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

This is a patient with a past medical history significant for a thoracic (T) 6 complete spinal cord injury resulting in paraplegia. Documentation also notes that the patient has chronic low back pain, lower extremity spasticity, urinary tract infections and irregular and difficult bowel movements. At issue is whether the ReWalk Personal lower extremity robotic exoskeleton is  medically necessary for this patient. The health plan's determination is upheld
This is a patient with a T6 complete spinal cord injury. He suffered this injury in October 2018. Two, 60 minute, ReWalk trials occurred on. Based on the review of the submitted documentation, research and medical literature, the requested Rewalk Personal 6.0 Lower Extremity Robotic Exoskeleton is not necessary to meet the patient's basic health needs nor is it standard of care in spinal cord injury patients who do not have adequate truncal support.
Documentation fails to support that the patient is utilizing the ReWalk with good form. Furthermore, documentation failed to show that the patient had the necessary truncal support to safely execute use of this exoskeleton. While initial evaluation was noted, this did not document trial of the exoskeleton. Additionally, trials failed to show adequate ability to safely maneuver such a device. The patient continued to require maximal assistance (MAXA) to initiate gait. He also required moderate assistance (MODA) for sit to stand transfer and minimal assistance (MINA)-MODA for turning. Furthermore, while the first trial did document ambulation of 150 feet (') this was with MAXA for anterior weightshifting. Also, while the patient was noted to ambulate 400 steps , the documentation failed to state the level of assist but only noted that the patient improved. The use of an exoskeleton in a T6 complete spinal cord injury is not supported in a patient that does not have strong truncal support. Research shows that most recovery from spinal cord injury occurs within the first one to two years.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain 
Treatment: Inpatient admission 
The inpatient admission was not medically necessary. 

The patient is a male. He presented to the hospital with acute abdominal pain.  He had comorbid health conditions that included diabetes, hypertension, obesity, hyperlipidemia, and sleep apnea. 

The patient's vital signs were normal at the time of presentation.  His evaluation in the ED identified abdominal tenderness, an elevated WBC (white blood cell) count of 17.7 K, and gallstones noted on ultrasound and CT scan.  The complete metabolic panel was normal.  There was no gallbladder wall thickening or pericholecystic fluid on imaging.

The patient was admitted to the hospital and was treated with antiemetic medications, pain medications and antibiotics.  The next day, the WBC count was 13 K.  He underwent laparoscopic cholecystectomy on that day.  The operative dictation describes standard technique of cholecystectomy.  The pathology report describes gangrenous cholecystitis.  

The post-operative course was uncomplicated.  The patient was in no acute distress and had normal vital signs.  The WBC count was elevated at 14 K.  He remained clinically stable as documented in a progress note.  He was transitioned to oral pain medications and diet.  He was discharged from the hospital on the following day.  

The health plan rationale for denial is that this procedure is considered to be an ambulatory procedure and there is no documentation of complications, uncontrolled pain, nausea or vomiting that mandated inpatient admission.  

This patient is a man who presented to the ED with abdominal pain.  His evaluation yielded the diagnosis of cholecystitis.  The operation (laparoscopic cholecystectomy) was performed. The operative note describes an uncomplicated operation.  This patient manifested no post-surgical complications.  

The patient remained clinically stable following the laparoscopic cholecystectomy procedure.  Based on the available medical record the medical necessity of inpatient admission is not established.  The records support the health plan contention that this procedure could have been completed in the outpatient (ambulatory) setting.  This level of care would have allowed for provision of medical treatment, diagnostic work up, operative treatment, and post-surgical care.  Overnight stay for post-surgical monitoring could have been provided with an ambulatory level of care with brief extension based on the MCG.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Endocarditis

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission. The denial is upheld.

This patient is a male who presented to the Emergency Department (ED) complaining of pain in his hand. He complained of right-hand numbness and pain for the past five days. He reported using some crystal meth and GHB one week prior to presentation which led to him passing out a few times during that night; he was not sure of what happened subsequently. He claimed he woke up feeling funny in his hands. He noted progressive worsening numbness in his hands and swelling and bruising in the fingertips, right more than left, which prompted him to visit a clinic for further evaluation. He denied fever, chills, pain, shortness of breath, nausea or vomiting. The patient's past medical history included an immune disorder. The patient had a prior history of a viral infection for which he had completed therapy six months ago.

Blood cultures in an aerobic bottle showed growth of Staph epidermidis. His physicians did not think that there was consistent proof of endocarditis. His physician thought this was most likely a contaminant. They were to discharge the patient on no antibiotics and do repeat blood cultures and follow-up with an echocardiogram. Given the patient's history of polysubstance abuse and the possibility of endocarditis, the patient was started on vancomycin treatment empirically. The plan was to follow up with an echocardiogram.

Major criteria for infective endocarditis [IE] include Blood culture positive for IE. Evidence of endocardial involvement. Minor criteria include Predisposition, predisposing heart condition, or injecting drug user [IDU] Fever, temperature >38C. Vascular phenomena, major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and Janeway lesions. Immunological phenomena: glomerulonephritis, Osler nodes, Roth spots, and rheumatoid factor. (1)

This patient presented to the hospital with a complaint of pain in his hands. He also noted numbness in his hands and swelling and bruising in his fingertips. The patient is a known drug user and admits to using crystal meth recently. He has a past medical history of an immune disorder and syphilis, both conditions having received treatment. The patient was admitted as an inpatient because his physicians were concerned that he had bacterial endocarditis because they suspected that the lesions on his fingertips represented signs of bacterial endocarditis.  

The literature cited shows typical features of endocarditis which are not present in this patient. The inpatient hospital admission was not medically necessary. He could have been managed in an observation unit, since the literature cited shows that these units may be used for other medical conditions other than chest pain. For these reasons, the denial of coverage for the inpatient hospital admission should be upheld.

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

Diagnosis: Alzheimer's dementia
Treatment: Consumer directed personal assistance services 50 hours per week

Summary:
This is a female with a history of Alzheimer's dementia. Due to this condition, she requires assistance with the majority of her activities of daily living (ADLs). The currently approved plan of 35 CDPAS hours/week is not sufficient to meet the patient's needs. Specifically, documentation from the patient's physician indicates that the patient's functionality and clinical status have progressively declined and she currently requires assistance with all ADLs including eating, cooking, bathing, toileting and laundry/housekeeping. For these reasons, the CDPAS at 50 hours per week is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Suicidal ideation

Treatment: Inpatient mental health admission

The insurer denied coverage for continuation of coverage for inpatient mental health admission. The denial was modified.

This patient is a female was admitted to this inpatient mental health treatment in this hospital due to suicidal ideation, intent, and plan to overdose on 27 pills that she had in her possession. She had a depressed and irritable mood, low energy and anhedonia. She had a history of alcohol and cannabis use. She had diagnoses of Depressive Disorder, Generalized Anxiety and Disruptive Mood Dysregulation Disorder. She took Seroquel and Trazodone. The plans were for the patient to go to a residential treatment, but she improved and was discharged with follow up at a partial hospital program (PHP).

This reviewer disagrees with the decision to deny coverage for continued inpatient mental health treatment in this hospital but agrees with the decision to deny coverage for continued inpatient mental health treatment in this hospital. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports that patients with suicidal intent, plan, and attempts are at high risk for suicide and that past suicide attempts are the single most reliable predictor of suicide. It also reports that patients may require more time in the hospital to better assess suicide because they sometimes do not tell the truth regarding their suicidal thoughts in order to leave the hospital and that observation in the hospital is appropriate to better ensure their safety. This patient was considered a high risk patient and benefitted from remaining in the hospital and being observed and assessed for safety for at least another week without reported symptoms. 

As a result, modify the previous decision and approve coverage for continued inpatient mental health treatment in this hospital for the first date range, but deny coverage for continued inpatient mental health treatment in this hospital for the second date range. The insurer acted reasonably, with sound medical judgment, and in the best interests of the patient for one date range but not the date range thereafter.

The carrier's partial denial of continuation of coverage for inpatient mental health admission is modified. Approve the first date range. Deny the second date range.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: OSA, obesity, asthma
Treatment: Inpatient admission
The Inpatient admission was not medically necessary.

The patient is a female with a history of OSA (obstructive sleep apnea), asthma and obesity.  A tonsillectomy and adenoidectomy was performed.   The patient was admitted as an inpatient and discharged the next day. 

All records were reviewed.  The patient is a female with a history of OSA, asthma and obesity.  A tonsillectomy and adenoidectomy was performed.   The patient was admitted as an inpatient and discharged the next day.  

There were no intraoperative complications or post op complications.  Vital signs were stable, and the patient was afebrile.  There was no respiratory distress or active bleeding documented.  The patient's clinical condition did not deteriorate while in the hospital.  Pain started as severe but improved.  The patient tolerated sips of water, advanced to a soft diet.  Based on the above, the medical necessity of the inpatient admission cannot be confirmed, as the patient could have been cared for at a lower level of care, observation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left-sided chest pain

Treatment: Inpatient hospital admission

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

This patient is a woman who had a history of diabetes, hypertension, hyperlipidemia, fatty liver, morbid obesity, gastroesophageal reflux disease (GERD) and hypothyroidism.  She presented to the Emergency Department with complaints of left-sided chest pain for one day, radiating to the left shoulder and neck, intermittent, occurring with walking or at rest and relieved in the ambulance after aspirin and nitroglycerin. The initial EKG was normal other than borderline first degree atrioventricular (AV) block (PR 0.21) and initial vital signs included a blood pressure of 175/79, a heart rate of 106, a respiratory rate of 18 and an oxygen saturation of 100%. Laboratory test results included a white blood cell (WBC) count of 9.1, a hemoglobin of 11.9, a creatinine of 0.91 and a troponin of <0.015, with a subsequent troponin level also <0.015. A chest x-ray was normal, as was an echocardiogram with a left ventricular ejection fraction of 60% and no regional wall motion abnormalities. She was discharged on her home medications of levothyroxine, metformin and spironolactone, as well as aspirin and atorvastatin for outpatient management.

There is no evidence that this patient required an acute inpatient level of care to determine that her chest discomfort was not related to acute coronary syndrome.  The healthcare plan acted reasonably and with sound medical judgment and in the best interest of the patient.

The denial of coverage for the inpatient hospital admission is upheld because there is no evidence that the patient was at increased risk for short-term adverse cardiovascular events requiring inpatient monitoring and management based on her clinical presentation and results of testing performed in the Emergency Department.

The carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia

Treatment: Inpatient admission

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

This patient is a female with a history of fibroids and menorrhagia. She presented to the hospital with complaints of weakness and shortness of breath on exertion. She stated that she had been having dizziness while ambulating over the past several days. Her vital signs were; blood pressure 180/99 heart rate (HR) 81, respiratory rate (RR) 20, temperature 97.1. Initial blood work revealed hemoglobin 7.9 g/ml. and hematocrit 26.5. The patient was admitted for management of anemia and was transfused 1 unit of packed red blood cells. The patient was clinically stable and discharged home with gynecological after care instructions.

This patient was complaining of dizziness; in other words she was symptomatic for anemia. This patient also fulfills the transfusion guidelines for use of blood components: her hemoglobin was less than 8 g/ml (normal 12-20 g/ml) and she was symptomatic, so transfusion was necessary.

It is common that transfusions are done in the outpatient settings (oncology clinics, infusion centers, even at home). So the need for transfusion is not a reason for admission. This patient was admitted and transfused. The primary reason for admission was for receiving 1 unit of packed red blood cells (PRBC). Ideally this patient could have been transfused in the emergency department (ED), monitored for a few hours, her complete blood cell count (CBC) repeated and then discharged home with a follow up appointment within 24 hours with her primary physician or gynecologist.

The MCG guidelines list the clinical indication for inpatient care for patients with anemia. These include: active massive hemorrhage, active hemolysis, cognitive impairment, tachycardia, orthostatic changes, heart failure, chest pain, syncope. This patient did not have any of these conditions. The patient could have been transfused in the Observation area and discharged after finishing her transfusion.

The inpatient hospital admission is not considered medically necessary for this patient.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.

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

Diagnosis: Chest pain 
Treatment: Inpatient  stay

Summary:
The patient is a male. He had a past medical history significant for atrial fibrillation, migraine headaches, hypertension, and non-sustained ventricular tachycardia. The patient presented to the ER with a complaint of new onset left-sided chest pain at rest, as well as sudden onset palpitations. His prior work-up included a stress test and an echocardiogram, which were unremarkable, as well as a Holter monitor, which revealed episodes of non-sustained VT 
(ventricular tachycardia). 

The patient presented for evaluation of chest pain at rest in the setting of ventricular tachycardia. He had documented episodes of non-sustained VT, and based upon the ER documentation, the concern was for more prolonged, symptomatic VT episodes. This would require urgent work-up and treatment. Also, given the chest pain at rest, there was concern for an acute coronary syndrome (ACS). Given the presentation, risk factors, chest pain at rest and episodes of ventricular tachycardia, this patient would not be an appropriate candidate for an ED chest pain observation unit. 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: Upheld

Diagnosis: Erythema Multiforme

Treatment: Xeljanz 5 milligrams (mg) tablet

The insurer denied Xeljanz 5 milligrams (mg) tablet. The denial was upheld.   

This is a male patient who consulted a dermatologist for complaints of lesions of the mouth with associated pain and hands. He received a diagnosis of Rheumatoid Arthritis (RA). His Anti-CCP level was intermediate at 44. It was reported that he had been taking methotrexate, Enbrel, Otezla and high-dose prednisone. His Enbrel had been stopped and he was started on Xeljanz. 

Based on the review of the literature, Xeljanz is not approved for pediatric use. Based on the review of the medical record, there was insufficient clinical information to justify its off-label use to treat this patient's medical condition. Based on the one office visit note there is insufficient documentation on the patient's rheumatoid arthritis history and exam. The patient was noted to have wrist and hand pain. However, the extent of the rheumatoid arthritis was hard to assess. The Enbrel medication was stopped, but there was no other information available to assess whether this was a primary or secondary failure with Enbrel. While Xeljanz is not approved for this patient's age group, other alternatives that are approved for use include Humira, Actemra, Orencia and sulfasalazine (SSA). As to date, the literature support for pediatric use of Xeljanz is lacking. There is a small phase 1 trial submitted by the treating physician and a case report, but do not have any high quality research study to support the safety and efficacy of the use of Xeljanz on pediatric patients.  Thus, the medical necessity for Xeljanz in this patient is not established. 

The health plan has acted reasonably with sound medical judgment and in the best interest of the patient.

The carrier denial of coverage for for Xeljanz 5 milligrams (mg) tablet is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Schizoaffective disorder, unspecified type
Treatment: Continued inpatient admission 

The Continued inpatient admission was medically necessary for this patient.

The patient's symptoms of psychosis and mood disorder together with continued risk of impulsive behavior and issues with compliance warranted the continued acute inpatient level structure and monitoring through discharge. The case is complicated by non-compliance with medication adherence problems and by a formal thought disorder with poor insight and problems with executive functioning (organizing, sequencing, problems solving and decision making). The residual symptoms of mood disorder and psychosis and treatment issues related to arranging a safe and appropriate discharge plan to prevent non-compliance together with a history of medication non-adherence warranted the continued services at an acute inpatient level of care and support the medical necessity for continued inpatient level structure and 24-hour monitoring through the day of discharge when the patient had reached a level of stability that she could return to the community with clinically appropriate follow-up and aftercare.

This answer is consistent with the scientific literature and published practice guidelines, referenced below, as well as New York State instruction for medical necessity reviews.

The Continued inpatient admission could not have been safely or effectively provided at a lower level of care. Thus, the requested benefit of Continued inpatient admission is reasonable and in the patient's best interest, and is consistent with prevailing standards of medical practice for the treatment of the condition diagnosed in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Blindness
Treatment:  Home Health Care 

The patient with a past medical history significant for vision disorder/legally blind.  The patient has other medical problems which include coronary artery disease, urinary incontinence, anemia, gastroesophageal reflux disease and chronic pain syndrome.
The patient is requesting an increase in personal care services.  The patient  is requesting 24 hours a day 7 days a week by split shift.  The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of Increased personal care services (24 hours a day split shift, x 7 days per week) is not medically necessary for this patient.  The personal care aide service hours are sufficient to meet the patient's needs.  Additional service hours are not medically necessary.  The services which are provided mainly include Instrumental Activities of Daily Living (IADLs), which can be performed during the allotted time.
 The Uniform Assessment System (UAS) state of NY, noted that the patient needed assistance with Instrumental activities of daily living (IADL's) including housework, managing medications shopping and meal preparation.  Patient needed limited assistance with dressing upper and lower extremities.  Patient was able to ambulate independently inside with assistance of a cane.  Patient was able to transfer independently on and off the toilet.  The patient was able to feed herself.  Patient did have bladder incontinence but no bowel incontinence.  There are no recent falls noted.