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

Diagnosis: Dementia.
Treatment: Personal Care Assistance services, level II, 24 hours per day, 7 days per week (live-in)
The insurer denied the Personal Care Assistance services, level II, 24 hours per day, 7 days per week (live-in).
The denial is overturned. 

The patient is a female with a history of dementia and associated cognitive impairment. 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 Personal Care Assistance services, 24 hours per day, 7 days per week (live-in) to offer increased ADL (activities of daily living) support.

Yes, the proposed treatment of 24 hours per day, 7 days per week (live-in) Personal Assistance Services is deemed medically necessary. 

This is a female with a history of dementia and associated cognitive impairment. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Recent documentation received from the patient's medical provider indicates that due to worsening cognitive decline and mental status, the patient's overall functionality and ability to perform ADLs (activities of daily living) has significantly decreased, and her currently approved plan of 51 hours/week Personal Assistance Services is insufficient to meet the patient's current needs. For these reasons, the proposed treatment 24 hours per day, 7 days per week (live-in) Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gastroesophageal reflux disease (GERD), oral aversion to textured solids, reactive airway disease, and autism with developmental and speech delays
Treatment: Special Feeding Routine Evaluation 
The insurer denied the Special Feeding Routine Evaluation.
The denial is overturned.

The patient is a male child with medical history significant for gastroesophageal reflux disease (GERD), oral aversion to textured solids, reactive airway disease, and autism with developmental and speech delays. His diet is severely limited to liquids and purees. Although his weight is at the 50th percentile for age and gender, his diet does not provide well-balanced nutrition to meet his needs. He has failed treatment by a feeding therapist and is now being referred to a special day feeding program (with site modifications due to the pandemic).

Yes, the proposed treatment, Special Feeding Routine Evaluation (92205 x 1), is medically necessary.

Successful feeding of infants and children entails a complex interplay between neuromuscular function, behavior, and environment. Well-coordinated feeding supports weight gain, good health, and achievement of developmental milestones. Disrupting these interdependencies causes feeding disorders.

About 25 percent of all children and up to 80 percent of developmentally disabled children exhibit feeding disorders. Severe and persistent feeding disorders occur in up to ten percent of children, particularly those with chronic conditions. The etiology of feeding disorders is multifactorial, and includes medical, nutritional, behavioral, psychological, and environmental factors. If not dealt with appropriately, feeding disorders can lead to cognitive decline, malnutrition, growth retardation, increased susceptibility to illness, and even death.

A feeding disorder is an inability to consume adequate and appropriate nutrition by mouth. While feeding disorders may ultimately lead to eating disorders, they are not the same. Feeding disorder symptoms include inadequate fluid intake, food refusal, difficulty swallowing, inability to feed oneself, prolonged feeding time, choking or gagging with or without emesis, inappropriate mealtime behaviors, and selecting food by its type or texture.

This young male child has a severe feeding disorder, and in spite of his seemingly age-appropriate weight, he is not consuming adequate nutrition to support growth and development. He has tried and failed outpatient feeding therapy, with ongoing refusal to eat textures, relying solely on liquids and purees. The recommended program provides a multidisciplinary evaluation to identify all aspects contributing to his feeding disorder, as well as therapies to provide him with a much needed chance to achieve a well-balanced age-appropriate diet. The requested Special Feeding Program Routine Evaluation (99205x1) is thus medically necessary and appropriate for the requested duration.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Multiple fractures (lumbosacral fracture, sacral closed fracture, interior pubic ramus fracture)

Treatment: Continued inpatient subacute rehabilitation hospital stay, Level 1 services

The insurer denied coverage for continued inpatient subacute rehabilitation hospital stay, Level 1 services.

The denial is upheld. 

This is a female patient who sustained multiple fractures (lumbosacral fracture, sacral closed fracture, interior pubic ramus fracture) as a result of a fall. She was eventually transferred to a skilled nursing facility (SNF) for subacute rehabilitation. Under review is the medical necessity for continued subacute rehabilitation hospital stay, Level 1 services.
  
The clinical records demonstrate a level of physical impairment and functional progress that initially supported the medical necessity for subacute rehabilitation (Level 1) services at the SNF.  However, there are no physical or occupational therapy notes made available for review in order to make a determination of medical necessity for the continuation of Level 1 rehabilitation services.  

The healthcare plan acted reasonably, with sound medical judgment and in the best interest of the patient. From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, there is a lack of clinical information made available for review to support the medical necessity for continued skilled subacute rehabilitation hospital stay, Level 1 services.

Based on the above, the medical necessity for continued inpatient subacute rehabilitation hospital stay, Level 1 services is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Cancer
Genetic Testing
Diagnosis: Prostate Cancer
Treatment: Genetic Testing
The insurer denied the genetic testing. The health plan's determination is upheld. 

The patient is a male who underwent a prostate biopsy for an elevated prostate-specific antigen (PSA). The biopsy showed Gleason 6 adenocarcinoma in 6 out of 12 cores. The clinical stage was T1c. An Oncotype DX  test was ordered on the biopsy specimens. The medical necessity of the Oncotype DX test is under review.
 
The Genetic Testing of Prostate Tissue with Oncotype DX is not medically necessary for this patient.
The Oncotype DX Prostate Cancer Assay is a real time polymerase chain reaction (RT-PCR) assay designed for analysis of prostate core needle biopsies. The assay measures the expression of 17 genes to calculate a Genomic Prostate Score (GPS). A lower GPS score more favorable biology and less aggressive disease. This test may be utilized to counsel men regarding the best course of therapy (active surveillance versus (vs). treatment) in newly diagnosed low or low-intermediate prostate cancer.

The American Society for Clinical Oncology Guideline on Molecular Biomarkers in Localized Prostate Cancer states "Tissue-based molecular biomarkers (evaluating the sample with the highest volume of the highest Gleason pattern) may improve risk stratification when added to standard clinical parameters, but the Expert Panel endorses their use only in situations in which the assay results, when considered as a whole with routine clinical factors, are likely to affect a clinical decision. These assays are not recommended for routine use as they have not been prospectively tested or shown to improve long-term outcomes-for example, quality of life, need for treatment, or survival."
While Oncotype DX may eventually have a role in making treatment decision about patients with prostate cancer, there is limited data on clinical outcomes to currently support its routine use. Hence, it is not considered a generally acceptable standard of care for management of patients with a diagnosis of prostate cancer and is not medically necessary for his patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient Hospital. 
The insurer denied: Inpatient hospital admission. 
The health plan's denial is upheld in whole.

The patient is a male who presented to the hospital for scheduled catheter ablation of paroxysmal atrial fibrillation. His medical history was remarkable for hypertension, hyperlipidemia, diabetes, coronary artery disease and heart failure with reduced ejection fraction (20%). The procedure was uncomplicated. Post-procedure, the patient was admitted to the hospital. That evening, when the groin access site suture was removed, there was some oozing that resolved with manual pressure and subcutaneous injection of lidocaine with epinephrine. No hematoma developed. The patient was discharged. The subject under review is the medical necessity of the inpatient admission.

The health plan's determination is upheld in whole.

This patient underwent transcatheter pulmonary vein isolation (PVI) procedure for paroxysmal atrial fibrillation. Given the complexity of the procedure, with transseptal punctures, catheter manipulation and ablation within the left atrium, full dose anticoagulation, and the proximity of the ablation lines to the esophagus, the complication rate is higher than that of catheter ablations for other supraventricular arrhythmias. Accordingly, despite at least two reports demonstrating the safety of same day discharge after PVI, most electrophysiologists admit patients for overnight observation post-procedure. This patient's procedure was uncomplicated, and he was hemodynamically stable. Accordingly, while overnight monitoring was reasonable and prudent, the records provided do not indicate that an inpatient level of care was medically necessary. The patient could have been safely managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Cardiac/Circulatory issues. 
Treatment:  Inpatient Hospital. 

The insurer denied the Inpatient stay.  The denial is upheld in whole.

The patient is a male with coronary artery disease, previous coronary stenting, atrial fibrillation, hypertension, and alcohol abuse.  He presented to the emergency room (ER) for alcohol detoxification.  On presentation, he was in atrial fibrillation (AF) with a heart rate of 110 beats per minute (bpm).  Blood pressure (BP) was 140/93 millimeters of mercury (mmHg) and respiratory rate 18.  Electrocardiogram (EKG) showed a prolonged QT interval of 516 millisecond (ms) (QTc) and no ischemic changes.  Magnesium was 1.6.  Urine toxicology screen was positive for cocaine.  He was evaluated and cleared medically for detox admission.

However, he was admitted to the medical service, telemetry, for prolonged QT and AF.  Electrolytes were supplemented.  He was given his usual medications for hypertension (HTN) and AF.  Multivitamin, thiamine, folic acid and acamprosate were given for alcohol abuse.  He was evaluated by cardiology.  QTc decreased to normal.  He ruled out for myocardial infarction.  He was discharged.

The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld in whole.

The inpatient stay is not medically necessary.  The patient presented to the psychiatry ER initially, for alcohol detox.  However, as he was found to be in atrial fibrillation with increased ventricular rates and had a long QT interval on EKG and low magnesium level, he was admitted to telemetry.  He stabilized within 24 hours of hospitalization.  He was hemodynamically stable, however, with no hypotension, no evidence for myocardial ischemia or heart failure.  His QT interval was elevated, and he required evaluation and treatment, as he was at risk for ventricular tachyarrhythmias.  Within 24 hours of hospitalization, however, his ventricular rates were controlled, QT normalized, and he was hemodynamically stable.  The inpatient stay was not medically necessary, as the patient could have been safely cared for at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal-Abdominal pain
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld the health plan's determination in whole.

The patient has a history of kidney stones and presented to the hospital with  reported four days of abdominal pain that had been worsening and was stabbing in nature. The patient stated that pain was in the right flank, denied nausea, vomiting, diarrhea, and fevers but  did report chills. Vital signs showed blood pressure 121/66, temperature 98.6 Fahrenheit, and respiratory rate 20. On physical exam, heart was regular, breath sounds were normal with no wheezing, abdomen was soft and nontender, and there were no neurologic deficits. Labs showed white blood cell count (WBC) 3.51, hemoglobin 13.5, platelets 143, sodium 133, and potassium 4.0, blood urea nitrogen (BUN) 21 and creatinine 1.59, calcium 8.2. Analysis of urine was positive for nitrate, white blood cells and bacteria. A computed tomography (CT) scan of the abdomen showed evidence of inflammation of the omental fat. There was no diverticulosis. A right ovarian cyst was observed. The patient was admitted for abdominal pain. There was concern for urinary tract infection, hidden renal stone and ovarian torsion although suspicion was low. The plan of care included urine culture, antibiotics, intravenous (IV) fluids, pain management, antiemetics, and hold antihypertensive therapy. Symptoms improved and the patient was discharged with a plan for follow up with gastroenterology as an outpatient.

The inpatient stay was not medically necessary.  The patient was admitted with suspected urinary tract infection in the setting of possible acute kidney injury, and did require further medical management. However, The patient was hemodynamically stable, had no significant electrolyte abnormalities beyond the elevated creatinine, did not have evidence of multi system involvement, and had no imaging evidence of pyelonephritis or abnormalities that routinely require inpatient care. The patient could have been safely and effectively managed at a lower level of care.
The patient primarily received IV antibiotics, IV fluids, and diagnostic laboratory testing and diagnostic imaging, however did not receive other more intensive interventions during the hospital stay. The treatment  received could be provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Thyroid goiter.
Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission. The denial is overturned. 

This is a female patient with a history of large bilateral thyroid goiter with some compressive symptoms who presented to the hospital for a scheduled total thyroidectomy. She has a history of a neck mass that caused dysphagia and hoarse voice. The patient underwent anesthesia for 4 hours and 29 minutes to accomplish a total thyroidectomy. 

The peer reviewed literature documents an increased risk for postoperative complications of obese patients as was documented for the patient who had a body mass index (BMI) of 33 which is noted as obesity. Prolonged anesthesia time such as the 4 hour 29 minutes which the patient underwent has been documented in the peer-reviewed literature as increasing postoperative risk and an increasing length of stay. The patient was in the 4th quintile of anesthesia time which was found to have the higher risk of complications. In this case, the patient had symptoms of dysphagia and hoarseness which was consistent with upper airway obstruction. As per the Milliman Care Guideline 20th Edition Ambulatory Surgery Discharge Complications: Common Complications and Conditions, the patient meets the criteria for prolonged hospital stay. According to Milliman Care Guidelines criteria, the patient had multiple indications for the prolonged hospital stay which included obesity with a BMI of 33, the need for airway monitoring resultant of her symptom of dysphagia and hoarseness and very prolonged anesthesia time. 

The inpatient hospitalization was medically necessary for this patient as she had multiple risk factors for postoperative morbidity. 

The health plan did not act reasonably with sound medical judgment or in the best interest of the patient. 
	
Based on the above, the medical necessity for the inpatient hospital admission is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Anxiety, chronic hypertension, vertigo, lower extremity edema and left knee osteoarthritis. 
Treatment: Personal Care Services, 24 hours a day, 7 days a week (live-in). 

The insurer denied the Personal Care Services, 24 hours a day, 7 days a week (live-in).  
The denial is overturned. 

The patient is a female with a history of anxiety, chronic hypertension, vertigo, lower extremity edema and left knee osteoarthritis.  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 24 hours a day, 7 days a week (live in) Personal Assistance Services to offer increased ADL (activities of daily living) support. 

Yes, the proposed treatment of 24 hours a day, 7 days a week (live-in) Personal Assistance Services is deemed medically necessary. 

The patient is a female with a history of anxiety, chronic hypertension, vertigo, lower extremity edema and left knee osteoarthritis.  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 provider indicates that, due to worsening anxiety, chronic hypertension, vertigo, lower extremity edema and left knee osteoarthritis, the patient's functionality and ability to perform ADLs (activities of daily living) has progressively worsening; hence the currently approved plan of 49 hours/week Personal Assistance Services is insufficient to meet the patient's current needs.  For these reasons, the proposed treatment of 24 hours a day, 7 days a week (live in) Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Left lower extremity swelling and erythema.
Treatment:  Inpatient admission.

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

This is a female patient with a past medical history significant for diabetes mellitus, hyperlipidemia, obesity, anxiety, and alcohol abuse, who presented to the Emergency Department (ED) with complaints of left lower extremity swelling and erythema.  The patient's vital signs on presentation included: temperature 97.7, blood pressure 126/88, pulse 107, respiratory rate 15, and oxygen saturation 97% on room air. The patient's laboratory results included the following: white blood cells (WBC) 11.0, hemoglobin 13, hematocrit 40.0, creatinine 0.5, and lactate 2.3. The patient was empirically treated with intravenous (IV) antibiotics (i.e., ceftriaxone and azithromycin) for lower extremity cellulitis.  The patient's Doppler of lower extremity was negative for deep vein thrombosis (DVT). The patient's X-ray of right foot showed fracture of 5th proximal phalanx.  The patient's magnetic resonance imaging (MRI) showed edema of the calf muscles, as well as increased signal throughout the proximal tibial metadiaphysis. Orthopedic service was consulted and they stated that no surgical intervention was deemed necessary.  Vascular service also evaluated the patient and signed off.  The patient underwent rehabilitation and physical therapy (PT).  The patient remained afebrile, hemodynamically stable, and she was discharged to continue management as an outpatient. 

According to documentation submitted, the patient presented with lower extremity complaints.  Otherwise, the patient was afebrile, hemodynamically stable, and laboratory results showed normal leukocyte count.  Although the patient was empirically started on antibiotics, it was unclear if an infection was present.  The differential diagnoses for this patient's clinical presentation were broad and non-specific including "metastatic disease, multiple myeloma, lymphoma, avascular necrosis, bone contusions, or infection...".  No acute intervention was recommended or required according to vascular, orthopedic, and primary team consultants.  Based on above findings, literature review supports that this patient was medically stable for outpatient management.  The review of the clinical documentation submitted for this case does not support the need for acute hospitalization.  Thus, the inpatient admission was not medically necessary for this patient.

The health plan acted reasonably, with sound medical judgment, and 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 should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pelvic inflammatory disease.
Treatment: Full hospital admission.

The insurer denied coverage for the full hospital admission. The denial is upheld. 

This is a female patient with a past medical history significant for uterine fibroids, thrombocytopenia, and pelvic inflammatory disease (PID) who was admitted to the hospital for administration of intravenous (IV) antibiotics for refractory PID. The patient's vital signs on presentation included: temperature of 97.7, blood pressure of 117/65, pulse of 60, respiratory rate of 18, and oxygen saturation of 100% on room air. The patient's laboratory values were notable for the following: white blood cell (WBC) count of 4.34, hemoglobin of 12.4, hematocrit of 38, glucose of 86, and creatinine of 0.7.The patient was empirically started on IV antibiotics (i.e., ampicillin, gentamicin, and clindamycin) for possible PID. There were no cultures or imaging studies.  The patient remained asymptomatic, afebrile, and hemodynamically stable throughout her hospital course.  The patient completed a 5-day course of antibiotics and was uneventfully discharged to continue outpatient management.  

Based on the review of the patient's medical record and literature, the full hospital admission was not medically necessary for this patient. The patient was electively admitted for IV antibiotics for PID.  Otherwise, the patient was afebrile, hemodynamically stable, and her laboratory results were unremarkable with a normal WBC count.  More importantly, the patient denied any complaints-"denies fever, chills, shortness of breath (SOB), diarrhea, vaginal discharge/bleeding." There were no culture results, no imaging studies, and no details of PID diagnosis or outpatient treatment.  Based on the above findings, there is insufficient clinical support in the documentation submitted for this case to substantiate the need for an acute inpatient admission for this patient. 

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

The carrier's denial of coverage for the full hospital admission should be upheld.  The medical necessity is not substantiated.