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


Diagnosis: Acute sickle cell vasoocclusive crisis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient who presented to the emergency department with concerns for back, hip, and leg pain. The pertinent history included sickle cell disease with multiple related complications.  The patient was admitted to the hospital with an impression of acute sickle cell vasoocclusive crisis. The treatment plan included continued intravenous fluids and intravenous/ oral analgesia. The patient was discharged on her prior home regimen. At issue is the medical necessity of an inpatient stay.

Based on the clinical documentation provided, evidence based literature and standard of care, acute inpatient level of care was not medically necessary for the entire admission. Evaluation and management could have been performed at a lower level of care.
The patient had a history of sickle cell anemia and presented with concerns of musculoskeletal pains. The initial examination documented the patient as alert, oriented, tachycardic, without hypoxia, and with clear lungs. Initial laboratory testing did not reveal acute abnormalities compared to baseline. Treatment included intravenous fluids and intravenous/oral analgesia. Following observation care, the patient was deemed medically stable and was discharged. No other issues or complications were documented.
The clinical indications for admission to inpatient care were not met. The patient did not have signs or symptoms of central nervous system acute injury, acute chest syndrome, hypoxemia, emergent surgery needed, splenic or hepatic sequestration, acute ischemia, acute renal failure, aplastic crisis, priapism or other vascular complications, traumatic hyphema, infection requiring inpatient treatment (eg, bacteremia), altered mental status, need for exchange transfusion, inability to maintain oral hydration despite observation care treatment, or pain insufficiently responsive to lower level of care treatment that requires treatment in inpatient setting (eg, PCA).[2]
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Breast cancer
Treatment: FoundationOne CDx comprehensive genomic 
profiling test (F1CDx)
The insurer denied: FoundationOne CDx comprehensive genomic profiling test (F1CDx)
The denial is upheld.

The patient is an adult female. She is diagnosed with stage mT1CN0M0 (1.2 centimeters, 0.5 centimeters, 0.6 centimeters, 0/2 sentinel nodes) ER+ (estrogen receptor positive), PR+ (progesterone receptor positive), HER2 (human epidermal growth factor receptor 2) negative left breast cancer. Her Oncotype DX score was 17. Foundation One CDx was denied coverage by the health plan as unproven to improve net health outcome and not medically necessary. The denial is being appealed.

The FoundationOne CDx comprehensive genomic profiling test (F1CDx) was not medically necessary.

This patient had an Oncotype DX study and the Foundation One CDx test, both of which evaluate gene expression. The Foundation One study was obtained to evaluate for HOXB13 (Homeobox B13) gene expression, which helps to determine the administration of tamoxifen. The SHIVA trial noted no statistical improvement in progression free survival in patients receiving molecularly targeted medications compared to the control arm (1). NGS (next generation sequencing) targeted therapy did not improve outcome in a randomized phase 2 trial for triple negative breast cancer (2). Additional evidence is needed to prove the benefit of precision cancer therapies (3,4,5) and additional studies are needed to validate the drug sensitivity of targetable mutations (6). Using NGS (next generation sequencing) panel testing to match patients to an appropriate therapy needs further study (7). Mosele noted that currently, there is no need to perform tumor multigene NGS (next generation sequencing) for patients with metastatic breast cancer in the context of daily practice (8). Clinical trials in breast cancer are needed to support the use of NGS (next generation sequencing) testing to provide treatment recommendations (9).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lewy body dementia
Treatment: Nuplazid 34 mg (milligrams) Capsule
The insurer denied the Nuplazid 34 mg (milligrams) capsule.
The denial is overturned.

The patient is an elderly male with Lewy body dementia with psychosis. The provider wishes to start Nuplazid. The request was previously denied as the plan only covers this medication for a diagnosis of Parkinson's disease.

The proposed treatment is medically necessary.

Nuplazid is medically necessary. Lewy body dementia is closely related to Parkinson's and many patients exhibit Parkinson's symptoms. Furthermore, treatment of psychosis is challenging as patients with this condition tend to have severe reactions to atypical antipsychotics, causing Parkinsonism symptoms. There are no other antipsychotics that could be reasonably given to the patient without causing Parkinsonism symptoms.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult male who presented to the emergency ward with the complaint of an unwitnessed episode of loss of consciousness. At presentation, the patient had a normal neurological examination, normal vital signs, normal electrocardiogram and normal orthostatic vital signs. The patient was admitted to the acute inpatient level of care and 
discharged on day # (number) 3. Echocardiogram and electroencephalogram (EEG) were interpreted as 
normal.

The proposed treatment was not medically necessary.

The patient presented with a single episode of brief loss of consciousness. He did not have any emblematic features of seizure. He had a normal neurological examination and vital signs at presentation. There were no recurrent events. The diagnostic studies, monitoring and treatment could have been safely and effectively provided at a lower level of care (Shellhaas, 2019; Goldberger et al., 2019).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental implant
Treatment: D6010 implant placement, D6104 bone graft, D4266 gum surgery, tooth 4
The insurer denied coverage for implant placement, bone graft, gum surgery, tooth 4.
The denial is upheld. 

Based on review of the submitted documentation which includes copy of panoramic radiographs, narrative letter from the provider, in addition to insurer correspondence, it appears that this patient presented for dental evaluation and treatment and discussion regarding prosthetic rehabilitation for the tooth number (#) 4 area. The provider is recommending bone replacement graft and gingival surgery prior to surgical placement of implant at the #4 site to restore function. The insurer has denied the aforementioned services stating that in their estimation endosteal implants are not the only appropriate treatment, and implant and related services are only covered when documented and meeting medical necessity criteria. The insurer states that the medical records received do not demonstrate such a condition and therefore the endosteal implants and related services are considered not medically necessary, considered elective and therefore no benefit is available. The patient is appealing the decision.

Upon review of the objective documentation which primarily consists of the undated pretreatment panoramic radiograph, the patient exhibits a heavily restored dentition in the right maxilla. As regards endosteal implant placement, although implants are an acceptable treatment to restore edentulous spaces, an accepted standard of care in dentistry is not exclusively endosteal implants. Alternative appropriate treatment would include conventional removable dentures or fixed denture prostheses. Further, the documentation provided does not support, justify, or substantiate the requested treatment, particularly as the only objective documentation provided for review is the radiographic examination. There are no dental treatment records or periodontal records provided. Therefore, as the documentation is inadequate, the recommended services are considered elective and not medically necessary.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient. The medical necessity for D6010 implant placement, D6104 bone graft, D4266 gum surgery, tooth #4 services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizures

Treatment: Inpatient Admission

The insurer denied coverage for Inpatient admission

The denial is upheld

 
The patient presented to the emergency department (ED) following two witnessed seizures at home. Emergency Medical Services (EMS) was called, and on route to the hospital he had a third seizure, requiring midazolam. At the time of presentation, he is noted to be postictal but awakened to voice; was oriented to name and place but not year. His examination revealed him to be postictal in no apparent distress, with no gaze deviation, and the presence of tachycardia, with normal head, ears, eyes, nose throat (HEENT), eye, pulmonary, abdomen, musculoskeletal, and skin examinations. He was noted have a history of alcohol abuse and a known seizure disorder. He was provided with Keppra 1500 milligrams (mg) intravenous load. Electrocardiogram (EKG) revealed sinus tachycardia with the depression in the aVL lead. Vital signs revealed tachycardia and blood pressure up to 140/86. Laboratory testing revealed elevated potassium at 5.5, low carbon dioxide (CO2) at 20. Head computed tomography (CT) scan revealed no acute intracranial pathology and right frontal encephalomalacia that was previously noted. Chest x-ray was negative. He was admitted to the medical floor. It was noted that his last drink was two days previously and his alcohol level less than 10, and he had no sign of withdrawal.  He was admitted and received intravenous hydration. He was placed on thiamine, folic acid and multivitamins, Wernicke encephalopathy prophylaxis. No other treatment was provided, and he was discharged on 03/08/2023.

He was seen by neurology who recommended a workup that included urine toxic screen, Keppra levels, and rapid plasma reagin (RPR). Nutritional supplementation with thiamine, B12, folate and vitamin D was recommended. Consideration for rehabilitation discussion and physical therapy were also recommended.

Given the above, acute inpatient hospitalization was not medically necessary.

"Accurate diagnosis and classification of first seizures and new-onset epilepsy are key to choosing optimal therapy to maximize seizure control and minimize comorbidities." (Wirrell, 2022)

"Seizure- and epilepsy-related complications are a common cause of emergency medical evaluation, accounting for 5% of 911 calls and 1% of emergency department visits. Emergency physicians and neurologists must be able to recognize and treat seizure- and epilepsy-related emergencies." (Bank & Bazil, 2019)                                                         

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: Upheld

Diagnosis: Palpitations
Treatment: Mobile Cardiovascular Telemetry (Heart Monitor - Code 93229
The insurer denied: Mobile Cardiovascular Telemetry (Heart Monitor - Code 93229
The denial is upheld.

This patient is an adult male referred for Mobile Cardiovascular Outpatient Telemetry (MCOT) (heart monitor- code 93229). His past medical history includes atypical chest pain, palpitations, premature ventricular contractions (PVCs), left ventricular ejection fraction (LVEF) 55-60 percent, and no structural heart disease. The clinical note submitted from three years ago indicated palpitations and a 3.3 percent premature ventricular contraction (PVC) burden on the Holter monitor. The requested coverage for the service has been denied based on his policy and the patient is appealing decision.

The proposed treatment was not medically necessary.

The Mobile Cardiovascular Outpatient Telemetry (MCOT) cardiac event monitor (EM) is not medically necessary since it does not meet medical necessity as it is not a generally accepted national standard of medical practice. The current published peer-reviewed medical literature considers Mobile Cardiovascular 
Outpatient Telemetry (MCOT) to be medically necessary when suspected cardiac arrhythmia is not detected with standard cardiac event monitoring, for cryptogenic stroke with suspected occult atrial fibrillation as the cause of the stroke, and for monitoring arrhythmia status following an ablation procedure. Mobile Cardiovascular Outpatient Telemetry (MCOT) for the evaluation of arrhythmias for all other indications continues to be considered unproven, since efficacy has not been established, as is in this patient's particular case. The patient's physician has not submitted any clinical evidence to demonstrate improved patient health outcomes by use of Mobile Cardiovascular Outpatient Telemetry (MCOT) in the proposed manner for this patient's medical condition, palpitation syndrome and premature ventricular contractions (PVCs), or that the information gained is only possible with Mobile Cardiovascular Outpatient Telemetry (MCOT) or why standard cardiac monitoring techniques, like a patient-activated or auto-triggered cardiac event monitor without the real-time telemetry could not have been utilized instead. Mobile Cardiovascular Outpatient Telemetry (MCOT) under these circumstances has not been shown to be of additional benefit. Therefore, based on the submitted information and the current published literature, the requested service Mobile Cardiovascular Outpatient Telemetry (MCOT) is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is a female child. She presented to the hospital with complaint of right lower quadrant abdominal pain which began the night before. The patient denied fever.
The patient's vital signs were normal. Physical examination demonstrated right lower quadrant abdominal tenderness. White blood cell count was elevated to 20,000 with left shift (85% neutrophils). Ultrasound was not diagnostic, and the patient underwent CT (computed tomography) scan. CT (computed tomography) scan reported acute uncomplicated appendicitis. 
The patient tested positive for COVID. The patient had no symptoms related to the positive COVID test.
The patient was admitted to the acute inpatient level of care. She was started on antibiotics and scheduled for laparoscopic appendectomy the following day. The patient 
underwent straightforward laparoscopic appendectomy the following afternoon. Findings at surgery were acute non-perforated appendicitis. The patient was continued on intravenous antibiotics for 24 hours after the surgical procedure.
The patient was discharged home in the afternoon on day #3.
The acute inpatient admission was denied coverage by the health plan as not medically necessary. The hospital has appealed the denial of the acute inpatient level of care. The appeal notes that inpatient services were appropriate and that enclosed medical records support the medical necessity of the submitted level of care.

The Inpatient Hospital Admission was not medically necessary.

The care rendered did not require acute inpatient level of care.
The delay in surgery was only for convenience of the surgeon and the hospital, as there was no medical indication for the interval to surgery. Asymptomatic COVID infection would not affect the necessary level of care or postoperative course.
On day #2, the patient underwent laparoscopic appendectomy. The findings were non-perforated appendicitis. The operative report describes a straightforward laparoscopic appendectomy for uncomplicated appendicitis. Postoperative orders included 24 hours of antibiotics. Routine continuation of antibiotics after appendectomy for uncomplicated appendicitis is unnecessary and not medically indicated. The care rendered did not require acute inpatient level of care. The care the patient would have received at a lower level of care would have been identical to that which she received. The most appropriate level of care for appendectomy for non-perforated acute uncomplicated appendicitis is ambulatory.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: arthritis
Treatment: home health care
The insurer denied Personal Care Services - 3 Hours per day, 5 Days per Week. The health plan's determination is overturned. 

This is a case review for a female with medical history notable for arthritis, sciatica, glaucoma, and overweight. The patient and her care team requested an increase in personal care services to 3 hours per day, 5 days per week (total 15 hours per week). A Uniform Assessment System (UAS) was completed and was available for review. The patient was alert and oriented. She is able to direct her own care and call for help in an emergency. She requires extensive assistance for meal preparation, housework, stairs, shopping, and transportation. She requires limited assistance for bathing and is otherwise independent for activities of daily living (ADL). A task tool associated with the assessment recommended 14 hours per week to address her personal care needs.

The requested Personal Care Services - 3 Hours per day, 5 Days per Week is medically necessary for this patient.
The task tool recommends 14 hours per week, and the patient and her care team are requesting one additional hour per week. The patient requires assistance with meal preparation and must have adequate access to pre-prepared food on the weekends when she does not have a caregiver. The task tool can serve as a useful approximation for the required amount of care but should not be viewed as a strict guideline. The small, requested increase in hours to prevent food insecurity is medically reasonable and appropriate for the patient. The requested hours are medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pelvic Pain. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the Inpatient Hospital Stay. 
The determination is upheld. 

This is a female patient with pelvic pain and a thickened endometrial stripe with polyps. She had a dilation and curettage performed without complication. She was discharged the same day. She presented to the emergency room with chest pain, back pain, dizziness, near syncope and epistaxis. The vital signs, electrocardiogram (EKG) and a chest x-ray were normal. A computed tomography (CT) scan showed intraperitoneal gas. She was admitted as an inpatient for treatment. A surgery consultation indicated there was a pneumoperitoneum with unclear etiology, however, a hole appeared contained and the abdomen was benign. A small uterine perforation was likely the reason that had resealed and the patient was discharged with antibiotics. At issue is the medical necessity of the inpatient admission. 

The requested health service/treatment of inpatient stay is not medically necessary for this patient. The patient is a female without significant comorbidities. She had generalized complaints in the emergency room, however, the vital signs were stable and she had no hemodynamic instability. A surgical consultation indicated no further surgical procedures were needed and only observation. She had no pulmonary, renal nor hepatic complications. She could have been observed after surgery or under observation status as she was discharged less than 24 hours later. There was no need for acute, inpatient monitoring as there was no treatment provided except for pain medication and antibiotics.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left sided numbness, weakness
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient who presented to the emergency department with concerns for left-sided numbness, weakness, and a headache. She had no significant medical history.  The initial examination documented a National Institute of Health Stroke Scale (NIHSS) of 0.  A computed tomography (CT) scan of the head was unremarkable. Computed tomography angiography (CTA) of the brain/neck were unremarkable. The symptoms improved significantly while she was in the emergency department. She was admitted to the hospital with plans to obtain a magnetic resonance imaging (MRI) scan of the brain. The MRI of the brain was unremarkable. An electroencephalogram (EEG) did not reveal epileptiform activity. The patient was discharged with plans for outpatient follow-up. At issue is the medical necessity of an inpatient stay.

Based on the clinical documentation provided, evidence-based literature and standards of care, acute inpatient level of care was not medically necessary for the entire admission. Evaluation and management could have been performed at a lower level of care.

The patient had no significant medical history and presented with left-sided weakness and numbness. The initial examination documented an NIHSS (National Institute of Health Stroke Scale) of 0. An extensive evaluation including laboratory testing, computed tomography (CT) imaging, magnetic resonance (MR) imaging, and an electroencephalogram (EEG) were essentially unremarkable. Aspirin was prescribed. No other issues or complications were documented. The patient was deemed medically stable and was discharged the same day.
The clinical indications for admission to inpatient care were not met. The patient did not have hemodynamic instability, recurrence of focal neurologic signs, finding on brain imaging that requires inpatient care (eg, mass), altered mental status, cardiac arrhythmias of immediate concern, clinically significant cardiac or vascular disorder identified that require inpatient care (eg, severe valvular disease, arterial dissection), severe hypertension systolic blood pressure greater than 180 millimeters of mercury (mmHg) or diastolic blood pressure (DBP) greater than 120 mmHg), prolonged cardiac telemetry monitoring needed beyond observation care time frame, suspected vasculitis, pregnancy, or parenteral anticoagulation required due to embolic etiology concern (eg, atrial fibrillation, intracardiac thrombus) and inpatient anticoagulation is needed (eg, contraindications to oral regimens such as severe thrombocytopenia, liver disease with coagulopathy, advanced renal failure).[2]