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

Diagnosis: Depression and suicidal ideation, history of recurrent major depressive disorder with associated symptoms of anxiety and insomnia
Treatment: Inpatient mental health treatment
The insurer denied the inpatient mental health treatment.
The denial is upheld.

The patient is a male with a history of recurrent major depressive disorder with associated symptoms of anxiety and insomnia. He was re-admitted to acute inpatient psychiatric care after discharge from another psychiatric treatment facility and an eviction from his apartment. He presented to the emergency department with worsening symptoms of depression and suicidal ideation. The severe symptoms of depression occurred in the context of severe social stressors including homelessness and financial problems. He was admitted due to the severity of symptoms and risk for suicidal behavior in the context of past suicidal behavior and past psychiatric hospitalizations with the most recent occurring in the same month of his admission.

The patient's admission and initial treatment for mood disturbance with suicidal risk and severe psychosocial stressors did require inpatient level services, structure, and monitoring that included a comprehensive evaluation with affirmation of diagnosis and development of a comprehensive treatment plan. The patient's severity of symptoms, and safety risks necessitated continued acute inpatient care. However, the patient had improved to the extent that he did not need the continued structure of an acute inpatient setting or 24-hour monitoring going forward. The patient had improved clinically, and, he did not require continued acute inpatient level services in order to be safely and effectively treated for his mental health condition; he was more motivated and capable of participating in treatment with medication adherent and had shown compliance with the treatment plan targeting mood disturbance and functioning. The patient no longer exhibited or displayed severe psychiatric symptoms or inability to function that had required admission and acute inpatient level treatment. Again, he was generally compliant with the treatment plan and adherent with medications, and attending to daily activities, and, he denied suicidal ideation, plan or intent; he was therefore amenable to treatment at a lower level of care. This answer is consistent with the scientific literature and practice guidelines, referenced below, as well as prevailing standards of care and New York State instruction for medical necessity reviews.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Papillary carcinoma of the thyroid
Treatment: Inpatient admission
The insurer is denied coverage for inpatient admission. 
The denial is reversed. 
The patient is a male with a history of diabetes mellitus, hyperlipidemia, essential hypertension and removal of the schwannoma from his neck. The patient presented with a presumptive diagnosis of papillary carcinoma of the thyroid.  The patient underwent a total thyroidectomy which took 4 hours and 3 minutes. The operative procedure was finished at 15:35 h. Post-operatively; the patient's pain was controlled with intravenous (IV) fentanyl and opioids. The patient's electrocardiogram (EKG) obtained revealed sinus tachycardia and nonspecific T wave abnormality. The patient was found to have an increased serum lactate at 13:45h it was at 3.6 and at 18:42h, it was 3.14.
The peer reviewed literature is consistent in finding that prolonged operative time results in substantial complications and prolonged length of stay.1, 2 In this case, the patient underwent a 4 hour and 3 minute procedure which is the third longest quintile in the Phan study.2 Studies have shown that "prolonged anesthesia duration is associated with increased odds of complication, venous thromboembolism, increased length of stay, and return to the operating room."2
The patient was found to have an elevated lactate and this did not return to a normal value until the following morning. Elevated lactate is a sign of probable cellular hypoxia.3,4 Thus, with these elevated lactate levels as well as this patient's history of diabetes and this patient's electrocardiogram (EKG) showing sinus tachycardia and non-specific T wave abnormalities, there was clinical concern of probable anoxic and/or cardiac complications. Thus, it was medically appropriate and necessary to observe the patient until this patient's lactate value returned to normal.
The patient was at considerable risk for post-operative complications due to his diabetes, his abnormal EKG findings, prolonged anesthesia1,2 and his increase lactate levels.3,4 To have discharged this patient sooner would have been contrary to best medical practice. Thus, inpatient admission was medically necessary for this patient.
The health plan did not act reasonably with sound medical judgment, and in the best interest of this patient.
The carrier's denial of coverage for the inpatient admission should be reversed. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fecal smearing
Issue under review: Somatuline Depot
The insurer denied the Somatuline Depot. 
The denial is upheld. 

No, the proposed treatment, Somatuline Depot, is not medically necessary. 

The patient is a male diagnosed with fecal smearing (R15.1). The medical documentation submitted consists only of a Patient Submission of Case Materials which provides a chronology of various therapeutic modalities employed in the treatment of his condition over this period of time. These treatments include dietary modification, use of anti-diarrhea agents such as Imodium, hemorrhoid sclerotherapy and banding, Solesta and Phase-1 Interstim placement - recommended by multiple providers and all without success. His current treating physician has recommended a trial of Somatuline Depot as treatment for this condition. The authorization for the medication was denied as the patient's condition does not support its use. An appeal and request for independent external review has been filed.

The medical records submitted consist only of the patient's statement of his condition and course of treatment over time. References to same are included in the health plan's Final Denial Notice as well. No records from any of the treating physicians are provided to substantiate the diagnosis or treatment history. A request for additional case materials indicates that the patient's provider had no additional information to provide. The records submitted, however, are sufficient to respond to the questions posed.  

Somatuline Depot is approved by the Food and Drug Administration (FDA) for the treatment of acromegaly, neuroendocrine tumors of the gastroenteropancreatic system and carcinoid syndrome. The records submitted do not show that the patient has any of these conditions as the cause of his bowel problems. A search of the peer review medical literature found one article (Reference 1) on its use in treating idiopathic diarrhea but was limited by a small sample size (33 patients) and concluded that while it did decrease symptoms in some patients, the findings needed to be confirmed by further clinical trials. Since the patient does not have any of the conditions for which somatuline is approved and since its use in the treatment of fecal smearing is not supported by medical research the treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Post-op syncopal episode 
Treatment: Inpatient admission 
The insurer is denied coverage for inpatient admission. 
The denial is reversed. 

This was then a female with degenerative arthritis of the left hip. The patient also had cardiac valvular abnormalities. The patient underwent an elective left hip arthroplasty. The patient's post-surgical course was complicated by dizziness, fainting on ambulation, nausea and vomiting. The patient's condition stabilized with discharge.

Based on the review of the medical record, this patient underwent a complex major orthopedic procedure. The patient had underlying cardiac problems which required post-surgical monitoring, especially given this patient's report of dizziness and syncopal episode after the surgery. As per operative note, the patient's operation/anesthesia time was greater than 3 hours with estimated blood loss (EBL) of 150 cc. The physician performed a full arthrotomy to hip, resection of arthritic bone and placement of femoral head and socket. This type of surgery is not performed in an Ambulatory Surgical Unit (ASU). Literature support that this procedure is not completed in an outpatient facility. It is listed as an approved procedure for inpatient admission. Although this patient's post-surgical course was satisfactory, the nature and extent of the procedure substantiated this patient's inpatient level of care. Thus, inpatient admission was medically necessary for this patient.

The health care 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 inpatient admission should be reversed. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Right shoulder arthritis and SLAP tears.
Treatment:  Shoulder surgery, Arthroscopy, repair of Superior Labral Anterior-Posterior lesion.

The insurer is denied coverage for shoulder surgery (29807 Arthroscopy, shoulder, surgical; repair of Superior Labral Anterior-Posterior [SLAP] lesion.  The denial is upheld. 

This was a male patient who was involved in a motor vehicle accident (MVA).  The patient was evaluated by his physician and complained of bilateral shoulder pain.  The patient's right side had limitation to motion and difficulty with overhead activities.  The patient was taking Celebrex twice a day as needed.  The patient was working full time as a mechanic.  No physical examination was reported on that date of service.  The physician diagnosed this patient with right shoulder arthritis and SLAP tears.  The patient was asymptomatic prior to accident and had failed conservative treatment.  The physician recommended arthroscopic surgery for this patient's shoulder (several procedures).  The patient was advised to follow up in a few months.

Additional record reported that the accident occurred over a year prior to this appeal.  The patient's magnetic resonance imaging (MR) showed labral tears to both shoulders; there were also degenerative changes to both shoulders.  The physician reported surgery would be beneficial to treat the SLAP tears.  A steroid injection was provided to the right subacromial space, and shoulder replacement option was discussed.

The physician documented that the patient had osteoarthritis and SLAP tear and needed arthroplasty.  However, the patient had deferred the procedure.  Thus, the recommendation was made for debridement.

Guidelines and criteria for management of SLAP tear require consistency of complaint, physical examination and imaging.  The submitted medical records do not include positive physical findings for SLAP tear.  According to AIM Clinical Guidelines for SLAP tear, labral tear including SLAP tear is supported by physical exam demonstrating a positive response to at least one of the following tests: O'Brien (active compression) test, Anterior slide test, Biceps load test, Pain provocation test, Crank test, Jobe relocation test, Forced shoulder abduction and elbow flexion test, and/or Resisted supination-external rotation test.

In this case, the documents reported decreased motion and weakness, which are nonspecific for SLAP tear.  The patient's diagnosis was more consistent with exacerbation of underlying osteoarthrosis.  There were no objective findings for a mechanical interference to joint function (i.e. SLAP tear).  Arthroscopic management would thus not be indicated at this time.

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 shoulder surgery (29807 Arthroscopy, shoulder, surgical; repair of Superior Labral Anterior-Posterior [SLAP] lesion) is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Speech and language screening 

Treatment: Speech Therapy services

The insurer is denied coverage for Speech Therapy services. 
The denial is upheld. 

At the time of Speech Therapy evaluation, the patient was then a female child. The patient was referred for speech and language evaluation by her private school. Testing was provided by a licensed Speech-Language Pathologist (SLP), using the RESCA-E, a respected standardized test battery for elementary school aged children. The subsections of Receptive Language and Expressive Language were assessed. The patient scored within high average to average range on all subtests. While the patient did exhibit a relative disparity in scores on the Expressive Language to Describe and Explain, the patient's scores were still within the average range, with her overall percentile rank of 93 for receptive and 73 for expressive language skills. No information regarding academic performance was provided to underscore any functional deficit.

In terms of medical necessity, this patient's disparity is mild and is not caused by any underlying neurologic, medical or congenital issue. The patient's scores did not meet the criteria of being 33% deficit in any one functional area. Additionally, the patient only scored in the average range in one of the three expressive language subtests, with the others being in the high average range. Thus, based on this review of the medical record, Speech Therapy services 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 Speech Therapy services is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Acute exacerbation of asthma.
Treatment:  Hospital admission. 

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

The patient was then a female with history of hypertension, asthma, and obesity who presented to the Emergency Department (ED) complaints of shortness of breath and cough of two days duration.  The patient also complained of some headache.  The patient's vital signs in the ED were: temperature 98.9 F, blood pressure 163/98 mm Hg, heart rate 83, respiratory rate 22, and oxygen (O2) saturations 94 %; the patient's peak expiratory flow (PEF) was 100 L.  On exam the patient was in mild respiratory distress with wheezing heard on both lungs upon auscultation.  The patient's cardiovascular and neurological exam was normal.  The patient was awake and alert.  The patient's white blood cell count (WBC) was 10.6K, and her electrolytes were within normal limits.  The patient's electrocardiogram (EKG) showed normal sinus rhythm (NSR) with some flattening in lateral leads.  The patient's chest x-ray revealed no acute infiltrates.  The patient's troponin was 0.02. 

The patient was treated with intravenous steroids, bronchodilators via nebs, and Magnesium.  The patient was admitted for acute exacerbation of asthma.  After admission, the patient was continued on steroids, bronchodilators, and added Singulair and Symbicort.  The patient remained stable after admission.  The patient's repeat troponins and EKG remained negative and unchanged, respectively.  The patient remained stable.  The patient was afebrile and hemodynamically stable.  The patient's respiratory rate was 20 with oxygen saturation of 100% on room air.  On exam, the patient had some decreased air entry into the lungs.  The patient was continued on steroids, bronchodilators and Singulair and Symbicort.  The patient was tolerating oral (PO) intake, and her white blood cell (WBC) count was 10.1 K.

Based on the review of the medical record and the literature, this patient did not need acute hospitalization.  The patient could have been placed in observation while diagnostic testing and treatment were initiated.  At the time of admission, the patient was afebrile and hemodynamically stable.  The patient was not hypoxic and did not require supplemental oxygenation.  The patient was able to tolerate oral intake.  The patient's initial troponins were negative and repeat, serial troponins and electrocardiograms (EKG) ruled out acute coronary syndrome.

The patient had no evidence of pneumonia or pneumothorax on chest x-ray.  If needed, the patient could have been monitored in the observation level of care and discharged home with oral antibiotics with close outpatient follow-up.  Inpatient admission was not medically necessary.

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 the hospital admission is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Digestive System/Gastrointestinal.
Inpatient Hospital.

Diagnosis: Appendicitis.
Treatment: Inpatient stay.
The insurer denied the inpatient stay. The health plan's determination is upheld. 

This patient is a female without significant past medical history (PMHx) who presented to the emergency room (ER) with complaints of abdominal pain for 2-3 days localizing in the right lower quadrant. She was afebrile and had stable vital signs but did have an elevated white blood cell (WBC) of 26.25 and elevated lactate 2.6. A CT scan showed acute appendicitis. 

The inpatient stay was not medically necessary.
The patient presented with acute appendicitis and underwent laparoscopic removal. The procedure was uncomplicated as was the postoperative course. The patient was able to be discharged home on oral diet, oral pain medication and abx within a 23 hour observation period.
Ambulatory level of care for uncomplicated acute appendicitis is medically standard based on available published literature. This patient was an otherwise healthy person with uncomplicated appendicitis (without abscess) who underwent surgical intervention, and met all standard discharge criteria (tolerating po, stable vital signs and pain controlled with oral medication) in less than 23 hours and was discharged to home. In this particular case, there is nothing in the medical chart that documented that the patient had any complicating comorbidity, required ongoing treatment, developed a complication or was being monitored or treated for potential sepsis. In cases where patients require ongoing clinical monitoring or treatment for suspected systemic infection (e.g. need for prolonged IV antibiotic) or develop a complication or are unable meet discharge criteria within an observation period, acute inpatient stay or prolonged stay may be necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nephrotic Syndrome.
Treatment: Acthar Gel.

The insurer denied the Acthar Gel. The determination is upheld. 

The patient has a history of nephrotic syndrome secondary to diffuse membranous glomerulonephritis, hyperlipidemia, and hypertension. Per the documentation provided, she has failed conventional therapy with long-term corticosteroid use, Cellcept, Tacrolimus, and Atorvastatin. She has an intolerance to corticosteroids due to chronic avascular necrosis of her right hip with a need for a total hip replacement. She remains on prednisone 5 milligrams (mg) daily. The health care provider wishes to start her on highly purified (HP) Acthar Gel as a corticosteroid sparing regimen to treat her nephrotic syndrome. At issue is the medical necessity of the Acthar Gel. 

The requested treatment with Acthar Gel is not medically necessary for this patient. The sole use of corticosteroids, such as SoluMedrol, is not recommended for the treatment of membranous glomerulonephritis as this has not proven to be effective.  Corticosteroids should only be used in combination with other agents such as cytoxan or calcineurin inhibitors for the treatment of membranous glomerulonephritis. SoluMedrol by itself would not be a viable formulary alternative. 

The patient has a diagnosis of membranous nephropathy and has failed corticosteroids, tacrolimus, cellcept and Lipitor therapies. The primary treatment options for membranous glomerulonephritis include cytotoxic agents such as cytoxan in combination with corticosteroids, calcineurin inhibitors, and B-cell depleting therapies such as rituximab. Options for resistant disease include Cellcept and natural ACTH such as Acthar Gel. There was no documentation that the patient had undergone treatment with either cytotoxic agents or Rituximab. Treatment with cytotoxic agents might be challenging in this case due to the requirement for concomitant high dose corticosteroids. The standard of care in this case would be to document that standard therapies have been tried either without response or with intolerance. There is no documentation to support that this has occurred with respect to Rituximab.
Appeal type: Medical necessity
Decision: Overturned

Respiratory System.
Inpatient Hospital.

Diagnosis: Respiratory failure/overdose.
Treatment: Inpatient stay.
The insurer denied the inpatient stay. The health plan's determination is overturned. 

This is the case of a male with past medical history of depression, anxiety, chronic pain and chronic opioid abuse, on methadone, who presented to the emergency department with concern for opioid overdose. The patient had been found on the side of the road by Emergency Medical Services (EMS) sleepy and difficult to arouse.

The the inpatient stay was medically necessary for this patient. This is a patient who presented with lethargy, decreased respiratory drive with hypoventilation, and acute hypercapneic respiratory failure in the setting of opioid overdose with pH of 7.28 and pCO2 of 62 despite repeated Narcan in the emergency department. He was at risk for worsening hypercapneic respiratory failure with need for repeated Narcan, hypotension, ongoing altered mental status, and hypotension, particularly given he was on methadone usually which is long-acting on top of having taken oxycodone, and required very close monitoring of his mental status and telemetry with consideration of continuous Narcan infusion. Though he was able to recover and be discharged within one midnight, his risk of adverse event including requiring need for Narcan drip or intubation was quite significant given his presentation with acute hypercapneic respiratory failure and lethargy in the setting of taking long-acting methadone. The inpatient care was medically necessary in this setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis Palpitations
Treatment Inpatient Stay
The insurer denied the Inpatient Stay
The determination is upheld.

The patient presented to the emergency department (ED) with palpitations, chest pain, dizziness and nausea since the previous night. He had been seen in the ED two days prior with chest pain and was discharged. He did not have a significant past medical or cardiac history. He has a history of marijuana and tobacco abuse. His vital signs in the ED were normal. His physical examination was unremarkable. His white blood cell count (WBC) was elevated to 11.56. His electrocardiogram (ECG) revealed sinus bradycardia and a heart rate of 56 beats per minute (BPM). His thyroid stimulating hormone (TSH) was normal. His chest x-ray (CXR) was normal. The patient was discharged home. At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient stay was not medically necessary for this patient.
The patient was given an intravenous (IV) fluid bolus and admitted to the hospital. He underwent a cardiology evaluation. His serial troponin was normal. His chest computed tomography angiography (CTA) was negative for pulmonary emboli. His echocardiogram was normal.
This is very young patient with palpitations. There were no supporting abnormalities;  tests, lab results and imaging were normal. There were no indications for inpatient admission. All tests could have been done at a lower level of care.