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

This is a patient with no significant medical history. She presented to the emergency department with worsening burning non-radiating abdominal pain, nausea, and vomiting. Her nausea was worse after taking her oral contraceptive pill. She had presented to the emergency department the day before and had a computed tomography scan of the abdomen and pelvis, ultrasound, and blood tests, and then was discharged on Zofran and antacids. Vital signs were unremarkable. Lab results showed a low potassium of 3.4 millimoles per liter (mmol/L). A urinalysis showed ketones, large amount of blood, and many bacteria. She was treated with intravenous Reglan, Zofran, Toradol, pantoprazole, and fluids. She had no further diarrhea, and some persistent epigastric discomfort. She was on a clear liquid diet. Lab results showed a normalized potassium. An ultrasound of the gallbladder was negative for cholelithiasis and cholecystitis. A gastroenterology consultation recommended a proton pump inhibitor twice daily, intravenous antibiotics, Zofran, obtaining imaging records, and a possible esophagogastroduodenoscopy. The next day she had no further diarrhea, and some persistent epigastric discomfort; she had tolerated advancement of her diet. An esophagogastroduodenoscopy showed gastritis and bile reflux; the recommendation was a follow-up biopsy, pantoprazole 40 milligrams (mg) twice daily, Carafate, Zofran, and Reglan. She was discharged on pantoprazole, sucralfate, and Zofran, with Gastroenterology follow-up. At issue is the medical necessity for the inpatient level of care.
The health plan's determination is upheld. In this case, the patient presented with abdominal pain, nausea, and vomiting. This was consistent with inflammation (esophagitis, gastritis, duodenitis, peptic ulcer disease) or gastroenteritis, and the patient was appropriately treated with proton pump inhibitor therapy; however, there was no sustained tachycardia or hypotension, gastrointestinal bleeding, acute pancreatitis, gastrointestinal perforation, abscess, fistula, peritonitis, sepsis, or bowel obstruction [1-5]. The patient had an endoscopy with a finding of gastritis two days after presentation, and had close monitoring and treatment with pain medication, which were warranted. However, all of the measures that were undertaken, such as observation, monitoring, labs, endoscopy, intravenous fluid administration, and proton pump inhibitor therapy, could have been performed without acute inpatient level of care [2-5].
The patient did not meet the Milliman Care Guidelines, Abdominal Pain, Undiagnosed for an inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal
Treatment: Inpatient Hospital
The insurer denied: Inpatient stay
The denial is: Overturned in whole

The patient is a male who presented to the emergency room for acute onset abdominal pain, diarrhea, and vomiting. He had a computed tomography (CT) scan done at the emergency room which showed inflammation at the terminal ileum but could not fully visualize the appendix. He was admitted and started on intravenous fluids. He improved the following day and tolerated diet advancement. He was discharged home with plans for outpatient follow up. The subject under review is the medical necessity for the inpatient stay.

Yes, the inpatient stay was medically necessary for this patient. This patient presented with acute onset of right lower quadrant pain. He also had vomiting and diarrhea. His vital signs at the emergency room showed tachycardia, which indicates dehydration. The CT scan was not able to fully visualize the appendix, therefore, acute appendicitis was not ruled out. Acute appendicitis can be life threatening if undiagnosed in a timely manner.

The patient continued to have pain despite the treatments receiving in the emergency room. Continued monitoring and repeated exams were indicated in order to detect early signs of acute appendicitis. The patient also required to remain fasting during the monitoring period and receive intravenous fluids. Therefore, outpatient management was not appropriate for this child.

Therefore, the admission was consistent with the generally accepted practices and was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic /musculoskeletal/back pain  
Treatment: Inpatient hospital stay
The insurer denied  the inpatient hospital stay
The denial is upheld in whole 

The patient with a past medical history significant for chronic kidney disease, hypertension, transient ischemic attack (TIA), sickle cell trait/thalassemia trait, cervical spinal stenosis with cord impingement at Cervical (C)5-C6 level, and possible history of sarcoma who presented to the hospital with acute onset of pain, which was located in the left lower back/buttock with radiation down the posterior aspect of the left lower extremity. The hospital stay was not medically necessary for this patient at the acute inpatient level of care. In this clinical case, the patient presented to the hospital with complaints of sudden onset of back pain, hip pain. At the time of admission and during the hospital stay the patient remained afebrile and hemodynamically stable. Neither the review of systems nor the results of the physical examination were suggestive of the presence of a serious medical problem that would necessitate admission at the acute inpatient level of care. Specifically, the patient had no signs of cord compression. Multiple diagnostic tests were performed and demonstrated no evidence of vertebral compression fractures that were unstable or required any surgical intervention. There was no evidence that the patient's symptoms were related to any kind of infection, including infection in the spine. The thorough evaluation performed in the hospital did not reveal that the patient's symptoms were related to any other serious conditions, including aortic dissection or perforated bowels. The pain was managed with the application of Lidocaine patches, oral pain medications, and muscle relaxants. There was no need for frequent administration of parenteral pain medications to achieve adequate pain control. Taking into consideration all these facts, the severity of the patient's condition or the complexity of services provided during the hospitalization were not medically necessary at the acute inpatient level of care.
The admission for a lower level of care to ensure adequate pain control and to rule out the potentially serious reason for the patient's symptoms was necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male at the time of admission to the hospital, with a past medical history significant for HTN (hypertension), dyslipidemia, GERD (gastroesophageal reflux disease), diabetes and family history of CAD (coronary artery disease), who presented for evaluation of non-exertional chest pain, epigastric pain and vomiting. The patient was hypertensive on admission. ECG revealed no acute ischemic changes. Chest CTA revealed no PE (pulmonary embolism), no aortic dissection and aortic dilatation at 4.0 cm. Cardiac troponins were negative. The patient was admitted to rule out ACS (acute coronary syndrome). Repeat cardiac enzymes were negative. The blood pressure was controlled with medical therapy. Patient was seen in consultation by cardiology. 2D echo revealed normal wall motion. Outpatient follow-up for stress test was recommended.

No, the proposed Inpatient admission is not "medically necessary".

This patient presented for evaluation of chest pain. The diagnosis of an acute MI (myocardial infarction) was ruled out by cardiac enzymes, which were negative. There was no evidence of acute myocardial infarction, ACS, decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability.  Chest CTA revealed no acute PE or dissection. There was no indication for an acute surgical pathology. Outpatient stress test was recommended. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission and the care required could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain 
Treatment: Inpatient admission 

The insurer denied the inpatient admission. The denial is overturned. The inpatient admission was medically necessary. 

The patient has a past medical history significant for connective tissue disease, rheumatoid arthritis. She presented to the ER for evaluation of new onset chest pain. 

The patient was hypertensive with BP (blood pressure) of 168/80. ECG (electrocardiogram) revealed normal sinus rhythm with prolonged QT interval. Chest X-ray was unremarkable. The cardiac troponin was elevated at 1.7, consistent with myocardial injury/NSTEMI (non-ST elevation myocardial infarction). The patient was admitted to telemetry and started on medical regimen for ACS (acute coronary syndrome). 

The patient's repeat troponin was trending up to 2.13. The patient underwent cardiac catheterization, and she was found to have non-obstructive CAD (coronary artery disease). Her LV (left ventricle) function was normal. No revascularization procedure was required. The patient was continued on medical therapy and discharged home with a plan for outpatient follow-up. 

The patient presented with new onset chest pain, suggestive of unstable angina. The ECG was unrevealing for ACS, but was abnormal, with QT prolongation. Troponin was elevated, and trended up on repeat testing, consistent with myocardial injury/NSTEMI. There was a high index of suspicion for an ACS, and a cardiac catheterization was performed. Given the presentation, elevated cardiac biomarkers, as well as clinical suspicion for an acute coronary syndrome/unstable angina, she would not be an appropriate candidate for an ED chest pain observation unit, and it would be consistent with the current standard of care that this patient be managed in an inpatient setting. Therefore, the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain 

Treatment: Inpatient admission 

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

The patient was a male with a history of hypertension, diabetes, hyperlipidemia, hypothyroidism, cardiac stents, ablation, and coronary artery bypass graft (CABG), and myocardial infarctions who presented to the Emergency Department (ED) for complaints of burning substernal discomfort for 4 days, chest pain and neck pain. The patient's initial blood pressure was 184/97. The patient's initial lab findings showed elevated glucose of 555, CK-MB 308, cholesterol 209, triglyceride 361, VLDL of 72, HDL of 33, Troponin of 0.26, 0.37, Lipase of 60, HgA1C of 12.6, and low total protein of 6.2, and eGFR 66.10.  The patient's electrocardiogram (EKG) revealed sinus bradycardia with nonspecific inferior ST depressions, along with borderline ST depressions in leads V4 to V6. The patient was admitted to the Telemetry unit.  The patient was seen by the cardiologist.  The patient was ruled out for myocardial infarction.  The patient was cleared for discharge home.

Based on the review of the medical record, the patient presented with chest pain. Considering this patient's extensive cardiac history, including myocardial infarction and coronary artery bypass graft surgery, this patient was a high-risk patient for an acute cardiovascular event. The patient's ED workup showed concerning signs of elevated blood pressure of 184/97 and uncontrolled diabetes of 12.6 with elevated glucose level of 555. The patient's EKG and troponin level increased from 0.26 to 0.37 was suspicious for acute myocardial infarction (AMI). Though this patient was later ruled out AMI by cardiologist, this patient presented to the ED with alarming clinical signs and symptoms of angina as well as uncontrolled diabetes that needed inpatient level of care, treatment and monitoring. The patient's blood pressure also needed to be treated and stabilized. Based on the review of the clinical guidelines, this patient met the criteria for inpatient level of care and admission. Thus, inpatient admission was medically necessary to treat this patient's medical condition.

The carrier's denial of coverage for the inpatient admission should be reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Alcohol Abuse.
Treatment:  Intensive outpatient substance use treatment. 
The insurer denied the Intensive outpatient substance use treatment.  The denial is overturned.

The proposed treatment, intensive outpatient substance use treatment, was medically necessary for this patient.

The requested benefit of Intensive outpatient substance user treatment could not have been effectively provided at a lower level of care in this case scenario.  The patient in this case presented with a mood disturbance with suicidal risk and was using large quantities of alcohol on a daily continuous basis with severe psychosocial stressors and functional impairments that did warrant continued IOP level structure, monitoring and services.  The treatment for the co-occurring disorders diagnosed in this case could not have been safely or effectively provided at a lower level of care following the comprehensive assessment that was provided at the time of admission.  Moreover, the patient's social environment was not conducive to lower level treatment, and the patient struggled with craving in the context of the mood disturbance and associated symptoms of anxiety with limited insight, impaired judgment and poor control of impulses.

Thus, the clinical features and treatment dimensions did necessitate the continued structure of an IOP level setting with intensive treatment, structure, supports, and safety monitoring.  The patient's history of substance use (frequency and quantity) together with the severe psychosocial stressors and co-occurring psychiatric disorders do reflect a complicated clinical picture and do support and the need for a safe and effective treatment setting, especially in regard to recent suicidal threats while using alcohol and the potential for high risk behaviors while under the influence of alcohol.  The documentation clearly indicated that the patient was at high risk for treatment failure if treatment were to be attempted at a lower level of care.  Therefore, medical necessity is met in this case, consistent with prevailing standards of professional practice, published practice guidelines, the American Society of Addiction Medicine (ASAM) Criteria, and the scientific literature, referenced below, and it is consistent with New York State instruction for medical necessity reviews including the appropriate application of NY OASAS LOCADTR 3.0 Criteria.

The requested benefit of continued intensive outpatient substance use treatment is clinically appropriate, medically necessary and warranted, and, therefore, a covered benefit in this case scenario.  The treatment of the patient's co-occurring mental health and substance use disorders could not have been safely or effectively provided with lower level services, as notes above.  Thus, the requested benefit is not excluded under the plan and should be covered in keeping with prevailing standards of care and the guidelines and scientific literature, referenced below, as well as NY State instructions for this case review.
Appeal type: Medical necessity
Decision: Upheld

Prostate Cancer
Cancer Screening

The patient is a man who was diagnosed with prostate cancer, with elevated prostate-specific antigen (PSA) 3.3, Gleason score of 3+3, and clinical stage T2c, maximum % of tumor involvement in any core < (less than) 50%. PSA volume was 30, and PSA density of was 0.11. The number of cores + (positive) was 2 and 10 were collected. Only the right lobe had adenocarcinoma. It was grade group 1 of 5. Therefore, the patient is considered to be intermediate risk (favorable) according to National Comprehensive Cancer Network (NCCN) Guidelines/risk stratification.
The Oncotype DX Prostate cancer assay was ordered and is under review.

The health plan's determination is upheld. The Oncotype DX prostate cancer assay is not medically necessary for this patient based on the provided documentation. The NCCN Guidelines state this assay can be considered if life expectancy is > (greater than) 10 years. There is no mention of this patient's life expectancy in the provided records. Full assessment of such assay's clinical utility requires prospective, randomized clinical trials, which have not been completed at this time. The data are based on retrospective case cohort studies. Most experts in the field consider additional studies to be needed before any of such assays can be incorporated into routine clinical care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Moderate to severe left arterial insufficiency 

Treatment:  Inpatient admission

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

This patient is a man with a past medical history notable for diabetes mellitus, hypertension, coronary artery disease, and peripheral artery disease.  He presented to the hospital for elective peripheral angiogram with possible intervention.  He had heavy right calf pain and lower extremity edema.  His angiography revealed diffuse aortic disease, severe right common iliac disease, and moderate left common iliac disease.  Medical management versus intervention was discussed.  There were no complications, and he remained hemodynamically stable during his hospitalization.  He was admitted to the hospital and, when deemed appropriate for discharge, was discharged home for outpatient follow-up.

Acute inpatient admission is not medically necessary.  According to MCG Guideline "Peripheral Revascularization, Lower Extremity" (ORG: S-1310 (ISC)), the patient did not meet a priori indication for inpatient admission, but rather the elective peripheral angiogram with intervention is, per the guideline, an outpatient procedure. This procedure allows for extended stay up to 1 day, however this would meet criteria for observational status.  The patient did not have any qualifying conditions warranting inpatient admission status, and remained clinically stable post-procedurally, exhibiting no signs of organ system dysfunction, hemodynamic instability, infection, bleeding, or other cardiac abnormalities. 

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

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

Diagnosis:  Psoriasis
Treatment: Taltz

The treatment with Taltz is not medically necessary.

The patient is a male with psoriasis, treated with topicals and Stelara.  The provider wants to switch the patient to Taltz after failure of Stelara.

Taltz is not approved in patients under age 18, and there is insufficient evidence in current peer-reviewed literature to support its use in adolescents.  The request is therefore not medically necessary.  No literature was found studying Taltz in patients under age 18.

Enbrel is a treatment that has been used in children with psoriasis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low back pain
Treatment: Spinal Cord Stimulator, two units
The insurer denied the spinal cord stimulator, two units.  
The denial was upheld.
The use of dorsal root ganglia is not considered medically necessary for this patient. 
The patient is a female with history of post laminectomy syndrome. The patient has attempted physical therapy (PT), medications, radiofrequency ablation (RF) ablation, acupuncture, and massage without improvement. She had previous L5-S1 decompression. 
The patient underwent dorsal root ganglion (DRG) trial which provided significant relief.  The patient was recommended for DRG nerve stimulator for treatment of pain related to anterior superior iliac spine (ASIS) musculature.
The patient's pain is noted to be mainly in the low back and does not correlate with the ASIS muscles that were described. The notes do not support that DRG stimulation would be beneficial based upon the clinical documentation provided and it is not well documented the outcomes from the previous DRG trial. Notes do indicate the patient was considered for lumbar fusion as well as spinal cord stimulator trial. Based upon all the documentation provided, the proposed DRG stimulator is not medically necessary.
The denial is appropriate and there is insufficient evidence provided that the patient would benefit from DRG stimulation; therefore, it is not deemed medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who presented with complaints of a headaches. He had an elevated blood pressure. He was treated in the emergency department with antihypertensives with improvement in symptoms and improvement in blood pressure. Acute stroke or hemorrhage required exclusion. It was noted "patient is still awaiting placement to Skilled Nursing Facility (SNF)." It was noted "patient is still awaiting placement to SNF. The patient is medically stable and discharged on 11/6/19 and "patient still awaiting placement to SNF." At issue is the medical necessity of an inpatient stay.
The health plan's determination is upheld.

No. The inpatient stay was not medically necessary. According to the provided documentation, the patient was admitted on and discharged by his treating physicians on and was awaiting placement after that date. However, there is no clear need for an acute inpatient hospitalization. An inpatient admission was not medically necessary.
The patient underwent a head computed tomography (CT) scan that was suspicious for a possible stroke. A stroke was ruled out with a brain magnetic resonance imaging (MRI) scan and a venous sinus thrombosis was ruled out with magnetic resonance venography (MRV). A stroke, venous sinus thrombosis and intracranial hemorrhage could have been ruled out in the emergency department or at a lower level of care with a head CT scan, brain MRI and MR venography. Once a stroke was excluded, the patient could have been discharged as acute inpatient hospitalization was not needed. He otherwise did not require any neurological or hemodynamic monitoring once his blood pressure was stabilized. He did not have any arrhythmia or other cardiac abnormalities requiring monitoring. He did not require any oral medications or hydration. He had an abnormal mental status that was chronic. There was no need for any intravenous medications or hydration. There is no expectation of any neurological decline once his blood pressure was stabilized and acute stroke, hemorrhage and sinus thrombosis were ruled out. Acute inpatient hospitalization was not medically necessary.