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

The patient is a female G3 P1 011 who at 33-1/7 weeks gestation presented with complaints of right-sided flank pain. The patient had a present history of pregnancy at 33 weeks gestation with normal prenatal care. The patient had a prior history of kidney stones as well as an episode of pyelonephritis in 2014 during pregnancy. She reported no dysuria, fever, chills, nausea or vomiting. She denied any muscle pain, strain or trauma. The patient's prior history was noted for a prior obstetric delivery by cesarean delivery for arrest of descent complicated by chorioamnionitis and cholestasis. She also had a previous history of a first trimester spontaneous miscarriage in 2017 that did not require dilation and curettage (D&C). Her past gynecologic history was notable for fibroadenoma of the breast and this was removed surgically in 2014. Her past medical history was noted for renal stones.

The patient was noted to be afebrile and feeling much better. She was tolerating a diet and had a soft abdomen. She had only mild right sided costovertebral angle tenderness. The patient was planned for discharge on oral analgesics at that time with follow-up as an outpatient. The patient had pain control on oral Dilaudid for pain medication. She had no complains and was for discharge to home. She had a nonstress test (NST) that was reassuring with regard to fetal status.
The following day, the patient was noted to have complaints of right flank pain and 5/10 pain. She had received Dilaudid on the night prior and was requesting this again on this AM. She had not received IV Dilaudid and was on oral medication. She was tolerating a regular diet and had good fetal movements. She had a reactive and Category I NST for fetal reassuring state. Plan was to discharge patient on oral Dilaudid. She was also to have milk of magnesia for constipation.

The health plan's determination is upheld.

In this case, the requested health service/treatment of inpatient stay was not medically necessary for this patient as reviewed in the case and in concert with the Milliman Care Guidelines (MCG) entitled "Renal Colic and Kidney Stones." In this case, the patient was stable on oral pain medications on the period from January 4, 2019 through January 5, 2019. The patient was on an oral diet and had no nausea or problems with taking adequate oral intake. There were no problems noted with intake. The patient had a prior history of renal colic with her prior pregnancy and had known renal stones on prior imaging. She underwent renal imaging with this hospitalization that noted no obstruction and physiologic renal hydronephrosis on the right. There were no stones noted and no obstruction noted. Renal function was also normal by creatine on serum analysis. Based upon a review of the medical records, the medical care provided could have been safely provided at a lower level of care and was not medically necessary at the inpatient level of care in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skin Disorders (Psoriasis vulgaris)
Treatment: Pharmacy/ Prescription Drugs (Humira)

Summary:  This patient has a history of psoriasis vulgaris.  Per the office visit with her Dermatologist, the patient was using Calcipotriene cream 0.05% cream in the morning and Betamethasone in the evening Monday-Thursday; Mometasone cream twice daily Friday-Sunday; Clobetasol to scalp three times weekly and Nizoral shampoo three times weekly.  The patient complained of continued itching.  Scattered red plaques were noted on the upper and lower extremities.  The Dermatologist is requesting authorization for Humira Pen for the patient.

The insurer has denied coverage for Humira Pen-Ps/UV/Adol; HS Start 40mg/0.8ml SC PNKT.  The denial was reversed.
 
The patient has poorly controlled hypertension, and as confirmed by the pharmacy records, is on triple therapy.  She also has severe nausea and diarrhea problems.  Cyclosporine can exacerbate existing hypertension.  Methotrexate can exacerbate nausea and diarrhea in an individual so predisposed.  Acitretin would be inappropriate, since the amlodipine is metabolized in the liver; adjunctive use of acitretin could have an adverse interaction in the liver.  It appears that the plan preferred medications would be inappropriate for this individual due to her complex medical history.  With regard to methotrexate, aside from its recognized side effects, there is a randomized study showing that Humira is superior to methotrexate in patients with severe psoriasis which has more recently been confirmed albeit in the pediatric age group.  The medical record shows contraindication to the patient utilizing the preferred options listed by the insurer based on the medications that the patient already uses and her history.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension, diabetes, GERD, memory impairment
Treatment: Increase in PCA services to 25 hours per week
The increase in PCA services to 25 hours per week is not medically necessary.
Based upon the medical records and documents presented for review at this time, the patient's medical needs are met by the current level of PCA care at 19 hours.  The patient performs most adult daily living tasks for herself.  The patient is self-directing and makes most decisions for herself. There are no facts presented to demonstrate a need for increased PCA services at this time.
Appeal type: Medical necessity
Decision: Upheld

The patient has past diagnoses of depression, post-traumatic stress disorder (PTSD), alcohol and opiate use disorders and a medical history of human immunodeficiency virus (HIV) who was admitted to the Hospital. The health plans determination is upheld. The notes during these dates of service support that the patient was cooperative, collaborative, without suicidal or homicidal thoughts, or any significant behavioral disturbances. No medication changes were made during this time. He was discharged once accepted to an inpatient rehab. In conclusion, the submitted medical records do not document that inpatient level of care was medically necessary from the dates of service at issue.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems (Malocclusion)
Treatment:  Dental/ Orthodontic Procedure (Braces)

Summary: This patient presented for evaluation for orthodontic care. The orthodontist identified several clinical findings including overjet, overbite, and anterior crowding and has recommended orthodontics. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 26 total points to support orthodontic care. 

The insurer has denied coverage for dental codes D8080 (braces) and D8670 (monthly visit) as not medically necessary. The denial was upheld.

Upon review of the submitted documentation, it is evident that the patient exhibits a 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 HLD Index Report (New York State Medicaid program) modeled after HLD 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 does not claim an automatic qualifying condition and completes the second portion of the index arriving at 26 points to justify orthodontic care. This reviewer concurs with the index completed by the insurer attaining a total of 18 points on the HLD index (6 overjet, 4 overbite, 5 anterior crowding, 3 labiolingual spread) which is below the threshold of 26 points to support 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 need is a valid approach. The dental codes D8080 (braces) and D8670 (monthly visit) are not considered medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Headache with nausea and vomiting
Treatment: Inpatient Hospital 

Summary: This patient presented to the Emergency Department (ED) complaining of a headache as well as nausea and vomiting. The patient did arrive via emergency medical services who indicated they gave the patient 4 mg of Zofran. The patient had an episode of emesis during triage. The documentation details the patient has a history of prolonged complex seizure. He was mildly confused but able to answer questions and was re-directable. On physical exam he was oriented to person place and time and was in no acute distress. The documentation detailed they were unable to get a good neurological examination as the patient was nauseous and vomiting. It was recommended the patient undergo multiple laboratory and diagnostic studies. The physician detailed the patient's vitals were stable on presentation and he was given a fluid bolus as well as Zofran, Toradol and Reglan. The patient did have improvement. Laboratory studies to include a comprehensive metabolic panel (CMP) and complete blood count (CBC) were reassuring against meningitis. It was recommended the patient be admitted per pediatric neurology and undergo video electroencephalogram (EEG). The patient's numbness did resolve and headaches were improved. Neurology was able to get a neurological examination that did not reveal any significant abnormalities. The patient was neurologically intact to include mentation. He continued with treatment. The patient did not have any acute events overnight and the EEG performed showed slowing present in the right posterior region with no epileptiform activity noted. The diagnosis was likely acute episode of migraine without aura and it was recommended the patient undergo an additional EEG in 3 months. The patient was discharged the following day in stable condition.

The insurer has denied coverage for the inpatient hospital admission as not medically necessary. The denial was upheld.

According to current literature, a patient may be admitted to inpatient services when there is evidence of severe central nervous system (CNS) infection, vasculitis, cerebral aneurysm, myasthenia gravis crisis, multiple sclerosis, complications of neurologic devices, or evidence of hemodynamic instability, complex febrile seizure, status epilepticus or repetitive seizures that are not controlled with emergent treatment or there are new focal neurologic deficits. Within the documentation, there was no indication of the above. While it was noted the patient continued to have symptoms while in the ED, the physician detailed the patient did improve with medication. There was no indication of why the patient could not have been observed at a lower level such as observation. Therefore, given this is not consistent with current literature the previous denial of coverage for the inpatient hospital admission remains upheld.
Appeal type: Medical necessity
Decision: Upheld

The patient with a history of hypertension, rheumatic heart disease, aortic and harmonic valve replacement, chronic obstructive pulmonary disease (COPD), mild ascending thoracic aortic aneurysm, obesity, and polysubstance abuse  was admitted with two days of shortness of breath, chest pain, and cough. The chest pain was intermittent and self-limiting.  Patient  was diagnosed with a COPD exacerbation and atypical chest pain. There was no severe congestive heart failure (CHF), severe respiratory distress, ongoing symptoms suggestive of angina or angina equivalent, severe arrhythmia, hemodynamic instability, suspicion of another serious cause for chest pain, such as a pulmonary embolism (PE) or aortic dissection, need for prolonged intravenous (IV) medications or oxygen support, introduction of high risk medications requiring ongoing in-hospital monitoring, severe electrolyte abnormality, or supporting evidence for an acute coronary syndrome such as elevated cardiac biomarkers or an abnormal ECG. In the setting of this case an acute inpatient level hospitalization has not been established as standard of care towards improved cardiac outcomes. It is therefore, considered not medically necessary in this case. HP determination is upheld in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System (Asthma)
Treatment: Inpatient Hospital

Summary: This patient with a past medical history of asthma, arthritis and hypertension presented to the Emergency Department (ED) with complaints of worsening shortness of breath along with cough and sputum production. The patient reported that she had run out of her medications. The patient reported that her daughter at home was sick. She denied fever or chest pain. Vital signs at presentation to the ED included a temperature of 98.4F, a heart rate of 98, a respiratory rate of 21, a blood pressure of 134/86 mm Hg and an oxygen saturation of 100%. As per the ED physician note, the patient was in no acute distress. No accessory muscle use was noted. Expiratory wheezing was noted. The cardiac exam was within normal limits. The patient was awake and alert. The WBC count was 8.3K, the hemoglobin was 11.8, and electrolytes were within normal limits. A brain natriuretic peptide (BNP) was normal and influenza screening was negative. The patient was treated with DuoNebs, steroids and Azithromycin. A chest x-ray showed no acute infiltrate. An electrocardiogram (EKG) showed normal sinus rhythm. There were no acute changes. The patient was still wheezing after three DuoNebs and was admitted for an asthma exacerbation and viral upper respiratory tract infection.

The insurer has denied coverage for the inpatient hospital admission as not medically necessary. The denial was upheld.

As per the history & physical, the patient was in no acute distress. Her temperature was 98.4, her blood pressure was 125/80 mm Hg, her respiratory rate was 21, her heart rate was 98 and oxygen saturations were 100%. Lung exam showed diffuse wheezing bilaterally. The patient was treated with steroids, bronchodilator, Azithromycin and Tamiflu. Peak expiratory flow (PEF) was noted to be 280L/min. Arterial blood gases (ABGs) revealed a pH of 7.41, a partial pressure of carbon dioxide (pCO2) level of 32, a partial pressure of oxygen (pO2) level of 96, a bicarbonate of 20, and a blood oxygen saturation of 98%. The patient was seen by Pulmonary who recommended changing antibiotics to the oral route and also to taper steroids and switch to the oral route. The patient was to be referred for a sleep study after discharge for possible obstructive sleep apnea (OSA).  The patient could have been switched to oral steroids, bronchodilators, oral antibiotics and long-acting beta-agonists/inhaled corticosteroids combo and discharged home with close follow-up in the outpatient setting. The patient was afebrile, hemodynamically stable and in no acute distress. The WBC count was normal with mild elevation likely a steroid effect. ABGs were acceptable. There was no hypoxia. A chest x-ray showed no pneumonia or pleural effusion. PEF was 280. The patient was tolerating oral intake. The patient did not need acute inpatient hospitalization. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Allergy to Strawberries

Treatment: Inpatient admission, diagnostic testing, and medication management.

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

This patient was seen in the Emergency Department.  The patient presented complaining of left-sided facial swelling, pruritus, tingling to the upper lip since the previous night after eating french fries.  As per the patient, this happened once before in 2017 where she was admitted for angioedema and told to follow-up with an allergist.  The patient stated that she has yet to follow-up with an allergist.  The patient was noted to have an allergy to strawberries.  On examination, there was left eyelid inflammation there was facial swelling to the left lower eyelid, left maxillary prominence and upper left lip.  The patient was given intravenous (IV) Solu-Medrol, IV famotidine and oral hydroxyzine.  A chest x-ray had no evidence of acute cardiopulmonary disease.  The patient was admitted and was felt to have angioedema.  After medications the patient did improve.  The patient then left the hospital against medical advice.

The medical literature indicates that inpatient admission is warranted for patients with hemodynamic instability, systemic or infectious condition causing severe symptoms or findings, high fever high risk infection situation, high risk febrile neutropenia, suspected infection with rapid progression or severe symptoms, severe adverse drug or systemic toxin reaction, allergic reaction with severe symptoms such as airway edema, stridor, respiratory distress, bronchospasm or hemodynamic instability.  

The documentation noted that the patient was seen in the Emergency Department due to complaints of left-sided facial swelling, pruritus, tingling to the upper lip after eating french fries.  The patient had a past medical history of angioedema.  In the Emergency Department the patient was administered several medications and did have improvement.  The above noted admission criteria was not met.  Inpatient hospital services were not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems (Syncope)
Treatment: Inpatient Hospital

Summary: This patient with a past medical history of schizoaffective disorder was upgraded from the psychiatric floor to telemetry after experiencing a near syncopal episode while on the psychiatric floor. She had been admitted to the psychiatric floor two days prior to this episode as she had auditory hallucinations. At the psychiatric floor nursing station, the patient reported that she felt dizzy and lightheaded and then fell on her knees, as witnessed by the nursing staff. There was no seizure witnessed and there was no incontinence. When she was examined by the psychiatric floor nursing team, a temperature of 101 was noted. A review of systems revealed no complaints other than fever and syncope. An electrocardiogram (EKG) was done and showed normal sinus rhythm at 95 beats per minute (bpm). There was no evidence of tachyarrhythmia, bradyarrhythmia or atrioventricular (AV) block. The QTc was within normal limits. The monitor strips that were recorded showed sinus rhythm or sinus tachycardia at a rate of 112 bpm. The assessment and plan stated that she had pre syncope likely due to poor oral intake. Measurement of orthostasis was negative and she had no significant past history of any cardiac event. It was noted that she had a fever likely due to a urinary tract infection. She was being treated with Rocephin 1 gm intravenous push (IVP) twice a day (BID) with intravenous (IV) hydration. A note stated that the patient was refusing IV fluids, and antibiotics were switched to oral ciprofloxacin BID. She stated that she wanted to return to the psychiatric floor. 

The insurer has denied coverage for the inpatient hospital admission as not medically necessary. The denial was upheld.
 
This patient had an episode of near syncope while on a psychiatric floor in the hospital. She did not have any prior cardiac history or prior episodes of syncope or near syncope. There was no family history of sudden death. It was noted that she was dehydrated and was initially febrile, presumably secondary to a urinary tract infection. She does not show any of the warning signs that are mentioned in the literature cited which would indicate a poor outcome after a syncopal attack. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: sickle cell anemia, pain
Issue under review: Inpatient admission
Summary: The proposed treatment of inpatient admission is not deemed medically necessary.
This patient with a history of sickle cell anemia, avascular necrosis of bilateral femoral heads and jaw, prior CVA, chronic left upper extremity DVT and adrenal insufficiency on chronic hydrocortisone supplementation presented to the ER for further evaluation/management of new onset, severe bilateral knee and low back pain characterized as 8/10 in severity.  Intake vitals were afebrile, hemodynamically stable with no evidence of febrile temperature, malignant hypertension, profound hypotension, severe tachycardia or hypoxemia on room air.  Examination was non-focal with no significant abnormalities noted including no evidence of acute cardiopulmonary abnormalities or findings consistent with acute chest syndrome.  Laboratory, ECG and chest x-ray testing was also within normal limits with no significant abnormalities noted, including no evidence of acute end organ damage.  The medical records indicate that this patient was admitted to the inpatient medical service in stable condition where she received supportive care with IV fluids, prn analgesics and IV hydrocortisone.  She responded well to the prescribed therapies and was subsequently discharged in stable condition.  There is no evidence of intensification of services throughout the course of this patient's hospital stay.  Hence, patient's care could have been safely furnished in a less intensive setting without adversely affecting patient's safety or outcome.
Appeal type: Experimental/Investigational
Decision: Upheld

This is a patient who underwent radiofrequency ablation of left lumbar (L)3, L4, L5 "paravertebral facet joint nerves" secondary to diagnoses of lumbar facet hypertrophy and lumbar spondylosis.  The health plan's determination is overturned. Radiofrequency ablation of left L3, L4, L5 medial branches is likely to be more beneficial than any standard treatment. The patient received greater than 50% pain relief from left L3, L4, L5 medial bundle branch blocks (the operative note confirmed that a steroid was not used) which indicates a successful trial and therefore it was appropriate to continue with a left L3, L4, L5 radiofrequency ablation.
Appeal type: Experimental/Investigational
Decision: Upheld

This is a patient whose diagnoses include lumbar spondylosis, lumbar intervertebral disc displacement and lumbar intervertebral disc generation. Radiofrequency ablation  was denied by the health plan noting that the patient has back pain and related complaints and it appears the patient's pain may be from a pinched nerve . 

The health plan's determination is upheld. The patient is noted to have a history of lumbar radiculopathy and had complaints of low back pain radiating to the legs at the posterior upper leg. The physical examination did not include a full neurological exam to rule out active lumbar radiculopathy. There was no objective documentation provided suggesting the patient to have primarily facet mediated pain and no imaging studies provided to confirm no other obvious causes for the patient's pain, such as nerve root impingement/compression. There were also no physical therapy or chiropractic notes provided showing that the patient has had any recent active conservative treatment for the current episode of pain.