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

This is a patient was admitted for respiratory monitoring for croup that required Decadron and racemic epinephrine x 2 doses. He presented with a history of one day of a cough associated with a tactile fever. His mother states that she noticed that the child had increased work of breathing over the course of the night and was fussy, crying and unable to sleep so she brought him to the emergency room (ER). She denied a change in by mouth (PO) intake, urinary output or stooling. There was no recent travel or sick contacts. In the ER, the patient was afebrile, heart rate (HR) 141, respiratory rate (RR) 30 and oxygen saturation (O2 sat) 100% on room air (RA). The health plan's determination is upheld.  This patient presented with respiratory distress from a bout of croup. He presented with increased work of breathing and was noted to have stridor. In the ED he was managed appropriately with IM Decadron and two doses of nebulized racemic epinephrine. After his second treatment child showed improvement and no longer had stridor or increased work of breathing.
Studies have shown it is" safe to dismiss a child who has received nebulized epinephrine for croup from the emergency department after 3 to 4 hours of observation if the child has:

 No stridor at rest
 Normal air entry
 Normal color
 Normal level of consciousness
 Received one dose of 0.6 mg/kg dexamethasone orally or intramuscularly"

This patient met all criteria for discharge from the emergency room post his second racemic epinephrine administration. All of his respiratory assessments after admission were stable with no distress or return of stridor. Inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain

Treatment: Inpatient Admission

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

This is a middle age male patient who presented to the Emergency Room with complaints of chest pain and shortness of breath for the past several days, accompanied with nausea and vomiting for the past three days.  Vital signs were stable, and the physical examination was unremarkable. He had a past medical history of insulin-dependent diabetes mellitus, ketoacidosis, and hyperlipidemia. He was admitted for chest pain and a cardiology consult was ordered. An EKG was performed that showed mild ST changes.  His Troponin level was negative.  He was ruled out for a myocardial infarction. A coronary angiography was done which revealed normal coronary arteries. It was noted that he had a right groin hematoma post procedure; an ultrasound was done which was negative.  He was discharged home. 

The patient presented with chest pain; however, the initial evaluation in the ER was unremarkable, including negative cardiac troponin and a nondiagnostic EKG.  Inpatient admission was not medically necessary for this patient.  In the absence of elevated cardiac biomarkers and a diagnostic electrocardiogram, the patient's care could have been provided in the observational setting, allowing for additional cardiac testing.  Further evaluation was warranted; however, inpatient admission criteria were not met.  

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

Diagnosis: Substance abuse disorder
Treatment: Inpatient detox

Summary:
The patient is an adult male who presented with a request for detoxification services. The patient reported that he was using alcohol, cannabis, and opioids (heroin), as well as a past history of sedative-hypnotic-anxiolytic use (benzodiazepine) and tobacco. 

The proposed inpatient stay and detoxification treatment and other medical services could have been safely and effectively provided at a lower level of care. The treatment of this patient's substance use disorder did not require the structure of an inpatient setting or 24-hour monitoring. The patient displayed no serious disturbance of mental status despite having a history of PTSD and depressive disorder and despite ongoing substance use disorder with multiple substances of abuse. Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance, or other emotional disturbances that would have warranted an inpatient level admission and detoxification treatment. There were no severe symptoms of withdrawal or biomedical issues in this case, and the patient had received detoxification treatment and rehabilitation substance use treatment recently with discharge from another facility five days prior to admission. The patient had fair insight and control of impulses, and a working knowledge of substance use disorder treatment with an extensive past history of multiple treatment episodes. Thus, an inpatient admission for detoxification treatment and 24-hour monitoring, and the requested inpatient level services were not medically necessary in this case scenario.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Pain Syndrome
 
Treatment:  Medication coverage

The insurer denied Medication coverage. The denial was upheld. 

This is a male patient with severe lumbar disc disease. The patient has been diagnosed with chronic pain syndrome, as well as psychiatric issues.  The patient did not have any complaints.  He was seen for his psychiatric issues at home and was doing well.  He stated he had adequate pain control with medications. The patient was noted to be moderately depressed.  It was recommended that the patient continue Depakote for bipolar disorder and continue acetaminophen-hydrocodone, as well as oxymorphone.  According to patient documentation the patient suffers from severe lumbar disc disease and was not a surgical candidate.  The patient utilizes oxymorphone and Lortab with a total morphine equivalent of 780 mg a day.  He also has participated in physical therapy and the goal for treatment is pain relief and independent living.  Patients receiving opioids should have their morphine equivalent dose (MED) calculated (mg/d) using an opioid calculator and documented. Overdose risk increases by 3.7% in patients taking an MED of 50 to 99 mg/d. This risk increases to 8.9%, with an annual overdose death rate of 1.8%, when the MED is 100 mg/d or greater.  When higher dosages are necessary, documentation of specific informed consent by the patient, closer monitoring, and periodic co-management by an appropriate subspecialist is required. The use of MED of greater than 90 mg/d is recommended to be avoided. The current medical literature supports periodic urine drug screens and a pain contract. It is also recommended by the literature if there is documentation of an objective decrease in pain and functional improvement.  According to the submitted documentation, this patient has been utilizing this medication for ongoing chronic pain.  The documentation details that the patient's morphine equivalent dose is 780 mg/day.  This highly exceeds the literature recommendation.  Furthermore, it is unclear whether the patient has a recent pain contract and undergoes urine drug screening.  

Based on the above, the medical necessity for Oxymorphone ER40mg is not substantiated.  The insurer's denial is upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Dyspnea on exertion
Treatment: Cardiopulmonary exercise testing (CPET)
The health plan should cover the proposed treatment.
The requested health service or procedure is likely to be more beneficial than any standard treatment or treatments for the patient's condition or disease.
This is a patient with unexplained dyspnea on exertion who underwent cardiopulmonary exercise testing. The patient had undergone pulmonary function testing and it was normal. No identifiable cause of dyspnea on exertion could be found on history and physical.  Thus, cardiopulmonary exercise testing is medically indicated to evaluate either cardiac or pulmonary cause of dyspnea on exertion.  This is the standard of care and is medically indicated.
Cardiopulmonary exercise testing (CPET) provides a global assessment of the integrative exercise responses involving the pulmonary, cardiovascular, hematopoietic, neuropsychological, and skeletal muscle systems, which are not adequately reflected through the measurement of individual organ system function. This relatively noninvasive, dynamic physiologic overview permits the evaluation of both submaximal and peak exercise responses, providing the physician with relevant information for clinical decision making. Once the exclusive province of research physiologists and specialized centers, CPET is increasingly being used in a wide spectrum of clinical applications for the evaluation of undiagnosed exercise intolerance and exercise-related symptoms, and for the objective determination of functional capacity and impairment. The use of CPET in patient management is increasing with the understanding that resting pulmonary and cardiac function testing cannot reliably predict exercise performance and functional capacity, and that overall health status correlates better with exercise tolerance rather than with resting measurements.
Therefore, the CPET is medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Dyspnea on exertion
Treatment: Cardiopulmonary exercise testing (CPET)
The health plan should cover the treatment. 
According to UpToDate: The optimal sequence of diagnostic testing for chronic dyspnea has not been determined.   In this patient, she had a PFT which did not show conclusive evidence for pulmonary etiology for shortness of breath.  Her complaints are mostly with exercise.  Therefore, a CPET in this patient would be justified.  
The CPET is likely to be more beneficial than any standard treatment(s) for the patient's condition or disease.
The requested testing is more likely to be helpful then an echo in determining the cause of dyspnea in this patient.  According to the American Thoracic Society and American College of Chest Physicians - the CPET is more helpful in determining the cause of dyspnea especially in a patient with exercise induced symptoms.  This patient fits that description.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Dyspnea on exertion
Treatment: Cardiopulmonary exercise testing (CPET)
The health plan should not cover the cardiopulmonary exercise testing.
It is not concluded that the cardiopulmonary exercise testing is likely to be more beneficial that any standard treatment(s) for the patient's condition or disease.
In the absence of clinical information, such as a comprehensive history about the patient's symptoms, clinical examination, assessment of the patient, appropriate laboratory data including but not limited to blood tests such as CBC looking at the hemoglobin level, blood chemistry levels looking at the electrolytes and kidney function, thyroid function, x-ray of the chest, office based six minute walk test, echocardiogram looking at the left ventricular (LV) function in the pulmonary artery pressure, and/or electrocardiogram (EKG),  it cannot be concluded that the requested service would provide benefit to the patient based on the standard of care in practice.  
There was no clinical data provided suggesting that the patient has significant cardiac disease causing congestive heart failure, or the patient had any congenital cardiac defect.  Based on the pulmonary function test, the patient does not have any pulmonary disease such as COPD, interstitial lung disease in which a cardiopulmonary stress test is required for prognostication.  There was no clinical data provided that there was a concern for mitochondrial myopathies; based on the pulmonary function test the patient is not a candidate for lung transplantation; there was no report of echocardiogram pulmonary artery pressures.  Therefore at this time with the data provided, the benefit of cardiopulmonary stress test in this individual is of unclear nature.  The standard of care evaluation and management required in patients who have dyspnea of unclear etiology is that a comprehensive clinical history with examination be performed followed by appropriate laboratory data such as blood work which includes measurement of hemoglobin electrolytes kidney function thyroid function, six minute walk test in the office, pulmonary function test, echocardiogram along with EKG, and exclusion of bronchial asthma.  If the pulmonary function test is normal, which can be possible if the asthma is under good control or in between attacks, bronchial challenge test is recommended especially in patients who have dyspnea on exertion or exercise-induced asthma.  Due to the lack of standard of care data available, it cannot be concluded that cardiopulmonary stress testing is appropriate for this patient at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertriglyceridemia 
Treatment: Lovaza
The Lovaza is not medically necessary.
Lovaza (omega-3-acid ethyl esters) is a combination of fatty acids used together with diet and exercise to help lower triglyceride levels in the blood. Lovaza is made of omega-3 polyunsaturated fatty acids, which are found in oil from fish, vegetables, and other plant sources. The patient has not tried, or is not currently receiving, one of the following products: niacin (immediate-release or extended-release), a fibrate (e.g., gemfibrozil, fenofibrate, fenofibric acid), a statin (e.g., atorvastatin).  His TG is 198 (upper limit 149). Plan requirements recommend use only for TG over 500. While there is a greater concern in transplant hearts, there is no literature that states that Lovaza is effective in outcomes in patients with TG already below 200. Treatment of hyperlipidemia in cardiac transplant recipients is similar to that in patients, without transplants, with the major exception being the issue of drug interactions between immunosuppressive agents and the lipid-lowering medications.
Thus, the plan's requirement to use fish oils prior to prescribe Lovaza is consistent with literature and common practice.  The requested Lovaza is not medically necessary at this time.
Appeal type: Medical necessity
Decision: Upheld

The patient is a male who presented to the hospital with fever, body aches, and pain with urination.On presentation, he was noted to have a temperature of 100.4 with other vital signs and the rest of his physical exam within normal limits. Labs were obtained and notable for white blood cell count (WBC) of 11 in addition to basic metabolic panel (BMP) consistent with dialysis status and without hyperkalemia. A urinalysis (UA) was noted to have >50 WBC. A chest x-ray (CXR) was unremarkable and an electrocardiogram (EKG) did not show obvious concern for acute ischemia or arrhythmia. Given concerns for urinary tract infection and possible sepsis, the patient was given antibiotics, blood cultures were drawn, and he was subsequently admitted to the hospital. A urine culture (UCX) subsequently resulted with enterococcus. He was ultimately deemed stable for discharge on 2/18 with amoxicillin.  At issue is the medical necessity of an inpatient hospital stay. The health plan's determination is upheld. 
An acute inpatient stay was not medically necessary for this patient. The patient presented with a temperature of 100.4, a positive urinalysis, and a mildly elevated WBC in the setting of recent stenting and atrial flutter ablation without other signs of sepsis. He did not have persistent fevers after admission, sepsis, bacteremia, or other reason for requiring inpatient admission. He was appropriate for a lower level of care but did not require care at the acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnoses: Chest pain, atrial fibrillation, coronary artery disease (CAD), status post stent, tachypnea
Treatment: Inpatient care, diagnostic testing and medication management.

The insurer denied inpatient hospital admission. The denial was upheld.

This patient presented to the emergency room with complaints of sharp chest pain associated with exertional and non-exertional shortness of breath for two weeks. He ran out of his medication two weeks prior and did not refill them. His past medical history diminished lung sounds, expiratory wheezes, and oxygen saturation 95% on room air. An EKG showed atrial flutter with rapid ventricular response. A chest x-ray showed concern for early congestive heart failure. He was treated with intravenous Lasix and Albuterol nebulizer. Labwork was negative. An echocardiogram was stable with low ejection fraction (EF), 35%. He was discharged to home with follow up. 

The patient does not meet the Chest Pain MCG Guidelines for acute inpatient admission. There was no documentation of hemodynamic instability, respiratory distress, and there was no evidence to support a diagnosis of acute coronary syndrome.
Appeal type: Medical necessity
Decision: Upheld

The patient with history of hypertension, hyperlipidemia, diabetes and coronary artery disease presented for elective cardiac catheterization for one month of chest pain.  Restenosis was found and treated with balloon angioplasty.  Post-procedure the patient had an episode of shaking, a possible reaction to midazolam.  This resolved. The patient was admitted and discharged the following day. The health plan's determination is upheld.

The 2009 Expert Consensus Document from the Society for Cardiovascular Angiography and Interventions recommends inpatient stay for acute ST or non-ST elevation MI, and unstable acute coronary syndrome with hemodynamic instability.  The patient was hemodynamically stable and had no abnormal biomarkers or electrocardiographic changes. The procedure was uncomplicated.  While some period of monitoring following percutaneous coronary intervention is needed, this could have been accomplished at a lower level of care status.  An inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System (Asthma)
Treatment: Inpatient Hospital

Summary: This patient with history of asthma presented to the Emergency Department (ED) with a complaint of shortness of breath. The patient also reported some cough, chills, sweating and one episode of vomiting. The patient did not obtain relief from his rescue inhaler and Symbicort; therefore, he came to the ED. The patient's past medical history included gastroesophageal reflux disease and hypertension. The patient had been recently treated for pneumonia five weeks ago for which he was treated with antibiotics and steroids. Vital signs at presentation to the ED included a temperature of 98.8F, a heart rate of 110, a respiratory rate of 28, and a blood pressure of 169/130 mm Hg. Oxygen saturations were 94% on room air. Lung exam revealed bilateral wheeze. The patient was treated with intravenous (IV) steroids and nebulizers in the ED. The patient also received magnesium. The white blood cell (WBC) count was 12.4K. The hemoglobin was 17 and the hematocrit was 52.8. Blood urea nitrogen (BUN)/Creatinine levels were 18/1.52. An influenza screen was negative. A chest x-ray showed no acute infiltrates. The patient was admitted and treated with IV fluids, IV steroids, and DuoNebs. Hydrochlorothiazide was held as the patient was clinically dry. As per the history & physical, the patient was in no acute distress. Peak expiratory flow (PEF) after treatment was 400. A lung exam revealed mild expiratory wheeze in the upper lobes. Cardiovascular heart sounds were S1 S2 normal. The abdomen was soft, nontender, and with positive bowel sounds.
 
The insurer has denied coverage for the inpatient hospital admission as not medically necessary. The denial was upheld. 

This patient had a mild asthma exacerbation which was improving after treatment in the ED. The patient had possible mild acute kidney injury secondary to dehydration (the patient was also on hydrochlorothiazide) for which he was receiving IV hydration. As per the history & physical, discharge was anticipated in 12-24 hrs. This patient did not need acute hospitalization. He could have been placed in observation while diagnostic testing and treatment were being initiated. The patient could have received oral and IV hydration in observation status. The patient improved with treatment. He remained afebrile and hemodynamically stable. PEF was 400 after treatment. He was tolerating oral intake. There was no pneumonia or influenza.  The patient was not hypoxic. He was stable for discharge on oral medications and inhalers with close follow-up in an outpatient setting.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems (Claudication of lower extremities)
Treatment: Inpatient Hospital

Summary: This patient presented to the hospital for an elective peripheral angiogram. She has claudication of both lower extremities. Her past medical and surgical history includes spinal stenosis, claudication of lower extremities, hypertension, diabetes mellitus type II, herniated disc and hyperlipidemia. Electrocardiogram (EKG) showed sinus rhythm at 82 beats per minute. The P-wave was biphasic in V1 suggesting possible left atrial enlargement. The patient's pre-study assessment of conscious sedation revealed that she was fully awake and able to maintain oxygen saturation greater than 92% room air which resulted in a perfect pre-study total of 10. She also achieved a post study conscious sedation assessment of 10. The case was listed as starting at 9:06 AM and ending at 10:48 AM. The patient tolerated the procedure well. The left superficial femoral artery (SFA) showed diffuse disease with proximal 80%, mid-90% and distal 70% stenosis. A drug eluting stent (DES) was placed in the proximal SFA and mid SFA. A drug-eluting Boulogne was used to treat the distal SFA. Post procedure pulses were 2+ in both the right dorsalis pedis and left dorsalis pedis. No complications were listed. The impression listed after the study was right SFA totally occluded, left SFA severe diffuse stenosis and left profunda femoris had moderate stenosis. It was recommended that the patient take aspirin and Plavix for at least three months and schedule an angioplasty of the right SFA in four weeks. A cardiology progress note states the reason for admission was a peripheral angiogram due to claudication. The patient was discharged home with arrangements made for outpatient follow-up with cardiology in two weeks.

The insurer has denied coverage for the inpatient hospital admission as not medically necessary. The denial was upheld.

This patient presented for an elective peripheral intervention. The patient had no symptoms at rest and was hemodynamically stable. The procedure was uncomplicated and immediately following the procedure she remained asymptomatic. The hospital notes documented that no complications occurred. Review of the literature supports this patient could have been treated as an outpatient and discharged after a short period of observation.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with skeletal class I, severe maxillary crowding, mild mandibular crowding, and anterior crossbite. The issue under review is the medical necessity for braces. The health plan's determination of medical necessity is upheld in whole.  The malocclusion in question does not meet the criteria used in most programs to be classified as handicapping and treatment would not be considered medically necessary. Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score an 18 with no auto qualifier present.