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

The patient has a past medical history of hypertension (HTN). The patient presented to the emergency department (ED) with substernal chest pain, pressure-like, radiating to both shoulders and worsened with deep inspiration. The pain started one week before the presentation. It was associated with shortness of breath, nausea, and vomiting. The patient took aspirin at home without relief. The patient also reported watery diarrhea and leg swelling. The patient stopped the blood pressure (BP) medication amlodipine one month ago. The patient was given Aspirin and Clopidogrel in the ED. The patient was admitted to the hospital and received intravenous (IV) Lasix and Lovenox. The patient underwent a computed tomography angiography (CTA) to rule out pulmonary embolism (PE), and it was negative. The patient's condition was stable. 

The health plan's determination is upheld. The inpatient stay was not medically necessary. The Acute Inpatient Hospital Admission was not medically necessary for this patient. The patient presented with chest pain and was not compliant with the BP medication. The BP was elevated initially but responded well to oral antihypertensive medications. The elevated BP was due to non-compliance and was managed with oral medications. That supports a lower level of care.

The patient presented with chest pain. The cardiac enzymes were harmful, and the ECG did not reveal any ischemic changes. The workup for pulmonary emboli was negative. Chest pain syndrome could have been managed at a lower level of care. The Inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

The patient has a history of hypertension, diabetes, chronic obstructive pulmonary disease (COPD) on home oxygen, and metastatic lung cancer who presented to the hospital with a chief complaint of shortness of breath, wheezing and coughing.  The patient was discharged one week ago for COPD exacerbation but reported that her shortness of breath had worsened.  The patient also had a mechanical fall and struck her head while preparing to go to the hospital.  The patient was unsure whether the patient lost consciousness.  The patient denied fevers, chills, nausea, vomiting and chest pain. On physical examination, the patient was tachypneic, heart was regular, breath sounds had wheezing and decreased air movement, abdomen was soft.  Vital signs showed blood pressure 144/103, heart rate 85, temperature 98.3 Fahrenheit, respiratory rate 18, and oxygen saturation 98%. Labs showed D dimer 509, troponin negative, BNP 23.5, white blood cell (WBC) 10.1, hemoglobin 12.5, platelets 244, creatinine 0.63, and calcium 9.3. Head computed tomography (CT) was negative for intracranial bleed but showed a scalp hematoma.  Chest CT angiography was negative for acute pulmonary embolus.  The patient was admitted for a suspected acute COPD exacerbation. The plan of care included bronchodilators, steroids, supplemental oxygen as needed, antibiotics, Treatment of hypertension, and continue other home medications. The inpatient stay is under review. 

The health plan's determination is overturned.  The inpatient stay is medically necessary. The patient presented with worsening shortness of breath in the setting of lung cancer and required bronchodilators and steroids for acute COPD exacerbation. Patients with COPD exacerbations are at increased risk of having rapid decline in their respiratory status, and these patients are at increased risk of needing mechanical ventilation. This is particularly heightened in patients with lung cancer.  Patients like this require closer monitoring and are not typically managed at a lower level of care because of the risk of worsening organ failure and the need for aggressive IV antibiotics, respiratory support, and nebulizer therapy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right hand pain
Treatment: Inpatient admission

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

The patient is a female with a past medical history pertinent for prior right upper extremity deep venous thrombosis (DVT), Tourette's syndrome s/p placement of deep brain stimulator and anxiety who presented to the ER for further evaluation/management of right hand swelling, pain and coolness. 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, neurologic or vascular abnormalities. Laboratory, ECG testing and imaging 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, analgesics and Benadryl. 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 has a Class I occlusion with appropriate overjet and a slightly deep bite. The maxillary arch has some spacing, and the mandibular arch has some crowding. The patient's treatment planned for 24 months of orthodontics to correct the malocclusion.

The health plan's determination is upheld. The Braces: Comprehensive Orthodontic Treatment is not medically necessary for this patient.

There is no medical reason to correct the mild crowding with braces. The patient does have a mild deep bite, however, that alone is not a medical necessity to treat. There are many ways to correct patients with a deep bite and retroclined incisors, and there is strong evidence that one treatment is not better than another. Furthermore, deep bites may be corrected in adulthood, so it is not as if the patient will lose the ability to correct the malocclusion should the patient choose to do so as an adult.
Appeal type: Medical necessity
Decision: Upheld

The patient has a history of dementia, anemia, hypertension, and dyslipidemia who is requesting an increase in personal care assistance from 18 hours per week to 30 hours per week. The medical documentation  states that the patient has been receiving care from a home attendant and also attends a nearby adult day care program. The patient needs assistance with bathing and dressing. In addition, it states that the patient receives help from the patient's daughter and another family member to provide an evening meal and assist with personal hygiene. Patient is dependent across all instrumental activities of daily living including transportation, meal preparation, housekeeping, and medication management. Also requires assistance for bathing, dressing, eating, and toileting. Uniform Assessment System-New York Comprehensive Community Assessment Report.The summary of the report shows that a total of 2.52 hours of assistance per day is needed for activities of daily living. It is not medically necessary. The assessment form demonstrates that the amount of assistance needed by the patient for medical activities is fulfilled by the amount of time that has previously been allocated. There does not appear to be a significant change in the patient's medical needs relative to the period before the assessment was performed. The Comprehensive Community Assessment Report from incorporates the patient's current activities and limitations and impairments. Therefore there does not appear to be a basis for increasing the amount of support. The HP determination is upheld in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Depression, Suicidal ideation
 
Treatment:  Mental Health Inpatient Admission

The insurer denied the Inpatient Admission.  The denial was upheld.   

This is a young female patient who was admitted to a facility for treatment for her depression and suicidal ideations.  Her symptoms on admission include depressed mood, tearfulness, decreased need for sleep, increased social interaction.  She has a history of cutting her legs with a razor.  She was treated with individual, group, and family therapy.  It was reported that the patient was non-compliant with her medication during her hospitalization.  The patient requested to be discharged from the facility.

The insurer denied coverage for inpatient mental health treatment.  They stated that she did not present as an imminent danger to self or others and did not need acute psychiatric hospitalization, and they recommended a less restrictive level of care.

This reviewer agrees with the decision to deny coverage for inpatient mental health treatment in this hospital, as the chart notes did not provide enough specific evidence to support that she was an imminent danger to herself and could only be treated in a 24-hour acute psychiatric hospitalization then.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Major Depressive Disorders reports that the least restrictive level of care for safe and effective treatment is appropriate and that patients with suicidal plan or intent or behaviors, or inability to adequately care for basic needs are candidates for hospitalization.  This patient reportedly had suicidal ideation on admission with depressed mood, tearfulness, and sleeping issues, but she did not have reports of suicidal plan or intent.  She had a reported history of self-injurious behavior but no reported suicide attempts. 

Based on the above, the medical necessity for the inpatient admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

The patient has a complex medical history: velocardiofacial syndrome, pulmonary atresia with ventricular septal defect status post right ventricle to pulmonary conduit and ventricular septal defect (VSD) repair, chronic lung disease with baseline supplemental oxygen requirement, gastroesophageal reflux disease, asthma, right main stem bronchomalacia, and hypoparathyroidism. The patient presented to the ED with persistent shortness of breath and wheezing, and Pulmonary recommendations for admission for continuous positive airway pressure (CPAP) trial. Vital signs included temperature 37.3, heart rate 114, respiratory rate 38, and 96% saturation in room air. Examination was significant for non-toxic appearance, no distress, moist mucous membranes, grade 4/6 continuous systolic murmur, tachypnea, decreased breath sounds bilateral bases, no wheezing, no accessory muscle usage, and non-focal neurologic exam. Chest x-ray was obtained and was unchanged from previous. Respiratory panel was negative. The pulmonologist was contacted; and had already made arrangements for the patient to be admitted to the Pediatric Intensive Care Unit (PICU) with acute on chronic respiratory insufficiency for CPAP trial.

The health plan's determination is overturned. The inpatient stay was medically necessary. This patient bears the diagnosis of velocardiofacial syndrome with many organ systems affected. The patient has history of complex congenital heart disease that has been repaired, chronic respiratory insufficiency with unilateral bronchomalacia and asthma, gastroesophageal reflux disease, and hypoparathyroidism. She was hospitalized with pneumonia, and thereafter had worsening respiratory symptoms with increasing respiratory distress. The patient was hospitalized because of distress with plans to trial CPAP should the acute on chronic respiratory insufficiency and respiratory distress persist. The mother was administering albuterol almost continuously as well as all of the child's routine respiratory medications, including increased doses of some medications and systemic steroids. Despite aggressive home management the patient continued to worsen. The patient was taken to the ED at the point that the patient was having difficulty sleeping due to respiratory distress. The patient was subsequently admitted to the PICU for CPAP trials. It took several days of hospitalization to fine-tune the settings, establish optimal management, and arrange for home equipment. This patient failed aggressive outpatient management of the acute on chronic respiratory insufficiency, necessitating admission for introduction of non-invasive ventilatory support with CPAP. This level of care is most consistent with acute inpatient management.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left Atrial Appendage Closure with the WATCHMAN Device

Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld.

This is a male patient who presented to the hospital for an elective WATCHMAN procedure. It was reported that the patient was not currently on anticoagulant medication due to an episode of neck bleeding while on Xarelto. He has a medical history of atrial fibrillation with rapid ventricular response, (status post automated implantable cardioverter defibrillator (ICD), implanted approximately 9 years earlier), congestive heart failure (CHF), hypertension, hyperlipidemia, insulin-dependent diabetes, obstructive sleep apnea and chronic kidney disease. The procedure was performed without complications. He was monitored on telemetry overnight and then discharged home.

This was an elective procedure which is done on an outpatient basis, with up to 23 hours of observational level of care.  During the initial presentation and subsequent clinical course, there was no evidence of any organ system dysfunction warranting acute inpatient admission status.  The patient's care could have been rendered in the outpatient or observational setting.  The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.

Based on the above, the medical necessity for the inpatient hospital admission  is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

The case involves a patient admitted to acute inpatient psychiatric services for bizarre behavior associated with verbal aggression towards the family.  The patient had shown increasing symptoms of psychosis that included bizarre and erratic behavior together with motor agitation and increasing responses to internal stimuli.  The family called emergency response, and the patient was brought to the emergency department and was subsequently admitted after medical clearance that included physical examination, laboratory assessment and drug screen.  The assessment included no abnormal or remarkable laboratory findings including a negative drug screen consistent with his history.  The health plan's determination of medical necessity is overturned.  The patient's admission and continued treatment is reasonable and in the best interest of the patient.  The patient had severe symptoms of psychosis and agitation with responses to internal stimuli that were associated with erratic and problematic behavior.  The case was complicated by medication non-adherence and decline in functioning.  The patient had deteriorated to the point that he was a safety risk due to the erratic and bizarre behavior, and outpatient treatment had failed to prevent the worsening of the  psychiatric disorder precipitated by medication non-adherence.  The patient could not have been safely or effectively managed during the time interval under review at a lower level of care or in a less restrictive treatment setting.  Thus, medical necessity is met in this case scenario with prevailing standards of medical practice consistent with the scientific literature and practice guidelines.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Arthritis
Treatment: Hyaluronan injection

The Hyaluronan injection is medically necessary.

Various formulations of hyaluronan injections are FDA-approved for the treatment of knee osteoarthritis, as seen in this specific patient.  This patient has failed treatment with numerous other appropriate conservative modalities (i.e., physical therapy, multiple NSAIDs and steroid injections), and has responded favorably to repeat courses of viscosupplementation with hyaluronan injections for a few years.  

Although there is discrepancy among evidence in the literature to support of the widespread use of intra-articular hyaluronic acid (IAHA) to treat knee osteoarthritis in clinical practice, a 2019 literature review advocates, "for the consideration of recommending IAHA injection as a treatment option in the management of knee OA, tailored by disease stage and patient phenotype."  Furthermore, in a 2016 network meta-analysis of the relevant literature to determine if there is a benefit from IAHA, "those participants receiving IAHA were 15% and 11% more likely to respond to treatment ... than those receiving intra-articular steroid or intra-articular placebo, respectively (p<0.05 for both)."  Thus, the American Medical Society for Sport Medicine recommends the use of IAHA "for the appropriate patients with knee OA."  

Continued treatment with hyaluronan injections in this specific patient with knee osteoarthritis who has failed other modalities and is responding well to this therapy is clinically appropriate and in accordance with standard of care in the rheumatology community.  Discontinuation of hyaluronan injections continues to put this patient at unnecessary risk of arthritis flare.
Appeal type: Experimental/Investigational
Decision: Overturned

The patient is a male who presented with decompensated congestive heart failure. Cardiac catheterization performed showed severe three vessel coronary artery disease with a left ventricular ejection fraction (LVEF) of 10%. Cardiac magnetic resonance imaging (MRI) performed showed nonviable basal inferior and basal inferolateral walls; the remainder of the myocardium was viable. The patient's LVEF was 12%. He underwent coronary artery bypass graft surgery. A LifeVest wearable cardioverter defibrillator (WCD) was prescribed postoperatively. 
The subject under review is whether the requested LifeVest was likely to be more beneficial for the patient than other standard treatment for the patient's condition. 

The health plan's determination is overturned.

Yes, the treatment with a wearable cardioverter defibrillator (WCD), in this instance, was likely to be more beneficial than any other standard treatment.
Depressed left ventricular systolic function is a risk factor for, and powerful predictor of, sudden arrhythmic death. Consequently, implantation of an implantable cardioverter defibrillator (ICD) for the primary prevention of sudden cardiac death is a widespread practice, proven to be beneficial to heart failure patients with a variety of cardiac diagnoses. Current guidelines support ICD implantation in patients, such as this patient, with ischemic cardiomyopathy and left ventricular ejection fractions of 35% or less. However, due to the possibility that left ventricular function may improve with revascularization, it is recommended that device implantation be delayed for at least 90 days following coronary artery bypass graft surgery or percutaneous coronary intervention. If, 90 days post-revascularization, the LVEF remains less than or equal to 35%, ICD implantation is then recommended. However, the degree to which revascularization mitigates the risk for serious ventricular arrhythmias during this 90 day period is unclear. Accordingly, many physicians prescribe the LifeVest wearable cardioverter defibrillator (WCD) as a "bridge" to potential ICD implantation in these patients. The efficacy of the WCD in terminating serious ventricular arrhythmias compares favorably to that of the implanted device. In one large retrospective study of patients with left ventricular ejection fractions less than or equal to 35% after coronary artery bypass graft surgery (CABG) or percutaneous intervention, the WCD was associated with a lower 90-day mortality in patients after CABG (no WCD: 7% vs WCD: 3%) and after PCI (no WCD: 10% vs WCD: 2%). No other therapies, including antiarrhythmic drugs, have been shown to decrease the risk of sudden cardiac death after revascularization. Per the 2016 Science Advisory from the American Heart Association, use of the WCD in cases such as this one is a reasonable approach. The medical literature supports the use of the WCD in this instance.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Type 1 Diabetes Mellitus
 
Treatment: Sensors, Transmitter, and Receiver for use with a Continuous Glucose Monitoring System

The insurer denied the Sensors, Transmitter, and Receiver for use with a Continuous Glucose Monitoring System. The denial was reversed.    

This is a young female patient who was recently hospitalized for diabetic ketoacidosis resulting in a diagnosis of Type I Diabetes Mellitus. She was discharged home on insulin management. She has a history of acne, scoliosis, and irregular menses. Due to her new onset diagnosis she was forced to withdrawal from college. The patient was experiencing fluctuations in her blood sugars and was started on a glucose monitoring device and transmitter.  This allowed her the ability to manage her blood sugar promptly alleviating emergent conditions. The implementation of this device has improved the patient's blood sugars and management of her disease.

The medical literature notes that usage of real time continuous glucose monitoring reduces the number of hypoglycemic events in individual with type 1 diabetes who are treated with multiple daily insulin injection. The patient has had improvement in blood sugar control since utilizing the continuous glucose monitor. The patient had uncontrolled diabetes prior to the use of the continuous glucose monitor. Therefore, the requested sensors, transmitter, and receiver for use with a continuous glucose monitoring system were medically necessary.

Based on the above, the medical necessity for the sensors, transmitter, and receiver for use with a continuous glucose monitoring system is substantiated. The insurer's denial is reversed.