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

Diagnosis: Chest pain
Treatment: Inpatient admission
The Inpatient admission was medically necessary.

This patient had a past medical history of coronary artery disease and pulmonary embolism. He presented to the hospital with chest pain, nausea and diaphoresis, and poorly controlled hypertension (201/124mmHg).  He required inpatient hospital admission for diagnosis and treatment.  Given the complexity of the patient's past medical history, it was appropriate to rule out myocardial infarction.  His pretest probability of a coronary event was elevated (Reference 1).  He was also at high risk for pulmonary embolism and was noted to have an elevated D dimer test and was not taking anticoagulant medication as prescribed. 

The proposed treatment was medically necessary given the patient's past medical history.  This patient with multiple coronary stents, presenting with hypertensive urgency (chest pain and diaphoresis with poorly controlled HTN) had an extremely high risk of morbidity and mortality.  Using the One risk Score designed for individuals presenting with chest pain, negative cardiac enzymes and no ST segment deviation on ECG, his risk of death or myocardial infarction in the next year would be 18% (Reference 2).  Using the TIMI (thrombolysis in myocardial infarction) risk score, the event rate would be 20% (reference 3).  Given the high risk nature of the patient and his presentation, evaluation and treatment of hypertensive urgency was indicated, and such observation is necessary and beneficial for the patient.  Rapidly discharging the patient would potentially result in a 20% chance of death or myocardial infarction. In conclusion, it was appropriate to manage this patient at an inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Edentulous in the maxilla

Treatment:  Cone beam CT capture and interpretation with field of view of both jaws with or without cranium, and surgical placement of implant body: endosteal implant for teeth 13, 11, 6 and 4.

The insurer denied coverage for Cone beam CT capture and interpretation with field of view of both jaws with or without cranium, and surgical placement of implant body: endosteal implant for teeth 13, 11, 6 and 4.  The denial was reversed.

This patient is a female a history of diabetes, chronic alcoholic, cardiomyopathy, hypertension, peripheral vascular disease post-stenting, pacemaker and chronic obstructive pulmonary disease who is edentulous in the maxilla.  The patient cannot wear an upper complete, as the patient has a palatal torus. Four (4) implants are planned in the maxilla to retain a denture.  A computed tomography (CT) and the implant are only authorized if they are to alleviate a medical condition.  A denture was suggested.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.  An implant retained denture would be in the best interest of the patient.  Perhaps the best known use of dental implants is treating patients without any teeth.  Denture wearers often suffer due to loose and "floating" dentures, and dental implants offer many benefits to patients without teeth.  Stability of the dentures is improved with the use of dental implants with attachments.  

A Cone beam CT provided significantly more information than a plane film radiograph and is indicated in this case due to the resorption of bone.  A 3D image is necessary to find the best available bone to determine implant placement.  A comprehensive evaluation of the oral cavity begins with a detailed medical and dental history, and a dental hard and soft tissue clinical examination.  This is followed by conventional imaging such as two dimensional imaging (intraoral periapical and panoramic radiography), followed by cross-sectional imaging using MDCT or CBCT.  CBCT imaging is the current method of choice because it provides the greatest diagnostic yield at an acceptable radiation dose risk.  The American Academy of Oral and Maxillofacial Radiology (2012) recommends that cross-sectional imaging be used for the assessment of all dental implant sites and that CBCT is the imaging method of choice for gaining this information.

"Cross-sectional imaging (CBCT is preferable over CT due to its significantly lower radiation dose) is recommended for preoperative implant assessment" (ACP., 2016).    

Based on the above, the medical necessity for Cone beams CT capture and interpretation with field of view of both jaws, with or without cranium and surgical placement of implant body: endosteal implant for teeth 13, 11, 6 and 4) is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest pain
Issue under review:  Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient presented with substernal chest pain with radiation that did not respond to NTG (nitroglycerin). 

While this patient has an objective history of CAD, it was also documented that he has had multiple episodes of similar presentation without any evidence of ischemia.  The probability that this represented new and active ischemic disease was small.  He had negative enzymes, a normal EKG, and recent cardiac Cath that showed no significant objective disease.  The patient left before recommended noninvasive tests were performed.  Those tests did not require an inpatient level of care.

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.  It is highlighted in the orders for care. 

In this case, the patient's symptoms were atypical and unlikely to be representative of acute coronary syndrome (ACS).  The patient's exam and cardiac findings were normal.  Biomarkers and EKG showed no evidence of acute ischemia.  Recent echocardiogram showed no wall motion abnormality (WMA).  Recent heart catheterization did not show obstructive CAD.  The physicians' treatment did not reflect any serious concern about patient's cardiac condition.  Orders did not include medical therapy for ACS such as IV heparin, dual anti-platelet inhibitors, high dose beta blockers or IV NTG.   

The letter of appeal was carefully considered, but it offered no evidence to support inpatient level of care. Only cardiac care provided was telemetry, which is frequently performed in a lower level of care. The patient was admitted for monitoring, and the subsequent tests and therapy did not require an inpatient level of care. Leaving against medical advice did not change appropriate level of care.

There was no "complex" care that required inpatient level of care in this patient's care.  This patient had no evidence of CAD. In fact, all recent tests showed absence of ischemia.  While there was always a potential for an adverse event, one did not happen, and no actual treatment was added.  All of the testing and therapy that were provided would have been appropriate, safe and guidelines-consistent in a lower level of care. Thus, inpatient level of care was not medically necessary.

Milliman criteria requirements for admission for diagnoses of MI (myocardial infarction) or angina were not fulfilled, as there was never any evidence of ACS present.  The working diagnosis was atypical chest pain. 

The denial explanation was consistent with guidelines and usual community care.
Appeal type: Experimental/Investigational
Decision: Overturned

The patient is a male with a diagnosis of Leigh Syndrome, which is a degenerative disease, a rare genetic neurometabolic disorder that leads to degeneration of the brain, spinal cord and optic nerves. At this time there are no standard treatments for this disorder, but recently the medical community has become interested in the use of mTOR inhibitors such as rapamycin derivatives as potential non-invasive treatment options. The provider has recommended Afinitor as a potential treatment option for this patient. The use of Afinitor is under review to determine if it will be more beneficial for this patient than any standard treatment.

The health plan's determination is overturned. 
Yes, the proposed health service / treatment with Afinitor is likely to be more beneficial as there is no standard treatment or treatments for this condition that are approved by the Food and Drug Administration (FDA).
Leigh syndrome is associated with progressive neurodegeneration, external ophthalmoplegia, seizures, lactic acidosis, and symmetric lesions in the basal ganglia or brain stem on magnetic resonance imaging (MRI). This patient has had an early childhood / infant development of the disorder. It is noted that patients with suspected Leigh syndrome should be treated with biotin and thiamine daily, and this patient has been getting this therapy without improvement in his disease status. It is reasonable to treat Leigh syndrome empirically with a combination of antioxidant and oxidative phosphorylation cofactors, including coenzyme Q10, carnitine, and riboflavin as first-tier supplements. Alpha lipoic acid, creatine monohydrate, and vitamin E can be added as second-tier supplements. However, none of these are associated with improvement in the status of the child and only serve to slow the progression of the disease.
The provider has recommended Afinitor (everolimus) as treatment of the child's condition. Sage-Schwaede et al. demonstrated clinical improvement with restoration of lost neurologic function in a child with Leigh syndrome receiving Afinitor. Franz and Capal also noted the potential benefits of this treatment in the setting of neurodegenerative disease.
Given the degenerative nature of this disease, the lack of other treatment options and current literature showing potential improvement in children with Leigh disease receiving treatment with Afinitor, the recommended treatment approach is clinically appropriate and reasonable. There are no other treatments that would be expected to result in any improvement for this child at this time.
Therefore, this request is likely to be more beneficial for this child than any other treatment.
Appeal type: Experimental/Investigational
Decision: Overturned

The patient is a male with a diagnosis of Leigh's syndrome based on clinical findings and homozygous mutation of NDUFV2 mutation. The patient has progressive neurologic decline. There are no treatments or curative therapies for Leigh's syndrome. The provider is requesting approval for treatment with the mTOR inhibitor, Afinitor (everolimus).
The subject under review is whether the Afinitor is likely to be more beneficial than any standard treatment for this patient's life threatening disease.

The health plan's determination is overturned.

Yes, treatment with Afinitor is likely to be more beneficial than any standard treatment for this patient's life threatening disease.
Although the data is very limited, if the treatment does work in this patient, it will be more beneficial than standard treatment, which is vitamins/enzymes. There is no cure. This patient will continue to decline and ultimately succumb to this disease at a young age.
While the data is very limited, this is a rare disease in which clinical trials are not available. There is a clinical trial planned to open in 2021 with a similar mTOR agent, however, it is not currently enrolling. It seems reasonable to attempt to treat this patient based on the pre-clinical and single patient data. Side effects are minimum, and the agent is well tolerated. There is sufficient pediatric experience with this drug. The treatment duration would be expected to be short if the drug fails to help this patient.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who suffered a traumatic brain injury. She was admitted to skilled care for further evaluation and treatment. This review is for the medical necessity of acute inpatient skilled nursing center treatment. The health plan's determination is upheld.  The patient was injured after a fall resulting in a traumatic brain injury status post right frontal temporal parietal hematoma with emergent evacuation and partial temporal lobectomy. She also had a frontotemporal hemorrhage and subarachnoid hemorrhage, bilateral parietal occipital hemorrhage, tracheostomy, respiratory failure, percutaneous endoscopic gastrostomy (PEG) placement right wrist fracture, aspiration pneumonia, hypertension, and sleep apnea. She was admitted for acute hospitalization and subsequently skilled nursing facility care.
The patient did not make significant gains in regard to increasing her functional status during the confinement in the skilled facility. It was noted that the patient suffered an intracerebral hemorrhage. The patient did not make significant gains in the ability to transfer, stand, or walk. The patient's progress with other therapies was limited. She required maximal assistance with activities of daily living.
The patient required tube feedings. There is no documentation of intravenous medication administration. There is no documentation of complex wound treatment. There is no documentation noted for other continued skilled services to support continued inpatient nursing facility care.
According to the physician documentation, the patient is noted to have expressive aphasia and cognitive impairment. She is noted to be alert and disoriented. The patient was noted to be incompetent in regards to medical affairs. A physician note stated that the patient was clinically stable.
A physical therapy evaluation and progress reports show that as a baseline, the patient was total assist in total care for most activities of daily living (ADLs). For almost all categories the patient is maximal assist. There was limited progress if any in any ADL.
In conclusion, the patient had a fall causing severe traumatic brain injury, however, the patient's response since the injury was limited in regard to rehabilitation. Almost 3 months subsequent to the injury the patient has had limited if any improvement. In the 1 month confinement in the nursing home, the patient had limited if any improvement. Without any functional improvement and no other skilled needs, the skilled nursing center would not be considered medically necessary. The health plan's determination is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease
Treatment: Personal care services 12 hours/day, 7 days/week, for a total of 84 hours/week

Summary:
This is a  male with a history of Alzheimer's disease, stroke and renal insufficiency. Due to impairments related to his various medical conditions, he requires assistance with many of his activities of daily living (ADLs). Although an in home assessment was completed, there is more recent documentation from the patient's health care provider that indicates that the patient is now demonstrating additional functional decline. For these reasons, the currently approved plan of 21 hours/week of personal care services is not sufficient to meet the patient's needs. Therefore, the proposed treatment of an increase in Personal care services to 12 hours/day, 7 days/week, for a total of 84 hours/week is deemed medically necessary to offer increased assistance with completion of the patient's ADLs.
Appeal type: Medical necessity
Decision: Upheld

Diabetes
Inpatient Hospital

The patient is a female with past medical history of morbid obesity, history of deep vein thrombosis (DVT) not on anticoagulation, and anemia who presented to the emergency department with complaints of increased thirst, urinary frequency and blurred vision. The patient lived in one room with her friend and her friend's mother. Blood pressure was 150/100 and heart rate 117. The patient was found to have markedly elevated blood sugar in the high 500 range. Urine was positive for acetone, but serum acetone was negative. The patient was admitted to the hospital. 

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient presented to the emergency department with elevated blood sugar and was diagnosed with new onset diabetes mellitus type 2. The patient did not have diabetic ketoacidosis or hyperosmolar coma. The patient had no altered mental status. The patient didn't have severe or persistent dehydration or vomiting. The patient did receive IV insulin x 2 in the emergency department, but then was treated with subcutaneous insulin. The patient did not have frequent glucose checks as she only had it checked QAC and QHS. The patient received IV fluids at 60 ml per hour and was tolerating oral intake. The inpatient hospital admission was not medically necessary. The patient could have been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of a cough and rhinorrhea, fever  with a high temperature of 101 degrees Fahrenheit, and difficulty breathing due to congestion. In the Emergency Room (ER) she was noted to be positive for respiratory syncytial virus (RSV) bronchiolitis with decreased oral intake. She had neutropenia, lymphocytosis, anemia, elevated erythrocyte sedimentation rate (ESR) of 70 and a lactate dehydrogenase (LDH) level of 929. Her physical exam was notable for scattered lymph nodes that were all less than 0.5 centimeter (cm) in diameter. She was admitted for further treatment and care. She was noted to require nebulizer treatments every 3 hours with suctioning and she was documented as having difficulty drinking. She was closely monitored, her status improved, her blood count changes were thought to be related to her viral infection and she was discharged home.
The health plan's determination is upheld.
This patient presented with an RSV infection and blood count abnormalities concerning for a possible serious bone marrow disorder such as leukemia. The provider recommended acute inpatient level of care to help evaluate and treat the patient. However, there is no clinical information provided to show that the acute inpatient level of care was required at this time. From the standpoint of the patient's blood counts, there were no issues with severe anemia, high-risk febrile neutropenia, high-risk low platelet count, active hemolysis, Henoch-Schonlein purpura, bleeding disorder, congenital immunodeficiency state, hyperviscosity syndrome, cryoglobulinemia, methemoglobinemia, spleen trauma, transfusion reaction, or thrombotic disorder. While there were some abnormal types of white blood cells seen from the patient's blood, there were no clear leukemia cells, and the lower blood counts were not severe enough to warrant any specific treatment.
In regards to the RSV infection, while the patient was noted to be RSV positive, there was no respiratory fatigue, hypoxemia, central cyanosis, apnea, tachypnea in the setting of chronic lung disease, feeding difficulties, lethargy or other condition necessitating the inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of ulcerative colitis.  The patient  has been treated with Remicade infusions since 2011.  The provider seeks continuation of therapy with Remicade.  The health plans determination is upheld.  The requested Remicade is not medically necessary for this patient.  The formulary alternatives have also been proven to be safe and effective for treatment of this patient's medical condition and have not been found to be inferior or have an increased risk of adverse effects compared to the current therapy including Remicade.  There are no well-designed, randomized, controlled trials that show that Remicade is superior to the biosimilar agents and potentially decreases risks of adverse effects than the formulary alternatives.  For these reasons, the requested therapy is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroenteritis

Treatment: Inpatient admission

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

This patient is a female who presented to the Emergency Department (ED) with complaints of nausea, vomiting, diarrhea, and generalized abdominal pain that had occurred for three days prior to presentation.  The patient had a past medical history significant for hepatitis A antibody positive, hepatitis B core antibody positive, and a cesarean section (C-section).  The patient previously thought she had contracted food poisoning after eating left out fettuccine alfredo.  The patient then began to feel nauseated and had episodes of diarrhea.  The patient then woke up at 4:00 and had a total of six episodes of non-bloody emesis.  The patient had not attempted to eat or drink anything at home. The patient had a blood pressure of 107/65 with pulse of 78, respirations of 18, temperature of 97.6 and an oxygen saturation of 100%.  The patient was given intravenous fluids for hydration, analgesia for pain, and antiemetics. The patient was then discharged home after a period of monitoring.

There is no documentation that indicated that this patient was likely to require two days or more of inpatient care, and there was no specific explanation of the clinical conditions, circumstances, complications, comorbidities and risks to the patient upon which that expectation was based.  There was no evidence of severity of the gastroenteritis that warranted inpatient care.   There was no evidence of C. difficile that would be reason for hospitalization as inpatient with a clinical presentation of severity.  There were no co-conditions requiring care and management as an inpatient.

The insurer acted reasonably, and with sound medical judgment, and in the patient's best interest.

Based on the above, the medical necessity for the inpatient admission is not substantiated.  The insurer's denial is upheld.