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

Diagnosis: Cardiac/Circulatory Problems.
Treatment: Inpatient Hospital.
The insurer Denied: Inpatient Stay.
The denial is: Upheld in whole.

The patient is a female with a history of diabetes, hypertension, hyperlipidemia, sickle cell trait and paroxysmal atrial fibrillation. She presented to the emergency department complaining of palpitations, dyspnea and lightheadedness. She had recently been diagnosed with a pituitary adenoma. In the emergency department her blood pressure was 115/58 millimeters of mercury (mmHg) with a heart rate in the 130s. Her physical exam was remarkable for a rapid and irregular heart rate. Her oxygen saturation was 100%. An electrocardiogram showed atrial fibrillation with a ventricular rate of 131 beats/minute. Her serum troponin and pro brain natriuretic peptide (BNP) levels were normal. She was admitted to the hospital for management of atrial fibrillation. Her rhythm converted to sinus shortly after admission. She was seen by a cardiologist who recommended treatment with metoprolol and flecainide. She had brief episodes of atrial fibrillation with a maximum ventricular rate of 120 beats/minute. Flecainide was continued and she had no further atrial fibrillation. She was seen in consultation by a neurosurgeon and resection of the pituitary adenoma was performed. The patient was discharged. Medical necessity for an inpatient stay is the subject under review.

The health plan's determination is upheld in whole.

An inpatient level of care for management of this patient's atrial fibrillation was not medically necessary. For patients presenting with acute atrial fibrillation (AF), the safety of observation level care or discharge to home with close follow-up has been well demonstrated. As stated by Lin et al., "There is growing evidence to suggest that outpatient management is a safe and effective alternative to hospital admission for the management of many patients with acute AF or atrial flutter. Protocols for early rhythm control, clinical decision rules to guide the decision to initiate antithrombotic therapy, and low molecular weight heparin and direct oral anticoagulants have reduced the need for acute inpatient hospitalization. Vinson et al, based on a smaller study and a review of the literature, stated, "The short-term home observation management approach for atrial fibrillation/flutter patients who present early in their symptomatic course has been mentioned in the literature (sometimes called the "wait and watch" method), but it has not been well described. In our sample, 11 of 16 patients (69%) managed with this approach spontaneously cardioverted to normal sinus rhythm within 48 hours of symptom onset. Our findings are consistent with previous studies, which have reported that up to two-thirds of selected patients with presumed recent-onset atrial fibrillation spontaneously convert to normal sinus rhythm within 2-3 days."
The patient could have been managed at a lower level of care status for atrial fibrillation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis Coronary Artery Disease
Treatment Repatha
The insurer denied the Repatha
The determination is upheld.

The patient has coronary artery disease, previous percutaneous coronary intervention (PCI) /stent placement, most recently to the left anterior descending and first diagonal, history of 2 previous episodes of in-stent restenosis, and hyperlipidemia. He has a family history of premature coronary disease. Per his cardiologist, he has been on rosuvastatin 10 milligrams (mg) daily and Zetia 10 mg daily; he experienced myalgias on higher dose statins. His low density lipoprotein (LDL) was 150, high density lipoprotein (HDL) 37 and total cholesterol 221. At this time, he was on pravachol 10 mg daily and Zetia 10 mg daily. Per the appeal letter, the patient is currently taking Repatha, without side effects.
At issue is the medical necessity of Repatha.

Repatha is not medically necessary for this patient. He has atherosclerotic cardiovascular disease and hyperlipidemia. He is on Crestor, 10 mg daily and Zetia, 10 mg daily, but has not had lipid levels drawn on this combination of medications. There is no documentation of failure of these medications in LDL lowering for this patient. The labs provided are from , prior to starting Crestor. Repatha is not indicated, as it is not established that the patient is not at LDL goal.
Appeal type: Medical necessity
Decision: Upheld

Orthopedic/Musculoskeletal
Inpatient hospital

Diagnosis: Back pain
Treatment: Inpatient stay.
The insurer denied the inpatient stay. The health plan's determination is upheld.

The patient is a male with an approximate 5 year history of back pain who had failed conservative treatment. His History and Physical was reviewed for a longstanding history of opioid use for acute on chronic pain. His past medical history included opioid abuse and asthma. He had no surgical history. His exam noted 3/5 weakness in the tibialis anterior on the right. His home medications included oxycodone 5/325, albuterol inhaler, Claritin D, Prozac and Klonopin. He was admitted for an elective L4-5 laminectomy discectomy. 

The inpatient stay is not medically necessary. This patient's care could have been provided at a lower level given his need for a PCA pump due to a chronic opioid use and the hemovac drain. Lumbar laminectomies are considered to be outpatient or observation level unless there are significant complications, have an ASA score of 3 or above with prolonged anesthesia, poor pain control or motor loss. In this case, his surgery had no complications, his PCA was planned with good pain control overnight, he was voiding, taking oral fluids/solids, and ambulating without difficulty. A lower level of care was appropriate.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Narcolepsy with Cataplexy

Treatment: Formulary Exception for Xyrem 500mg/ml OR SOLN

The insurer denied coverage for Formulary Exception for Xyrem 500mg/ml OR SOLN. The denial is upheld. 

This patient is a male with a diagnosis of Narcolepsy with Cataplexy. The patient has an Epworth Sleepiness Scale (ESS) of 9 (9-24: abnormal (possibly pathologic) sleepiness). The patient is being prescribed Xyrem. As per insurance company this medication is not in their formulary. The medications in the Formulary include: Venlafaxine ER, Fluoxetine, Atomoxetine, Protryptyline, and Clomipramine.

As noted in Up to Date, the "Antidepressants that selectively inhibit the reuptake of norepinephrine or serotonin include venlafaxine, atomoxetine, and fluoxetine. Clinical experience suggests that they may substantially reduce cataplexy with relatively few side effects, although data from clinical trials are lacking [37]. We prefer extended release venlafaxine at a dose of 37.5 to 150 mg each morning, although fluoxetine is also acceptable. With either of these medications, a reduction in cataplexy should be obvious within a few days." In addition, "For many years, cataplexy was treated with tricyclic antidepressants such as protriptyline or clomipramine that decrease the reuptake of aminergic neurotransmitters. These drugs are very effective, but many patients are bothered by anticholinergic side effects, including dry mouth and constipation [38]. Nonetheless, they are quite effective for suppressing cataplexy, and low doses can be effectively used on an as-needed basis just before social events likely to trigger cataplexy such as a party or wedding."

The formulary drugs are not likely to cause the patient an adverse reaction. The formulary drugs have not been ineffective based on the patient's clinical history. As per the submitted notes the patient has tried Modafinil, Armodafinil, Methylphenidate, Atomoxetine, and Vyvanase and had some side effects or non-response to these medications. However there is no documentation indicating the patient was tried on Venlafaxine ER, Protryptaline or Clomipramine or that he had side effects or non-response from these.  

The requested drug has not been shown more effective in comparative trials. In addition, it has abuse potential and can result in severe sedation and coma. 

In summary, several of the medications on the formulary are effective in treatment of narcolepsy/catoplexy with reasonable side effects. 

Based on the above, the denial for Formulary Exception for Xyrem 500mg/ml OR SOLN is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tachycardia, Hypertension
Treatment: Inpatient admission
The insurer is denied coverage for inpatient admission.
The denial is upheld. 
This is a female patient with a past medical history of asthma, diabetes mellitus and hypertension. She presented to the ER with complaints of palpitations and shortness of breath. Her initial vital signs noted a blood pressure of 176/117 and pulse 123. The patient reported feeling fatigued and appeared drowsy on exam. The ER provider notes the patient was previously seen in the ER for the same symptoms. Laboratory work up was performed that revealed carbon dioxide 21, troponin 0.00, d-dimer 426 (previous result was 462 and b-type natriuretic peptide 11.4. An electrocardiogram (EKG) showed sinus tachycardia with no acute ST-T changes. The patient refused a chest X-ray or computed tomography (CT) scan. A urinalysis showed moderate bacteria, large ketones, trace protein, and moderate epithelial cells. A urine drug screen was negative. She was treated with intravenous (IV) fluids, Diltiazem IV and oral doses, and Metoclopramide. The patient was admitted to telemetry for hypertensive urgency due to medication non-compliance, and unspecified tachycardia. Anti-hypertensive medications were initiated. An echocardiogram showed mild concentric left ventricular hypertrophy with normal global systolic left ventricular function and no regional wall motion abnormality. Grade I diastolic dysfunction was noted. Her symptoms improved and she was discharged.

The patient presented to the emergency department with generalized symptoms of fatigue, palpitations, and shortness of breath. She was not in congestive heart failure. She was noted to have an elevated blood pressure, but no evidence of end-organ dysfunction. Specifically, she exhibited no evidence of acute neurological injury, myocardial ischemia, heart failure, arrhythmias, hemodynamic instability, or other general medical conditions necessitating inpatient admission status. The patient's care could have been provided under observational level of care. Inpatient admission status criteria was not met or justified based on her clinical presentation, the absence of any evidence of hypertension-associated end-organ dysfunction, or on the clinical course of evaluation and management.

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

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: Orthopedic/ Musculoskeletal
Treatment: Home Health Care
The insurer denied an increase in personal care hours to 84 per week. 
The denial was overturned in whole.

The patient is a female with multiple medical problems. This review is for the medical necessity of level 2 personal care services, per 15 minutes increase to 84 hours per week. The patient was previously receiving 35 hours a week. The increase in hours was denied by the plan based on lack of medical necessity.

The health plan's determination of medical necessity is overturned in whole. 

The requested health service of Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 minutes increase to 84 hours per week is medically necessary for this patient. The patient is a female with a past medical history significant for depression, hallucinations, dementia, uterine cancer status post total abdominal hysterectomy (TAH) bilateral salpingo-oophorectomy (BSO), asthma, hypertension, atrial fibrillation, osteoarthritis, hypothyroidism, peripheral artery disease, anxiety, congestive heart failure (CHF), hyperlipidemia, breast cancer status post mastectomy, and advanced age with mobility issues.
The rationale for denial by the health plan indicates: Patient has a past medical history significant for arthritis with no loss of motor function noted. It is not medically necessary to increase her hours 84 hours per week. There is no demonstrated changes with most severe functional abilities since prior assessment. She showed no changes with abilities to perform physical functions such as bed mobility, bathing, personal hygiene, dressing upper and lower body, walking, eating, meal preparation, ordinary housework and medication management. Her memory is okay. There is a report of both bladder and bowel incontinence.

Uniform Assessment System (UAS) State of New York completed in the fall, notes the following. Patient ambulates with the use of a roller walker indoors with guided assistance. She self-reported difficulty standing for long period of time due to pain. She needs assistance with access to clothing but is able to button up her body. She needs some assistance to get on and off the toilet. Member reports bowel and bladder incontinence. Patient was able to walk between 150-299 feet. Patient was able to walk 13 feet in 22 seconds. Patient did not use a wheelchair. Tasking tool noted a total 27 hours a week of services being medically necessary. Patient is currently receiving 35 hours a week.

Secondary to the coronavirus pandemic, a reassessment with an updated UAS was not able to be completed. Therefore, based upon the medical records provided and the statement from the patient's physician stating that the patient's functional status has declined, the request for additional hours is deemed medically necessary. Determination is based upon the medical records and physician statement noting a decrease in function which support a need for increased hours.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ankle fracture.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female who sustained a left trimalleolar ankle fracture. She was admitted to hospital one week after her injury. Her elective admission diagnosis was listed as left ankle trimalleolar fracture dislocation, traumatic arthropathy. 

On the day of admission, the patient underwent ORIF (open reduction internal fixation) to her ankle fracture. She received spinal anesthesia with popliteal and saphenous nerve blockade. Her operation was non complicated. 

The patient began PT (physical therapy) services. She reported anxiety and lightheadedness. She received a bolus of IV fluid and associated medications. She had difficulty with PT. 

No, the Inpatient admission was not medically necessary.

The medical records demonstrate the woman was admitted to the hospital on a semi-elective basis for her ankle surgery. The injury was low energy. There were no open wounds. She did not injure any other body part. She did not require management of an underlying medical condition. Her operation was straight-forward and performed in a satisfactory manner. 

The patient's post-surgical course was noncomplicated. There were no problems with the surgical site. Her "dizziness" was managed with a bolus of fluid and did not require repeat. Her vital signs then stabilized. The level of anesthesia and pain relief was satisfactory. She was able to tolerate oral pain medication. She received the appropriate prophylactic antibiotic for sufficient duration. 

The patient's findings did report difficulty with mobilization and PT services. Additional and ongoing rehabilitation did not require acute level hospitalization. 

The medical record described DC (discharge) planning involved on POD (postoperative day) #1. There is no documented reason why the patient could not have been treated at a lower level of care.

There were no extenuating circumstances to warrant the admission and length of stay. Therefore, given the above, the Inpatient admission was not medically necessary, as the patient could have been treated at a lower level of care without compromise to her safety or the quality of care provided
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Prostate Adenocarcinoma
Treatment: SpaceOAR, perirectal spacer, procedure code 55874
The insurer denied the SpaceOAR, perirectal spacer), procedure code 55874
The denial was overturned.

This is a male patient who was diagnosed with prostate cancer with a Gleason score of 7 and PSA of 8.42. Recommendations were made for a procedure which will allow advanced radiotherapy protocol without compromising the surrounding organs.  The documentation indicated he has already started treatment with Casodex and Lupron.  He did report side effects including night sweats interfering with sleep.  He also noticed worsening of urinary tract symptoms which included a weak urine stream and urgency.  

The Scientific evidence in peer reviewed literature supports a result in improvement in health outcome.  SpaceOAR, perirectal spacer was tested in a randomized controlled trial.  The spacer was found to reduce the radiation does deliver to the rectum by 73% leading to a 75% decrease in late rectal toxicity (grade 1).

The perirectal spacer is FDA approved for this condition.

This is the appropriate patient to use the SpaceOAR, perirectal spacer.  This is the FDA approved indication, and the patient would have been eligible for the randomized trial showing the benefit of using the spacer.

The SpaceOAR, perirectal spacer would be the best available treatment.

The SpaceOAR, perirectal spacer is the only method to reduce the dose significantly to the rectum.  The perirectal spacer is more beneficial than any other standard treatment/procedures for this patient.

The carrier's denial of coverage for (SpaceOAR, perirectal spacer), procedure code 55874 should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Orthopedic/musculoskeletal. 
Pharmacy/Prescription Drugs. 

Diagnosis: Pain. 
Treatment: Buprenorphine SL 2mg Tab. 

The insurer denied Buprenorphine SL 2mg Tab. The health plan's determination is overturned. 

The patient is a female who was diagnosed with neurofibromatosis at birth. She started to complain of chest pain, neck pain, as well as mid-back pain following the discovery of tumors in her chest and spine. The patient's diagnoses include chronic pain disorder, myalgia, opioid dependence in a controlled environment, and anxiety disorder. Previous attempts at treatment have included acupuncture, medications including narcotic medications, and spinal cord stimulator. 

The Buprenorphine SL 2mg Tab is medically necessary for this patient. The patient was placed on medication-assisted therapy with buprenorphine in the setting of chronic pain disorder and opioid use disorder. However, the patient is noted to be on chronic use of medical marijuana. Like opioids, chronic cannabis exposure induces the development of tolerance, physical dependence, and withdrawal symptoms during abstinence from opioids. A review of recent literature suggests that the relative safety profile of cannabis warrant further exploration of cannabis as an adjunct or alternative treatment for opioid use disorder. 

The patient has chronic pain disorder and developed opioid use disorder. The patient was appropriately placed on medication-assisted therapy with buprenorphine SL 2mg Tab. Although the patient is noted to have concurrent use of medical marijuana, there is no indication of adverse effects from the patient's medication regimen, as well as potentiating opioid withdrawal symptoms.
Appeal type: Medical necessity
Decision: Overturned

Cardiac 
Inpatient hospital 

Diagnosis: Chest pain 
Treatment: Inpatient stay 

The insurer denied the inpatient stay. The health plan's determination is overturned. 

This case involves a male, with a known history of coronary disease, with previous stent placement, who presented to the hospital with substernal chest pain. The patient has a history of polysubstance abuse. He describes the pain as tightness, with diaphoresis, nausea, and radiation of the pain to the left arm. By the time of arrival in the hospital, the patient was pain-free. The patient reported spotty compliance with aspirin, Lipitor, and antihypertensive medications. The last reported use of cocaine was one week before this presentation. The patient also used heroin about 4-5 days before the presentation. There are no fevers chills, syncope, abdominal pain. The patient was admitted to a telemetry floor, started on aspirin, nitroglycerin, and Lipitor. A 2D echocardiogram was ordered to evaluate for regional wall motion abnormalities, as well as a stress test was scheduled for the following day. 

The inpatient hospital stay is medically necessary for this patient. 

The patient satisfies clinical indications for admission to inpatient care, based on the presence of chest pain, and peri-infarct ischemia on the nuclear medicine stress test. The cardiologist recommended an invasive angiogram, to further delineate the causes of the peri-infarct ischemia, and the patient required transfer to the facility with the greater capability of managing these kinds of complex conditions. Therefore, inpatient hospitalization criteria are satisfied. 

The patient is with known coronary disease, used cocaine, and is at a significantly increased risk of developing an acute coronary syndrome, severe vasospasm, which can further damage the myocardium and increase the risk of death. This patient falls into the category and clinically failed observation care.
Appeal type: Medical necessity
Decision: Overturned

Respiratory System
Inpatient hospital

Diagnosis: shortness of breath
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a boy who presented with shortness of breath and cough. He was well until 2 weeks prior to presentation when he developed cold symptoms. Most of his symptoms resolved, however, his cough continued. The day prior to admission, he developed shortness of breath along with the coughing so he was brought to the emergency department. He was given albuterol nebulized treatments and was then sent home with an inhaler. He was using the inhaler every 4 hours at home, however, he continued to have significant breathing difficulty so he returned to the emergency department. He also had decreased oral intake with fewer wet diapers. His past history was significant for eczema. He has a family history of asthma in his father.
In the emergency department, he was found to have a heart rate of 150, respiratory rate of 26, and oxygen saturation of 95% on room air. He had retractions and wheezing on physical examination. He was given albuterol and saline nebulized treatments. However, he continued to have significant symptoms with retractions and an oxygen saturation between 91% and 93% on room air. He was admitted for ongoing treatment for wheezing and respiratory distress.

The inpatient hospitalization was medically necessary for this patient.
This is a young infant who presented with wheezing and respiratory distress. He had been seen in the emergency department and sent home with bronchodilator treatment. However, his symptoms were worsening, and had continued increased work of breathing. When he returned to the emergency department, he was found to have wheezes as well as retractions. After initial treatment in the emergency department, he developed hypoxemia and continued to have these symptoms. He required ongoing treatment in an inpatient setting for frequent bronchodilator administration as well as intravenous fluids with close monitoring and additional treatments as needed.
The decision-making at the time of admission for this patient was consistent with his young age, the presence of ongoing wheezing with respiratory distress despite appropriate treatments, and the need for continued frequent treatments and close monitoring for potential deterioration of clinical status.