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

The patient has diagnoses of schizoaffective disorder (SCZD), anxiety disorder, and history of poly-substance use disorder (PSUD). The question is whether dates of service (DOS) at the Inpatient Hospital Level (IHL) are medically necessary, Case notes document that the patient suffers from chronic psychiatric symptoms with the most recent exacerbation leading to emergency department evaluation and discharge. The recent exacerbation began two to three weeks prior to admission. The patient was referred to the emergency department (ED) for overwhelming anxiety, suicidal ideation with a plan, and auditory hallucinations as well as paranoia. The patient was then admitted to the IHL. The treatment included psychopharmacological medications of Abilify, Celexa, Neurontin, and Klonopin. Her risperidone was discontinued. Additionally, the patient received psychotherapy and discharge planning.

The health plan's determination is upheld. Case notes documented that while the patient was experiencing anxiety, the patient had no delusions or hallucinations, was not suicidal, and had organized reality-based thoughts. The patient was cooperative with the health care team and showed good insight and judgment. The patient could therefore be discharged to a lower level of care. The patient no longer required an inpatient level of care on the dates in question.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Obstructive Pulmonary Disease (COPD) Exacerbation
 
Treatment: Inpatient Admission

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

This is a female patient who presented to the emergency department with complaints of radiating chest pain; to her left arm and jaw, and shortness of breath. The patient reported that she had experienced an increase in stress and lacked sleep. She had serial electrocardiogram and troponin levels; both were noted to be negative.  It was reported that the patient's lung fields had bilateral wheezes. The patient was treated with Duo Nebs, Azithromycin and steroids. The patient responded well to the respiratory treatment. A urine culture and sensitivity (C/S) was performed that revealed Escherichia Coli, gram negative infection urinary tract infection (UTI). She was treated with Levaquin. The patient responded well to the respiratory treatments, she remained hemodynamically stable and afebrile. 

The patient was stable for discharge on oral steroids, oral antibiotics and bronchodilators after a period of observation in the emergency department with close follow-up in an outpatient setting.  A potential cause such as myocardial infarction (MI) had been ruled out by serial EKGs and Troponins. There was no evidence of pneumonia. The prior denial is upheld. The health plan acted 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 upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
 
Treatment: Inpatient Admission

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

This is a female patient who presented to a rehabilitation facility for detoxification treatment. Her presenting withdrawal symptoms included chills, cravings, headache, lethargy, tremors, sweats, nausea, vomiting, body aches, increased heart rate, restlessness, irritability, anxiety, fatigue, and depressed mood. The patient reported that she had a history of opioid abuse and traumatic brain injury, depression, self-injury behavior; cutting herself. Her initial Clinical Institute Withdrawal Assessment (CIWA) for Alcohol Scale scores were: 6 and 13 and at the time of discharge it was a 4. She was placed on Methadone protocol. While at rehabilitation she attended individual and group therapy. The patient was safely discharged after completing her detoxification. 

The 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. This was the case with this patient. 

According to the LOCADTR she did require 24 hour treatment throughout her admission as she needed and received detoxification medication of Methadone to modify withdrawal and prevent severe withdrawal. She had continued withdrawal symptoms during the denial period including chills, cravings, headache, lethargy, tremors, sweats, nausea, vomiting, body aches, increased heart rate, concentration problems, restlessness, irritable mood, anxiety, fatigue, and depressed mood.

Based on the above, the medical necessity for medically supervised inpatient withdrawal and stabilization services is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes
Treatment: Continuous glucose monitor
The Continuous glucose monitor is medically necessary.

Continuous glucose monitoring systems (CGMS) including real-time systems have FDA approval (1, 2). 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 ADA position statement on standards of medical care in diabetes published in January 2011(3), states, "Continuous glucose monitoring (CGM) in conjunction with intensive insulin regimens can be a useful tool to lower A1C in selected adults with type 1 diabetes." The ADA considers this to have a level of evidence of "A," which is, "Clear evidence from well-conducted, generalizable, randomized controlled trials that are adequately powered."

This is based on a recent large scale trial published in the New England Journal of medicine in September 2008 that showed that CGMS is effective in reducing HbA1c in adults with type 1 diabetes over a six month period (4).

The latest ADA statement on the standards of medical care in diabetes- 2011 states the following regarding the use of CGM in children and adolescents (3): "Although the evidence for A1C lowering is less strong in children, teens, and younger adults, CGM may be helpful in these groups. Success correlates with adherence to ongoing use of the device."

This is based on a recent trial published in the New England Journal of Medicine (5) showing benefit of CGMS in children and adolescents with type 1 diabetes who are not well controlled. 

In addition, the peer-reviewed literature supports the use of long-term CGMS in patients with type 1 diabetes with hypoglycemia unawareness and episodes of hypoglycemia (6). The ADA position statement on standards of medical care in diabetes published in January 2009(7) states, "CGM may be a supplemental tool to SMBG in those with hypoglycemia unawareness and/or frequent hypoglycemic episodes." There is evidence that real-time CGMS with an alarm function detects hypoglycemia (8), leads to an improvement in glycemic excursion, leads to a reduction in duration of hypoglycemia prevents hypoglycemic reactions in adult patients with type 1 diabetes (9-12). Although not all episodes were detected (13), the majority were detected. This represents a 60% reduction in patients with complete hypoglycemia unawareness. 

The requested CGM with Medtronic 670 G insulin pump (14-16) has been shown to reduce hemoglobin A1C as well as hypoglycemia when compared with a standard insulin pump and continuous glucose monitor.

The request is for CGM supplies in the form of sensors. The patient has an A1C not at goal despite being on an insulin pump. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.
Appeal type: Medical necessity
Decision: Upheld

The patient had no significant past medical history. The patient had a 3-day history of fever and then developed a rash. The patient was seen in the emergency department (ED) and lab studies were normal. The patient was given intravenous (IV) fluids and IV ceftriaxone in the ED and IV steroid.The patient was admitted with a diagnosis of viral exanthem versus urticaria. Following admission, the patient was given oral acetaminophen for fever and oral Benadryl for rash. The rash and fever improved as the day went on and he was discharged to home the same day of admission with no further treatment. The inpatient stay is under review.

The health plan's determination is upheld. The inpatient admission was not medically necessary. This patient had a classic presentation of a viral illness with viral exanthem. An inpatient hospital admission was necessary. All of the labs done were all normal and supports the diagnosis of viral exanthem. The patient received no other treatment other than oral medications after admission. Clearly, this could have been accomplished at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of Breath
 
Treatment: Inpatient Admission

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

This is a female patient who presented to the emergency department with complaints of shortness of breath and wheezing for the past several days.  It was reported that the patient was 11 weeks pregnant. On exam, the patient's vital signs were noted to be normal. There was an audible wheeze present bilaterally. The patient was consulted by Pulmonology who suggested she receive a short course of steroids. She was treated with antibiotics, bronchodilators, and nebulizers. The patient was safely discharged when her condition improved.

It appears that this patient did not need acute hospitalization. She was afebrile and hemodynamically stable.  She was in no acute distress.  She was not hypoxic.  She had responded to treatment in the Emergency Department.  The patient was tolerating oral intake and was stable for discharge home on oral antibiotics, bronchodilators, inhaled corticosteroids (ICS), and oral steroid taper with close follow-up in an outpatient setting.  The health plan acted reasonably with sound medical judgment in the best interest of the patient.

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

The patient suffered a left middle cerebral artery infarct requiring tissue plasminogen activator (TPA) and mechanical thrombectomy as-well-as intubation.  Acute hospital complications included ventilator associated pneumonia, acute kidney injury, pulmonary edema and left external iliac deep vein thrombosis (DVT).  He was admitted to Rehab following cerebral infarction.  He returned to acute hospital following an unwitnessed fall  to the hemiparetic side and head.  A computed tomography (CT) head scan was negative for acute pathologies. The patient was kept overnight for trending of cardiac enzymes.  He was stabilized and returned to Rehab.

The health plan's determination is upheld.  The inpatient acute rehabilitation is not medically necessary for this patient. During his acute rehabilitation stay the patient required physician management of hypertensive episodes, evaluation of right upper limb edema (negative for DVT), mild hyponatremia, diabetic management and treatment of his "volatile personality" with lab work to follow his valproic acid levels.  While these medical issues did require physician oversight and treatment this reviewer opines that the patient could have been appropriately cared for at a lower level of care, specifically at a post-acute rehab/skilled nursing facility.  In addition, the functional progress documented was minimal.  Upon admission and, again, at discharge patient required total assistance for ambulation, bathing and lower body dressing.  At discharge, he required total assistance for toileting.  Memory at admission and discharge remained maximal assistance.  Upper body dressing only improved from total assistance to maximum assistance.  While the patient did improve with eating from minimum assistance to supervision, grooming to supervision, problem solving from total assistance to minimum assistance and social interaction from total assistance to moderate assistance this is not enough functional progress to support continued acute rehabilitation especially since it took the patient since admission to make these small gains.  Discharge to post-acute rehabilitation/skilled nursing facility is more appropriate with re-evaluation for return to acute inpatient rehabilitation if further gains in function are made.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prostate Cancer
 
Treatment: Oncotype DX test for prostate cancer

The insurer denied the Oncotype DX test for prostate cancer. The denial was upheld.  

This is a male patient who had a PSA level of 6.96 and a Gleason score of 3+3. The patient underwent a biopsy of his prostate. Oncotype DX PCA test was performed. He had cryoblation for the treatment of his disease. 

While it is true that NCCN guidelines state that this test should be considered for men with NCCN low risk or favorable intermediate risk prostate CA and a greater than 10 year life expectancy, they do note the absence of randomized prospective trials. American Urological Association (AUA) guidelines on the other hand do not view this test very favorably, stating that: "tissue based genomic biomarkers have not shown a clear role in active surveillance for localized prostate CA, and are not necessary for follow-up." The impact of tissue based gene expression tests, such as Oncoype Dx PCA, on clinical practice and long term patient outcomes remains to be empirically demonstrated. Prospective studies of these tests (Oncotype Dx OCA, prolaris, decipher, etc.) yielding a true clinical benefit when implemented on clinical practice are still lacking.


Based on the above, the medical necessity for the Oncotype DX test for prostate cancer is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope, Chest Pain
 
Treatment: Inpatient Hospital Admission

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

This is a female patient who presented to the emergency department with complaints of severe chest discomfort, dyspnea, and tachycardia, with witnessed syncopal episodes. It was reported that the pain was located on the right side of her chest and radiated to her back and down her arm. At the time of her syncopal episode the family administered rescue breathing with no compressions; she regained consciousness within 1-2 minutes. Vital signs on arrival were noted to be normal. The patient was consulted by Cardiology. She had an electrocardiogram which revealed normal sinus rhythm. It was noted that after consulting on patient cardiology felt her symptoms were related to a vasovagal reflex precipitated by her hiatal hernia. She was discharged on omeprazole with plans for an outpatient echocardiography.  

There is no evidence that this patient required an acute inpatient level of care to determine that her chest discomfort and syncope were not related to an acute coronary syndrome. The healthcare 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: Upheld

Gynecological 
Inpatient Hospital

The patient is a female, gravida 6 para 4, at 9 weeks gestational age in pregnancy, presented to the emergency room with right lower quadrant pain. She was found to have a large right ovarian cyst on imaging measuring over 6 centimeter (cm). A viable intrauterine pregnancy was confirmed on the ultrasound. Her history was remarkable for a history of surgery for ovarian cysts. She was admitted the night she presented, and then discharged the following day pain-free. She did not undergo surgery.
The subject under review is the medical necessity of the inpatient stay.

The health plan's determination is upheld.

The health plan has acted reasonably. The brief time in the hospital did not require an inpatient level of care. This was time in the hospital to assess what clinical action should be taken (surgery or discharge). The patient underwent pain control measures, but otherwise no interventions other than assessment of the need for surgery. She was not receiving any significant interventions during that time. The progress notes demonstrate a resolution of pain overnight followed by no further need for analgesics. There is nothing to suggest there was ongoing concern for infection or other serious problem. She did not require transfusion, she was afebrile, and there was no pending clinical problem requiring the hospital.

Inpatient admission was not medically necessary for this patient. The patient presented with a very common complaint - ovarian cyst. Ovarian cysts are evaluated in the emergency room on a regular basis, usually with discharge once blood flow to the ovaries is documented on sonography (i.e. ruling out torsion). Professional guidelines recommend surgery for functional cysts only if they are 10 cm or above or associated with ovarian torsion. The providers in this case took a conservative approach in placing this patient in the hospital to assure surgery was not needed. Her pregnancy no doubt influenced that level of caution and is completely reasonable. However, the patient's pain resolved within hours of her placement on the floor. Her vital signs remained normal (for a pregnant patient) and her labs likewise were unremarkable for a pregnant patient (mild anemia and mild leukocytosis are normal in pregnancy). She did not require surgery, or other interventions that could not be provided in an emergency room setting, and so inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Other
Inpatient Hospital

At the time of his admission, the patient was a child who was brought to the emergency department (ED) in the evening after ingesting an unknown amount of olanzapine 15mg (Zyprexa), he was found with pills on the floor and some chewed pill pieces in his mouth at approximately 9 pm that evening. The parents told the ED physician that they noticed he seemed overly excitable and crying more than usual. Poison control was contacted. It recommended administration of activated charcoal and observation for 8 hours. The ED ordered 60ml of activated charcoal, but the patient only took 15ml of it. He was admitted to the hospital early in the morning for observation and discharged later the same day, having not experienced any significant medication effects. The health plan denied coverage at the acute inpatient level, stating that the observation care could have been provided at a lower level, such as the ED or an observation area. The hospital is appealing this determination. The health plans determination is upheld. No, the requested health service/treatment of an inpatient stay was not medically necessary for this patient. The patient did not meet medical necessity for acute inpatient care, but rather met criteria for a lower level of care. The main clinical concerns with accidental ingestion of olanzapine in toddlers are sedation, hypotension, and arrhythmia. The medical record indicates that he experienced none of these concerning effects, and that poison control recommended observation for a period of eight hours. He required short-term treatment for possible consequences of the olanzapine ingestion, however that care could have been rendered at a lower level.
Appeal type: Medical necessity
Decision: Overturned

Rash
Inpatient Hospital

The patient is a male who presented with diffuse hives. He was well until the morning of admission when he developed a fever. Later that day, approximately 15 minutes after taking ibuprofen, he developed extensive hives. He also had lip swelling but did not experience shortness of breath, wheezing, or loss of consciousness. He had some viral symptoms over the past several days and had taken ibuprofen in the past without a reaction. He had never had a similar rash in the past. The rash got progressively worse, so he was brought to the emergency department for further care. He was admitted to the hospital. 

The health plan's determination is overturned. The Inpatient Hospital Admission was medically necessary for this patient. This is a young boy who presented with rapid progression of diffuse hives following ibuprofen administration at home. He also had lip swelling and tachycardia. He required prompt initiation of treatment in the emergency department setting, including a fluid bolus, epinephrine, intravenous diphenhydramine, and Solu-Medrol. However, his symptoms only slightly improved. He therefore required inpatient admission for further administration of intravenous therapies with close monitoring and additional administration of treatment as needed. Admission for anaphylaxis is necessary for patients who do not respond to initial measures. The decision-making at the time of admission for this patient was consistent with his young age, the persistence symptoms despite appropriate and intensive treatment in the emergency setting, and the need for continued treatment and close monitoring for potential deterioration of clinical status.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a skeletal Class I occlusion, mild maxillary spacing and mild mandibular crowding, moderate overbite and moderate overjet. The proposed treatment is braces.

The health plan's detrmination is upheld.
The malocclusion in question does not meet criteria to be classified as handicapping and treatment would not be considered medically necessary. Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 14 with no auto qualifiers. Auto qualifiers include deep impinging overbite, anterior crossbite causing clinical attachment loss and recession of the gingival margin, overjet 9 millimeters (mm) or greater and underbite 3.5 mm or greater. The patient requires a score of 26 or more for treatment to be considered medically necessary. Thus, braces are not medically necessary for this case.