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

Diagnosis: Schizophrenia, CAD
Treatment: Additional seven skilled nursing visits
The proposed treatment of seven additional skilled nursing visits is not deemed medically necessary. 

This is a male patient with a history of schizophrenia, diabetes mellitus and coronary artery disease. The medical records indicate that the patient has been effectively taught how to correctly perform daily insulin injections for treatment of his diabetes mellitus. Furthermore, the patient is not homebound/bedbound and therefore is able to attend outpatient clinic appointments. For these reasons, the requested health service of seven additional skilled nursing visits is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Dependence 
 
Treatment: Inpatient Substance Detoxification

The insurer denied the Inpatient Substance Detoxification. The denial was reversed.    

This is a middle aged female who was admitted to the hospital for inpatient heroin detoxification treatment (medically supervised withdrawal service) in early 2019. She was using multiple bags of intravenous (IV) heroin, crack, and smoking tetrahydrocannabinol (THC) daily. She had a history of two past substance treatments and was unable to maintain abstinence. Her withdrawal symptoms included; restlessness, joint pain, yawning, anxiety, and insomnia. She had a Clinical Opiate Withdrawal Scale (COWS) score of 8.  She was put on a methadone detoxification protocol and Clonidine to assist with treatment of withdrawal during her admission. She completed detoxification treatment and was discharged to an outpatient substance abuse discharge program. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders report 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.  In this case, this patient had use of multiple substances including heroin, crack, and cannabis and was at risk for overdose. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), she did require 24-hour treatment as she could not safely and effectively be treated for detoxification in a less restrictive setting. This was evidenced by her continued use of substances despite multiple prior substance treatments. The patient needed two detoxification medications to modify withdrawal for heroin, including taking methadone and also using Clonidine to modify withdrawal symptoms. She had long term multiple substances use including using heroin, crack, and cannabis, and she needed 24-hour treatment as she was at risk for worsened withdrawal symptoms if not in this 24-hour setting.  She likely would have relapsed again as she had relapsed after prior treatments. Patient documentation reported that she still required and received methadone 10 mg for detoxification treatment and that the methadone taper was in progress.

The carrier's denial of coverage for the inpatient hospital services at the Medically Supervised Withdrawal Service level of care is reversed. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sudden heart problems
Issue under review: Inpatient admission

Determination:
The Inpatient admission was medically necessary.

The patient presented with dyspnea, and had a cardiopulmonary arrest, requiring 30 minutes of active ACLS code. The patient was found to have severe LV dysfunction with reduced systolic function and suspected ACS. The patient was transferred to the medical center for cardiac catheterization for suspected ACS in the setting of cardiac arrest. Given the presentation, cardiac arrest, as well as clinical suspicion for an acute coronary syndrome/unstable angina, she would not be an appropriate candidate for an observation unit, and it would be consistent with the current standard of care that this patient be managed in an inpatient setting. Therefore, the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope/seizure
 
Treatment: Inpatient admission, monitoring

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

This case involves a young male who presented to the Emergency Room due to a collapse and loss of consciousness while running at school.  There was no shaking movement or tongue biting reported.  The patient had some confusion for 10-15 minutes that prompted a work-up for possible seizure activity.  The patient's vital signs included a blood pressure of 117/62, heart rate of 102, respiratory rate of 19 and temperature of 97.8 degrees.  It was stated that following the incident, the patient was confused for several minutes; he was unable to recognize teachers and had slurred speech and weakness in the right upper extremity.  On examination, the patient had a negative pronator drift.  The patient had 4/5 strength in the right upper extremity.  The treatment plan included laboratory studies, EKG, a non-contrast CT of the head, and consults with neurology and cardiology.  Laboratory studies, echocardiogram and CT scan of the head were normal.  The patient was admitted with a diagnosis of syncope/seizure with recommendation for video electroencephalogram (vEEG) and monitoring.  The patient's right arm weakness and decreased sensation resolved.  The patient was subsequently discharged home.

The MCG indicate that admission would be appropriate for a patient with an altered mental status that is severe or persistent, or for a patient with cardiac disease or finding.  It would also be appropriate for a patient when they have other conditions, treatment, or monitoring required.  They also indicate that observation would be appropriate for a patient with vital sign abnormality or altered mental status. The records failed to support the patient could not have been placed on observation status, and if admission was necessary, could not have been admitted at that time.  The patient had undergone studies that were normal.  The CT scan of the head was normal.  The EKG was normal.  The patient had no further instances. 

The inpatient hospital admission is not considered medically necessary for this 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: Upheld

This is a patient who sustained a left fibula fracture as a result of an injury while playing football. The patient was admitted to the hospital on  for evaluation of this injury. The recommendation was for surgical intervention. Due to significant soft tissue swelling, the patient was advised on icing and elevation until 3/6/19 at which time he underwent open reduction and internal fixation and syndesmotic ligament fixation. The health plan's determination is upheld.  The provided medical records document a displaced left fibula fracture with an associated syndesmotic ligament disruption. The records also document swelling in the left ankle and leg which delayed surgical intervention. The patient had the surgery on that date and was discharged home the same day. There is no rationale provided in the medical record as to why the patient was not discharged home in a splint. He could have been brought back to the hospital at a later date when the swelling subsided to complete the operation on an outpatient basis. Outpatient management of ankle fractures has been shown to have a lower complication rate by Qin and colleagues who published their results in the Journal of Bone and Joint Surgery. 

The health plan's determination of medical necessity is upheld. The current literature has documented that outpatient management of ankle fractures such as the one in this case have a lower complication rate. Therefore, the medical necessity of the inpatient stay in this case is not supported by the current, peer-reviewed orthopedic literature.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory failure due to bronchiolitis
 
Treatment: Inpatient admission, medication, monitoring

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

This patient is a female child, with a history of premature birth at 33 weeks of gestation and a previous admission to the hospital for bronchiolitis which required intubation. The child had been sick for 2 weeks with a cough and congestion, and there were sick contacts in the home. The child was seen by the pediatrician and was treated with amoxicillin and inhalation treatments. Following treatments in the home, the child developed fever for 4 days, and when there was increasing difficulty breathing the mother brought the child to the emergency room (ER). In the ER the child was noted to be in respiratory distress with tachypnea, wheezing, retractions and stridor was noticed when crying. She was treated with intravenous (IV) bolus of normal saline, Decadron and (3) series of treatments with Combivent. A chest x-ray and testing for influenza and RSV were normal. The patient had an elevated lactate level of 3.5 and low bicarbonate of 17. Following the treatment in the ER the child continued to have evidence of respiratory distress with intercostal retractions and she was started on high flow oxygen and antibiotic. The decision was made to admit the child to the pediatric intensive care unit (PICU) for continuation of respiratory treatments.

The patient was at high risk for severe respiratory illness because of premature birth, a previous hospitalization which required intubation and the stridor noted when crying. She was treated appropriately for respiratory distress in the ER and when her symptoms did not improve, she required high flow oxygen and admission to PICU for frequent administration of nebulizer treatments. The clinical impression on admission was respiratory failure from bronchiolitis, and subsequently the respiratory viral panel was positive for a metapneumovirus infection. The admission to the hospital for continued treatment was medically necessary and the child could not have been safely discharged when still requiring high flow oxygen.

Based on the above, the medical necessity for the inpatient hospital admission is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

The patient  who was brought by Emergency Medical Services (EMS) to the emergency department with worsening chest pain radiating to left arm and into the fingertips and associated with epigastric discomfort, nausea and diarrhea. The chest pain was graded 9-10/10 in severity, like "someone putting pressure", and lasting for 5-10-minute intervals since Saturday. The patient was treated with sublingual nitroglycerin and aspirin with mild relief. The patient underwent a stress test, which was abnormal, there was "small, mild to moderate defect in basal to mid inferior wall that is reversible". The patient underwent cardiac catheterization. The coronary intervention with stent placement in RCA was done at the same setting. The health plan's determination of medical necessity is upheld in whole. This patient could have been managed at a lower level of care. The inpatient stay was not medically necessary. The patient  did not have acute coronary syndrome. The troponin was normal, and there were no ECG changes. No arrhythmia, heart failure or hemodynamic instability. The RCA lesion was severe, but with brisk flow. There was no evidence of thrombus formation or plaque rupture. The lesion was severe but stable, due to chronic coronary artery disease, not acute coronary syndrome.
Appeal type: Medical necessity
Decision: Overturned

The patient is a female who fell from the monkey bars and sustained a left supracondylar humerus fracture and left distal radius fracture. The supracondylar fracture is described as comminuted. The patient was initially seen at one hospital, then transferred to another hospital for treatment. She underwent closed reduction and percutaneous pinning of the supracondylar fracture, and closed reduction of the distal radius fracture. The health plan's determination is overturned.

The inpatient stay is medically necessary for this patient. Supracondylar humerus fractures are usually described as being Type 1, 2, or 3. Types 1 and 2 have a low risk of neurovascular problems and can generally be managed on an outpatient basis. Type 3 fractures are more severe and can lead to severe neurovascular problems. This patient's fracture is described as "comminuted" and there is an associated distal radius fracture. These two findings suggest that this is a higher energy fracture, probably a Type 3 fracture. For such fractures it is important to monitor neurovascular functions carefully and to be ready to intervene if problems arise. This higher level of care justifies treating this admission as an inpatient hospital stay.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left shoulder pain
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

The patient presented with left arm pain. He gave a history of using his left arm to drive his taxi cab and was recently lifting heavy luggage. He denied any cardiac symptoms. He presented pain free. It is unclear why an EKG was done. The EKG revealed frequent PVCs, but the patient was asymptomatic. He also admitted to drinking a lot of coffee. There was no documentation of any runs of ventricular tachycardia. The patient did need an evaluation for the frequent PVCs which were an incidental finding. This could have been done as an outpatient or in a monitored observation bed status. He had pain relief with Toradol, no elevated serial troponins, a normal ejection fraction and had a stress test and echocardiogram, in addition, to a cardiology consult. Cardiology felt the left arm pain sounded non-cardiac with negative cardiac enzymes. The patient was recommended for an echocardiogram to check if the PVCs were affecting the patient's left ventricular function and if the ejection fraction was normal; an outpatient 24 Holter and stress test were advised.

Again, the patient's evaluation again could have been done in a monitored observation bed. His diagnoses were left arm pain likely musculoskeletal, no evidence of cardiac ischemia and PVCs stable.
In view, of the frequent premature ventricular contractions, it was appropriate to further evaluate the patient's cardiac status. However, a cardiology consult, echocardiogram and stress test could have bed done as a monitored observation status.  It is unclear why the EKG was done without any symptoms, no cardiac history, and no cardiac complaints.
Appeal type: Medical necessity
Decision: Overturned

This patient has allergic rhinitis, and had 2 episodes of anaphylaxis after strenuous exercise, with no other etiology found. The first episode was very severe, and did not resolve after 2 doses of epinephrine. The patient was eventually taken to the emergency department (ED), where the patient received an additional epinephrine plus steroids before he improved. The second episode resolved with one epinephrine injection alone. The patient was started on subcutaneous immunotherapy, as high pollen counts were thought to contribute to his symptoms, but since the allergy shots will take around one year to become effective, his doctors are requesting omalizumab for him in the interim period.

The health plan's determination is overturned. The omalizumab is medically necessary for this patient. The patient has had life threatening episodes of exercise-induced anaphylaxis. Since this condition is rare, there are no randomized trials of therapy for exercise-induced anaphylaxis. Thus, there are only low-quality evidence and clinical experience on which to base recommendations. Several case reports describe the successful use of omalizumab to prevent episodes of exercise induced anaphylaxis. Omalizumab is indicated in this case for the prevention of symptoms associated with exercise-induced anaphylaxis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Abdominal pain; blood in stool
Treatment:  Inpatient admission
The inpatient hospital services were not medically necessary.

The proposed acute level care for the management of this patient's condition was not medically necessary.  She was admitted with one to two day h/o left lower abdominal pain and bright red blood per rectum.  In the ED, her blood pressure was markedly elevated, which was controlled with antihypertensive medication recommended by the Nephrologist who also saw the patient for the management of hemodialysis.  In the ED the rectal examination revealed brown to brick colored stools.  Her Hb/HCT were stable.  She was started on IV PPI, IV Zofran and IV Dilaudid.  She was evaluated by GI consultant, and EGD was done which revealed pill-induced esophagitis and no evidence of bleeding.  The colonoscopy revealed normal ileocolonic anastomosis and no evidence of bleeding.  During the patient's hospitalization her Hb/HCT remained stable, and she did not require any blood transfusion.  During her hospitalization she had no recurrence of GI bleed.  She was initially started on clear liquid diet, and then her diet was progressed to regular diet after her colonoscopy.  Her abdominal pain was controlled with Dilaudid IV PRN.  Since she was taking PO diet without any nausea and vomiting, her pain could have safely managed with oral pain medications instead of IV Dilaudid.  In view of this clinical scenario this patient could have been safely managed under lower level of care, and acute level care was not appropriate and medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Foot pain
Issue under review: Custom shoe orthotics

Determination:
The Custom shoe orthotics are medically necessary.

The treatment delivered is in keeping with reasonable acceptable standard of medical care for this condition.  Typically for plantar fasciitis, conservative care involves using custom orthotics.  The patient has been using custom orthotics for several years and they have worn out, and the treatment has already been shown to be effective for the patient.

Plantar fasciitis is typically treated with orthotics conservatively prior to more invasive treatment, such as corticosteroid injection and surgery.
Appeal type: Medical necessity
Decision: Upheld

The patient presented to the emergency room after a fall down the stairs from which he had multiple facial fractures including acute fractures the right lateral, medial, and inferior orbital walls; acute fractures of the right maxillary sinus and anterior nasal spine of the right maxilla; a fracture of the right zygomatic arch; bilateral nasal bone fractures and fracture of the nasal septum. He also had hyphema of the right eye. A computed tomography (CT) scan of the head also showed a possible intraparenchymal hemorrhage in the right frontal lobe. He was evaluated by oral surgery and neurology and admitted  with plans for surgical intervention on the day of admission after he was cleared by neurology. He was also evaluated by ophthalmology. The patient underwent an open reduction internal fixation (ORIF) of his zygomatic fracture. He was discharged to home on the following day.

The health plan denied the inpatient admission as not medically necessary. The health plan's decision is upheld. Although this patient had multiple fractures, the repair was the same day and did not require inpatient management. The antibiotics could have been oral and, while close follow up was necessary, this could have been done at a lower level of care, as documented in the articles referenced. The case also does not meet InterQual criteria for inpatient management. The hypertension that was cited by the hospital as part of the reasoning for inpatient stay was treated with oral Norvasc and the patient was not symptomatic from it. It did not require inpatient management.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nasopharyngeal invasive Squamous Cell Carcinoma.  
 
Treatment: Proton Beam Radiation Therapy


The insurer denied the Proton Beam Radiation Therapy
The denial was upheld.

This case involves a male who has been diagnosed with nasopharyngeal invasive squamous cell carcinoma.  The documentation indicated the patient was seen in late 2018 for an initial consult/initial visit.  The patient previously underwent a nasopharynx biopsy weeks earlier with outside pathology noting invasive squamous cell carcinoma.  The patient did report he continued to have some left ear pressure with occasional self-limited left nose bleeding.  The patient has not had any prior radiation.  The physical exam did not reveal any significant abnormality.  The patient did undergo flexible fiberoptic nasopharyngoscopy and it was recommended that the patient undergo radiation therapy.  The physician explained proton beam therapy was able to spare more normal and important organs.

Based on the above, the medical necessity for the proton beam radiation therapy performed is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Hemophilia B
Treatment:  Inpatient Hospital Stay

The Inpatient admission 02/09/2019 through 02/13/2019 was medically necessary.

The patient is a male with hemophilia B with known factor IX (FIX) inhibitors.  He presented with forearm edema.  He was found to have a muscle bleed.  He was admitted to the hospital and was started on Factor VIIa every four hours and was monitored for compartment syndrome.

FIX inhibitors are associated with allergic reactions to FIX, including lifethreatening anaphylaxis, especially in those with gene deletions.  Any reaction should prompt inhibitor testing before further FIX exposure, as even low level FIX inhibitors may cause anaphylaxis.  Patients should have their mutation established as soon as the diagnosis is made to identify the minority of patients with major gene deletions, since FIX inhibitor risk is almost completely confined to this group. 

Randomized trials have compared multiple standard doses of rFVIIa (90 ug/kg) with a single higher dose to treat hemarthroses.  The studies have been small and used different measures of effectiveness but suggest that a single dose of rFVIIa (270 ug/kg) is as effective and as safe as three doses of 90 ug/kg.  A randomized study compared these regimens in 18 patients and showed similar success rates and median rFVIIa usage.  Similar results were obtained in a randomized, crossover, doubleblind study.  Comparative studies of a single dose of rFVIIa 270 ug/kg compared with one or two doses of rFVIIa 90 ug/kg have not been undertaken, although the median number of infusions required to treat haemarthroses has previously been reported to be 24 (including one consolidation treatment), and this must be recognized in any cost effectiveness analysis. 

Therefore, the use of Factor VIIa would be medically necessary for this patient.  Since the patient requires the drug every six hours and is at risk of thrombosis, it is the standard of care to hospitalize these patients until the bleeding is resolved and the drug is being given less frequently.