Persius/hicric huggingface dataset:
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Fibromyalgia. 
Treatment: Savella 50 milligrams (mg) tablet. 

The insurer denied coverage for Savella 50 milligrams (mg) tablet. 

The denial is overturned. 

The patient has a past medical history of chronic pain, chronic kidney disease, attention-deficit/hyperactivity disorder (ADHD), depression, arthritis, and FM (fibromyalgia). The patient presented to an office visit with Physician Assistant. The patient has chronic pain and has been on multiple medications in the past. She is on sertraline (an SSRI). Savella (an SNRI) was added and helped. Coverage was denied due to there being formulary alternatives. Lyrica was begun. Later, it was stopped due to side-effects. Coverage for a Formulary Exception for Savella 50 milligrams (mg) tablet for the treatment of fibromyalgia is requested. 

As per Up to Date, "Milnacipran(Savalla) is an alternative to duloxetine(Cymbalta) in patients with severe fatigue in addition to pain. We initiate therapy with 12.5 mg each morning, gradually titrating as tolerated to 50 mg twice daily." 

Physician Assistant, is appealing the decision. She notes that the formulary alternatives to Savella are not safe with sertraline. 

The denial indicates that a trial of pregabalin needs to be done before Savella can be approved. Lyrica (pregabalin) was tried and the patient did not tolerate it. The treating doctor has followed the guidelines established by the insurer, and Savella should be approved. 

The patient has already taken Savella and tolerated it. She reacted adversely to the suggested alternative Lyrica. 

Savella appears to have worked where many medications have failed. 

The insurer's denial of Formulary Exception for Savella 50 milligrams (mg) tablet for the treatment of fibromyalgia is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Functional impairment.
Treatment: Housekeeping services.

The insurer is denied coverage for housekeeping services.  The denial is upheld. 

This female patient has a history of osteoarthritis, sequelae of poliomyelitis, depression, type 2 diabetes mellitus and a frozen right shoulder.

As per New York Codes Rules and Regulations, Title 18: Section 505.14 Personal Care Services, the scope of care provided by personal care aides for household related tasks includes: making and changing the bed; dusting and vacuuming the rooms the patient uses; light cleaning of kitchen, bedroom and bathroom; dishwashing; listing needed supplies; shopping for patient (if no other arrangements are available); patient's laundry (including ironing and mending when necessary); assistance with paying bills; assistance with essential errands; preparing meals (including simple modified diets). 

The patient is currently approved for personal care services 12 hours per day, 7 days per week. Within the 12 hour shift per day, the aide provides assistance with personal care tasks as needed, including: bathing; personal hygiene; dressing; toileting related tasks; bed mobility; eating; mobility around the home and outside (including transfers and wheelchair mobility). Within the 12 hour shift, the aide is also expected to assist with or completely perform (depending on the patient's level of function) household related tasks as described above. The aide can perform these tasks during times of the day when the patient does not need assistance with ADLs.  It is expected that some household tasks need to be done daily, such as meal preparation, keeping the kitchen and bathroom clean, making the bed, keep environment uncluttered. Some tasks are not necessarily needed daily, such as vacuuming, shopping, laundry. 

There was no information provided for review that describes the specific housekeeping services the patient is seeking and not currently receiving with her current home care services. The housekeeping tasks as described in the NYS (New York State) regulations for personal care services (noted above) include the typical range of housekeeping-related activities performed in most homes. If the patient is not receiving the housekeeping services as described above, then this can be discussed with the home care agency and/or the MLTC (Managed Long Term Care) plan (VNSNY CHOICE) to determine the reason, and possible solution. However, if the aide is currently providing standard housekeeping services (as noted above), but the patient needs additional type and/or frequency of household services beyond the level of service that can be provided by a personal care aide, then the patient may need to pursue other sources of assistance in her community. The insurer recommended a social worker referral to help the patient with her search for services that meet her needs.
   
The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.

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

Diagnosis: Crowding; Crossbite. 
Treatment: C8080 Braces, D8670  Monthly Visit x 12, Pre-service. 

The insurer denied the C8080 Braces, D8670  Monthly Visit x 12, Pre-service
The denial is upheld. 

The patient is a female. The request is for Orthodontic treatment (Braces) and monthly visits. Clinical consultation was performed, orthodontic records were made. 

The patient presented with class I skeletal relationship, Class II canines, mild maxillary and mandibular crowding, and anterior crossbite with gingival attachment loss (mandibular right canine and lateral incisor). 

The health plan denied treatment because the patient did not score a 26 on the HLD (Handicapping Labio-Lingual Deviation) index. 

The provider appealed the decision based on the clinical summary diagnosis of anterior crossbite. 

No, the orthodontic therapy (Braces) and monthly visits are not medically necessary.
The provider is appealing, because they believe the case should automatically qualify due to the anterior crossbite with gingival attachment loss on the mandibular canine and lateral incisor. However, the information supplied does not support the existence of an anterior crossbite with gingival attachment loss for the lower right canine and lateral incisor. 

Therefore, given the above, the orthodontic treatment and monthly visits are not medically necessary. 

The health plan denied the treatment, because the patient did not score the necessary points on the HLD (Handicapping Labio-Lingual Deviation) index or show that she was eligible for any of the automatic qualifiers on that index. 

Orthodontic treatment is an invasive and multi-year process that is intended to correct a dental alignment problem. If this problem is not present, then the treatment is not warranted. Therefore, the orthodontic treatment and monthly visits are not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite.
Treatment: Braces and Monthly Visit, Pre-service.
The insurer denied the Braces and Monthly Visit, Pre-service.
The denial is overturned. 

The patient is a female, skeletal class I, with normal vertical growth pattern and permanent dentition.  She has moderate maxillary crowding, moderate mandibular crowding, moderate maxillary protrusion, moderate mandibular incisor protrusion, and a crossbite of an anterior tooth (#23, lower left lateral incisor) with gingival attachment (gum) loss.   The request is for orthodontic benefits.

Yes, the proposed braces and monthly visit are medically necessary.
The patient has a crossbite of an anterior tooth (#23, lower left lateral incisor) with gingival attachment (gum) loss. This is an automatic qualifier according to the handicapping index scale.   Therefore, the proposed braces and monthly visit are medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dyspnea on exertion with positive nuclear test. 
Treatment: Inpatient admission. 

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

The patient is a female who presented with dyspnea on exertion. She underwent an outpatient nuclear test which was consistent with coronary artery disease (CAD). She was electively scheduled for a cardiac catheterization. She has co-morbidities of hypertension, diabetes, and hyperlipidemia. She underwent an uncomplicated percutaneous coronary intervention (PCI). She was admitted to telemetry post procedure. After an uneventful night, she was discharged. Final diagnosis included atherosclerotic heart disease without angina. 

No, the proposed inpatient admission was not medically necessary. 
This was an elective, uncomplicated catheterization and percutaneous coronary intervention (PCI) that was scheduled after a positive nuclear test. The patient was always hemodynamically stable with normal vital signs, normal electrocardiogram (EKG), normal left ventricular (LV) function, and no ectopy. The only care given after the uncomplicated radial catheterization was monitoring, intravenous fluids (IVF), and routine medications. This care does not require an inpatient admission. 

Radial catheterization was developed with one of its advantages being the safety in early ambulation and discharge. An overnight stay for observation and telemetry does not change that determination. While possible, bleeding post radial artery intervention is not seen, nor does it require extended monitoring. 

The letter of appeal was carefully considered but it offered no evidence to support a higher level of care. The only care provided was telemetry; telemetry does not require inpatient admission. The patient was admitted for monitoring and routine post catheterization care; neither required an inpatient level of care. There was no "complex" care required in this patient's care post catheterization.  While there is always a potential for an adverse event, one did not happen and no actual treatment was needed. 

Milliman criteria requirements for acute coronary syndrome (ACS) do not apply as patient does not meet criteria to support that diagnosis. It is incorrect to label the presentation of this case as unstable angina, as patient was pain free. Electrocardiogram (EKG) showed no changes, and no acute medical treatment was given for acute coronary syndrome. 

All testing and therapy would be appropriate, safe and guidelines consistent to be performed at a lower level of care. Thus, inpatient level of care was not medically necessary. 

The discharge summary lists the final diagnosis as atherosclerotic heart disease without angina. 

Same day discharge is standard at many hospitals. The denial was consistent with guidelines and usual community care. This patient's post catheterization care did not require inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: chronic cough 
Treatment: High Frequency Chest Wall Oscillation Air-Pulse Generator System
The insurer denied High Frequency Chest Wall Oscillation Air-Pulse Generator System. The health plan's determination is upheld. 

The patient is a female with chronic cough since she was a toddler and frequent pneumonia who has been under treatment for last 2 to 3 years. Also, the patient underwent the BAL (Bronchoalveolar lavage) and showed HIB (Haemophilus influenzae). The patient was treated with Albuterol, ICS (Inhaled corticosteroids)/ SABA (Short-acting -agonist) combination, and 3 sets of antibiotics with little benefit. The PFTS (Pulmonary function tests) was grossly normal. The patient does not have any neuromuscular dysfunction. She was also treated with HFCWO (High-frequency chest wall oscillation) to prevent the bronchiectasis.

High Frequency Chest Wall Oscillation Air-Pulse Generator System is not medically necessary for this patient.
High-frequency airway clearance (HFCWC) assist devices generate either positive or negative trans-respiratory pressure excursions to produce high-frequency, small-volume oscillations in the airways. This is effective in CF (cystic fibrosis) and non CF bronchiectasis.
HFCWC can lead to changes in volume of 15-57 ml (milliliters) and in flow up to 1.6 L/s (liters/second), which generate minimal coughing to mobilize secretions. The typical treatment lasts 20-30 minutes and consists of short periods of compression at different frequencies, separated by coughing.
Airway clearance with Vest or HFCWC is a mainstay of CF therapy and PCD (Primary ciliary dyskinesia) or bronchiectasis. Several studies showed that HFCWO produced an improvement in several lung function parameters such as higher forced expiratory volume (FEV), lower sputum volume, and less days sick when compared to traditional chest physiotherapy.
However, this patient does not have CF/Bronchiectasis/neuromuscular disease. Also, there is no class 1 evidence the HFCWO device has changed the outcome in patients with protracted bacterial bronchitis diagnosis. Therefore, it is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory. 
Treatment: Inpatient Hospital. The insurer denied inpatient stay. 

The denial is upheld.

This male presented to the hospital for scheduled peripheral vascular intervention for complaints of lower extremity claudication and for cardiac catheterization for exertional dyspnea. His medical history was remarkable for hypertension, peripheral arterial disease, heart failure with reduced ejection fraction (31%) and cigarette smoking. Coronary angiography showed mild nonobstructive disease. Peripheral angiography showed total occlusions of the left superficial femoral artery (SFA) and left popliteal artery, a 60% stenosis of the left deep femoral artery and a 100% stenosis of the left posterior tibial artery. Balloon angioplasty and stenting of the mid left SFA was performed. A lesion in the proximal vessel was treated with balloon angioplasty. The procedure was uncomplicated. The patient was discharged the next day. Medical necessity for an inpatient admission is at issue.

The health plan's determination is upheld.

The inpatient stay was not medically necessary. This patient was admitted to the hospital following coronary angiography and peripheral arterial intervention. The coronary angiography showed no obstructive disease and was uncomplicated. This is typically an outpatient procedure and did not justify an inpatient admission. Moreover, peripheral arterial interventions in stable patients with claudication are increasingly being performed in the outpatient setting. This patient had an uncomplicated procedure. If it was felt necessary to monitor him overnight, this could have been accomplished under a lower level of care status. Mesbah et al., based on a retrospective chart review of 500 consecutive peripheral arterial intervention procedures that were performed at an outpatient catheterization laboratory from February 2012 through February 2013, concluded that performance of these procedures in a lower level of care setting was safe and effective. Only one patient required immediate post-procedure hospitalization for a procedural complication. Akopian et al., in a study of 112 patients, found that 8% required admission. The need for admission was evident within two hours of the procedure. Based on the medical records provided, an inpatient level of care was not medically necessary in this instance.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Uterine Fibroids

Treatment: Inpatient Hospital Admission

The insurer denied coverage for inpatient hospital admission

The denial is upheld

The patient is a female with a history of anemia and fibroids.  She presented to the hospital for a scheduled laparoscopic hysterectomy to treat uterine fibroids and abnormal uterine bleeding (AUB).  The patient underwent a laparoscopic supracervical hysterectomy, bilateral salpingectomy, and myomectomy.  Estimated blood loss (EBL) was 800 milliliters (ml). Hematocrit (hct) level was low.  The patient was admitted for postoperative care.  She was kept on a regular diet.  Heparin was given for deep vein thrombosis (DVT) prophylaxis.  The patient was able to void and the Foley was removed.  She was discharged after a period of hemodynamic stability.  

There are many ways of doing a hysterectomy.  The trend has been towards less invasive procedures.  Conventional and robotic laparoscopy share similar advantages over laparotomy, including decreased morbidity, rapid recovery, and improved aesthetics of incisions.
Laparoscopic supracervical hysterectomies are outpatient procedures unless a complication arises.  Admission becomes necessary if the patient is febrile, hypotensive, bleeding, has difficulty breathing or the severity of the pain is such that admission is necessary.

According to Milliman Care Guidelines, Inpatient and Surgical Care 24 Edition, Laparoscopic hysterectomy, a laparoscopic hysterectomy is an ambulatory procedure.  Inpatient stay may be needed for:

1) Surgical complications (bladder ureter or bowel injury or hemorrhage)
2) Conversion to abdominal hysterectomy
3) Complex surgery (staging of endometrial cancer)
4) Wound complications
5) Co-morbidities.

This patient did not have any of these criteria.  Her procedure was uncomplicated.  There was no evidence of any injury to other organs.  Post-operatively, the patient was stable.  Nothing in the operative report or the progress notes suggested any serious problem that warranted admission.  Please note that laparoscopic hysterectomy is an outpatient procedure and includes appropriate postoperative monitoring and an overnight stay if required.
Please note that this patient had a supracervical hysterectomy.  In other words the vagina was not entered and the procedure is much less invasive than a total hysterectomy.  So the recovery period and complications should be much less than with a total hysterectomy.

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

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

Diagnosis: Right-Sided Diverticulitis

Treatment inpatient level of care

The insurer denied coverage for inpatient level of care

The denial is overturned

The patient has a past medical history of diabetes mellitus, coronary artery disease, hyperlipidemia, obesity, pulmonary nodules, hypertension, diverticulosis, right-sided diverticulitis, and tobacco use. The patient presented to the emergency room with subjective complaints of abdominal pain for 3 days.  The patient noted the pain was worse with movement.  The patient noted the pain was mainly in the right abdomen, especially mid to upper abdomen that was severe. The pain was associated with fever (up to 103 degrees) and chills.  The patient underwent a surgical consultation and a medicine consultation.  The patient underwent a computed tomography (CT) scan revealing ascending colon diverticulitis.  The patient was admitted with acute right-sided diverticulitis.  The patient was treated with intravenous fluids, antibiotics, and pain management.  The patient was subsequently discharged in stable condition.

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

The patient has history of recurrent diverticulitis and had been advised to have colectomy in the past. She has multiple significant comorbidities including coronary artery disease (CAD) and obesity. She presented with severe abdominal pain and clinical exam and imaging was consistent with acute right colon diverticulitis. This recurrent infection in the setting of multiple comorbidities warrants close observation and consideration of surgery, hence admission to Surgery Service.

The insurer's denial of coverage for inpatient level of care is reversed. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: dyspnea on exertion, fatigue and chest discomfort

Treatment: inpatient admission

The insurer is denied coverage for inpatient admission

The denial is upheld. 

This male patient has a history of coronary artery disease (CAD), hypertension, diabetes, dyslipidemia and prior stent placement.

This patient presented for elective percutaneous revascularization.  He underwent an uncomplicated procedure and stents were placed in the mid LAD and Ramus arteries. He was subsequently discharged the following day.  Several investigators have studied the safety and cost savings surrounding same day discharge following percutaneous intervention and demonstrated no difference between patients that are discharged on the same day as compared to patients admitted to the hospital.(Reference1-4)  

Current expert consensus from The Society of Cardiovascular Angiography and Interventions support treatment at a lower level of care. (Reference 4) In conclusion inpatient admission was not medically necessary.  The patient could have been managed at a lower level of care.

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

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

Diagnosis: Genitourinary/Kidney Disorder. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital admission. 
The denial is overturned. 

The patient is a male with a past medical history significant for hypertension, hyperlipidemia, chronic obstructive pulmonary disease (COPD), coronary artery disease, bipolar disorder, anxiety, depression polysubstance abuse, and hepatitis C who presented to the emergency department, with complaints of bilateral flank pain that started 3 days before the presentation. In addition, the patient had abdominal pain, nausea, vomiting, and loss of balance. He also reported a clogged ear on the right side and difficulty eating for three days.
At the time of the initial evaluation, the patient also reported a fall that occurred 10 days before his presentation and resulted in an injury to the right leg.
Two days before his admission, he developed chest pain, which he described as squeezing. The review of systems was also positive for constipation for at least two weeks. The patient also complained of abdominal pain that was periumbilical, with radiation to the left flank.
At the time of the initial evaluation, the patient was afebrile. The pulse rate was 65 beats per minute (bpm), respiratory rate was18 breaths/minute, blood pressure was 124/78, and oxygen saturation was 98% on room air. The patient was admitted to the hospital with a diagnosis of abdominal pain that was attributed to constipation. The constipation was likely related to Methadone use. The patient was started on a bowel regimen.

The health plan's determination is overturned in whole.

The inpatient hospital admission was medically necessary.  The presence of persistent acute kidney injury that was associated with significant hyperkalemia completely justified admission at the acute inpatient level of care.
The review of the medical records demonstrated that during almost the entire hospital stay the patient continued to be in acute kidney failure, which was associated with significant hyperkalemia. The patient received treatment with intravenous fluids, insulin, glucose, and Lokelma, but continued to be hyperkalemic.
Hyperkalemia might cause cardiac toxicity and requires proper evaluation and treatment. During this period, the patient needs to be monitored closely.
The review of the medical records demonstrated that despite treatment, the patient remained hyperkalemic. Eventually the serum potassium level came down to normal, but the patient still had mild acute kidney injury.
Taking into consideration all these facts, the admission at the acute inpatient level of care was completely justified to treat acute kidney injury and hyperkalemia.
In this clinical case, the treatment of acute kidney injury and associated hyperkalemia went far beyond what can be usually accomplished at the a lower level of care status.