Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Cough
Treatment: RVP (respiratory viral panel) testing
The insurer denied coverage for RVP testing.
The denial is overturned.

According to medical records, this patient has a past medical history of migraines, allergic rhinitis, uterine leiomyoma, breast cancer, osteoporosis, and arthritis who presented to her physician's office with complaints of cough. A respiratory viral panel (RVP) was done to try to find the source of symptoms.

According to the Infectious Diseases Society of America (IDSA) guidelines on Molecular Testing for Acute Respiratory Tract Infections: Clinical and Diagnostic Recommendations, "highly sensitive and specific nucleic acid amplification tests have become the diagnostic reference standard for viruses, and translation of bacterial assays from basic research to routine clinical practice represents an exciting advance in respiratory medicine."

Advances in PCR [polymerase chain reaction] technology has led to significant changes in diagnosis of viral, bacterial, and/or other infectious agents. Molecular diagnostics have revolutionized the detection of respiratory viruses. Compared with classical culture- and antigen-based methods, these tests have high sensitivity and with improved turnaround time, may result in reduced diagnostic uncertainty and avoid use of unnecessary antibiotics. Although there are institutional variations in how these assays are being utilized, from routine initial diagnosis to being reserved based on certain criteria, these rapid multiplex assays are becoming standard of care.      

Based on above findings, including IDSA guidelines, FDA (Food and Drug Administration) approval, and other studies suggesting respiratory viral panel, despite some limitations, is an acceptable diagnostic option for patients with respiratory symptoms of unclear etiology. 

This testing is likely to be more beneficial than any other standard testing without increased risk.

The carrier's denial of respiratory viral panel (RVP) testing performed should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Altered mental status. 
Treatment: Inpatient stay. 

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

The patient is a female with a history of lupus, alcohol abuse, and recurrent syncope, who presented with altered mental status. There were reports of slurred speech noted by the patient's husband. Review of system was negative for additional symptoms. The patient was admitted for possible syncope, rule our cerebrovascular accident (CVA) and alcohol intoxication. The patient was treated with intravenous (IV) fluids, thiamine, folic acid, and lorazepam. 

The inpatient hospital admission was not medically necessary for this patient. The care could have been safely rendered at a lower level of care for imaging studies and supportive care. 

The patient was admitted for subjective symptoms that were concerning for a stroke versus transient ischemic attack (TIA). The patient had no objective focal neurologic deficits that represented a central nervous system (CNS) etiology (NIH stroke score was zero), and imaging studies were unremarkable for acute neurologic finding. The documentation does not support an inpatient level of care since the patient was hemodynamically stable, had no electrolyte derangements and had no acute neurologic findings. In this case, a lower level of care would have been appropriate to monitor patient and rule out of a stroke and supportive care for alcohol intoxication.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male. He was hospitalized for evaluation of atypical, right-sided, persistent chest pain in the setting of known CAD (coronary artery disease) and an abnormal stress echocardiogram. He was sent to the ED (emergency department) by his cardiologist, and he had an emergent cardiac catheterization with coronary angiography showing non-obstructive CAD (coronary artery disease) and no need for a PCI (percutaneous coronary intervention) intervention. His PMH (past medical history) is significant for known CAD (coronary artery disease) with prior stenting to LAD (left anterior descending), current smoking, HTN (hypertension), HLP (hyperlipidemia) and prediabetes.

The patient's vitals were stable. There were no procedural-related complications. He was admitted as inpatient status to the hospital for post-procedure care and he was discharged to home on the same day. This is an appeal of the denied claim the requested Acute Inpatient Hospital stay was medically necessary for this patient.

No, the Inpatient admission was not medically necessary.
Based on the peer reviewed medical literature, the documentation submitted for review do not establish the requested Acute Inpatient Hospital Stay was medically necessary for this patient. 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 national guidelines, criteria for inpatient Hospital Admission are not met, including hemodynamic instability, respiratory distress, pulmonary edema, angina with acute coronary syndrome, chest pain that is indicative of a serious cardiac condition like evidence of acute myocardial infarction, pulmonary embolism, aortic dissection, pneumonia, or any other medical condition that warranted inpatient hospitalization. The care he received is routinely provided safely and effectively at a lower level of care, such as at the observation level of care. Therefore, based on the submitted information and the current standard of care, there was not a medical need for the acute inpatient hospital stay for date of service requested.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic subdural hematoma

Treatment: Inpatient admission

The insurer denied coverage for an inpatient admission

The denial is upheld 

This case involves a female who presented to the emergency department with complaints of dizziness in addition to weakness and vomiting. The documentation indicated she does have a history of kidney disease and she is on dialysis. She stated this was her third episode experiencing the same symptoms. She reported her blood pressure has been elevated more than usual; however, she has been utilizing amlodipine as prescribed. She stated her vision was initially blurry; however, it was now only mildly blurry. She reported she previously had an echocardiogram; however, it was within normal limits. The physical examination revealed no significant findings. She according to the physician had a likelihood of dialysis disequilibrium syndrome. However, it was recommended she undergo additional studies to rule out a possible TIA (transient ischemic attack). She did undergo a CT (computed tomography) scan showing a chronic subdural hematoma and was admitted for further treatment and monitoring. The documentation indicated she did not have any further significant adverse events while hospitalized. The documentation indicated she was discharged the following day with instruction to follow-up.

The patient is a female with chronic kidney disease who was on dialysis and presented to the emergency department with dizziness with weakness and vomiting. CT scan of the head showed no acute changes but evidence for a chronic subdural hematoma. Examination was non-focal. The patient was discharged the following day with instructions for follow up for chronic subdural hematoma. Care provided, including diagnostic imaging study, medical management and specialty consultation could have been performed in the emergency department and at an observation level of care. Therefore, the inpatient admission was not medically necessary.

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

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

Diagnosis: Dementia. 
Treatment: Home health care/ Personal Care HHC - Level 2 Personal Care Services: 24 Hours per Day (Split Shift). 

The health plan's determination is overturned. 

The patient is a female with past medical history of cerebrovascular accident (CVA) with right-sided weakness, vascular dementia, wheelchair-bound, homebound, coronary artery disease, chronic obstructive pulmonary disease (COPD), osteoarthritis, depression, hypertension, hyperlipidemia, urinary incontinence, and occasional bowel incontinence who had been in rehabilitation following hospitalization for a hip fracture. Discharge instructions from the rehabilitation stay stated that the patient required assist of 1 for transfers, ambulation, bed mobility, hygiene, dressing, toileting, and wheelchair mobility. The patient underwent assessment tool assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, stairs, and shopping while maximum assistance with tasks of managing medication, transportation, and equipment management. With tasks of phone use, bathing, personal hygiene, dressing lower body, transfer toilet, and toilet use the patient was assessed at extensive assistance while limited assistance with tasks of dressing upper body, walking, locomotion, bed mobility, and eating. 

Home Care / Personal Care HHC - Level 2 Personal Care Services: 24 Hours per Day (Split Shift) is medically necessary for this patient. 

There is documentation both from her medical provider, rehabilitation notes and the assessments themselves of cognitive and functional decline. The patient requires at least limited assistance with walking, locomotion, transfer toilet, and toilet use. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. There are overnight logs documenting the patient's assistance with activities of daily living (ADL) in the overnight hours as well as the PCP (primary care provider) recommendation for prompt bathroom trips and incontinence cares to prevent urinary tract infection (UTI) that a PCA (personal care assistant) would be unable to obtain at least 5 hours of uninterrupted sleep. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and Instrumental activities of daily living (IADL). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, Home Care / Personal Care HHC - Level 2 Personal Care Services: 24 Hours per Day (Split Shift) are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a female with PCOS (polycystic ovarian syndrome). She presented to the ED (emergency department) with acute appendicitis seen on CT (computed tomography) scan. The patient's WBC (white blood count) was 14, and she had abdominal pain for several days with diarrhea. The patient opted for non-operative management for her appendicitis.

Yes, the Inpatient admission was medically necessary.
The patient was admitted for early appendicitis. She had symptoms consistent with appendicitis. The patient had opted for non-operative management of her appendicitis and was treated with IV (intravenous) antibiotics.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
The patient was admitted to assess the progression of her appendicitis. The patient was offered operative versus non-operative treatment. The patient exhibited fever 101 and leukocytosis on admission. The patient opted for non-operative treatment. Her abdominal pain improved and she was discharged. She required admission for IV (intravenous) antibiotics and continue to monitor her progression. She improved and was discharged on oral antibiotics.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Cervical disc displacement .
Treatment: procedure code 64555, 2 units, implantable peripheral nerve stimulation device.
The insurer denied coverage for procedure code 64555, 2 units, implantable peripheral nerve stimulation device.
The denial is upheld.

This patient has chronic right shoulder pain after total shoulder replacement. She also has a herniated disc at cervical levels C5-C6. She takes oxycontin and Zanaflex. She has failed conservative therapy. The request is for Sprint peripheral nervous system (PNS) placement for right shoulder pain.

The Sprint PNS System has received Food and Drug Administration (FDA) clearance and is indicated for up to 60 days in the back and/or extremities for symptomatic relief of chronic intractable pain, postsurgical and posttraumatic acute pain, posttraumatic pain, and postoperative pain.

Wilson et al (1) have described the current state of peripheral nerve stimulation:
"Peripheral nerve stimulation has been studied in musculoskeletal pain syndromes, neuropathic pain syndromes, craniofacial pain, and in acute post-operative pain. This pain-relieving treatment is a promising treatment though many applications have not yet been well studied." 

Both Emergency Care Research Institute (ECRI) (2) and Hayes (3) have evaluated the clinical evidence about the StimQ system and concluded that this is an experimental/ investigational procedure. Similarly, Kaye et al (4) described the limited long-term data on the benefit of this device: "Additional research is needed to determine the long-term risks and benefits of peripheral nerve stimulation as the majority of available information on its effectiveness is based on short-term improvements in chronic pain."

The requested service is NOT likely to be more beneficial than any of the standard treatments/procedures for this patient.

Only short-term data is available.

The procedure has final approval from the appropriate regulatory bodies for this diagnosis.

It is unclear if the patient is a good candidate for the procedure.

The procedure is not the best available treatment for this patient at this time.
It is uncertain at this time, if the adverse risks are increased over standard treatment/services.

The carrier's denial of procedure code 64555, 2 units, implantable peripheral nerve stimulation device should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Cervical disc displacement.
Treatment: procedure code 64555, 2 units, implantable peripheral nerve stimulation device.
The insurer denied coverage for procedure code 64555, 2 units, implantable peripheral nerve stimulation device .
The denial is upheld.

This is a female with a history of lymphoma and cervical (c) disc displacement at C5-C6. She presented to the Pain Medicine physician's office for the evaluation of right shoulder pain. The patient takes Oxycodone and Zanaflex with limited relief. The treating practitioner recommended a SPRINT peripheral nerve stimulator to treat shoulder pain. 

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome.

Food and Drug Administration (FDA) approval has been granted for marketing; FDA approval makes no recommendation with regard to efficacy.

This patient is not a good candidate for procedure code 64555, 2 units, implantable peripheral nerve stimulation device.

The procedure is not the best available treatment for this patient at this time.

The adverse risks do increase over standard treatment/services.

The requested service is NOT likely to be more beneficial than any of the standard treatments/procedures for this patient. 

The medical record demonstrates inconsistency for isolated shoulder pain with an unclear etiology. The facts are she has had shoulder pain for years. She had undergone a total shoulder replacement. She had undergone a cervical disc displacement. She reported continued pain to her back and shoulder. She was taking long term narcotics. There were reports of improvement on her current regimen. 

Nevertheless, the references submitted specifically document, "additional studies are required as long-term risks and benefits have not been well studied as well as effectiveness in the short term."

A search was performed using Pub Med and National Library of Medicine. The key word was peripheral nervous system (PNS) and shoulder. There were no references found showing this to be a standard of treatment. There are no National Organizations nor guidelines which report benefit. 

The carrier's denial of procedure code 64555, 2 units, implantable peripheral nerve stimulation device should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stroke.
Treatment: Continued Inpatient Hospital Admission.
The insurer denied the Continued Inpatient Hospital Admission.
The denial is upheld.

The patient is a female with a history of deep venous thrombosis on oral anticoagulation and metastatic cholangiocarcinoma who presented to the emergency ward with the complaint of left hemibody weakness. She was admitted to the acute inpatient level of care. Magnetic resonance image (MRI) showed acute left cerebellar stroke and subacute scattered infarctions. Magnetic resonance image (MRI) of the spine showed pre-existing metastatic disease and T4 (fourth thoracic vertebra)  fractures. She was recommended for acute rehabilitation. Neurology note did not recommend any further diagnostic tests or change to treatment regimen. The patient was continued on her outpatient chemotherapy regimen while admitted to the acute inpatient service. She was subsequently discharged.

No, the proposed inpatient admission was not medically necessary.
The patient was admitted for acute stroke, confirmed by magnetic resonance (MR) imaging. However, her stroke evaluation including diagnostic studies and establishing definitive treatment were completed. The continued inpatient treatment was not medically necessary. The rehabilitation needs and continuation of the patient's previously established outpatient chemotherapy regiment could have safely and effectively provided at a lower level of care. There was no indication for continued inpatient care.  Therefore, the acute inpatient admission was not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Community acquired pneumonia (CAP)

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

The patient is a male with history of chronic obstructive pulmonary disease (COPD) and granulomatous disease who was being evaluated as an outpatient for a 6.2-centimeter (cm) lung mass with hilar and mediastinal adenopathy.

The patient had undergone interventional radiology (IR) guided biopsy which was negative for malignancy. There was concern for bronchiolitis obliterans organizing pneumonia (BOOP). The patient also had drainage of empyema. He had a positron emission tomography (PET) scan which had revealed fluorodeoxyglucose (FDG) uptake.
A repeat IR guided biopsy was done and was negative for malignancy. The patient had undergone a bronchoscopy with endobronchial ultrasound (EBUS) by thoracic surgery. Biopsy results were pending.

The patient presented to the emergency department (ED) with complaint of right sided pleuritic chest pain for about 3 days. The patient also complained of subjective fever and chills. The patient reported that his sputum had become more productive, and he was producing yellowish sputum.

Vital Signs at presentation included temperature 98.7, heart rate 107, and respiratory rate 20. The lung exam revealed rales over right lungs.

Labs revealed sodium (Na+) 130 and white blood cell (WBC) count was 22.

The patient underwent a computed tomography (CT) chest as D-dimers were elevated.
It revealed worsening of right upper lobe (RUL) opacity compared to prior imaging and also presence of right lower lobe (RLL) opacity which was slightly improved. No obvious pulmonary embolism (PE) was found.

The patient was evaluated by Thoracic Surgery, Pulmonary and Oncology.

Given the patient's presentation and unclear diagnosis it was decided to admit him for treatment of CAP and to continue to rule out malignancy. The patient was started on intravenous (IV) Rocephin and Azithromycin for CAP. In addition, as there was a possibility that patient may also have BOOP, Pulmonary recommended Prednisone.

Given the patient's complicated history and unclear diagnosis despite outpatient workup and continued symptoms despite outpatient treatment it was appropriate to admit this patient. The patient also had some low-grade temps, hyponatremia, leukocytosis with left shift, worsening of RUL consolidative changes admission was appropriate to start treatment for pneumonia (PNA) and BOOP and observe patient closely while continuing to rule out malignancy.

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 admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Vaginal Bleeding. 
Treatment: Inpatient Services. 
The insurer denied coverage for inpatient services. 
The denial is modified. 

The patient is a female at 35 weeks gestation who presented to the emergency department with complaints of painless vaginal bleeding. There was no evidence of blood clots. 

The patient was admitted for vaginal bleeding and concerns for pre-term labor. The treatment plan included fetal monitoring, intravenous fluids, intravenous antibiotics, magnesium and betamethasone. The patient's vital signs were stable, and she did not have any further episodes of bleeding. She was discharged with instructions to follow up with Obstetrics. 

According to MCG (Milliman Clinical Guidelines) admission is indicated for one or more of the following: Condition requiring premature delivery: Fetal distress or demise, preterm prelabor rupture of membranes, significant maternal disease, vaginal bleeding, complications of tocolytic treatment, continued fetal monitoring that require inpatient care, tocolytic therapy needed that requires inpatient care, and inability to stop preterm labor. 

This patient had vaginal bleeding with concern for placenta previa or abruption in a multigravida. Admission for monitoring and close follow-up was needed. However, there was no evidence of bleeding or cervical dilation and continuous admission was not medically necessary. 

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

Inpatient services on day 1 is considered medically necessary for this patient. However continuous admission on day 2 was not 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 services is modified. Medical Necessity is partially substantiated.