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

Diagnosis: Dementia, arthritis and weakness
Treatment: An increase in Personal Care Aide (PCA) services for the total amount of 84 hours per week
The insurer denied the increase in Personal Care Aide (PCA) services for the total amount of 84 hours per week.
The denial is overturned.

The patient is an elderly female. Per the Uniform Assessment System (UAS) evaluation from last year the patient has total dependence with meal preparation, extensive assistance is needed with finance, and maximum assistance is needed with activities of daily living. The patient does have bilateral leg weakness and debility.

Per the Uniform Assessment System evaluation performed this year, the patient's status has declined. The patient lives with her daughter. The patient's cognitive skills are minimally impaired. She does have some memory problems. She is alert and oriented to person and the place. The patient needs maximum assistance with meal preparation. She is total dependence with ordinary housework, and maximum to extensive assistance with shopping and phone use. The patient requires maximum assistance and extensive assistance with activities of daily living. The patient does have history of arthritis. The patient is not able to get in and out of bed. The patient is occasionally incontinent to bladder.

The request is for increasing personal care aide services to 12 hours per day - 7 days a week a total of 84 hours per week. The health plan approved 25 hours/week.

The requested Increase Personal Care Aide (PCA) Services for the Total Amount of 84 Hours Per Week is medically necessary.

The patient is an elderly female. She does have history of arthritis and weakness. She requires maximum assistance with activities of daily living, lives with her daughter, who is the blind in the right eye, and also has mental issues. The patient's daughter is not able to provide enough care for the patient's needs. The requested 12 hours per day seven days a week is medically necessary for this elderly patient.

The patient has weakness, she needs maximum assistance with daily activities, and her daughter is not able to help with the patient's needs. The currently approved hours are not sufficient to meet the patient's needs. The patient cannot get out of bed by herself. The patient is occasionally incontinent to bladder.

The health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: alcohol withdrawal

Treatment is an inpatient admission 

The insurer denied coverage for an inpatient admission 
 
The denial is overturned

This adult female was admitted for inpatient hospital treatment due to alcohol intoxication with auditory and visual hallucinations, electrolyte abnormalities including low sodium, magnesium, potassium, and calcium, anemia, elevated liver function test (LFT), and prolonged QTc (interval on a ECG). She reportedly had a seizure and fell and hit her head, had vertigo, dizziness, nausea and vomiting, and an elevated blood pressure of 157/77. She reportedly had 2 past strokes and arthritis and had past seizures. She reportedly had a blood alcohol level of 364.6. There was reported concern for encephalopathy, alcohol withdrawal, psychosis, and epilepsy. She reportedly was drinking alcohol instead of eating and drank up to 4 beers per day. She reportedly was given IV (intravenous) fluids, IV Metoclopramide and odansetron, IV potassium, magnesium, and calcium, and was prescribed Ativan and Librium per CIWA (Clinical Institute Withdrawal Assessment) protocol. It was reported that she had acute alcohol intoxication with psychosis, labile blood pressures, and electrolyte abnormalities. 
  
The insurer denied coverage for inpatient hospital treatment stating that it was not medically necessary treatment then. They stated that she had no unstable blood pressure or heart rate, no withdrawal seizures, and did not require 24-hour hospital treatment then. They recommended a less restrictive level of care then.
  
The medical records provided enough evidence to support that she required this level of care. The InterQual Criteria for acute adult-toxic exposure or ingestion criteria report that if one has carbon monoxide poisoning, alcohol or drug intoxication with either agitation, confusion, disorientation, psychosis, airway assessment, aspiration precautions, and neurological assessment 6 times in 24 hours, or ingestion of a potential toxic substance with unknown type or quantity with assessment every 4 hours then criteria for hospitalization are met. In this case this patient had reports of alcohol intoxication with a high blood alcohol level of 364.6 and had a seizure after falling down the stairs and hitting her head, had auditory and visual hallucinations, and multiple medical issues which required 24-hour hospital treatment and could not be effectively and safely treated in a less restrictive setting. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Uterine fibroids

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is overturned

The patient is an adult female with a history of symptomatic uterine fibroids. She presented to the hospital and underwent an abdominal myomectomy. Three fibroids were removed. The blood loss was 100 cubic centimeters (cc). The hospital course was uneventful. The patient was discharged after a period of medical stability. 

This patient underwent a laparotomy and was managed according to the Milliman Care Guideline (MCG) Laparotomy guidelines and the standards of care. The patient was discharged 24 hours earlier than expected and the admission was medically necessary.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for inpatient hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: deep vein thrombosis (DVT)
Treatment: Eliquis
The insurer denied: Eliquis
The denial is: Upheld

The patient is a female with a deep vein thrombosis of questionable etiology. The patient has been on Eliquis, but this is non-formulary; ongoing use is under review.

The health plan's determination is upheld.

Neither Xarelto nor warfarin have been demonstrated to be inferior to Eliquis. The included documentation does not indicate that this patient is intolerant of either of the formulary alternatives nor that she has failed them; similarly, there is a paucity of documentation indicating this patient has a contraindication to the formulary alternatives. Neither the authors of UpToDate nor the peer-reviewed literature recommend one of these agents as being superior to another and thus given their relative equivalency, the formulary options are reasonable and would not have adverse effects that the non-formulary alternative would.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic obstructive pulmonary disease (COPD) exacerbation
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has overturned in whole the health plan's determination. 

The patient is an adult male who was admitted to the hospital for a chronic obstructive pulmonary disease (COPD) exacerbation. The question at hand is whether the patient met medical necessity for the acute inpatient level of care. He has a history of pulmonary embolism, dyslipidemia, COPD, hyperthyroidism, polysubstance dependence, and hypertension. On presentation the patient required bi-level positive airway pressure (BiPAP) for a COPD exacerbation with improvement of the arterial blood gas (ABG). A computed tomography angiography (CTA) of the chest was negative for pulmonary embolism (PE). Echocardiogram showed normal ejection fraction and diastolic dysfunction. He was started on intravenous (IV) steroids, bronchodilators, and IV antibiotics. Pulmonary was consulted and continued current treatment. Home medications were resumed, and smoking cessation counseling was given. His condition improved and he was stable at discharge.

The patient in question does meet medical necessity for the acute inpatient level of care per current literature and standard of care. According to The Global Initiative for Chronic Obstructive Lung Disease (GOLD), National Institute for Health and Care Excellence (NICE), and Wedzicha, et al, the patient had a clinically significant COPD exacerbation requiring noninvasive ventilation on presentation. Symptoms were slow to improve, and the patient remained symptomatic during the hospital stay. Due to the severity of illness and complexity of care, a lower level of care would not have been appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Renal mass.
Treatment:  Inpatient Stay.

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

The patient is a male with a right renal mass. Radiologic evaluation was concerning for malignancy. A robotic partial nephrectomy (RPN) was performed. The patient was admitted to the hospital postoperatively. On day 1 the patient walked, had minimal pain, tolerated his diet, and was discharged.

No. The inpatient hospital stay was not medically necessary. Literature notes: "Concurrent with the allocation of surgical procedures to the outpatient setting, there has been a steady increase in the adoption of clinical care pathways, which have demonstrated a safe decrease in postoperative lengths of stay (LOS) while meeting patient care standards and providing safe discharges."

Following the robotic partial nephrectomy (RPN), the patient had stable vital signs, minimal pain, tolerated his diet, was able to walk, and was discharged in stable condition. In this case, a lower level of care would be appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Narrow upper and lower arches and multiple out-of-position teeth.
Treatment: D8080 Braces, D8680 Retainer, D8670 Monthly Visit.
The insurer denied: D8080 Braces, D8680 Retainer, D8670 Monthly Visit.
The denial is overturned.

The patient is an adolescent female. The request is for orthodontic benefits. She has narrow upper and lower arches and multiple out-of-position teeth. The prior denial of coverage was due to handicapping index score of 20. The denial is being appealed. 

The requested braces, retainer, and monthly visits are medically necessary. 

The patient has 3 out of her 4 permanent canines out of position. Without all the canines being in their proper positions, there can be no "canine guidance." This is when the canines glide over one another in a smooth fashion during the chewing cycle. When there is canine guidance, the posterior teeth disarticulate and do not grind into each other. Without canine guidance, the chewing cycle is disordered, and many of the patient's teeth grind together in a traumatic way, which will, over time, loosen, break and/or grind down many of her teeth. Orthodontic treatment is medically necessary to correct this, and the monthly visits are needed to make sure the treatment is corrective.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma.
Treatment: Hospital Admission.

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

This is a child with cough for months. Her father indicated that the cough started after being infected with the coronavirus. She also has a history of eczema. She was taken to urgent care the day before the admission with nasal congestion and a cough, and she was diagnosed with asthma. The pediatrician prescribed albuterol, but it is unclear if the parents administered the medication at home. On the day of admission, the parents noticed that her breathing was more labored, and the father brought the child to the emergency room (ER) for evaluation.

In the ER, she was noted to be coughing and have bilateral wheezing on physical examination. Her pulse oximeter reading was 98% (percent) on room air upon arrival at the ER. Her oral intake and urine output were normal. She was treated with intramuscular (IM) dexamethasone and one nebulizer treatment with albuterol and Atrovent. A chest x-ray was unremarkable, and a respiratory viral panel was positive for the respiratory syncytial (RSV) virus. Her pulse oximeter remained in the normal range, and she was not treated with oxygen supplementation. The medical record indicates that the parents were not comfortable with taking the child home, and the decision was made to admit her for observation with a diagnosis of RSV bronchiolitis and a plan to administer albuterol Q (every) 4hours on a PRN (as needed) basis. She only received one additional dose of albuterol in the hospital. The insurer has denied the medical admission as being not medically necessary.

The child was treated appropriately in the ER for coughing, wheezing and increased work of breathing. Her oxygen saturation was normal, and she did not require oxygen supplementation. Her increased work of breathing responded to treatment with bronchodilators and dexamethasone. The decision to admit for observation and PRN treatment with albuterol was not medically indicated and the child could have been safely discharged with education of the parents in appropriate treatment to be administered at home, if her cough and increased work of breathing recurred. The child could have had a follow up visit with a pediatrician in 24 - 48 hours. 

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

The insurer's denial of coverage for the hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bronchiectasis

Treatment is for procedure code E0483, high frequency chest wall oscillation (HFCWO) system, includes all accessories and supplies, each

The insurer denied coverage for procedure code E0483, high frequency chest wall oscillation system, includes all accessories and supplies, each
 
The denial is overturned

The patient is an adult female with history of (H/O) Bronchiectasis, Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) related disease, Chronic Sinusitis with nasal polyps, chronic cough and Chronic Pseudomonas infection. The patient was having extensive respiratory tract secretions and was having difficulty expectorating it out. A computed tomography (CT) of the chest revealed chronic bronchiectasis. The patient had been using Aerobika Oscillating Positive Expiratory Pressure Device but did not have much success with expectorating her sputum.

This patient was experiencing repeated respiratory tract infections with Serratia and Pseudomonas and needed frequent hospitalizations and treatment with intravenous (IV) and oral antibiotics (Abx). The patient's medical doctor (MD) prescribed HFCWO device - Vest to mobilize her secretions. She had been using it and had achieved good results with it.

HFCWO is standard of care in CF (cystic fibrosis) and also used in patients with bronchiectasis. Chest PT (physiotherapy) is not suitable for this patient as she has reflux and cannot do chest PT with her head down. The vest is a good device for aggressive airway clearance and is helping this patient mobilize her secretions.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for procedure code E0483, high frequency chest wall oscillation system, includes all accessories and supplies, each service is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Supraventricular Tachycardia
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld

This adult female presented to the emergency department following abrupt onset of heart racing. Her past medical history was remarkable for known atrioventricular nodal reentry tachycardia (AVNRT) treated with diltiazem. Telemetry showed supraventricular tachycardia (SVT) in the 180s. Treatment included intravenous adenosine and potassium replacement for potassium (K) of 2.5 with conversion to normal sinus rhythm (NSR). Troponin was 0.012. Subsequent electrocardiogram (EKG) showed sinus rhythm with nonspecific ST-T changes. There were no subsequent arrhythmias, and the patient was discharged to home later the same day.
This is an appeal of the denied claim that the requested acute inpatient hospital stay was medically necessary for this patient.

The proposed inpatient hospital admission was not medically necessary.

Based on the provided guideline (Milliman Care Guideline M-510 ISC ORG-AP Supraventricular Arrhythmias (25th Edition), there was not a medical need for the acute inpatient hospital stay because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. Per the guideline, admission is indicated for arrhythmia causing significant symptoms or findings not readily reversible by emergency department or observation care. However, none of the criteria were met in this case, including subsequent chest pain, myocardial ischemia, dizziness, weakness, lightheadedness, dyspnea, hypoxia, heart failure, hemodynamic instability, thyrotoxicosis, need to initiate antiarrhythmic therapy or cardioversion. The care the patient received is routinely provided at a lower level of care and is considered the standard of care for this patient. Therefore, based on the submitted information and the current published medical guidelines, the proposed treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Supraventricular Tachycardia
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld

This adult female presented to the emergency department following abrupt onset of heart racing. Her past medical history was remarkable for known atrioventricular nodal reentry tachycardia (AVNRT) treated with diltiazem. Telemetry showed supraventricular tachycardia (SVT) in the 180s. Treatment included intravenous adenosine and potassium replacement for potassium (K) of 2.5 with conversion to normal sinus rhythm (NSR). Troponin was 0.012. Subsequent electrocardiogram (EKG) showed sinus rhythm with nonspecific ST-T changes. There were no subsequent arrhythmias, and the patient was discharged to home later the same day. 

This is an appeal of the denied claim that the requested acute inpatient hospital stay was medically necessary for this patient.

The proposed inpatient hospital admission was not medically necessary.

Based on the provided guideline (Milliman Care Guideline M-510 ISC ORG-AP Supraventricular Arrhythmias (25th Edition), there was not a medical need for the acute inpatient hospital stay because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. Per the guideline, admission is indicated for arrhythmia causing significant symptoms or findings not readily reversible by emergency department or observation care. However, none of the criteria were met in this case, including subsequent chest pain, myocardial ischemia, dizziness, weakness, lightheadedness, dyspnea, hypoxia, heart failure, hemodynamic instability, thyrotoxicosis, need to initiate antiarrhythmic therapy or cardioversion. The care the patient received is routinely provided at a lower level of care and is considered the standard of care for this patient. Therefore, based on the submitted information and the current published medical guidelines, the proposed treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back Pain
Treatment: Back Surgery
The insurer denied: Back Surgery
The denial is: Overturned

The patient is a female with a past surgical history significant for lumbar (L)4/5 fusion. The patient did have symptom improvement post-operatively. She presented with 1 year history of new bilateral leg radicular symptoms in an L3, L4, and L5 distribution. left lower extremity (LLE) is in L3 and L4 distribution and right lower extremity (RLE) is in a more posterior, possibly L5 distribution. Physical exam notable for 4+(plus) strength in the L extensor hallucis longus (EHL). X-ray of the lumbar spine demonstrates prior L4/5 fusion. There is grade 1 spondylolisthesis at L5/sacral (S)1 which is progressed compared to prior radiograph. Prior x-ray of the lumbar spine demonstrates osseous fusion of prior L4/5 instrumented level. A lumbar magnetic resonance imaging (MRI) showed a large facet cyst at L3/4 with severe neural compression, worse compared to MRI one year prior. Prior treatments include narcotics, gabapentin, non-steroidal anti-inflammatory drugs (NSAIDs), muscle relaxers, Lyrica, physical therapy (PT), home exercise program (HEP), massage therapy, and injections. Symptoms are significantly affecting her ability to walk and perform activities of daily living (ADLs). The patient was recommended an L3/4 laminectomy with possible L3/4 instrumentation and fusion if decompression required stabilization. Also requested is removal of hardware at L4/5, autograft and allograft. This was denied by the health plan as not medically necessary. This is the issue under review.

The health plan's determination is overturned in whole. 

the requested back surgery is medically necessary for this patient. Medical necessity for the proposed surgery is met both per clinical evidence as well as criteria for laminectomy and fusion.
The patient has bilateral leg radicular symptoms and adjacent segment disease at L3/4 status/post (s/p) prior L4/5 fusion. Imaging demonstrates a concordant L3/4 facet cyst with severe thecal sac compression. She has failed conservative treatment. She was recommended L3/4 decompression with possible fusion pending need for bony removal. Standard of care would be decompression with possible fusion if necessary. As per Khan et al., "underlying spinal instability has a strong association for formation of spinal cysts and worsening symptoms. Synovial cysts resistant to conservative therapy should be treated surgically. Resection and decompression with fusion remain an appropriate option."
InterQual 2022 Lumbar laminectomy and fusion criteria are reviewed.
20. Adjacent segment disease after spinal surgery and nerve root compression by imaging.
1. A through D but not E-> MET
2. B-> MET
3. C-> MET
6. A and B but not C-> MET
7. A and V but not C-> MET
8. A-> MET
4. B-> MET
5. A or B pending intraoperative needs-> MET
Criteria is satisfied.