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

Diagnosis: Metastatic liver cancer
Treatment: Radiation therapy, Yttrium-90 (Y90)
The insurer denied coverage for radiation therapy, Yttrium-90 (Y90).
The denial is upheld.

According to the medical records, the patient has metastatic cancer to the bone and liver causing severe abdominal pain. The provider is requesting Yttrium-90 (Y90) radioembolization for pain control as part of her palliative care.

Y-90 radioembolization is not appropriate in patients with extrahepatic metastatic disease and is also not appropriate as a palliative treatment for pain. Standard medical practice at this time would include traditional chemotherapy, external beam radiation and pain control. Y-90 radioembolization is not an appropriate end of life treatment to reduce pain. 

"Conclusions: Radioembolization with 90Y for unresectable Intrahepatic cholangiocarcinoma (ICC) results in substantial downstaging, disease control, and survival." (Schartz, D. A., et al, 2022).

"Transarterial radioembolization with yttrium-90 resin microspheres (SIR-Spheres; Sirtex Medical Limited, Sydney, Australia) is a liver-directed therapy that is gaining recognition as a treatment option for liver-dominant primary and metastatic cancers. The incidence of complications is low and can be further reduced by patient selection and rigorous pretreatment assessment. Ideal candidates for radioembolization have preserved liver function without ascites or encephalopathy, Child-Pugh score < (less than) 7 and limited lung shunting. Phase III (3) randomized controlled trials (RCTs) against other liver-directed therapies are lacking for intermediate-stage hepatocellular carcinoma. However, preliminary data from a recent RCT has suggested that radioembolization has a similar time-to-progression and comparable toxicity to selective chemoembolization. Phase II (2)/III RCTs are now ongoing to evaluate the combination of radioembolization with systemic therapies in advanced-stage hepatocellular carcinoma and metastatic liver-dominant colorectal cancer in order to expand the treatment opportunities for patients with cancers in the liver." (Golfieri R., 2014).

"Conclusions: This practice parameter is a tool to guide clinical use of radioembolization. It focuses on the best practices and principles to consider when using radioembolization effectively. The clinical benefit and medical necessity of the treatment should be tailored to each individual patient." (Hong, K., et al, 2022).

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 radiation therapy, Yttrium-90 (Y90) is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes, neuropathy, stroke with left hemiparesis, prostate cancer and multiple toe amputations

Treatment: Personal Care Assistance, a total of 42 hours per week

The insurer denied coverage for Personal Care Assistance, a total of 42 hours per week

The denial is overturned

This is a geriatric patient with multiple medical problems including diabetes, neuropathy, stroke with left hemiparesis, prostate cancer and multiple toe amputations. The patient requested an increase in Personal Care Assistance (PCA) hours from 30 (6 hours per day, 5 days per week) to 42 hours per week (6 hours per day, 7 days per week) since the nephew who was providing care on the weekends is no longer available. The request was denied by the insurer and is currently under review.  

The Uniform Assessment System (UAS) report was reviewed. The patient's cognition is described as independent. However, the patient requires extensive to maximal assistance for much of the Instrumental Activities of Daily Living (IADL) tasks including ordinary housework, meal preparation and shopping. Extensive assistance is needed for bathing, dressing, bed mobility, locomotion, ambulation and toilet transfer/use. The patient is continent of bowel and bladder. Limited assistance is needed for personal hygiene, and the patient is independent for eating. The patient's condition has declined and there have been reported falls (resulting in a tibia fracture requiring surgical intervention) over the past 90 days. The patient's condition and functional deficits are at a level or unpredictable as to require an increase in PCA hours to 42 hours/week; particularly with the informal care by a relative on weekends no longer being available. Based on the enclosed documents reviewed, the patient's health and safety are more appropriately provided and maintained by increasing PCA services from 30 to 42 hours/week.   

From a physical medicine and rehabilitation perspective, the requested increase in PCA hours to 42 hours per week is medically necessary.  

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Personal Care Assistance, a total of 42 hours per week is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Spondylolisthesis of Lumbosacral Region
Treatment: Inpatient Procedure
The health plan denied the requested inpatient procedure as not medically necessary. The health plan's determination is upheld.

This is a female with a history of low back and left leg pain. She has had physical therapy, injections, and medications without relief. She is a current smoker.

There has been discussion about smoking cessation, but no definitive documentation that the patient complied. The neurologic exam shows no motor, sensory, or reflex abnormalities. The lumbar magnetic resonance imaging (MRI) shows at L (lumbar) 4-5 mild degenerative changes, and at L5-S (sacral) 1 there is a left paracentral disc protrusion and mild anterolisthesis. Flexion/extension x-rays show grade 1/2 spondylolisthesis and unquantified movement at L5-S1. The provider has recommended an L4-S1 fusion.

At issue is the medical necessity for the inpatient procedure.

The health plan's determination of medical necessity is upheld, in whole.

The patient is a current smoker, which has worse outcomes with fusion. The L5-S1 level shows a herniated disc and spondylolisthesis, and the patient has back and leg pain and has failed conservative therapy. Other than the smoking, this level would be medically necessary based on standard of care. The L4-5 level, however, is not medically necessary as there is minimal degeneration at this level with no stenosis.

Smoking: Martin, et al cite "current smoking is associated with a small but significant increase in systemic morbidity and wound complications following elective lumbar spine procedures. Increasing pack year history was also associated with wound complication risk, suggesting a dose-related effect." Berman, et al cite "it has been clearly demonstrated from both a biochemical and clinical perspective that smoking increases the rate of perioperative complications for patients undergoing spinal fusion surgery, particularly pseudoarthrosis. It has also been shown that there are certain approaches that can reduce the risk of morbidity."

The health plan's determination of medical necessity is upheld, in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of Breath
Treatment: Inpatient Hospital Stay
The health plan denied: Inpatient Hospital Stay
The determination is: Upheld

The patient is a female with a history of hypertension, chronic dyspnea, chronic obstructive pulmonary disease (COPD) on home oxygen, asthma, tobacco use, and anxiety. She presented to the emergency room with worsening shortness of breath. The vital signs were notable for a blood pressure of 156/110 millimeters of mercury (mmHg), a respiration rate 24/minute, and a pulse of 125 beats per minute (bpm). She appeared to be in moderate distress, and the lung exam revealed bilateral diminished breath sounds and the use of accessory muscles. Labs were remarkable for a glucose of 236, a white blood cell (WBC) count of 15,500, and a hematocrit of 49.7. The arterial blood gas showed a partial pressure of oxygen (pO2) of 82, a partial pressure of carbon dioxide (pCO2) of 53, and a potential hydrogen (pH) of 7.36. There was no focal consolidation on the chest x-ray. The critical care consultant evaluated the patient and concluded that admission to the intensive care unit was not required. The patient was treated with bi-level positive airway pressure (BiPAP) and nebulizers, and he showed improvement. The patient was admitted for further treatment and evaluation.
Upon admission, the patient was treated with empiric antibiotics, parenteral corticosteroids, BiPAP, nebulizers, and oral medications. The remainder of the stay was clinically uneventful, and the patient was discharged.

At issue is the medical necessity of the inpatient admission.
The health plan's determination of medical necessity is upheld in whole.
Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, or imaging of an imminently life-threatening cause of the patient's complaints that required acute inpatient admission. There was no hemodynamic instability, mental status changes, or severe metabolic disarray. The COPD and hypoxemia were not new, as the patient uses home oxygen. There was no evidence of pneumonia, and she responded promptly to straightforward therapy. There was no clear need for parenteral antibiotics. The services provided - antibiotics, corticosteroids, nebulizers - were not at the acute inpatient level of intensity.
Therefore, based on the standard of care, as well as the peer reviewed literature cited in the references, the acute inpatient level of care was not medically necessary, and the patient could have been managed at an alternate level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: transient ischemic attack
Treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

This case involves a male admitted to the hospital for dizziness, confusion, and balance issues. Symptoms began on the morning of the presentation, after waking up from sleep. After evaluation in the emergency department (ED), the symptoms resolved. A computed tomography (CT) head was unremarkable in the ED. A computed tomography angiography (CTA) of the carotids showed no blockage, hypoplastic basilar artery was noted. The perfusion study was negative. The patient was not given thrombolytics, given an unknown time of onset. The National Institute of Health (NIH) stroke score was 0 at the time of admission. At the time of presentation, the patient was on aspirin and was switched to Plavix. Neurology was consulted. The medical team ordered an magnetic resonance imaging (MRI) and an echocardiogram.

The inpatient hospital admission was not medically necessary. The patient had an NIH score of 0, with complete resolution of the symptoms at admission. The extensive brain imaging with CT scan, MRI, and MRA (magnetic resonance angiography), failed to demonstrate an acute stroke, bleed, or tumor. This was deemed a TIA (transient ischemic attack), treated with the addition of Plavix and high-dose statin, and the patient as safely released home. Evaluation and treatment of TIAs can be completed under a lower level of care, per nationally published studies in reputable journals.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lymphedema

Treatment: Flexitouch compression device

The insurer has denied coverage for a replacement pneumatic compression device

The decision was reversed.

The insurer denied coverage for replacement pneumatic compression device due to the lack of documentation from the treating physician showing that the patient has been compliant with the use of the device and will continue to benefit from use of the device. However, the letter from the manufacturer's Claim Appeals Supervisor indicated the treating physician "proceeded with prescribing pneumatic compression with Flexitouch after ruling out basic pump due to risk of inappropriate fluid displacement into the already congested chest and trunk as well as her compromised skin integrity." This statement is corroborated by the Prescription for EO652 Pneumatic
Compression Device Flexitouch system, and indicated the patient discontinued the basic pneumatic compression device due to trunk/chest/abdominal swelling, exacerbated symptoms; compromised skin integrity." This physician agrees with the
manufacturer of the device and the treating physician regarding the clinical appropriateness and medical necessity of the replacement pneumatic compression device.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for a replacement pneumatic compression device is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lymphedema

Treatment: Flexitouch compression device

The insurer has denied coverage for a replacement pneumatic compression device

The decision was reversed.

The insurer denied coverage for replacement pneumatic compression device due to the lack of documentation from the treating physician showing that the patient has been compliant with the use of the device and will continue to benefit from use of the device.

However, the letter from the manufacturer's Claim Appeals Supervisor indicated the treating physician "proceeded with prescribing pneumatic compression with Flexitouch after ruling out basic pump due to risk of inappropriate fluid displacement
into the already congested chest and trunk as well as her compromised skin integrity." This statement is corroborated by the Prescription for EO652 Pneumatic Compression Device Flexitouch system, and indicated the patient discontinued the
basic pneumatic compression device due to trunk/chest/abdominal swelling, exacerbated symptoms; compromised skin integrity." This physician agrees with the
manufacturer of the device and the treating physician regarding the clinical appropriateness and medical necessity of the replacement pneumatic compression device.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for codes E0652 and E0667, a replacement pneumatic compression device is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lymphedema

Treatment: Flexitouch compression device

The insurer has denied coverage for a replacement pneumatic compression device

The decision was reversed.

However, the letter from the manufacturer's Claim Appeals Supervisor indicated the treating physician "proceeded with prescribing pneumatic compression with Flexitouch after ruling out basic pump due to risk of inappropriate fluid displacement into the already congested chest and trunk as well as her compromised skin integrity." This statement is corroborated by the Prescription for EO652 Pneumatic Compression Device Flexitouch system, and indicated the patient discontinued the basic pneumatic compression device due to "trunk/chest/abdominal swelling, exacerbated symptoms; compromised skin integrity." This physician agrees with the manufacturer of the device and the treating physician regarding the clinical appropriateness and medical necessity of the replacement pneumatic compression device.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient hospital stay
The insurer denied coverage for the inpatient hospital stay.
The denial is upheld.

This adult male presented to the hospital complaining of chest pain and headache. Past history was significant for paroxysmal atrial fibrillation, noncompliance with oral anticoagulant therapy, and a recent admission to another hospital one week prior for transient ischemic attack (TIA) symptoms. On arrival to the hospital, vital signs were stable with blood pressure 140/78 and pulse 104. Physical exam revealed no abnormality. 12 lead electrocardiogram (EKG) demonstrated sinus tachycardia with ST segment (the region between the end of ventricular depolarization and beginning of ventricular repolarization on the EKG) depressions in the inferior leads. Serum troponin was less than (<) 0.01 x (times) 3 and B type natriuretic peptide was not elevated. The patient was admitted to the hospital, but ultimately signed out against medical advice. 

This patient presented with chest pain and a past medical history of paroxysmal atrial fibrillation and possible TIA. His pretest probability of coronary artery disease was low. [1] Utilizing the HEART (history, EKG, age, risk factors, troponin) score he was considered low risk. [2] Utilizing the Thrombolysis in Myocardial Infarction (TIMI) risk score he also had a low risk of developing major adverse cardiac events in the subsequent 30 days. [3] Risk assessment of patients presenting with chest pain and no significant ST changes on EKG was reviewed by Hedayati, et al. [3] Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events, defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death, in the six weeks following presentation.  Using the TIMI risk score, this patient would have a low risk of major cardiac events, defined as all-cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization within the two weeks following presentation. In conclusion, admission to the hospital to treat an acute cardiac event was 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 the inpatient hospital stay is not substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Bladder Incontinence
Treatment: Home health care (HHC) level 2 personal care services (PCS), per 15 minutes increase to 42 hours/week
The insurer denied HHC level 2 PCS, per 15 minutes increase to 42 hours/week.
The determination is overturned in part.

This is a female patient with a medical history notable for incontinence. The patient is approved for 27 hours/week of level 2 personal care services (PCS). The patient and her care team requested an increase to 42 hours/week and the request was denied by the health plan. This denial is the subject under review.

No medical records or letters of medical necessity were provided as part of this case review.

A Uniform Assessment System (UAS) was completed and was available for review. The patient's expressed goal was "I need more help with daily routine." The patient was alert and oriented to person and place. She is able to direct her own care and call for help in an emergency. For her instrumental activities of daily living (IADLs), she requires total dependence for housework. She requires maximal assistance for meal preparation and shopping. She requires extensive assistance for finances, medications, stairs, and transportation. For her activities of daily living (ADLs), she requires extensive assistance for bathing and dressing lower body. All other ADLs require limited or no assistance. She ambulates with a slow and unsteady gait due to knee pain. She is occasionally incontinent of urine and infrequently incontinent of stool. She uses pullups for incontinence care. Compared with a prior assessment, there was not a significant decline in functional status. A task tool associated with the most recent assessment recommended 33.8 hours/week to address her personal care needs, an increase from the 27 hours/week recommended on the prior assessment.


The requested health service/treatment of home health care (HHC) level 2 PCS, per 15 minutes increase to 42 hours/week has not been demonstrated to be medically necessary for this patient.

The patient requires assistance mostly with IADLs. She does require some help with bathing and dressing. The task tool can be helpful in these cases to determine an appropriate amount of personal care for the patient. In this instance, the tool is recommending 33.8 hours/week, which is greater than the 27 hours she is currently approved for.

There is no documentation regarding any unmet personal care needs, so it is not clearly demonstrated that an increase to 42 hours/week (an increase beyond the level recommended by the UAS task tool) is medically necessary at this time. However, the patient should be approved for 34 hours/week as recommended by the UAS task tool.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial fibrillation, glaucoma and arthritis.

Treatment: Increase in Personal Care Worker (PCW) services from 7 days per week, 24 hours live-in; 91 hours per week to 7 days per week, 24 hours by more than one person; 168 hours per week.

The insurer denied coverage for increase in PCW services from 7 days per week, 24 hours live-in; 91 hours per week to 7 days per week, 24 hours by more than one person; 168 hours per week.

The denial is upheld.
 

This is an elderly male with chronic medical problems including atrial fibrillation, glaucoma and arthritis.  He lives with his wife; who currently has a live-in Personal Care Worker (PCW).  The insurer approved PCW services live-in (91 hours/week).  The patient is seeking an increase to split-shift services.   

The recent Uniform Assessment System (UAS) report was reviewed.  The patient's cognitive skills are described as moderately impaired.  He is reportedly totally dependent to maximal assistance for much of his Instrument Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.  Extensive assistance is reportedly needed for bathing, personal hygiene, dressing and toilet use.  He reportedly requires only limited assistance for eating, bed mobility, locomotion, toilet transfer and ambulation (uses a cane).  The patient is occasionally incontinent of bladder and infrequently incontinent of bowel. His functional ability is much the same when compared to the prior UAS report.

The patient's medical condition and physical limitations are not at the level or unpredictable as to require the requested PCW services; 7 days per week, 24 hours per day, continuous care by more than one person; 168 hours per week.   It should also be noted that his wife is approved for live-in PCW.  This physician would agree that given the patient's reported cognitive deficits and general weakness, he may benefit from additional safety monitoring.  However, safety monitoring under personal care services (PCS) does not include monitoring an individual when no other Level I or Level II personal care services task is being provided, a live-in PCW is likely capable of providing for the patient functional needs with the ability to consistently obtain uninterrupted 5 hours of sleep.  The patient's functional needs are appropriately provided and maintained with the currently approved live-in PCW services.  

From a physical medicine and rehabilitation perspective, an increase in PCW services to 7 days per week, 24 hours per day, continuous care by more than one person; 168 hours per week is not medically necessary.  The current live-in PCW is clinically appropriate.  

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 an increase in Personal Care Worker (PCW) services from 7 days per week, 24 hours live-in; 91 hours per week to 7 days per week, 24 hours by more than one person; 168 hours per week is not substantiated.