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

Diagnosis: Dementia, Chronic pain, and Cardiovascular disease.
Treatment: personal care services (PCS), Level II - split shift.
The insurer denied coverage for PCS, Level II - split shift.
The denial is overturned. 

This is a female patient who has advanced dementia and requires total care for all instrumental activities of daily living (IADLs) and activities of daily living (ADLs). The patient has personal care services (PCS) 24 hours per day, 7 days per week, live-in. A request was made to change PCS to 24 hours per day split shift. 

The patient is totally dependent on caregiver assistance for all IADLs and ADLs; except managing medications and eating, reported as maximal assistance. Functional decline in older people is usually the result of cumulative and interactive effects of multiple medical conditions plus non-medical factors (e.g. social, economic, caregiver support). Based on the available records, it appears the patient's functional decline is the result of both cognitive and physical impairments from various medical conditions, including the following: dementia, chronic pain, and cardiovascular disease. 

Considering the patient's medical history and functional impairment, it is medically necessary and in the patient's best interest to have a caregiver present and available to provide assistance for all ADLs and IADLs, including ADLs that occur throughout the day and night. The patient's daughter and son are identified in the Uniform Assessment System (UAS) report as informal caregivers. They do not live with the patient, and it appears they provide some assistance with IADLs. The patient is receiving PCS 24 hours per day live-in services. Considering the family is requesting change to 24 hours per day split shift services, it is reasonable to conclude that there are no informal caregivers who can provide care to the patient for 5 continuous hours per day when a live-in aide sleeps. Assistance from informal caregivers is voluntary, as per New York State (NYS) regulations for personal care services. When informal caregivers are unable to provide necessary assistance on a consistent basis, then personal care services are indicated to provide assistance with all daily activities when needed. 

The patient has advanced dementia and other chronic medical conditions contributing to her poor functional status. It is reasonable to expect that her daily care needs will continue at a high level, including the need for ADL assistance through the night. The report of insufficient sleep for the live-in aide noted in the tasking tool supports the need for a change in the current plan. Based on the records provided for review, continuous personal care services (i.e. split shift) are indicated.

PCS Level II: 24 hours per day, 7 days per week, split shift is medically necessary. 

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

The carrier's denial of coverage for the requested PCS, Level II - split shift is overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rectal and Vaginal bleeding.

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld. 

This is a female patient who presented to the hospital with rectal and vaginal bleeding. The patient stated that she was feeling well and denied dizziness, chest pain, shortness of breath, or abdominal pain. The patient had a past history of anemia. The patient's vital signs were stable although she had a mild tachycardia. The patient's abdominal exam was benign and no blood was seen on the rectal exam. The patient's hemoglobin was 10.9. The patient's computed tomography (CT) scan showed a possible mass in the rectum. The patient's colonoscopy was performed, and prolapsing tissue was found coming from the vagina with extrinsic compression of the rectum; hemorrhoids were present but there was no sign of active gastrointestinal (GI) bleeding. A gynecology evaluation was done, and no acute interventions were advised. The patient planned to follow-up with her gynecologist as outpatient.

As per literature, clinical indications for admission for lower GI bleed include ongoing active bleeding, failure to control bleeding after a colonoscopy, severe coagulopathy hemodynamic instability, and anemia with signs of cardiac ischemia, severe pain, and severe thrombocytopenia. In this case, the patient did not have these conditions. The patient had a mild tachycardia which subsequently resolved and was hemodynamically stable.

Based on the review of the medical record and literature, the inpatient hospital admission was not medically necessary for this patient. This patient had bleeding that she reported from the rectum. The patient required a colonoscopy and then a gynecological exam. However, this could have been done on an outpatient basis. The patient was not actively bleeding and did not meet Milliman Care Guidelines (MCG) criteria for admission for lower GI bleeding. 

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

The medical necessity for the inpatient hospital admission is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.

The patient is a male who fell while riding his bike and sustained a displaced left elbow lateral condyle fracture. His physical exam showed some weakness of wrist and finger extension and he was thought to have a possible nerve injury. He was brought to the operating room and underwent an open reduction and internal fixation. He was placed in a splint and later discharged. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination was upheld in whole.

An inpatient stay was not medically necessary for this patient. Displaced lateral condyle fractures are initially painful, and the degree of swelling is often impressive. However, there is very little risk of vascular injury or ischemia or compartment syndrome. These injuries are often splinted when seen in the emergency room, and outpatient follow-up and surgery is the usual standard treatment. The presence of an associated nerve injury is unusual and may suggest a higher degree of energy in the injury, however it does not by itself indicate that urgent treatment is required or alter the treatment in any way. The patient could have been managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma.
Treatment: Inpatient hospital stay.
The insurer denied the inpatient hospital stay. The health plan's determination is upheld. 

This is a female with history of asthma, sarcoidosis, hypothyroidism, and hypertension who presented to the emergency department (ED) with a complaint of shortness of breath. She reported worsening dyspnea and wheezing beginning 2 weeks prior. Vital signs were blood pressure (BP) 136/86, temperature 98.1 Fahrenheit, pulse 86, respiratory rate 22, and pulse oximetry 98% on room air. Physical examination on admission revealed a female in mild distress with expiratory wheezes and diminished air entry bilaterally. An electrocardiogram (EKG) showed a normal sinus rhythm. Chest x-ray did not reveal any active disease. Abnormal laboratory values included potassium 3.4. Usual Peak flow is documented at 350, on arrival in ED 200 and was 250 on admission.

The inpatient hospital admission was not medically necessary. This patient was admitted with an asthma exacerbation. Her usual peak flow was 350 and was 200 upon ED arrival. The peak flow improved to 250 upon admission, which is approximately over 70% of predicted based on usual peak flow. The patient did not require ventilatory assistance. There was no evidence of hypoxemia or hemodynamic instability. There was no abnormalities on imaging. The patient did not have altered mental status. Based on Milliman Care Guidelines (MCG) for Asthma, none of the severity of illness criteria were present to support an inpatient admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Central Nervous system/Neurological Disorder - Parkinson's disease.
Treatment:  Increase in Home Health Care - Personal Care Assistance Services (PCA), Level 2.

The health plan denied an increase in Home Health Care - Personal Care Assistance Services (PCA), Level 2 as not medically necessary.  The reviewer has overturned in whole the health plan's determination.

The patient has a past medical history of dementia, hypertension, Parkinson's disease, transient ischemic attack, tremor, osteoarthritis, history of falls, dizziness, prostate cancer, and benign prostatic hyperplasia who had been assigned Personal Care Assistance (PCA) services 4 hours/day, 7 days/week, to total 28 hours/week based on telephonic assessment tool. There was a request to increase PCA services, and the patient underwent a new telephonic assessment tool. Notes from the assessment stated the patient resides alone, had attended day program one day a week but this was closed due to COVID-19, ambulates with a cane indoors, ambulates with a walker outdoors, gait is slow and unsteady, tremor limits ability to write and hold spoon/fork to eat, had 2 falls with episodes of dizziness, and the patient has no informal helper. 
The patient's neurologist provided a letter stating the patient's medical diagnoses of severe Alzheimer's dementia, Parkinson's disease, and frequent falls. The patient has had cognitive decline, which is interfering with all activities of daily living, especially bathroom use, stating "he cannot use the bathroom on his own at all".  The patient attempts to get out of bed on his own resulting in frequent falls, cannot independently perform bathing, food preparation, cleaning, and shopping, and has left the gas on the stove and keys in the front door. 

The requested health service/treatment of Increase in Personal Care Assistance Services, Level 2 to 8 hours per day, 7 days per week, total 56 hours per week is medically necessary for this patient.

The patient has progressive chronic illnesses of dementia and Parkinson's disease with documentation from his neurologist of progression. The patient's neurologist documented the patient's need for increased PCA hours.  The patient needs assistance with all activities of daily living (ADLs) / instrumental activities of daily living (IADLs) except phone use. The patient has unscheduled needs and assistance needs. The increase in PCA hours is not solely for safety and supervision but to assist the patient with safe completion of ADLS/IADLs. Taking into account all of the information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, an increase in PCA services is medically necessary. 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 his own home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left ventricle thrombus. 

Treatment: Inpatient admission.

The insurer denied coverage for the inpatient admission.

The denial is overturned. 

This is a male patient with a history of non-ischemic cardiomyopathy and ventricular tachycardia with multiple implantable cardioverter defibrillator (ICD) shocks.  The patient was referred for electrophysiology study and ablation.  Multiple introducer catheters were inserted via femoral arterial and venous vessels.  Intraoperative transesophageal echocardiography revealed a left ventricle (LV) thrombus and the procedure was aborted.  Catheters were removed and the patient was admitted to the hospital for initiation of anticoagulant therapy with unfractionated heparin and resumptions antiarrhythmic medications (i.e., sotalol and mexiletine).  The patient was transitioned to Lovenox therapy and warfarin, and was then discharged once sheath removal sites were deemed stable.

Based on the review of the medical record and literature, inpatient admission was medically necessary for this patient.  This patient presented to the hospital for electrophysiology study following 44 ICD shocks that occurred prior to presentation.  The patient was appropriately scheduled for catheter ablation of ventricular tachycardia (VT) and had held all antiarrhythmic medications for 48 hours prior to the planned procedure.  Following vascular access with sheaths placed in femoral arterial and venous vessels, intraoperative transthoracic echocardiogram (TEE) revealed a LV thrombus making any type of left ventricular catheter manipulation too dangerous due to the potential for a stroke or other thromboembolic event.  Catheters were removed and the patient needed immediate anticoagulation with a reversible agent (unfractionated heparin) while femoral access sites were monitored.  Moreover, the patient required electrocardiogram (EKG) monitoring while being re-loaded on antiarrhythmic therapy.  Such management is clearly delineated in all care guidelines for the management of ventricular arrhythmia.  In conclusion, the inpatient admission was medically necessary for both monitoring post-procedure while administering anticoagulant therapy and for antiarrhythmic drug loading in this very high risk patient. 

The health plan did not act reasonably with sound medical judgement, and in the best interest of this patient.  

The carrier's denial of coverage for the inpatient admission should be overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status post cardiac catheterization
 
Treatment: Inpatient services

The insurer denied coverage for inpatient services.  The denial is upheld. 

This patient is a man with a past medical history of coronary artery disease, stent placement, diabetes, hyperlipidemia, stroke, renal insufficiency and hypertension.  The patient presented to the hospital for elective cardiac catheterization.  The patient received (2) drug-eluting stents to the right coronary artery.  There were no procedural complications, and the patient was then admitted for further monitoring.  The patient remained hemodynamically stable, was ambulatory, and was tolerating oral intake.  The patient had a history of hypertension, was noted as hypertensive pre, during the procedure and post procedure.  There was no evidence of end-organ damage.  There were no vascular access complications.  The patient was subsequently discharged home after an uneventful, brief overnight hospital stay. 
Inpatient admission status was not medically necessary for this patient.  Per MCG Angioplasty, Percutaneous Coronary Intervention ORG: M-52 (ISC), the procedure that the patient received is an outpatient surgery.  The patient's clinical presentation and peri-procedural course did not require inpatient management.  In view of his history of HTN and absence of any end-organ damage, management of the HTN is done as an outpatient.  Acute inpatient level monitoring was not medically necessary or appropriate.  There were no extenuating circumstances in this case which warranted inpatient admission status following elective cardiac catheterization and attempted angioplasty.  

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

The carrier's denial of coverage for the inpatient services is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient admission

The Inpatient admission was not medically necessary for the management of sigmoid diverticulitis in this case. 

The patient is a female with past medical history significant for diverticulitis. She presented with a three-day h/o (history of) left lower quadrant pain with radiation to right lower quadrant, not associated with any fever or chills. She had history of hysterectomy and right oophorectomy in the past. She was taking Ibuprofen at home but without much relief. She had a colonoscopy approximately four years prior, and it revealed diverticulosis without cancer. 

In the ED, the patient was hemodynamically stable and afebrile. The abdominal examination was remarkable for left lower quadrant tenderness, but no rebound. The surgical consult was done, and IV fluids and antibiotics were recommended. The CBC (complete blood count) revealed mild leukocytosis with WBC 10.7. The Hb/HCT (hemoglobin/hematocrit) were normal. The chem-panel was unremarkable. She had mildly elevated lactate level of 2.5, which normalized with IV fluids. The CT scan of the abdomen revealed sigmoid diverticulitis and possible coexisting continued perforation.

The patient was made NPO (nothing by mouth) and started on IV Morphine prn (as needed) for pain, and IV Zosyn prn for nausea. The antibiotics were then changed to IV Cipro and Flagyl, and her pain medication was changed to IV Ketorolac. She was also started on 2g Na (sodium) diet. 

Thepatient was discharged home on PO (oral) antibiotics, including Cipro and Flagyl, and advised to follow up with surgery for surgical evaluation for recurrent diverticulitis.

The patient presented with three-day h/o lower abdominal pain due to mild to moderate sigmoid diverticulitis. The CT scan revealed sigmoid diverticulitis with possible contained perforation. The General surgery recommended IV fluids and IV broad spectrum antibiotics and no surgical intervention. The patient responded very well to 48 hrs of IV antibiotics and was able to tolerate diet after 24 hrs. Her leukocytosis resolved and her abdominal pain improved significantly. After 48 hrs, she was switched over to oral antibiotics and was discharged home in a fair and stable condition. Given this clinical course, she could have been safely managed under lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Migraine Headaches

Treatment: Ajovy

The insurer denied the medication Ajovy. The denial was reversed.   

This is a female patient with a history of chronic migraine without an aura. The patient reported that she had an increase in headache frequency over the past year, approximately 15 per month with a duration of 4 hours. According to her treating Neurologist she had tried a series of medication that included Maxalt (Rizatriptan), Topiramate, magnesium oxide, riboflavin, coenzymeQ-10, Prozac all of which provided insufficient results. She was prescribed Aimovig; her symptoms were well controlled. Her medication was switched to Ajovy as it was preferred by her insurer.

Based on the review of the medical records provided, the patient met the clinical criteria of Ajovy coverage. The patient was then older than 18 years of age, and was requesting coverage for the prevention of chronic migraines defined as having at least 15 headaches per month, with headache lasting at least 4 hours per day; and the patient was not on concurrent treatment with botulinum toxin and has tried multiple medications to control her migraines. Based on the review of the literature and insurer's guideline for Ajovy coverage, this patient met the clinical criteria for Ajovy coverage. 

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

Based on the above information, the medical necessity for Ajovy is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back pain and left leg numbness
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.
The Inpatient admission was not medically necessary.

The patient is a female with a history of lumbar disc issues in the past who developed a severe acute low back pain/radiculopathy over the prior four days.  She was subsequently transferred to the emergency department via ambulance, and was subsequently admitted.  On admission, she was in severe pain, and was found to have some mild weakness in the lower extremities.  She was ambulatory.  She did require IV pain medication.  There was no concern for cauda equina syndrome or emergent surgery.  She was weight-bearing.  An MRI was performed which showed no changes from her previous images two years prior.  No neurosurgery consult was made during the admission.  If there was concern about the need for immediate surgery/admission, stat MRI could have been obtained via the emergency department, and neurosurgery consultation would have been ordered.  If this had been done, the images would have been available, reviewed and shown to be stable. Additionally, she can receive IV medications in the emergency department or in a lower acuity setting other than inpatient admission.  Nursing notes state throughout the night of her initial admission that she was ambulatory and able to walk to the restroom and that her pain was much improved.  No interventions were planned.  The patient was given a prescription for pain medication and discharge with outpatient follow-up.  Given the above, the above treatments did not require inpatient hospitalization.  As such, the requested admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer - lymph node cancer
Treatment: Inpatient hospital
The health plan denied the inpatient hospital stay.
The denial is upheld.

The patient is a male with past medical history of ACTH-dependent Cushing's disease and brain mass who presented to the hospital for fatigue, generalized weakness, low back pain, difficulty breathing with occasional hyperventilation, and uncontrollable crying. A computed tomography (CT) angiogram of the chest showed no evidence of pulmonary embolism and unchanged thoracic (mostly anterior mediastinal) partially imaged neck adenopathy. An electrocardiogram showed sinus bradycardia without acute ischemia. He underwent ultrasound-guided biopsy of an enlarged right cervical lymph node. Biopsy results returned notable for metastatic well-differentiated neuroendocrine tumor. He continued to await confirmation that he could obtain medication as an outpatient. The health plan denied the inpatient stay. 

The health plan's determination is upheld. The inpatient stay was not medically necessary. This is a patient with known Cushing's disease who presented with lethargy, reports of generalized weakness, and mild hypernatremia and hypokalemia. He was appropriately brought into the hospital for ongoing monitoring of his electrolytes and response to up titration metyrapone to 500mg oral q8hours, in addition to further imaging. He subsequently was noted to have adenopathy and underwent cervical lymph node biopsy the day after admission. It is noted that for the rest of the stay, he otherwise remained hemodynamically stable without severe uncontrolled hypertension, with only mild electrolyte abnormalities, with strength noted to be 5/5, no confusion, and on the same dose of metyrapone. It appears as though the patient stayed in the hospital from hospital day 2 onwards primarily in the setting of concerns that he needed confirmation that he could obtain this medication at an outside pharmacy, with him otherwise stable to discharge on no IV medications, with normal strength, and with no further titration of his metyrapone occurring.