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

Diagnosis: Right leg weakness
Treatment: Inpatient admission

The proposed treatment of inpatient admission is not deemed medically necessary. 

The patient is a female with a history of chronic low back pain and lower extremity sciatica who presented to the emergency department (ER) for further evaluation/management of right leg weakness. 

Intake vitals were noted to be afebrile, hemodynamically stable. Examination was non focal with no significant abnormalities noted. Laboratory and electrocardiogram (ECG) testing was also within normal limits with no significant abnormalities noted. Imaging studies revealed no critical findings. The medical records indicate that this patient was admitted to the inpatient medical service in stable condition where she received pain management with lidocaine patch and oral morphine. She was otherwise continued on her prior outpatient pain medication regimen of gabapentin, diclofenac and tizanidine. She responded well to the prescribed therapies and was subsequently discharged in stable condition. 

This is a female with a history of chronic low back pain and lower extremity sciatica who presented to the ER for further evaluation/management of right leg weakness. Intake vitals were noted to be 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. Laboratory and ECG testing was also within normal limits with no significant abnormalities noted including no evidence of acute end organ damage. Imaging studies revealed no critical findings. The medical records indicate that this patient was admitted to the inpatient medical service in stable condition where she received pain management with lidocaine patch and oral morphine. She was otherwise continued on her prior outpatient pain medication regimen of gabapentin, diclofenac and tizanidine. 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. For these reasons, the proposed treatment of inpatient admission is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

The patient is a female who was admitted to the inpatient mental health level of care due to acute psychosis with thought disorganization and disorganized behavior.  The patient also stated that she has been using multiple substances and exhibited paranoia, per the patient's mom.
The patient was on Olanzapine 17.5 milligrams (mg).  The patient had no active suicidal ideation with plan, homicidal ideation with plan or command hallucinations.  The patient was not physically aggressive, acutely manic or sexually inappropriate.  The patient was not catatonic.  The patient had no significant medical instabilities.  There was no indication the patient is at risk for life threatening withdrawal.  The patient had no required emergency medications, restraints or seclusions in the previous 24 hours.  The patient was noted to be attending groups and activities with participating and was calm.  The patient's mood was stable.  The patient was in behavioral control.  The patient is compliant with medications.  She had adequate sleep, appetite and activities of daily living (ADLs).
The patient continued to not be an imminent risk concerns.  The patient was guarded and had an episode of putting Vaseline on her face as lotion, and there was concern for thought disorganization, but the patient had no active suicidal ideation with plan, homicidal ideation with plan, or command hallucinations.  The patient was not physically aggressive, acutely manic or sexually inappropriate.  The patient was not catatonic.  The patient had no significant medical instabilities.  There was no indication the patient was at risk for life threatening withdrawal.  The patient had no required emergency medications, restraints or seclusions in the previous 24 hours.  Through discharge the patient had no imminent risk concerns.  The patient stepped down to a Partial Hospitalization Program (PHP) level of care.
The health plan's determination is upheld. 

The inpatient mental health treatment for the dates of service under review was not medically necessary for this patient.
The patient had no active suicidal ideation with plan, homicidal ideation with plan or command hallucinations.  The patient was not physically aggressive, acutely manic or sexually inappropriate.  The patient was not catatonic.  The patient had no significant medical instabilities.  There was no indication the patient was at risk for life threatening withdrawal.  The patient had no required emergency medications, restraints or seclusions.  The patient was not presenting as an imminent risk to self or others to warrant an inpatient level of care, and it was not medically necessary for the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Gastroesophageal Reflux disease /GERD
Treatment:  Inpatient Hospital 

This is a patient who presented with complaints of 4 to 5 episodes of emesis in one day associated with symptoms of rhinorrhea and sneezing.  There was no fever or diarrhea.  Emesis was non-projectile and occurred with every feeding.  It was described as a moderate amount.  The physical examination was unremarkable.  The patient was given one bolus of IV fluid.  The health plan's determination is upheld in whole.  There were no significant physical findings on examination to suggest dehydration.  All work up, including a pyloric US to rule out pyloric stenosis, was negative.  The management  received included a formula change and thickening of the feeds. This patient did not require any highly skilled or technical care to manage  safely.  The patient did not have any physical findings of significant dehydration at presentation.  The patient did not demonstrate any weight loss, only poor weight gain.  The patient also had mildly elevated LFTs.  An ultrasound (US) was ordered to investigate.  The vital signs remained stable throughout the  hospital stay.  This patient could have been managed at a lower level of care with the IV fluid bolus and a PO trial of the new thickened formula with subsequent discharge and follow up as an outpatient.  This patient did not require any highly skilled or technical care to manage.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse

Treatment: Inpatient substance abuse 

 The insurer denied coverage for inpatient substance abuse. The denial was reversed.

This patient is a male who was admitted to this inpatient substance detoxification treatment due to substance detoxification treatment. He had withdrawal symptoms including tremors, nausea, vomiting, sweats, diarrhea, teary eyes, runny nose, anxiety, irritable mood, yawning, and had a Clinical Opiate Withdrawal Scale (COWS) and Clinical Institute Withdrawal Assessment of Alcohol (CIWA) of 11. He reportedly was using 8-10 bags of intravenous (IV) heroin per day for more than 2 decades, drinking alcohol, and smoking cannabis 3-6 times per week for more than 3 decades.

The insurer denied coverage for inpatient substance detoxification treatment as not medically necessary treatment. They stated that he had mild withdrawal, no medical or mental health condition requiring 24 hour inpatient treatment, and they recommended a less restrictive level of care.

This reviewer disagrees with the decision to deny coverage for inpatient substance detoxification treatment. The chart notes provided enough specific evidence to support that he required this level of care. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment.

In this case this patient had been using large amounts daily of intravenous (IV) heroin daily including up to 10 bags per day, and was using alcohol and cannabis. According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) he did require 24 hour treatment as he could not safely and effectively be treated in outpatient detoxification settings as he continued to use multiple serious substances daily despite reports that he had past inpatient substance detoxification treatments. As, it was reported, he had multiple past inpatient substance detoxification treatments in the past several years.

As a result, the determination is to reverse the previous decision and approve coverage for inpatient substance detoxification. The health care plan did not act reasonably with sound medical judgment in the best interests of the patient.  

The carrier's denial of inpatient substance abuse is reversed. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Alcohol Dependence

Treatment: Inpatient substance detoxification Admission

The insurer denied the Inpatient Admission. The denial was modified: Approved for specific days and denied for specific days.

This is a middle aged female who was admitted to inpatient substance detoxification treatment in early 2019. She was noted to have been drinking four 24 once beers per day. She had a history of alcohol dependence, nicotine dependence, inpatient detoxification treatment, and hypertension. Her withdrawal symptoms included trouble sleeping, anxiety, joint pain, tremors, and sweating. Her Clinical Institute Withdrawal Assessment for Alcohol (CIWA) Scale and Clinical Opiate Withdrawal Scale (COWS) scores were 8.  During her admission she was treated with Librium detoxification protocol.  She reportedly lacked coping skills for sobriety and the ability to identify relapse triggers. The patient successfully completed detoxification and was discharged. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders report that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment.  In this case this patient still had reports of alcohol withdrawal symptoms and required and received continued Librium detoxification medication to modify withdrawal and prevent severe, complicated, or life threatening withdrawal then so she required continued inpatient detoxification treatment.

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) she did require 24 hour treatment as he could not safely and effectively be treated in outpatient detoxification settings as she continued to use alcohol despite past inpatient detoxification treatment,  and needed she detoxification medication to modify withdrawal and needed 24 hour treatment then as she was at risk for worsened withdrawal symptoms if not in this 24 hour setting then including severe and life threatening withdrawal symptoms.

The carrier's denial of coverage for inpatient hospital services is modified. Approved for specific days and denied for specific days.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endometriosis 
Treatment: Orilissa 

The proposed treatment is medically necessary since the patient has tried NSAIDs, Tylenol without relief of her pain. She has tried and failed use of oral contraceptives to manage her pain. She is not a candidate to use any of the other hormonal agents, such as danazol and Synarel, because of her history of deep vein thrombosis (DVT) treated with anti-coagulation therapy and these medications are associated with clot formation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Type II diabetes, HTN (hypertension) and mixed hyperlipidemia
Issue under review: Repatha

Determination:
The Repatha is not medically necessary.

The patient is an elder male with a history of type II diabetes, HTN (hypertension) and mixed hyperlipidemia. There is no history of CAD (coronary artery disease). There is no history of CVA (cerebrovascular accident). There is no history of abnormal stress test, catheterization or coronary CT. There is no history of familial hypercholesterolemia. The patient had myalgia with the use of statins. He is currently maintained on Zetia with LDL (low density lipoprotein) that is above goal. The use of Repatha was requested for LDL control.

Repatha is indicated as an adjunct to diet and maximally tolerated statin therapy for the treatment of adults with heterozygous familial hypercholesterolemia (HeFH) or clinical atherosclerotic cardiovascular disease (CVD), who require additional lowering of low density lipoprotein cholesterol (LDL-C). Currently, it does not have an FDA indication for treatment of mixed hyperlipidemia in patients without clinical atherosclerotic cardiovascular disease (CVD). There is no approved FDA indication for treatment of mixed hyperlipidemia in patients with diabetes with no history of clinical atherosclerotic cardiovascular disease. 

There is no sufficient medical or scientific evidence to determine the benefit in patients such as this one, as the medication has not been studied in this population. This patient had no history of myocardial infarction, acute coronary syndrome, stable or unstable angina, CVA or TIA (transient ischemic attack), peripheral or coronary revascularization, and thus does not meet the criteria for clinical atherosclerotic cardiovascular disease. The effect of Repatha on cardiovascular morbidity and mortality in such patients has not been determined. Therefore, the medical necessity of using Repatha in this clinical scenario could not be established.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a past medical history of dementia, hypertension, anxiety and depression. The patient lives in a split level home. The patient was approved for 24 hour/day, split shift personal care aide (PCA) services but following the  assessment tool, it was noted that there had been a mistake and the patient was approved for 24 hour/day PCA services (not in split shift). Her son appealed this decision and the health plan denied the appeal. The son again appealed the decision and there was a letter from the health plan stating that the patient's overnight needs are for oversight and supervision which are not a covered service but are covered under the diversion waiver program. The patient does not require positioning overnight and does wear a pull-up which may be checked overnight to see if soaked but the patient is not transferred to the toilet overnight. The patient's assessment tool  indicated the patient needed total assistance with meal preparation, ordinary housework, managing finances, and equipment management. The patient needed maximal assistance with phone use, stairs, transportation, bathing, dressing upper/lower extremities and toilet use. Extensive assistance was required for personal hygiene and limited assistance with toilet transfer. The patient needed supervision only for walking, locomotion and bed mobility. At issue is the medical necessity of personal care aide services- 168 hours per week.
The health plan's determination is upheld. The requested health service/treatment of personal care aide services- 24 hour/day, in split shifts, to total 168 hours per week is not medically necessary. The patient has the diagnoses of dementia and anxiety and has limitations in activities of daily living (ADLs) and instrumental activities of daily living (IADLs) due to these medical conditions and her age. The patient does not have specific overnight tasks or ADLs requiring PCA services. The patient does not require frequent positioning or incontinence care overnight. The PCA would be able to have 5 hours of uninterrupted sleep during a 24 hour period of time. Oversight supervision and stand alone tasks are not covered PCA services. The health plan did indicate these tasks would be covered under a waiver program.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Central Nervous System/Neuromuscular disorder
Treatment:  Inpatient hospital

The patient is a male with past medical history of hypertension, back surgery and recently diagnosed atrial fibrillation on Eliquis who had recently been hospitalized at outside hospital for stroke symptoms and was told he had narrowing of the blood vessel to the brain (per patient words to triage nurse in ED).  He presented to emergency department with a two week history of intermittent left sided burning and a 30 minute history of facial burning radiating down the left arm and left leg similar to when he had previous stroke.  The inpatient stay is under review.

The health plan's determination is overturned.  The inpatient stay is medically necessary.  The patient's presenting symptoms and prior history were concerning for possible severe neurologic event such as a stroke.  The patient had reported prior history of neurologic event and some sort of abnormality of the blood vessels of the head and neck.  He had history of atrial fibrillation, as well, making him more at risk for an embolic event.  The patient required inpatient monitoring with frequent neurologic and vital sign checks given the severity of his symptoms.  The patient had urgent consultation with neurology to determine next steps in evaluation of his symptoms given his prior history.  MRI of the brain subsequently showed abnormality suggesting significant stenosis of the vertebral-basilar arterial system.  Neurosurgery consultation then recommended further imaging to rule out severe vertebral basilar artery disease/stenosis.  The patient's severity of symptoms at admission (new neurologic symptoms in the setting of reported neurovascular disease) were appropriate at inpatient level of care.  The patient's intensity of care at the time of admission were appropriate at inpatient level of care.  Per neurology GRG general recovery care 23rd edition, the patient had neurologic condition, symptom or finding for which emergency and observation care have failed or are not considered appropriate.  In summary, the inpatient hospital stay was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Cardiac/Circulatory Problems
Inpatient Hospital

The patient is a male with a history of hypertension, hyperlipidemia, cigarette smoking and coronary artery disease. He presented to the emergency department complaining of several days of intermittent chest pain, dyspnea and lightheadedness. His blood pressure was 149/98 millimeters of mercury (mmHg) with a heart rate of 79 beats/minute. His respiratory rate was 20/minute with a room air oxygen saturation of 99%. His cardiac and respiratory physical exams were unremarkable. His electrocardiogram and serum troponin level were normal. He was treated with aspirin and clopidogrel and admitted to the hospital. His repeat troponin level was normal. He had an episode of chest pain with no associated electrocardiographic changes. His pain resolved with alprazolam. Cardiac catheterization was performed which showed nonobstructive disease. There was moderate plaque in the left anterior descending and right coronary arteries. The procedure was uncomplicated, and the patient was discharged. Medical necessity for an inpatient admission is at issue.

The health plan's determination is upheld.
An inpatient stay was not medically necessary. This patient, with known coronary artery disease, presented with symptoms that were thought to be suspicious for acute coronary syndrome (ACS). Accordingly, monitoring until ACS could be ruled out was a reasonable approach. On the other hand, he was hemodynamically stable, with normal cardiac biomarkers, and a normal electrocardiogram. He did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received did not require an inpatient admission and could have been provided under a lower level of care status. This approach has been shown to be both safe and is in accordance with the 2014 American Heart Association (AHA)/American College of Cardiology (ACC) Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes.
Appeal type: Medical necessity
Decision: Upheld

Back pain
Inpatient hospital stay

This is the case of a patient with a past medical history of hyperlipidemia (HLP), nephrolithiasis, osteoporosis, appendectomy, hysterectomy, and C-section x2, who presented to the emergency department  with flank pain. Patient endorsed dysuria and vomiting and denied fevers, chills, chest pain, shortness of breath, or other complaints.  A urinalysis was noted to be negative for infection. A computed tomography A/P showed 2mm left renal stone without hydronephrosis. Patient was given Morphine, Toradol, Percocet, Robaxin, and intravenous fluids without relief and was subsequently brought into the hospital with an assessment of  intractable pain and plans for pain management, physical therapy, and CT lumbar spine.
CT lumbar spine showed spinal canal stenosis with disc bulge at lumbar (L)3-L4, L4-L5, and L5-Sacral (S)1.
The patient was seen by PT, pain was better managed, and she was subsequently discharged. The health plan's determination is upheld in whole. This is a patient who presented with back pain and an initial concern for nephrolithiasis that was refractory to pain medications in the emergency department. Patient was treated with pain medications, ultimately determined to have pain secondary to lumbar disc disease, and discharged home. Patient was appropriate for a lower level of care in the setting of ongoing pain despite multiple attempts at pain control in the ER, but did not have any symptoms or a diagnosis felt to be high risk or meeting medical necessity for inpatient treatment. Specifically, patient did not have evidence of infected stone, urinary or bowel symptoms suggestive of cauda equina, other process requiring emergent surgical treatment, or abnormal labs or imaging expected to require extensive further work-up or treatment beyond a reasonable period.