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

Diagnosis: Asthma		

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission 

The denial is upheld

The child presented with respiratory symptoms of a cough and fast breathing. The patient was noted to not be in distress. In the Emergency Department (ED) physician's note, it was documented "no distress", smiling, oxygen saturation greater than ( >) 90 percent (%), and no hemodynamic instability. Perfusion was adequate, and the respiratory rate was 20 to 30s (breaths per minute). The patient was treated with nebulization and steroids. The clinical status improved. The patient was noted to have improved after 2 duo nebulizers, and 1 dose of steroids. The patient and family were noted to be missing. The ED provider later obtained the information that parent took the child to another hospital. 

There was no persistent hypoxia and no need for continuous positive airway pressure (CPAP) or high flow nasal canula as oxygen saturation was 95% and above. There was no need for pressors nor multiple boluses. There were no abnormal labs documented. No blood gas was drawn because there was no hypoventilation nor hypercarbia. Also, there was no second line treatment such as continuous albuterol nor epinephrine nor terbutaline. If one were to take the Pediatric Respiratory Assessment Measure (PRAM) score to assess the pediatric asthma, it would be in the category of mild asthma. If one were to take the Pediatric Early Warning Systems (PEWS) score, it would have been desirable and perhaps the patient could be discharged from the ED. The patient self-discharged and perhaps this was possible because the patient might have improved after the duo nebulizers and steroids. This child with mild to moderate asthma exacerbation could have been treated in observational status. 

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 emergency admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Functional impairment.

Treatment: Consumer directed personal assistance services (CDPAS).

The insurer denied coverage for CDPAS 24 hours per day live-in.

The denial is overturned.

 
This elderly patient has extensive functional impairment associated with several medical conditions and needs assistance with all daily activities. The patient currently lives at home. The patient was in a skilled nursing facility (SNF) for short term rehabilitation. The most recent Uniform Assessment System (UAS) was done when patient was still in the SNF. The UAS reported patient lives alone, but monthly call assessment indicates family (son and daughter-in-law) lives with the patient. Prior to hospitalization (for fall/fracture) and SNF admission, patient was receiving personal care services provided as CDPAS 45 hours per week. 

The records indicate the patient fell at home. As per physician's letter, the fall resulted in fracture of right elbow and shoulder; patient was hospitalized then transferred to SNF for rehabilitation The UAS (done in SNF) reported patient's right arm was in a brace; there is no mention of surgery in the available records. No rehabilitation records were provided for review, but the SNF physician's letter from day of discharge home reported patient needed extensive assistance with all activities of daily living (ADLs), including total care for toileting and diaper changes; maximal assistance for transfers. It was noted the patient had multiple falls at home. Even if there was some improvement from physical and occupational therapy, the physician's letter indicates the patient still had significant functional impairment and needed assistance with all ADLs at the time of discharge from SNF. The community friend's letter reports patient lost use of her right hand; noted as dominant side (unclear whether loss of hand function is related to recent right elbow and shoulder fractures). The physician's letter reports patient has restriction of arm movement due to shoulder trauma. Loss of hand function and decreased shoulder range of motion affects most daily activities, including all personal care tasks. It is not known to what extent (if any) the patient is able to compensate with her left upper extremity for tasks she usually performs with her right upper extremity. 

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

The insurer's denial of coverage for the home care/personal care HHC - level 2 personal care services, per 15 minutes increase to 24 hours per day (live in) is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Traumatic Brain Injury.

Treatment: Acute rehabilitation (inpatient medical rehabilitation).

The insurer denied coverage for continued acute rehabilitation hospital admission.

The denial is modified.

This is a young adult who was involved in a motorcycle accident and sustained a traumatic brain injury. He was subsequently admitted to a rehabilitation facility for acute inpatient rehabilitation. He developed a gastrointestinal (GI) bleed and transferred back to the acute hospital. He was readmitted to the acute rehabilitation facility and approved by the insurer. Under review is the medical necessity of continued stay, acute rehabilitation (inpatient medical rehabilitation). 

The patient was initially an excellent candidate for acute inpatient rehabilitation. He has physical and cognitive deficits that were potentially amenable to comprehensive rehabilitation (including physical, occupational and speech therapy); and requiring at least 3 hours therapy/day. His inpatient rehabilitation hospital course was complicated; requiring transfer back to the acute hospital for GI bleed and readmission to the acute rehabilitation facility for continued inpatient treatment. Subsequent treatment included intravenous (IV) antibiotics for suspected aspiration, tracheostomy management and injection procedures for spasticity management as well as continued comprehensive skilled multi-disciplinary therapy services.  

Unfortunately, the provision of multi-disciplinary (medical, nursing and rehabilitation therapy) services failed to result in significant functional improvement to support continued inpatient acute rehabilitation services. His acute medical problems had stabilized. The patient has remained otherwise fully dependent to maximal assistance for activities of daily living and functional mobility. In addition, there were no subsequent acute medical interventions or complicated nursing care issues to support continued inpatient rehabilitation.

Based on the above, the insurer's denial must be modified. 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 ten additional days of acute rehabilitation (inpatient medical rehabilitation) is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, hyperlipidemia, osteoarthritis, dementia, and wandering.

Treatment: PCS (Personal Care Services) 10 hours/day, 6 days/week and 4 hours/day, 1 day a week for a total of 64 hours/week.

The insurer denied coverage for requested PCS 10 hours/day, 6 days/week and 4 hours/day, 1 day a week for a total 64 hours/week.

The denial is overturned.

This is an elderly patient with dementia and who often wanders. She lives in a 1-bedroom apartment. The insurer approved Personal Care Services (PCS) 7 hours/day, 6 days/week and 8 hours/day for 1 day/week: totaling 50 hours/week. Under review is the requested PCS 10 hours/day, 6 days/week and 4 hours/day, 1 day a week for a total 64 hours/week.  
The Uniform Assessment System (UAS) report was reviewed. The patient has Alzheimer's dementia, and her cognitive skills are described as moderately impaired.  She requires extensive assistance for bathing, personal hygiene, dressing and toilet use.  She is frequently incontinent of bladder and bowel.  However, the patient's functional mobility is at the independent to supervision level (e.g., bed mobility and ambulation). Her condition and functional needs are unpredictable so as to require the requested PCS 10 hours/day, 6 days/week and 4 hours/day, 1 day/week for a total 64 hours/week.

Based on the enclosed documents reviewed, the patient's health and safety; particularly as it relates to instrumental activities of daily living (IADL) and activities of daily living (ADL) tasks; the requested PCS 10 hours/day, 6 days/week and 4 hours/day, 1 day a week for a total 64 hours/week are necessary.
The healthcare plan did not act reasonably, with sound medical judgment and in the best interest of the patient.  

From a physical medicine and rehabilitation perspective, the requested PCS 10 hours/day, 6 days/week and 4 hours/day, 1 day/week for a total 64 hours a week are medically necessary.   

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 personal care services 10 hours a day, 6 days a week and 4 hours a day, 1 day a week for a total 64 hours a week services is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: ventricular fibrillation (VF) 
Treatment: subcutaneous implantable cardioverter defibrillator (ICD)
The insurer denied subcutaneous implantable cardioverter defibrillator (ICD). The health plan's determination is upheld. 

The patient is a male who presented with an out of hospital cardiac arrest. Cardiopulmonary resuscitation (CPR) was performed by a bystander until Emergency Medical Services (EMS) arrived. Upon their arrival, ventricular fibrillation was detected for which he received multiple shocks. In the emergency department (ED), an electrocardiogram (EKG) revealed ST elevation myocardial infarction with atrial fibrillation. He underwent cooling protocol and emergent coronary angiography showed 100% left anterior descending (LAD) occlusion which was treated with a drug-eluting stent. 

Subcutaneous Implantable Cardioverter Defibrillator is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
This patient presented with out of hospital cardiac arrest with ventricular fibrillation in the setting of ST elevation myocardial infarction. While implantation of a traditional implantable cardioverter defibrillator (ICD) for secondary prevention of sudden cardiac death is certainly appropriate, there is insufficient clinical data to support the implantation of a subcutaneous ICD. Subcutaneous ICDs are not considered standard of care and evidence in the medical literature has not demonstrated long-term efficacy.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: ventricular fibrillation (VF) 
Treatment: subcutaneous implantable cardioverter defibrillator (ICD)
The insurer denied subcutaneous implantable cardioverter defibrillator (ICD). The health plan's determination is overturned. 

The patient is a man who suffered an acute ST segment myocardial infarction and associated cardiac arrest. Coronary angiography showed a totally occluded mid-left anterior descending coronary artery that was treated with a stent. His course was complicated by cardiogenic shock requiring hemodynamic support with an Impella device and extracorporeal membrane oxygenation. 

Based on the documentation provided, given this man's young age, the subcutaneous implantable cardioverter defibrillator (SICD) is likely to be more beneficial for him than a transvenous device. This man was young when he underwent device implantation. Overall, the failure rate of transvenous leads has been shown to be approximately 0.58%/year. Certain leads that have been under advisory have clearly demonstrated a non-linear failure rate that increases dramatically after seven or eight years. Thus, younger patients are therefore at greater risk of experiencing lead failure at some point based on their projected longevity. In addition, their more active lifestyle increases the risk of lead fracture. Use of the SICD in this young man mitigates his risk for transvenous lead failure and possible need for lead explantation. It also preserves central venous access and would allow for implantation of a transvenous device, such as a cardiac resynchronization device, should that become necessary in the future, without the need for lead explantation and associated risks.
Appeal type: Experimental/Investigational
Decision: Upheld

Cardiac
Surgical Services

Diagnosis: ventricular fibrillation (VF) 
Treatment: subcutaneous implantable cardioverter defibrillator (ICD)
The insurer denied subcutaneous implantable cardioverter defibrillator (ICD). The health plan's determination is upheld. 

The patient is a man who suffered a ventricular fibrillation (VF) cardiac arrest while hiking, He was resuscitated and hospitalized. He underwent emergency coronary angiography which showed a 100% left anterior descending (LAD) occlusion, which was stented. He subsequently had cardiogenic shock, requiring impella and ECMO (Extracorporeal membrane oxygenation) support. He required a tracheostomy, which was eventually removed. On subsequent evaluation, ejection fraction (EF) was 45-49%.

The subcutaneous implantable cardioverter defibrillator (ICD) is not likely to be more beneficial than any standard treatment for this patient.
The subcutaneous ICD has been shown to be effective in detection and termination of ventricular tachyarrhythmias. However, it has been associated with an increased rate of inappropriate defibrillator shocks compared to the transvenous ICD. The subcutaneous ICD has not been shown to be more effective than the transvenous ICD.
With regard to ICD placement, the patient suffered a cardiac arrest in the setting of an acute myocardial infarction. He had acute revascularization and recovery of left ventricular (LV) function to an ejection fraction (EF) of 45-49%. Per the current American College of Cardiology (ACC) / American Heart Association (AHA) guidelines for ICD implantation, "in survivors of life-threatening ventricular arrhythmias (ventricular tachycardia (VT) /VF) that may be due to transient or reversible factors, such as acute myocardial infarction (AMI), proarrhythmic medication effects, or electrolyte disturbances, an ICD is not implanted if the cause may be correctable."
In this case, the cause was AMI, which was treated with acute revascularization.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient admission
The insurer denied coverage for an inpatient admission
The denial is upheld. 

This is a patient with a history of ischemic heart disease, hypertension and a recent percutaneous coronary intervention who presented to the emergency department (ED) complaining of sharp atypical chest pain and dizziness. Pain radiated to the left axilla and was exacerbated by movement. Upon arrival, vital signs were stable (blood pressure 145/81, pulse 64). Physical examination revealed no major abnormality. A 12-lead electrocardiography (ECG) revealed sinus rhythm with no evidence of ischemic ST (interval on an ECG) or T wave (interval on an ECG) abnormalities. High sensitivity troponin levels were not elevated (< (less than) 6 nanograms per milliliter). The patient was discharged with a cardiology follow up the day after presentation.

The patient's pretest probability of coronary artery disease was high, however, utilizing the History, Electrocardiograph, Age, Risk Factors and Troponin (HEART) score, the patient was considered low risk. Additionally, when utilizing the Thrombolysis in Myocardial Infarction (TIMI) risk score, the patient also had a low risk of developing major adverse cardiac events in the subsequent 30 days. Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (such as a myocardial infarction (MI)), or need for percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), or death in the six weeks following presentation. Admission to the hospital to treat this acute cardiac event was not medically necessary.

Based on the above, the insurer's denial must be upheld. The health plan acted reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for coverage for the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory syncytial virus
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld.

The child presented to the hospital beyond the 4th day of the onset of symptoms. As indicated it is well known that peak symptoms of bronchiolitis are the 3rd or 4th day. Even at the 3rd day which may be the peak there was no documentation of oxygen saturation less than 90% (percent) consistently. The attending and resident always documented "smiles" and "no distress". There was no documentation that the patient required continuous positive airway pressure (CPAP) or high flow nasal canula (HFNC) (only oxygen, there was no mention of HFNC). The patient had only mild respiratory distress. The Emergency Department (ED) doctor mentioned also "nontoxic" appearance. The respirations were less than 30s initially, and also by the time the admission History and Physical was done the Respiratory syncytial virus (RSV) was positive. A basic metabolic panel showed carbon dioxide (CO2) of 27. Also, there was no leukocytosis. There was no significant acidosis or respiratory acidosis in the initial labs. There was also no need for multiple boluses for severe dehydration or shock. The patient did not have underlying chronic lung disease or congenital heart disease or prematurity or age less than 1 year or any neuromuscular deficits. The hospital course was representative of "as expected clinical course", the trajectory showed improving respiratory status. Also, there was no evidence of the patient needing continuous nebulizers, epinephrine injections or a terbutaline drip. Intravenous (IV) fluids and nebulizers could be administered in observation status. Also, there is clear evidence of etiology. Due to the above facts, the patient could have been managed as observational status. 

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 the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Post-operative wound infection
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is overturned

Patient is an adult with past medical history significant for bipolar disorder, chronic headache, hypertension, morbid obesity, post-traumatic stress disorder, obstructive sleep apnea, and status post laparoscopic appendectomy for acute appendicitis who presented to the emergency department with complaints of fever and drainage from surgical incision site.

Vitals on presentation included: Temperature 101.7 degrees Fahrenheit, blood pressure-148/87, pulse 121, respirations 22, oxygen saturation 99%(percent) on room air. Laboratory results included the following: white blood cells-7.6, Hemoglobin-10.9, Hematocrit-34.8, creatinine-1.24, glucose-145.

Patient was admitted for possible post-operative wound infection. She was started on intravenous antibiotics (vancomycin, cefepime and metronidazole). Computed tomography (CT) scan of the abdomen showed soft tissue infiltration throughout abdominal wall, expected postoperative sequelae without evidence of loculated collection. Patient remained afebrile, hemodynamically stable. She was discharged on oral antibiotics (Cefdinir and metronidazole) to continue outpatient management.

According to documentation, patient underwent a recent laparoscopic appendectomy for acute appendicitis. Despite outpatient intervention with oral antibiotics (Bactrim), patient returned to the emergency room with fever (101.7 degrees Fahrenheit), tachycardia (pulse-121), pain and drainage from incision site. Based on above findings, including failure of outpatient intervention, hospital admission was medically necessary for administration of intravenous antibiotics and surgical intervention.

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 an inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Stay.
The determination is overturned.

The patient has a past medical history of asthma and allergy to dust mites who presented with cough, wheeze, and shortness of breath. The patient was well until 2 days prior to presentation when they developed dry coughing spells, nasal congestion, and rhinorrhea. They were treated with cough medicine and acetaminophen at home. They also received albuterol via nebulizer, with little relief of symptoms. They were brought to the emergency department with complaints of (c/o) difficulty breathing.

In the emergency department the patient was noted to have retractions with bilateral expiratory wheezes. Their oxygen saturation was 94%. They received 3 albuterol/Atrovent nebulizer treatments as well as dexamethasone and magnesium sulfate. The laboratory values were drawn as well as a viral panel, which revealed enterovirus and rhinovirus infection. After treatment, they continued to have persistent wheezing and low pulse oximetry readings, and therefore they were admitted to the hospital for further care.

The patient received albuterol treatments every 2 hours, methylprednisolone, ipratropium, and incentive spirometry. The following day they had improved but were still wheezing with decreased air entry. They were able to wean to every 3-hour albuterol treatments. Eventually, they were able to wean to every 4-hour albuterol treatments and were felt to be stable for discharge to home with follow up as an outpatient.

At issue is the medical necessity of the inpatient stay. The requested health service/treatment of inpatient stay was medically necessary for this patient.

This is a young patient who presented with status asthmaticus. The patient had retractions and wheezing upon presentation and continued to have significant wheezing with decreased air movement despite appropriate and intensive treatment in the emergency department setting. In the hospital they initially required bronchodilator treatments with Albuterol every 2 hours, corticosteroids, magnesium, and close monitoring for potential deterioration of clinical status.

They also continued to require frequent bronchodilator treatments and the need for beta-agonist therapy more often than every four hours, and that alone is an indication for hospitalization for children with asthma.

According to the Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care Guidelines, 24th Edition, Asthma, Pediatric; inpatient admission is indicated for patients who have an inadequate response to therapy with lack of significant improvement after 1 hour of bronchodilator therapy.