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

Diagnosis: Cardiac Ablation 
Treatment: Inpatient admission 
The insurer is denied coverage for inpatient admission. 
The denial is partially overturned. 
This is a male patient with a long history of paroxysmal atrial fibrillation who has had several ablation procedures, gastroesophageal reflux disease (GERD), obesity and sleep apnea.  He was instructed by his physician to come to the Emergency Department after having had a few hours of palpitations and lightheadedness. He described the symptoms to be as similar to his previous episodes of atrial fibrillation. His presenting vital signs were: blood pressure of 141/81, heart rate of 99, temperature of 98.2 F, respiratory rate of 18, and oxygen saturation of 96% on room air. An electrocardiogram (EKG) was done that revealed sinus tachycardia. The patient's chest x-ray was unremarkable other than a small scar at the right base. The patient's laboratory test results included white blood cell (WBC) count of 8.5, hemoglobin of 14.1, creatinine of 1.1, troponin of 0.00, BNP of 12, and TSH of 1.99. The patient was admitted to the hospital and underwent an ablation and MitraClip procedure under general anesthesia. The patient's postoperative electrocardiograms (EKG)s were remarkable for diffuse ST segment elevations consistent with pericarditis. A chest x-ray was done that showed bilateral pleural effusions. The patient was discharged on pantoprazole, sulcralfate, colchicine, apixaban, amiodarone, Percocet, Colace, sennakot, miralax, multiple vitamins, magnesium oxide, and folate.

Although there is evidence that this procedure was complex enough to require post-operative monitoring in an inpatient setting, rather than in a same -day procedure area, there is no evidence that this patient required an acute inpatient level of care until the morning. This ablation procedure with MitraClip should have been scheduled electively after outpatient medical treatment of recurrent, hemodynamically stable paroxysmal atrial fibrillation. This patient did not require Emergency Department (ED) care or inpatient admission to treat hemodynamically stable paroxysmal atrial fibrillation prior to his endoscopic modified MAZE procedure without cardiopulmonary bypass. This should have been scheduled as an elective procedure.

The health plan acted reasonably with sound medical judgment to deny coverage for but did not act in the best interest of the patient to deny coverage.

Based on the above, the medical necessity for the inpatient admission is partially substantiated. The insurer's denial should be partially overturned. Medical necessity is established.
Appeal type: Medical necessity
Decision: Upheld

Cardiac/Circulatory Problems
Inpatient hospital

The patient is a man who presented for diagnostic catheterization for unstable angina. He had an abnormal stress test. Cath showed high grade stenosis of the left anterior descending (LAD) (80%), diagonal (80%), circumflex (80%), right coronary artery (RCA) (99%) and posterolateral segment (70%). The patient underwent intervention of the RCA and PLS (Primary lateral sclerosis) with plan to perform intervention in the circumflex and LAD in 5-6 weeks. The patient was admitted and observed uneventfully overnight and discharged the following day.

The health plan's determination is upheld. The inpatient admission was not medically necessary. The patient had an elective uncomplicated catheterization and coronary intervention. It was appropriate to monitor the patient post-procedure for several hours, but that could have been performed at a lower level of care. It was expected that discharge would have been accomplished within 24 hours in this low risk patient. A full inpatient hospitalization was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Central Nervous System/Neuromuscular Disorder
Treatment:  Inpatient hospital

This case involves a female with a history of type I Arnold-Chiari malformation, as well as asthma, who presents to the hospital with a chief complaint of head fullness and visual disturbance.  Per the history and physical, the patient has a history of presyncope episodes, previously attributed to heavy periods and severe anemia for which she required transfusions.  The patient reports several months-long accounts of diffuse head fullness, as well as white out of her vision while driving.  During this episode, she had to pull over and called the ambulance.  A similar incident occurred on the day of admission; she was driving on the highway and experienced the symptoms after using an inhaler.  The patient follows with neurology.  She denied any focal weakness.  She did not lose consciousness.

The health plan's determination is upheld.  The inpatient stay was not medically necessary.  This is a near syncope presentation without evidence of cardiac arrhythmias, stroke, or seizure activity.  The vital signs are normal during the entire hospitalization, and there were no severe laboratory abnormalities that would warrant inpatient admission.  There is no clear documentation of persistent altered mental status.  The imaging fails to demonstrate a stroke or hydrocephalus in the setting of Arnold-Chiari malformation.  The patient has no evidence of other cardiac or pulmonary abnormalities, such as aortic dissection or pulmonary embolism (PE).  There were no arrhythmias on the telemetry.  There are no bradycardia or sinus pauses.  The patient did not have a real syncopal episode; she had a near syncope, without any injury.  She is not profoundly anemic, such as previously due to heavy periods, and her hemoglobin remained stable throughout the hospitalization.
In conclusion, the presentation of near syncope can be managed at a lower level of care.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Status post kidney transplant  
Treatment: Envarsus XR 4MG or TB24  

The health plan should cover the Formulary exception Envarsus XR 4MG or TB24. 

The patient is a female African-American.  She underwent a deceased kidney transplant secondary to hypertensive nephropathy.  Her post-op course was characterized for early delayed function.  Now the patient is off dialysis.  

This patient has factors that increase the risk of post-operative complications such as rejection due to the fact that she is Afro-American and has a kidney that has suffered acute tubular necrosis requiring transplant.  These two factors are diminished by the use of Envarsus XR, which provides a better profile of absorption and decreases the dose requirements, and consequently provides less exposure to nephrotoxicity for the long term management.  It is proven that African-Americans have a polymorphism at the receptor of the cytochrome 450, which is the site for the metabolism of tacrolimus.  This is reflected in an increased and faster metabolism of tacrolimus and irregularities on the trough tacrolimus blood levels, thus increasing the possibility of rejection.  Envarsus XR provides better tacrolimus blood levels, less rejection, and less nephrotoxicity, thus requiring less of a dose of tacrolimus.
Appeal type: Medical necessity
Decision: Overturned

Mental Health 
Inpatient Mental Health 

Diagnosis: Depression 
Treatment: Inpatient Mental Health

The insurer denied the patient's inpatient mental health stay. The health plan's determination is overturned in part. Two inpatient days were medically necessary. 

The patient is a male with diagnoses of Major Depressive Disorder (MDD), Cocaine Use Disorder (CUD), and multiple medical co-morbidities. Case notes document that the patient has a history of chronic and severe MDD requiring multiple hospitalizations. He was recently discharged from a prior IMHT (inpatient mental health treatment). The hospitalization under review resulted from a relapse in the patient's MDD in the context of medication non-compliance, cocaine use, and a family dispute. He voiced suicidal ideation with a plan to overdose. His mental state exam documented that the patient felt helpless, hopeless, and worthless. 

The IMHT for 2 days was medically necessary. Discharge prior to that would incur a high probability of readmission or a recurrence of suicidal ideation. The only acceptable goal for treatment of mood disorder is achievement of a euthymic state. This patient had multiple factors associated with suicide, especially if not brought to a euthymic state. Poor social attachment is associated with increased suicide risk. This patient had poor social adjustment and was at increased risk for suicide. The patient had intermittent suicidal ideation on the initial day in question. Additionally, he was depressed in mood. Only on the next day, was the patient euthymic without suicidal ideation. Therefore, he could be safely and with good judgment be discharged after two days. As of this day, the patient no longer required inpatient mental health treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Suspected glaucoma.
Treatment:  Vision services rendered. 

The insurer denied the vision services.  The denial is overturned.

The testing/services performed for this glaucoma suspect were medically necessary.

The patient is a female glaucoma suspect for whom coverage of optic nerve OCT (optical coherence tomography) and visual fields and fundus photos of the optic nerve is requested. 

An exam documents the patient following up for evaluation of nuclear cataracts of both eyes.  Ocular history was also notable for glaucoma suspect based on large cup/disc ratios.  On exam, vision was corrected to 20/25 OD (right eye) and 20/20 OS (left eye).  Intraocular pressures were 20 mm Hg OU (both eyes).  A dilated exam found cup/disc ratios of 0.7 x 0.8 OD and 0.7 x 0.75 OS.  Optic nerve OCT was performed and identified superior quadrant thinning OU outside of normal limits. It was recommended that the patient return in one week for Humphrey visual field testing and optic disc photos. 

An exam documents intraocular pressures as 18 mm Hg OD and 17 mm Hg OS.  Visual field testing did not identify any significant defects.  Optic disc photos were taken to document the patient's deep cupping.  It was recommended that the patient return in six months for repeat optic nerve OCT and in one year for repeat visual field testing. 

In this case, testing (including optic nerve OCT, formal visual field testing, and optic disc photos) was performed in the evaluation of a patient suspected of having glaucoma based on increased cup/disc ratios.  Such testing is considered medically necessary per standard of care as reflected in the Preferred Practice Patterns of the American Academy of Ophthalmology, which states that the ophthalmic evaluation should focus specifically on the following elements in the comprehensive adult medical eye evaluation:  1) Visual acuity measurement, 2) Pupil examination, 3) Anterior segment examination, 4) IOP (intraocular pressure) measurement, 5) Gonioscopy, 6) ONH (optic nerve head) and RNFL (retinal nerve fiber layer) examination, and 7) Fundus examination.

"The appearance of the optic nerve should be documented...Computer-based imaging and stereoscopic photography of the optic nerve provide different information about optic nerve status, and both are useful adjuncts to a good clinical examination."

Important ophthalmic testing also includes the following components:  1) Central corneal thickness measurement, 2) Visual field evaluation, and 3) ONH and RNFL imaging

Therefore, given the above, the services rendered were medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skeletal Class I Malocclusion, Maxillary and Mandibular Crowding, Maxillary and Mandibular Incisor Protrusion and Severely Excessive Overjet 

Treatment: D8080 Braces and D8670 Monthly Visit 

The insurer denied the D8080 braces and D8670 monthly visit. The denial was reversed. 

This is a female patient who consulted an orthodontist for orthodontic treatment. Diagnostic testing was performed that included lateral cephalometric radiograph, panoramic radiograph, montage of extraoral, intraoral clinical images and a HLD index evaluation. Recommendations were made for orthodontic therapy due to the patient's diagnosis of skeletal Class I malocclusion, maxillary and mandibular crowding, maxillary and mandibular incisor protrusion and severely excessive overjet. 

Upon review of the submitted documentation (study models were not provided for review), it is evident that the patient exhibits a significant malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care, a total score of 26 points is necessary. 

In this case, the treating orthodontist claims an automatic qualifying condition of overjet greater than 9 mm with incompetent lips or reverse overjet greater than 3.5 mm. This reviewer finds that this automatically qualifying condition criterion is met and does support the comprehensive orthodontic care. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care. 

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. This is confirmed by several studies. Each of the peer reviewed articles cited below concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need. 

The health plan did not act reasonably with sound medical judgment and in the best interest of the patient. 

The carrier's denial of coverage for the D8080 braces and D8670 monthly visit is reversed. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Weakness
Issue under review: Continued SNF

Determination:
The Continued SNF was medically necessary.

The patient is an adult male. The patient was diagnosed with a grade 4 glioblastoma multiforme.  The patient underwent left frontal craniotomy with tumor resection and carmustine (chemotherapy) wafer insertion.

The patient had progressive overall health and functional decline through discharge to the hospital overnight.  This was due to persistent herpes zoster-related neuralgia, combined with delirium.  Good faith efforts were made with physical and occupational therapies to participate as able.  The patient regressed functionally but did participate to a degree, as able.  He received nursing care related to his skin lesions and pressure ulcer, as well as opioid pain medications for 10/10 level pain.  He was followed closely by nurse practitioners and a physician during the time period under review, with medication adjustments.  There were further complications possibly due to the medication adjustments.  

Overall, the patient had frequent periods of uncontrolled pain and frequent, significant periods of delirium necessitating ongoing skilled nursing care until it was no longer reasonable or appropriate to continue care at the skilled nursing facility level.  He was not sufficiently stable for community reintegration to home or to a custodial facility, but not acutely ill enough for hospital transfer until he was transferred overnight.  Upon review of the available documentation, the health plan denial of the skilled nursing facility dates of service in question is overturned, which were medically necessary and in the best interests of the patient.
Appeal type: Medical necessity
Decision: Upheld

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

No, the inpatient admission was not medically necessary.

The patient is a male admitted with left renal colic.  Vitals were 98.5-110/75-69.  The white blood cell (WBC) count was 17,400.  The creatinine was 1.09.  Computed tomography (CT) imaging demonstrated a five millimeter (mm) right distal ureteral calculus with hydronephrosis.  Intravenous (IV) pain medications, nausea medications, IV antibiotics and IV fluids were administered.   

An acute inpatient level of care was not medically necessary.  Care could have been provided at a lower level of care.  The patient was afebrile and hemodynamically stable throughout the hospitalization. There was no significant evidence for sepsis.  Following admission, there were no unstable vital signs reported.  He did not have a documented infection or kidney failure, solitary kidney or a kidney transplant, or need for an open surgery. He did not have bilateral obstruction, acute renal failure, severe vomiting.  Pain control, IV antibiotics and IV fluids followed by next day discharge in a non-toxic patient can be provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Self-induced laceration to left wrist
Treatment: Inpatient admission
The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a man. His medical history included schizoaffective disorder, bipolar disorder, obsessive-compulsive disorder, attention deficit hyperactivity disorder, cocaine abuse, alcohol abuse, and suicidality. 

The patient presented to an emergency department as a trauma activation/evaluation after attempted suicide by self-inflicted laceration of the left wrist. En-route, his vitals became unstable with a heart rate of 144 and a blood pressure of 50/30. On physical examination, he had a three centimeter (cm) wound of his left wrist; however, it was hemostatic. Laboratories demonstrated evidence of anion-gap metabolic acidosis. Moreover, he had hyperglycemia to 500, which was treated with an insulin sliding scale and an insulin drip. Finally, the patient had elevated troponin levels. 

The patient was admitted at an acute inpatient level of care for "Near lethal suicide attempt" and anion-gap metabolic acidosis. In the emergency department, the patient was resuscitated with sterile saline and blood products; and his wound was repaired. There was no evidence of ongoing anatomic or physiologic derangements. 

According to a psychiatric consultation, "Patient will require inpatient psychiatric admission"; "He will require a 1:1."; "JUSTIFICATION FOR INPATIENT CARE: Danger to self"; and "He is at acutely elevated risk of self-harm".

The patient was deemed stable for discharge to inpatient psychiatry -- "Hypotension resolved, HR normalized, AG closed, lactate cleared, and glucose normalized. Patient medically cleared for transfer to psychiatry". 

No, the proposed treatment -- admission at an acute inpatient level of care was not medically necessary. The patient sustained a wound of his left wrist; and hemorrhage with shock, metabolic acidosis, hyperglycemia, and elevated troponin levels. However, all of these resolved with treatment in the emergency room; there were no ongoing anatomic or physiologic derangements. Therefore, there was no need for admission at an acute inpatient level of care; the patient could have been treated at a lower level of care while awaiting psychiatric admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bilateral Flank Pain, Nausea 
Treatment: Inpatient admission 
The insurer is denied coverage for inpatient admission. 
The denial is upheld. 
This is a female patient who has a history of polycystic ovarian syndrome. She presented to the Emergency Department (ED) with complaints of bilateral flanks and lower abdomen pain with associated nausea and vomiting. She was informed by her primary care provider that the urine showed signs of a urinary tract infection; she was prescribed Cipro. As directed the patient took the medication. She began to develop pain and went to an urgent care facility. She was informed that her creatinine level was 2.5. She was given intravenous (IV) fluids; her creatinine level improved to 2.1. A couple of days later, she presented to a different facility with complaints of pain. The patient underwent a computed tomography (CT) scan which was negative. Her bilateral flank pain and nausea continued; she went to the ED. Laboratory work up was performed that revealed a creatinine of 1.87 with hemoglobin at 11.3, a CPK of 64 and her urinalysis showed moderate blood; she reported that she was currently menstruating. The patient was treated with Tylenol as well as Zofran. She was admitted to the hospital for further management. She continued to receive intravenous (IV) Zofran and was able to tolerate an oral diet. An electrocardiogram (EKG) was performed. The following day after admission the patient denied any further complaints. The patient's creatinine was down-trending from 1.87 to 1.72 and her hemoglobin remained stable. The patient was discharged with instruction to follow-up. 

Based on the review of the medical record and literature, this patient could have safely been treated in an observation setting. The patient required intravenous (IV) fluids for her acute kidney injury and symptomatic relief for her nausea. The patient had no sign of
urinary obstruction, electrolyte imbalance, altered mental status, or hemodynamic instability that warranted a higher level of care. Thus, inpatient admission was not medically necessary for this patient.

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

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

Diagnosis: Spontaneous miscarriage
Treatment Inpatient Hospital
The insurer denied the Inpatient Hospital Stay
The determination is upheld.

The patient is a pregnant female who presented to the emergency room  complaining of vaginal bleeding and pelvic pain consistent with a spontaneous miscarriage. Her vital signs were normal. She had a loss of consciousness in the emergency room. She was admitted as an inpatient.  She was given intravenous fluids. She had a dilation and curettage and was discharged the same day. At issue is the medical necessity of the inpatient hospital admission.
The requested health service/treatment of inpatient stay was not medically necessary for this patient.
The patient had vaginal bleeding, however, her vital signs were stable and she was hemodynamically stable without hemorrhage. She had a hematocrit of 38 which was unchanged over time. She also had an outpatient uncomplicated procedure without excessive bleeding. She was discharged the same day and there was no intervention that required acute, inpatient monitoring. She also had no comorbidities, anesthesia complications, cardiovascular complications and she was discharged without any inpatient intervention. Her entire stay could have been accomplished at a lower level of care.