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

Diagnosis: Tachycardia
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

Asked to review the case of a patient with a history of hypertension and amaurosis fugax that presented to the hospital for tachycardia and lightheadedness. The patient was sent to the emergency department after his heart rate was noted to be 150 while undergoing outpatient echocardiography. On arrival to the hospital vital signs were stable (BP (blood pressure) was 143/90 and Pulse 98). Physical examination was without any abnormality. A 12-lead electrocardiogram (ECG) revealed normal sinus rhythm with nonspecific ST (interval on an ECG) or T (interval on an ECG) wave abnormalities. Serum blood testing demonstrated normal hemoglobin, electrolytes and troponin levels. The patient was admitted to telemetry for observation and treatment. No rhythm abnormalities were noted on telemetry and echocardiography revealed normal left ventricular function without valvular abnormalities. The patient was discharged home the day after presentation.

This patient presented with an elevated heart rate and symptoms of intermittent lightheadedness. There were no significant abnormal findings on physical examination or subsequent ECG to warrant acute inpatient hospital admission. Treatment of tachycardia can be performed with atria - ventricular (AV) nodal blocking medications in the outpatient setting. Most patients with palpitations can be evaluated in the outpatient setting. In conclusion, acute inpatient admission was not medically necessary in this case.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient stay is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity
Treatment: Wegovy
The insurer denied Wegovy. 
The health plan's determination is upheld.

This is a case review for a female being prescribed Wegovy for the diagnosis of overweight (body mass index (BMI) 25.7).

Wegovy is not medically necessary for this patient.

The patient's current BMI of 25.7 is near the normal range (normal is 25 or less) and is below the threshold for treatment of 27. This treatment threshold of a BMI of 27 is based on not only the health plan's approval but also on the Food and Drug Administration (FDA) approval for the prescription of Wegovy. She does not meet the FDA"s current criteria for ongoing treatment with the medication. Therefore, it is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Oligodontia in the maxilla and mandible.

Treatment: Partial upper denture, partial lower denture, nerve treatment on front tooth for tooth 7, and white glass with high gold content crown for tooth 7.

The insurer denied coverage for partial upper denture, partial lower denture, nerve treatment on front tooth for tooth 7, and white glass with high gold content crown for tooth 7.

The denial is overturned.

 
Based on review of the submitted documentation it appears that this patient presented for evaluation and comprehensive dental care. Recommended treatment was for a maxillary removable partial denture to restore function in addition to endodontic therapy on tooth 7 with post endodontic therapy crown restoration for the same tooth. 

Upon review of the documentation, in particular the radiographs, the patient exhibits oligodontia in the maxilla and mandible. Review of the remaining dentition on the radiograph indicates a level of moderate periodontal alveolar bone loss corresponding to periodontal disease. However, the teeth that would be supports for the removable partial dentures are stable and would be adequate abutment teeth. This treatment of a removable partial dentures is a standard of care in dental practice for this clinical circumstance. This service is indicated for restoration of function and occlusal stability and the partial dentures are considered medically/dentally necessary. 

As regards tooth 7 the patient exhibited caries on this tooth which necessitated the endodontic therapy which was completed appropriately. Standard of care therapy subsequent to endodontic therapy on a maxillary anterior tooth would be a full coverage crown restoration as recommended. Endodontic therapy and subsequent crown services are considered standard of care therapy and therefore medically necessary.

Partial upper denture, partial lower denture, nerve treatment on front tooth for tooth 7, and white glass with high gold content crown for tooth 7 is considered medically necessary for this patient.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for partial upper denture, partial lower denture, nerve treatment on front tooth for tooth 7, and white glass with high gold content crown for tooth 7 is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse
Treatment: Inpatient rehabilitation
The insurer denied coverage for inpatient rehabilitation
The denial is overturned

This adult was admitted to this inpatient substance rehabilitation treatment as he reportedly was using large amounts of serious substances of use.  He reportedly had 6 past treatment episodes and was unable to maintain abstinence. He had a positive toxicology for cocaine, heroin, fentanyl, THC(tetrahydrocannabinol), and methadone. He reportedly was in substance intensive outpatient program and Methadone maintenance (MAT) and still could not maintain abstinence. He lived alone and was socializing with active users. He attended group and individual therapy.

The medical records provided enough specific evidence to support that he required this level of care. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that inpatient treatment is indicated primarily for individuals whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. 

In this case this patient was considered in need of 24-hour substance rehabilitation treatment as he was discharged. He reportedly lacked the coping skills and ability to identify relapse triggers to stop use. 

According to the Level of Care Determination (LOCADTR) he met criteria for inpatient substance rehabilitation treatment as he continued to use large amounts of serious substances of use and cannabis daily and was unable to stop use without a 24-hour substance free therapeutic treatment setting despite multiple past treatment episodes. He reportedly lacked coping skills for abstinence, the ability to identify triggers to use,  insight into use,  and needed to learn better coping skills, improve insight into use, and better identify relapse triggers. He was at risk for medical complications from his serious substances of use and also overdose as well as severe withdrawal symptoms. He was unable to stop substance use without being in a sober and supervised therapeutic inpatient substance rehabilitation setting. He required 24-hour inpatient substance rehabilitation treatment in this therapeutic, supervised, and structured treatment setting.  He required the entire time in this therapeutic structured and supervised inpatient rehabilitation treatment. Without this structured and supervised therapeutic rehabilitation treatment he likely would have relapsed and likely would not have been able to maintain abstinence and would have been at risk medically for overdose and severe withdrawal. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the admission at the substance abuse inpatient rehabilitation level of care is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse
Treatment is inpatient substance abuse rehabilitation stay
The insurer denied coverage for inpatient substance abuse rehabilitation stay
The denial is upheld

According to his initial assessment, the patient reported history of nicotine and cannabis use without potentially harmful behaviors associated with it. The patient denied history of overdose, history of blackouts or withdrawal and denied "other addictive behaviors." According to the individual clinical session: "the patient's substance use disorder reflects cocaine and cannabis use and progress to daily use to manage stressors". This information does not correlate with information from the initial assessment. 

The patient had moderate functional impairment. He is homeless with severe deficits in the ability to engage in socially constructive activities and the ability to maintain responsibilities. He does odd jobs. At the same time, on assessment of the patient's self-sufficiency of activities of daily living (ADLs), he reported "10" (very easy) for all ADLs, reported minor past, current or pending legal issues and denied mandatory treatment. 

The patient has minor co-morbidity with regards to medical and psychiatric disorders. The patient has diagnosis of Post-Traumatic Stress Disorder (PTSD), he is not taking psychiatric medications and does not have a history of psychiatric hospitalizations. On initial assessment psychiatric evaluation was recommended. The patient denied having medical diagnoses. His vital signs were within normal limits and continued to be normal throughout his stay at the center. 

He has a moderately stressful environment. The patient is doing odd jobs, he does not have significant decline in his health or recent onset of severely disabling or life-threatening illness. The patient does not have overwhelming demands to meet immediate obligations, does not have legal issues causing severe disruption of his life.

The patient has a limited support system. On admission assessment, he reports that his family is supportive of the recovery process. In the letter written by the LMSW (licensed medical social worker), utilization review specialist,: "He admitted that he does have support from his immediate family, but his immediate family only, which he stated are estranged". 

The reviewer utilized Level of Care Utilization System (LOCUS) assessment tools. The patient met criteria for Level 3 Level of Care (LOC) based on a total score. However, due to having a combined score for level of stress and support system as being above 5, it puts the patient in level 4 LOC, which correlates to Medically monitored non-residential services.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for inpatient substance abuse rehabilitation stay, is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse

Treatment is inpatient substance abuse rehabilitation stay

The insurer denied coverage for inpatient substance abuse rehabilitation stay

The denial is upheld

According to his initial assessment, the patient reported history of nicotine and cannabis use without potentially harmful behaviors associated with it. The patient denied history of overdose, history of blackouts or withdrawal and denied "other addictive behaviors." According to the individual clinical session: "the patient's substance use disorder reflects cocaine and cannabis use and progress to daily use to manage stressors". This information does not correlate with information from the initial assessment. 

The patient had moderate functional impairment. He is homeless with severe deficits in the ability to engage in socially constructive activities and the ability to maintain responsibilities. He does odd jobs. At the same time, on assessment of the patient's self-sufficiency of activities of daily living (ADLs), he reported "10" (very easy) for all ADLs, reported minor past, current or pending legal issues and denied mandatory treatment. 

The patient has minor co-morbidity with regards to medical and psychiatric disorders. The patient has diagnosis of Post-Traumatic Stress Disorder (PTSD), he is not taking psychiatric medications and does not have a history of psychiatric hospitalizations. On initial assessment psychiatric evaluation was recommended. The patient denied having medical diagnoses. His vital signs were within normal limits and continued to be normal throughout his stay at the center. 

He has a moderately stressful environment. The patient is doing add jobs, he does not have significant decline in his health or recent onset of severely disabling or life-threatening illness. The patient does not have overwhelming demands to meet immediate obligations, does not have legal issues causing severe disruption of his life.

The patient has a limited support system. On admission assessment, he reports that his family is supportive of the recovery process. In the letter written by the LMSW (licensed medical social worker), utilization review specialist,: "He admitted that he does have support from his immediate family, but his immediate family only, which he stated are estranged". 

The reviewer utilized Level of Care Utilization System (LOCUS) assessment tools. The patient met criteria for Level 3 Level of Care (LOC) based on a total score. However, due to having a combined score for level of stress and support system as being above 5, it puts the patient in level 4 LOC, which correlates to Medically monitored non-residential services.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for inpatient substance abuse rehabilitation stay, is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female who presented from urgent care with complaints of right lower quadrant (RLQ) pain for one day duration without nausea or vomiting. The patient had stable vital signs and a normal white blood cell count (WBC) of 5.6. The computerized axial tomography (CAT) scan did not identify acute appendicitis, although a portion of the appendix was not visualized. The patient was admitted for observation, evaluation and for an oral nutrition (po) trial. The patient was able to tolerate an oral challenge and was discharged home.

The health plan, in its determination of medical necessity, did act reasonably, with sound medical judgment and in the best interest of the patient.

The requested health service/treatment of an inpatient stay was not medically necessary for this patient. The patient was discharged within a 23 hour period without acute findings. The patient was able to have improvement in the pain, with stable vital signs and tolerating a diet within the same day. The patient was not identified to have an acute infectious process with normal diagnostic findings. The patient was discharged home with a plan for outpatient follow-up and criteria to return.

The health plan's determination of medical necessity is upheld in whole.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis:  Pneumonia.
Treatment:  Inpatient admission.
The insurer denied coverage for inpatient admission.  
The denial is modified.
 
Patient is an adult, who has multiple medical problems - hypertension, hyperlipidemia, Allergic bronchopulmonary aspergillosis, and chronic lymphedema. The patient was previously hospitalized for pulmonary embolus. Subsequently he was admitted for treatment of Covid for 3 days. Patient was discharged home earlier on the day of admission. He had refused sub-acute rehabilitation. While at home later in the day the patient felt weak and dizzy and was brought back to the hospital.

Vital signs at presentation Temperature 99 degrees F, Pulse 91, Respirations 18, Blood Pressure 94/64. Oxygen saturation on room air was 98% (percent). He was noted to have a doubling of his white blood cell count (WBC) from earlier that morning to 19. It was 9 at the time of discharge earlier that morning. There was significant worsening of his creatinine to 1.48. It was normal at the time of discharge. A chest x-ray was done, which revealed possible new right middle lobe opacity. The patient was admitted to the hospital for treatment of healthcare-associated pneumonia and acute kidney injury.

He was treated with intravenous (IV) fluids, and antibiotics were started. He was given aggressive hydration and started improving after initiation of treatment. The patient was seen by physical therapy and occupational therapy and was now agreeable for transfer to sub-acute rehabilitation. He was medically cleared for discharge to sub-acute rehabilitation by the fourth day of admission under review.

Thus, as of the fourth day of admission under review, he was eligible for a lower level of care and no longer required acute inpatient level of care.

Based on the above, the insurer's denial must be modified. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. Allow acute inpatient care for first three days, but uphold denial of acute inpatient care for the remainder of the hospital stay.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Obstructive Pulmonary Disease.

Treatment: Inpatient hospital.

The insurer denied coverage for inpatient hospital.

The denial is overturned.


 
Patient is an adult male with a past medical history of asthma/ chronic obstructive pulmonary disease (COPD), nasal polyposis, and heart failure admitted with acute hypoxemic respiratory failure. The patient had presented with an unclear diagnostic picture. Leukocytosis was noted along with peripheral eosinophilia, elevated Immunoglobin E (IgE), elevated erythrocyte sedimentation rate ESR) and elevated C reactive protein. The patient's chest computed tomography (CT) was negative for pulmonary emboli.Mucus plugging was seen in both lower lobes and right lower lobe atelectasis was noted.

The patient was transferred to the Intensive Care Unit (ICU) for worsening respiratory status and he was placed on bi-level positive airway pressure (BIPAP). The patient was treated with intravenous (IV) steroids, bronchodilators and IV antibiotics. Patient underwent bronchoscopy for bronchoalveolar lavage and was found to have eosinophilia of 37%in bronchoalveolar lavage. The possibility of Allergic bronchopulmonary aspergillosis was entertained.  Eosinophilic granulomatosis with polyangiitis was also in the differential.

The patient was tapered off steroids and was switched to long-acting beta-2 agonist / inhaled corticosteroids.  Continuous positive airway pressure (CPAP) was recommended at night.
Given the patient's complex presentation with an unclear diagnosis, full hospital admission was appropriate for diagnostic testing and treatment in the hospital setting. The patient underwent multiple tests, consultations by specialists and bronchoscopy. The patient's White Blood Cell (WBC), sodium and Glucose remained elevated and he had slightly improving atelectasis.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for continued hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Throat pain
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is overturned.

The patient is an adult complaining of difficulty swallowing following a cervical fusion operation. Six days postoperative, the patient noted that the throat was closing. This sensation progressed and the patient presented to the emergency room and was seen with a chief complaint of difficulty breathing, throat pain and sensation that something was constricting the throat. A Computed Tomography (CT) with contrast was conducted. The CT revealed that there was pre-vertebral collection which may be postoperative in nature with communication with a larger pocket in the right parapharyngeal and soft tissues and subcutaneous space associated with droplets of air seen. The presence of superinfection or abscesses cannot be excluded.

The Milliman Care Guidelines (MCG) inpatient and surgical care 24th edition states that clinical indication for inpatient care is a complicating feature which requires inpatient care as indicated by one of the following: other complicating features which require inpatient care. The patient was found objectively to have a probable serum collection in the area of the previous surgery which was causing the patient to have the feeling of a compromised airway. It was necessary for the patient to have treatment and to be observed in order to confirm that the treatment would be effective and not prevent the patient from having a major airway pathology.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The patient was found to have a fluid collection which would give rise to the symptoms of throat pain and compromised airway. The patient needed the hospitalization to receive proper therapy and to be observed so that the condition did not worsen in order to avoid severe morbidity and possible mortality.

The inpatient admission is considered medically necessary for this patient. The patient had objective evidence of the compromised airway by the observation of fluid on the CT. It was a medical necessity for the patient to receive treatment and be observed within the hospital to ensure that the condition did not worsen which could have resulted in substantive morbidity and mortality.

The denial should be overturned as the hospitalization was medically necessary for the proper care of the patient as noted in MCG inpatient surgical care guidelines 24th edition.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for the inpatient admission is substantiated.