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

Diagnosis:  Neck and Back Pain
Treatment: lnpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is upheld.

The was admitted with complaints of (c/o) neck and upper back pain radiating to both lower extremities and associated with numbness/tingling after a fall. Vital signs were unremarkable. Physical exam notable for no apparent distress (NAD), well-appearing, 4/5 strength in the upper extremities (US). Lab work was unremarkable. A magnetic resonance imaging (MRI) scan showed no intrinsic cord signal abnormality in the cervical spine, no MRI evidence of acute ligamentous injury. Neurology was consulted and felt the patient's neuropathy was likely related to diabetes, rather than the fall. Orthopedics was consulted and they recommended pain control, mobilization, and a cervical collar for mobilization. The patient was diagnosed with cervical radiculopathy and was treated with pain control, a radiological work-up, and neuro checks. The patient was discharged  in stable condition. At issue is the medical necessity of an inpatient stay.

No, the hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with c/o back pain without associated bladder dysfunction or saddle numbness. The patient received a thorough diagnostic and imaging work-up, which did not demonstrate any acute fractures, dislocations, and an MRI of the spine did not reveal any major compressive pathology. Orthopedics did not recommend any acute surgical intervention and neurology determined that the neuropathy was related to diabetes, not the fall. The patient did not have an abdominal aortic aneurysm, aortic dissection, cauda equina syndrome, epidural abscess or hematoma, acute spinal fracture, meningitis, osteomyelitis, progressive neurologic deficits, fever, discitis, or tumor. The patient received intravenous (IV) pain control, radiologic work-up and neurological checks, all of which could have been safely provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Genitourinary.
Inpatient Hospital.

Diagnosis: laparoscopic myomectomy with incisional hernia repair and lysis of adhesions.
Treatment: Inpatient stay.
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a female who underwent robot-assisted laparoscopic myomectomy with incisional hernia repair and lysis of adhesions. The procedure started at about noon and was completed at 16:40. The patient was admitted at the level of an inpatient. The inpatient hospital admission is under review.

The inpatient stay was not medically necessary. There is nothing documented in this record to suggest an inpatient level of stay was medically necessary. The laparoscopic procedure is reported to have been performed as planned without intraoperative complication. The procedure included lysis of adhesions that appeared unexpected, but there were no bowel injuries or other complications reported during that portion of the surgery. The patient did undergo additional surgery to remove adhesions, but this was all accomplished laparoscopic and without any notation of a bowel injury or other complication. These are common components of laparoscopic cases. There was a hernia repair as well, but this consisted of one suture by the general surgeon involved and clearly did not generate any change in her recovery or status. The patient's vitals were normal the day after surgery.
The American Congress of Obstetricians and Gynecologists (ACOG) outlines criteria for discharge after outpatient procedures, and states vitals need to only be within 20% of baseline. The physician notes on postoperative day 1 suggest a routine postoperative course other than the pain. The management described in the record on the day after surgery included oral pain medication, spontaneous voiding, and tolerating oral diet - these are traditional targets for discharge that appear to have been reached. Again, there is no reference to an unanticipated event or an explanation as to why the patient was not discharged later on postoperative day 1. The next physician note after postoperative day 1 rounds is the discharge on postoperative day 2, where no complication is mentioned. Without such an explanation or extenuating circumstances, the patient qualified for a lower level of care. The inpatient level of care was not indicated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System / Neuromuscular Disorder.
Treatment: Pharmacy/Prescription Drugs.
The insurer denied: Aimovig.
The denial is: Overturned in whole.

The patient is a female. She has chronic migraine headaches. She is treated with Botox and Aimovig for migraine prevention. The subject under review is the medical necessity for Aimovig. 

The health plan's determination is overturned in whole.

The treatment with Aimovig is medically necessary for this patient. In the clinical trials leading to the Food and Drug Administration (FDA) approval of Aimovig patients were excluded if they had been treated with Botox within 4 months. This was part of the control for the clinical trial and does not implicate Botox as a contraindication to Aimovig. Botox is not mentioned as a contraindication in the Aimovig prescribing information. There is no evidence in the current medical literature to indicate that concurrent use of Botox and Aimovig is either unsafe or otherwise contraindicated.
Aimovig (erenumab) is a calcitonin gene-related peptide receptor antagonist indicated for the preventive treatment of migraine in adults. The patient meets this indication.
Per Goadsby et al. (2017): "A total of 955 patients underwent randomization: 317 were assigned to the 70-milligrams (mg) erenumab group, 319 to the 140-mg erenumab group, and 319 to the placebo group." "Erenumab administered subcutaneously at a monthly dose of 70 mg or 140 mg significantly reduced migraine frequency, the effects of migraines on daily activities, and the use of acute migraine-specific medication over a period of 6 months." 

Per Dodick et al. (2018): "In this randomized, double-blind, placebo-controlled, phase 3 study, 577 adults with episodic migraine were randomized to placebo or 70 mg erenumab; 570 patients were included in efficacy analyses. Primary endpoint was change in monthly migraine days. Secondary endpoints were greater than or equal to (>=) 50% reduction in monthly migraine days, change in acute migraine-specific medication treatment days, and >=5-point reduction in Physical Impairment and Impact on Everyday Activities domain scores measured by the Migraine Physical Function Impact Diary. All endpoints assessed change from baseline at month 3." "Conclusions: As a preventive treatment of episodic migraine, erenumab at a dosage of 70 mg monthly significantly reduced migraine frequency and acute migraine-specific medication use." 

There a valid scientific and medical basis for the requested treatment and evidence that the requested service is reasonably safe and effective for this individual under these circumstances. Aimovig is medically necessary for this patient's condition.
Appeal type: Medical necessity
Decision: Upheld

Cardiac/Circulatory Problems
Inpatient hospital

Diagnosis: Hypotension
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a woman who presented to the hospital with a chief complaint of hypotension. According to the patient's daughter, the patient had a low blood pressure reading at home and an episode of syncope. She also reported nasal congestion, weakness, and fever. Her episode of syncope occurred while she was eating food. According to emergency medical services, her blood pressure was 82/54 when they arrived. 

The inpatient stay was not medically necessary. The patient primarily received an outpatient evaluation including EKG testing, cardiac enzymes, chest x-ray, intravenous fluids, and monitoring of blood pressure. There was no indication that more aggressive or invasive therapy was being pursued, such as diagnostic cardiac cath for evaluation of new syncope in the setting of worsening cardiac ischemia. In addition, there were no other significant complications such as sepsis or end organ ischemia. Overall, her presentation of syncope is typically managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse
Issue under review: Inpatient substance abuse treatment 
The insurer denied the inpatient substance abuse treatment.
The denial is upheld. 

The patient is a male who was re-admitted to inpatient level services for continued detoxification treatment, stabilization and withdrawal management of severe opioid use disorder. The patient had initially presented to the hospital emergency department requesting detoxification services in the context of withdrawal symptoms and abnormal vital signs with low blood pressure and bradycardia. He was admitted for detoxification treatment with a methadone taper, but was transferred to intensive care with telemetry due to continued concerns with bradycardia and evidence of a thyroid problem. He received cardiology and endocrinology consults and supportive measures with transfer back for continued detoxification treatment.

The patient in this case was using heroin on a continuous daily basis together with intermittent use alcohol and daily use of tobacco. The patient presented as cooperative and motivated to continue detoxification treatment in the absence of severe symptoms of opioid withdrawal. Mental status examination was free of severe symptoms, and the patient was noted to deny suicidal ideation or aggressive impulses at the time of re-admission. There were no co-morbid general medical problems or co-occurring psychiatric disorders that would have required inpatient level services at the time of re-admission and the patient had received intensive care with cardiology and endocrinology consultation services to address his general medical needs with stabilization of vital signs. Moreover, the withdrawal symptoms were not reported to be severe, and the patient's clinical presentation was not serious enough to warrant the continued inpatient level treatment or 24-hour monitoring. Additionally, the patient did not present with severe psychosocial stressors that would have posed a problem if detoxification treatment was provided in a less restrictive treatment setting at a lower level of care. Thus, the detoxification treatment (and referral/treatment for/with rehabilitation services) could have been effectively provided at a lower level of care, as the health plan asserts. 

Medical necessity is not met in this case for the time interval under review, consistent with prevailing standards of professional practice, published practice guidelines, American Society of Addiction Medicine (ASAM) Criteria, and the scientific literature, referenced below, as well as the clinically appropriate application of NY State OASAS LOCADTR 3.0 Guidelines/Criteria.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin disorders/abscess.
Treatment: Inpatient hospital 
The insurer denied the inpatient hospital stay. 
The denial is upheld in whole .

The patient who presented to the emergency department (ED) at the hospital  with a pilonidal cyst infection of 5-days duration. the patient  had no comorbid health conditions.
No, the inpatient stay was not medically necessary for this patient. this procedure and inpatient stay could have reasonably and safely been performed in the lower level care setting. There are no records that support the need for inpatient care. The patient was clinically stable prior to and following the  operation. A lower level care designation would have reasonably satisfied the clinical needs of this patient.
Generally accepted practice standards support that a reasonable and appropriate goal level of care for this patient would be observation at a lower level. These standards support that in the absence of hemodynamic instability, sepsis or toxicity, significant electrolyte imbalance, bleeding, gastrointestinal (GI) obstruction or surgical complications, the procedure may be performed with a lower level of care. In this case the patient tolerated oral hydration, diet and medication and pain was well controlled. A lower level of care would have appropriately provided for presurgical assessment, pilonidal cyst abscess drainage, and post-surgical monitoring. Inpatient care was not required or medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Legal blindness, diabetic neuropathy and urinary incontinence
Treatment: Increase Personal Care Worker (PCW) Services to six days a week, six hours a day (Tuesday - Sunday); 36 hours per week; Level I PCW Services

The insurer denied the Increase Personal Care Worker (PCW) Services to six days a week, six hours a day (Tuesday - Sunday); 36 hours per week; Level I PCW Services.

The denial is overturned. 

Yes, the proposed treatment of an increase in Personal Care Worker (PCW) Services to six days a week, six hours a day (Tuesday - Sunday); 36 hours per week; Level I PCW Services is deemed medically necessary. 

The patient is a male with a history of legal blindness, diabetic neuropathy and urinary incontinence. Due to impairments related to his various medical conditions, he requires assistance for completion of many of his activities of daily living (ADLs). 

Due to impairments related to his various medical conditions, he requires assistance for completion of many of his activities of daily living (ADLs). Recent documentation from the patient's provider indicates that due to the patient's conditions of progressively worsening visual impairment, diabetic neuropathy and urinary incontinence; he is now totally dependent and requiring the use of incontinence diapers 24 hours/seven days a week and requires assistance changing his diapers, toileting and personal hygiene. Hence, the currently approved plan of personal care worker services three days per week, four hours per day (Tuesday - Sunday) and three days per week, 3.5 hours per week (Friday-Sunday); 22.5 hours per week is insufficient to meet the patient's current needs. For these reasons, the proposed treatment of an increase in Personal Care Worker (PCW) Services to six days a week, six hours a day (Tuesday - Sunday); 36 hours per week; Level I PCW Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems
Treatment: Inpatient Hospital
The insurer denied: Inpatient stay
The denial is: Upheld in whole

The patient is a male with a history of hypertension and cocaine abuse, who presented the hospital with a chief complaint a headache and chest pain for 3 days. The headache was a 6/10 without nausea, vomiting, visual changes, weakness, numbness or tingling. The chest pain was pressure like, rated 5/10, mid sternal without any radiation. He admitted to cocaine use 3 days prior.
Vital signs on presentation showed a blood pressure of 196/122, a pulse of 101, a respiratory rate of 21, a room air pulse oximetry of 99% and he was afebrile. On exam he was in no acute distress, his chest was clear to auscultation bilaterally, his heart showed a regular rate and rhythm, and his neurologic exam was unremarkable. He was diagnosed with hypertensive urgency and admitted for further management and treatment. A head computed tomography (CT) showed intracranial volume loss more pronounced than expected for patient age but no acute intracranial hemorrhage. Labs showed a white blood cell (WBC) count of 8.9, a hemoglobin of 11.4, a creatinine of 1.3, a bicarbonate of 25, and troponin levels of 0.12 and 0.10. His urine drug screen was positive for cocaine and benzodiazepines. An electrocardiogram (EKG) showed normal sinus rhythm, left ventricular hypertrophy (LVH), ST changes likely due to LVH and no significant changes compared with prior EKG. Cardiology was consulted for chest pain and recommended to avoid beta blockers and to arrange for outpatient follow up and echocardiogram. He was started on intravenous fluids (IVF) and his creatinine improved. The patient left against medical advice.

The health plan's determination is upheld in whole.

Based on the documentation provided, the inpatient stay was not medically necessary in this case. The patient presented with headaches and chest pain was found to be hypertensive. The patient did not however, have any documentation of ongoing or impending end organ damage from his elevated blood pressure such as cardiac ischemic, cerebrovascular ischemia, dissecting or ruptured aortic aneurysm, malignant retinopathy, flash pulmonary edema. thrombotic microangiopathy or acute kidney injury. The patient did not require prolonged intravenous (IV) anti-hypertensive medications beyond what could have been provided in an emergency room or observation care setting based on the standard of care. He did not have persistent or severe nausea, vomiting, or changes in mental status. His cardiac, pulmonary and neurologic exams were unremarkable. An EKG, chest X-ray and head CT were also unremarkable. His presentation could have been safely and effectively managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Impacted upper cuspids and upper right central incisor
Issue under review: Cone beam CT capture and interpretation with field of view of both jaws, with or without cranium
The insurer denied the cone beam CT capture and interpretation with field of view of both jaws, with or without cranium.
The denial is upheld. 

This is a female who has been denied a computed tomography (CT) scan. 

There are no clinical records.  There is an appeal form regarding comprehensive orthodontic treatment stating that the reviewer did not take into account the impacted upper cuspids and upper right central incisor. 

No, the proposed CT scan is not deemed medically necessary at this time. 

A patient's medical record should include:
1) documentation of the patient's history;
2) physical examination findings;
3) assessment and diagnosis, including differential diagnosis;
4) all discussions, including the informed consent process before a procedure;
5) the treatment provided; 
6) any plan for follow up, including discharge instructions given to the patient and;
7) note any images taken, and the results/review of the images. 

The key element in the design of this set of parameters for comprehensive evaluation is the professional judgment of the attending dentist, for a specific patient, at a specific time.

The patient's chief complaint, concerns and expectations should be considered by the dentist.

The dentist should perform a comprehensive oral evaluation when indicated by his or her professional judgment.

The dental and medical histories should be considered by the dentist to identify medications and predisposing conditions that may affect the prognosis, progression, and management of the oral health condition.

None of this information is present in the file for review; there are no clinical records to include an evaluation, diagnosis, clinical findings and rationale for treatment and no radiographs.

The CT scan was denied due to lack of clinical information; it is agreed that the proposed CT scan is not supported as medically necessary at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse
Treatment: Inpatient substance use rehabilitation treatment
The insurer denied the inpatient substance use rehabilitation treatment. 
The denial is upheld. 

The patient is an adult male who received detoxification treatment and was then admitted for inpatient rehabilitation and substance use disorder treatment to address longstanding substance use disorders with alcohol and stimulant (cocaine) substance use disorders in remission and opioid (heroin) use disorder with use of up to five bags of heroin daily with inhalation. 

The patient presented with substance use disorders, diagnosed with alcohol and stimulant/cocaine use disorders in remission, and opioid and tobacco use disorders. He readily engaged in treatment and had no biomedical or psychiatric treatment issues that warranted inpatient level care. During the time interval under review, the patient was noted to be in no distress with reasonable functioning and active participation in treatment including positive interactions with staff and peers. Throughout his inpatient stay, there were no complicating treatment issues or biomedical or co-occurring psychiatric issues that would have warranted the inpatient level of care, structure or 24-hour monitoring. The application of NY State OASAS LOCADTR 3.0 Criteria (referenced below) did indicate that the patient was clinically appropriate for treatment with lower level care in a less restrictive treatment setting, as the health plan asserts. Thus, medical necessity for the Inpatient substance use rehabilitation treatment is not met in this case scenario, also consistent with the American Society of Addiction Medicine (ASAM) Criteria, the scientific literature and published guidelines, referenced below.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastrointestinal
Treatment: Inpatient hospital stay
The insurer denied the impatient hospital stay.
The denial is upheld.

This is a patient who presented to the Hospital with abdominal pain, nausea, vomiting and diarrhea. Patient was recently taking Bactrim for a hip abscess. The patient was admitted to the medical floor and treated with conservative management with intravenous fluid hydration and antibiotic therapy. Gastroenterology service consulted. Although the patient remained febrile for days, the patient also remained hemodynamically stable without development of abscess/phlegmon, sepsis, bowel perforation and did not require endoscopic, Interventional Radiology or surgical intervention. The patient did not have suspected severe infection, severe abdominal tenderness, toxic megacolon, hemodynamic instability, severe or persistent vomiting or dehydration, hemolytic uremic syndrome, absent bowel sounds, signs of intestinal obstruction, or require parenteral nutrition and therefore an acute level of care and inpatient admission was not medically necessary.