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

Digestive System/Gastrointestinal - Abdominal/Stomach Pain
Pharmacy/Prescription Drugs

The patient is a male with low back pain. The patient's diagnoses include abdominal pain, anemia due to gastrointestinal blood loss, anxiety, back pain, depression, gastrointestinal stromal tumor, gastroparesis, nausea. There is a request for Zubsolv 8.6-2.1 mg three times a day. This is under review for medical necessity.

The health plan's determination is upheld, in whole.

Zubsolv (buprenorphine and naloxone), a Food and Drug Administration (FDA)-approved medication for maintenance treatment of opioid dependence, is a once-daily sublingual tablet that offers higher bioavailability that allows patients to use lower strength and reduce the amount of available drug for potential misuse and diversion. In this case, the medication is being utilized for neoplasm related pain. There is no support for the use of this medication in this clinical scenario. Hence, the requested health service/treatment of Zubsolv 8.6-2.1 mg three times a day is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dumping Syndrome 
 
Treatment: Inpatient Admission 

The insurer denied the inpatient admission. The denial was reversed. 

This is a female patient with a medical/surgical history of gastric bypass with intermittent dumping syndrome. She presented to the emergency department (ED) with complaints of epigastric pain, nausea and vomiting.  She was consulted by Gastroenterology.  Laboratory work up was performed noting hemoglobin of 8.8 and hematocrit of 29.6.  A computer tomography (CT) of the abdomen, chest and pelvis were performed revealing a dilated esophagus, with small free fluid in the pelvis, and a 4 mm nodule in the anterior medial basal left lower lobe.  An oral challenge was ordered and administered; the patient failed the exam. An attempted esophagogastroduodenoscopy (EGD) with dilatation was performed however it was incomplete due to retained food in the lumen of the esophagus.  It was noted that the patient's presenting abdominal pain was likely from esophageal complications after surgery.  Intravenous (IV) fluids and Reglan were administered.  The patient was medically stabilized and discharged home. 

The clinical parameters at presentation were stable, but the CT findings and the inability of the patient to take anything oral warranted admission and endoscopic evaluation.  The EGD findings also corroborate the severe dysphagia that the patient had.  She also had significant anemia which warranted evaluation.  However, the reason for acute care management was inability to take any nutrition orally.  
The insurer did not act reasonably, or with sound medical judgment, or in the patient's best interest.  

The carrier's denial of coverage for the inpatient hospital services at the acute level of care is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of hypertension who was admitted to the hospital. He was racing on his bicycle when he swerved to avoid an individual who was texting while walking. He collided with a vehicle and experienced an episode of mental cloudiness during the incident. In the emergency department, he had a laceration of the chin that was repaired. He had otherwise been in his usual state of health and denied fevers, chills, nausea, vomiting, chest pain and shortness of breath. Vital signs showed a temperature of 36.2 degrees Celsius, heart rate 74,  and blood pressure 138/100. On physical examination, he was in no distress, neck was supple, heart was regular, and breath sounds were normal. There were no cranial nerve deficits. There was no joint swelling or tenderness. The health plan's determination is upheld.
No. The patient was admitted for suspected syncope. The plan of care included electrocardiogram (EKG), telemetry, intravenous (IV) fluids, monitor blood pressure, cardiac enzymes, and consider Holter monitor with cardiology as an outpatient. There was no evidence of an arrhythmia on telemetry overnight. He was also provided with a referral to neurology as an outpatient, although there was low suspicion.
Based on the available documentation, the patient was hemodynamically stable, had no evidence of sepsis, negative cardiac enzymes, no acute abnormality seen on telemetry, no evidence of encephalopathy or ingestion, and stable labs. He needed further evaluation but it could have been safely and effectively provided a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Concussion

Treatment: Inpatient admission

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

This patient is a male child with no past medical history who presented to the Emergency Department as a level 2 pediatric trauma after falling 2 feet and missing a step while running in the park. The patient's mother reported that the patient had lost consciousness at the scene for approximately 2 minutes and was difficult to arouse. The hospital records detailed that the patient had lost consciousness immediately after arrival to the trauma bay and was noted to be in bradycardia while on the cardiac monitor. His Glasgow Coma Scale (GCS) was detailed as 15. The Computer Tomogram (CT) scans of the cervical spine were negative for fracture, dislocation, and ligamentous injury. It was detailed that the patient will be admitted for observation due to suspected concussion. It was briefly stated that upon immediate arrival to the Emergency Department, the patient appeared confused but obeyed commands and was alert to verbal stimuli. The patient's eyes were detailed as pupil's equal, round and reactive to light.

The health plan acted reasonably with sound medical judgment and in the best interest of the patient. The inpatient admission is not considered medically necessary. The current literature indicates a pediatric patient may be admitted when there is evidence of a metabolic disorder persisting despite observation, recurrent seizure, increased intracranial pressure, new and persistent focal neurologic deficits, altered mental status that is severe persistent or there is evidence of hemodynamic instability. Within the documentation it was noted the patient presented with some confusion, but the symptoms resolved quickly without intervention. The submitted documentation does not detail the patient had a trial and failure of care at a lower level such as observation. The documentation detailed the patient did continue to slowly improve and was discharged the following day. However, as there were no documented clinical symptoms requiring inpatient admission, the prior denial was appropriate.

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: Advanced metastatic melanoma
Treatment: CDPAP (consumer directed personal assistance program) 12 hours/day, seven days/week

The CDPAP 12 hours per day, seven days per week, is medically necessary.  

The patient is a male. The patient in this case has metastatic melanoma.  He was recently treated with whole spine radiation therapy.  He has symptoms which include fatigue, pain, mobility limitation and neurologic symptoms.  He was recently hospitalized and his physician wrote a letter indicating that due to this and effects of radiation treatment he cannot walk, bathe, toilet or dress independently.  He requires total assistance with activities of daily living (ADLs) and personal care.  He has been getting 6.5 hours/day of in home assistance.  The request in this case is for an increase to 12 hours/day.
Additional records clearly indicate that this patient has suffered continued functional decline and now needs assistance with essentially all activities of daily living and otherwise.  They specifically catalog the degree of decline in functional activity and the significant increase in level of assistance needed.  Given the significant change in this patient's functional status due to worsening medical condition, the request for 12 hours per day is considered medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse
Treatment: Continued residential rehabilitation 

The Continued residential rehabilitation is not medically necessary for this patient.

The patient presented with alcohol use disorder with the past use of other substances of abuse and prior treatment episodes, and with continued use of large quantities of alcohol on a daily continuous basis with decline in functioning and psychosocial consequences/stressors. He received residential level rehabilitation treatment. He readily engaged in treatment with continued progress, as noted in the clinical summary. During the time interval under review, the patient is noted to be in no apparent distress with improved functioning and active participation in treatment including positive interactions with staff and peers. From the date of service under review and forward, there were no remaining treatment issues or biomedical or co-occurring psychiatric issues that would have warranted continued residential level of care. 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 continued residential rehabilitation treatment is not met in this case scenario consistent with ASAM Criteria, the scientific literature and published guidelines, referenced below.

The patient in this case scenario is not clinically appropriate for the continued residential level of care during the time interval under review. The patient had reached a level of stability by the date of service under review such that he no longer warranted residential level care and could have been/can be effectively managed in a less restrictive treatment setting with sober supports and monitoring. He no longer needed/needs 24-hour monitoring or the intensity of residential level treatment to address the co-occurring psychiatric disorder or remaining symptoms related to his substance use disorder. He is noted to be engaged with treatment and involved with peer supported recovery groups, as noted in the clinical summary. 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 entirely consistent with the NY State instruction for this review and NY State OASAS LOCADTR 3.0 Guidelines applicable in this case.
Appeal type: Medical necessity
Decision: Upheld

Back Pain
Pharmacy/Prescription Drugs

This is a patient with a medical history significant for chronic pain in the lower back, neck and upper back. A magnetic resonance imaging (MRI) scan of the cervical spine noted no cord compression or abnormal cord signal. "Mild canal stenosis at cervical (C) 4-5, C6-7, and C7-T1 due to disc osteophyte complexes...Right greater than left foraminal narrowing at C3-4 and C4-5 due to facet arthropathy. Moderate left foraminal narrowing at C6-7." An MRI of the lumbar spine noted "Mild 1 millimeter (mm) disc bulging at L4/L5 without nerve root compression; otherwise, negative MRI." It was noted that patient requested Oxycontin along with Endocet for the treatment of pain. "The medication was denied and Morphine Sulfate extended release and Fentanyl patches (total opioid daily dose of less than or equal to 90 Morphine Milligram Equivalents [MME]) were recommended." At issue is the medical necessity of OxyContin 15mg OR T12A.
The health plan's determination is upheld.

The requested treatment of Oxycontin 15mg OR T12A is not medically necessary. The patient is taking Oxycontin 15 milligrams (mg) BID and Endocet 10/325 mg every (q) 6 hours number (#) 120/month. This is a daily MME of 105. "Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain--United States, 2016" stated that clinicians should "carefully reassess benefits and risks when considering increasing dosage to 50 morphine milligram equivalents or more per day." Additionally, "Chronic opioid therapy for chronic non-cancer pain: a review and comparison of treatment guidelines" does support opioid use in chronic pain but does note that "100 to 120 mg morphine equivalent seems to be a prudent reference level for heightened caution , due to evidence of increased morbidity and mortality at these doses." As this patient has non-cancer related pain and his imaging findings are minimal this does not support a MME of 105 and therefore Oxycontin 15 mg BID is not medically necessary.
As noted in the included documentation "Morphine Sulfate extended release and Fentanyl patches (total opioid daily dose of less than or equal to 90 Morphine Milligram Equivalents [MME] 0 were recommended." Both of these medications would be appropriate as there was no documentation stating an inability to use them.
Appeal type: Medical necessity
Decision: Upheld

The patient was brought to the emergency department (ED) with a three day history of a fever and cough. He had no prior history of asthma or wheezing. On arrival at triage, his temperature was 37.9 degrees Celsius, oxygen saturation 92% on room air, and respiratory rate (RR) 37. Triage comments were that he had increased work of breathing and oxygen saturation (O2 sat) 92-93% on room air, with a capillary refill of less than two seconds. The initial physician physical exam documented a well-nourished, well-developed, well-hydrated patient in no distress, but with positive retractions and positive wheezing. 

Physician follow up notes indicate that the patient initially had retractions and wheezing and was placed on observation status in the ED and treated with duonebs and steroids. On reassessment, he continued to have wheezing and was given more nebulizer treatments. Physician notes indicate that on reassessment, "after treatment of albuterol and decadron, patient with significant improvement. Work of breathing has improved." A viral respiratory swab was positive for rhinovirus. 
He was admitted to the hospital for further management. Documentation upon arrival is RR 18, oxygen saturation 92-94% on room air, intercostal retractions, clear breath sounds bilaterally, well hydrated and well perfused. The diagnosis is bronchiolitis versus reactive airway disease. The patient was admitted to the hospital for further management and discharged later the same day. The issue under review is the medical necessity of an inpatient stay. 

The health plan's determination is upheld. This patient presented to the ED with upper respiratory infection (URI) symptoms for a week and one day of increased work of breathing. He had mild tachypnea, retractions, and hypoxemia on arrival and documentation of significant improvement following ED management. He did not require inpatient acute care following the ED/observation management because of the significant improvement and a lack of serious respiratory distress or hypoxemia upon presentation or during any time he was in the ED.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal - Abdominal/Stomach Pain 
Treatment: Inpatient Hospital 

The patient is a male with a history of pancreatitis due to alcohol, continued alcohol abuse, marijuana abuse, tobacco abuse, hypertension, and abnormal glucose. He presented to the emergency room with a 3 day history of abdominal pain and vomiting. He appeared well and was in no apparent distress. His vital signs were unremarkable, and he was afebrile. The physical exam was only notable for left upper quadrant tenderness without rebound. Lab studies were unremarkable. The abdominal computed tomography (CT) scan showed "suspicious stranding around the pancreatic head that may indicate early stage of pancreatitis." Despite the minimally abnormal abdominal exam and normal lab studies, a diagnosis of acute pancreatitis was made, and the patient was admitted. 

Upon admission, the patient was treated with intravenous fluids with advancement of the diet as tolerated, along with an alcohol withdrawal protocol. Soon after admission the patient indicated that he felt well and had no further abdominal pain, nausea, or vomiting. He requested discharge but was asked to sign out against medical advice. 

The health plan's determination is upheld. 

Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, or imaging of an imminently life-threatening cause of the patient's complaints. The vital signs were normal, the abdominal exam revealed minimal tenderness, the labs were normal, and the CT scan was nonspecific. There was no evidence of severe withdrawal, sepsis, or severe metabolic disarray. In addition, his symptoms rapidly cleared. The patient's care could have been safely provided at a lower level of care status. Based on the standard of care and peer reviewed literature, the inpatient level of care was not medically necessary, and the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems - Other 
Treatment: Inpatient Hospital 

The patient is a female with a history of multiple medical problems including morbid obesity, asthma, sleep apnea, diabetes, gastroesophageal reflux disease (GERD), and depression. She presented to the emergency room complaining of episodes of postural lightheadedness and possibly an episode of syncope. Of note: she was on a very large number of medications including furosemide, metolazone, oxybutynin, pregabalin, tizanidine, propranolol, and Percocet. Vital signs were notable for a blood pressure of 173/81 and a body mass index (BMI) of 45. She was afebrile and the oxygen saturation was 99% on room air. On physical exam, she was in no distress, and the exam was otherwise non-contributory. Labs were notable for a creatinine of 2.47. The electrocardiogram (EKG) was negative for acute ischemia and the chest x-ray did not show an infiltrate. The patient was admitted for further treatment and evaluation.
Upon admission, the patient was treated with intravenous fluids and oral medications. The diuretics were discontinued. The creatinine was down to 1.12. The remainder of the stay was clinically uneventful, and she was discharged. 

The health plan's determination is upheld. 

Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or EKG of an imminently life-threatening cause of the patient's complaints. The presenting symptoms, signs, and laboratory findings readily supported a diagnosis of postural lightheadedness (including possible syncope) and dehydration, most likely due to a very potent diuretic regimen (loop diuretic and metolazone) in the setting of polypharmacy. There was no evidence of a more serious cause of dehydration, such as infection. There was no vomiting or evidence that the patient was unable to maintain oral hydration. In addition, there were no clinical indications supporting the need of acute inpatient care for the syncope. The services provided - EKG monitoring, intravenous fluids, oral medications - did not require acute inpatient care. Indeed, the creatinine readily corrected with several hours of intravenous hydration.
Appeal type: Medical necessity
Decision: Upheld

GERD
Surgical Services  (All)

This patient is a man (body mass index (BMI) 24 kg/m2) who sought surgical evaluation for the condition of gastroesophageal reflux disease (GERD). The records indicate that the patient has had GERD symptoms for many years (heartburn, chest pain, and regurgitation) and has been treated with Famotidine, Zantac, and Lansoprazole. Despite this, he continues to have breakthrough symptoms. The records do not mention if there is dysphagia. The treating surgeon has proposed the LINX procedure as treatment of GERD. The health plan has denied this treatment. The LINX Reflux Management System Surgery and Inpatient Stay is under review.

The health plan's determination is upheld. The LINX Reflux Management System Surgery and inpatient stay is not medically necessary for this patient. Considering the submitted documentation, the published literature, and the clinical details of this case, the requested LINX procedure and inpatient stay is not indicated for the condition being treated in this case. In this case, there is an esophageal motor abnormality noted on motility testing. There is no documentation regarding symptoms of dysphagia. There has been a recommendation for a gastric emptying study that is not submitted with the review material.
LINX has been shown to be an effective therapy for well selected patients with pathological esophageal acid exposure, preserved esophageal motility and no alternative diagnosis or contraindication to application of LINX. While LINX is appropriate for selected patients with GERD, the submitted medical record does not support that this patient is such an appropriately selected patient due to the esophageal dysmotility condition and possible alternative gastric emptying condition. Therefore, LINX and inpatient stay is not medically necessary in this case.