify, Trazodone, and Klonopin.  Her Effexor was gradually discontinued and finally stopped.  In addition to her psychopharmacology, she was treated with individual, couples, and group therapy.
The patient was at risk for decompensation because of her multiple psychosocial stressors that she had not learned to cope with.  Her disorder was chronic and required a prior psychiatric hospitalization. 
This patient has a long-standing depressive disorder.  While not psychotic, her MDD and comorbid AUD and GAD were functionally impairing and associated with continuous suicidal ideation.  Her psychosocial stressors were high.  When MDD is associated with AUD and GAD, it is more complex to treat.  Case notes document that she was feeling sedated, overwhelmed by her stressors, foggy in mentation.  Her sleep was only intermittent.  Poor sleep is often associated with incompletely treated MDD.  She was irritable, experienced insomnia, was dysphoric in mood, with a high level of psychiatric symptomatology.  Her attending clinician noted that continued inpatient hospitalization was necessary for continued progress.  She was not on that date yet able to identify the factors related to her decompensation or how to improve her coping skills.  The patient was still irritable (also a sign of untreated depression), dysphoric, anxious, restless, feeling "sick."  Her final dose of Effexor was discontinued, and she required time to assess any serious side effects of discontinuation, common with Effexor.  She returned to her normal baseline state, without suicidal ideation or homicidal ideation without psychosis, with improved insight and judgment.  Poor social attachment is associated with increased suicide risk.  This patient experienced marital and parenting difficulties (1).  This patient experienced GAD which made her MDD more complex to treat (2).  Substance use in serious mental disorders results in worse outcomes.  This patient had an alcohol use disorder, which she used to cope with her MDD (3).
Appeal type: Medical necessity
Decision: Upheld

This is a patient who presented to the hospital for a scheduled laparoscopic cholecystectomy. At the time of presentation, the patient was without a fever and her vital signs were normal. She was treated with a laparoscopic cholecystectomy. The operative dictation and the anesthetic record describe an uncomplicated cholecystectomy procedure.
The patient was treated with post-surgical monitoring, intravenous (IV) fluids, IV analgesia, and antiemetics. The immediate post-surgical recovery was notable for dizziness. On post-operative day #1 following surgery, the patient had stable vital signs. Her pain was controlled. The diet was advanced. The patient remained clinically stable and was discharged from the inpatient setting.
At issue is the medical necessity of the inpatient stay.
The requested health service/treatment of Inpatient Hospital Admission  was not medically necessary for this patient.
This was an otherwise healthy female who presented to the hospital with cholelithiasis. There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care. Additionally, there is no documentation of failure to achieve discharge criteria, conversion to open surgery, care for comorbidities, procedural complications, or any other condition requiring inpatient admission.
This patient was admitted to the hospital with the diagnosis of cholelithiasis/biliary colic. She underwent an uncomplicated laparoscopic cholecystectomy procedure. There were no peri-operative complications or other clinical issues. She remained stable and was discharged from the hospital.
Inpatient care is indicated when there is right upper quadrant pain, and systemic signs of inflammation (fever, C-reactive protein greater than (>) 10, white blood cell count (WBC) count > 10 thousand [K]). Inpatient admission is also indicated for acute cholangitis, common bile duct obstruction, vomiting that is severe or persistent, dehydration that is severe or persistent, hemodynamic instability, severe pain requiring acute inpatient management, signs of intestinal obstruction, bacteremia, need for percutaneous or open procedures, or other condition that requires inpatient admission.
In this case, none of these indications existed to justify an inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

The patient has a history of asthma and came to the emergency department (ED) for progressive dyspnea and chest tightness, and a minimally productive cough. The patient had been hospitalized the month prior with an asthma flare. At time of ED presentation, the patient was still on prednisone from the recent admission.

The health plan's determination is overturned. The inpatient stay was medically necessary. The met patient met generally accepted criteria for an inpatient admission for close monitoring for clinical deterioration.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Syncope
Issue under reivew: Inpatient admission

Determination:
The inpatient admission was medically necessary.

The female patient presented to the ER for further evaluation/management of syncope. Her intake vitals were afebrile, hemodynamically stable with no evidence of febrile temperature, malignant hypertension, profound hypotension, severe tachycardia or hypoxemia on room air. However, her examination was notable for rhonchi and pulmonary wheezing. Furthermore, Laboratory and ECG testing was notable for critical hypokalemia of 2.6 and severely prolonged QT interval of 497 ms. 

The medical records indicate that this patient was admitted to the inpatient medical service in stable condition, where she received treatment with nebulized bronchodilators, IV potassium for electrolyte repletion along with supportive care with IV fluids and continued cardiac monitoring. She responded well to the prescribed therapies, and she was subsequently discharged in stable condition. 

Given the presence of critical hypokalemia and severely prolonged QT interval, this patient's care could not have been safely furnished in a less intensive setting without adversely affecting patient's safety or outcome. For these reasons, the proposed treatment of Inpatient admission is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever
Issue under review: Inpatient admission

Determination:
The inpatient admission was not medically necessary.

The patient was afebrile in the ED and remained so during her hospital stay.  Blood cultures were negative.  Her WBC count was within normal limits.  The spine CT did not show a clear infection.  Her spinal cord stimulator incision appeared well healed. Her neurological examination showed 5/5 strength, gait normal, intact cranial nerves, and sensation within normal limits.  There was no source of infection found during the hospitalization.  Spinal cord stimulator infections are typically associated with incision pain and wound erythema.  They occur in approximately 2.45% of patients and are usually caused by Staph aureus.  Explant of the device is typically needed (Bendel et al., 2017).

The level of care provided could have been rendered at a lower level of care than acute inpatient status.  Thus, based upon the records provided, the Inpatient admission was not medically necessary.

As there was no infectious source identified, and the patient was afebrile with a stable neurological examination, the Inpatient admission was not medically necessary.  The level of care provided could have been delivered at a lower level of care than acute inpatient status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity, OSA, GERD
Treatment: Surgical Services and Inpatient Hospital

Summary: This patient has a history of morbid obesity, obstructive sleep apnea (OSA) requiring continuous positive airway pressure (CPAP) and gastroesophageal reflux disease (GERD). The patient has been 100 pounds overweight for six years and has tried numerous diet and exercise attempts. The patient's body mass index (BMI) was 40.03. She has attended monthly nutrition and exercise counseling sessions.  A polysomnogram study showed an Epworth score of 4 and an apnea hypopnea index of 12.2 events/hour, with the lowest saturation 86%.  The bariatric surgeon is requesting approval for laparoscopic sleeve gastrectomy surgery. 

The insurer has denied coverage for CPT 43775 (laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (i.e. sleeve gastrectomy) and inpatient stay. The denial was reversed.

Based upon the records provided and Milliman Care Guidelines, the patient does meet the criteria and indications for bariatric surgery for sleeve gastrectomy. At the most recent visit, the patient had a BMI of 40.03 and intermittently goes below this. She does have sleep apnea/OSA. She has undergone appropriate evaluations including psychological and nutrition evaluations, and has followed a medically supervised program.  She does meet the BMI criteria and she does have significant co-morbidities.