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

Diagnosis: Central Nervous System/Neuromuscular Disorder
Treatment: Skilled Nursing Facility
The insurer denied: Extended stay skilled nursing facility
The denial is: Upheld in whole

This case involves a male with medical history significant for left thalamic intracranial hemorrhage, pontine hemorrhage, hydrocephalus with ventriculoperitoneal (VP) shunt placement. He was transferred to long-term acute care hospital (LTACH) for chronic respiratory management and then he was admitted to acute inpatient rehabilitation. He was admitted to skilled nursing facility for continued rehab. He did have a break in skilled therapy for hospitalization for a month. The patient was re-admitted to the skilled nursing facility.  The patient continued in the skilled nursing facility and therapy noted that patient had expired. The subject under review is the medical necessity for the extended stay in skilled nursing facility.

No, the requested service of extended stay in skilled nursing facility is not medically necessary for this patient. The patient was not making functional progress to support continued stay. The patient in this case experienced two intracranial hemorrhages requiring tracheostomy, VP shunt and percutaneous endoscopic gastrostomy (PEG) tube. While he did require pause in his skilled rehab  for medical reasons, the therapy documentation does not support continuation of skilled nursing. For example, speech therapy noted that patient completed inconsistent nodding for yes/no questions and despite attempting to verbalize he was noted to be unintelligible. Similarly, the ability to perform grasp release to right hand was dependent and a month later he was noted to be "inconsistently totally dependent [TD]" which is not functional progress. He also remained totally dependent for bed mobility and sitting and therapy noted that at time of discharge he required total dependence without attempts to initiate for hygiene/grooming, bathing, upper body dressing, lower body dressing, functional mobility during activities of daily living (ADLs) and community ADLs. Unfortunately, the patient was not making any true functional progress and his needs could have been met at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Depression.
Treatment: Inpatient residential mental health treatment.
The insurer denied the inpatient residential mental health treatment. 
The denial is upheld. 

No, the residential mental health treatment is not medically necessary. 

The patient is a female who was admitted to this residential program in Utah for treatment of mood, behavioral, and eating disordered problems. Her diagnoses were disruptive mood dysregulation disorder, unspecified anxiety disorder, unspecified feeding or eating disorder, non-suicidal self- harming behavior, and parent-child relational problem.  

The patient did not present any behavioral issues which required 24-hour daily observation and treatment. Furthermore, the treatment as documented by this facility was purely behavioral in nature and does not reflect any psychological understanding of the reasons for the patient's behavior or give any reason to believe that the behaviors would not return outside of this controlled environment. This patient's problems would have been more effectively addressed in the real world setting of her community, with her family, in a less restrictive setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Kidney stones
 
Treatment: Inpatient admission

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

This patient is a male with no significant past medical history who presented to the Emergency Department (ED) with complaints of right flank pain radiating to the groin.  The patient stated that he was recently admitted for the same symptoms, was told that he had a kidney stone and was discharged.  The patient had two episodes of emesis, returned to the ED because the right flank pain was never really alleviated.  ED triage revealed temperature of 37.40C, blood pressure 142/91, and heart rate 73.  CT scan of the abdomen and pelvis revealed a distal 5 mm right ureteral calculus causing mild right hydronephrosis - hydroureter.  The patient was admitted, and urology was consulted.  The patient received conservative management, consisting of pain medications, intravenous (IV) fluids, and antibiotics.  The patient is noted to improve with such management, and he was discharged home with outpatient urology follow-up.

The insurer has denied coverage for the inpatient admission. Per MCG Health (23rd Edition) Renal Colic & Kidney Stones, the patient fails to meet clinical indications for admission to inpatient care.  These include bilateral obstruction, acute renal failure, bilateral obstruction, urinary tract infection (UTI), severe pain requiring acute inpatient management, vomiting that is severe or persistent, etc.

The healthcare plan acted reasonably and with sound medical judgment and in the best interests of the patient.  The inpatient admission was not considered medically necessary for this patient.

The carrier's denial of coverage for the inpatient admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest, abdominal and left arm pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

This female patient presented after being involved in a car accident and developing chest, abdominal pain, and left arm pain.  She may have had a seizure prior to the accident.  

The patient's vital signs were stable. Her exam was remarkable for chest wall tenderness, left arm tenderness distal to the radium, and left upper quadrant tenderness.  Labs were remarkable for white blood cell count of 26.53, hemoglobin of 13.5., creatinine of 1.1, and Troponin of 51.  The patient's forearm x-ray showed a comminuted fracture of fifth metacarpal.  An abdominal computed tomography (CT) showed a grade II splenic laceration without active extravasation and left renal injury.  Head, chest and cervical was seen on computed tomography (CT) with no acute disease.  

The patient was admitted.  The next day, the patient's vital signs were stable.  Her pain well controlled and the abdomen was soft.  The patient had a hemoglobin of 12.1.  She was cleared for transfer from the intensive care unit (ICU) to stepdown.  She underwent surgery for her hand.  On day three, the patient was stable for discharge but wished to stay one more day.  The patient was discharged on day four.

No, the proposed inpatient admission was not medically necessary.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
This patient was admitted for monitoring of traumatic spleen laceration.  Imaging showed that she had a low-grade injury with no bleeding.  She was hemodynamically stable.  Her hemoglobin was normal.  She did not have findings of peritonitis.  The patient was stable.  She did not require an acute inpatient level of care.  Monitoring of vial signs, exam and serial hemoglobin levels could have been provided at an observation level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hepatitis B
Treatment: Vemlidy
The insurer denied the Vemlidy.
The determination is overturned.

The patient has Hepatitis B, cirrhosis, and hepatocellular carcinoma. He was positive for Hepatitis B surface antigen. He had elevated transaminases, positive Hepatitis B core antibody, negative surface antibody, negative e antigen, positive e antibody, and Hepatitis B viral load of 152 international units per milliliter (IU/mL). He has been on Viread, but a change to Vemlidy was recommended to address microalbuminuria. At issue is the medical necessity of Vemlidy.
The request for Vemlidy is medically necessary for this patient.
Guidelines for the treatment of Hepatitis B from the American Association for the Study of Liver Disease (AASLD) recommend entecavir and tenofovir compared with alternatives for the treatment of chronic Hepatitis B [1]. In comparison with tenofovir disoproxil fumarate (Viread), the Vemlidy formulation of tenofovir is effective for Hepatitis B, but is associated with lower incidence of side effects such as osteopenia and renal disease [2-4]. Viread can be associated with slow but progressive renal dysfunction, which the patient may be experiencing given finding of microalbuminuria, thus supporting Vemlidy as more appropriate [5,6]. The use of tenofovir (Vemlidy) is supported as safe and effective in patients with decompensated cirrhosis, and therapy is needed in this case as hepatitis B (the patient has a positive viral load) is a risk factor for hepatocellular carcinoma (which the patient has) [7-10]. For these reasons, the request for Vemlidy is supported as medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Congestive heart failure (CHF).
Treatment: Inpatient admission.
The insurer denied coverage for an inpatient admission.
The denial is upheld.

This is a patient that was transferred to the hospital from a skilled nursing facility for decreased oral intake and failure to thrive. Past medical history was significant for systolic congestive heart failure, a previous admission for CHF exacerbation was three months earlier, ICD (implantable cardioverter defibrillator) in situ, diabetes mellitus, hypertension, substance abuse, and schizophrenia. Upon arrival to the hospital vital signs were stable (BP (blood pressure) was 105/81 mmHg (millimeters of mercury), and Pulse was 89 bpm (beats per minute). Physical exam revealed no evidence of fluid overload. A 12 lead electrocardiogram (ECG) revealed normal sinus rhythm with left ventricular hypertrophy and non-specific ST-T (interval on a electrocardiogram) wave abnormalities. Serum blood testing revealed an elevated B (brain) type natriuretic peptide (BNP) (936 pg [picograms]/ml [milliliters]) and an elevated Troponin I (0.038ng [nanograms]/ml). An echocardiogram from a previous admission revealed global LV (left ventricular) systolic dysfunction with an LVEF (left ventricular ejection fraction) of 25-30%. The patient was admitted to the hospital for treatment of systolic congestive heart failure and treated with intravenous diuretic therapy. 
The patient remained stable and was ultimately discharged to the skilled nursing home facility.

The health plan acted reasonably and with sound medical judgment and in the best interest of the patient. This patient presented with decreased oral intake, no dyspnea and no hemodynamic instability. Serum BNP level was elevated, however there was no evidence of congestive heart failure on physical examination or on chest X-Ray. The patient was treated with intravenous diuretics and ultimately discharged. This patient was already appropriately treated with guideline directed medical therapies (Reference 1). Masri et al compared patient outcomes following treatment of acute congestive heart failure in observation and inpatient settings and demonstrated no difference in mortality between the two groups. (Reference 2). There was no evidence that this patient was suffering from decompensated heart failure. In conclusion this patient could have been treated at a lower level of care and did not require inpatient admission.

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

The insurer's denial of coverage for an inpatient hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a history of hypertension (HTN) and diabetes mellitus (DM) who presented with a fever, fatigue, cough, and congestion worsening over the prior 5 days.
In the emergency department (ED), her temperature was 99 degrees Fahrenheit, blood pressure (BP) 123/61, heart rate (HR) 77, respiratory rate (RR) 20, peripheral capillary oxygen saturation (SpO2) 99% on room air (RA). She was in no distress, was breathing comfortably, with a mild wheeze, and alert and oriented. Her white blood cell count (WBC) was 4.9, sodium (Na) 141, bicarbonate 32, blood urea nitrogen (BUN)/creatinine (Cr) 7/0.72; arterial blood gas (ABG) 7.38/54/73. A computed tomography pulmonary angiogram (CTPA) found no pulmonary embolism (PE) but did uncover multifocal infiltrates. She was diagnosed with pneumonia and started on ceftriaxone and azithromycin. She was feeling better; the antibiotics were continued. She was saturating well on room air (RA), and the antibiotics were continued. She felt ready to go home, but was noted to be wheezy, and prednisone was considered. She was doing better, with no further wheezing, and she was discharged on cefpodoxime and azithromycin.
At issue is the medical necessity of an inpatient stay.

An inpatient admission was not medically necessary.
The patient presented with a fever and congested cough and was diagnosed with pneumonia. She was not severely ill at presentation, no encephalopathy, hemodynamic instability, respiratory distress or gas exchange abnormality, or acute kidney injury or major electrolyte abnormality. She had evidence of chronic but not acute hypercarbic respiratory failure. Scoring systems would suggest a low risk of worsening. She improved over an observation care length of stay. With a low severity of illness, low risk of worsening, and no alternative diagnoses, she did not need close inpatient only testing, monitoring, or treatment, and with improvement over an observation care time frame, she did not need prolonged treatment. As such, she did not need an inpatient admission. Care could have been provided at a lower level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Premature Ventricular Contractions (PVC).
Treatment: Inpatient admission.
The insurer denied coverage for an inpatient admission.
The denial is upheld.

This patient that was presented to the hospital complaining of palpitations and lightheadedness and blurry vision. Past medical history was significant for hypertension, COPD (chronic obstructive pulmonary disease) and GERD (gastroesophageal reflux disease). The patient presented to the ED (emergency department) one week earlier with similar complaints and was found to have sinus rhythm with Ventricular premature complexes (VPCs) on electrocardiogram. Upon arrival to the hospital vital signs were stable BP (blood pressure) 144/86 mmHg (millimeters of mercury), Pulse 91 bpm (beats per minute)). No abnormal findings were noted on physical examination. CT (computed tomography) of the head revealed no abnormalities. A 12 lead ECG (electrocardiogram) demonstrated sinus rhythm with occasional ventricular premature beats. Serum blood testing revealed no significant abnormality. Previous echocardiogram revealed a preserved LVEF (left ventricular ejection fraction) without valvular abnormality. The patient was admitted to the hospital for observation and treatment. Beta blocker therapy was continued, and the patient was ultimately discharged the following day with cardiology follow up. 

An acute inpatient admission was not medically necessary for this patient without significant past cardiac history. Her symptoms were due to ventricular ectopy. There were no significant findings on physical examination to warrant acute inpatient hospital admission. Echocardiogram revealed a normal left ventricular ejection fraction. Evaluation of premature ventricular ectopy is performed in the outpatient setting utilizing multiday ambulatory monitoring. (Reference 1) Most patients with palpitations can be evaluated in the outpatient setting. (Reference 2,3)

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

The insurer's denial of coverage for an inpatient hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Impacted maxillary left lateral incisor

Treatment: Braces

The insurer denied coverage for braces
The denial is overturned

Upon review of the submitted documentation including lateral cephalometric radiograph, pan radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to an impacted maxillary left lateral incisor. The orthodontist has completed the HLD (Handicapping Labiolingual Deviation) index as required and has chosen the automatically qualifying condition of impacted permanent anteriors where extraction is not indicated. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index. 

Upon review of the submitted documentation, (study models were not provided for review), it is evident that the patient exhibits a significant malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires, as of September 1, 2012, the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index. Report (HLD New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 

In this case, the treating orthodontist claims an automatic qualifying condition of impacted permanent anteriors where extraction is not indicated. This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care.

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic needs is a valid approach. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the braces is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal-Back pain.
Treatment: Radiology Services-MRI (Magnetic Resonance Imaging).
The health plan denied the MRI study as not medically necessary.
The reviewer has overturned in whole the health plan's determination.

The patient has a history of chronic pain. A letter from her provider noted that the patient was having low back pain radiating into their buttocks for at least 2 years and had failed conservative care including a home exercise program, activity modification, heat/cold application, and non-steroidal anti-inflammatory drugs (NSAIDs). No recent imaging was performed of their lumbar spine according to the records submitted for review.

The requested health service/treatment of MRI (Magnetic Resonance Imaging) was medically necessary for this patient.

Pain and tenderness are subjective in nature and are normal findings during the acute phase of soft tissue injury. MRI is not necessary for the majority of soft tissue injuries. Soft tissue injuries have similar findings of radiculopathy during the acute phase (headache, pain, swelling, radiating pain to the upper extremities). Testing is not supported if the claimant is "complaining" of the above symptoms. Evidence of neurologic compromise must be documented in the physical examination of the referring provider. 
In order for an MRI to be considered medically necessary for soft tissue injuries of the spine, within the first 30 days after the injury, the medical records from the referring provider should document objective evidence or radiculopathy or neuropathy such as loss of grip strength, positive pin prick for loss of sensation, muscle wasting/atrophy, or changes in bowel/bladder function.
MRI scans can be considered after the initial 30-day period for the reasons listed above and/or the following reasons: failure to progress with worsening of symptoms or lack of progress with conservative care.
In this case the patient had persisting complaints despite conservative treatment therefore the imaging was indicated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Acute respiratory failure, COPD.
Treatment Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is overturned in part.

The patient has chronic obstructive pulmonary disease (COPD), Takotsubo cardiomyopathy and presented with dyspnea and a cough that began that morning. Emergency Medical Services (EMS) found she was saturating 84% on room air (RA). She was given dexamethasone and nebulizers and placed on a non-rebreather.
In the emergency department (ED), her temperature was 98.6 degrees Fahrenheit, blood pressure (BP) 204/102, heart rate (HR) 123, respiratory rate (RR) 26, SpO2 (oxygen saturation) 84% on room air (RA). She was ill appearing, wheezy, alert and oriented. Her white blood cell count (WBC) was 11.67, blood urea nitrogen (BUN)/creatinine (Cr) 7/0.5.
She was diagnosed with acute respiratory failure, acute chronic obstructive pulmonary disease (COPD) exacerbation and started on bi-level positive airway pressure (BiPAP), intravenous (IV) steroids, ceftriaxone and azithromycin, and nebulized bronchodilators.
She was feeling better, continued on antibiotics, steroids, and nebulizers, remained on BiPAP and was saturating well. She was doing much better, off BiPAP, saturating 96% on RA, with clear lungs, treatments continued. She remained stable, was felt ready to go home by the patient and team, and continued on treatments. She was feeling much better and wanted to go home. She was saturating well on RA. Treatments continued. She felt well, discharge was held up due to homelessness. She was treated with prednisone and Symbicort. She was feeling well, with no complaints, continued on prednisone and Symbicort. She continued to feel well and was discharged on prednisone.
At issue is the medical necessity of an inpatient stay.

An inpatient stay was medically necessary in part for the first three days of the stay but not after that.
The patient presented with dyspnea and was found to be in acute hypoxemic respiratory failure and acute respiratory distress requiring non-invasive ventilation. Disease this severe requires close inpatient monitoring to ensure the patient does not deteriorate and require endotracheal intubation. BiPAP for acute respiratory failure is an inpatient only treatment. Care on the first three days could not be provided on an outpatient basis. However, after that, she was feeling much better, was off BiPAP and supplemental O2, had clear lungs and on these days, she was much better, had recovered, and did not need inpatient only testing, monitoring, or treatment. Care could then have been provided on an outpatient basis as she had recovered from her severe illness.