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

The patient with history of hypertension and kidney stones presented for an elective percutaneous nephrolithotomy. Intraoperative findings include a left staghorn calculus. After the procedure the patient was put on an inpatient status and was managed with intravenous (IV) fluids, IV antibiotics and monitoring. Follow-up computed tomography (CT) scan showed no stones. The Foley catheter and nephrostomy tube were discontinued. There were no intraoperative or postoperative complications. The patient had an uneventful hospital stay and was discharged. The health plan's determination is upheld.

An inpatient stay was not medically necessary for this patient.
The majority of patients who undergo transurethral resection of prostate can be discharged within 24 hours of the procedure. The procedure was an elective scheduled procedure. The patient did not have any significant risk factors which increased risk of post-operative complications. The post-operative course was essentially normal without any significant complications or issues with pain control. The patient could have been managed at a lower level of care status given the patient's clinical presentation and post-operative course. A lower level of care status is safe, effective, and a generally accepted standard, and would be the most appropriate treatment option. Admission status may be changed anytime during a lower level of status if the patient requires continuing services and monitoring, and if the patient's condition is severe enough to require inpatient treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Primary mediastinal B cell lymphoma
Treatment: Inpatient admission
The inpatient admission was medically necessary.  

Dose adjusted R-EPOCH is an intensive chemotherapy regimen which consists of administration of multiple chemotherapeutic agents simultaneously via continuous infusion.  This regimen is commonly given in the inpatient setting due to the potential toxicity and complications associated with continuous infusion therapy with three different chemotherapeutic agents simultaneously.  This treatment cannot be given safely in a reliable fashion at an alternative level of care.  Furthermore, this patient required daily monitoring for toxicity assessment. Inpatient admission was medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Open Heart Surgery
 
Treatment: Coverage for Air Ambulance Services

The insurer denied the coverage for Air Ambulance Services. The denial was upheld. 

This is a male patient that presented to the Emergency Department in early 2019 in an Upstate NY facility with a myocardial infarction. He has a history of Hodgkin's Lymphoma and was treated with 30 Gy radiation therapy many years ago. He requested that the cardiologist at that facility discuss evaluation and intervention with his cardiologist at Cleveland Clinic.  The decision was made to perform coronary angiography in the Upstate NY facility but any intervention at Cleveland Clinic.  In early 2019, he underwent coronary angiography which revealed a 90-99% coronary artery lesion (location not specified in letters) and several hours later developed acute distress requiring intraaortic balloon pump for hemodynamic support.  A letter indicates that calls were made about emergency transport to several facilities and that helicopter transport was limited by high winds.  Air transport was dispatched by the Cleveland Clinic and after he arrived there he deteriorated again but was stabilized.  Once again he again deteriorated while being prepared for surgery, requiring emergency sternotomy followed by prolonged surgery.

There is no evidence that this patient required transportation to Cleveland Clinic for mitral valve surgery or coronary artery intervention or bypass.  While air ambulance services were appropriate it was medically necessary to transfer him to a closer facility that could provide appropriate care, based on his recurrent episodes of hemodynamic instability after diagnostic coronary angiography.

The carrier's denial of coverage for the air ambulance services performed should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

The patient is a male with sleep apnea.  Apnea hypopnea index (AHI) is 17.9.  Body mass index (BMI) is 31.6.  The patient cannot tolerate continuous positive airway pressure (CPAP).  Sleep endoscopy did not reveal concentric collapse at level of hypopharynx or oropharynx.  The hypoglossal nerve stimulator (HGNS) has been proposed.  The subject under review is whether the HGNS is likely to be more beneficial for this patient's condition than any standard treatment.  The health plan's determination is overturned, in whole.  Based on the patient not being able to tolerate the first line therapy for sleep apnea, CPAP, and that there are no reasonable surgical options, the hypoglosal nerve implant is a likely to be more beneficial for this patient than any standard treatment.  There is supporting literature demonstrating the safety and efficacy of the device.  It is likely that the patient will have significant improvement in his sleep apneas symptoms and decreased long term morbidity if the implant is placed.  There are no reasonable surgical or medical alternatives.  Untreated sleep apnea has long term cardiopulmonary and neurologic morbidity.  Inspire Hypoglossal Nerve Implant (HGNS) is Food and Drug Administration (FDA) approved and has a very good safety and effectiveness profile based on published literature.  HGNS therapy has been established as being safe and effective with sustained long-term outcomes at 60 months and would not be considered investigative in nature by most sleep specialists.  CPAP remains the treatment of first choice for obstructive sleep apnea based on recent data and task force guidelines [Epstein et al].  For patients who fail positive airway pressure, the 2009 Clinical Practice Guideline indicated that "surgical procedures may be considered as a secondary treatment for OSA when the outcome of PAP therapy is inadequate, such as when the patient is intolerant of PAP, or PAP therapy is unable to eliminate OSA (Consensus)".  It is well known that significant morbidity, as well as mortality, exists in patients when moderate to severe OSA is left untreated.
Appeal type: Experimental/Investigational
Decision: Upheld

The patient has sleep apnea. The patient per history tried multiple masks without (w/o) success and was intolerant of continuous positive airway pressure (CPAP).  Sleep study revealed an apnea hypopnea index (AHI) of 17.9.  Body mass index (BMI) is 31.6.  Prior medications include Flonase, but no history of nasal obstruction or allergies provided.  No history of hypertension or cardiac disease is documented.  A seep endoscopy showed complete obstruction in antero-posterior (AP) dimension at level of soft palate.  There is a partial AP collapse at the level of the tongue and epiglottis.  The exam documents a septal deviation with normal inferior turbinates.  There is no mention of occlusion class, hyoid position, or neck anatomy.  The subject under review is whether the proposed hypoglossal nerve stimulator is likely to be more beneficial for this patient than any standard treatment.  The health plan's determination is upheld, in whole. Uvulopalatopharyngoplasty (UPPP) is as likely to produce an equivalent result in this patient.  Per the inspire candidacy, recommendations are patients 22 and older with AHI between 15 and 65.  In patients with a BMI 32 or greater Inspire has not been clinically tested.  This patient is at the upper limit of BMI in the only BMI reported.  They also list bi-level positive airway pressure (BiPAP) and CPAP trial.  This patient has only tried CPAP.  Also, hypoglossal nerve stimulation is not recommended for patients with complete concentric collapse at the level of the soft palate.  This patient's sleep endoscopy shows complete collapse at the level of the soft palate.  This patient is not a good candidate for this method of treatment per the Inspire indications/contraindications, as recommended by the product manufacturer.  As a result, the proposed service is not likely to be more beneficial than other standard treatments.
Appeal type: Experimental/Investigational
Decision: Upheld

This is a male who complained of loud snoring, frequent awakenings, daytime somnolence, not feeling rested, and difficulty sleeping.  Previously, nocturnal apneas were witnessed.  Comorbidities include ulcerative colitis and attention deficit hyperactivity syndrome.  Exam revealed normal hard and soft palate with a midline uvula.  A polysomnogram revealed a respiratory event index of 17.9 with an oxygen nadir of 81 percent.  A drug induced sleep endoscopy revealed nonconcentric collapse at the level of the velopharynx.  The service under review is implantation of a hypoglossal nerve stimulation device.  The health plan's determination is upheld, in whole.  The proposed health service, implantation of a hypoglossal nerve stimulator system is not likely to be more beneficial than any standard treatment or treatments for the insured's diagnosed condition, moderate obstructive sleep apnea (OSA).  A Hayes report concluded that the overall quality of the evidence evaluating hypoglossal nerve stimulation for treating obstructive sleep apnea is very low.  According to the Hayes report (2016), stimulation of the hypoglossal nerve may provide a treatment option for patients with moderate-to-severe OSA for whom continuous positive airway pressure (CPAP) has failed to provide relief, but the procedure may carry risks for complications and postimplantation surgical procedures.  The evidence is still unclear as to whether improvements translate to better sleep quality and improved quality of life.  Additional good-quality comparative studies with larger sample sizes are called for to define the patient population that is most likely to respond to this therapy option.  In a review of 381 patients by Kompelli (2018), with CPAP refractory obstructive sleep apnea, the authors concluded that the hypoglossal nerve stimulation device was safe and effective, and that pain, tongue abrasion, and internal/external device malfunction were common occurrences and that comparison to other therapies was recommended.  Based upon the peer reviewed medical literature, the proposed health service, implantation of a hypoglossal nerve stimulator system is not likely to be more beneficial than any standard treatment or treatments for the insured's diagnosed condition, moderate obstructive sleep apnea (OSA).
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of acute intermittent porphyria who presented to the hospital with abdominal pain. The patient reported similar pain during prior episodes. The patient also stated there were multiple triggers. The patient stated that the pain started suddenly overnight and was generalized and radiated to the back into the thighs. The patient was admitted with abdominal pain secondary to suspected acute intermittent porphyria. The health plan's determination of medical necessity is upheld.  The plan of care included intravenous (IV) fluids, blood cultures, urine cultures, gabapentin, neuro checks, monitoring off of antibiotics, and monitoring complete blood cell counts.  The patient was hemodynamically stable, did not require intravenous (IV) opioids for pain management during the hospital stay, had no evidence of an acute infection or sepsis, and there were no other complications such as an acute kidney injury or acute liver injury.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low blood sugar and abdominal pain
Treatment: Inpatient admission
The inpatient admission was not medically necessary.
This child presented to the ED symptomatic from hypoglycemia, in conjunction with abdominal pain (likely from constipation) and sore throat (viral panel positive). Because of the profound hypoglycemia (36) there was concern for an underlying endocrine problem. A full laboratory work-up was performed and Endocrinology was consulted. While it was reasonable to provide a comprehensive work-up in search of etiology for hypoglycemia, as well as monitor for further episodes, she was overall hemodynamically stable, pain free in the ED. She could have been safely managed at a lower level of care while in the hospital such as observation.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Testicular hypofunction
Treatment:Testosterone 12.5mg/ACT(1%) TD Gel
The health plan should not cover the proposed Testosterone 12.5mg/ACT(1%) TD Gel.
The appeal letter indicates that the patient is on testosterone 12.5 mg/act gel because this patient only needs low dose testosterone. The formulary alternatives include testosterone 10mg/act gel, which also delivers a low dose of 10mg of testosterone per actuation. The Endocrine Society guidelines on the treatment of male hypogonadism do not recommend the use of testosterone 12.5 mg/act gel over testosterone 10 mg/act gel. This patient does not have a documented trial or contraindication to testosterone 10 mg/act gel. Therefore, no, the health plan should not cover the proposed treatment.
Appeal type: Medical necessity
Decision: Upheld

The patient was admitted to inpatient rehabilitation substance use disorder treatment of opioid (heroin), stimulant (cocaine) and cannabis (marijuana) use disorders. The patient was using one bag of heroin and one bag of cocaine daily with intranasal administration together with one joint daily. His use of these substances was causing significant risk to health and impairing the ability to function. The patient was also tobacco dependent. The self-referral was prompted by legal issues with a charge for petty larceny and the understanding that treatment for the substance use disorders would allow for the legal charges to be dropped. The patient has no acute or chronic general medical issues that were a focus of treatment. There are co-occurring psychiatric disorders in this case diagnosed as major depressive disorder and an unspecified anxiety and depressive disorders, as well as trauma history related to emotional abuse experienced as a child. The patient denied psychiatric hospitalization or suicidal behavior. The patient was treated with sertraline and quetiapine at clinically appropriate dosages.

The health plan's determination is upheld. The Alcohol and Substance Abuse Treatment: Inpatient Rehabilitation Level of Care is not medically necessary for this patient. The Inpatient substance use disorder rehabilitation services in this case scenario were amenable to treatment at a lower level of care. The patient was motivated and was capable of effectively participating in substance use disorder treatment in a less restrictive treatment setting with sober supports and/or housing. The patient did not need the structure of an inpatient setting in order to effectively participate in rehabilitation substance abuse treatment, or to receive effective treatment for the mood and anxiety related disturbances.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with a history of sickle cell disease who presented to the hospital  with severe back pain that had failed treatment at home. She had a 5-day history of pain which was evaluated in the Emergency Department (ED), where she was given intravenous (IV) fluids, morphine and ketorolac, but continued to have 8/10 pain. She was subsequently admitted for further treatment of her pain. The health plan's determination of medical necessity is overturned.
The patient was admitted with sickle cell disease and a pain crisis. She had been seen in the ED the day prior to admission and failed outpatient management of her condition. 
In this case, the patient required continuous narcotic treatments/pain management with 10 doses of IV pain medications scheduled per day at the time of her admission, She required IV fluids and aggressive management of her pain that had already failed a lower level of service.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Abuse, alcohol withdrawal
 
Treatment: Inpatient admission

The insurer denied the coverage of hospital treatment. The denial was reversed.
This case involves male patient who presented to the Emergency Department with a past medical history of sarcoidosis, asthma, hypertension and depression.  The patient stopped drinking two days prior and was drinking about a half a gallon of vodka each day.  The patient developed chest pain, weakness and lightheadedness.  The patient has been drinking with binges for many years.  The patient has had alcohol withdrawal when he stops drinking previously.  The patient was grocery shopping and fell after being lightheaded.  The patient had chest pain that was pressure-like and constant.  The patient stated he had dizziness described as lightheadedness with chest pain.  It was noted that the patient was hemodynamically stable but tachycardic.  The patient was awake and alert.  Orthostatic hypotension was negative.  The patient was to be placed in observation for ataxia.  
The patient did not meet inpatient criteria for the neurological complaints as there was no indication that the patient had a severe CNS infection, vasculitis, cerebral aneurysm requiring inpatient care, myasthenia gravis, multiple sclerosis, Parkinson's disease, severe myopathy, neuropathy or other neuromuscular disease, complications of congenital or degenerative disease or neurological trauma.  
However, in this case this patient had been drinking large amounts of alcohol on a binge for days and stopped two day prior to admission so he was at risk of severe, life threatening, and complicated withdrawal symptoms including delirium tremens (DT).  The notes reported that he was on DT watch as he had medical issues as well complicating the management of withdrawal in an outpatient setting.  According to the Level of Care for Alcohol & Drug Treatment Referral (LOCADTR) he did require 24 hour treatment as he could not safely and effectively be treated in outpatient detoxification settings as he continued to drink large amounts of alcohol despite medical issues and he required and needed detoxification medication to modify withdrawal.
The carrier's denial of coverage for the inpatient hospital services from is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

This patient  presented to the emergency department  for evaluation of shortness of breath and cough.  He was afebrile, hemodynamically stable, and had normal room air oxygen saturation.  The physical examination was significant for bilateral ankle edema.  A review of laboratory data was significant for leukocytosis with a left shift, thrombocytosis, elevated D-dimer, and normal cardiac biomarkers.  A chest x-ray revealed a new right lung base infiltrate.  A computed tomography angiography (CTA)of the chest was positive for left lower lobe partially occlusive pulmonary emboli and mild bibasilar linear atelectasis versus scarring.  The patient was admitted for management of an acute pulmonary embolism and possible community acquired pneumonia.  The health plan's determination of medical necessity is upheld.  The patient's pulmonary embolism severity index was indicative of a low risk of death.  He was hemodynamically stable and did not have hypoxia or respiratory distress.  There was no documentation of associated deep vein thrombosis (DVT), severe pain requiring administration of narcotic analgesics, elevated cardiac biomarkers, recent hemorrhage, high risk for bleeding from anticoagulation, or a serious comorbid condition such as ischemic heart disease, chronic lung disease, liver or renal failure, or cancer. An echocardiogram was also negative for evidence of right ventricular strain.
Appeal type: Medical necessity
Decision: Overturned

Diagosis: UTI
Issue under review: Inpatient admission

Determination:
The Inpatient admission was medically necessary.

A patient with uncomplicated pyelonephritis can be safely treated as an outpatient with oral antibiotics (1). This patient does not meet the definition of "uncomplicated," because she has a history of frequent UTIs, and she had signs of sepsis in the ER (high WBC count, high fever, tachycardia). Thus, the admission is supported by IDSA guidelines as well as standard of care. Failure to admit such a patient could result in complications of pyelonephritis (abscess), loss of function (renal injury), sepsis, or death.
Appeal type: Medical necessity
Decision: Upheld

The patient has a past medical history significant for diabetes, hypertension, coronary artery disease, proximal atrial fibrillation, hyperlipidemia, end-stage renal disease requiring dialysis. The patient suffered a fracture resulting in orthopedic injuries along with gait abnormalities including right foot drop.
The request is for 84 hours week, and the plan has approved 42 hours a week, 6 hours a day 7 days a week Monday through Sunday.
The subject under review is the medical necessity of the requested 84 hours of care per week.

The health plan's determination is upheld.

No, the requested health service/treatment of Personal care assistance services from 42 to 84 hours per week is not medically necessary for this patient.

Uniform Assessment System (UAS) State of New York noted a total of 20.57 patient hours to be medically necessary.
Most of those services were necessary for activities of daily living (ADLs) including bathing, personal hygiene, and toileting.
Subsequent UAS State of New York noted total of 35.65 patient hours to be medically necessary.
In addition to the ADLs such as bathing, personal hygiene, and toileting, there is noted to be new services which include medical necessity including meal preparation and housework shopping and managing medications were which were not previously noted.
The patient has multiple medical problems along with orthopedic problems including gait dysfunction secondary to right foot drop post hip fracture in February. Most of the patient's services including ADLs, bathing, personal hygiene, and toileting remain similar to previous evaluation however the patient has had increased need for other services such as meal preparation and housework shopping and managing medications.
The patient did have a fall in May 2015 while at home. The patient was transferred for inpatient care and subsequently released to go home with spouse. The patient's spouse is quite ill and does have difficulties according to the records.
The time allotted on the UAS, is sufficient to meet the patient's medical needs in regard to ADLs and instrumental activities of daily living (IADLs). Additional services are not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Advanced osteoarthritis
Issue under review: Increased personal care services

Determination:
The Increased personal care services are medically necessary.

This is an elderly female with a history of advanced osteoarthritis, associated arthralgias, myalgias, generalized pain and gait ataxia. For these reasons, she requires assistance with the majority of her activities of daily living (ADLs). Furthermore, the medical records demonstrate progressive worsening of her functional ability with regards to ambulation, transfers and toileting. The currently approved plan is insufficient to meet the patient's needs. For these reasons, the proposed increase in Personal care services for improved assistance with completion of the patient's ADLs is deemed medically necessary.