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

Diagnosis: Spina bifida, paraplegia, gastric adenocarcinoma, GI bleeding and a stage IV sacral pressure ulcer 
Treatment: Continued Long Term Acute Care Facility 

The insurer denied the continued long term acute care facility. The denial is overturned. 

The patient is a male with a history of spina bifida, paraplegia, gastric adenocarcinoma, gastrointestinal (GI) bleeding and a stage IV sacral pressure ulcer (measuring 13.5 by 12.5 by 2.0 centimeters). The patient was admitted for wound care and comorbidity management, pain management and physical therapy. He was in long term acute care (LTAC) and underwent local wound care as well as surgical debridement. The patient's hemoglobin was noted to be 7.7.  Per the appeals letter from the provider, the patient was on a specialty mattress and also continued to receive blood transfusions for continued anemia and bleeding on several dates. He continued to receive fluids for electrolyte imbalance, blood transfusions for anemia and glucose control. Methadone management and tapering was also initiated and eventually weaned upon discharge. The patient wished to be weaned at the facility and was noted by the facility that he was unable to be weaned in a skilled nursing facility (SNF). 

The records indicate prolonged Methadone weaning, multi-specialty involvement, blood transfusions, frequent wound care and electrolyte management. The patient wished to continue Methadone weaning while inpatient. Due to multiple co-morbidities and inability to obtain all interventions at a lower acuity facility, the inpatient stay for the dates in question is medically necessary (1, 2). 

The ongoing need for weaning, transfusions, and frequent wound care required a prolonged inpatient stay. Since a facility was not willing to accept the patient for Methadone management, a prolonged length of stay was required.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Recurrent and metastatic endometrial cancer. 
Treatment:  Proton treatment delivery; intermediate and Proton treatment delivery; complex.
The insurer denied proton treatment delivery; intermediate and proton treatment delivery; complex. The denial is upheld.

No, the health plan should not cover the proton beam radiotherapy and is not likely to be more beneficial than standard radiotherapy. 

The patient is a female with recurrent and metastatic endometrial cancer s/p (status post) TAH BSO (total abdominal hysterectomy bilateral salpingo-oophorectomy), vaginal brachytherapy, and systemic chemotherapy referred for palliative radiotherapy.   

Proton beam radiotherapy can be controlled with greater precision than x-ray radiotherapy.  This means that more energy goes into destroying the tumor, and less radiation is delivered to surrounding healthy tissue.  For this reason, proton therapy is particularly good for treating tumors near healthy organs, including pelvic tumors.  When treating pelvic tumors, it is critical to protect the delicate organs that surround the tumor.  Proton therapy can potentially reduce damage to small bowels, kidneys, spinal cord, and other organs nearby, thereby reducing the likelihood of side effects and complications. Secondary malignancies are also less likely with proton beam therapy.

Long term clinical evidence to support the use of proton therapy in this case in terms of safety and efficacy has not been well-established.  Peer-reviewed medical articles pertaining to this case to justify the use of proton therapy are few and retrospective in nature.  Standard radiotherapy with photon, either 3D or IMRT (intensity-modulated radiotherapy), for this case would still be considered the standard approach.  Even though technically the proposed treatment is dosimetrically superior to photon therapy, this has not been shown to translate to a clinical advantage.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Recurrent and metastatic endometrial cancer. 
Treatment:  Proton treatment delivery; intermediate and Proton treatment delivery; complex. 
The insurer denied proton treatment delivery; intermediate and proton treatment delivery; complex.  The denial is overturned.

Yes, the health plan should cover the proton beam therapy in this case and is likely to be more beneficial.

The patient is a woman.  She was diagnosed of stage IB grade 2 endometrial cancer in 2016 s/p (status post) TAH-BSO (total abdominal hysterectomy- bilateral salpingo-oophorectomy) and pelvic node dissection followed by vaginal cuff brachytherapy.  She then developed metastasis to cervical/mediastinal/retroperitoneal/pelvic nodes, omentum and peri-rectal mass and has been treated with multiple courses of chemotherapy regimen. 

The patient had progression of metastatic nodes in the abdomen and pelvis and has developed swelling and pain in the right leg.  Proton beam therapy of 3750 cGy in 15 fractions was delivered for palliation of metastatic retroperitoneal/right pelvic/inguinal nodes with avoidance of horseshoe kidney in this member.

In general, proton beam has the advantage of being able to deposit high dose of radiation to a tumor with sharp dose fall off from normal tissues.  Proton beam RT (radiotherapy) can enable delivery of higher dose to the tumor without exceeding normal tissue tolerance compared to IMRT (intensity modulated radiotherapy) alone. 

Proton beam therapy in this case was delivered for palliation of retroperitoneal and pelvic nodes to total dose of 3750 cGy in 15 fractions.  Medical documents provide comparison of proton beam therapy plan and photon RT plan, which demonstrated that photon IMRT was not able to achieve normal tissue sparing (kidney) due to unusual anatomy with horseshoe kidney.  The Photon IMRT plan resulted in mean dose of 18 Gy to the horseshoe kidney, which exceeded the tolerance dose of kidney, 15 Gy.  Proton beam therapy plan was able to reduce the mean dose to horseshoe kidney to 13 Gy, which is under the tolerance dose of kidney, 15 Gy.

Based on demonstrated high risk radiation induced nephritis and renal failure with IMRT in this patient with unusual horseshoe kidney, proton beam therapy is likely to be more beneficial than any standard treatment or treatments for decreasing risks of radiation induced renal failure in this patient who has been treated with nephrotoxic chemotherapy.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Substance Abuse.
Treatment:  Inpatient Substance Abuse stay. 
The insurer denied the inpatient stay.  The health plan's determination is overturned. 

The patient is an adult male who presented for detoxification and substance-related services.  The patient has a history of severe substance use disorders with alcohol, opioid (heroin), stimulants (cocaine), and cannabis (marijuana) class substances of abuse.  He has a history of multiple detoxification treatment episodes with relapses.  He was using a 12-pack of 24 ounce beer on a continuous daily basis together with up to six bags of heroin with intravenous (IV) administration, as well as intermittent use of non-prescribed methadone and tobacco (12 pack per day) and one joint of marijuana and $20 worth of cocaine one to two times per week.

The patient's treatment could not have been safely or effectively provided at a lower level of care in this case scenario.  The patient in this case was using large quantities of alcohol and heroin on a daily continuous basis together with intermittent use of methadone, cocaine and cannabis that did warrant the admission and the continued inpatient level detoxification and withdrawal management and monitoring. Detoxification, as necessary, and other treatments pertinent to the detoxification treatment episode could not have been safely or effectively provided at a lower level of care following the comprehensive assessment that was provided at the time of admission.  Moreover, the patient's social environment was not conducive to an effective detoxification, and the patient had struggled with withdrawal symptoms, which were being effectively addressed with Librium and methadone protocols and supportive measures.  The patient had associated clinical features that included lack of sober supports and limited insight, impaired judgment and poor control of impulses.  Thus, the adult inpatient stay and continued detoxification treatment of this patient's substance use disorders did necessitate the hospital admission and the continued structure of an inpatient level setting with withdrawal management and psychosocial supports, and 24-hour monitoring.  The patient's history of substance abuse (frequency and quantity) together with the severe psychosocial stressors and functional impairments do reflect the seriousness of the substance use disorder and the need for a safe and effective detoxification with withdrawal management, as the patient was at high risk for treatment failure or general medical complications such as seizures if detoxification and withdrawal management were to be attempted at a lower level of care.  Therefore, medical necessity is met in this case, consistent with prevailing standards of professional practice, published practice guidelines, American Society of Addiction Medicine (ASAM) Criteria, the scientific literature, and NY Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Digestive system/gastrointestinal/cholecystitis.
Treatment:  Inpatient hospital. 

The insurer denied the inpatient hospital stay.  The denial is upheld in whole. 

The patient  who presented to the hospital on with right sided abdominal pain of 2-weeks duration.  An ultrasound had identified cholelithiasis/cholecystitis.  The patient was previously healthy.  At the time of presentation, the patient was without fever and vital signs were normal.  The patient was tender in the right upper abdomen.  No, inpatient hospital admission was not medically necessary in this case.  This patient is an otherwise healthy female, who presented to the ED with cholelithiasis/biliary colic.  There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care at the time of presentation.  The submitted records document that this patient was clinically and hemodynamically stable at the time of presentation.  The WBC count was normal.  Serum chemistries identified normal bilirubin and transaminases.  Ultrasound showed gallstones.  Surgery consultation was obtained and surgery (laparoscopic cholecystectomy) was performed.  Inpatient stay related to cholecystectomy may be needed for failure to achieve discharge status criteria, conversion to open surgery, systemic infection, care for active comorbidities, or complications of procedure. In this case, none of these indications existed to justify an inpatient level of care.  The perioperative period was uncomplicated, and there is no documentation of failure to achieve discharge criteria, conversion to open surgery, care for comorbidities, procedural complications, or any other condition requiring inpatient admission.  The patient was clinically stable following surgery as supported by the corresponding medical records.

The treatment provided could have been rendered at a lower level of care.  A lower level of care would have provided for surgical consultation, perioperative care and monitoring, the provision of IV antibiotics and fluid, and overnight care.  A lower level of care would have satisfied the clinical needs of this patient and would have been consistent with medical standards of care.

Therefore, based on the submitted clinical documentation, and medical standards of care, an inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Forehead laceration
Treatment: Treatment with out-of-network provider 
The insurer denied the Treatment with out-of-network provider.
The denial is upheld. 

The patient is a female who hit her head on a counter and sustained a forehead laceration described as 0.7 inches in length. The laceration was stabilized at home with wound care and Steri-Strips.  She then presented to the out-of-network physician for consult.  The patient is seeking the health plan to provide in-network coverage for treatment codes 13131 and 99202. 

No, the patient's presentation was not such that the out-of-network provider outpatient facility services were medically necessary.

The following CPT codes are listed:
1) 13131 - Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 1.1 cm to 2.5 cm
2) 99202 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: An expanded problem focused history; an expanded problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 20 minutes are spent face-to-face with the patient and/or family.	

Based on the documentation provided, the patient underwent treatment by an out-of-network provider. No precertification was obtained for treatment. Based on review of the submitted clinical information, the patient did not require emergent or urgent surgery. The forehead laceration was described as 0.7 inches in length and was stabilized at home with Steri-Strips and wound care. An acute emergent situation was not present. Therefore, coverage for an out-of-network provider is upheld as denied as not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: fever, urinary frequency, and incontinence. 
Treatment: Inpatient admission.
The insurer denied the inpatient admission. 
The denial is overturned. 

The patient is a male whose inpatient admission is under review. The patient has a history of morbid obesity, gastric bypass, asthma, and DM (diabetes mellitus). He was admitted with a fever, urinary frequency, and incontinence. He had been treated as an outpatient with Augmentin two weeks prior, then with PO (oral) azithromycin for asthma and cough.

In the ER, the patient's vitals were as follows: T (temperature) - 102, P (pulse) - 110s, R (respiration rate) - 22, BP (blood pressure) - 116/54. On general exam, the patient was noted to be NAD (no acute distress). The patient's HEENT (head, eyes, ears, nose, throat), CVS (cardiovascular system), abdominal and skin exams were normal. Examination of his chest was notable for wheezing.

The patient's UA (urinalysis) was positive for LE (leukocyte esterase). CT scan revealed no infectious foci. CXR (chest x-ray) was normal.

In the ED, the patient was thought to have sepsis. IV fluids and IV antibiotics (Zosyn) were started. After initial work-up, the source was unclear, but urinary source was suspected. The patient was admitted for further treatment, work-up and inpatient observation. He signed out AMA (against medical advice) shortly afterwards.

Yes, the Inpatient admission was medically necessary.

The patient had suspected urosepsis. In a urinary infection that is complicated with evidence of systemic signs of infection (high WBC count, tachycardia, tachypnea) such as in this case, the Infectious Diseases Society of America (IDSA) recommends inpatient admission (1). Thus, this admission was warranted, supported by IDSA guidelines. Failure to admit such as a patient can lead to loss of function, septic shock, or death.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, Diabetes Mellitus, Dementia, Kidney Cancer and CHF (congestive heart failure). 
Treatment: 168 Hours/Week, 12hrs x 2 x 7 days-split shift; CDPAS, 1 Client.
The insurer denied the 168 Hours/Week, 12hrs x 2 x 7 days-split shift; CDPAS, 1 Client. 
The denial is overturned. 

The patient is a female with a history of Hypertension, Diabetes Mellitus, Dementia, Kidney Cancer and CHF (congestive heart failure). Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). An appeal review requested for potential approval of an increase in Personal Assistance Services to 168 Hours/Week, 12hrs x 2 x 7 days-split shift to offer increased ADL support.

Yes, the 168 Hours/Week, 12hrs x 2 x 7 days-split shift; CDPAS, 1 Client is medically necessary.

Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Recent documentation from the patient's provider indicates that due to progressive functional decline including worsening insomnia, brittle Diabetes with wide ranging blood sugars and worsening gait ataxia with frequent falls, the currently approved plan of 84 hours/week Personal Assistance Services is not sufficient to meet the patient's current needs. For these reasons, the proposed treatment of an increase in Personal Assistance Services to 168 Hours/Week, 12hrs x 2 x 7 days-split shift is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Viral Gastroenteritis.
Treatment:  Inpatient hospital admission.

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

This is a female patient presented to the Emergency Department (ED) with complaints of abdominal pain, nausea, vomiting, and diarrhea.  She was afebrile, and the vital signs were stable.  There was no abdominal rebound or guarding.  There was no leukocytosis; a CAT scan revealed enteritis.  The D-dimer was elevated, but she did not have a pulmonary embolism.  By the following day the abdominal pain, vomiting and diarrhea resolved.  She was able to tolerate a regular diet.  She was diagnosed with a viral gastroenteritis.  The abnormal renal function resolved after receiving intravenous fluids.

Clinical indications for admission for gastroenteritis (M-170) include having a suspected severe infection such a bloody diarrhea, peritoneal signs, hemodynamic instability, severe vomiting and severe dehydration.  The patient did not have these conditions.  She had dehydration, but it rapidly improved with intravenous hydration.

Clinical Indications for admission for undiagnosed abdominal pain (M-05) include hemodynamic instability, severe pain not responsive to pain medications, peritoneal signs, and the need for a procedure that could not be performed on an ambulatory basis.  The patient did not have these conditions.

This patient had a viral gastroenteritis.  She was stable to have been given intravenous hydration and anti-emetics in the emergency room as an outpatient.  The kidney injury resolved with the intravenous fluids.  She could have been managed with observation status.  She did not meet MCG criteria for admission for either gastroenteritis or undiagnosed abdominal pain.  The health care plan acted reasonably and with sound medical judgement.  An inpatient hospitalization was not medically necessary. 

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: of Major Depressive Disorder.

Treatment: Inpatient Mental Health Treatment, revenue code 0124.

The insurer denied the Inpatient Mental Health Treatment, revenue code 0124.

The denial was upheld.

This is female who was admitted for inpatient mental health treatment due to worsened depressive symptoms including suicidal plan to overdose with medication, depressed mood, crying, and self-injurious behavior as she was biting her arms, and experiencing agitation, poor sleep and appetite. The patient had a reported diagnosis of Major Depressive Disorder (MDD). The patient had four past reported psychiatric hospitalizations. The patient was admitted and required a series of  electroconvulsive therapy (ECT) treatments and medications that included lithium, olanzapine, venlafaxine, clonazepam, and gabapentin. The patient was stabilized and discharged with a referral to partial hospitalization program (PHP).

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Major Depressive Disorders reports that the least restrictive level of care for safe and effective treatment is appropriate and that patients with suicidal plan or intent or behaviors, severe depressive symptoms, or inability to adequately care for basic needs are candidates for hospitalization. In this case this patient had no reports of suicidal ideation, plan, or intent, severe depressive symptoms, inability to care for basic needs, aggressive or self-injurious behavior, psychotic symptoms, substance use problems or substance withdrawal, or acute medical instability. Notes reported significant improvement in patient's mood with denial of suicidal/homicidal ideation, plan, or intent and hallucinations. The noted indicated that the patient was in no apparent distress, had no acute issues, and was compliant to treatment with good sleep and appetite. Notes dated a few days later reported that the patient had no heightened anxiety or ruminating thoughts, and did report severe depressive symptoms. There was no documentation at that time that this patient had severe depressive symptoms or suicidal thoughts. 

Based on the review of the medical record the chart notes did not provide enough clinical evidence to support that this patient was an imminent danger to self or others, or unable to adequately care for her basic needs. Also, as of then, there were no reports of specific identifiable or quantifiable treatment goals or objectives that could only be achieved in a 24-hour acute psychiatric hospital setting or that could not be achieved in a less restrictive setting.  

The health plan acted reasonably with sound medical judgment, and in the best interests of the patient.

Based on the above, the medical necessity for continued Inpatient Mental Health Treatment, revenue code 0124 is not substantiated.  The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: History of Alzheimer's Disease, Coronary Heart Disease and End Stage Osteoarthritis of Bilateral Knees. 
Treatment: CDPAS 80 hours per week 
The insurer denied the CDPAS 80 hours per week. 
The denial is overturned. 

The patient is a female with a history of Alzheimer's Disease, Coronary Heart Disease and End Stage Osteoarthritis of Bilateral Knees. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). An appeal review was requested for potential approval of an increase in Personal Assistance Services to 80 hours/week to offer increased ADL support.

Yes, the proposed treatment of an increase in Personal Assistance Services to 80 hours/week is deemed medically necessary. 

Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Recent documentation from the patient's physician indicates that the patient has demonstrated progressive functional decline with worsening bilateral knee pain and decreased range of motion secondary to worsening osteoarthritis and worsening lower extremity edema. For these reasons, her gait ataxia has worsened and the currently approved plan of 40 hours/week Personal Assistance Services is no longer sufficient to meet the patient's current needs. For these reasons, the proposed treatment of an increase in Personal Assistance Services to 80 hours/week is deemed medically necessary.