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

Diagnosis: Central Nervous System/ Neuromuscular Disorder - Other 
Treatment: Skilled Nursing Facility 

The patient is a female with history of subarachnoid hemorrhage status/post (s/p) ventriculoperitoneal shunt (VPS) complicated by seizures and deep vein thrombosis (DVT) s/p inferior vena cava (IVC) filter on Xarelto who presented to outside hospital (OSH) with 2 day history of altered mental status. Computed tomography (CT) of the head was without acute changes. Shunt revisions occurred and her mental status improved. Therapy noted that patient lived in a wheelchair accessible home with her husband. Prior to hospital admission she was independent with feeding, upper body dressing and indoor wheelchair mobility. She required assistance with all transfers. She had a certified nursing assistant (CNA) 4-5 hours/day 3-4 days week. 

The request was for continued skilled nursing facility stay. This was previously denied by the Health Plan due to lack of medical necessity. At issue is the medical necessity for the continued care in the skilled nursing facility. 

The health plan's determination is upheld. 

The patient is an unfortunate female with history of subarachnoid hemorrhage s/p VPS complicated by seizures and DVT s/p IVC filter on Xarelto who presented to OSH with 2 day history of altered mental status. CT head was without acute changes. Shunt revisions occurred and mental status improved. Unfortunately, she had a significant decline in function being essentially dependent for all tasks. Despite this decline, the CT of the head done in the summer as well as scan on subsequent date did not demonstrate evidence of an acute cerebrovascular accident (CVA) or hemorrhage. CT of the head noted persistent diffuse mild atrophy, extensive encephalomalacia in the cerebellum, right greater than left and right posterior parietal lobe consistent with old infarct. Imaging also noted that patient was s/p posterior craniotomy and ventriculoperitoneal (VP) shunt visualized. While the patient initially made slow, but steady, functional progress she then plateaued with therapy. Her treating provider noted that the patient had recently seen Neurology, Orthopedics, Hematology and Neurosurgery and opined that "Due to the severity of her medical condition including a major cerebral bleed, the patient requires therapy. She requires multiple medical consultants. Medications have needed to be adjusted on several occasions and at this point remains unstable to go home." 

This reviewer agrees that the patient needs continued therapy but not at the skilled level. She is taking multiple medications, but this patient does not require continuous supervision by a nurse or doctor. She is breathing on room air. She does have a right heel pressure sore, but this is being appropriately treated and not of the severity level to support skilled nursing. She is also not requiring any IV medication. She has chronic medical conditions (seizure disorder and liver disease) that do require medical attention but not at a skilled level. 

Therefore, continued skilled nursing facility stay was not medically necessary nor supported.
Appeal type: Medical necessity
Decision: Upheld

Cardiac/Circulatory problems
Inpatient hospital

The patient who presented to the Emergency Department complaining of epigastric and midsternal chest pain that started 2 days ago. The pain was similar to the pain he had one year ago, when the  patient suffered a myocardial infarction (MI). The pain is dull aching, precipitated by walking few steps, and associated with dizziness and nausea. The  dizziness was with moving of the head. The patient had one episode of vomiting. The patient was admitted to the hospital. 

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient presented with atypical chest pain, which reminded him of chest pain he suffered with a previous acute MI. The patient has a history of CAD and multiple coronary risk factors.
However, the patient did not have elevated troponin, dynamic ECG changes or hemodynamic instability. The patient was ruled out for acute MI. The patient underwent coronary angiography while staying in the hospital. It revealed moderate to severe CAD. However, he did not have unstable acute lesions which would cause acute coronary syndrome. All his lesions were chronic.
The patient's chest pain was not caused by acute coronary syndrome. The  coronary angiography could have been done at a lower level of care. Inpatient admission was not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Cardiac /Circulatory Problems 
Treatment: Surgical Services  

The patient who has pelvic pain and heaviness that is limiting the  quality of life. The patient had a pelvic venogram that showed venous reflux in the left gonadal vein that is consistent with symptoms of pelvic congestion syndrome. Treatment options given to the patient were either medical management, gonadal vein embolization, or surgical hysterectomy. The health plans determination is overturned in whole regarding gonadal vein embolization.
Yes, the Gonadal vein embolization is likely to be more beneficial than either of the two options of medical management or open surgical hysterectomy.
This treatment is considered the treatment choice by a reputable and respected medical organization, the Society for Vascular Surgery. Society for Vascular Surgery clinical guidelines states: Percutaneous transcatheter embolization of refluxing ovarian and internal iliac vein tributaries with coils, plugs, or sclerotherapy, usually as combination treatment, has become the standard approach for management of both pelvic congestion syndrome and varices arising from a pelvic source.
Studies have shown that embolization of gonadal veins can provide better long-term pain relief than medical therapy and clinical guidelines recommend embolization over medical or surgical therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Cardiac /Circulatory Problems 
Treatment: Surgical Services  

The patient who presents with symptoms of pelvic congestion syndrome. The patient's main symptoms include pelvic pain and pressure. The patient  is also experiencing heaviness and rectal pressure. The patient  also presents with lower extremity and vulvar varicosities. The symptoms are lifestyle limiting. The  venogram demonstrated reflux in the left gonadal vein. the  provider is recommending left gonadal vein embolization for treatment of her ongoing symptoms. The health plans determination is overturned in whole.
Yes, the proposed gonadal vein embolization is likely to be more beneficial than any standard treatment or treatments for the patient's disabling condition, pelvic congestion syndrome.
Vascular Occlusion and Embolization - 37241 is considered Medically Necessary for this particular patient based on the peer reviewed literature. Transcatheter embolization for refluxing ovarian and pelvic veins for Pelvic Congestion syndrome is supported by the peer reviewed literature and is considered standard of care therapy in the Vascular Surgery community.
The most recent consensus guidelines from the Society for Vascular Surgery and the American Venous Forum lists the following recommendations regarding this specific therapy:
1) "We recommend retrograde ovarian and internal iliac venography in patients with pelvic venous disease, confirmed or suspected by noninvasive imaging studies, in whom an intervention is planned."
2) We suggest treatment of pelvic congestion syndrome and pelvic varices with coil embolization, plugs, or transcatheter sclerotherapy, used alone or together.
The peer reviewed literature supports the use of pelvic embolization for this particular patient. She presents with clinical and radiographic evidence of pelvic venous reflux in addition to lifestyle limiting symptoms. Several recent peer reviewed papers support the use of technique with good efficacy and safety profile.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Cardiac /Circulatory Problems 
Treatment: Surgical Services  

The patient who was evaluated by the physician and after an extensive work up that included an abdominal computed tomography (CT) scan on and a Pelvic Ultrasound  was diagnosed with pelvic congestion syndrome. The diagnosis of pelvic congestion syndrome was confirmed when  underwent diagnostic iliac and pelvic venography by the physician. The health plans determination is overturned in whole.
Yes, the proposed service of the Vein embolization is likely to be more beneficial than any standard treatment or treatments for the patient's life threatening or disabling condition or disease.
This patient with pelvic congestion syndrome will benefit from the treatment of Vein embolization.
The health benefits of gonadal vein embolization are known scientifically for this type of patient. Pelvic congestion syndrome is believed to be caused by absent or incompetent valves in the gonadal and pelvic veins, resulting in venous pooling and pelvic vein distension. Mass effect from enlarged veins can lead to bulk symptoms and irritation of adjacent nerves. Embolization of the gonadal veins and pelvic veins results in reduction of venous pooling and pelvic vein distension resulting in improvement and resolution of pelvic congestion symptoms.
Pelvic venography and gonadal vein embolization are proven treatments of pelvic congestion syndrome. Pelvic venography and gonadal vein embolization are the standard of care for the treatment of pelvic congestion syndrome.
Appeal type: Medical necessity
Decision: Upheld

Cardiac/Circulatory Problems
Inpatient hospital

This is a case of a man with a history of hypertension diabetes and hyperlipidemia, presenting to the emergency room with complaints of left shoulder and arm pain, with radiation into the left hand. Symptoms have been present for at least a week, with associated intermittent headaches and blurred vision. The patient denied chest pain or shortness of breath. There was no associated nausea or vomiting. Vital signs on arrival included a temperature of 97.9 Fahrenheit, respirations of 26, and blood pressure of 204/127. The heart rate at this time is documented at 84 beats per minute (bpm). On exam, the patient is described as well-appearing well-nourished awake, and alert. The cardiac exam showed a regular rate and rhythm with normal heart sounds and no murmurs. The pulmonary exam was fairly unremarkable, and so was the rest of the exam. 

The health plan's determination is upheld. The inpatient stay was not medically necessary. This presentation of hypertensive urgency can be managed under at a lower level of care. The presentation does not satisfy clinical indications for admission to inpatient care. The patient has a diagnosis of hypertensive urgency or emergency, without evidence of target organ damage. There is no evidence of hypertensive encephalopathy or cerebral infarction. There is no evidence that the patient suffered from myocardial ischemia or infarct. There is no evidence of heart failure or aortic dissection. There is no evidence of seizure activity associated with hypertensive urgency. Within 24 hours, the addition of antihypertensive medications produced adequate control of blood pressures. This type of presentation is typically managed at a lower level of care for chest pain rule out protocol.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary tract infection (UTI) 
 
Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission. The denial is upheld. 

This patient is a female with a history of diabetes mellitus, hyperlipidemia, anxiety, and hypothyroidism. The patient was admitted for a urinary tract infection (UTI) and treated with intravenous fluid and antibiotics. She did not have signs of severe sepsis or complicated infection as defined by the Infectious Diseases Society of America and her condition responded within 48 hours. In addition, she was hemodynamically stable with normal oxygenation and had negative blood cultures.  Both the computed tomography (CT) and ultrasound (US) showed no evidence of kidney stone obstruction. She did not have significant electrolyte disturbances, cardiac arrhythmias, altered mental status or persistent nausea and vomiting with dehydration. There was no documentation of refractory pain and she was able to tolerate an oral diet and did not require total parenteral nutrition.  There is no evidence-based literature indicating that the patient's condition could not be treated safely under lower level of care; therefore, the inpatient admission was not medically necessary. 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 hospital admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Limb girdle muscular dystrophy 
Treatment: Power wheelchair 

The insurer denied coverage for preservice request for a power wheelchair. The denial is reversed. 

This patient is a male with limb girdle muscular dystrophy.  The patient was noted to have upper and lower extremity strength measures 1-3/5 and he is wheelchair dependent.  The patient's current power wheelchair is in need of replacement.  Currently under review is the medical necessity of a requested power wheelchair.  

Based on the submitted clinical records, the requested motorized wheelchair with power tilt and recline is medically necessary.  Contrary to the assertions of the insurer, the requested power lift components should be considered primarily medical in nature.  The patient has a diagnosis of girdle muscular dystrophy and has maintained a certain level of functional independence with the assistance of adaptive durable medical equipment.  The requested power lift components for this patient's approved power chair will assist him with mobility, such as transfers, and perform activities of daily living, which includes home management tasks as well as provide a measure of safety while cooking, reaching, and carrying activities.  The power tilt component is particularly necessary for this patient to help clear thresholds and steep curb cuts, when maneuvering over city streets.  

Based on the literature and professional judgment, it is determined that the requested power components of the motorized power chair are medically necessary to allow the patient to have a higher level of functional independence for a greater length of time.  

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

The carrier's denial of coverage for the preservice request for a power wheelchair is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis
 
Treatment: Inpatient admission

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

This patient is a female child with no past medical history. The patient was picked up due to complaints of leg pain and abdominal pain. When the parent of the patient picked her up, the patient was walking normally but was noted to have a runny nose. The patient was noted to have gone out of the country the previous month, and had sustained multiple insect bites during the visit. On examination, the patient was alert and awake, not in pain, had nasal discharge and had multiple skin lesions up to 2 cm diameter with overlying scabs over both legs. There was an area of erythema 8 x 6 cm with indistinct borders and mild tenderness over the posterior aspect of her left calf with no significant swelling or oozing.
The patient's white blood cell count was elevated for her age, but this was a non-specific finding that correlated with any amount of inflammation of infection. In this patient's case, this leukocytosis supports the diagnosis of cellulitis, but by itself, does not constitute a reason for treating the cellulitis with intravenous (IV) antibiotics.  There were no other clinical signs of sepsis, specifically hemodynamic changes, or documentation of the patient appearing septic or toxic in appearance. This patient's fever could have been due to a concurrent upper respiratory infection (URI). 
The decision to admit the patient was based upon "Considering patient is febrile, and that the lesions are multiple, will admit for IV antibiotic to treat spreading cellulitis" (see ED Provider Notes). The evidence for "spreading" was not supported. There was nothing in the medical record that indicated the patient had any delayed capillary refill in the affected leg. As per literature review, outpatient therapy is recommended for children with mild, non-purulent who do not have systemic inflammatory response syndrome (SIRS), altered mental status, or hemodynamic instability. Hospitalization is recommended if there is concern for a deeper or necrotizing infection for patients with poor adherence to therapy, for infection in a severely immunocompromised patient, or if outpatient treatment is failing. However, since in this case, this patient had mild, non-purulent cellulitis with no records of failing outpatient treatment, inpatient admission (hospitalization) was not medically necessary. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the inpatient admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rectus diastases and umbilical hernia
Treatment: 15830 - Excision skin and infraumbilical panniculectomy
15847 - Excision excessive skin & subq tissue abdomen
14041 - Adjt/reargmt f/c/c/m/n/ax/g/h/f 10.1-30.0 subcutaneous cm
The proposed treatment is not medically necessary.

The patient is a female. She complains of abdominal discomfort and abdominal wall bulging. She has rectus diastases and an umbilical hernia. Her surgeon recommends abdominoplasty and adjacent tissue transfer.

The clinical significance of a rectus sheath diastasis is questionable, since it is considered a cosmetic deformity rather than a medical problem (Gutowski et al.). However, occasionally patients notice improved quality of life and abdominal wall function after rectus diastasis repair, but this has not been substantiated with high level evidence. Diastasis recti is a very common condition after pregnancy in women. Back pain was not linked to rectus diastasis in a study published by Fernandes da Mota et al., who noted that "Women with diastasis recti abdominis at 6 months postpartum were not more likely to report lumbo-pelvic pain than women without diastasis recti abdominis. Diastasis recti abdominis is prevalent at 6 months postpartum, but is not linked with lumbo-pelvic pain." 
Diastasis recti is considered a cosmetic condition without functional issues, and repair is generally done for cosmetic concerns (Akram et al.). A systematic review by Hickey et al. concluded that, "Correction is largely cosmetic." A recent randomized trial was reported by Wilhelmsson et al. on the functional effects of abdominoplasty with or without plication of the rectus abdominis muscle. The authors concluded, "No significant differences in trunk muscle endurance, lung function, or self-rated physical function were found." According to American Society of Plastic Surgeons (ASPS) guidelines, "Plication of the rectus abdominis muscle and/or translocation of umbilicus should be considered purely cosmetic and separately billed to the patient," and "In rare circumstances, plastic surgeons may perform a hernia repair in conjunction with an abdominoplasty. A true hernia repair involves opening fascia and/or dissection of a hernia sac with return of intraperitoneal contents back to the peritoneal cavity. A true hernia repair should not be confused with diastasis recti repair, which is part of a standard abdominoplasty." 

For the aforementioned reasons, the requested surgery is not medically necessary, and it is cosmetic.
Appeal type: Medical necessity
Decision: Overturned in Part

Ulcerative Colitis
Inpatient Hospital

The patient is a female with a medical history of ulcerative colitis on mesalamine and budesonide. She presented to the emergency department with abdominal pain for 4 days, watery diarrhea, nausea, and vomiting. Her vital signs were notable for fever with temperature of 103 Fahrenheit, tachycardia with pulse rate of 118/minute, and low blood pressure of 91/59 mm Hg. Her physical examination was notable for oropharyngeal exudate, abdominal distention, and generalized abdominal tenderness with rebound tenderness. 

A computed tomography (CT) scan of the abdomen and pelvis showed acute enterocolitis involving the colon and distal small bowel, most prominent in the distal rectosigmoid colon and distal small bowel; small partially loculated free fluid in the pelvis with prominent surrounding inflammatory changes near the sigmoid colon, prominent edematous/inflammatory changes in the mesentery, moderate dilation of the proximal small bowel without abrupt transition into non-distended thickened distal small bowel which could be due to ileus; distal small bowel obstruction cannot be completely excluded. She was made nil per os (nothing by mouth). She was treated with intravenous corticosteroids and Zosyn.

A Gastroenterology consultation concluded that she had a severe ulcerative colitis flare, with surgery as the most viable option; the recommendation was to keep nil per os, continue serial abdominal examinations, check C-reactive protein daily, start methylprednisolone, and check labs required before starting a tumor necrosis factor antagonist medication (hepatitis B serology and tuberculosis testing).

The health plan has denied the inpatient hospital stay as not medically necessary. The health plan's determination is overturned, in part. The first three days at issue were medically necessary. The last day was not. The patient had abdominal pain, nausea, diarrhea, and hematochezia consistent with ulcerative colitis. Imaging and flexible sigmoidoscopy showed severe disease, and the patient demonstrated signs of severe disease including fever, tachycardia, and severe leukocytosis on presentation. She had ongoing diarrhea and limited oral intake two days after presentation. On hospital day four, the flexible sigmoidoscopy had been completed and she was able to tolerate a diet that would sustain nutrition outside the hospital. Before that date, she was at risk for severe complications of ulcerative colitis including perforation, abscess, and toxic megacolon, and at risk for needing surgery; close monitoring was required. Therefore, the inpatient level of care is supported until and including that day. After that date, as she was clinically feeling well and tolerating oral intake with normal bowel movements, the inpatient level of care was not supported.