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

Diagnosis: Myocardial Infarction

Treatment: Wearable Defibrillator

The insurer denied the wearable defibrillator.

The denial was upheld.

This is a male patient with a history of hypertension, dyslipidemia and diabetes mellitus type 2. He presented to the emergency department (ER) with complaints of chest pain, back pain, diaphoresis. An EKG showed sinus rhythm with ST elevation. Initial troponin was negative, but then peaked at 55. The patient was diagnosed with an ST elevation myocardial infarction. He underwent a cardiac catheterization and angiography, which demonstrated 2-vessel vessel coronary artery disease with proximal left anterior descending (LAD) artery involvement. He had a 100% thrombotic occlusion of the ostial LAD and severe left ventricular systolic dysfunction, with an estimated ejection fraction of 30%. Two drug-eluting stents were placed and dual antiplatelet therapy was initiated. An external defibrillator was ordered prior to discharge.

Question:

1) Did the health care plan act reasonably and with sound medical judgment and in the best interest of the patient? 

Yes. The hospital plan allows for use of this technology in the appropriate clinical setting.

2) Is a wearable automatic external defibrillator life vest (K0606RR) considered medically necessary for this patient?

The Life Vest is FDA approved for prevention of sudden cardiac death, however the use of Life Vest for the dates under review is not medically necessary. The patient was diagnosed with ischemic cardiomyopathy, with ejection fraction of 30%, following acute ST-segment elevation myocardial infarction (STEMI). This technology has not been shown to be clinically beneficial when compared with standard-of-care medical therapy for prevention of sudden cardiac death in patients with newly diagnosed ischemic cardiomyopathy immediately following STEMI. For the dates under review, Life Vest technology is not medically necessary. There is no clinical research evidence documenting incremental benefit of this technology over conventional medical therapy in prevention of sudden cardiac death. This technology would therefore be considered experimental and/or investigational in this clinical setting, and does not represent the standard of care for such patients. The patient's clinical presentation and the absence of extenuating circumstances do not support medical necessity for use of Life Vest for the dates under review. 

Based on the above, the medical necessity for a wearable defibrillator is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain with dyspnea 
Treatment: Inpatient admission 

The insurer denied the inpatient admission. The denial is upheld. 

This is a female with approximately one year of atypical chest discomfort associated with dyspnea. She recently developed a cough and was referred to the emergency department (ED) for chest x-ray (CXR). The patient has a history of human immunodeficiency virus (HIV), hypertension and polysubstance drug abuse. She had an abnormal electrocardiogram (EKG) and was admitted for "unstable angina". Her exam was normal. Troponins were negative and the pain resolved with nitroglycerin (NTG). Echocardiogram showed normal left ventricular (LV) function. The patient underwent an uncomplicated right radial cardiac catheterizations which revealed normal coronaries. She received antihypertensives, nitrates, antibiotics and was discharged on medications. 

No, inpatient level of care was not medically necessary. 

The patient presented with atypical symptoms for nearly a year with history of polysubstance drug abuse. The working diagnosis included "cocaine chest pain". Although the patient was in the hospital for nearly six days, no care or testing was performed that required an inpatient level of care. The determination of level of care is primarily dependent on the actual care a patient receives and, whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results; and highlighted in the orders for care. In this case, the symptoms were atypical, present for months and unlikely to be representative of acute coronary syndrome (ACS). Exam and cardiac findings were normal. Biomarkers and EKG showed no evidence of acute ischemia. CXR was normal. Echocardiogram and heart catheterization showed no wall motion abnormality. The physicians' treatment did not reflect any serious concern about patient's acute cardiac condition as ACS. Orders did not include medical therapy for ACS such as intravenous (IV) heparin, dual antiplatelet inhibitors, high dose beta blockers or IV NTG. 

In the appeal letter, it stated that increase risk implies admission for "clinical observation". All testing and therapy would be appropriate, safe and guidelines consistent to be in lower level of care. Thus, inpatient level of care was not medically necessary. 

Milliman criteria requirements were not fulfilled as there was never any evidence of ACS present. 

The denial explanation was consistent with guidelines and usual community care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Community acquired pneumonia (CAP)

Treatment: Inpatient admission 

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

The patient was a male with history of hypertension and depression. The patient presented to the Emergency department (ED) with complaints of productive cough, chest pain and fever. The patient had a history of polysubstance abuse. The patient's vital signs in the ED were: temperature 99.1, blood pressure 150/90, heart rate 61, respiratory rate 20, and Oxygen (O2) saturations 98%. On exam, the patient was in no acute distress, was alert and oriented, and had clear lung exam. The patient's white blood cell (WBC) count was 11.2K, Hemoglobin 13.9, BUN/Cr 21.8/1.34, and troponin was negative. The patient's urine toxicology was positive for Cocaine and Opiates. The patient's electrocardiogram (EKG) revealed sinus rhythm at 59 and no acute ST-T changes. The patient's chest x-ray revealed patchy left lower lobe infiltrate. The patient's lactate level was 0.8, and the patient's arterial blood gas (ABG) showed pH 7.44, pCO2 36, pO2 95, base excess 24, and O2 saturation 98% on room air.

The patient was treated in the ED with intravenous (IV) fluids, analgesics, nitrates and Levaquin. The patient was admitted for treatment of community acquired pneumonia (CAP). As per the H&P note, the patient's vitals on admission were: temperature 99.1 F, blood pressure, 150/90 mm Hg, heart rate 61, respiratory rate 20, and O2 saturation 97% on room air. The patient remained stable after admission. The patient was afebrile and hemodynamically stable and was ambulatory. The patient tolerated oral intake, and was not hypoxic. The patient's follow up cardiac enzymes and EKG remained negative. The patient had no clinical signs of myocardial ischemia. The patient was evaluated by Cardiology who indicated that the patient's chest pain was related to his pneumonia. The patient was treated and discharged in stable condition.

Based on the review of the medical record, this patient did not need acute inpatient hospitalization. The patient could have been placed in observation status while diagnostic testing and treatment were initiated. The patient's CURB 65 score was zero. The patient BUN/Cr at admission was 21.8/1.34, and on the day of discharge, was 21.4/1.49. The patient did not have myocardial infarction, and the patient's chest pain was non-cardiac in etiology. The patient had pneumonia but the patient was not hypoxic and was tolerating oral intake. There was no documentation of patient failing outpatient treatment. This patient was stable to be discharged after a period of observation on oral antibiotics and close follow-up at outpatient setting. Thus, inpatient admission was not medically necessary to treat this patient's medical condition.

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

Based on the above, the medical necessity for the inpatient hospital admission at the inpatient level of care is not substantiated. The insurer's denial should be upheld.
Appeal type: Step Therapy
Decision: Overturned

Vision
Pharmacy/Prescription Drugs

Diagnosis: Glaucoma
Treatment: Cosopt PF
The insurer denied Cosopt PF. The health plan's determination is overturned. 

The patient is a woman with severe low tension glaucoma. She has advanced visual field defects in both eyes, cup to disc ration of 0.9 and has previously had bilateral trabeculectomies to treat her glaucoma. She has had her intraocular pressure (IOP) well controlled with Cosopt preservative free (PF) for many years. She is on this medication due to extreme dry eye and an allergy to benzylalkonium chloride (BAK) a preservative found in many eye drops that is well known to cause ocular sensitivity, allergies and to exacerbate dry eyes. 

Cosopt PF (dorzolamide-timolol) is medically necessary. The formulary medications most likely all contain BAK or another preservative. The patient can't tolerate this ingredient and has an allergic reaction. This causes ocular damage through exacerbation of corneal disease as well as progression of glaucoma due to noncompliance since the BAK causes so many side effects. The required prescription drugs(s) (those on formulary) are expected to be ineffective based on the known clinical history and conditions of the patient and the patient's prescription drug regimen. The patient has an allergy to BAK containing topical eye drops.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse.
Treatment: Inpatient admission.
The insurer denied the inpatient admission. 
The denial is upheld. 

No, the Inpatient admission is not medically necessary. 

This is a man with a history of poly substance abuse, including IVDA (intravenous drug abuse), who presented requesting detox.  No history of alcohol withdrawal seizures.  No SI/HI (suicidal/homicidal ideation).  VS (vital signs):  temperature 98.4, pulse 85, respirations 20, blood pressure 111/70, oxygenation 97%.  Exam was normal; no tremors; steady gait.  Labs:  WBC (white blood count) 6.5, H/H (hemoglobin/hematocrit) 13/40.3, Plt (platelet) 231, Na (sodium) 144, K (potassium) 3.8, BUN/Cr (blood urea nitrogen/creatinine) 17/1.2, CIWA (Clinical Institute Withdrawal Assessment) 13, UDS (urine drug screen) + cocaine, BZD (benzodiazepine), and opiates. CXR (chest x-ray) - NAD (no appreciable disease), EKG - NSR (normal sinus rhythm).  The patient was admitted for detox with Methadone taper for heroin and benzodiazepines for alcohol.  

This patient was admitted after presenting for alcohol and heroin detox.  The patient did not have active comorbid conditions.  The patient was hemodynamically stable and afebrile.  He did not have tachycardia or arrhythmia.  He did not have persistent vomiting, delirium, seizures, or gross tremor.  Labs were unremarkable for severe electrolyte or renal abnormalities.  The patient was admitted with plan for treatment with methadone and benzodiazepines.  The patient was clinically stable and did not have findings of severe withdrawal.  He remained clinically stable during hospital stay without signs of severe withdrawal.  He did not have symptoms that required an acute inpatient level of care.  He had not failed management in a lesser level of care.  The requested inpatient admission was not medically necessary.  Withholding the treatment would not reasonably be expected to affect the patient's health adversely.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle Cell Disease
Treatment: Inpatient admission
The insurer is denied coverage for the inpatient admission.
The denial is upheld.

This is a young male patient with a medical history of sickle cell disease, sickle cell anemia, and malaria infection. He presented to the Emergency Department (ED) with complaints of abdominal and left lower extremity pain for one week.  The patient had been compliant with his Hydrea (hydroxyurea). The patient was given Intravenous (IV) therapy with hydration and morphine, and was admitted for vasospasm-occlusive disease. The patient had one episode of breakthrough pain that required morphine. The patient's pain was controlled. The patient's medications were switched from intravenous to oral route. The patient was medically stable and discharged home.

According to Telfer & Kaya (2017), "Opioid analgesics are required as part of the management of severe pain but there is no consensus on the type of opioid or route of delivery and there is evidence from trials that an oral morphine protocol can be as effective as IV morphine." And as per Uwazezuoke et al (2018), "The treatment of vaso-occlusive pain is sequential and can be done in a stepwise manner with the use of non-opioid in a week opioid medications prior to strong opioid and non-opioid adjuvants."

Based on the review of the medical record and the literature, inpatient admission was not medically necessary for this patient. Though this patient with a history of sickle cell disease and presented to the Emergency Department (ED) with pain, his vital signs were stable, and by the next day, the patient only required one extra breakthrough pain. The patient could have been managed at an Observation level of care instead of the inpatient level of care. The inpatient admission is not medically necessary.

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

Chest pain
Inpatient hospital

The patient is woman who presented to the hospital with a chief complaint of chest pain and shortness of breath with wheezing. She stated that her symptoms started overnight with mild shortness of breath. She received bronchodilators immediately after arriving to the emergency department. She reported that the chest pain involved the left side of her chest and was worse with deep inspiration. Past history included Crohn's disease and Graves' disease. In addition, she reported irregular menstrual bleeding. On physical examination, heart was regular, breath sounds were diminished with wheezing. Vital signs showed temperature 98.1 Fahrenheit, heart rate 100, respiratory rate 19, oxygen saturation 98%, and blood pressure 137/68. Labs showed glucose 83, sodium 142, creatinine 0.6, calcium 8.4, lactate 0.8, white blood cell (WBC) 3.9, hemoglobin 11.5, platelets 227, and Troponin 0.00. Liver enzymes were negative. Blood gas showed pH of 7.41 and PCO2 of 34. Chest computed tomography (CT) angiography was negative for pulmonary embolism. The inpatient stay is under review. 

The health plan's determination is upheld. The inpatient stay was not medically necessary. This patient could have been safely and effectively managed at a lower level of care. She was hemodynamically stable and had a normal blood gas with no evidence of acute respiratory failure. In addition, there was no evidence of acute pneumonia as a cause of her symptoms or acute pulmonary embolus. There was some concern for lupus and possible pleuropericarditis but blood studies for lupus were negative and there was no pericardial effusion reported. Overall, she was hemodynamically stable and could have safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Orthopedic/Musculoskeletal
Treatment:  Home Health Care

This is a patient with a past medical history of osteoarthritis, fibromyalgia, chronic pain syndrome, hypertension, syncope, incontinence of urine, unsteady gait, anxiety, dizziness and vascular headaches who had personal care aide services 4 hours/day, 4 days per week to total 16 hours per week.  The patient's last assessment stated that the patient needed extensive assistance with meal preparation, ordinary housework, stairs, shopping and transportation.  The patient needed limited support with bathing, dressing upper extremity (UE) / lower extremity (LE), toilet transfer and was independent with toilet use, bed mobility, personal hygiene and eating.  The assessment noted that the patient gets up at 8 AM and goes to bed at 8 PM.  The patient ambulated slow and unsteady, even with a cane.
The patient requires assistance when she goes out into the community.  She lives with her adult children.  The patient attends social daycare 2 days per week.  The provider requested an appeal of personal care services requesting 12 hours/day, 7 days/week to total 84 hours per week.  The plan has denied coverage for 12 hours/day, 7 days/week to total 84 hours per week.  At issue is the medical necessity of the requested Personal Care Aide Level II Basic Services: 84 Hours per Week (12 Hours per Day, 7 Days per Week).
The health plan's determination is overturned.  Personal care aide level ll basic services: 84 hours per week (12 hours per day, 7 days per week) are medically necessary for this patient.  This is a patient with osteoarthritis, fibromyalgia, chronic pain syndrome, hypertension, syncope, incontinence of urine, unsteady gait, anxiety, dizziness and vascular headaches.  The patient was approved at 4 hours/day, 4 days/week to total 16 hours per week.  The plan stated that the patient attends a social daycare 3 days a week, but she only attends 2 days per week.  In addition, the patient lives with her family, but they are not able to provide personal care services during the other 152 hours per week.  The patient requires help with scheduled and unscheduled tasks.
Appeal type: Medical necessity
Decision: Upheld

Digestive System/Gastrointestinal - Other
Inpatient Hospital

The patient is a male with a past medical history significant for diabetes mellitus, hypertension, and hypothyroidism who came to the emergency department with complaints of an inability to swallow food and epigastric and chest tightness. His symptoms started acutely when he ate his dinner. The patient had some problems with dysphagia in the past, but it acutely exacerbated on the day of admission. At the time of admission, the patient denied any melena, bright red blood per rectum, or weight loss. The review of systems was negative for everything except for the symptoms described above. At the time of the initial evaluation, the patient was diagnosed with dysphasia and a foreign body in the esophagus. The patient was admitted to the medical floor and kept nothing by mouth (NPO) status. The gastroenterology service was consulted. According to the gastroenterologist, the patient had a food bolus impaction in the esophagus. An esophagogastroduodenoscopy (EGD) was performed and revealed that the patient had eosinophilic esophagitis. The impacted meat bolus was seen near the gastroesophageal (GE) junction. The disimpaction was performed with an endoscope. There were no complications of the procedure reported. After the procedure, the patient was recommended treatment with proton pump inhibitors. Since the patient's condition remained stable, he was discharged home. At issue is the medical necessity of the inpatient stay. The health plan's determination of medical necessity is upheld in whole. The reason for the patient's symptoms was a food impaction in the distal esophagus. This condition caused significant discomfort but did not lead to hemodynamic instability, respiratory compromise, significant dehydration, or electrolyte abnormalities. In general, the bolus can be removed from the esophagus using grasping devices (either in bloc or piecemeal, depending upon the consistency of the bolus), or it can be gently pushed into the stomach using the endoscope. In this clinical case, the food bolus was moved into the gastric fundus. During the very short hospital stay, the patient remained afebrile and hemodynamically stable. The patient did not require any procedures or surgical interventions necessitating admission at the acute inpatient level of care. This patient was in stable clinical condition throughout the entire hospitalization. The patient's hospital stay was very short since the patient was discharged on the day of admission. Neither the severity of the patient's condition nor the complexity of the services provided raised to the level of the acute inpatient care.
Appeal type: Medical necessity
Decision: Upheld

Blood Disorder - Anemia
Inpatient Hospital

The patient is a female with a history of hypertension. She presented to the emergency room with worsening fatigue one week after a liposuction procedure. On physical exam, she was well appearing, alert and oriented, and in no acute distress. The vital signs were unremarkable. She was afebrile and the oxygen saturation was 99% on room air. The exam was otherwise non-contributory. Labs were notable for a hemoglobin of 7.2 g/dl and moderately elevated liver transaminases. An ultrasound revealed evidence of hepatic steatosis. The patient was admitted for further treatment and evaluation.
Upon admission, the patient was treated with one unit of packed red blood cells and her usual home oral medications. A computed tomography (CT) scan of the abdomen revealed a right paracolic fluid collection consistent with a hemoperitoneum, along with subcutaneous edematous changes.
The surgical consultant evaluated her and did not think surgical intervention was required. The hemoglobin rose to 9 g/dl after the transfusion. The hospital course was otherwise unremarkable, and she was discharged.

The health plan's determination is upheld.

Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, other than the anemia, which was very likely due to bleeding from her recent procedure, there was no objective evidence on physical exam, labs, imaging, or electrocardiogram (EKG) of an imminently life-threatening cause of the patient's complaints. There was no evidence of hemodynamic instability, acute renal failure, altered mental status, or chest pain. In addition, there was no evidence that the patient failed an observation stay. The services provided - repeat labs, blood transfusion, CT of the abdomen, and surgical consultation - could have been safely provided at a lesser level than acute inpatient care. Therefore, based on the standard of care, peer reviewed literature, and widely accepted guidelines, the acute inpatient level of care was not medically necessary, and the patient could have been managed at a lower level of care.