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

Diagnosis: Chest Pain.
Treatment: Inpatient Hospital.

The health plan denied the inpatient hospital stay. The health plan's determination is upheld.

The man presented to the emergency department complaining of sharp chest and epigastric pain and generalized weakness. His medical history was remarkable for diabetes, hypertension, polysubstance abuse and schizophrenia. His blood pressure was 106/94 millimeters of mercury (mmHg) with a heart rate of 72 beats/minute. His respiratory rate was 18/minute with a room air oxygen saturation of 99%. His physical exam was remarkable for epigastric tenderness. His electrocardiogram showed sinus rhythm without acute ischemic changes. His serum troponin level was mildly elevated at .032 ng/dl (nanograms per deciliter). Urine toxicology screen was positive for Methadone and Benzodiazepines. The patient was admitted to the hospital to rule out acute coronary syndrome. His repeat serum troponin level was .083 ng/ml (nanograms per milliliter). His D-dimer level was elevated. A chest computed tomography (CT) angiography showed multiple bilateral pulmonary emboli. The patient was anticoagulated. He was discharged at his request.
The medical necessity for an inpatient admission is at issue.

I uphold the determination that an inpatient level of care was not medically necessary.

No.  An inpatient level of care was not medically necessary. This patient presented with atypical chest pain. Given his cardiac risk factors and mild troponin elevation, there was concern for possible acute coronary syndrome (ACS). Accordingly, admission for monitoring and further testing was a reasonable approach. However, the patient was hemodynamically stable and had no electrocardiographic manifestations of ischemic. His HEART (predictor of risk for major adverse cardiac event) score was 2, indicating a low risk for major adverse cardiac events. Other than Aspirin, he was not treated for ACS nor was any further cardiac workup deemed to be necessary. His chest pain and troponin elevation were ascribed to pulmonary emboli. Despite his pulmonary emboli there were no signs of hemodynamic compromise and the patient was not tachycardia, tachypneic or hypoxic. Based on the Pulmonary Embolism Severity Index (PESI) score, he was at low risk for major adverse events. He did not meet any of the HESTIA (outpatient pulmonary embolus treatment) exclusion criteria for outpatient management of pulmonary embolism. In low-risk patients with pulmonary embolism, studies have shown that observation level care is associated with reduced length of stay, fever hospital-acquired complications and reduced cost, as compared to inpatient care. Thus, based on this man's stable hemodynamics and the absence of high-risk features for his chest pain or his pulmonary emboli, an inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Blood Disorder-Other-Sickle Cell Disease
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld the health plan's determination.

This is a patient with sickle cell disease who presented to the emergency room with 8/10 pain in the low back and hips. The pain did not respond to her typical pain regimen of hydromorphone. The patient was admitted to inpatient care. The patient received oxygen, incentive spirometry, and oral fluids. The patient decided to be discharged shortly after admission and was discharged against medical advice.

The requested inpatient hospital admission was not medically necessary for this patient. 

This patient was admitted for sickle cell disease. The patient did not require blood products and had normal vital signs. The patient had no source of infection and did not require intravenous (IV) therapies including fluids. The patient did not require surgery, and did not require intensive nursing care. For these reasons, medical necessity for this patient's hospitalization cannot be established.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer. 
Treatment: Radiation Therapy. 
The insurer denied radiation therapy for primary central nervous system tumors. 
The denial is upheld in whole.

The patient is a male who underwent resection surgery which showed right frontal anaplastic glioma, World Health Organization (WHO) Grade III.  The patient initially had presented with a seizure. Subsequently computed tomography (CT)/magnetic resonance imaging (MRI) of the head showed a 2 centimeter (cm) right parietal mass. The patient was recommended adjuvant radiation therapy (RT) using proton beam. The subject under review is the medical necessity for the use of radiation therapy for primary central nervous system (CNS) tumors.

The requested health service/treatment of radiation therapy for Primary CNS Neoplasms (Tumors) is not medically necessary for this patient. There is no published data suggesting improved long term outcome with proton beam compared to photon based intensity modulated radiation therapy (IMRT).

Though such studies show the potential for a benefit of proton beam therapy in the treatment of glioblastoma multiforme (GBM), there remain insufficient clinical publications documenting the benefits, risks or efficacy of proton beam therapy. Studies to evaluate any benefit of proton beam therapy are ongoing, Therefore, until such data is published and until there is clear data documenting the clinical outcomes of proton beam therapy (PBT) in the treatment of glioblastoma multiforme, PBT remains unproven.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. The denial is upheld in whole. 

The patient is a male who presented to the emergency department complaining of palpitations and dyspnea. His medical history was remarkable for paroxysmal atrial fibrillation, hypertension and hyperlipidemia. His blood pressure was 141/112 millimeters of mercury (mmHg) with a heart rate of 111 beats/minute. His room air oxygen saturation was 97%. An electrocardiogram showed atrial fibrillation with a ventricular rate of 138 beats/minute. His serum troponin level was normal. The patient was treated with two doses of intravenous diltiazem and with oral diltiazem. Initially his heart rate slowed to less than 100 beats/minute; however, he remained intermittently tachycardic. He was started on a heparin infusion and admitted to the hospital. He then underwent successful direct current (DC) cardioversion. The patient remained in sinus rhythm overnight with one 14 beat run of non-sustained atrial tachycardia. He was discharged. The subject under review is the medical necessity of the inpatient stay.

The health plan's determination is upheld in whole.

This patient presented with acute onset atrial fibrillation (AF). He was hemodynamically stable, there was no evidence of ischemia, he was not in decompensated heart failure, and was not at high short-term risk for thromboembolism. For stable patients presenting with acute AF, the safety of treatment at a lower level of care status with close follow-up has been well demonstrated. As stated by Lin et al, "There is growing evidence to suggest that outpatient management is a safe and effective alternative to hospital admission for the management of many patients with acute AF or atrial flutter." Protocols for early rhythm control, clinical decision rules to guide the decision to initiate antithrombotic therapy, and low molecular weight heparin and direct oral anticoagulants have reduced the need for acute inpatient hospitalization. Thus, treatment at a lower level of care would have been appropriate for this stable patient who was successfully cardioverted to sinus rhythm on the day of presentation.
The Milliman Care Guideline, Atrial Fibrillation General Recovery Guidelines (GRG), was provided for review. This patient did not meet any of the listed criteria for inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right elbow cellulitis
Treatment: Acute inpatient admission

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

This is a male patient with past medical history significant for obesity, bipolar disorder, gout, and right ankle surgery who presented to the Emergency Department (ED) with complaints of fever and right elbow pain and swelling. The patient's vital signs on presentation included: temperature 98.6, blood pressure 152/85, pulse 98, respiratory rate 20, and oxygen (O2) saturation 98% on room air. The patient's laboratory results included the following: white blood cell (WBC) count 7.45, hemoglobin (HGB) 13.8, hematocrit (HCT) 40.3, creatinine 0.9, glucose 98, lactate 1.07, erythrocyte sedimentation rate (ESR) 32, and C-reactive protein (CRP) 25. The patient was admitted with a possible right elbow cellulitis. The patient was empirically started on intravenous (IV) antibiotics (i.e., vancomycin and Unasyn).  Orthopedic service was consulted and they deemed no surgical intervention was necessary.  The patient remained afebrile, and hemodynamically stable. The patient was discharged to continue oral antibiotics as an outpatient. 

The patient presented with a possible right elbow cellulitis. Otherwise, the patient was afebrile, hemodynamically stable with unremarkable laboratory findings including a normal WBC count.  The patient had a localized infection versus inflammation with no evidence of systemic toxicity; moreover, no surgical intervention was required. Lack of response to outpatient antibiotics alone does not warrant acute hospitalization in a patient described as comfortable and non-toxic appearing. Given this patient's history of gout, symptoms could have been secondary to inflammatory arthritis. Based on the above findings, the patient met criteria for observation level of management. Thus, inpatient admission was not medically necessary for this patient.

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

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

Diagnosis: acute appendicitis
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a woman. Her medical history included nephrolithiasis. The patient presented to an emergency department with abdominal pain. Physical examination demonstrated tenderness to palpation of the right lower quadrant of the abdomen. Serum laboratories demonstrated leukocytosis to 17.15. Computed tomography demonstrated acute appendicitis. 

The patient was admitted at an acute inpatient level of care with a diagnosis of acute appendicitis. She was made nil per os (nothing by mouth [NPO]); and provided with intravenous fluids, antibiotics, analgesics, antacids, and antiemetics. The patient underwent laparoscopic appendectomy, enterolysis, and umbilical hernia repair. Surgery and recovery were uncomplicated. Having returned to her baseline health and function, the patient was discharged home in good and stable condition with outpatient surgical follow-up. 

No, the proposed inpatient admission was not medically necessary. 

According to several studies, the majority of patients with uncomplicated appendicitis who undergo laparoscopic appendectomy can be treated effectively and safely on outpatient or observational status [Gilliam et al; Cross et al; Cosse et al]. In fact, most patients can be discharged from the post-anesthesia care unit -- the recovery room --, precluding the need for inpatient admission, even on observational status [Mitchell et al; Dubois et al; Cash et al]. 

The patient underwent laparoscopic appendectomy, enterolysis, and umbilical hernia repair. Surgery and recovery were uncomplicated. 

Therefore, for this patient, there was no need for admission at an acute inpatient level of care; she could have been treated at a lower level of care. 

Patients with uncomplicated appendicitis who undergo laparoscopic appendectomy can be treated effectively and safely on outpatient or observational status; most patients can be discharged from the recovery room. The patient could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Physical therapy
The insurer denied the physical therapy. 
The denial is upheld. 

The patient is a female. The patient started outpatient physical therapy at a practice earlier in the year, referred by her doctor to reduce her back pain and improve her functional mobility.  She had low back pain of insidious onset starting two weeks earlier.  She underwent a therapy program that included therapeutic exercises and modalities.  

The patient had undergone 22 therapy visits. She reported decreased back pain and improved mobility.  She reported occasional back spasms when lifting a filled laundry basket.

No, the Physical Therapy was not medically necessary.

The patient has had persistent low back pains despite a prolonged course of formal physical therapy.  There are no indications, however, that she has impairments that would preclude full transition to a self-directed exercise and modality program.  There are no exercises that she has been doing in the formal therapy setting that could not be performed independently or substituted with independent exercise.  There is no proven benefit of formal modalities and manual therapy over palliative modalities that can be applied independently for the patient's condition.  Although the patient has persistent symptoms, no significant difference in outcomes would be reasonably expected between additional formal therapy versus a compliantly followed independent program.  The additionally requested therapy is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  End-stage renal disease.
Treatment:  Consumer Directed Personal Assistance Services.

The insurer denied the Consumer Directed Personal Assistance Services.  The denial is overturned. 

The patient is a male with end-stage renal disease who does home hemodialysis four times per week.  He does not have a care partner available during set up or during his dialysis sessions.  The request is for consumer directed personal assistance services for five hours, four times per week, to assist with setup and provision of dialysis, medication administration, assisting with activities of daily living during treatment, removal of needles with obtaining hemostasis, and vital sign monitoring.

Yes, the Consumer Directed Personal Assistance Services are medically necessary.

Home hemodialysis requires a partner in the home, and the patient does not have anyone in the home to assist with his dialysis.  The patient would not be able to perform vital signs, medication administration, or needle removal on his own or without a caregiver.  He would also require assistance with activities of daily living such as going to the bathroom during dialysis.  The requested consumer directed personal assistance services are medically necessary as requested.  The health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient in making its determination.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Spinal stenosis, osteoarthritis and urinary incontinence
Treatment: Personal Care Services, 24 hours/day, 7 days/week (split shift)
The insurer denied the Personal Care Services, 24 hours/day, 7 days/week (split shift). 
The denial is overturned. 

The patient is a female with a history of spinal stenosis, osteoarthritis and urinary incontinence. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). An appeal review was requested for potential approval of 24 hours/day, 7 days/week (split shift) Personal Assistance Services to offer increased ADL (activities of daily living) support.

Yes, the proposed service 24 hours/day, 7 days/week (split shift) Personal Assistance Services is deemed medically necessary. 

The patient is a female with a history of spinal stenosis, osteoarthritis and urinary incontinence. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Recent documentation from the patient's medical provider indicates that due to worsening pain, immobility, weakness and need for increased ADL (activities of daily living) assistance including toileting, ambulation, bathing and dressing; the currently approved plan of 42 hours/week Personal Assistance Services is no longer sufficient to meet the patient's current needs. For these reasons, the proposed treatment of 24 hours/day, 7 days/week (split shift) Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Dental Disorder.
Treatment:  Braces.

The insurer denied Braces.  The determination is overturned.

The patient presented with a skeletal Class III malocclusion.  Teeth 7, 10 and 11 are in anterior crossbite.  She is treatment planned for orthodontics to correct her malocclusion.  At issue is the medical necessity of braces.

Teeth 7, 10 and 11 are at high risk for restorative problems in the future, due to their traumatic occlusion with the mandibular teeth.  Studies have shown that even the untreated dentition shows increased anterior irregularity with time (4), which will make treating this occlusion at a later time more difficult.  Further movement of tooth 21 will likely lead to the need for future for periodontal grafting on these teeth.  Orthodontic treatment now will likely prevent the need for future periodontal and restorative procedures.  For these reasons orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Left elbow fracture.
Treatment:  Inpatient Hospital Stay.

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

The patient sustained a left elbow fracture dislocation.  He underwent multiple elbow surgeries, including open reduction and internal fixation on followed by ulnar nerve transposition and placement of a spanning elbow plate.  The patient elected to undergo revision elbow surgery.  This operation involved removal of the spanning elbow plate followed by revision open reduction and internal fixation of a displaced proximal ulna fracture with iliac crest bone graft.  The surgery was successful with no documented complications.  The patient, however, had a history of renal insufficiency, and his creatinine was elevated to 2.0 after surgery.  He remained admitted to the hospital until his creatinine decreased to 1.5, at which time he was deemed stable for discharge.  At issue in this case is the medical necessity of the inpatient hospital stay.

The requested health service/treatment of an inpatient stay was medically necessary for this patient.  The provided medical records in this case document that the patient underwent revision elbow surgery with removal of hardware and open reduction and internal fixation of an olecranon non-union.  The care rendered for this patient was consistent with the recommendations of the peer-reviewed literature as documented by Duckworth and colleagues in the Journal of Bone and Joint Surgery.  The records document that this surgery was successful with no recorded complications.  The patient however, had a history of renal insufficiency, and his creatinine was elevated to 2.0 after surgery.  The patient was appropriately fluid managed and his creatinine decreased to 1.5.  The patient was then deemed stable for discharge.  The medical necessity of the inpatient stay is justified based upon the documented medial management of this patient's elevated creatinine level after surgery.  Appropriate medical management of this condition required inpatient hospital admission.  The patient's creatinine level was restored to 1.5, and he was deemed stable for discharge.
Appeal type: Medical necessity
Decision: Overturned

Orthopedic/Musculoskeletal
Durable Medical Equipment (DME) (including Wearable Defibrillators)

Diagnosis: Back pain
Treatment: Spinal Cord Stimulator (SCS) Trial 
The insurer denied the Spinal Cord Stimulator (SCS) Trial. The health plan's determination is overturned. 

The patient underwent lumbar decompression and instrumented fusion. The postoperative course is complicated by intractable low back and bilateral lower extremity pain. Conservative and interventional measures failed to provide meaningful improvements. A diagnosis of failed back surgery syndrome is substantiated in the supporting medical reports. A trial of spinal cord stimulation is proposed. 

The Spinal Cord Stimulator (SCS) Trial is medically necessary for this patient.

A review of SCS states (in part) "Spinal cord stimulation (SCS) is a minimally invasive therapy used for the treatment of chronic neuropathic pain. SCS is a safe and effective alternative to medications such as opioids, and multiple randomized controlled studies have demonstrated efficacy for difficult-to-treat neuropathic conditions such as failed back surgery syndrome".

Review of clinical best practices for SCS state (in part) "For more than 30 years, SCS has successfully alleviated patient suffering and enhanced the lives of patients with refractory pain conditions. Prospective studies of SCS have consistently demonstrated benefits through reduction of pain, improvement in function, and reduced healthcare expenditures in select patient diagnosis groups".

A review of the evidence for an American Pain Society Clinical Practice Guideline-Surgery for low back pain, states (in part) "Surgery for radiculopathy with herniated lumbar disc and symptomatic spinal stenosis is associated with short-term benefits compared to nonsurgical therapy, though benefits diminish with long-term follow-up in some trials. For non-radicular back pain with common degenerative changes, fusion is no more effective than intensive rehabilitation, but associated with small to moderate benefits compared to standard nonsurgical therapy".

Based on the submitted clinical material, peer-reviewed medical literature and experience, further lumbar spine surgery is not likely to improve this patient's condition because the pain they experience is not likely originating from the foraminal stenosis seen on lumbar MRI.

In this case, the spinal cord stimulator trial is medically necessary.