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

Genitourinary/Kidney disorder
Inpatient hospital

Diagnosis: Kidney Stones
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a woman who presented to the emergency department with a chief complaint of right sided flank pain for the past five days. She had a history of kidney stones and asthma and she reported that the pain had been intermittent initially and had worsened. She rated her pain was a nine out of 10 in severity. She also reported nausea and vomiting, but denied fevers and chills. The patient was admitted for renal colic and kidney stones with hydronephrosis. The plan of care included intravenous (IV) fluids, urology consult, urine culture, Zofran, pain management and monitor kidney function. 

The inpatient stay was medically necessary. This is because the patient had risk factors for development of pyelonephritis, sepsis, and prolonged disability from acute pain. Imaging findings demonstrated evidence of obstruction and there was concurrent concern for urinary tract infection. Urology also planned to perform a procedure. Her recovery was rapid but at the time with her admission, it was appropriate to treat her aggressively in consultation with urology. The patient presented with kidney stones in the setting of acute kidney injury and hydronephrosis. She did improve rapidly but, given the complications of worsening kidney function in the setting of a stone, it was reasonable to treat her at the inpatient level of care. Moreover, urology initially planned to place a stent. She was at increased risk of developing an infection, uncontrolled pain with need for prolonged IV opioids, and worsening kidney function.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath and dizziness
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male with a past medical history significant for HTN (hypertension), diabetes mellitus, type 2, CVA (cerebrovascular accident), dyslipidemia, and depression. He presented to the ER for evaluation of dyspnea of one week's duration and right arm pain. 

The patient was hemodynamically stable. Cardiac troponins were negative. Chest X-ray revealed no acute cardio-pulmonary disease. ECG (electrocardiogram) revealed no acute ischemic changes. BNP (brain natriuretic peptide) was low. The patient was admitted for evaluation of dyspnea. 

CTA of the chest was done, revealing no pulmonary embolism, aortic dissection or pneumonia. X-ray of the right arm was negative. Echocardiogram was done, revealing normal wall motion with EF (ejection fraction) of 65%. The patient was discharged with a plan for outpatient follow-up.

No, the Inpatient admission was not medically necessary.

This patient presented for evaluation of dyspnea and right arm pain. There was no evidence of acute myocardial infarction, ACS (acute coronary syndrome), decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability. CTA of the chest was negative for pulmonary embolism or any other significant pathology. CHF was ruled out by low BNP and echocardiographic findings, as well as negative chest X-ray. X-ray of the right arm was negative. Given this presentation and findings, the clinical information provided in the record submitted for review does not support medical necessity for this admission, and the care required could have been provided at an observational level of care.
Appeal type: Medical necessity
Decision: Upheld

Primary Diagnosis: Digestive System/ Gastrointestinal
Primary Treatment: Surgical Services
GERD

This patient is a man who sought surgical evaluation for the condition of gastroesophageal reflux disease (GERD) of 10 years duration. His symptoms include heartburn and regurgitation. The patient has been treated with proton pump inhibitor (PPI) medications, but that he has breakthrough symptoms. He has been diagnosed with Barrett's despite ongoing treatment with PPIs. He denies dysphagia. The patient was evaluated due to ongoing symptoms. The LINX procedure is under review.

The health plan's determination is upheld. The LINX Reflux Management System is not medically necessary for this patient.

While LINX magnetic sphincter augmentation has been shown by scientific evidence to be safe and effective for the condition of GERD with proven elevated esophageal acid exposure, preserved esophageal motility, no alternative diagnosis and no contraindication to application of the LINX device, in this case, the records indicate a history of Barrett's metaplasia.

General precautions/contraindications listed by the manufacturer for LINX implantation include a diagnosis of Barrett's as the safety and effectiveness of the LINX device has not been evaluated in patients with Barrett's esophagus or Grade C or D (LA classification) esophagitis. This patient has a history of Barrett's as detailed in the EGD biopsy report.
Appeal type: Medical necessity
Decision: Upheld

Central Nervous System
Nursing Services (including Private Duty Nursing)

Diagnosis: Dementia
Treatment: Personal Care Services: 24 Hours per Day, 7 Days per Week (Split-Shift) for a Total of 168 Hours per Week
The insurer denied the Personal Care Services: 24 Hours per Day, 7 Days per Week (Split-Shift) for a Total of 168 Hours per Week. The health plan's determination is upheld. 

The patient is a female with past medical history of dementia, depression, osteoarthritis, coronary artery disease, chronic obstructive pulmonary disease (COPD) and gait disturbance who had been assigned PCA (personal care assistant) services. The patient was also assessed at extensive assistance with personal hygiene, dressing upper body, walking, locomotion, transfer toilet and eating while assessed at limited assistance for task of bed mobility. This assessment noted that the patient was frequently incontinent, the patient was unable to express goals of care, the daughter directs all of her care, the patient continued to wear the cam boot to her fractured leg and needed feeding by others. The patient's daughter told the assessor that the patient was typically up 4 times at night to use the bathroom.

The Personal Care Services: 24 Hours per Day, 7 Days per Week (Split-Shift) for a Total of 168 Hours per Week are not medically necessary.
The patient had a loss of her informal helper following her hospitalization and rehabilitation stay where she had deterioration of her mental and physical abilities requiring PCA services 24 hours per day, 7 days per week. The patient no longer had informal helper as other children were not able to provide support. The patient's telephonic assessment underestimated the patient's assistance needs for tasks of eating, bed mobility, toilet use, transferring toilet, walking, locomotion, personal hygiene and bathing. At this assessment, the daughter mentioned that the patient got up 4 times at night to use the bathroom however there is no specific documentation of overnight needs that require split shift PCA services. Documentation provided does not state the patient needed frequent turning or repositioning at night or frequent use of the bathroom. Based on documentation provided split-shift PCA services are not medically necessary. The services authorized by the plan (PCA service hours were authorized at 24 hours/day, live-in, 7 days/week) are adequate to meet the patient's needs.
Appeal type: Medical necessity
Decision: Overturned

Mental Health
Mental Health: Inpatient

Diagnosis: Depression
Treatment: Inpatient mental health inpatient
The insurer denied inpatient mental health inpatient stay. The health plan's determination is overturned. 

This case involves a female who was medically screened in the emergency department and admitted for acute inpatient psychiatric treatment. The patient had become increasingly depressed with self-harming behavior (cutting) and suicidal ideation and deterioration in functioning culminating in her presentation. She had a history of bipolar disorder and severe depressive episodes associated with suicidal behavior and psychiatric treatment with therapy and medications. Her presentation was characterized by worsening symptoms of depression and suicidal ideation in the context of multiple psychosocial stressors and substance use disorder with cannabis and alcohol, as well as past use of opioids and history of medication assisted treatment with Suboxone.

The Behavioral Health Inpatient Level of Care is medically necessary for this patient.
The patient required the admission and continued acute inpatient level care and the continued structure of an acute inpatient level setting through discharge in order to provide safety monitoring and to administer treatment for the psychiatric disturbance while conducting an evaluation, and while observing functioning with the resumption/adjustment of clinically appropriate medications including continued medication assisted treatment for opioid use disorder.
The medical necessity for acute inpatient level structure and monitoring is reasonable and in the patient's best interest in view of the patient's severe symptoms of mood disorder and co-occurring substance use disorders; in view of the severe psychosocial stressors; and in view of the need for continued active treatment in the context of deteriorated functioning and persistent symptoms representing a safety concern and needing inpatient level structure and supervision.
Additionally, the inpatient stay during the time interval under review is medically necessary in order to monitor the response to medications, to insure that the patient will have a sustained response to treatment, and to continue to address the acute risk of suicidal behavior in the context of severe symptoms of bipolar mood disorder with depression and the co-occurring substance use disorders that were only in partial remission. The necessity for the admission and the continued inpatient level services reflects sound medical judgment in keeping with prevailing standards of professional practice, and with the published practice guidelines and criteria, referenced below, as well as New York State instruction for medical necessity reviews, as well as NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Guidelines.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Stenosis of the right internal carotid artery.
Treatment:  Continued admission at the inpatient level of care.

The insurer denied coverage for continued admission at the inpatient level of care.  The denial is upheld.

This patient is a female with a history of myocardial infarction and cardiogenic shock.  She presented to the emergency department of an out-of-network facility with complaints of right-eye vision loss.  A stroke code was called, and consults with vascular surgery, ophthalmology and neurology were obtained.  Exam was consistent with retinal detachment, and a computed tomography (CT) scan was obtained, which showed no acute intracranial hemorrhage.  A computed tomography angiogram of the neck showed 85-95% stenosis of the right internal carotid artery.  The patient was admitted to vascular surgery service.  Per a cardiology consult, the patient was advised to resume Brillinta for recent stents.  She underwent a right carotid artery endarterectomy with patch angioplasty.  There were no complications.  The patient remained stable and was cleared for discharge home.

The patient presented to the ER for unilateral vision loss.  She was clinically stable following diagnostic evaluation.  Her CT imaging noted significant right-sided obstructive atherosclerotic disease involving the right internal carotid artery.  Given the ipsilateral findings of clinical right-sided vision loss with radiographic findings, her severe right internal carotid stenosis did not require immediate or emergent treatment at a non-network facility.  Moreover, given the time separation from initial symptoms to the time of her procedure, out-of-network treatment was not indicated.  Her care could have been rendered electively at an in-network facility, and, therefore, the continued inpatient hospital stay at an out-of-network facility is denied as not medically necessary.  

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

Substance Abuse
Substance Abuse: Inpatient
Diagnosis: Substance Abuse
Treatment: Inpatient Substance Abuse Treatment
The insurer denied the Inpatient Substance Abuse Treatment. The health plan's determination is upheld. 

The patient is an adult male who self-referred and requested detoxification from alcohol. The patient was using alcohol on a continuous daily basis with up to one pint of liquor per day together with crack cocaine and cannabis intermittently. He reported a history of poly-substance use beginning in adolescence. The patient provided no history of withdrawal seizures, delirium tremens or severe alcohol withdrawal symptoms; vital signs were normal, and the Clinical Institute Withdrawal Assessment (CIWA) scale score was 10 with mild symptoms including mild tremor or shakes and reports of nausea, irritability and anxiety. The urine drug screen was positive for cocaine. There was no reported use of other illicit drugs or other drugs of abuse. 

The Inpatient Substance Abuse Treatment was not medically necessary for this patient.
The proposed inpatient detoxification treatment and other inpatient medical services noted in the clinical summary could have been safely and effectively provided at a lower level of care. The clinical features and indicated treatment dimensions of this patient's alcohol use disorder, and other substance use disorders, did not require or warrant the structure of an inpatient setting or 24-hour monitoring. The patient displayed no serious disturbance of mental status despite having a history of ongoing substance use disorder with alcohol and ongoing treatment for an unspecified depressive disorder. Moreover, the patient had been evaluated and cleared with regard to safety concerns in the emergency department, and did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance, or general medical concerns that would have warranted an inpatient level admission and treatment.
Thus, admission for detoxification treatment and 24-hour monitoring, and the requested inpatient level services were not medically necessary in this case scenario. The indicated treatment for alcohol use disorder in this case could have been provided at a lower level of care following the comprehensive assessment and stabilization in the emergency department.
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 female patient with a past medical history of coronary artery disease status post stent placement, diabetes mellitus, status post right third toe amputation, hypertension, atrial flutter, Gastroesophageal reflux disease (GERD), hyperlipidemia, psoriasis, and chronic alcohol dependence.  She presented to the Emergency Room (ER) with complaints of severe and sharp left-sided chest pain, which radiated to the left arm.  It was associated with numbness in the fingertips.  Blood pressure was 190/98.  The urine toxicology was positive for alcohol.  The electrocardiogram showed normal sinus rhythm with left atrial enlargement and non-specific T wave abnormalities.  The patient was admitted to telemetry unit.  She ruled out for myocardial infarction with unremarkable cardiac biomarkers.  The patient was cleared for discharge after a period of medical stability, with recommendations to follow-up with her primary care doctor.

The patient presented to the ER with chest pain.  The initial evaluation in the ER was unremarkable, including a non-diagnostic EKG and negative cardiac biomarkers.  There were no other high-risk symptoms suggestive of acute coronary syndrome.  Though it was appropriate and indicated for the patient's symptoms to be evaluated and her blood pressure treated, inpatient admission was not medically necessary in this instance.  The patient's care could have been provided under the observational setting, allowing for additional diagnostic testing.  There were no high-risk or concerning findings on diagnostic testing to necessitate further inpatient evaluation.  During the patient's initial evaluation and subsequent hospitalization, there was no objective evidence of hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions warranting acute inpatient level of care.  

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

The carrier's denial of coverage for acute inpatient admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: disorganized schizophrenia.
Treatment: Mental Health Inpatient
The insurer denied inpatient mental health treatment. The health plan's determination is overturned in part. 6 additional days with discharge on the 7th day were medically necessary. 

The patient is a woman with diagnoses of disorganized schizophrenia (DSCZ) and diabetes mellitus II (DMII). The patient was brought by Emergency Medical Services (EMS) to the hospital, with the EMS activated by her case worker. The concern was that she was not adequately caring for herself. On mental state examination, the patient was documented to be euthymic, without suicidal or homicidal ideation; she denied auditory hallucination (AH) but most likely she was responding to internal stimuli. She showed poor insight and poor judgment. Her feet were dirty, and she was malodorous. She was not taking any medications for her DSCZ or her metformin.

This patient's DSCZ was chronic and severe. She was not taking care of her serious medical disorder, DMII, or of her activities of daily living (ADL) in general and appeared to be in denial of her DSCZ. She was not taking any psychotropic medication. The question is how much improvement was necessary to safely discharge the patient with good medical judgment. She was still disheveled and unkempt. She was isolative with poor ADLs. The patient was euthymic, denying AH, even though she may have been continuing to experience them. She never stopped talking to "no one." After education about the need to take her medications, she promised to take them including her psychotropic medications. She was documented to say she was getting better and feeling better. This was an indication of some improvement, but her anti-psychotic medication was not considered adequate. She was transitioned to Haldol. She was taking her medication as directed. While she would most likely experience continued symptoms of DSCZ in any context, the fact that she showed improvement overall and some awareness of the need to take both her medical and psychiatric medications, her care could continue in a less restrictive environment.
On the 7th day, the patient could be discharged with good medical judgment, in accord with current standards of best care, and in accord with the medical literature.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tooth decay 
Treatment: Cleaning inside roots of tooth (root canal) and tooth colored cap (crown) for teeth #s 21, 22, 23 and 29 

The insurer denied the Cleaning inside roots of tooth (root canal) and tooth colored cap (crown) for teeth #s 21, 22, 23 and 29. The denial is overturned. 

The patient is a female requesting dental benefits for root canal treatments and crown on teeth numbers 21, 22, 23 and 29. 

Yes, the Cleaning inside roots of tooth (root canal) and tooth colored cap (crown) for teeth #s 21, 22, 23 and 29 are medically necessary. 

All four teeth have severe decay, but they are restorable with crowns after the infected nerves are removed (root canal treatment). There is no reason these teeth need to be extracted, as they are not hopeless, and extracting them is not in the best interest of this patient. The root canal treatments and crowns for these teeth (21, 22, 23, and 29) are medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Cardiovascular disease.
Treatment:  Inpatient stay.

The insurer denied the medical necessity of the inpatient hospital stay.  The denial is upheld in whole.

The patient has a history of hypertension, hyperlipidemia, diabetes, and coronary artery disease with multiple percutaneous coronary interventions.  The patient presented to the hospital for elective cardiac catheterization for evaluation of recurrent angina.  Patient was hemodynamically stable upon presentation, without ischemic electrocardiographic changes.  Coronary angiography revealed in-stent restenoses in the mid and distal right coronary artery that were treated with drug-eluting stents.  After placement of the stent in the mid right coronary artery, thrombus was noted with normal flow.  The patient was started on tirofiban to be infused for 18 hours.  Patient was admitted to the hospital and remained stable overnight and was discharged on the next day. 

An inpatient level of care was not medically necessary.

While some period of observation immediately following elective percutaneous coronary intervention is needed to ensure hemodynamic and access site stability, as well as recovery from sedation, inpatient admission is not generally required for most patients.  The 2009 Expert Consensus Document From the Society for Cardiovascular Angiography and Interventions recommends inpatient admission in patients with acute ST segment elevation or non-ST segment elevation myocardial infarction, and unstable acute coronary syndrome with hemodynamic instability or dynamic electrocardiographic changes.  This patient met none of these criteria.  However, the procedure was complicated by development of thrombus in the mid right coronary artery.  There was no obstruction to flow, and this was treated with tirofiban infusion without further complications.  Per the expert consensus document, patients who experience complications associated with an important change in clinical status or those requiring vascular or endovascular repair require inpatient admission.  Patients with complications who are successfully treated without need for transcatheter or surgical intervention, and who do not develop myocardial infarction, can be admitted for overnight observation at a lower level care.  Accordingly, the care this patient received could have been provided under a lower level of care status, and an inpatient admission was not medically necessary.