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

This is a patient with a past medical history of anemia, chronic kidney disease (CKD), and type 2 diabetes on insulin, who presented to the emergency room (ER) with a possible syncopal episode and hypoglycemia. His blood sugar in the field was 31. He received dextrose (D)50 times one (x1).
The patient was admitted to the telemetry unit. He received a 1 liter (L) normal saline bolus. Hydralazine intravenous (IV) was given in the ER for blood pressure control. Endocrinology was consulted. The patient was found to have orthostatic hypotension. Thrombo-Embolic Deterrent (TED) hose were recommended, as the patient was hypertensive and additional intravenous fluids (IVF) were therefore not given. Nephrology was consulted. The patient's blood sugar remained between 100-180 in the hospital without periods of hypoglycemia. Tradjenta was started at discharge. The patient's blood pressure was controlled with oral hydralazine, Lasix, Procardia, and metoprolol, along with a low salt diet.
The health plan's determination is upheld.
The patient was hemodynamically stable. Although his blood pressure was elevated, it was improved with one dose of IV hydralazine in the ER and the patient did not require IV drip medication. No further episodes of hypoglycemia were documented in the hospital. There were no other severe electrolyte abnormalities. Conservative measures with TED hose were recommended for the patient's orthostasis.
The patient did not meet 2019 InterQual Level of Care criteria for inpatient admission for hypoglycemia. 
The patient also did not require any further boluses of glucose, did not require titration and monitoring every 1-2 hours, and did not require continuous glucose monitoring.
The patient also did not meet Milliman Care Guidelines, 22nd edition, for inpatient admission using the Hypertension subset.
Appeal type: Medical necessity
Decision: Upheld

This patient has a past medical history significant for Parkinson's disease, bilateral arthritis of the knee, chronic pain syndrome, coronary artery disease, hypertension, cervical disc disease, benign prostatic hypertrophy, constipation and hyperlipidemia. The patient requests personal care service hours 7 hours a day 6 days a week for a total of 42 hours a week. The health plan has approved 5 hours a day 6 days a week for a total of 30 hours a week. The patient required help with preparing meals, housekeeping, laundry, shopping, managing medicines, dressing, bathing and toileting. Based upon the records provided, it is medical opinion that the services provided can be met during the approved allotted time. Additional personal-care services are not medically necessary. In order for personal care services to be considered medically necessary, services need to be provided either to perform an activities of daily living (ADL) or an Instrumental activities of daily living (IADL). Services would not be considered medically necessary for supervision to prevent falls without the performance of other ADL's. The health plan determination is upheld in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rule out ACS versus pneumonia versus stable angina

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial was upheld.

This patient is a female who presented to the ED with a complaint of chest pain since this morning. She claims that she took her regular medications, and walked to work and develop dizziness, chest pain and diaphoresis. The pain radiated to her left arm and she states that she currently has the pain now as she is being evaluated. She previously had similar pain which was relieved with nitroglycerin. She denies nausea, diarrhea, recent travel and recent hospitalization. She has a past medical history which includes peptic ulcer disease, asthma and hypertension. She is known to have a factor seven deficiency but denies bleeding or clotting problems. She has a past surgical history of hysterectomy and laparoscopic examination. The patient denies being a cigarette smoker. Her family history reveals that her father died of a myocardial infarction (MI) while he was in his 60s. She describes similar episodes of pain the previous week, one month ago and several months ago. Her vital signs include BP 96/63, pulse 89, temperature 97.9, respirations 18 and oxygen saturation 96%. On physical exam she is described as in no acute distress. There were no abnormalities noted in her physical exam. Her EKG was described as showing normal sinus rhythm and nonspecific T-wave changes.

High-sensitivity cardiac troponin T (hs-cTnT) have been introduced as a highly sensitive and early biomarker of myocardial damage.(1)  In two prospective cohorts of patients admitted to the hospital for chest pain, undetectable hs-cTnT was found to have a very high negative predictive value for MI. (2, 3)  A 2014 study from Sweden evaluated the significance of undetectable troponin levels and EKGs which did not show signs of ischemia in patients presenting to the emergency department with chest pain. (4) 

This patient presented to the hospital with chest pain and then had a workup which included troponin x3 and Pro BNP X1 which were within normal limits and no ST segment abnormalities on her EKG. The literature cited makes it clear that acute hospital admission for this type patient is not medically necessary and that this patient was an ideal candidate for observation.

The inpatient admission is not medically necessary. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

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

Diagnosis: Epigastric pain
 
Treatment: Inpatient admission

The insurer denied the inpatient admission. The denial was reversed.

This female presented to the ER with complaints of epigastric pain that was crampy in nature but not radiating to the back. She had a history of hypertension, hyperlipidemia, pancreatitis and recent cholecystectomy. She stated the pain was not worse than the pain she had during her gallbladder episode.  The pain was worse before meals with no relief after meals and had been ongoing for 1 week; it was intermittent and partially resolved. Blood pressure was 130/87 with a pulse of 80, respirations 17 and temperature 98.3.  Oxygen saturation was 100%.  The patient had a white blood cell count of 9.4, hemoglobin 14.5, hematocrit 44.5, platelets 288, INR 1.1, BUN 15, creatinine 0.59, sodium 137, chloride 102, calcium 9.6, magnesium 1.4, CO2 25. She was given Protonix and Zofran in the emergency department.  CT of the abdomen and pelvis revealed no acute abnormality appreciated.  The patient was then discharged.

The medical literature indicates that inpatient admission is indicated for patients with acute pancreatitis if there is two or more the following: abdominal pain, serum amylase and serum lipase greater than 3 times upper limit of normal or characteristic findings from abdominal imaging.  The documentation indicated that the patient had complaints of epigastric pain and nausea.  The patient underwent x-ray as well as abdominal CT and ultrasound that were all negative for pancreatitis.  She was given Zofran and Protonix as well as IV fluids.  The patient's lipase was 3238. This is over 3 times the upper limit of normal. Therefore, the inpatient admission was appropriate.  

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

This is a patient with a skeletal Class II malocclusion (patient appears to be shifting his mandible forward in the intraoral photos and cephalometric x-ray), moderate mandibular crowding. The proposed treatment is braces. The health plan's determination is upheld.
Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 20 with no auto qualifiers. Auto qualifiers include deep impinging overbite, anterior crossbite causing clinical attachment loss and recession of the gingival margin, overjet 9 millimeters (mm) or greater and underbite 3.5 mm or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the criteria to be classified as handicapping and therefore, treatment would not be considered medically necessary. Thus, braces are not medically necessary for this case.
Appeal type: Medical necessity
Decision: Overturned

The patient presented for inpatient detoxification treatment to address severe substance use disorder with opioid and stimulant class substances of abuse. The patient has a longstanding history of heroin use with more recent use of crack cocaine. The patient reported a past history of severe withdrawal symptoms when attempting to curtail use, and had undergone multiple detoxification and rehabilitation treatments including medication assisted treatment with Suboxone, but reported relapses with the longest period of sobriety being 21 months with relapse. The patient entered outpatient level substance use disorder treatment, but continued to use heroin with up to two bundles daily with intravenous (IV) administration together with one-half to one gram of crack cocaine. Thus, the patient presented for detoxification treatment in the context of treatment failure with outpatient level services and with severe opioid and stimulant use disorders.

The health plan's determination is overturned. The treatment of this patient's substance use disorders with detoxification and withdrawal management did require the continued structure of an inpatient level setting and 24-hour monitoring in view of the patient's clinical presentation and history and course of treatment. Additionally, the patient had an extensive treatment history with relapses that supported the necessity for an inpatient level detoxification, and presented with moderately severe withdrawal symptoms. Withdrawal symptoms were appropriately managed with tapering dosages of Suboxone requiring monitoring and supportive measures including the use of clonidine, availability of nicotine replacement therapy, and comfort medications, as noted in the clinical summary. The patient's history of opioid use and more recent use of crack cocaine with daily use, limited psychosocial supports and psychosocial stressors within several domains, and limited social supports did reflect the seriousness of the substance use disorder and a complicated case with regard to the ongoing struggle with achieving abstinence from opioid and stimulant use disorders with high risk for continued use.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Active Inflammatory Brain Lesion
 
Treatment: Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh

The insurer denied the Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh. The denial was reversed.       

This patient had a history of a brain lesion with hemiparesis, and facial weakness. She was in need of a positron emission tomography (PET) scan to evaluate her enlarging brain lesion and the concern for sarcoidosis

The patient's underlying diagnosis and because of recurrent bouts of hemiparesis/neurologic deficits remain unclear despite extensive testing.  Diagnosis remained unclear as to what the cause of brain inflammation, unclear etiology with recurrent episodes of neurological deficits.  A PET/CT body scan is needed to evaluate for sarcoidosis or lymphoma. Isolated neurosarcoidosis is unusual. In one study of 2 sarcoid centers, of 91 cases of neurosarcoidosis, only 10 had isolated neurosarcoidosis,  Fritz, et al. reviewed the clinical features of neurosarcoid using meta-analysis.  In their report they quote from a study in which whole body FDG-PET CT found extraneurol sarcoid in 78% of patients. Stern, et al. in a consensus statement on Neurosarcoidosis note that as many as 50% of patients who present with neurologic findings will not initially show evidence of systemic disease. Yet, over 90% will in fact have extraneural sarcoidosis after appropriate studies.

As noted, the literature does indicate that while neurosardosis may appear to be isolated, in fact it is usually associated with extraneural sarcoid which can be detected by PET-CT. Such a finding would clearly support a diagnosis of neurosarcoidosis.

Based on the above, the medical necessity for CPT 78815- Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hyperlipidemia, coronary artery disease 
Treatment: Repatha

The proposed treatment is medically necessary.
REPATHA- is indicated as an adjunct to diet and maximally tolerated statin therapy for the treatment of adults with heterozygous familial hypercholesterolemia (HeFH) or clinical atherosclerotic cardiovascular disease (ASCVD), who require additional lowering of low density lipoprotein cholesterol (LDL-C). 
This patient has a known diagnosis of severe hyperlipidemia, and her lipid levels are uncontrolled. The most recent LDL-C level of 201 milligrams per deciliter (mg/dL) on 08/16/2019 was reported. Furthermore, multiple attempts have been to initiate statin therapy; however these agents have not been tolerated by the patient. The patient has documented coronary artery disease, as documented by the cardiac catheterization and PCI. Given the history and the findings as documented in the attached medical records, the patient meets criteria for the use of the requested agent in the setting of ASCVD, severely elevated LDL and statin intolerance.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma
Treatment: Dupixent

The proposed treatment with Dupixent is medically necessary.

The patient has not tried the formulary alternatives, Symbicort, Advair HFA, BREO Ellipta or Dulera in combination with Singulair for at least three months. Thus, the request for Dupixent is not medically necessary per the coverage criteria.  

However, the request for Dupixent is medically necessary per standard of care since the patient has difficult to treat asthma and has required multiple cycles of systemic steroids and continues to have uncontrolled asthma.  The patient has been on Advair and Singulair since 2016. Dupilumab has been shown to increase lung function and reduced severe exacerbations in patients with uncontrolled persistent asthma irrespective of baseline eosinophil count. Thus, addition to inhaled corticosteroids plus long-acting 2-agonist therapy could improve the lives of patients with uncontrolled persistent asthma compared with standard therapy alone. Since the patient's asthma is inadequately controlled with ICS/LABA, the addition of Dupixent is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Crohn's Disease
Inpatient hospital

This is a patient with a history of Crohn's disease who presented to the emergency department with abdominal pain and bloody ostomy output. On presentation, the patient had a temperature of 98.4, pulse rate of 66, blood pressure of 96/60, respiratory rate 18, and oxygen saturation 100% on room air. Bloodwork was notable for white blood cell (WBC) 7.9, hemoglobin 11.7, and hematocrit 38.4, platelet count 318,000, sodium 138, potassium 3.8, chloride 104, and bicarbonate 27, total bilirubin 1.4, alkaline phosphatase 81, aspartate aminotransferase (AST) 13, alanine aminotransferase (ALT) 14 and albumin 4.1. A computed tomography (CT) abdomen/pelvis revealed mild wall thickening, mucosal enhancement and mild fat stranding in the distal small bowel. The patient was admitted to the medical floor and treated with conservative management with intravenous fluid hydration, acid suppression therapy and pain control. Gastroenterology service consulted. The patient did leave the hospital against medical advice as he stated he needed to go to work. The health plan's determination of medical necessity is upheld in whole. The patient remained hemodynamically stable throughout the hospital course without complications related to inflammatory bowel disease in the way of ongoing active gastrointestinal bleeding, severe uncontrolled abdominal pain, perforation, bowel obstruction or the need for surgical intervention. The patient did not develop sepsis. Based on the Milliman Care Guidelines (MCG) guidelines, the patient did not have intractable bloody diarrhea, abdominal abscess, fistulizing Crohn's disease, massive gastrointestinal hemorrhage, toxic megacolon, intestinal perforation or obstruction, hemodynamic instability, severe electrolyte abnormalities, severe pain requiring inpatient management, severe or persistent vomiting, peritoneal signs, absent bowel sounds, acute blood loss, high fever, or require parenteral nutrition, percutaneous drainage or surgery and therefore an acute level of care and inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
 
Treatment: Inpatient Substance

The insurer denied the Inpatient Substance. The denial was reversed.    

This is a male patient who was admitted to a rehabilitation facility for alcohol rehabilitation after being treated in another facility days earlier. The patient's drug history included over a decade of using 9-10 bags of heroin IV per day, almost a decade-long history of using tens of dollars per day of IV cocaine per day, and almost three decades of drinking 1-2 pints per day of alcohol. He had drug overdosed years earlier. He had multiple past inpatient substance detoxification and rehabilitation treatments during 2019. It was reported that the patient had a past history comorbid depression, anxiety, and post-traumatic stress disorder (PTSD), and liver disease. He was treated with Clonidine and Trazodone and then discharged. 

According to the LOCADTR he met criteria for inpatient substance rehabilitation treatment as he continued to use large amounts of heroin, alcohol, and cocaine daily despite multiple past inpatient substance treatments including detoxification and rehabilitation early-2019 and late-2018 and a past inpatient substance detoxification treatment mid-2019. He was still unable to remain abstinent and relapsed after each treatment. Also, he continued to use despite negative consequences due to substance use including the overdose, medical issues as he had reports of having a disease of the liver. He also had reports of comorbid depression, PTSD, and anxiety. He reportedly lacked coping skills, needed to better identify relapse triggers, and needed to learn relapse prevention skills. He was also unemployed. He was unable to stop substance use without being in a sober and supervised therapeutic inpatient substance residential setting then. Without this structured and supervised therapeutic residential treatment he likely would have relapsed quickly. He also lacked sober supports as he was discharged to a men's shelter. As a result, the recommendation is to reverse the previous decision and approve coverage for inpatient substance rehabilitation treatment.

Based on the above, the medical necessity for the inpatient substance use rehabilitation treatment is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse
Treatment: Inpatient detoxification 

The Inpatient detoxification was not medically necessary for this patient.

The proposed inpatient stay and detoxification treatment and other medical services noted in the clinical summary 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 ongoing substance use disorder with alcohol and use of cocaine and cannabis and chronic general medical issues. Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance that would have warranted an inpatient level admission and treatment. There were no severe/objective symptoms of withdrawal or biomedical issues in this case, and the patient had received detoxification treatments recently with knowledge of substance use disorder treatment protocols, as noted in the clinical summary. The patient had fair insight and control of impulses, and a working knowledge of substance use disorder treatment with a past history of multiple treatment episodes, as noted. Thus, inpatient admission for detoxification treatment and 24-hour monitoring, and the requested inpatient level services were not medically necessary in this case scenario.

This answer is consistent with New York State OASAS LOCADTR 3.0 Criteria/Guidelines and with established practice guidelines, the scientific literature, and ASAM Criteria, as referenced below.

In this case scenario, the patient was amenable to treatment with lower level care in a less restrictive setting. The patient displayed no serious disturbance of mental status and no general medical complications or co-occurring disorders that would have warranted inpatient level services. Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance that would have warranted an inpatient level admission and treatment. There were no severe symptoms of withdrawal or biomedical issues in this case. The admission for detoxification treatment and 24-hour monitoring, and the requested inpatient level services were therefore not medically necessary in this case scenario, as the health plan asserts. And, NY State OASAS LOCADTR 3.0 Criteria/Guidelines are not met for the inpatient level of care, referenced below.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain; rule out for myocardial infarction

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial was upheld.

This patient is a man with a past medical history notable for: depression, tobacco use, diabetes mellitus, hypertension, and hyperlipidemia. He presented to the Emergency Room (ER) with complaints of chest pain. It was associated with nausea and had been present for three days prior to presentation. The EKG showed T-wave inversion in the lateral leads. The vital signs were stable. The Troponin was negative. He was admitted and ruled out for myocardial infarction. The follow-up EKG showed premature ventricular contractions (PVCs). He was discharged to home with instructions to follow-up with a cardiologist the following week. 

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. The patient presented with chest pain, however the initial evaluation in the emergency room (ER) was non-diagnostic and nonspecific.  The cardiac biomarkers were normal.  

The inpatient admission was not medically necessary for this patient. 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 was not met. There was no evidence of other medical conditions warranting inpatient level of admission.

The carrier's denial of coverage for the inpatient admission is upheld. The medical necessity is not substantiated.