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

Diagnosis:  Complex Regional Pain Syndrome and Amplified Musculoskeletal Pain Syndrome
Treatment:  Inpatient Rehab
The inpatient rehabilitation hospital stay is medically necessary.  

The patient in this case has been diagnosed with Complex Regional Pain Syndrome and Amplified Musculoskeletal Pain Syndrome that has persisted for the past seven years of her life.  She has failed an extensive course of outpatient treatment that has included physical therapy, oral and topical medications, activity modification, the use of crutches, etc.  This condition has seriously affected her ability to perform activities of daily living, attend school, or engage in other activities that are appropriate for her age and development.  A review of the medical literature (please see references listed below) clearly shows that children and adolescents with chronic disabling pain benefit from intensive, inpatient rehabilitation programs that can incorporate interdisciplinary pain treatment strategies to help these individuals improve.  References #1and #2 below review longitudinal observational studies that showed evidence of long-term effectiveness of intensive interdisciplinary pain treatment.  The requested inpatient rehabilitation stay is medically necessary and the standard of care for treatment of children with this condition who have failed outpatient therapy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Incontinence
Treatment:  Supplies T4535, T4526, T4541 - Underwear and underpads 
The supplies T4535, T4526, T4541 - underwear and underpads are not medically necessary.

The Plan's stated reason for the denial of pads in excess of the amount allowed is that "Notes do not show why current amount of supplies cannot meet your needs."  The appeal letter from Albany Med notes that the "Patient then had a month of excess and Liberatore medical decreased her shipment to account for what patient still had left on hand.  Unfortunately patient is again requiring the ORIGINAL PAID quantities."   

There needs to be more objective documentation of why this quantity is needed despite failure of fluid restriction and intermittent catheterization.  Pad weight measurements would be helpful to quantify the need for the additional pads required.  There needs to be a more detailed description of pad usage and needs after demonstration of compliance with intermittent catheterization.  Behavioral modification and fluid restriction may also decrease the need for pad utilization.  Therefore, at this time, the request is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary Artery Disease

Treatment: Inpatient Admission

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

This is a middle age male who was admitted to the hospital during the previous year for an elective cardiac catheterization. He had been experiencing intermittent chest pain. He had a medical history of hypertension, hyperlipidemia, and heart failure. He underwent coronary angiography which revealed severe obstructive coronary artery disease involving the right coronary artery requiring a drug-eluting stent, severe 80% disease in the left anterior descending, and 60% stenosis of the ostial left circumflex arteries. He was referred for elective staged percutaneous coronary intervention of the left anterior descending artery and medical management of the circumflex. The patient experienced no procedural complications and was admitted for further monitoring. He was discharged home the day after the procedure.

Inpatient admission status was not medically necessary for this patient. Per MCG Angioplasty, Percutaneous Coronary Intervention ORG: M-52 (ISC), this procedure is an outpatient one. The clinical presentation and peri-procedural course were unremarkable and uneventful, and acute inpatient level monitoring was not medically necessary or appropriate. There were no extenuating circumstances in this case which warranted inpatient admission status following elective cardiac catheterization, angioplasty, and coronary stenting. 

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

Diagnosis: Diabetes mellitus
Treatment: Afrezza
The proposed treatment with Afrezza is medically necessary.

Afrezza has a much shorter onset of action and offset of action than injectable rapid-acting insulin analogs, including the formulary alternatives Fiasp, Novolin R, and Novolog [1]. The patient is stable on Afrezza and has a needle phobia. The formulary alternatives require a needle for needle injection. In addition, there is a lack of published clinical trials supporting the safety of switching from Afrezza to Fiasp, Novolin R, or Novolog in patients with well controlled type-one diabetes stable on Afrezza therapy. Without continuation of Afrezza, this patient would be at higher risk of glycemic variability, which can cause hypoglycemia and hyperglycemia. Hypoglycemia can cause seizures. Hyperglycemia increases the risk for retinopathy, neuropathy, and nephropathy. Therefore, the requested Afrezza is medically necessary. 

This patient is stable on Afrezza and the requested Afrezza is medically necessary as outlined above.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Vomiting and diarrhea
 
Treatment:  Inpatient admission, medication, monitoring

The insurer denied the inpatient admission.  The denial was upheld.

This case involves a female who presented to the emergency department for vomiting and diarrhea.  The patient's temperature was 100.3F.  The patient had no past medical history.  She was sent from Urgent Care for an evaluation of the gallbladder.  The physical examination was normal.  An x-ray of the abdomen showed no acute findings. A CT scan without contrast revealed hepatomegaly with hepatic steatosis.  The patient's white blood cell count was 16.  She had elevated liver function tests (LFTs).  The patient had a urine culture, blood culture, and a urine toxicology screen, and all of them were normal.  She was treated with intravenous antibiotics.  The patient was stabilized and discharged the next day.

MCG indicates that admission may be appropriate for a patient who has hemodynamic instability, hypotension requiring inpatient treatment, abdominal abnormalities, severe anemia, severe pain requiring acute pain management, or when inpatient monitoring is needed.  The records submitted for review failed to indicate that the patient had hemodynamic instability or severe pain.  The patient was not noted to have the need for inpatient monitoring.  The records failed to support that the patient had objective findings on radiologic or microscopic examination supportive of the necessity for inpatient care.  Therefore, the patient could have been monitored at a lower level of care, such as observation, and discharged.  

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

The patient is a male with a history of diabetes, hypertension, hyperlipidemia and coronary artery disease. He presented to the emergency department complaining of stabbing chest pain and dyspnea. His pain was exacerbated by movement. His blood pressure was 128/91 with a heart rate of 78 beats/minute. Room air oxygen saturation was 97%. His cardiovascular exam was unremarkable. Chest wall tenderness was noted. His electrocardiogram and serum troponin level were normal. He was admitted to the hospital to rule out acute coronary syndrome. Repeat troponin levels were normal. Myocardial perfusion imaging showed no evidence of ischemia. He was discharged home. The health plan's determination is upheld. 

This patient, with known coronary artery disease, presented with atypical 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 no ischemic electrocardiographic changes. There is no indication in the records provided that other potentially serious diagnoses were thought to be likely. 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 at a lower level of care status. This approach has been shown to be 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

Diagnosis:  Abdominal pain
Issue under review:  Inpatient admission

Determination:  The Inpatient admission was not medically necessary.

Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care.  The patient had an infection [pneumonia]; yet, he did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for NPO (nothing by mouth) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission.  The patient did not fail outpatient antibiotic therapy.  As such, the care could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Endentulous space in left maxilla #9 area
 
Treatment: Endosteal implant

The insurer denied the endosteal implant. The denial was upheld.

This patient presented for dental evaluation and treatment and discussion regarding prosthetic rehabilitation for edentulous space in the area of the left maxilla #9 area. The patient had a pre-existing 4-unit bridge spanning teeth #7-10 in the area, which has loosened and fallen out. The treating doctor recommended endosteal implant to be placed at the site after discussion of treatment plans. 

Upon review of the objective documentation, which primarily consists of the radiographs and clinical images, it is evident tooth #9 was missing and teeth 7, 8 and 10 exhibited crown preparations. Restoration of the space was to be considered. The patient's dentist suggested an endosteal implant #9 area and associated services. Although implants are an acceptable treatment to restore edentulous spaces, as in this patient, an accepted standard of care in dentistry is not exclusively endosteal implants.  Alternative appropriate treatment would include a replacement fixed 4-unit bridge, especially since the other abutment teeth are already prepared for crowns, and the prior bridge was noted to be esthetically acceptable. Fixed bridges remain standards of care in general dental practice. Therefore, the endosteal implants are considered elective, and not medically necessary.  

Based on the above, the medical necessity for the (D6010) implant placement, tooth #9; (D6057) custom abutment tooth #9; (D6058) abutment supported porcelain/ceramic crown tooth #9 is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

The patient is a male with a past medical history significant for anxiety, hyperglycemia, and marijuana use who presented to the emergency department with complaints of chest pain that he described as pressure. On the physical exam, the patient was afebrile, blood pressure was 147/86, heart rate 88, oxygen saturation 100%. He looked uncomfortable. There was no reproducible chest wall tenderness. The breath sounds were shallow with splinting. At the same time, the lungs were clear to auscultation. The rest of the physical exam was unremarkable. A computed tomography (CT) angiogram of the chest was performed and demonstrated no evidence of pulmonary embolism.
An electrocardiogram (EKG) showed normal sinus rhythm, there were no signs of ST-segment elevation or depression. The patient was admitted to the telemetry floor to rule out acute coronary syndrome. Serial enzymes were ordered. He was seen by a cardiologist. During the hospital stay the patient underwent a stress test, which was normal. Serial troponins were obtained and remained within normal limits. The health plan denied the inpatient admission as not medically necessary. The health plan's determination is upheld. 

The main reason for this decision is the fact that the severity of the patient's condition, including lack of alarming features on the physical exam, in the laboratory studies, and also in the diagnostic tests, did not justify admission at the acute inpatient level of care.
Based on a careful review of the patient's records as well as MCG Health Inpatient and Surgical Care 22nd Edition criteria for Chest Pain, standards of care accepted in the US, an admission at the acute inpatient level of care is required in cases of chest pain and hemodynamic instability, respiratory distress, when chest pain is indicative of serious diagnoses such as aortic dissection, or in cases of angina or myocardial infarction.
A careful review of the patient's symptoms, results of the laboratory studies, and diagnostic tests did not reveal that the patient had any of the conditions listed above.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right-lower-quadrant abdominal pain
Treatment: Inpatient admission 

Summary:

The patient's history and physical were not entirely consistent with an urgent or emergent intra-abdominal processes, including acute appendicitis -- her pain was chronic, having continued for a "few weeks." The patient did not demonstrate any evidence of peritonitis; the patient did not demonstrate leukocytosis. Because the patient's symptoms and signs were not entirely consistent with urgent or emergent intra-abdominal processes, she could have been treated at a lower level of care for intravenous hydration and serial abdominal examinations; admission at an acute inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain
Treatment:Inpatient admission 

Summary:
The health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
The patient presented with an acute STEMI (ST elevation MI), ECG changes, abnormal troponins and required stent placement for treatment of her acute coronary syndrome. 
Given the presentation, acute MI/acute coronary syndrome, requiring emergent catheterization and PCI, she would not be an appropriate candidate for an ED chest pain observation unit.  It would be consistent with the current standard of care that this patient be managed in an inpatient setting. Therefore, the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Overturned

The patient with Type 1 diabetes, who was diagnosed at age 8. the  most recent hemoglobin (Hb) a1c is 6.2%. capillary blood glucose (CBG) values range from 52 to 350. The patient  has hypoglycemic unawareness and also nocturnal hypoglycemia.the patient  is currently on a Medtronic paradigm along with Dexcom G6 sensor. The health plans determination  of medical necessity is overturned in whole .The requested health service/treatment of Tandem insulin pump is medically necessary for this patient. Continuous glucose monitoring systems (CGMS) including real-time systems have Food and Drug Administration (FDA) approval [1]. They are not the subject of Phase I-III clinical trials. The peer reviewed literature supports the long-term use of CGMS in adult patients. The American Diabetes Association (ADA) position statement on standards of medical care in diabetes published in January 2012[2], states, "Continuous glucose monitoring (CGM) in conjunction with intensive insulin regimens can be a useful tool to lower A1C in selected adults (age greater than [>] 25 years) with type 1 diabetes.This patient has an erratic work schedule and is unable to calibrate her CGM device and therefore Dexcom G 6 which is a therapeutic CGM and does not need calibration by checking blood sugars would be ideal for her situation. The Tandem t-slim insulin pump along with integrated Dexcom G 6 CGM has the capability of suspending insulin delivery to avoid hypoglycemia .
Appeal type: Medical necessity
Decision: Overturned

The patient is a  male who had presented to the emergency department  for evaluation of recurrent falls, altered mental status, and left hip pain. He was afebrile, bradycardic, and hemodynamically stable. Physical examination was significant for left infraorbital and gluteal ecchymosis and left hip tenderness. A computed tomography (CT) scan of the head was negative for acute infarct or hemorrhage. A hip x-ray revealed cortical irregularity along the inferior margin of the left femoral neck suspicious for impacted fracture. A CT scan of the hip was recommended for further evaluation. A CT of the abdomen and pelvis was significant for prostatomegaly and 7mm bladder calculus. Review of laboratory data was significant for normocytic anemia, pyuria, and bacteriuria. He was admitted the following day for management of recurrent falls presumed to be secondary to urinary tract infection (UTI)-induced encephalopathy and left hip contusion with concern for femoral neck fracture.

The health plan denied the inpatient admission as not medically necessary. The health plan's determination is overturned. The patient presented with altered mental status, frequent falls, and urinalysis suggestive of UTI with imaging evidence of bladder calculi, benign prostatic hyperplasia (BPH), and urinary bladder obstruction. He was appropriately treated for a complicated UTI, which tends to be associated with more resistant infecting bacteria. Preliminary blood culture result was positive, requiring broadening on intravenous antibiotic coverage to cover for gram positive organisms. It was imperative to await final blood culture results, which eventually ruled out true bacteremia. Treatment of complicated UTI with possibility of associated bacteremia requires intravenous antibiotic therapy in the inpatient setting pending appropriate work up and final identification of infecting bacteria. Observation level of care with discharge after 24-48 hours would have put this patient at risk of inadequate treatment, worsening UTI, sepsis, and mortality.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who was admitted from the emergency room for glycemic control. The patient has a history of cholestasis. She was started on insulin and monitored. Her vital signs and lab results were normal. She was discharged for follow up in an outside facility. The health plan's determination is upheld.
The patient had diabetes in pregnancy, however, there were no acute changes or signs to support the need for inpatient hospital admission. She did not have severe elevations of glucose at home nor during her hospital admission. Vital signs were stable and she had no hemodynamic instability. She had no ketoacidosis nor ketonuria. She had no abnormal physical exam nor was her hemoglobin A1C elevated at 5.2%. She had no dehydration, altered mental status and she was able to take oral nutrition at home. Her medication could have been adjusted at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

The patient is a man who presented to the hospital.  He presented with a chief complaint of leg infection attributable to a spider bite.  He reported seeing a brown spider bite his right lower extremity and stated that he had worsening redness, swelling, and lymphangitis to the groin.  He denies shortness of breath, nausea, vomiting, fever and diarrhea.  Vital signs showed blood pressure 117/76, heart rate 128, temperature 98.7 Fahrenheit, and respiratory rate 19.  On physical examination, heart was regular, breath sounds were normal, there was a small wound on the lower lateral leg with a large area of erythema/rash with lymphangitis tracking up to the groin. The leg was warm and sensation was intact and equal bilaterally. Labs showed sodium 126, potassium 4.9, calcium 8.8, white blood count (WBC) 12.6, hemoglobin 15.2, platelets 144, and Creatinine 1.37. Computed tomography (CT) of the right lower extremity demonstrated subcutaneous infection with no drainable collection.  Ultrasound of the right lower extremity was negative for deep vein thrombosis (DVT).  The patient was admitted for right lower extremity cellulitis.  The plan of care included intravenous (IV) antibiotics, infectious disease consult, IV fluids, and monitor creatinine.  The Infectious disease service recommended modifying his antibiotics. Surgery was consulted to rule out necrotizing fasciitis, and blood cultures were also sent.  The erythema improved and he was discharged.  The health plan's determination of medical necessity is upheld in whole.  Yes, the health plan has acted reasonably, with sound medical judgement in the best interest of the patient.  The reason is that the patient had cellulitis in the setting of mildly elevated creatinine and hyponatremia, but he was hemodynamically stable, there was no evidence of necrotizing fasciitis, no evidence of abscess, no evidence of infection caused by resistant organisms, and no other significantly complicating factors.  In addition, there was no evidence of systemic toxicity or end organ injury.  Unless there are complicating comorbidities, which were not present in this patient, treatment could have been completed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Major Depressive Disorder and Obsessive Compulsive Disorder 

Treatment: Inpatient Admission 

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

This is a male patient who was admitted to a facility in early 2019 with complaints of depressed mood, poor sleep, poor energy, and intrusive/obsessive thoughts about suicide by gun or overdose. He had a past history of two hospitalizations for depression and OCD, with his most recent hospitalization occurring a month earlier to this admission. He was admitted for inpatient psychiatric care. His hospital treatment included a cross tapered from Geodon to Seroquel and from Effexor to Zoloft. Throughout his hospital stay he had recurrent episodes of feeling disheveled, depressed, hopeless, and anxious, although he did express that the treatment was helpful.  He did however, continue to have obsessive thoughts that he found unmanageable and he was noted to be socially isolated. He denied suicidal intent. The patient continued with these symptoms with some overall improvement through the remainder of his hospital stay. He was discharged home.    

The patient was admitted for depression, OCD and suicidal ideation/intent. He received two weeks of active psychiatric treatment and had shown improvement.  Although he continued to have chronic symptoms of depression and OCD (along with dependent personality traits), he no longer had suicidal intent.  He had shown overall improvement.  As such, he could have received ongoing safe and effective treatment as an outpatient. 
This finding is consistent with the general standards of psychiatric care as well as the APA Guidelines for the Treatment of Patients with Major Depressive Disorder.  

Based on the above, the medical necessity for the inpatient hospital services at the inpatient level of care is not substantiated.  The insurer's denial is upheld.