Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive Sleep Apnea
Treatment: Surgical Services (Hypoglossal Nerve Stimulator)

Summary: Reviewer #1:  This patient has a history of obstructive sleep apnea (OSA), atrial fibrillation, hyperlipidemia and hypertension.  Per initial consultation with his Otolaryngologist, a sleep study showed an apnea hypopnea index (AHI) of 28.8 with central and mixed apneas less than 25% of total apneas.  The patient has a body mass index (BMI) of 28.2 and had tried continuous positive airway pressure (CPAP) and an oral appliance without relief.  A uvulopalatopharyngoplasty (UPPP) did not improve the patient's symptoms.  The patient reported fatigue, daytime sleepiness, snoring, dizziness and vertigo.  A sleep endoscopy performed on in 2018 noted airway collapse in the anterior-posterior direction, making him a candidate for Inspire hypoglossal nerve stimulator implantation.

The insurer has denied coverage for Hypoglossal Nerve Stimulator-CPT codes 0466T: Insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator; 64568: Incision for implantation of cranial nerve - e.g., vagus nerve - neurostimulator electrode array and pulse generator; and 95971: Electronic analysis of implanted neurostimulator pulse generator system; simple spinal cord or peripheral - i.e. peripheral nerve, sacral nerve, neuromuscular- neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming as experimental.  The denial was reversed because the procedure is likely to be more beneficial than any other existing standard health service.

Inspire is currently Food and Drug Administration (FDA) approved for the treatment of moderate-severe OSA. The patient meets surgical criteria for surgical implantation of an upper airway stimulation device for the hypoglossal nerve and associated CPT codes 0466T, 64568 and 95971.  Surgical implantation of an upper airway stimulation device for the hypoglossal nerve and associated CPT codes 0466T, 64568 and 95971 is the best available treatment for this patient at this time, as the patient has attempted and failed alternative treatments including PAP therapy, surgical correction through UPPP, and the application of an oral appliance.  The patient has demonstrated trials through various modalities in the treatment of OSA by PAP therapy, surgical correction - UPPP, and oral appliance.  The use of nerve stimulators to treat OSA by protruding the genioglossus muscle is a viable resource in managing moderate to severe OSA. As such, the requested service is likely to be more beneficial than any standard treatments/procedures.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

The patient came to the ER for shortness of breath.  The electrocardiogram (EKG) and chest x-ray were normal.  The oxygen (O2) saturation on room air was 95% and 96%.  Heart rate was 88 beats per minute. Blood pressure was 132/76. 

By the afternoon, the patient's chest was clear.  In the ER, the patient was treated with intravenous (IV) steroids and Duoneb.  She improved and was in no distress. Blood urea nitrogen (BUN) was 10.0, sodium (Na) was 139, potassium (K) was 4.0 and creatinine was 0.66. There was no significant tachycardia or hypoxia.  

The patient could have been safely discharged home from the ER and the admission was not medically necessary.  She was discharged home the day after arrival.
Appeal type: Medical necessity
Decision: Overturned

This patient has a history of diabetes mellitus, hypertension, congestive heart failure, asthma, Ethyl Alcohol (ETOH) abuse, Cirrhosis of the liver and chronic stasis ulcer of the lower extremity. The patient was also homeless. He presented to the Emergency Department with complaints of shortness of breath and chest tightness, dizziness and cough. The patient was noted to have alcohol on the breath.  He was lethargic/drowsy.  He had 3  edema to the lower extremity.  White blood count was 8.2K, hemoglobin was 13.1, electrolytes were within normal limits, and he had an anion gap of 15.  Lactate was elevated to 4.6.  Brain natriuretic peptide was 135, ETOH Level 65 and Ammonia 68.  Liver function tests were elevated.  Troponin was 0.03.  Chest x-ray revealed bilateral increased interstitial opacities and patchy infiltrates and right basal opacity. The patient was admitted with a diagnosis of Sepsis and possible Community Acquired Pneumonia versus Aspiration Pneumonia.  Arterial blood gas was 7.345, partial pressures of carbon dioxide (PaCO2) were 39, and partial pressures of oxygen (PaO2) were 73.

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

The inpatient admission was appropriate given the patients multiple medical problems, co-morbidities, homelessness and unstable living situation.  The patient had a high anion metabolic acidosis and elevated Lactate.  He was placed on intravenous (IV) fluids and broad spectrum IV antibiotics - Cefepime, Azithromycin and Cleocin and was pan-cultured.  The patient was also treated with Lactulose and placed on ETOH withdrawal watch.  He was continued on maintenance medications.  Based on the patient overall condition with high Lactate secondary to Sepsis, bilateral infiltrates on chest x-ray and underlying multiple co-morbidities including congestive heart failure/ cirrhosis, ongoing alcohol abuse  and unstable living conditions, admission for treatment was appropriate.  He was not a suitable candidate for treatment in Observation status.  He was at high risk of non-compliance and treatment failure to his multiple medical and social problems.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Constipation and abdominal pain
Treatment: Inpatient admission
The proposed inpatient admission was not medically necessary.  
As documented in admission H&P, GI consult and discharge note, the patient had abdominal pain and constipation. Due to concerns for bowel obstruction, she was transferred to this hospital for evaluation for volvulus versus intussusception. She was subsequently admitted for IV hydration and consult. Further evaluation did not find bowel obstruction. The patient tolerated oral intake and acted normally. She was discharged home on the same day. During the hospital stay, she remained stable and did not have any acute events after admission. There was no persistent vomiting, diarrhea or fever. There were no documented acute interventions. Therefore, the acute hospital stay is not medically necessary and the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

The patient has a past medical history significant for hypertension and pre-eclampsia who presented to the emergency department (ED) on 1/12/19 with left facial numbness, left frontal headache, sharp pain behind the left eye, aphasia, and left arm and bilateral leg heaviness and weakness making it difficult to ambulate.
In the ED, the blood pressure was 157/87, pulse 82, respiratory rate 16, and she was afebrile. On exam, there was no nystagmus.

The health plan's determination is upheld. The inpatient admission from 1/12/19 to 1/13/19 was not medically necessary for this patient. This patient was only in for 1 night for neurologic symptoms that improved quickly. The patient does not meet Milliman Care Guidelines (MCG) for a transient ischemic attack (TIA) as she did not require an urgent surgery, was not hemodynamically unstable, and did not have persistent focal neurologic abnormalities.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes, obesity and sleep apnea

Treatment: Medication management.

The insurer denied the medication Afreeza. The denial was upheld.

This case involves a patient diagnosed with type 2 diabetes. She has utilized Victoza, as well as metformin and an SGLT inhibitor, which was also discontinued due to urinary tract infection.  The documentation indicated that the patient did not have any episodes of hypoglycemia noted.  The physical exam did not reveal any abnormalities.  The patient's hemoglobin A1c was noted to be 7.6%. The provider noted a discrepancy between A1c point-of-care blood glucose values as unclear etiology. The provider noted that her diabetes was poorly controlled as evidenced by review of the patient's continuous glucose monitor. It was recommended that the patient begin the requested medication.   Per prior authorization criteria, the documentation does not detail the patient has had a trial and failure of the recommended formulary medications such as Novolin R, NovoLog, or Fiasp.

Per literature, both basal and prandial regimens are similarly effective in reducing glycated hemoglobin (A1C) concentrations in patients who fail to gain glycemic control through lifestyle changes and oral glucose-lowering agents; however, it is recommended that patients initiating insulin therapy start with basal, rather than prandial, insulin as basal insulins provide relatively flat serum insulin concentration for up to 24 hours. Patients whose glycemia levels remain uncontrolled while receiving basal insulin, may require a combined basal and prandial insulin regimen. Current medical literature does not make recommendations regarding the use of rapid-acting analogs versus inhaled insulin, as both are effective; but, they are preferred over regular human insulin, as they provided more rapid onset and offset of action and are associated with less hypoglycemia events. Afrezza is a Food and Drug Administration (FDA) approved inhaled prandial agent. According to the documentation, the patient has not trialed and failed the recommended formulary medications prior to utilizing a non-formulary.  The documentation detailed that there are formulary alternatives appropriate for this patient.  Additionally, it does not appear that the patient's diabetes is not being somewhat controlled, as her hemoglobin A1c was only noted to be 7.6%.  Therefore, while the utilization of this medication may be appropriate for patient whose levels remain uncontrolled while receiving basal insulin, the documentation submitted does not provide evidence of the above.  As such, the requested Afrezza is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This patient presented to emergency department with complaints of abdominal pain and associated symptoms included chills, nausea and vomiting.The patient was admitted and underwent a cystoscopy and stent placement. The health plan's determination of medical necessity is upheld in whole. The inpatient hospital stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness
Treatment: Inpatient admission 

Determination:
The acute inpatient admission was not medically necessary.

The patient presented with the complaint of dizziness and had a normal neurological examination and CT scan. The diagnostic studies, clinical monitoring and treatment could have been safely and effectively provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a medical history significant for depression, hyperlipidemia, fatigue, gait mobility, hypertension, osteoarthritis, obesity, unspecified pain and stress incontinence.  The health plan's determination of medical necessity is upheld.  The amount of hours provided are adequate to meet this patient's medical needs for the required services. An increase in service hours is not medically necessary for a decrease in endurance.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis
Issue under review: Inpatient admission 

Determination:
Inpatient admission was medically necessary.

The patient meets the initial criteria for IV treatment and admission for cellulitis/abscess given by the Infectious Diseases Society of America (1), as he had failed outpatient therapy and had signs of systemic infection. There was a concern that he may have had resistant bacteria (MRSA), and thus admission was warranted by standard of care, also. Thus, this admission was warranted, supported by IDSA guidelines, as well as standard of care. Failure to admit such a patient can lead to loss of function, sepsis, deep abscess, or death.
Appeal type: Medical necessity
Decision: Upheld

The patient saw the primary care physician for palpitations. The PCP performed an echocardiogram that showed a possible pericardial effusion and referred the patient to the ER, after which the patient was admitted. The medical necessity of the inpatient stay is at issue. The health plan's determination is upheld. An inpatient level of care was not medically necessary. The admission was to rule out lupus pericarditis. The medical literature indicates that inpatient admission is not necessary for the majority of patients with acute pericarditis and pericardial effusion.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a past medical history significant for hypertension, hyperlipidemia, coronary artery disease (CAD) status post myocardial infarction (MI), chronic congestive heart failure with ejection fraction (EF)less than (<)15%, COPD, and cocaine abuse, who presented  a chief complaint of chest pain with associated shortness of breath that was worse with lying flat and present for the last 6 hours. He also endorsed a headache and cough productive of white sputum. The health plans determination of medical necessity is upheld. He did not have labs or an EKG suggestive of acute coronary syndrome, did not have a congestive heart failure exacerbation with acute hypoxia, COPD associated with acute hypoxia, arrhythmia, or other reason to require acute inpatient admission.  He had no evidence of acute ischemia on EKG and his troponins were negative, in addition to having had a recent negative stress test, all of which made acute coronary syndrome less likely.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse

Treatment: Inpatient Detoxification Treatment

The insurer denied the Inpatient Detoxification Treatment. The denial was reversed. 

This is a middle age male who was admitted to inpatient substance detoxification treatment for alcohol and heroin detoxification. He was experiencing withdrawal symptoms that included tremors, joint pain, anxiety, diarrhea, nervousness, and dilated pupils. He had a Clinical Institute Withdrawal Assessment (CIWA) of 17 and Clinical Opiate Withdrawal Scale (COWS) of 10. He had a past history of multiple and recent substance inpatient detoxification and rehabilitation treatments. He reportedly had poor coping skills for abstinence and lacked sober supports. During his admission he was treated with Librium and Methadone protocol. He left against medical advice (AMA) a few days after his admission.

In this case this patient had use of multiple substances including heroin, alcohol, and cannabis and was at risk for death from overdose and also severe, complicated, or life threatening withdrawal. According to the LOCADTR he did require 24 hour treatment, as he could not safely and effectively be treated for detoxification in a less restrictive setting as he continued to use alcohol and multiple substances despite multiple past inpatient substance detoxification and rehabilitation treatments, and he needed two detoxification medications including Librium and Methadone to modify withdrawal from alcohol and heroin. Also, he had long term multiple substances of use including using heroin and alcohol as well as cannabis, and he needed 24 hour treatment as he was at risk for worsened withdrawal symptoms if not in this 24 hour setting and he likely would have relapsed again as evidenced by relapsing after multiple past treatments. He also had poor coping skills for abstinence and lacked sober supports. He reportedly had 2 detoxification medications including Librium and Methadone. He required and received detoxification medication.

Based on the above, the medical necessity for the inpatient hospital services is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever
Treatment: Inpatient Hospital Services

Summary: This patient presented in the Emergency Department (ED) with a 3 day history of fever, vomiting for 2 days (with 5 episodes noted the day prior to presentation in the ED). Was also noted with complaints of cough, congestion, rhinorrhea and ear fullness for 5-7days. He was reportedly given 5ml (100mg) of Ibuprofen earlier in the day prior to presentation (for claimant's weight was under dosed). Vitals on ED presentation showed blood pressure (BP) of 105/69, Pulse rate of 154, temp of 103.2F, oxygen saturation on room air 100%. No respiratory distress was noted. Tylenol 240 mg orally was given. Respiratory Viral panel was positive for Influenza A. The patient was started on Tamiflu and was then admitted. History and Physical on admission documents regular rhythm and rate on cardiovascular exam, "tachycardia improved since 2 boluses in ED." 

The insurer has denied coverage for the inpatient hospital admission as not medically necessary. The denial was upheld. 
Based on the Milliman Care Guidelines, this patient did not meet the criteria for sepsis. The patient was documented as being positive for influenza. She did not qualify as septic either with physical exam or laboratory studies. This patient could have been further observed, managed and treated up to 48 hours.  Inpatient admission, based on the documented medical records reviewed, was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

The patient presented with abnormal right eye movements and was diagnosed with a cranial nerve palsy. There was no concerning findings on neurological examination, from history of present illness or on neuroimaging to warrant acute inpatient admission. There was no evidence of acute alcohol withdrawal with neurological involvement. The diagnostic studies, neurological consultation, monitoring and treatment could have been safely and effectively completed at a lower level of care. Therefore, the inpatient admission 01/07/2019 through 01/08/2019 was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Recurrent angina
Issue under review: Inpatient admission

Determination:
The inpatient admission was medically necessary.

The patient presented for management of recurrent angina, and was noted to have obstructive disease of the RCA on cardiac catheterization. A coronary intervention with stent placement was performed on a CTO (chronic total occlusion), with use of dual injection and rotational atherectomy, which is considered a complex PCI. In addition the patient's course was complicated by a post-procedure myocardial infarction. 

Patients such as this one were excluded from the studies of outpatient PCI. It would be consistent with the current standard of care that this patient, after this complex PCI with the use of rotational atherectomy, be managed in an inpatient setting. Therefore, the requested inpatient admission was medically appropriate in this clinical setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Difficulty breathing and cough
Treatment: Inpatient hospital admission
The inpatient hospital admission was not medically necessary.
This baby girl was referred to the ED by the pediatrician because of hypoxia with respiratory distress in the office. She was admitted because while in the ED she had episodes of desaturation to 88-92% in room air. While it was appropriate to continue monitoring this young infant for resolution of dehydration and need to apply supplemental oxygen, she was overall hemodynamically stable. She did not require acute inpatient admission and could have been safely managed at a lower level of care such as observation.
Appeal type: Medical necessity
Decision: Upheld

The patient presented with swelling to the dorsum of the left hand after a fall/bug bite . The patient was admitted for antibiotic treatment. The patient was treated with intravenous (IV) antibiotics for presumed cellulitis and admitted for antibiotic management and to rule out deep tissue infection. Consults were completed. A deep tissue infection was ruled out. The health plan has denied the inpatient stay as not medically necessary. The health plan's determination was upheld. Therefore the inpatient hospital stay was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: SLE nephritis
Treatment: Inpatient hospital admission
The inpatient hospital admission was medically necessary.
When there is evidence of bleeding post kidney biopsy, it is mandatory to admit the patient overnight or until no further bleeding.  Patients can die from bleeding after a kidney biopsy.
In addition, standard of care would warrant inpatient level of care over observation in this case since there was a life threatening bleed that requires greater than (>) 24 hours of monitoring.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis, hypertension, diabetes Type 2, dementia, CAD
Issue under review: Increase in PCA services

Determination:
Increase in PCA services is not medically necessary.

Based upon the documentation provided, including a review of the guidelines and instruments used to assess the patient's needs, including the helper tool , the patient's medical needs are met with the current provision of personal care services shared with her spouse.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal (Right shoulder rotator cuff tear)
Treatment: Surgical Services (Reverse shoulder arthroplasty)

Summary: This patient has right shoulder pain and reported loss of motion and difficulty with activities of daily living. She was found to have a full thickness tear to the rotator cuff. Her physician recommended a reverse shoulder replacement with associated procedures. It was denied based upon a lack of conservative treatment. 

The insurer has denied coverage for CPT code 23700-Manipulation under anesthesia, shoulder joint, including application of fixation apparatus (dislocation excluded), 23430-Tenodesis of long tendon of biceps, and 23472-Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (e.g., total shoulder). The denial was upheld. 

A review of the medical record denotes an initial consultation with an Orthopedic Surgeon. The reported onset of symptoms was one month. She was found to have poor strength and motion. Imaging studies of a magnetic resonance imaging (MRI) scan were reviewed which demonstrated a full tear to the rotator cuff tendons. He recommended surgery and discussed nonoperative treatment. The indications for surgery include pain and functional limitation which have not responded to conservative treatment. Conservative treatment includes use of pain medication, physical therapy and/or cortisone injection. The medical record (MRI report and indication) denotes a recent fall. There was no evidence that conservative treatment had been provided. The patient was evaluated in 2019 and the arthroplasty was suggested. Therefore, there would be no indication for surgery at this time.