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

Diagnosis: Coronary artery disease (CAD)

Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld. 

This is a female patient who presented to the hospital for scheduled percutaneous coronary intervention (PCI) of left anterior descending artery. She has a history of hypertension, hyperlipidemia, two vessel coronary artery disease (CAD) (right coronary artery, and left anterior descending artery), status post DES of right coronary artery. Immediately post procedure she experienced nausea and chest pain. She was given nitroglycerin and Zofran. She was treated with antiplatelet therapy and remained clinically and hemodynamically stable throughout her hospital stay. She was discharged home for outpatient follow up.

Per MCG Angioplasty, Percutaneous Coronary Intervention ORG: M-52 (ISC), this procedure is an outpatient one. The clinical presentation and peri-procedural course were unremarkable and uneventful, and acute inpatient level monitoring was not medically necessary or appropriate. There were no extenuating circumstances in this case which warranted inpatient admission status following elective cardiac catheterization, angioplasty, and coronary stenting.

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

The patient is a female with a history of a ruptured ovarian cyst, syncope and chronic back pain. She presented to the emergency room with abdominal pain, diarrhea, vomiting, and palpitations. Her vital signs were unremarkable, she appeared well and in no acute distress. There was slight epigastric tenderness. Except for a minimally elevated troponin, the labs, chest x-ray, and the electrocardiogram (EKG) were essentially normal. Apparently, due to the complaint of palpitations and the minimally elevated troponin, the patient was admitted.

Upon admission, she was placed in a telemetry bed. An echocardiogram was normal. The hospital course was clinically uneventful, and the patient was discharged the following day.
The health plan's determination is upheld.

No, the requested health service/treatment of Inpatient stay was not medically necessary for this patient.

Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or EKG of an imminently life-threatening cause of the patient's complaints. The services provided could have been safely and efficiently provided at a lesser level. The probability of an acute coronary syndrome was extremely low.
Appeal type: Medical necessity
Decision: Overturned

This is a patient is a patient with a past medical history significant for alcohol abuse, polysubstance abuse, depression, gastroesophageal reflux disease (GERD), and suicidal ideation who presented to the emergency department with alcohol intoxication and withdrawal symptoms.
The patient was admitted to the hospital and received treatment for alcohol withdrawal symptoms based on the Clinical Institute Withdrawal Assessment (CIWA) protocol. She also received treatment with intravenous fluids, thiamine, multivitamins, folic acid. It was indicated in the discharge summaries that the patient had signs of severe withdrawal.
Subsequently, patient's alcohol withdrawal symptoms completely resolved, and she was discharged home with a recommendation to follow up with a primary care physician as well as to attend alcohol anonymous group. The health plan's determination is overturned.
This patient was admitted to the hospital with alcohol withdrawal symptoms. Even though in some cases a patient with mild alcohol withdrawal symptoms could be managed as an outpatient and at the lower level of care, patients with moderate to severe withdrawal symptoms require admission to the hospital. They need very close monitoring, assessment of the withdrawal symptoms based on the CIWA score, and proper administration of benzodiazepines in accordance with CIWA protocol. In this particular case, the patient had a relatively low CIWA score, with several spikes in the CIWA score up to 26, which was in a category of severe withdrawal. Therefore, this patient had episodes of severe alcohol withdrawal qualifying for inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Prematurity
 
Treatment: Inpatient admission, medication, monitoring, phototherapy

The insurer denied the continued NICU level of care. The denial was reversed.

This male infant was born several weeks premature weighing 2630 grams; delivery was via spontaneous vaginal delivery complicated by Group B Streptococcus (GBS) and premature rupture of membranes (PROM).   The Neonatal Intensive Care Unit (NICU) admission was initially for preterm gestation and presumed sepsis.  As of Day #3, the patient was in room air without distress and with normal vital signs.  Fluids and nutrition were being provided by both enteral and intravenous (IV) routes with oral (p.o.) feeding gradually increased and IV fluid gradually decreased.  IV antibiotics had been started for presumed sepsis; the blood culture showed no growth to date.  Phototherapy was started for hyperbilirubinemia of prematurity, but discontinued 12 hours later.  On Day #4, antibiotics were discontinued. Feeding was advanced and IV fluid was decreased. On Day #7 IV fluid was discontinued. Bilateral casts were placed for club feet.  On Day #8 the infant was on p.o. feeding without any significant co-morbidity requiring treatment.   

According to MCG: Neonatal Care, Intermediate Care, Level 3 (LOC:012): Admission for or continuation (from higher level) of care at Level 3 indicated by: inadequate feedings (e.g., oral and nasogastric) requiring ongoing IV fluids. According to MCG: Neonatal Care, Continuing Care, Level 2 (LOC: 011):  Admission for or continuation (from higher level) of care at Level 2 indicated by presence of: Care for mild instability or condition as indicated by 1 or more of the following: Continued inpatient care during convalescence from condition or conditions treated at higher level of care; Limited or absent oral feedings requiring efforts to advance toward expected oral goal; Suspected sepsis: evaluation and observation of asymptomatic infant; Neonatal jaundice requiring monitoring (e.g., elevated bilirubin levels repeated more frequently than every 12 hours) or treatment with phototherapy; Supportive care needed for other instability or condition. 
 
Care at Neonatal Care, Intermediate Care, Level 3 is approved for Days #3-6, and care at Neonatal Care, Continuing Care, Level 2 is approved for the remainder of stay. The carrier's denial of inpatient hospital services at the Neonatal Intensive Care Unit level of care is reversed.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of diabetes, hypertension, hyperlipidemia, asthma, pulmonary embolism and obstructive sleep apnea. She presented to the emergency department complaining of chest tightness, dyspnea, palpitations and cough. Her blood pressure was 150/120 millimeters of mercury (mmHg) with a heart rate of 160 beats/minute. Room air oxygen saturation was 100%. Her physical exam was remarkable for obesity and a rapid, irregular rhythm. An electrocardiogram showed atrial fibrillation with a rapid ventricular rate and nonspecific repolarization changes. Her serum troponin level was normal. The health plan's determination of medical necessity is upheld. She presented with a new onset of atrial fibrillation (AF). She was hemodynamically stable and there was no evidence of myocardial ischemia or decompensated heart failure. In patients who present to the emergency department with acute AF, the safety of a lower level care or discharge to home with close follow-up has been well demonstrated. 
Per the Milliman Care Guideline for Atrial Fibrillation (ORG: M-505) , indications for inpatient care include: hemodynamic instability, myocardial infarction or ischemia, altered mental status, syncope, heart failure, implantable cardioverter defibrillator discharges, Wolff Parkinson White syndrome, medication toxicity, severe electrolyte or acid base disturbance or other acute serious medical condition requiring inpatient care, need for initiation of antiarrhythmic drug therapy in a patient at high risk for adverse effects, persistent symptomatic tachycardia despite outpatient or observation level care or need for urgent or elective cardioversion that cannot be performed on an outpatient basis or during observation care. This patient met none of these criteria.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient admission
The proposed inpatient treatment was not medically necessary.

After an uncomplicated elective laparoscopic cholecystectomy, patients can drink clear liquids once awake from anesthesia, and their diet can be advanced as tolerated.

Most otherwise healthy, reliable patients with good home support can leave the hospital within six hours after surgery. Cochrane reviews have found no significant differences for important clinical outcomes for patients discharged the same day versus admitted overnight following laparoscopic cholecystectomy. A retrospective review of the American College of Surgeon's National Surgical Quality Improvement Program (NSQIP) database, which included 15,248 patients older than 65 years of age who underwent elective laparoscopic cholecystectomy, identified congestive heart failure, American Society of Anesthesiologists class IV, bleeding disorder, and renal failure requiring dialysis as significant independent predictors of inpatient admission and mortality.

This patient presented with signs and symptoms of acute cholecystitis with confirmatory diagnostic imaging. There were no signs and symptoms of sepsis and no untoward events during or after surgery. All available laboratory data was trending downward after the infected organ was removed.  Therefore, the inpatient admission was not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

This is a patient with a history of malignant melanoma in situ on the left neck and right deltoid, and a history of malignant melanoma to the left scapula, Breslow 0.7 millimeter (mm). There is no ulceration and the mitotic index is less than one. This is a review for coverage of the DecisionDX melanoma assay.

The health plan's determination is upheld. The DecisionDX melanoma testing is not likely to be more beneficial than any standard treatment for the patient's condition. There is insufficient evidence to determine how gene expression profiling may be used to guide clinical decisions related to the diagnosis and treatment of cutaneous melanoma. Specifically, it is not known how or whether decisions concerning treatment and surveillance are improved over the current standard of care, and it is unknown whether health outcomes are improved as a result of those decisions. There is insufficient clinical evidence in the peer-reviewed medical literature to demonstrate improved long-term health outcomes of this testing.
Appeal type: Experimental/Investigational
Decision: Upheld

The patient has a history of Malignant Melanoma of the left medial scapula that was biopsied on 5/17/2017. The Melanoma was read out as having a Breslow depth of 0.7 millimeter (mm), no ulceration, and with less than one mitotic figure per square millimeter field. Regression was noted, but no perineural or lymphovascular invasion, or microsatellitosis were observed on histologic examination. The tumor was staged as pT1a. The DecisionDx-Melanoma Gene Expression Assay is under review.

The health plan's determination is upheld. The DecisionDx-Melanoma test is not likely to be more beneficial than standard treatment in this case. It is not in accordance with generally accepted standards of medical practice in the United States, and is not clinically appropriate for this patient's clinical condition. Standard treatment in this case is observation and followup based on the tumor's histologic features. This patient has a relatively superficial melanoma with no ulceration or significant number of dermal mitoses, so that wide excision and appropriate followup only is indicated for this patient. Therefore, at this time, the DecisionDx-Melanoma is not likely to be more beneficial than standard treatment in this case. The only consensus that exists for this test is that more studies need to occur in modern evidence-based and peer-reviewed literature.
Appeal type: Experimental/Investigational
Decision: Upheld

The patient has a cutaneous melanoma to the back, 0.7 millimeter (mm) in depth with absent ulceration. DecisionDx-melanoma assay designated the tumor class 1 (low risk of recurrence within 5 years). The use of the DecisionDx testing is under review.

The health plan's determination is upheld. There is no evidence based medical literature to support that a greater benefit is imparted after DecisionDx testing than current standard of care and there are insufficient outcomes data available from controlled clinical trials published in the peer-reviewed literature to substantiate its safety and effectiveness for melanoma. Standard of care in a melanoma greater than 1 mm (one millimeter) is wide local excision with a sentinel lymph node biopsy. Further testing or work-up is performed by symptoms and results of sentinel lymph node testing. For melanomas less than 1 mm, wide local excision with routine skin and physical exams is standard of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Constipation, tenesmus, bowel leakage
Treatment: Hospital Emergency Admission

The hospital emergency admission was not medically necessary.

The patient has human immunodeficiency virus and rectal squamous cell carcinoma status post chemotherapy and radiation.  He presented to the hospital with one week of constipation, tenesmus, and bowel leakage.  

The patient was afebrile with a blood pressure of 135/83.  Labs demonstrated a creatinine of 2.0, potassium of 6.1, bicarbonate of 21, magnesium of 1.4, and white blood cell count of 10,400.  Computed tomography (CT) of the abdomen/pelvis demonstrated perirectal fat stranding in the rectal area suggestive of proctitis.  Intravenous fluids, magnesium supplementation, and as needed analgesics were ordered.  One dose each of prednisone and azithromycin were administered for treatment of gonorrhea and chlamydia.  The potassium normalized, and the creatinine dropped to 1.4.  Hydrocortisone suppositories were provided.

The patient presented to the hospital with proctitis but did not have inflammatory bowel disease, gastrointestinal bleed, fever, hemodynamic instability, or evidence of bowel obstruction.  No surgical intervention was required.  The patient had only a mild degree of acute kidney injury, and renal function improved promptly with administration of intravenous fluids.  The patient's hyperkalemia was mild and was not associated with muscle weakness, ventricular arrhythmia, or electrocardiographic changes.  The potassium normalized with intravenous fluid administration.  In summary, inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe Obstructive Sleep Apnea
 
Treatment:  Laboratory based Sleep Study

The insurer denied the laboratory based Sleep Study.  The denial was reversed.  

This is a male patient who underwent a sleep study in early 2019 with decreased oxygen saturation indicative of severe obstructive sleep apnea.  The patient is symptomatic with nonrestorative sleep and excessive daytime somnolence.  A contributing factor to the obstructive sleep apnea is a significant anatomic abnormality in the patient's upper airway with evidence of prior horizontal nasal fracture and severe nasal septum deviations with multiple perforations.  The physician detailed that the first therapeutic modality would be considered continuous positive airway pressure (CPAP) trial with an attended in lab CPAP titration. The notes also indicate that the patient is being treated by a cardiologist for an aortic bicuspid valve.

Home-based sleep studies with portable monitors are preferred over in-laboratory polysomnography, except in those patients who have contraindications to a home sleep study. The patient has previously undergone a sleep study and he was diagnosed with severe obstructive sleep apnea. He is also being monitored by cardiology for an aortic bicuspid valve. He recently had a major facial injury as well with evidence of a prior horizontal nasal fracture, severe nasal septum deviations and multiple perforations.  Therefore, the patient would need to be monitored in a facility with supervision from a trained professional in order to optimize the CPAP and monitor the titration.  

Based on the above, the medical necessity for a laboratory-based sleep study is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Migraines
Issue under review:  Zembrace

Determination:
The Zembrace is not medically necessary.

There is no documented reason as to why the patient cannot be treated with the preferred formulary agents.  The patient can be treated with sublingual disintegrating triptans.  There is no evidence from high quality clinical trials or support from standard of care guidelines for the preferential use or superiority of Zembrace relative to the preferred agents.  The patient can be treated with sublingual disintegrating triptans.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parotid abscess

Treatment: Inpatient admission

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

The patient is a male child who presented to the Emergency Room (ER) for left lateral neck and cheek swelling after having failed to show improvement of the swelling after being started on clindamycin by his primary care physician.  Physical examination in the ER revealed a large area of tenderness and swelling over the submandibular and parotid area. The patient clearly needed intravenous antibiotic therapy and close monitoring as an inpatient for possible spread of infection or possible airway compromise. The following facts support this determination:
 
A CT confirmed a left intraparotid 2.2 by 1.4 cm fluid collection consistent with abscess. Moreover, the left parotid gland was enlarged and inflamed, consistent with parotitis, indicating that the abscess was a complication of the parotitis. It was also a concern that the left internal jugular vein was compressed, which this reviewer assumes was from the parotid mass. Incidentally found were middle ear effusions with possible otomastoiditis, which is another bacterial infection that would require antibiotic therapy. In fact, the sonogram of the neck done soon after ER arrival had been even more concerning for a finding of a more than 3 by 2 by 2 cm mass with heterogeneous density fluid components which could have raised suspicion of a deep neck abscess. Moreover, a chest x-ray noted rightward tracheal deviation with concern for left-sided mass, which could possibly be mediastinal, if indeed there was a left-sided deep neck abscess. The history of Methicillin-resistant Staphylococcus aureus (MRSA) infection in the neonatal period was also significant; therefore, it was reasonable to include MRSA in the list of possible organisms causing the parotid abscess.  There was leukocytosis at a level of 19,500 and an elevated C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) indicating a severe infection. 

It was ultimately evident that the parotid infection was caused by Strep pyogenes, which can be a rapidly progressing soft tissue infection and entails the risk of bacteremia in a young infant of this patient's age. The intravenous antibiotic regimen Vancomycin and Unasyn was standard of care.

In summary, the patient had significant co-morbidities with his bacterial parotid gland infection, and as supported by the review by Stong et al, "the presence of a significant co-morbidity, fever, or leukocytosis may require inpatient therapy and imaging if patients fail to improve with medical therapy." 

The health care plan did not act reasonably or with sound medical judgment or in the best interest of the patient. The inpatient hospital service is considered medically necessary for this patient. 

Based on the above, the medical necessity for the inpatient hospital services at the acute level of care is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lewy body dementia
Issue under review: Increase in PCW services

Determination:
The Increase in PCW services is not medically necessary.

This is a patient with a history of advanced Lewy body dementia and associated psychosis.  Despite the report from the patient's attending physician that the patient has sustained further cognitive and functional decline, a recent Uniform Assessment System of New York revealed that the patient had not experienced significant changes in her cognitive, functional status and overall self-sufficiency as compared to her last assessment date.  Furthermore, her currently approved PCW service is sufficient to meet her ADLs and other needs.  For these reasons, the proposed treatment of an increase in PCW services is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Migraines
 
Treatment: Medication- Emgality 

The insurer denied coverage for Emgality. The denial was upheld.

This child patient has a past medical history notable for anxiety, asthma and obesity with chronic headaches most consistent with migraines.  She has frequent headaches and they are severe, long-lasting and debilitating.  She was referred to a neurologist; she has never taken prophylactic headache medication.  Neurologist recommended Emgality.  

Emgality will only be approved for adult patients. Furthermore, the patient must have had serious side-effects or drug failure to a 3-month trial of at least two medications- examples include Propranolol, Topiramate, Valproic Acid, Amitriptyline, Venlafaxine and Botox. There is no documentation that the patient has failed 2 preventative medications for migraines. 

The patient's asthma is a contraindication to propranolol and other beta blockers.  Neurologist states that the patient cannot take amyitryptiline or nortryptiline because she is already taking two other antidepressants, though this is not an absolute contraindication. The patient has no contraindication to Topirimate, Valproate or Botox.