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

Diagnosis: Loss of consciousness

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
This case involves an adult male who presented to the emergency department (ED) with a chief complaint of a loss of consciousness and shortness of breath. While on a train, the patient developed shortness of breath and lost consciousness.  The conductor found him and called emergency medical services.  The emergency department provider notes stated the patient had a history of cerebrovascular accident, diabetes mellitus, depression, and schizoaffective disorder.  During physical examination, the patient had decreased breath sounds, blood pressure was 146/87, pulse 94, temperature 97.7, and respirations 18.   The patient denied alcohol or drug use, although he reported history of polysubstance use in the past and reported fevers.  The computed tomography (CT) of the head was normal with no acute hemorrhage, hydrocephalus, or territorial infarcts.  A chest x-ray noted that lung volume was low but that the patient was rotated.  Given positioning, the patient had suggestion of ill-defined left lower lung opacities.  The patient was subsequently admitted for further work-up and care for possible community-acquired pneumonia and to further assess the cause of his loss of consciousness and shortness of breath.  

According to the Milliman Care Guidelines (MCG), inpatient admission may be indicated for those individuals who had possible seizure activity for up to 2 days when they are hemodynamically unstable, are status epilepticus, have a brain disorder (e.g., tumor, edema, trauma, hydrocephalus, encephalitis, meningitis) that requires monitoring or intervention available only at inpatient level of care, etiology to suggest drug toxicity, withdrawal, nonadherence that requires monitoring or intervention available only at an inpatient level of care without persist despite observation care.  It may be indicated for patients with altered mental status that is severe or persistent, when there is new focal neurologic deficits, and metabolic disorder that persist despite observation care, the patient has recurrent seizures, or outpatient antiepileptic regimen cannot be established.  Inpatient care may also be indicated for cerebral bleeding, hydrocephalus, or vasospasm monitoring and when there is a need for monitoring of increased intracranial pressure or cerebral edema.  

The evidence did not suggest that the patient had any of these criteria to justify the inpatient stay.  Given the provided information, his care could have been safely and effectively rendered on an observational basis with the ability to place him on inpatient status should his condition worsen.  

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right Suprascapular Mass
Treatment: Inpatient stay
The insurer denied the inpatient stay.
The health plan's determination is overturned. 

The patient is a female child who presented to the emergency department (ED) with a one-month history of right posterior shoulder swelling, no pain, no redness. She had been seen previously in the ED with no imaging studies done. She denied any constitutional symptoms. Vital signs included temperature 36.4oC (degree Celsius), heart rate 91, respiratory rate 22, and blood pressure 99/67. Examination was significant for no acute distress, moist mucous membranes, regular heart rate and rhythm, clear lungs, benign abdomen, 2+ peripheral pulses, 4in (inch) x 4in cystic appearing mass in the right lateral scapular region. Laboratory evaluation was significant for white blood cell (WBC) count 7.68, platelets 298, lactate dehydrogenase (LDH) 264, and an unremarkable metabolic panel. Ultrasound revealed an 8cm (centimeter) x 4cm x 6cm subcutaneous mass with internal vascularization. Oncology and Surgery were consulted. 

Inpatient hospital services were medically necessary.
Small round cell tumors, or small round blue cell tumors, are undifferentiated neoplasms that are defined by immunohistochemical characteristics. Examples include rhabdomyosarcoma, Ewing sarcoma, neuroblastoma, non-Hodgkin's lymphoma, primitive neuroectodermal tumor. These tumors are frequently very aggressive and invasive. It is essential to obtain sufficient specimen for diagnostic purposes. Management may involve chemotherapy, radiation therapy, and surgical excision. This young female child presented with a large mass on her shoulder, unchanged in size by the family's perspective. The child was otherwise healthy without constitutional symptoms. She had been seen in the ED as well as the primary physician's office before being referred to this ED for management. She was overall hemodynamically stable without metabolic abnormalities or other complicating factors. However, the complexity of the situation, the need to seek out multiple consultations to facilitate diagnosis in anticipation of tumor board, formulation of a treatment plan, all are most consistent with inpatient level of care. Such a situation is not suitably managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sinusitis
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is overturned.

The patient has a past medical history significant for hypertension, asthma, anxiety disorder, fatty liver, and cervical spine herniation who presented to the emergency department with complaints of headaches.   

Vitals on presentation included: Temperature 39 (degrees) Celsius (C), Blood Pressure 158/77, Pulse 111, Respiratory Rate 18, and oxygen (O2) saturation 97% (percent). Laboratory values were notable for the following: white blood cell (WBC) count 18.59, Hemoglobin (Hgb) 14.9, Hematocrit (Hct) 43.7, creatinine 0.75, glucose 131, and lactate 2.6.

The patient was admitted for fever and headaches. The patient was started empirically on antibiotics (vancomycin and cefepime). A chest x-ray (CXR) showed no acute cardiopulmonary process. A computed tomography (CT) scan of abdomen/pelvis showed no acute intra-abdominal pathology. A CT scan of cervical spine showed non-specific multilevel degenerative changes of the cervical spine. A Head CT scan was negative. Infectious Diseases consulted and switched antibiotics to Unasyn for sinusitis. The patient's fever improved, and hemodynamically stable. All cultures were negative. The patient was discharged to continue oral antibiotics as an outpatient.    

According to documentation, the patient was initially admitted under observation for fevers and headache but transferred to acute care admission for continued fever and leukocytosis (WBC-18.59). Patient had fever to 39 C, and tachycardia (heart rate 111). Laboratory results were notable for elevated WBC and lactate, with unclear etiology. Based on these findings, hospital admission was medically necessary for administration of intravenous antibiotics and additional diagnostic evaluation. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. 

The medical necessity for an inpatient hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Digestive system
inpatient hospital

Diagnosis: nausea/vomiting
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld

This case involves a female with type 1 diabetes, on an insulin pump, with depression, anxiety, and gastroparesis, who was admitted to the hospital with three days of nausea and vomiting. The patient had similar symptoms in the past, requiring admission, and was discharged on antiemetics, Protonix and MiraLAX. The patient had not been taking these medications and reported mid-abdominal discomfort, relieved by vomiting. No sick contacts or unusual foods were noted. She also admitted to smoking marijuana for the previous three days. 

Based on the provided documentation, inpatient admission was not medically necessary. The patient reports intractable nausea and vomiting symptoms but has no severe electrolyte derangements, renal dysfunction, signs of intra-abdominal emergency, or diabetic ketoacidosis. Management of diabetic gastroparesis, causing nausea and vomiting, can be accomplished at a lower level of care. There were no life-threatening findings in the presentation to warrant an inpatient admission. There is no evidence that the patient failed treatment with IV fluids, Reglan, and proton pump inhibitor (PPI), which is the standard of care treatment for this condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: COPD (chronic obstructive pulmonary disease) with Acute Exacerbation
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld. 

The patient is an adult female with chronic obstructive pulmonary disease (COPD) on home oxygen. She presented to the emergency room with cough and shortness of breath (SOB) 
and was found to have chronic obstructive pulmonary disease exacerbation. The patient was admitted to hospital for the management of chronic obstructive pulmonary disease exacerbation. The patient was treated with prednisone, antibiotics, Duonebs, and oxygen. The acute hospitalization is denied due to lack of medical necessity. This denial is being appealed. 

The requested health service is not medically necessary. 

The patient was admitted with chronic obstructive pulmonary disease exacerbation. The patient was treated with oral prednisone as well as antibiotics and Duonebs. The patient was continued on oxygen at the home rate of 2L (2 liters). The patient was not on any invasive drips. The patient was tolerating oral diet. The patient did not receive any treatment that could not have been safely and effectively be treated at a lower level of care. The acute hospitalization is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hearing loss

Treatment: binaural hearing aids

The insurer denied coverage for binaural hearing aids

The denial is overturned
 

The patient presented for an evaluation.  Audiology evaluation noted bilateral symmetric moderate to severe sloping to severe sensorineural hearing loss with speech reception threshold of 60/60 and speech discrimination score of 76/72.  There was normal tympanometry bilaterally.  Audiology evaluation recently noted bilateral moderate to severe sloping to profound sensorineural hearing loss with stable speech reception threshold of 65/65 and speech discrimination score of 64/44.  There was bilateral sloping sensorineural hearing loss consistent with presbycusis.  There was significant decline in bilateral word recognition scores that was worse on the left.  The patient would benefit from binaural hearing aids.  

It was stated that the patient presented for hearing aid evaluation.  Pure-tone testing indicated that the patient had severe sensorineural hearing loss bilaterally.  There was severe sensorineural loss with poor word recognition ability.  The hearing loss required amplification to hear sound and to be aware that someone was speaking.  The patient had worn bilateral behind the ear hearing aids for more than 5 years.  The patient stopped wearing them as they were no longer helping them hear.  The patient did not bring them to the appointment.  The patient was independent, aware, and could insert/remove, charge, and operate the hearing aids safely.  The patient had the benefit of 24/7 home care assistance.  The patient met New York State Medicaid requirements for binaural hearing aids.  

The provider requested reconsideration for the patient's binaural hearing aids.  The patient had severe sensorineural hearing loss.  The patient had fair word recognition scores in both ears, though better in the right ear.  While cochlear implantation had previously been discussed with the patient, given the patient's advanced age and desire to avoid surgical intervention to the extent possible, binaural hearing aids were the best hearing rehabilitation option.  Hearing loss that was not rehabilitated with optimal amplification had been shown in numerous studies to increase the risk of depression, social isolation, and cognitive decline.  Given the severity of the patient's hearing loss in both ears, the patient would have the best hearing outcome with binaural amplification.  The patient required updated binaural devices.  If only one ear was rehabilitated, the patient would have severe difficulty hearing in background noise in group settings which would be especially debilitating as the patient lived in a group setting.

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 durable medical equipment- binaural hearing aids is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ankylosing Spondylitis
Treatment: Cosentyx Pen Injector
The insurer denied: Cosentyx Pen Injector
The denial is overturned.

This patient is an adult female with history of ankylosing spondylitis. The patient has previously tried and failed non-steroidal anti-inflammatory drugs (NSAIDs) naproxen, ibuprofen, and meloxicam. The patient has an x-ray showing bilateral sacroiliitis. The request for Cosentyx (secukinumab) was initially denied due to documentation not supporting that the patient had previously tried and failed at least two non-steroidal anti-inflammatory drugs. The reason the provider is appealing the determination is because the patient has tried and failed at least two non-steroidal anti-inflammatory drugs.

The proposed treatment is medically necessary.

The patient has history of ankylosing spondylitis and has x-ray changes showing bilateral sacroiliitis. The patient has previously tried and failed three non-steroidal anti-inflammatory drugs (NSAIDs). The patient is unable to utilize tumor necrosis factor (TNF) inhibitors due to family history of multiple sclerosis. Cosentyx is United States Food and Drug Administration (FDA) approved for the treatment of ankylosing spondylitis. It is supported by the American College of Rheumatology guidelines for treatment of ankylosing spondylitis. Therefore, the proposed treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Central Nervous system
Home health care

Diagnosis: dementia
Treatment: home health care
The insurer denied Personal Care Aide (PCA) Services: 24 Hours (Split-Shift) per Day, 7 Days per Week
The health plan's determination is upheld. 

The patient is a female with past medical history of dementia, osteoporosis, anemia, bowel incontinence, bladder incontinence, chronic kidney disease, hearing loss, gastroesophageal reflux disease (GERD), constipation, hyperlipidemia, and deep vein thrombosis (DVT) on chronic anticoagulation who had been assigned PCA (personal care aide) services. 

Personal Care Aide (PCA) Services: 24 Hours (Split-Shift) per Day, 7 Days per Week are not medically necessary for this patient.
Although the patient has documented sundowning and insomnia there is no documentation of specific activities of daily living (ADL) needs in the overnight hours that would not allow a PCA 5 hours of uninterrupted sleep. There are no overnight care logs with specific times and assistance documentation supporting split shift services. There is also no documentation that the patient requires or it is medically necessary for the patient to be turned and repositioned every 2 hours. 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, the requested PCA services are not medically necessary for this patient. The hours approved by the health plan are sufficient to meet the patient's needs.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anal Cancer

Treatment: PET Scan with CT for Attenuation-(Positron Emission Tomography with Computed Tomography- pictures of inside the body)

The insurer denied coverage for PET Scan with CT for Attenuation- (Positron Emission Tomography with Computed Tomography- pictures of inside the body).

The denial is upheld. 

This is the case of a patient with anal canal cancer that was treated with chemotherapy and radiation therapy (RT).  The patient had a Positron Emission Tomography (PET) scan followed by magnetic resonance imaging (MRI) which showed stable disease.  The radiologist recommended a follow-up PET (Positron Emission Tomography) scan; however, this can be clinically followed, and if there is suspicion of recurrence, a PET scan can be done at that time. 

PET Scan with computed tomography (CT) for Attenuation (Positron Emission Tomography with Computed Tomography- pictures of inside your body) is not considered medically necessary for this patient. As concluded in a Cochrane review, "There is insufficient evidence at this time to recommend a routine use of PET/CT in the assessment of treatment response or follow-up (2)."

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for PET Scan with CT for Attenuation (Positron Emission Tomography with Computed Tomography- pictures of inside your body) is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma exacerbation

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This is an adolescent female with a history of asthma and a previous emergency room (ER) visit for asthma 2 months prior to the admission. She was sick with a respiratory viral illness for 1 week, and 2 days prior to the admission she began to have a persistent cough and difficulty breathing. She was administered albuterol at home by her mother with no improvement. She had 3 episodes of post tussive (cough) vomiting and when she was not able to speak in complete sentences because of difficulty breathing so her mother contacted Emergency Medical Services (EMS) to transport her to the emergency room (ER) for additional treatment. In the ambulance she was administered Combivent twice and they administered intravenous (IV) dexamethasone and magnesium sulfate because of respiratory distress.

In the emergency room (ER) she was noted to have bilateral retractions and wheezing. She was treated with an additional Duoneb treatment followed by Albuterol. She also received treatment with Terbutaline because of ongoing respiratory distress. After treatment she required ongoing frequent Albuterol nebulizer treatments, and the decision was made to admit her with a diagnosis of status asthmaticus for ongoing treatment with Albuterol every 2 hours.

The patient was treated appropriately in the emergency room (ER) for a cough, wheezing and retractions. She was acutely sick with respiratory distress and difficulty speaking in complete sentences and she continued to have increased work of breathing. In addition, it was reported that the child was depressed because her father died 4 days prior to the admission to the hospital. This child with a history of asthma with a respiratory illness that resulted in increased work of breathing despite treatment with bronchodilators, decadron, magnesium sulfate and terbutaline could not have been safely discharged home since she required ongoing treatment with albuterol every 2 hours.

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 the hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Infertility

Treatment: in vitro fertilization

The insurer denied coverage for in vitro fertilization

The denial is upheld

 
The patient is an adult female with history of infertility due to decrease ovarian reserve secondary to advanced maternal age. The provider is requesting coverage for in vitro fertilization (IVF). The patient's anti-mullerian hormone (AMH)  is 0.36, antral follicle count (AFC)  is 3, and the follicle stimulating hormone (FSH) is 15.8.  

This patient has age related decrease in ovarian reserve. It has become clear that the decline in fertility with increasing female age is largely due to a rapid decrease in oocyte (egg) quantity and quality, with a higher proportion of oocytes displaying genetic abnormalities. Despite significant improvements in medical stimulation and laboratory culturing of embryos, successful pregnancies once women reach the age of 44 are exceedingly rare. In other words, this patient does not have a disease condition, she has normal age-related inability to conceive and therefore since she has no disease condition; treatment is not medically necessary.

The American College of Obstetrics and Gynecology (ACOG) and American Society for Reproductive Medicine (ASRM) have always recommended donor egg IVF for patients with ovarian insufficiency  as IVF is considered a futile treatment.

Based on a study at Boston IVF, cumulative live birth rates in women ranged from 28.4% (percent) if starting Assisted reproductive technology (ART) at age 40 to 0 by age 46. Assisted reproductive technology has a reasonable chance for success (>5%) (greater than 5 percent) up until the end of the forty-third year. 
According to published Society for Assisted Reproductive Technology (SART) data, the national success rate (live birth per IVF cycle in women above the age of 42 is 4.5%. Please note that this success rate is for women older than 42. If that success rate is divided into patients older than 44 years, the success rate is much less than that, definitely less than 5%.

The aim of any treatment is the final result. In this case the aim is to have a healthy live birth. At age 44+ (44 plus), the odds of aneuploidy are significantly increased, and the odds of conceiving are minimal if any.

As per the scientific literature, the provider's opinion, and based on the patient's tests of ovarian reserve, age, the proposed treatment is unlikely to be effective as the odds of conception and live birth are less than 5%.

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

An IVF procedure is not considered medically necessary for this patient.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 
The medical necessity for IVF procedure services is not substantiated.