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

Diagnosis: Stroke with right-sided weakness
 
Treatment: Continued inpatient subacute rehabilitation

The insurer denied coverage for continued inpatient subacute rehabilitation. The denial is reversed. 

This patient is a female with a past medical history of hypertension, hyperlipidemia, gastroesophageal reflux disease, type 2 diabetes, stress incontinence, peripheral vascular disease, obesity, glaucoma, status post bilateral cataract surgery, MCL, recurrent falls, and recent stroke with right-sided weakness in mid-2019. The patient was admitted to the subacute rehabilitation in late 2019. The patient was admitted for muscle weakness, decreased range of motion, the need for assistance from others for transfers, activities of daily living, ambulation, and difficulty walking.  While in the facility, the patient underwent physical therapy, Occupational Therapy, and speech therapy.  The patient was treated with medications during the rehabilitation.  It was further stated that after treatment and once medically stable, the patient was cleared for discharge to home with home care services and follow-up with the primary care doctor.

The insurer denied coverage for the continued inpatient rehabilitation stay. The appeal noted that the patient required extra stair training with 15 steps of stairs at home and she was Moderate Assist. The patient has a past medical history of hypertension, hyperlipidemia, gastroesophageal reflux disease, type 2 diabetes, stress incontinence, peripheral vascular disease, obesity, glaucoma, status post bilateral cataract surgery, MCL, recurrent falls, and stroke with right-sided weakness. The patient was still noted to need a moderate assist with activities of daily living (ADLs) and needed further physical therapy for weakness as well as continued monitoring of uncontrolled medical conditions as noted. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.  

The continued inpatient subacute rehabilitation stays was medically necessary for this patient. The carrier's denial of coverage for the continued inpatient subacute rehabilitation stays is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope 

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission. The denial is upheld. 

This patient is a woman had a history of stroke several years ago with patent foramen ovale closure at that time, syncope evaluated with Holter monitor and then electrophysiology studies which were unremarkable with no interventions performed other than implantation of a mechanic recorder, and mild asthma.  Home medications included cleocin, Percocet and aspirin.  While shopping with her companion dog she had an episode of loss of consciousness without prodrome and with her fall broken by her companion dog, suffering no injuries.  Bystanders related that the episode lasted approximately four minutes. 
On arrival in the emergency department (ED) vital signs included blood pressure 116/79, heart rate 80, respiratory rate 16, temperature 99.10F, and oxygen saturation on room air 97%.  EKG revealed normal sinus rhythm and was normal, as was chest x-ray.  Laboratory test results included white blood cell (WBC) count 8.5, hemoglobin 13.0, creatinine 0.7, BNP 21 and troponin <0.01, with subsequent  troponin level. She was treated with 1 liter intravenous saline bolus in the ED.  Echocardiogram was normal and she was seen by electrophysiology on that day who interrogated her loop recorder, found no arrhythmias, and felt that her syncope was related to hypotension.  
There is no evidence that this patient was at increased risk for short term adverse cardiovascular events requiring inpatient monitoring and management based on her clinical presentation and results of testing which was or could have been performed in the ED or at an observation level of care.  The healthcare plan acted reasonably, with sound medical judgment and in the best interest of the patient.   

The carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status asthmaticus 

Treatment: inpatient admission

The insurer denied coverage for inpatient admission. The denial is reversed. 

This patient is a male with a previous history of asthma and a previous hospital admission. The patient had been sick with a cough for several days. There were sick contacts in the home.  When the child developed difficulty breathing and wheezing at home the mother administered albuterol.  When there was no improvement in his shortness of breath the mother called an ambulance and he was taken to the Emergency Room (ER).

In the ER he was noted to be in respiratory distress with evidence of increased work of breathing and wheezing.  His heart rate was elevated and his respiratory rate was 45.  The ER physicians noted an increased work of breathing with wheezing and belly breathing.  He was treated with 4 treatments with albuterol and atrovent and decadron.  When there was no improvement in his respiratory distress and wheezing the decision was made to admit him to the hospital with a diagnosis of status asthmaticus for ongoing treatment with albuterol every 3 hours.  

The insurer has denied the admission as not medically necessary and indicated that there was no documentation in the medical record to support the need for inpatient treatment.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The hospital admission is considered medically necessary for this patient.

The patient was treated appropriately in the ER for a cough, wheezing and respiratory distress. When there was ongoing respiratory distress with wheezing and increased work of breathing, it was appropriate and consistent with the standard of care to admit him to the hospital for ongoing treatment with albuterol every 3 hours.  He was not stable enough to be sent home since the need for frequent albuterol administration could not have been safely administered in the home. 

Based on the above, the medical necessity for the hospital admission is substantiated.  The insurer's denial is reversed
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Occipital neuralgia
Treatment: Occipital nerve stimulation
The health plan should cover the Occipital nerve stimulation (64575, 64590, 95972, 76000, 64555).

The use of occipital nerve stimulator trial followed by permanent implant in the case of positive trial results is medically appropriate and standard of care and has been well studied and accepted within the functional neurosurgery community. The planned stage procedure is appropriate to better assess whether the patient will have adequate relief to warrant permanent placement. The overall surgical plan and the surgical candidate are both appropriate for this treatment option.

The Occipital nerve stimulation (64575, 64590, 95972, 76000, 64555) is likely to be more beneficial.

Other treatments for this, such as neurectomy and ablation, are short-lived. The Occipital nerve stimulation (64575, 64590, 95972, 76000, 64555) has been shown to provide long lasting benefit and is well-tolerated, safe, and effective for his type of issue.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Occipital neuralgia
Treatment: Occipital nerve stimulation
The health plan should cover the Occipital nerve stimulation (64575, 64590, 95972, 76000, 64555).

The Occipital nerve stimulation (64575, 64590, 95972, 76000, 64555) is likely to be more beneficial.

The patient has medically refractory occipital neuralgia.  Based upon the published literature, including the evidence-based guideline by Sweet et al. (2015), the use of occipital nerve stimulation is a treatment option for patients such as this patient, who has a history of occipital neuralgia and intractable pain with refractoriness to medical management and limited relief from injections.  In a more recent case series of occipital neuralgia patients treated with nerve stimulation, there was an 85% overall success rate (Keifer et al., 2017).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Muscular dystrophy
Issue under review: Modafinil

Determination:
The Modafinil is not medically necessary.

The patient is an adult male with limb girdle muscular dystrophy. He reported fatigue with a normal sleep study. His AP is requesting modafinil. 

In the absence of an FDA-approved indication or data derived from clinical trials to support efficacy, Modafinil is not a standard of care treatment option for muscular dystrophy and co-morbid fatigue.  There are no high quality clinical trials or standard of care guidelines supporting the use of modafinil in this clinical setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure 
Treatment: Inpatient hospital services 

The insurer denied coverage for inpatient hospital services. The denial is upheld. 

This patient is a female who had a repeat cesarean section and presented to the emergency department several weeks later for seizure activity.  The documentation detailed in the history and physical indicates that this patient had 4 seizures in 24 hours.  The patient reported headache rated at a 10/10 and denied visual disturbances.  The patient denied seizure activity since the admission.  The patient has been diagnosed with a seizure disorder several years prior, and was taking carbamazepine.  Objectively, the history and physical noted the patient refused examination.  The patient's vital signs revealed a blood pressure of 140/84, pulse of 89 bpm and oxygen saturation of 100%.  The patient was recommended to undergo laboratory studies and neurology consult evaluation.  The documentation indicates that prior to arrival the patient was given Valium by emergency medical services for one witnessed seizure.  The patient was noted to be uncooperative during a neurology consultation, and she did not permit a full neurological examination and wanted to leave.  

Based on the documentation, there were no significant abnormalities noted.  The patient's speech was clear, and there was no evidence of any facial asymmetry.  The patient signed out against medical advice the following day prior to completion of laboratory studies.  

Based on this review of the medical record provided, this patient did not meet the Milliman Care guidelines and InteQual 2016 criteria for inpatient admission.  Though the patient had an episode of seizure activity prior to arrival to the ED, there was not recurrent seizure activity noted upon arrival to the ED, and the patient was hemodynamically stable.  There were no clinical indications of brain disorder, cardiac arrhythmias, new focal neurologic deficit or support that this patient's care could not be established as outpatient (e.g., patient cannot tolerate medication, initiation requires inpatient care).  The patient could have been treated with appropriate anti-convulsant therapy in the ED and have the neurological consultation performed in the ED with expeditious outpatient follow-up with neurology for an outpatient electroencephalography (EEG) testing. The care that the patient received as an inpatient did not warrant the acute level of care of inpatient admission.  

The health plan acted reasonably with sound medical judgment and in the best interest of the patient.  

The carrier's denial of the coverage for the inpatient hospital services at the acute level of care is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Iris hypoplasia, Bilateral Optic Disc Hypoplasia, 

Treatment: Comparative Genomic Hybridization (CGH) test

The insurer denied the comparative genomic hybridization (CGH) test. The denial was reversed.   

This is a male infant with a medical condition of iris hypoplasia, bilateral optic disc hypoplasia, poorly formed foveal contours, and coarse horizontal nystagmus. He has subsequently developed small central cataracts.

Based on the literature review, optic nerve hypoplasia (ONH) is a congenital disorder characterized by underdevelopment (hypoplasia) of the optic nerves. Those who have ONH may have brain malformations and pituitary problems, and the abnormalities of structure of the brain that is not usually visible on magnetic resonance imaging (MRI). Some affected children have normal intelligence and others have learning disabilities and developmental delays. Deficiencies of certain hormones may result in growth retardation, poor development, and may be life-threatening without treatment, such as hormone replacement therapy. Approximately 10% of children diagnosed with ONH prior to age 2 years have no pituitary problems and normal MRI scans of the brain. However, these children are still at risk for developmental delays.

Based on the review of this patient's medical record, this patient presented with multiple ocular and ophthalmologic malformations that also functionally implied and included a central nervous system (CNS) malformations in the areas of the brainstem controlling the extraocular muscle function; thus, producing nystagmus, as well as optic nerve, optic globe, and anterior segment abnormalities. The patient's optic disc hypoplasia with iris hypoplasia and nystagmus is a major malformation that qualifies for comparative genomic hybridization (CGH) testing. The patient has been evaluated by a Medical Geneticist, Developmental/Behavioral Pediatrician, and Pediatric Neurologist who have evaluated the patient, and considered that this test was necessary to impact management of this patient. Thus, the comparative genomic hybridization (CGH) test performed is considered medically necessary for this patient.

The health care plan did not act reasonably with sound medical judgment and in the best interest of the patient.

The carrier's denial of coverage for the comparative genomic hybridization (CGH) test is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status asthmaticus 

Treatment: inpatient hospital admission

The insurer denied coverage for inpatient hospital admission. The denial is reversed. 

This patient is a male child with a history of asthma and a previous hospital admission for status asthmaticus. The patient had been sick for a few days, and his sibling was a sick contact.  When the patient's dry cough worsened at home, the patient's mother administered albuterol with no improvement.  The patient was noted to have a posttussive vomiting at home.  The mother decided to bring the patient to the emergency room (ER) for additional treatment. In the ER, the patient was noted to be in moderate respiratory distress with evidence of increased work of breathing, prolonged expiration and wheezing. The patient's heart rate was elevated and his respiratory rate was 44. The patient was administered oxygen supplementation when his pulse oximeter was recorded at 92%. On physical examination, the patient was noted to have nasal flaring and subcostal retractions. The patient was treated with albuterol and atrovent inhalations treatments three times. The patient also required prednisone and an intramuscular (IM) injection of epinephrine. The patient's blood test was significant for low bicarbonate of 18 suggesting acidosis. The patient's chest x-ray did not demonstrate pneumonia. When the patient's respiratory distress did not improve with these treatments, the patient was given intravenous (IV) magnesium. The decision was made to admit the patient with a diagnosis of status asthmaticus for ongoing treatment with albuterol every 1 hour.  
Based on the review of the medical records provided, the patient was treated appropriately in the ER for a cough, wheezing and respiratory distress. When there was ongoing respiratory distress with wheezing and increased work of breathing, literature review indicates that it was appropriate and consistent with the standard of care to admit this patient to the hospital for ongoing treatment with albuterol every 1 hour.  The patient was not stable enough to be sent home since the need for frequent albuterol administration could not have been safely administered at the home. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The carrier's denial of coverage for the inpatient hospital admission is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right Lower Leg Cellulitis

Treatment: Inpatient Hospital

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

This is an elderly female who presented to the emergency department (ED) with complaints of fevers, chills, pain and redness of the right lower leg following a cat scratch. She has a past medical history of hypertension, status post total abdominal hysterectomy, and meniscus repair. She has a Doppler ultrasound which was negative for deep venous thrombosis (DVT). Podiatry consulted and debrided her toenails. She was empirically started on intravenous (IV) antibiotics (Vancomycin). The patient remained afebrile, hemodynamically and clinically stable. She was discharged to continue management as an outpatient.

According to documentation, the patient was admitted for a right lower leg cellulitis following a cat scratch. She was afebrile (<100.4 F) and mildly tachycardic (HR-103) while in the ED. Laboratory results showed leukocytosis (wbc-16.35) and a normal lactic acid. Progress notes indicate that the puncture site was closed with no drainage or discharge. There was no evidence of a systemic infection and no surgical intervention was required. Moreover, patient had not failed an outpatient course of antibiotics.

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

Diagnosis: Atrial fibrillation & right lower and middle lobe collapse with a right pleural effusion
Treatment: Inpatient admission
The proposed treatment, inpatient admission, was medically necessary.
This patient was an elderly female with multiple medical problems including hypertension (HTN) and stage IV lung cancer on chemotherapy that presented with new symptoms of worsening shortness of breath that progressed over a two day period.  She was diagnosed with AF and rapid ventricular rate upon presentation.  In addition, lung exam was consistent with bilateral wheezing, right lower and middle lobe collapse and possible pneumonia.  She required admission for further diagnosis and treatment of both rapidly conducted atrial fibrillation, right lung atelectasis and fluid overload that required diuretic treatment.  
Patients presenting with atrial arrhythmia and ventricular rates up to 150 require acute therapy and further monitoring to ensure that medications control heart rate and rhythm without producing significant bradycardia. An analysis of 68 million Medicare patients admitted to the hospital for atrial fibrillation over a fifteen year period demonstrated an average length of stay of three days. (Reference 1)  This analysis also demonstrated decreased mortality and readmission rates following admission to the hospital.  
In this case, the patient had multiple medical problems and in addition to atrial fibrillation including right lung atelectasis requiring additional monitoring and treatment.  The current standard of care for patients presenting with rapidly conducted atrial fibrillation alone merits hospital admission.  
In conclusion, this patient required treatment at a higher level of care.
Appeal type: Medical necessity
Decision: Upheld

The patient is a female who presented to the emergency room with symptoms of generalized weakness and facial numbness. She also reported intermittent chest discomfort. She had intermittent chest pain for a period of 2 months prior to presentation. Electrocardiogram (EKG) showed sinus rhythm and ST depression and T wave inversion in V3. Initial troponin was 0.02. She was admitted for observation. Repeat troponin levels were 0.05 and 0.04. Per the admit note, suspicion for an acute coronary syndrome was low, as the patient had no coronary risk factors - no diabetes, hypertension, hypercholesterolemia, no history of tobacco uses or family history of premature coronary disease. An echocardiogram (ECHO) was obtained which was unremarkable. Her pain was reproducible on palpitation, and felt possibly musculoskeletal, due to costochondritis, as there was chest wall tenderness to palpation, or due to anxiety. She was discharged home the following day.

The health plan's determination is upheld.

No, inpatient hospitalization is not medically necessary. This hemodynamically stable patient with intermittent chest pain and no objective evidence for an acute coronary syndrome could have been managed at a lower level of care status. The patient has minimal coronary risk factors and was hemodynamically stable on presentation with chest pain, which had a 2-month chronicity. Her cardiac troponins and EKGs were not diagnostic for ischemia or infarction, and there was no evidence for another serious cardiac or pulmonary diagnosis.
Appeal type: Medical necessity
Decision: Upheld

Other
Inpatient Hospital

The patient is a male who presented with left extremity weakness and slurred speech. The patient reported right side body being paralyzed but upon arrival at emergency room (ER), the patient regained ambulation. During the hospital stay, he developed worsening weakness and a STAT magnetic resonance imaging (MRI) Brain was obtained. Imaging showed acute non-hemorrhagic infarction of left basal ganglia/corona radiata. Also noted, were 2 old cortical infarcts in the right cerebral hemisphere. He was discharged to acute inpatient rehabilitation. The Plan denied the inpatient rehabilitation stay.

The health plan's determination is upheld. The acute inpatient rehabilitation was not medically necessary for this patient. The patient was medically stable. He did not require close physician oversight of 3 visits/week and there were not acute rehab nursing needs. In addition, the plan remained the same each visit. These visits do not support acute inpatient rehabilitation as the consulting cardiologist was not actively changing his medication nor was the patient reporting any concerns. Similarly, while the patient was also seen regularly by the Rehab Attending, the patient was always noted to be without complaints. Vitals were always stable and the treatment plan remained the same. The patient was not requiring any complex medical decision making to support the need for this frequency physician oversight. There was also no documentation to support need for acute rehab nursing. Therefore, while the patient did benefit from physical therapy, speech therapy and occupational therapy, these services would have been more appropriately provided at a lower level of care.