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

Diagnosis: Pulmonary Embolism
 
Treatment: Inpatient Admission

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

This is a female patient with history of hypertension and liver disease.  She presented to the emergency department (ED) with complaints of pleuritic type chest pain, shortness of breath, and dizziness.  The patient's blood pressure on presentation was 153/111.  It was reported that she failed to take her blood pressure medication the morning of presenting to the ED.  Laboratory work up including a Troponin level were performed and were within normal limits.  A brain natriuretic peptide level was negative and her D-Dimer test was elevated.  A chest x-ray was performed with no pulmonary pathology.  A computed tomography (CT) of the chest was done which was positive for a medial right lower lobe sun segmental pulmonary embolism.  A CT of the head was done which was unremarkable.  She was treated with Lovenox and Lasix.  The patient was hemodynamically stabilized and discharged home on oral Eliquis. 

This patient did not need acute inpatient hospitalization.  She could have been placed in Observation status with diagnostic testing and treatment initiated.  The patient remained stable after admission.  A myocardial infarction (MI) was ruled out.  This patient was not hypoxic.  She was stable to be discharged home on an anticoagulant after a period in observation.  The patient had some transient elevation in blood pressure due to noncompliance with blood pressure medications.  However, once she was treated, her blood pressure improved.  The patient was stable for discharge after a period in observation with close follow-up in an outpatient setting for her mild PE.  The patient could have been switched to oral Eliquis and discharged home.  The prior denial is upheld.

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

Diagnosis: ADHD
Issue under review: Vyvanse

Determination:
The Vyvanse is medically necessary.

The patient is an adult male with a long-standing diagnosis of ADHD (attention deficit hyperactivity disorder) and learning disability. He has been treated by this provider since he was a young teenager. The documentation submitted indicates that the patient has done well on Vyvanse, at varying doses, since that age. The medication has been denied by the insurer on the basis of lack of documentation of failure of various generic formulary stimulant medications. In a note, the provider writes that the patient had failed trials of methylphenidate and amphetamine-dextroamphetamine ER, although no details are given. The patient has had therapeutic benefit from Vyvanse for a number of years.  Progress notes consistently reflect a positive response to Vyvanse without significant adverse effects.

The provider writes that the patient did have failed trials of at least two of the recommended formulary medications. Furthermore, the patient has consistently benefited from treatment with Vyvanse for years. Even if he had not had trials of other medications, it would not be clinically appropriate to change this medication at this time without a medical reason for doing so. The current medication is considered medically necessary over the health plan's preferences.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain, nausea
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.
The Inpatient admission was not medically necessary.

The patient is a female. She presented to the emergency department with the complaints of abdominal pain for four days preceding presentation, with nausea and emesis for the last two days. The patient noted epigastric and umbilical pain with radiation to the back. The pain was noted to be seven out of ten. She had no relevant medical history. 

A CT scan performed of the abdomen and pelvis was consistent with ileus. The patient received supportive care including intravenous (IV) fluids, IV antinausea medication, and IV Tylenol. Surgery was consulted. The plan was for conservative management.  

While the care as provided was medically appropriate, the level at which the care was provided was not medically necessary, as noted below.

Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had an infection; yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for NPO (nothing by mouth) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission. As such, the care could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Upheld

Skin Disorders
Pharmacy/Prescription Drugs

The patient is a male with plaque psoriasis affecting 10% of the body surface area (BSA). The patient has involvement of the scalp. The patient has failed treatment with topical steroids. The provider requests Stelara, which is under review for medical necessity.

The health plan's determination is upheld.

Treatment with Stelara is not medically necessary for this patient.
According to the 2018 American College of Rheumatology and National Psoriasis Foundation guidelines phototherapy and oral agents for psoriasis (i.e., acitretin, cyclosporine, and MTX) may be used first-line in various clinical situations. For example, acitretin is a first-line systemic drug for palmoplantar or pustular psoriasis and is especially useful in those with severely sun damaged skin, in which it may suppress actinic keratoses and even invasive malignant neoplasms. Cyclosporine may be effective long-term but is normally reserved for intermittent use (up to 12 weeks) to control a flare so the patient can transition to another drug for long-term maintenance. When used intermittently, a course of cyclosporine can induce an average decrease of greater than (>) 75% in psoriasis severity. MTX is considered a first-line systemic agent for plaque psoriasis that may be used continuously for many years or decades with durable benefits. The patient has no documented contraindication, intolerance, or failure (CIF) to phototherapy or systemic disease modifying anti-rheumatic drugs (DMARDs). Stelara is not medically necessary.

While the patient does have involvement of the scalp, phototherapy can still be an option as UVB may be delivered with handheld devices such as XTRAC laser. The patient does not have a history skin cancer or elevated liver function tests (LFTs) or liver disease or uncontrolled hypertension. The records indicate that the patient cannot afford blood work associated with treatment, but this is not a medical contraindication to the most appropriate service that can be given to this patient. Medical necessity for Stelara has not been established.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cerebrovascular Accident

Treatment: Consumer Directed Personal Aide Services of 49 hours per week; Consumer Direct, 1 client.

The insurer denied the consumer directed personal aide services of 49 hours per week; Consumer direct, 1 client. The denial was upheld.

This is a male patient with a history of coronary artery disease, diabetes, prior stroke/cerebrovascular accident, and hemiplegia. The patient is alert and has adequate memory and recall ability that requires maximal assistance with meal preparation and ordinary housework and needed extensive assistance with managing finances, toilet use, personal hygiene, dressing his upper body, and medication and phone use. It was reported that the patient lives with his spouse in an apartment with no significant family members to help with his needs. He uses a motorized wheelchair and requires limited assistance with ambulation, locomotion, and transfers. A request was made for Consumer Directed Personal Aide Services of 49 hours per week. 

Home health services are supported for patients who are considered confined to home, such as patients who have an illness or injury that requires the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person in order to leave their place of residence or the patient has an inability to leave home as doing so requires a considerable and taxing effort. Such patients include those with late stage or complex neurodegenerative conditions. The need for assistance and support can fluctuate depending on environmental factors, underlying health conditions, and the level of individual functioning. Home health disciplines included in guideline recommendations include skilled nursing services, home health aide services, physical therapy, speech language pathology services, occupational therapy services, and medical social services.

The record failed to include a recent evaluation by his provider or the home health service to support the need for extensive personal aide service, 49 hours per week. The requested coverage for the requested Consumer Directed Personal Aide Services of 49 hours per week; Consumer Direct, 1 client is not medically necessary.

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

The carrier's denial of coverage for the requested Consumer Directed Personal Aide Services of 49 hours per week; Consumer Direct, 1 client is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Overbite/Underbite
Dental/Orthodontic Procedure

The patient has a Class II occlusion and slightly high overjet and overbite. The maxillary arch has mild crowding, and the mandibular arch has moderate crowding. He has treatment planned for 18-24 months of orthodontics to correct his malocclusion but his insurance company rejected the claim on the basis that treatment is not medically necessary. The health plan's denial of medical necessity is upheld in whole. The health plan has acted in the best interest of this patient. The patient has some maxillary and mandibular crowding. His bite is slightly deep but there is no indication of damage to the incisors or the palate in the photographs, and his cephalometric radiograph show the lower incisors are contacting the maxillary teeth in occlusion, not the palate. There is no indication from the photographs there is severe soft tissue damage (or any soft tissue damage) on this patient. There is no medical reason to correct his malocclusion with braces. The patient does have a deep bite, however, that alone is not a medical necessity to treat. The photographs do not illustrate any damage to the teeth or soft tissue damage from their current position. There are many ways to correct patients with a deep bite, and there is strong evidence that one treatment is not better than another (1). Furthermore, deep bites may be corrected in adulthood (2), so it is not as if he will lose the ability to correct his malocclusion should he choose to do so as an adult.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes; psychotic symptoms and fear of needles
 
Treatment: Skilled Nursing and Licensed Practical Nurse services

The insurer denied coverage for Skilled Nursing and Licensed Practical Nurse services. The denial is reversed. 

This patient is a male who reportedly was receiving skilled nursing services as he had medical conditions requiring nursing interventions, and he reportedly had confusion and disorganization due his psychiatric symptoms including mood and psychotic symptoms and fear of needles, as well as cognitive issues including memory deficits, confusion, and altered mental status.  He reportedly had his insulin medications of Levemir and NovoLog given by the nurse and also the nurse was monitoring his glucose twice per day.  It was reported that he was unable to self-administer medications.  He reportedly lived in an adult care facility and had no caregiver to help him with this.

The insurer denied coverage for skilled nursing and licensed practical nurse services. This reviewer disagrees with the decision to deny coverage for skilled nursing and licensed practical nurse services as this patient had psychiatric symptoms and cognitive deficits interfering with his ability to care for his medical needs.  According to Neuropsychiatric Disease and Treatment, 2013; 9; 1403-1481, "Current Approaches to Treatments for Schizophrenia Spectrum Disorders" the conclusion was that in order to improve longer term outcomes, future strategies should focus on risk identification, early intervention, partnership and teaming with caregivers, and evidence based social interventions into existing services.  

In this case, this patient lived in an adult care facility and had no caregiver to help him take his diabetes medications so he required skilled nursing and licensed practical nurse services. He reportedly had confusion and disorganization due his psychiatric symptoms including mood and psychotic symptoms and fear of needles, as well as cognitive issues including memory deficits, confusion, and altered mental status.  It was reported that he was unable to self-administer medications so the nurse was needed for this and also to monitoring his glucose twice per day.  Without these nursing interventions he reportedly would have been at risk for worsened glucose readings and complications from diabetes or even lower glucose if his medications were not properly monitored and dispensed. His psychiatric and cognitive impairments rendered him unable to do this and he was at risk medically if he did not get the proper medications dispensed or if his glucose were not monitored adequately.  

As a result, the recommendation is to reverse the previous decision and approve coverage for skilled nursing and licensed practical nurse services. The carrier's denial of coverage for Skilled Nursing and Licensed Practical Nurse services rendered is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure 
Treatment: Inpatient stay

Summary:
The patient is a male who presented to the emergency room via ambulance after a seizure event wherein he was home alone, felt dizzy, and the next thing he knew he was on the floor and his arms and hands were shaking. He complained of a constant aching headache and dizziness, and that he awoke that morning feeling confused.  He denied post-ictal symptoms. There was no incontinence.  The patient reported had a similar witnessed episode several weeks prior wherein he was shaking. Medical history was otherwise notable for bipolar disorder, insomnia, and GERD.  

The patient had seizure-like activity in the setting of abrupt discontinuation of benzodiazepine. This entity, benzodiazepine withdrawal seizures, is well known and is typically managed by reinstating benzodiazepine treatment, which usually addresses the issue. The patient was not documented to be a danger to himself or others. Considering that seizure occurred in a setting off abruptly stopping clonazepam, the risk of subsequence seizures after re-instituting clonazepam was low. Therefore, the patient could have been managed at a lower level of care, instead of inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back pain
Issue under review: Inpatient admission

Determination: The inpatient admission was not medically necessary.

The patient is an adult female with history of HIV (human immunodeficiency virus), asthma, hepatitis C, coronary artery disease status post PCI (percutaneous coronary intervention)  3, diabetes mellitus, chronic low back pain (L4-S1 disc bulge), chronic obstructive pulmonary disease on home oxygen, hypothyroidism, borderline personality disorder, depression, anxiety, and cerebrovascular accident with residual symptoms.  She presented to the emergency room with complaints of worsening low back pain, associated with bilateral lower extremity numbness.  She also reports intermittent urinary incontinence and being unable to make it to the bathroom for bowel movements, as well as chest pressure.  The patient reports falling on her back two months prior.  Per medical records, she denies fever, chills, urinary retention, bowel incontinence, saddle anesthesia, lower extremity weakness/numbness, headaches, chest pain, shortness of breath, nausea, vomiting, abdominal pain, leg swelling, and recent travel or sick contacts. Habits: Illicit drug user. 

The patient was admitted to the hospital for complaints of low back pain, lower extremity weakness, and numbness.  However, MRI of the lumbar spine did not show evidence of high-grade foraminal stenosis.  Inconsistency in medical documentation is noted: the patient was seen ambulating without any assistive device, which argues against significant lower extremity weakness.  There was no evidence to support significant focal neurological deficits or cauda equina syndrome.  Hospital management/treatment was conservative, without any surgical intervention.  For most patients with acute low back pain, bed rest is not typically advised; however, patients are usually encouraged to perform activities as tolerated.  Furthermore, she was hemodynamically stable on admission; there was no evidence of sepsis, change in mental status, acute respiratory failure, active hemorrhage that required blood transfusion, cardiac arrhythmia, severe heart failure, acute renal failure, and severe electrolyte abnormalities.   

The proposed treatment is not medically necessary, because the care rendered could have been performed at a lower level of care without adversely affecting the patient's health.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse
Treatment: Inpatient substance abuse rehab
The inpatient substance abuse rehabilitation treatment was not medically necessary for this patient.

The patient presented with substance use disorders, diagnosed with alcohol and stimulant/cocaine and sedative hypnotic anxiolytic and cannabis use disorders. He tested positive for cocaine, benzodiazepine and cannabis consistent with history. He was medically screened and had not general medical issues. He received inpatient level rehabilitation treatment. He readily engaged in treatment and had no biomedical (withdrawal symptoms or signs) or psychiatric treatment issues and did not have a psychiatric disorder. During the time interval under review, the patient was noted to be in no apparent distress with reasonable functioning and active participation in treatment including positive interactions with staff and peers. Throughout his brief inpatient stay, there were no complicating treatment issues or biomedical or co-occurring psychiatric issues that would have warranted inpatient level of care, structure or 24-hour monitoring. 

The application of NY State OASAS LOCADTR Criteria (referenced below) did indicate that the patient was clinically appropriate for treatment with lower level care in a less restrictive treatment setting, as the health plan asserts. Thus, medical necessity for the inpatient substance abuse rehabilitation treatment is not met in this case scenario, also consistent with ASAM Criteria, the scientific literature and published guidelines, referenced below. 

The patient in this case scenario is not clinically appropriate for an inpatient level of care during the time interval under review. The patient had presented with a level of stability and no general medical issues or co-occurring psychiatric disorders or safety concerns that would have warranted inpatient level care. He did not need 24-hour monitoring or the structure of an inpatient setting in order to receive effective substance use disorder treatment. He readily engaged with treatment and was involved with peer supported recovery groups that could have been provided in a less restrictive treatment setting with sober supports. Thus, the health plan's determination is reasonable in this case scenario. This answer is consistent with prevailing standards of medical practice for the conditions diagnosed and under treatment in this case, and consistent with the application of NY State OASAS LOCADTR 3.0 Guidelines.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma 
Treatment: Inpatient Stay 

Summary:
Patient with history of asthma with worsening SOB (shortness of breath) and wheezing presented to ER. Despite receiving multiple nebs and IV steroids, patient continued to have dyspnea, wheezing and was admitted to observation level of care. Patient continued to receive IV steroids and frequent nebulization treatment. Despite observation level of care, patient continued to have dyspnea, wheezing and minimal improvement in peak flow. Patient was then admitted to acute in hospital level of care. Patient's asthma exacerbation slowly improved and was discharged home after three days of total length of stay.

Patient had new onset worsening dyspnea and wheezing. Patient had significantly reduced peak flow. Despite emergency room and observation level of care, patient's asthma exacerbation was resistant to treatment and required prolonged IV steroids and nebulization treatment for improvement. Thus, the acute in hospitalization for asthma exacerbation was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertensive urgency.
Treatment Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a patient with a history of hypertension, chronic kidney disease, descending thoracic aortic aneurysm that was treated with a stent, and heart failure with reduced ejection fraction. He presented to the emergency department complaining of an acute onset of a cough. He also reported a headache, dyspnea and lower extremity edema. His blood pressure (BP) was 221/132 millimeters of mercury (mmHg) with a heart rate of 75 beats/minute. His room air oxygen saturation was 95%. An electrocardiogram showed sinus rhythm with lateral ST segment depression. His serum troponin level was elevated. His creatinine level was 3.5 milligrams per deciliter (mg/dl) (last known level was 1.8 milligrams per deciliter (mg/dl)). He was treated with intravenous nicardipine and labetalol infusions and admitted to the intensive care unit. He was transitioned to oral antihypertensive agents with intermittent intravenous hydralazine. Over the next several days he remained hypertensive intermittently with an intermittent headache. His medical regimen was adjusted. His creatinine level remained stable. He was discharged. The medical necessity of an inpatient admission is at issue.

An inpatient level of care was medically necessary.
This patient, with a history of thoracic aortic disease, presented with uncontrolled hypertension. His electrocardiogram and serum troponin level suggested the possibility of myocardial ischemia and there was a concern for an acute kidney injury given his creatinine elevation. This is consistent with a diagnosis of hypertensive emergency. Current guidelines recommend admission to an intensive care unit and intravenous antihypertensives in this situation. In addition, this patient had known thoracic aortic disease. Strict blood pressure control is important in this situation to prevent progressive aortic dilatation or dissection. In this patient, this required careful monitoring and an inpatient level of care.