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

Diagnosis: Dementia, Arteriosclerotic Heart Disease, Diabetes, Hypertension, Incontinence of urine and feces, Spinal Stenosis, Asthma/ Chronic Obstructive Pulmonary Disease (COPD), and stage 1 decubitus ulcer
Treatment: Home Health Care

Summary: This patient's physician submitted a letter in support of increasing the patient's Personal Care Assistance (PCA) hours and includes the following: The patient is homebound. Her diagnoses include: dementia, arteriosclerotic heart disease, diabetes mellitus, hypertension, incontinence of urine and feces, spinal stenosis, asthma/ chronic obstructive pulmonary disease, and stage 1 decubitus ulcer. Due to the decubitus ulcer, the patient needs repositioning every 2 hours. She needs 1 person assist for transfers, ambulation, bed mobility, toileting, incontinence care, bathing, dressing. She is high risk for falls and had a fall the previous week resulting in left lower rib contusion. The patient requires frequent PCA day and night to ensure safety with activities of daily living (ADLs) and prevent progression of decubitus ulcer.

The insurer has denied coverage for Personal Care Aide Level 2, 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - a total of 168 hours per week as not medically necessary. The denial was reversed.

Based on the patient's medical history and functional impairment, it is evident that the patient needs assistance for ADLs during day and nighttime hours. Her needs are not limited to activities that can be scheduled for specific times of the day. Due to her toileting and incontinence needs, the high level of assistance needed for mobility (transfers, walking, bed mobility), and her impaired judgment limiting her ability to perform routine daily activities properly and safely, it is medically necessary that she has a caregiver present (either voluntary or paid) to assist with these ADLs throughout the day and night. Per NYS regulations for personal care services, assistance provided by informal caregivers is voluntary. It was noted in the report from the patient's advocate that the family cannot provide the necessary care the patient needs when the PCA is not present. Without care provided by informal caregivers, it is therefore medically necessary for care to be provided by personal care services. The patient needs PCA services 24 hours per day, provided as split shift; as the patient's ADL needs (toileting, incontinence care, transfers, walking, bed mobility/turning and positioning) are of such frequency that it is a unlikely that a live-in aide would be able to obtain the required hours of sleep (5 uninterrupted hours per day, as per NYS regulations) on a regular basis.
Appeal type: Medical necessity
Decision: Upheld

The patient has a history of hypertension and hyperlipidemia and presented to the emergency department (ED) with chest pain radiating to his right arm and associated with diaphoresis.

The health plan's determination is overturned. The inpatient stay was medically necessary for this patient. The patient had a substantial myocardial infarction which requires inpatient care and high-intensity monitoring. The patient had a coronary intervention, echocardiography, and treatment plan and was able to be discharged within a day. The care was quite efficient but required inpatient management because of the risks associated with potential adverse events such as a fatal arrhythmia.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnoses: suicidal ideation, history of generalized anxiety disorder, bipolar disorder, obsessive compulsive disorder and post-traumatic stress disorder

Treatment: Inpatient mental health admission, medication changes

The insurer denied coverage for inpatient mental health treatment in this hospital from 6/12/19-6/17/19. The denial was modified to approve 6/12/19-6/13/19 and deny 6/14/19-6/1719.
 
This patient was admitted to inpatient mental health treatment on 6/12/19 due to worsened depressive symptoms, suicidal ideation, and inability to care for herself.  She reportedly thoughts of not wanting to join her deceased father who committed suicide by shooting himself.  She had a serious past suicide attempt by shooting herself in the arm.  She reportedly was the victim of abuse and had post-traumatic stress disorder (PTSD) symptoms also as well as anxiety. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Suicidal Behaviors report that patients with past suicide attempts are at high risk for suicide and that past suicide attempts are the most reliable predictors of suicide.  It also reports that patients with bipolar disorder, history of abuse / victimization, and substance use are at increased risk for suicide.  

Notes on 6/13/19 reported continued suicidal ideation and depression still at 5 out of 10 with poor appetite  and poor coping skills so she was still considered in need of hospital treatment then as she was still at high risk for suicide while presenting with those symptoms so she still required 24 hour hospital treatment until then.  As of 6/14/19, there were no reports of bizarre behavior, psychomotor agitation, aggression, self-injurious behavior, manic episodes, suicidal or homicidal ideation, intent, or plan. She reportedly was discharged 6/17/19
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity
Issue under review: Saxenda

Determination:
The Saxenda is medically necessary.

Saxenda is a GLP-1 (glucagon-like peptide-1) agonist that is used in the treatment of obesity [1-3]. The FDA label is below [4]. 

INDICATIONS AND USAGE  

Saxenda is a glucagon-like peptide-1 (GLP-1) receptor agonist indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index (BMI) of 
1) 30 kg/m2 or greater (obese) (1) or
2) 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbid condition (e.g. hypertension, type 2 diabetes mellitus, or dyslipidemia) (1).
Limitations of Use: 
3) Saxenda is not indicated for the treatment of type 2 diabetes (1).
4) Saxenda should not be used in combination with any other GLP-1 receptor agonist (1).
5) Saxenda should not be used with insulin (1, 5.4).
6) The effects of Saxenda on cardiovascular morbidity and mortality have not been established (1).
7) The safety and efficacy of coadministration with other products for weight loss have not been established (1).
8) Saxenda has not been studied in patients with a history of pancreatitis (1, 5.2). 

The patient has obesity and has been participating in a reduced calorie diet and physical activity. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.

The health plan's denial of the Saxenda based on their assertion that there is no documentation submitted showing that the patient has been, and is currently enrolled in, a comprehensive weight management program for at least three months is not consistent with the FDA-approved indications for this treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Periodontal pocketing and calculus
 
Treatment: Request for periodontal scaling and root planing

The insurer denied the request for periodontal scaling and root planing. The denial was upheld.

This patient presented for evaluation for dental services and periodontal therapy. There were documented periodontal chartings indicating scattered 3-5 mm periodontal pocketing and calculus. The recommended treatment was scaling and root planing in all four maxillary and mandibular quadrants.  

Upon review of the periodontal probing and bitewing and periapical radiographs, there is minimal if any loss of alveolar bone height affecting these teeth. The increased pocket depths likely represent pseudopocketing due to superficial calculus accumulation and poor oral hygiene.  It is focal and isolated to only a few teeth in these quadrants. The dental treatment notes do not reflect a diagnosis of periodontitis.  

Deep cleaning (periodontal scaling and root planing) of the entire mouth (LL, LR, UL, UR) was not medically necessary as the clinical and radiographic documentation does not support or substantiate scaling and root planing services.

Based on the above, the medical necessity for Deep Cleaning (periodontal scaling & root planning is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right ankle fracture
 
Treatment: Increase in Consumer Directed Personal Assistance Services (CDPAS)

The insurer denied the increase in Consumer Directed Personal Assistance Services (CDPAS).  The denial was reversed.

This is an elderly female patient with a history of diabetes, chronic kidney disease stage lll, anemia, hypertension, cerebrovascular accident, and a neurogenic bladder.  She presented to hospital after a fall with a right ankle fracture.  She was evaluated for surgery, however she refused treatment. She was discharged home with instruction for non-weight bearing on her right foot.  It was reported that she is dependent in all activities of daily living and requires 24 hour supervision with her care.  She suffers from urinary frequency and incontinence.  Additionally she has cognitive deficits that include memory impairment and communication problems which attribute to the concern for the patient's safety and well-being.   

The UAS reports patient needs limited assistance with bed mobility.  It was noted that she could turn in bed by placing her left hand on bed rail to pull herself but she cannot use her right hand to turn to the other side, and she cannot sit up in bed without assistance.  Over the course of the entire night, it is not clear whether the patient can move sufficiently and often enough to provide adequate pressure relief.  The patient has a hospital bed and gel overlay.  A gel overlay on the mattress provides some pressure relief but is not a substitute for turning and repositioning.  Prevention of pressure ulcers needs to be a priority for the patient, as she is diabetic and incontinent, and so risk of infection and impaired wound healing is increased.  Aside from pressure ulcer prevention, the patient may need repositioning for comfort and pain relief.  She has arthritis and loss of use of her right upper extremity, both conditions can predispose to discomfort after lying in one position for an extended period of time.  The patient has very limited ability to help herself if she has pain at night if there is no assistance available.  The information provided for review supports the need for caregiver assistance 24 hours per day, including evening/nighttime ADL needs for toileting/incontinence care and bed mobility.  Based on available information, it is not clear whether a live-in aide would be able to have at least 5 uninterrupted hours of sleep each day (as per NYS requirements for live-in aide).

The carrier's denial of coverage for an increase in Consumer Directed Personal Assistance Services (CDPAS) 24 hours a day for 7 days a week (split shift), for a total of 168 hours (mutual case) is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who presented to the emergency department (ED) with a history of several hours of abdominal pain. Her evaluation included a physical exam, labs, and a computed tomography (CT) scan. She did not have a fever at the time of presentation. Her heart rate was 75 beats/minute. Lab data identified a white blood cell count (WBC) count of 10.6 thousand (K). The CT scan yielded the diagnosis of acute appendicitis. The health plan's determination of medical necessity is upheld. The records do not support the medical necessity of inpatient admission for this patient. The records do not support that there was complicated appendicitis, complications of the procedure such as wound infection, dehiscence or fistula, ileus, bleeding. In this case, the records do not document a complicated clinical course such that inpatient care was necessary. The records do not document hemodynamic instability, sepsis or toxicity, significant electrolyte imbalance, bleeding, gastrointestinal (GI) obstruction or surgical complications of the procedure that required inpatient care. In this case the patient tolerated oral hydration, a diet and medication and her pain was well controlled.
Appeal type: Medical necessity
Decision: Upheld

The patient was sent by ambulance to the Emergency Department from her cardiologist's office on with chest pain.  The patient underwent a stress test, which was positive for inferior wall ischemia.  Patient came for a follow up visit to discuss the results of the test and developed chest pain.  In the cardiologist's office patient was given sublingual nitroglycerin and aspirin.  The chest pain improved, and patient was sent to emergency department (ED) by ambulance.  The patient was given intravenous fluids (IVF) and was admitted to telemetry unit.  The patient underwent cardiac catheterization, and it revealed normal coronary arteries.  The patient was stable, without symptoms and discharged.  The health plan's determination of medical necessity is upheld in whole.  The inpatient stay was not medically necessary.  The physical examination, CXR, ECG and troponin were normal.  The coronary angiography was unremarkable and revealed patent coronary arteries.  There were no signs or markers supporting the presence of acute coronary syndrome.
Appeal type: Medical necessity
Decision: Upheld

The patient has a past medical history of hypotension, right eye blindness and pulmonary tuberculosis (TB) in 1986. The patient presented with dizziness, lightheadedness and loss of consciousness with fall to the ground. Vital signs showed a blood pressure of 157/80, pulse 114, temperature 36.7, respiratory rate 18 and oxygen saturation of 100%. Labs showed a white blood cell count of 16, hemoglobin 13.2, platelets 223, sodium 138, potassium 4.6, creatinine 2.26 and bicarbonate 22. Chest x-ray showed small opacity in right lung base. The patient was given Rocephin and Azithromycin along with fluids. The patient was admitted for further evaluation and management.

The health plan's determination is upheld. The inpatient stay was not medically necessary. Care could be provided at a lower level. He was hemodynamically stable at presentation. Labs showed leukocytosis. He was given Rocephin and Azithromycin along with fluids. No arrhythmia was noted on telemetry. A CT chest showed a cavitary mass in the right apex. The patient did not want workup including a bronchoscopy. Telemetry showed normal sinus rhythm. He remained hemodynamically stable throughout the stay and did not have any respiratory issues.
Appeal type: Medical necessity
Decision: Upheld

The patient presented to the emergency department (ED) with a history of runny nose, cough, and wheezing for approximately 6 hours. The mother gave a dose of albuterol and budesonide with no relief, then brought him to the ED. The patient has a history of allergies and asthma with poor compliance with budesonide. 
Following 3 hours in the ED, the patient was admitted with a diagnosis of acute asthma exacerbation with viral upper respiratory infection (URI). 
The patient was then given albuterol nebulizer treatments q 3 hours and oral Prelone. 

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient was discharged to home in good condition less than 24 hours after his symptoms began. His examination in the ED and at admission indicated no respiratory distress and no oxygen requirement with normal effort, although wheezes were heard. A venous blood gas was normal. The only abnormal vital sign was elevated temperature and elevated heart rate, which would be expected 
with both fever and albuterol treatments. The patient was noted to be markedly improved 4 hours after oral steroid started, 
which is typical with pediatric asthma. Inpatient stay was not medically indicated. Observation at a lower level of care to monitor response to treatment prior to discharge would have been appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Symptomatic Hypothyroidism 

Treatment: Inpatient Admission

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

This case involves a female patient who presented to the Emergency Department in early 2019 with anorexia and nausea x2 weeks.  The patient had a past medical history of depression, hypothyroidism on Synthroid and hypertension.  The patient's daughter reported the patient had decreased appetite and was refusing to eat.  The daughter believed that her mother was depressed and that she had not been taking her Synthroid as she should.  The patient was noted to have nausea.  She was to be admitted for symptomatic hypothyroidism.  During the hospitalization, the patient underwent treatment with normal saline fluids, intravenous medications, including Pepcid, Protonix, Synthroid and hydralazine.  Consultations made included nutrition services, endocrinology and psychiatry.  The laboratory studies indicated that the patient had a TSH of 112.  Urine analysis showed a urinary tract infection.  Endocrinology recommended she start Synthroid at 25 mcg for 2 weeks and then increase the dose.  The patient was stabilized.  The patient was cleared by the psychiatrist and noted to be medically stable. She was then discharged.

The Milliman Care Guidelines (MCG) indicate that admission is appropriate for patients who have severe malnutrition as indicated by an estimated nutritional intake of less than 25% of calculated energy needs, or body mass index of less than 18.5.  It is also appropriate for patients who have suicidal or homicidal ideation.  It is appropriate for patients who need inpatient monitoring.  Additionally, admission is appropriate for patients who have a subnormal body mass index or low expected body weight for height, age, and sex and the need for medical treatment of unstable physical condition and when urgent re-feeding is needed.  Additionally, it is appropriate when there is an imminent risk of developing significant medical instability due to rapid loss of weight.  The records indicated the patient was noted to be anorexic.  The patient was in need of medical treatment for an unstable medical condition, hypothyroidism, however, urgent re-feeding was not noted to be needed. 

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

This is a patient with a history of sickle cell disease on folic acid, hydroxyurea and pen VK. Her mother reports that the patient had a cough, runny nose for 3 days and back pain the day prior to presentation, which resolved, and a headache on the morning of presentation. There was also an associated low grade fever up to 100.7 degrees Fahrenheit. She also had one episode of vomiting at school and decreased activity. Her mother had been giving her Tylenol and Robitussin. 
The health plan's determination of medical necessity is upheld. At the time of admission she was not hypoxic, she was not in respiratory distress, toxic looking nor having by mouth (PO) intolerance or signs of dehydration. There is concern for acute chest syndrome in patients with sickle cell disease and respiratory symptoms but this child had no infiltrates on chest x-ray nor did she have any hypoxia or signs of respiratory distress. Lung exam at admission was normal and respirations were non-labored.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse
Issue under review: Continued inpatient rehabilitation

Determination:
The Continued inpatient rehabilitation was medically necessary.

The Continued inpatient rehabilitation was medically necessary in order to address issues related to  relapse with focus on a relapse prevention plan and additional work on developing coping skills in a case that poses high risk for relapse; in order to address co-morbid psychiatric disorders with medication and CBT; in order to address the patient's lack of awareness of the seriousness of his illness with psycho-education and evidence-based psychosocial interventions; in order to address the social environment including use of multiple substances of use with legal and family stress; and in order to work on coping skills that will be necessary in building an effective sober support system and continued recovery efforts with community providers while maintaining his abstinence with peer supported recovery groups. None of this therapeutic work could have been safely or effectively provided at a lower level of care in view of the multiple, complicating factors in this case, the high risk for relapse, the treatment history with relapses and continued use of substances despite access to treatment, and the lack of a reasonable recovery environment that includes high risk behaviors, including use of dangerous combinations of substances (alcohol and cocaine), and the patient's initial ambivalence towards treatment or lack of commitment to a recovery process. 

This answer is consistent with prevailing standards of professional practice and ASAM Criteria and scientific literature and published practice guidelines referenced below.
Appeal type: Medical necessity
Decision: Overturned

The patient was admitted following medical screening to acute inpatient level services for monitoring and detoxification and withdrawal management of severe opioid (heroin and prescription opioids) and cannabis use disorder (marijuana). He was using up to 10 bags daily of heroin with intermittent use of marijuana.

The health plan's determination is overturned. The admission and continued stay thru discharge for inpatient services and detoxification treatment and withdrawal management for severe substance use disorder and other services could not have been safely and effectively provided at a lower level of care. The adult inpatient treatment of this patient's substance use disorders did warrant the admission and the continued structure of an inpatient level setting and 24-hour monitoring in view of the severity of the substance use disorders with associated psychosocial stressors and impairment of functioning.
Appeal type: Medical necessity
Decision: Upheld

The patient has a history of peptic ulcer disease who presented to the emergency department (ED) with complaint of chest pain as well as shortness of breath and palpitations. Symptoms began approximately 6 months prior. The patient was found to have an elevated creatine phosphokinase (CPK) by his doctor and instructed to go to the ED. 

The health plan's determination is upheld. Inpatient admission was not medically necessary in this case. There was no evidence of hemodynamic instability, cardiac disease, worsened kidney function or renal failure. None of the severity of illness criteria were present to support an inpatient admission. This patient could have been managed with intravenous fluids and observation at a lower level of care. Further follow-up could have been done as an outpatient.