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

Diagnosis: Preterm rupture of membranes, vaginal bleeding
Treatment: Inpatient admission
The inpatient admission was medically necessary.
Regardless of the duration of labor or hospital stay, inpatient level of labor and delivery care with associated nursing and other support is required for patient safety, pain relief, and psychological support that is not available from outpatient surgery resources for patients laboring and delivering at any gestational age.  In all cases, but especially in the circumstance of a perinatal demise and associated need for grief support and compassionate caregiving, specialized nursing support is needed for both physical and psychological wellbeing that would not be possible in an outpatient surgical unit.  Patients in this situation often are at risk for numerous hemorrhagic, infectious, and obstetrical complications that require specialized nursing and access to specialized hospital resources.  Therefore, this care should be provided in a standard labor and delivery environment and is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

This patient was currently diagnosed with severe obstructive sleep apnea (OSA).  The patient underwent a sleep study in 2019 which revealed an apnea hypopnea index (AHI) of 40.  In the supine position, the AHI was 60.  The patient was treated with continuous positive airway pressure (CPAP).  The patient's body mass index (BMI) was 28.5 kg/m.  The physician letter indicated that the polysomnogram eliminated the possibility of central sleep apnea or complex sleep apnea.  The patient had failed and was intolerant to CPAP, the gold standard of care for patients with obstructive sleep apnea.  The patient was unable to tolerate CPAP as he found it very uncomfortable.  The patient took the mask off at night.  The patient had tried different masks and machines without improvement.  The patient had difficulty sleeping.  The patient reported very loud snoring and he woke up frequently gasping for air.  The patient was very tired throughout the day.  For this patient, there were noted to be limited alternative treatment options available.  Due to the obstructive sleep apnea severity, the provider did not feel the patient was a good candidate for oral appliance therapy (OAT).  After performing the sleep endoscopy, the provider confirms that the patient did not have complete concentric collapse of the upper airway.  Therefore, the provider felt the patient was an excellent candidate for stimulation of the upper airway via Inspire therapy.

The insurer has denied coverage for hypoglossal nerve stimulation (Inspire Upper Airway Stimulation System) as experimental/investigational. The denial was reversed as use of the implantable hypoglossal nerve stimulation will likely be more beneficial than any other standard treatment or procedure for this patient at this time.

The nerve stimulation surgery for the treatment of OSA has final approval from the appropriate bodies for this diagnosis.  The patient is a good candidate for nerve stimulation surgery for the treatment of OSA.  Nerve stimulation surgery for the treatment of OSA is the best available treatment for this patient, at this time, as he has failed CPAP therapy, has a body mass index of less than 32 kg/m, has a lack of central apnea, and has a favorable pattern of palatal collapse during a drug-induced sleep endoscopy.  The patient meets the criteria for performance of the procedure.
Appeal type: Experimental/Investigational
Decision: Overturned

This patient has obstructive sleep apnea.  He is not obese with a body mass index of 28 kg/m2.  He has loud snoring and daytime irritability. He underwent a sleep study that was obtained when he was intercurrently ill with a viral respiratory infection and thusly needs to be repeated according to the records submitted for review.  On this sleep study, he had an overall apnea-hypopnea index of 40 breaths per minute that was increased to 61 when supine and was low at 7 events per hour when in a non-supine position.  He has been intolerant of Continuous Positive Airway Pressure (CPAP), although there are no records provided about attempts at use of CPAP and whether medical advice was sought and followed or whether he actually wore the CPAP for any extended period of time. There are no records provided to indicate that CPAP settings were appropriate to relieve his sleep apnea.  He reports use of different mask interfaces as well as different machines.  He underwent endoscopy and was found to have non-concentric collapse of the upper airway in 2018.
  
The insurer has denied coverage for hypoglossal nerve stimulation (Inspire Upper Airway Stimulation System) as experimental/investigational.  The denial was upheld as the hypoglossal nerve stimulator is not likely to be more beneficial for this patient then other standard treatments/procedures.
  
There is no documentation to support failure of CPAP attempt, and there are no records provided to indicate that CPAP settings were appropriate to relieve his sleep apnea.  He reports use of different mask interfaces as well as different machines.  Therefore, the Inspire Upper Airway system would not be considered more beneficial for this patient. This patient has overall severe sleep apnea, but his study was obtained during an intercurrent viral illness and thusly requires the study to be repeated, as it may be falsely elevated in this clinical circumstance. This patient has only mild sleep apnea in the non-supine position, and therefore is a candidate for position therapy with or without an oral appliance which has not been unsuccessfully trialed and failed.  The provided documentation does not substantiate extended efforts at use of CPAP with assistance and guidance from a trained sleep physician.  Thus, it is impossible to know whether attempts at CPAP were simply unsuccessful or really could not be successful despite diligent efforts. There are other reasonable, and likely to be successful treatment options available for this patient that have not been fully explored that are known to be effective.  These treatments are likely to be successful at treating his sleep apnea, as is the hypoglossal nerve stimulator, and do not carry the unknown long-term potential adverse consequences inherent to a newer device like the hypoglossal nerve stimulator.
Appeal type: Experimental/Investigational
Decision: Overturned

This patient has severe obstructive sleep apnea (OSA) and oxyhemoglobin desaturations.  The OSA was documented by a polysomnography study which found an apnea hypopnea index (AHI) = 40.  The patient had a body mass index (BMI) = 28.15.  He failed the use of continuous positive airway pressure (CPAP).  A sleep endoscopy performed in 2018 found there was complete anterior posterior collapse.

The insurer has denied coverage for hypoglossal nerve stimulation (Inspire Upper Airway Stimulation System) as experimental/investigational. The denial was reversed as use of the implantable hypoglossal nerve stimulation will likely be more beneficial than any other standard treatment or procedure for this patient at this time.

The peer reviewed literature is abundantly clear concerning the efficacy for patients with a high AHI, and the inability to utilize some form of CPAP without concentric collapse of the upper airway.  This is the case with this patient.  The use of hypoglossal nerve stimulation for the treatment of OSA has been approved by the American Academy of Otolaryngology Head and Neck Surgery and the International Sleep Society. The Food and Drug Administration (FDA) of the United States Department of Health and Human Services has initially approved the use of hypoglossal stimulation for patients with the characteristics of this patient.  More recently, the FDA has expanded the clinical criteria for the use of the hypoglossal stimulation for which the patient qualifies.
Appeal type: Experimental/Investigational
Decision: Upheld

This case involves a patient who underwent the requested testing.  It was noted that the patient had a 57% probability that he would have a Gleason score of equal to or greater than 7 prostate cancer.  Urology notes indicated that the patient did have a history of elevated PSAs of 5.71 and 5.59.  The patient was seen to undergo a prostate biopsy.  The patient denied hematuria and dysuria, but he did complain of occasional pelvic pain.  The physical examination revealed a 40 g smooth prostate.  The elevated PSA was reviewed with the patient as was the risk of prostate cancer.  The patient did follow-up for the biopsy results.  The documentation detailed that the pathology results showed a Gleason 3+4 with 8/12 cores being positive.  The physician explained to the patient that he has the option for radiation therapy robotic assisted laparoscopic prostatectomy.  

According to current literature, the use of the requested testing is an appropriate option.  Peer-reviewed literature does support a result of improvement in health outcome as the utilization of the requested 4K score has been reported to have reduced the number of prostate biopsies.  The genetic testing does have final approval from the appropriate regulatory bodies.  The patient is also noted to be a good candidate given the elevated PSA.
Appeal type: Experimental/Investigational
Decision: Upheld

This is a patient with elevated Prostate Specific Antigens (PSAs) of 5.71 ng/mL and 5.59 ng/mL which was evaluated with a prostate biopsy.  Pathology revealed stage T2b Gleason's grade 3+4 adenocarcinoma involving 8 of 12 core biopsies.

The utility of the 4KScore test has not been scientifically determined to improve subsequent health related outcomes. The 4K Score test is not Food and Drug Administration (FDA) approved, but is offered as an LDT (Laboratory Developed Test) through BioReference Laboratories and Gen Path Diagnostics as an alternative to prostate biopsy.     

The patient would not be a good candidate for genetic testing (4K-Score biochemical assay of 4 protein testing) performed.  There is insufficient evidence to support the clinical utility of this test and there is insufficient evidence to support a conclusion concerning the health outcomes or benefits associated with this test.     

Neither the American Urological Association (AUA) guidelines nor the National Comprehensive Cancer Network (NCCN) guidelines recommend Genomic Prostate Score (4K score) testing as a screening tool for prostate cancer.  A prostate biopsy will be needed regardless of the results of this test.  The utility of the 4KScore test has not been scientifically determined to improve subsequent health related outcomes.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Prostate Cancer

Treatment: Diagnostic test

The insurer has denied coverage for genetic testing (4k-score biochemical assay of 4 protein testing) performed.  That denial was upheld since it was concluded that the requested procedure is not likely to be more beneficial than any other existing standard health service.
 
This is a patient with past history of elevated prostatic specific antigen (PSA) levels (5.71, 5.59).  The patient then had a 4K score test ordered. 4K score was (57%) = elevated risk.  

The 4K score test is a blood test indicated for men with an abnormal PSA or rectal exam to help determine an individual patient's risk for high grade prostate cancer on biopsy.  This lab test measures 4 Kallikrein in the blood combined with patient's clinical information in an algorithm to predict the individual patient's risk of having high grade prostate cancer on biopsy vs. indolent cancer or no cancer. The 4K score does not diagnose prostate cancer, but is a risk-indicator for high grade disease.  This test is not endorsed or recommended by American Urological Association (AUA) guidelines.

Scientific evidence in peer reviewed literature does not support an improvement in health outcomes based on this test.The 4K score test performed does not have final approval from the appropriate regulatory bodies for this diagnosis. Any patient with abnormal PSA/rectal exam is a candidate for the 4K score test, but there is no evidence of any improvements in health outcomes based on this test's performance.
Appeal type: Medical necessity
Decision: Overturned

This is a patient who was medically screened in the emergency department and admitted for acute inpatient psychiatric treatment . The patient had become increasingly anxious and depressed with suicidal ideation and deterioration in functioning culminating in his presentation. He had a history of bipolar disorder and severe depressive episodes and psychiatric treatment with therapy and medications. The health plan's determination of medical necessity is overturned.  The patient required the admission and continued acute inpatient level care; and the continued structure of an acute inpatient level setting through discharge was warranted in order to provide safety monitoring and to administer treatment for his psychiatric disturbance while conducting an evaluation, and while observing his functioning with the resumption/adjustment of clinically appropriate medications including the addition of the long acting injectable medication, Abilify Maintena.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Suicide Attempt
 
Treatment: Inpatient admission

The insurer denied the continued inpatient. The denial was upheld.

This patient was admitted to this inpatient mental health treatment in this hospital due to a suicide attempt in which she tried to jump out a window, but her father pulled her out of the window.  She had depressed mood, feelings of hopelessness, helplessness, and guilt, as well as tearfulness, decreased energy, poor concentration, decreased appetite, and she was non-compliant. It was reported that her depression worsened after her cat died.  She had multiple medical issues including multiple sclerosis and immunosuppression.  She had two past suicide attempts by jumping off a fire escape and slashing her wrist.  She had a reported diagnosis of Schizoaffective Disorder. She took Zyprexa. 

The chart notes did not provide enough specific evidence to support that she only required 24-hour hospital treatment.  The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Suicidal Behaviors report that patients with suicidal intent or plan are in need of inpatient treatment.  In this case, this patient had suicidal intent, plan, and attempt prompting this admission as she was trying to jump out a window; therefore, she required hospital treatment then.  

There were no reports of self-injurious, aggressive, or agitated behavior, suicidal or homicidal ideation, plan, or intent, and no reports of specific identifiable or quantifiable treatment goals or objectives that could only be achieved in a 24-hour acute psychiatric hospital setting or that could not be achieved in a less restrictive setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma
Issue under review: inpatient admission
Summary: The inpatient admission was not medically necessary.
The patient had shortness of breath and cough.  She was admitted and discharged at St Barnabas Hospital.  She had asthma.  She was morbidly obese with a BMI of 50.  The room air oxygen (O2) saturation was 98% and 97%.  She was not intubated.  
Each admission day, the room air O2 saturation was either 97% or 98%.  There was no documentation to substantiate the medical necessity of inpatient acute care.  Inpatient acute care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who presented to the emergency department (ED) on 10/13/18 with a history of progressively worsening abdominal pain of 3-4 days duration. The patient underwent a laparoscopic appendectomy on 10/13/18. The clinical notes and the anesthesia record indicate an uncomplicated appendectomy.  The health plan's determination of medical necessity is upheld.  The submitted clinical documentation does not support the need for inpatient admission for this patient. She required urgent surgical intervention for acute appendicitis, however, a lower level of care would have satisfactorily provided for the care provided and would have been consistent with the accepted standard of medical care.
Appeal type: Medical necessity
Decision: Upheld

No, the inpatient admission 11/25/2018 through 11/26/2018 is not medically necessary.

The medical record demonstrates admission was recommended based upon knee pain and inability to ambulate. Consultations and imaging reports show no evidence of an acute condition to warrant admission. There was no evidence of fracture, infection or compartment syndrome. The vital signs were stable. The patient was able to tolerate oral pain medication. She was independent when provided with walker.  Imaging studies were completed but could have been performed as outpatient. The Orthopedic and medical resident report necessity of imaging as outpatient. She could have been provided with a walker and stronger pain medication. There was neither listed diagnosis nor treatment, which required inpatient services. Of note, nursing record reported the patient was comfortable without signs of distress. There were no extenuating circumstances to substantiate the admission and length of stay.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Wheezing
Issue under review: Inpatient admission

Determination:
Inpatient admission was not medically necessary.

The patient did not require acute inpatient management, and he could have been safely managed at a lower level of care.

Asthma is an inflammatory process characterized by airway obstruction due to airway hyper-responsiveness, bronchospasm, airway inflammation, and mucus production. Gas exchange abnormalities are due to ventilation/perfusion mismatch, as a result of atelectasis and airway over-distention. Status asthmaticus is defined as "severe asthma that fails to respond to inhaled beta-agonists, oral or intravenous steroids, and requires admission to the hospital for treatment." (1) Unfortunately, asthma can still be a fatal illness if treatment is not initiated quickly or aggressively enough. "Despite advances in asthma management, acute exacerbations continue to be a major problem in patients  our review findings support the importance of controlling persistent asthma  early episodic intervention appeared to be crucial in preventing severe attacks and future exacerbations." (2)

In the ED, primary management strategies include correction of hypoxia, rapid improvement of airflow obstruction, and prevention of progression. This is achieved with supplemental oxygen, bronchodilators, and steroids. Fluid hydration may also be necessary. For patients with moderate to severe exacerbations that do not respond to such intensive therapy in the ED, admission is necessary.

This little boy with no prior history of wheezing presented to the ED with signs and symptoms consistent with bronchospasm likely secondary to viral respiratory illness (cough, low-grade fever, congestion). He demonstrated some improvement with bronchodilators in the clinic and ED, but remained tachypneic, and so he was admitted for further management. He remained afebrile following admission, was hemodynamically stable, and had no oxygen requirement. While it was not unreasonable to monitor him for continued response to bronchodilators, he was overall stable with no oxygen requirement. He did not require acute inpatient management, and he could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse
Treatment: Continued inpatient detox services from 03/03/2019 to 03/04/2019
The continued inpatient detox services were medically necessary for this patient.
The continued inpatient detoxification treatment of this patient's substance use disorders did necessitate the structure of an inpatient level detoxification setting and monitoring. The patients history of substance abuse (frequency and quantity) together with severe psychosocial stressors and functional impairments reflect the seriousness of the substance use disorder and the need for a safe and effective detoxification with withdrawal management, as the patient was at high risk for treatment failure if detoxification and withdrawal management were to be attempted at a lower level of care. 
Therefore, medical necessity is met in this case, consistent with prevailing standards of professional practice, published practice guidelines, the American Society of Addiction Medicine (ASAM) Criteria, and the scientific literature, referenced below, and, with New York State instruction for medical necessity reviews including the LOCADTR Tool (referenced below) that requires the patient in this scenario default to the higher level of care.
The requested benefit of continued inpatient detox services is considered medically necessary and is therefore a covered service in this case scenario. The substance abuse detoxification admission and treatment through discharge could not have been safely or effectively provided with lower level services. Moreover, the patient was using a dangerous combination of substances of abuse with high risk for withdrawal seizures and high risk for an overdose with continued use. The patient could not have been reasonably provided an effective or safe detoxification treatment in a less restrictive treatment setting in this case scenario. Thus, the requested benefit is not excluded under the plan, and should be covered in keeping with prevailing standards of care pertaining to substance use disorder services including ASAM Criteria and the appropriate application of New York State OASAS LOCADTR 3.0 Criteria, referenced below.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Urinary tract infection
Treatment: Inpatient Hospital Services

Summary: This patient with an unclear past medical history except for recent urinary tract infection (UTI), self- treated with cranberry juice, presented to the emergency department (ED) with complaints of fever, chills, and rigors. Vitals on presentation included: Temperature max-103 F, Blood Pressure-123/67, Pulse-73, Respiratory Rate-119, Oxygen saturation-96% on Room Air. Laboratory values were notable for the following: White Blood Count (WBC)-5.8 (32% bands), Hemoglobin-14.1, Hematrocrit-43.6, creatinine-0.89, glucose-112; urinalysis showed small leukocyte esterase, negative nitrite. The patient was empirically started on intravenous (IV) antibiotics (azithromycin and ceftriaxone) for possible UTI.  Chest x-ray was negative.  Urine culture grew Escherichia coli. The patient refused antibiotics and signed out against medical advice.

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

According to the medical records, the patient presented with symptoms suggestive of an infection. Urinalysis and urine culture confirmed a UTI. He had high fever, tachycardia and although a "normal" absolute WBC, he had elevated bands. Moreover, the patient failed outpatient management (seen at Urgent Care), but refused antibiotics. Based on above findings, in an unpredictable patient with unclear medical history, hospital admission was medically warranted for administration of IV antibiotics and further diagnostic management to rule out sepsis.