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

Diagnosis: Chest pain
Treatment: Inpatient admission

The inpatient admission was not medically necessary.

The patient is a female. She presented to the ED complaining of acute onset shortness of breath and chest pain that began one hour prior to presentation.  She also reported night sweats and pleuritic chest pain on deep inspiration over the right lung.  Past medical history was significant for coronary artery disease (CAD) status post (s/p) percutaneous revascularization, hypertension, pulmonary embolism and HIV disease.  Outpatient medication included hydrochlorothiazide, antiretroviral therapy and Xarelto. 

On physical exam, the patient was afebrile, and her vital signs were stable.  Lung exam was unremarkable.  Electrocardiogram did not reveal evidence of acute myocardial infarction, and serial blood testing did not reveal an elevation in cardiac enzymes.  CT angiogram was performed and ruled out pulmonary embolism, however findings of right lung atelectasis and fibrosis at the right lung base were noted.  The patient was admitted for further management.

This patient did not have a myocardial infarction.  No other abnormalities or findings consistent with an acute coronary syndrome were noted.  Based on history and presentation alone, this patient had a low short term risk of death and nonfatal cardiac ischemia (Reference 1).  Sudden onset shortness of breath is concerning for pulmonary embolism and this was ruled out with a CT angiographic study.  This finding is consistent with a low risk of future morbidity and mortality in three months following presentation (Reference 2).  Of note, the CT study revealed right lower lobe atelectasis and possible pneumonia, correlating with the patient's symptoms of right sided chest pain. She was not hypoxic and did not have fever or an elevated white blood cell count. She would be considered low risk and appropriate for treatment at a lower level of care (Reference 3).  In conclusion, it was appropriate to treat this patient at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia

Treatment: Inpatient hospital admission

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

This patient is a female with a history of fibroids and menorrhagia. She presented to the Emergency Room (ER) 19 per request of her gynecologist for evaluation of a low hemoglobin level. Her initial vital signs were: blood pressure 109/58, pulse 80, respirations 20, temperature 98.6F. She also reported generalized weakness over the past few weeks and recent shortness of breath and dizziness, especially when standing.  Initial blood work revealed hemoglobin 6.2 and hematocrit 21.2. The patient was admitted for management of anemia and was transfused 1 unit of packed red blood cells. Repeat blood work revealed hemoglobin 6.8 and hematocrit 22.2. A 2nd unit of packed red blood cells was transfused. Intravenous Venofer was administered. The patient remained stable and was discharged.

This patient was complaining of dizziness; in other words she was symptomatic for anemia. This patient also fulfills the transfusion guidelines for use of blood components: her hemoglobin was less than 8 g/dL and she was symptomatic, so transfusion was necessary.

It is common for transfusions are done routinely in outpatient settings (oncology clinics, infusion centers, even at home). So the need for transfusion is not a reason for admission. This patient was admitted and transfused. Except for receiving 2 units of packed red blood cells (PRBC) and Venofer nothing was done in the hospital. Ideally this patient could have been transfused in the Emergency Department (ED), monitored for a few hours, her complete blood count (CBC) repeated and then discharged home with a follow up within 24 hours with her primary physician or gynecologist. 

MCG: Anemia criteria list the clinical indication for inpatient care for patients with anemia. These include: active massive hemorrhage, active hemolysis, cognitive impairment, tachycardia, orthostatic changes, heart failure, chest pain, syncope. This patient did not have any of these. The patient could have been transfused in the observation area and discharged after finishing her transfusion.

Based on all of the above, the admission was not medically necessary. The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. The insurer's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stenosis
Issue under review: Inpatient Admission

Determination:
The inpatient admission was medically necessary.

The patient is an elderly adult male. He has a past medical history significant for HTN (hypertension), dyslipidemia, DVT (deep venous thrombosis), CAD (coronary artery disease), s/p (status post) CABG (coronary artery bypass graft), as well as s/p PCI (percutaneous coronary intervention) of SVG (saphenous vein graft) to OM1 (obtuse marginal), recently diagnosed severe aortic stenosis, systolic dysfunction with EF (ejection fraction) of 45-0%, who was planned to undergo TAVR (transcatheter aortic valve replacement) and a coronary angiogram was performed. 

The patient was found to have severe stenosis of SVG to LAD (left anterior descending) and OM1, and PCI of both vein grafts was performed with implantation of DES (drug-eluting stent). The patient was admitted to telemetry following this PCI and was monitored overnight.

This patient was admitted for an elective cardiac catheterization and PCI. It is common to perform these procedures on an outpatient basis in low risk patients with no significant peri-procedural complications. This patient has severe aortic stenosis, moderate LV systolic dysfunction and complex coronary anatomy, with significant stenosis in two vascular territories (LAD and LCX [left circumflex]), requiring PCI of 2 separate venous grafts. He would be considered a high risk PCI patient. 

Patients such as this one were excluded from the studies of outpatient PCI. It would be consistent with the current standard of care that this patient, after this complex PCI with stenting of two vein grafts, be managed in an inpatient setting. Therefore, the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Teeth Spacing Problem
Treatment:  Dental/Orthodontic Procedure

The patient in question is a male with a Class II malocclusion and anterior crossbite of tooth #7.  There is 3 millimeter (mm) of overjet and 4mm overbite.  There is some recession present on tooth #27.  He is treatment planned for 24 months of orthodontics to correct his malocclusion.  This is the subject of this review.

The health plan's determination is overturned.  Braces: Comprehensive Orthodontic Treatment is medically necessary for this patient.
The patient has significant maxillary anterior crowding with tooth #7 in crossbite.  This tooth has a high risk for restorative problems in the future due to their traumatic occlusion with the mandibular teeth.  Studies have shown that even the untreated dentition shows increased anterior irregularity with time, which will make treating this occlusion at a later time more difficult.  Tooth #27 already has some recession, and further movement of tooth #27 will likely lead to the need for future for periodontal grafting on this tooth.  Orthodontic treatment now will likely prevent the need for future expensive periodontal and restorative procedures.  For these reasons orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Spastic quadriplegic cerebral palsy
Treatment: Consumer Directed Personal Care Assistance services, 12 hours per day, 7 days per week; a total of 84 hours per week

The patient is a male child born prematurely following pregnancy complicated by ruptured uterus (he was in the abdominal cavity) and ruptured placenta, with initial Apgar score 2. He has since been diagnosed with spastic quadriplegic cerebral palsy, failure to thrive, and global developmental delay. He is wheelchair bound, non-verbal, and incontinent of bowel and bladder. He is dependent upon caregivers for assistance with all activities of daily living above and beyond needs of typical children his age. He is at risk for falls, and was seen in the ED earlier this year because of a fall. He lives with his parents and three older brothers. Historically, he had been approved for 18 hours daily of home care services, but under his current coverage has only been approved for 15 hours per week. When evaluated to assess needs, nursing confirmed that he requires 12 hours of nursing a day since he can do nothing by himself.   

This young school-aged male child has a number of deficits and disabilities as a result of and in addition to his anoxic birth injury (ruptured uterus, ruptured placenta). He is dependent upon caregivers for all activities of daily living. He is unable to perform age appropriate activities and care for himself in an age-appropriate manner. Based on the current standard of care and the documentation submitted, home health care services 12 hours daily are medically necessary and appropriate.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Thyroid Problems 
Treatment: Pharmacy / Prescription Drugs 

The patient has a history of multiple gastrointestinal surgeries, including bariatric bypass surgery, gastric sleeve and lap band.  The patient is also on Lithium for bipolar disorder.  The patient has tried Synthroid, Levothyroxine and other formulary preparations of thyroid hormone with failure to achieve the goal thyroid stimulating hormone (TSH) and clinical response.  The endocrinologist prescribed Tirosint with good response. 

Overturn, in whole the health plan determination. 

This patient has tried multiple formulary alternatives of levothyroxine with poor response, and for this reason the patient was referred to an endocrinologist who prescribed Tirosint with good response.  Unlike the formulary preparations, Tirosint has no inactive ingredients, and the absorption of Levothyroxine is more effective.  The patient has had multiple bariatric procedures that cause malabsorption of nutrients.  It is known that some inactive ingredients may be malabsorbed, therefore, the formulary alternatives are malabsorbed to different degrees and the response to therapy becomes inconsistent.  In this patient, Tirosint was prescribed with the expected good response and consistency and of the TSH value.

"Tirosint/Tiche/Syntroxine is a unique LT4 product available in the USA and Europe as a soft-gel capsule, and in Europe as a liquid formulation.  Lactose-free soft gel (LT4 dissolved in glycerin surrounded by a layer of gelatin) and liquid formulations (LT4 dissolved in glycerol and ethanol) are bioequivalent to traditional LT4 tablets in healthy volunteers, but may perform better in patients with gastrointestinal malabsorption conditions and when taken with foods and certain interacting drugs, and in patients with TSH values close to the limits of the desired therapeutic range" (1).
Appeal type: Medical necessity
Decision: Upheld

Chest pain
Inpatient hospital

The patient is a woman with a history of hypertension and bronchitis.  She presented to the emergency department complaining of two days of cough, dyspnea and intermittent chest pain.  She also reported lower extremity swelling.  Her blood pressure was 148/83 mmHg with a heart rate of 65 beats/minute.  Her respiratory rate was 20/minute with a room air oxygen saturation of 98%.  On physical exam, her chest pain was reproducible with palpation.  There was trace ankle edema.  Her electrocardiogram and two troponin levels were normal.  Chest X-ray was unremarkable.  Lower extremity venous ultrasound showed no evidence of deep vein thrombosis.  She was treated with an inhaled bronchodilator and a cough suppressant and was admitted to the hospital to rule out acute coronary syndrome.

The health plan's determination is upheld.  An inpatient level of care was not medically necessary.

This woman presented with atypical chest pain that was thought to possibly represent acute coronary syndrome (ACS).  Observation until ACS was ruled out was a reasonable approach.  However, she was hemodynamically stable, with a normal electrocardiogram and two normal serum troponin levels.  She 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.   This approach has been shown to be both safe and effective 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.  Moreover, the woman's HEART Score, based on the HEART Pathway decision aid designed to identify emergency department patients with acute chest pain who would be suitable for early discharge, was low at 2 and signified a low risk for major adverse cardiac events.
Appeal type: Medical necessity
Decision: Upheld

Spinal Cord Injury
Durable Medical Equipment (DME) (including Wearable Defibrillators)

The patient is a woman with unspecified level quadriplegia due to C7 fracture sustained during a fall down the stairs. She is dependent and requires maximal assistance for all ADLs (activities of daily living). Her course has been complicated by pneumonia and a stage IV sacral pressure ulcer. She was prescribed a Freedom Bed, by ProBed Medical. This is the subject of this review.

The health plan's determination is upheld. The Freedom Bed is not medically necessary for this patient. Per the documentation submitted, the patient is dependent and requires maximal assistance for all ADLs and bed mobility. She is unable to turn or reposition in bed. While the Freedom Bed would provide computer controlled, automated turning and pressure relief while the patient is in bed, it has not been proven to be superior to other pressure relief beds and/or mattresses. While there is one study from 1999 demonstrating the efficacy of the Freedom Bed, there are no other studies in the peer-reviewed medical literature to support this bed as being the most appropriate and economical device for the patient. While this particular bed does appear to be effective at laterally rotating the patient and reducing pressure areas and respiratory infections, it is not standard medical practice to use this type of device for prevention of complications of immobility.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Impairments due to multiple medical conditions
Issue under review: Consumer Directed Personal Assistance Services

Determination:
The Consumer Directed Personal Assistance Services is medically necessary.

This is an adult female with a history of obesity, depression, right hip, right knee pain, anxiety and asthma. Due to impairments related to these conditions, she requires assistance with many of her activities of daily living (ADLs). The patient is totally dependent on assistance from others for laundry and housekeeping. She needs extensive assist with shopping, lower body dressing and meals. She requires limited assist with toileting and bathing due to excessive skin causing her difficulties with self-hygiene. For these reasons, the currently approved plan of 29 CDPAS hours is not sufficient to meet the patient's needs. Hence, the proposed treatment of an increase back to CDPAS 41 hours per week is deemed medically necessary for improved assistance with completion of the patient's ADLs.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who presented to the emergency room (ER) with a chief complaint of fevers, chills, myalgias and abdominal pain and questionable urinary frequency (conflicting reports in the record).  She denied nausea, vomiting, chest pain, or other complaints.
On presentation, she was febrile to 100.6 degrees Fahrenheit with blood pressure (BP) 103/67, heart rate (HR) 90s-120s, and oxygen saturation 100% on room air (RA).  Her exam otherwise noted costovertebral angle (CVA) tenderness.  Lab results revealed white blood cell count (WBC) 21, Hemoglobin (HGB) 12.1, platelets (Plt) 215, sodium (NA) 139, potassium (K) 3.5 blood urea nitrogen (BUN) 8, creatinine 0.69.  A urinalysis (UA) was positive for nitrites and 25-50 WBCs.  The patient was given intravenous fluids (IVF) and IV antibiotics (abx) and was subsequently brought into the hospital with assessment that she had a UTI with hemodynamic stability and with plans for continuation of IV, IV abx, computed tomography (CT)of the abdomen/pelvis (A/P) to assess for pyelonephritis, and following up urine and blood cultures.
The health plan's determination is upheld.

This patient presented with fevers and body aches with concern for UTI and developing pyelonephritis. She had a fever, tachycardia, and leukocytosis on presentation, but she had no fever after the initial temperature, no hypotension, and no lactic acidosis. She was noted by the admitting physician to be hemodynamically stable. She had no history of recurrent UTIs and concomitant risk of growing resistant organisms, uncontrolled diabetes mellitus (DM) or other comorbidity complication her care and increasing her morbidity, no obstructive stone, and no associated renal failure.  In this setting, it could have been expected that she had a high likelihood of improving quickly, and she did.  Acute inpatient admission was not medically necessary and care could have been provided at a lower level.
In the absence of ongoing hemodynamic instability, with the patient noted to be hemodynamically stable at the time of admission  and in the absence of a urinary tract abnormality, concomitant UTI, emphysematous pyelonephritis, uncontrolled DM or other immunocompromising condition, history of UTIs at risk of growing an antibiotic-resistant organism, or nausea and vomiting precluding her from being able to take oral antibiotics, an inpatient stay not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with hypertension and hyperlipidemia who presented for elective coronary intervention on a 100% occluded left anterior descending lesion.  It had been tried unsuccessfully once before.  The procedure was performed successfully without complications.  The patient was monitored uneventfully overnight and discharged the following day.  The health plan's determination is upheld.  The patient had an elective uncomplicated catheterization and coronary intervention.  It was appropriate to monitor the patient post-procedure for several hours but that could have been performed at a lower level of care.  It was expected that discharge would have been accomplished within 24 hours in this low risk patient.  Therefore, an inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient stay

Summary:
The patient is a woman. She presented to the hospital complaining of left sided chest pain and shortness of breath after awakening in the morning.  She had similar symptoms with a negative cardiac catheterization several years earlier.  

This patient presented with chest pain and a past medical history of hypercholesterolemia.  Cardiac catheterization several years prior was unremarkable.  Her pretest probability of coronary artery disease is low (Reference 1).  Utilizing the HEART (History, EKG, Age, Risk factors, initial Troponin), score she was considered low risk (Reference 2).  Utilizing the TIMI (thrombolysis in myocardial infarction) risk score, she also had a low risk of developing major adverse cardiac events in the subsequent 30 days (Reference 3). 

Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati et al (Reference 3).  Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation.  Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation.   Admission to the hospital to treat an acute cardiac event was not medically necessary. In conclusion, this patient could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cervical radiculopathy and segmental dysfunction of thoracic spine.
Treatment: Continued chiropractic services

Summary:
The patient is a male. The SOAP (subjective, objective, assessment, plan) notes indicate that the patient presented complaining of neck and upper back pains. The patient reported unchanged to slightly worse symptomatology on those two dates of service. The patient was treated with spinal manipulation, traction and ultrasound. The records indicate that the patient's cervical ranges of motion were measurably restricted. The diagnoses are listed as cervical radiculopathy and segmental dysfunction of thoracic spine. 

The records are not sufficient to establish that the patient's condition was of such complexity to require the administration of a course of chiropractic care for more than six months in duration. Moreover, the records fail to establish through regular and timely collections of measurable objective data at the time of the initial evaluation and throughout the course of care to document that the patient was continuing to measurably and objectively improve in response to the ongoing course of chiropractic intervention. Moreover, the case notes report that the patient's subjective pain levels were improved, however, the case notes indicate that the patient's subjective pain levels did not substantially measurably improve or sustainably progress. Absent documented evidence that the patient was continuing to measurably progress from a subjective and/or objective standpoint, the records would not support the medical necessity for ongoing similar chiropractic intervention for the same/similar condition as effective for the patient's condition during the dates of service in question.