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

The patient is male with a past medical history significant for coronary artery disease, myocardial infarction, ischemic cardiomyopathy, congestive heart failure and surgical history of coronary artery bypass graft (CABG). He was hospitalized for heart failure and atrial fibrillation with rapid ventricular rate and subsequently admitted to skilled nursing facility (SNF). The health plan's determination of medical necessity is upheld. The patient made excellent progress since admission to the skilled nursing facility. For example, static standing balance had improved to good, supine to sit transfers had improved to supervision, sit to stand transfers had improved to stand by assist (SBA), bed mobility and transfers had improved to SBA. In addition, hygiene/grooming had improved from minimal assist (MINA) on admission to Modified Independence. Upper body dressing improved from moderate assistance (MODA) on admission to Set-Up. Lower body dressing and toileting had improved from maximum assistance (MAXA) on admission to SBA. While the nurse practitioner noted that patient had a small upper extremity tremor with "very poor stability" when ambulating he was still able to ambulate 30 feet with wheeled walker (WW) MINA which is great improvement form 5 feet with WW MAXA on admission. Also, documentation noted the patient to be medically stable and without any skilled nursing needs. It is not medically necessary for continued rehabilitation at this level of care as it is not within generally accepted standards of care to stay in a skilled nursing facility when you are medically stable and SBA for transfers, bed mobility, lower body dressing and toileting in addition to being modified independent for hygiene and grooming and walking 30 feet with WW MINA.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Crohn's disease
Treatment: Remicade
The treatment with Remicade is not medically necessary.
The patient has Crohn's disease and has been on Remicade for six years. The health plan's preferred agents are Renflexis and Inflectra. Medical literature supports that biosimilars such as Renflexis and Inflectra are equivalent to Remicade for the treatment of IBD (inflammatory bowel disease). There is nothing specific about this patient's disease that suggests that she would not do just as well with a biosimilar as she has with Remicade.
Therefore, medical literature supports changing this patient's Remicade to either Inflectra or Renflexis, and the proposed Remicade is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

The patient with a past medical history significant for diabetes mellitus type I, hypertension, hyperlipidemia, and tobacco use disorder who presented to the emergency department for evaluation of hyperglycemia. Over the course of one month that preceded the day of admission, the patient noticed increased polyuria, polydipsia, and generalized weakness. The patient was admitted to the hospital with a diagnosis of hyperglycemia due to noncompliance with his diabetes medications. Additional diagnoses included hypertension and hyperlipidemia. The Health plans determination of medical necessity is upheld in whole. Despite the patient's blood sugars being high, there was no evidence that the patient was in diabetic ketoacidosis since the anion gap was 12 (DKA is diagnosed by an arterial pH < 7.30 with an anion gap > 12).There were no significant electrolyte abnormalities, signs of acute kidney injury, concomitant infection, myocardial ischemia, peripheral ischemia, or any other condition that would justify admission at the acute inpatient level of care. Admission for a lower level of care to stratify the patient's home insulin regimen and to treat the hyperglycemia was reasonable.
Appeal type: Medical necessity
Decision: Upheld

The patient with past medical history significant for hypertension, seizures, depression, interstitial lung disease, schizoaffective disorder, and recent spontaneous pneumothorax presented to the emergency department on with chief complaint of bizarre behavior. The patient reported polydipsia as well as anxiety. The patient's spouse reported that the patient was acting strangely, sitting outside without shoes or a coat on. The health plan's determination is upheld.

This patient presented unable to self-care, and with paranoia and anxiety without evidence of acute medical problem, and in the setting of known psychiatric disease. There was no evidence of clear delirium, infection, cardiac ischemia, seizure, or other process causing the symptoms but was rather felt to have an exacerbation of known psychiatric disease. The patient was re-initiated on home psychiatric medications and improved to the point of being able to be discharged home in lieu of Skilled Nursing Facility (SNF). This patient who presented with an acute exacerbation of his psychiatric disease rather than medical disease did not require care at the acute inpatient medical level of care. Treatment could have been appropriately provided at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyperglycemia
 
Treatment: Inpatient admission, medication, monitoring

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

Patient was brought to the Emergency Department with burning sensation in his genitalia and priapism for the past two hours.  The patient had a past medical history of hypertension, diabetes and asthma.  Upon arrival, the patient had a temperature of 98, pulse 72, oxygen saturation 90%, respirations 16 and blood pressure 185/122.  The patient complained of 8/10 pain to the head.  Fingerstick blood glucose was 500.  Repeat blood pressure 131/59.  A CT of the head was normal; chest radiograph was negative. The patient underwent a decompression of the corpora cavernosa with flushing.  White blood cell count 6.1.  Venous pH of 7.38, venous HCO3 22.2.  The patient had a sodium 131, potassium 4.4, chloride 102, carbon dioxide 22, BUN 22, creatinine 1.42, glucose 561, calcium 9.2. The patient was given hydralazine, morphine, insulin, Apresoline and Procardia.  Fingerstick blood sugar decreased to 233.  Meal was given and tolerated well.  Cardiac monitor showed sinus rhythm.  The patient's symptoms improved.  The patient then signed out against medical advice.

The patient's condition was appropriate for observational care rather than inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with history of morbid obesity, asthma, kidney stones and cholecystectomy who presented to the emergency room on 01/05/2019 complaining of numbness and tingling to left side of tongue and 3 fingers on left hand that lasted a few hours. The patient was admitted to the hospital.

The health plan's determination is upheld. The inpatient stay was not medically necessary. This patient could have been treated at a lower level of care for further monitoring and testing. There were no planned procedures or clinical instability that warranted an inpatient level of care.Given that the patient was treated with oral medications and symptoms had resolved in the emergency department, there was no medical necessity of inpatient admission. This patient could have been treated at a lower level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Chest pain
Treatment:  Inpatient admission
The proposed treatment is medically necessary.
The patient presented with new onset chest pain, suspicious for unstable angina.  The patient had multiple risk factors for CAD, including diabetes, as well as a known history of coronary artery disease, requiring prior percutaneous revascularizations.  The ECG was unrevealing for acute coronary syndrome (ACS) but was abnormal, with findings suggestive of myocardial ischemia.  The cardiac troponin was elevated, consistent with myocardial injury, and suggestive of an NSTEMI.  Given the presentation, as well as clinical suspicion for an acute coronary syndrome/NSTEMI, she would not be an appropriate candidate for an ED chest pain observation unit, and it would be consistent with the current standard of care that this patient be managed in an inpatient setting, and, therefore, the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Overturned

The case involves an adult with schizoaffective disorder, depressed type and co-occurring substance use disorder (tobacco, cannabis and alcohol). He was admitted to acute inpatient level services with severe symptoms of depression, suicidal behavior, psychosis with delusions and morbid preoccupations, and motor agitation. The patient's admission had been precipitated by worsening symptoms of depression with suicidal ideation and a suicide attempt with slashing the wrist resulting in presentation to the emergency department. The patient endorsed symptoms of depression with suicidal ideation and was verbally aggressive and uncooperative at the time of presentation in the context of drug and alcohol use with us of cannabis with one to three joints per day and up to five shots of vodka in the days leading up to his admission. 

The health plan's determination is overturned. The patient's symptoms of psychosis and mood disorder together with continued risk of impulsive behavior and suicidal risk prompted the necessity for continue acute inpatient level structure and monitoring through discharge. The case is complicated by active substance use disorder; and non-compliance with treatment and medication adherence problems in the context of general medical illnesses and substance use with tobacco and alcohol and cannabis). The residual symptoms of mood disorder and psychosis; risk for suicidal or aggressive behavior, co-occurring substance use disorder/general medical conditions, and treatment issues related to arranging a safe and appropriate discharge plan together with a history of medication non-adherence warranted the continued services at an acute inpatient level of care to include safety monitoring and maintaining abstinence from substances of abuse.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure disorder
Treatment: Onfi

Summary:
The requested brand Onfi is not medically necessary. There are no high quality clinical trials or standard of care guidelines supporting that brand Onfi should be use preferentially or is superior to the generic clobazam. Standard of care guidelines do not currently support the use of brand name medications relative to generic versions.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a past medical history significant for migraine, thyroid disease, pneumonia, and asthma who presented to the emergency department with complaints of nausea, vomiting, diarrhea, a headache, and generalized weakness. She had a cough and chest congestion for one week prior. On the day of admission, she was unable to tolerate any fluids or solid food, and this prompted her to come to the emergency department. While in the emergency department she received treatment with intravenous fluids, antiemetics. The health plan's determination is upheld.
This patient presented to the emergency department with clinical signs of acute gastroenteritis. At the time of admission, she was afebrile and hemodynamically stable. There were no clinical or laboratory signs of severe dehydration. Laboratory studies and diagnostic tests did not reveal any signs of an ileus, small bowel obstruction, or any other circumstances that would necessitate admission at the acute inpatient level of care. The majority of the cases of acute gastroenteritis are self-limited and require only supportive care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pancolitis
 
Treatment: Inpatient hospital admission

The insurer denied the Inpatient hospital admission. The denial was upheld. 

This is a female patient with a history of hypertension, bronchial asthma, and gastroesophageal reflux disease (GERD).  The patient presented to the emergency department in early 2019 with a 2-day history of watery diarrhea, with 7 episodes of diarrhea the day before presentation.  The patient complained of midline abdominal pain.  The physical examination revealed the patient's abdomen was soft and was mildly tender.  The patient underwent a CT scan of the abdomen/pelvis which revealed findings consistent with pancolitis.  The patient was admitted to the hospital with abdominal pain associated with nausea, chills, and multiple episodes of non-bloody diarrhea secondary to pancolitis, probably infectious.  The patient was stabilized and discharged later that week.
The MCG indicate that inpatient admission is appropriate for patients with gastroenteritis, diarrhea, who have a suspected severe infection, or for vomiting or severe abdominal tenderness.  Admission is appropriate for patients with inflammatory bowel disease with acute severe ulcerative colitis including bloody diarrhea, pain, or intestinal obstruction.  It is also appropriate for patients who have severe electrolyte abnormalities requiring inpatient care or dehydration that is severe or persistent.  
Patient documentation indicated the patient had diarrhea for 2 days. She had mild tenderness and was noted to have pancolitis. Patient documentation failed to support that the patient had severe electrolyte abnormalities or dehydration that was persistent or severe. The patient was not noted to have bloody diarrhea or an intestinal obstruction and no surgical intervention was planned.  

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

Diagnosis: Right Tibia/Fibula Fracture
 
Treatment: Inpatient Admission 

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

This is a male patient who presented to the Emergency Department with complaints of right leg pain.  He was evaluated and diagnosed with a right tibia/fibula fracture.  He underwent intramedullary nailing to the right tibia.  He experienced no post-operative complications.  He was discharged home on pain medication.

"Minor Surgery or Other Treatment - When patients with known diagnoses enter a hospital for a specific minor surgical procedure or other treatment that is expected to keep them in the hospital for only a few hours (less than 24), they are considered outpatients for coverage purposes regardless of: the hour they came to the hospital, whether they used a bed, and whether they remained in the hospital past midnight."

When a patient has a significant adverse reaction (beyond the usual and expected response) as a result of the test that requires further monitoring, outpatient observation or inpatient hospital services may be reasonable and necessary.

The young man presented to the hospital with notation that he was to have surgery.  He did not have underlying co-morbidities.  He sustained a low energy type of injury.  His operation was not complex or extensive.  The duration of the procedure was approximately two hours and completed before evening.  There was limited to no blood loss.  There were no problems with his post-operative management.  He was able to tolerate oral pain medications and use crutches.  His vital signs remained stable with no other associated problems.  He would be expected to have been discharged under the definition of Observation Status.  There were no extenuating circumstances to substantiate.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.  The inpatient admission is 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

The patient presented to the dentist's office for evaluation and treatment of tooth #7 and 10. Provided for review are previous letters of denial, a full mouth panoramic radiographic image from an unknown date, and one page of ADA claim forms. The planned treatment is a predominantly base metal full coverage crown for teeth #7 and 10. The health plan has denied the crowns as not medically necessary. The health plan's determination is upheld. There is no documentation to support the prescribed therapy. There are no diagnoses nor descriptions given for the therapy or teeth in question. There is no narrative to explain why treatment is necessary. The radiographic image does not support the need for the prescribed therapy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
 
Treatment: Inpatient admission, diagnostic treatment, monitoring

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

The patient was referred to the ER from his physician's office for chest and jaw pain 2 days prior. The patient had no current chest pain upon arrival. The patient past medical history was notable for aortic aneurysm, bicuspid aortic valve replacement 11 years earlier, and obstructive sleep apnea. The patient was admitted. EKG's and troponins were unremarkable. The patient was referred for coronary angiography, which showed 90% stenosis in the LAD. He received a drug-eluting stent for this lesion. There were no procedural complications. The patient returned to the telemetry unit post-procedure where he remained clinically and hemodynamically stable. He was discharged home.

The inpatient admission status was not medically necessary for this patient. Per MCG Angioplasty, Percutaneous Coronary Intervention ORG: M-52 (ISC), the clinical presentation and peri-procedural course were unremarkable and uneventful, and acute inpatient level monitoring was not medically necessary or appropriate.
Appeal type: Medical necessity
Decision: Upheld

This is a patient  with a history of hypertension, diabetes, hyperlipidemia, atrial fibrillation, nonischemic cardiomyopathy and congestive heart failure with a left ventricular ejection fraction of 25-30%.  He was treated for congestive heart failure and was transferred to another hospital for implantation of a dual chamber implantable cardioverter defibrillator for primary prevention of sudden cardiac death. The procedure was uncomplicated. The health plan's determination is upheld. An inpatient level of care was not medically necessary.This patient was transferred from one hospital to another for implantable cardioverter defibrillator (ICD) placement for the primary prevention of sudden cardiac death. He was hemodynamically stable before and after the procedure. The procedure was uncomplicated.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who presented to the emergency department (ED) on 1/31/19 with complaints of flank pain.  Associated symptoms included diarrhea, nausea and vomiting.  She was on ciprofloxacin for a urinary tract infection (UTI).  She was afebrile and hemodynamically stable on presentation.  The health plan's determination is upheld.  This patient did not present with hemodynamic instability, renal failure, severe obstruction, sepsis or unstable medical problems requiring inpatient management.  The hospital course was essentially normal without any significant complications or major issues with pain control.  The procedure performed is considered a minimally invasive outpatient procedure and as such in the absence of a "high risk surgical patient" does not warrant acute inpatient care.
Appeal type: Experimental/Investigational
Decision: Upheld


The patient is a male child who received Vision Therapy for a  diagnosis of myopia, esophoria, accommodative spasm, and poor tracking.

CPT code 92065-Orthoptic and/or pleoptic training, with continuing medical direction and evaluation and CPT code 92499-Unlisted ophthalmological service or procedure is not considered to be more beneficial than any standard treatment or procedures for the diagnoses.

Vision therapy has not been proven to be effective for this patient's conditions (myopia, esophoria, accommodative spasm, and poor tracking), as there is a lack of published data from well-designed studies in the ophthalmic literature.

"Strabismus in children under 4 months of age sometimes resolves, particularly if the deviation is intermittent, variable, or measures less than 40 prism diopters. Repeat cycloplegic refraction is indicated when esotropia does not respond to the initial prescription of hyperopic refraction or when the esotropia recurs after surgery. Bilateral lateral rectus recession and unilateral recess-resect are both reasonable strategies for initial surgery of intermittent exotropia. Young children with intermittent exotropia and good fusional control can be followed without surgery because there is a low rate of deterioration to constant exotropia or reduced stereopsis.
Children with untreated strabismus can have reduced binocular potential and impaired social interactions, which may affect their interactions and quality of life. Simultaneous prism and cover testing, which measures the manifest angle of strabismus, and prism and alternate cover testing, which measures the total angle of misalignment, are important elements of binocular testing.  Both inform the ophthalmologist's decisions regarding management and surgical indications. Convergence insufficiency occurs in children and adults, and symptoms with near viewing (typically reading) can often be improved using vergence exercises." (Wallace, D. K., Christiansen, S. P., & Sprunger, D. T., et al., 2017).

The carrier's denial of coverage for the following codes for service:  92065-Orthoptic and/or pleoptic training, with continuing medical direction and evaluation; and  92499-Unlisted ophthalmological service or procedure should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Myopia, Accommodative Spasm, Poor Tracking, and Esophoria
 
Treatment: Vision Therapy

The insurer denied the Vision Therapy.   The denial was upheld as two of the three panelists determined that the treatment should be denied.

This case involves a young male child who was previously diagnosed with myopia, as well as accommodative spasm, poor tracking, and esophoria.  The patient's visual acuity was 20/200 to the right eye and 20/80 to the left eye.  The patient had double vision both far and near, and due to the accommodative spasm, he could not focus.  The patient had difficulty tracking to read and would lose his place if he did not use his finger.  The patient was noted to have participated in visual therapy services.  The patient's visual skills have improved dramatically and he can now read at his grade level.

According to medical peer-reviewed literature and the American Academy of Ophthalmology, orthoptic therapy is the primary treatment modality used by most eye care professionals for the treatment of convergence insufficiency.  During therapy, eye care professionals use multiple types of eye exercises and typically include treatment modalities such as home-based exercise, in-office exercise, computer vergence exercise, or a combination of these.  This type of therapy has been shown to be an effective treatment modality for many types of problems affecting the vision, and for the management of convergence insufficiency.  Vision therapy typically consists of a variety of treatments and rarely ever includes only orthoptics.  Physical exercises and reeducation of the eyes is often utilized in combination with orthoptics.  Orthoptic therapy is a reasonable request for patients with poor tracking, convergence insufficiency and accommodative spasm.  Therefore, as the requested treatment is likely to be more beneficial than any other available standard treatment for this patient and is widely accepted and utilized for a patient with the above diagnoses and clinical picture, the patient would be considered a good candidate for the requested treatment.  

The carrier's denial of coverage for the following codes of service:  92065-Orthoptic and/or pleoptic training, with continuing medical direction and evaluation; and  92499-Unlisted ophthalmological service or procedure should be reversed.