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

Diagnosis: Syncope.
Treatment: Inpatient admission. 
The insurer denied coverage for an inpatient admission. 
The denial is overturned.

This is a case of a woman that presented to the hospital following an episode of syncope. She reported fatigue and chills that were first noted two days prior to presentation. Past medical history was relevant for peripartum cardiomyopathy with an LVEF (left ventricular ejection fraction) of 41%, hypertension, diabetes and hyperthyroidism status post radioactive iodine ablation. Upon arrival to the hospital vital signs were stable (BP (blood pressure) 137/79mmHg (millimeters of mercury), Pulse 103 bpm (beats per minute). Physical exam was remarkable for two episodes of unresponsiveness, each lasting for about 30 seconds. She also vomited while in the ED (emergency department). Serum blood testing was significant for multiple electrolyte abnormalities (hypokalemia-3.3meq (milliequivalent) /L (liter), hypomagnesemia -1.2meq/L and hypocalcemia-5.3). A 12 lead electrocardiogram (ECG) revealed normal sinus rhythm with normal conduction intervals and no evidence of ST (interval on a ECG) or T (interval on a ECG) wave abnormalities. She was found to have an active COVID-19 viral infection. She was admitted to the hospital for monitoring and treatment. Echocardiogram revealed an LVEF of 40-45%. She was treated with IV (intravenous) fluids and electrolyte repletion and ultimately discharged home.

This patient presented to the hospital complaining of syncope and fatigue. Her past medical history was significant for systolic congestive heart failure. This patient falls into a high-risk group for syncope. According to AHA (American Heart Association)/ACC (American College of Cardiology) /HRS (Heart Rhythm Society) guidelines, patients with syncope and structural heart disease should be evaluated and treated in a hospital setting. (Reference 1). This patient required acute inpatient admission for monitoring and treatment of possible coronavirus mediated cardiac complications. Myocarditis and pericarditis have been well described in patients presenting to the hospital with COVID-19 infection. (2-4) In one study of patients hospitalized for COVID 19 infection almost 20% of patients had a prolonged QT (interval on a ECG) interval on ECG. Almost 2% of patients in this cohort had ventricular tachycardia or ventricular fibrillation. This patient was noted to have multiple electrolyte abnormalities that may have been led to ventricular arrhythmia and syncope. She was hypokalemic, hypomagnesemic and hypocalcemic and required telemetry monitoring and electrolyte repletion. Ultimately, work up was not consistent with myocardial inflammation and following a period of monitoring, she was deemed stable for discharge. In conclusion inpatient hospital admission was medically necessary to monitor and treat COVID-19 and syncope.

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

The insurer's denial of coverage for the inpatient hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prediabetes.
Treatment: Wegovy.
The insurer denied Wegovy. 
The health plan's determination is upheld. 

The patient is a female with a history of prediabetes. Per the provider appeal, the patient has been on multiple psychiatric medications.  She is currently on Viibryd. Due to these medication switches, she has had weight gain and prediabetes. Hemoglobin A1c via labs shows 5.8.

Wegovy is not medically necessary for this patient. 

The use of GLP1 (glucagon-like peptide 1) agonists in prediabetes patients are not currently standard of care. The American Diabetes Association (ADA) and American Association of Clinical Endocrinologists (AACE) in their type 2 diabetes guidelines do not recommend routine use of these medications for the treatment of metabolic syndrome/prediabetes. Metformin along with weight loss and lifestyle modification remains the mainstay of treatment, although both associations note that GLP1a can be considered in certain situations. There is currently one randomized controlled trial quality trial studying the use of GLP1 agonists for prediabetes patients. In the 2017 SCALE trial (le Roux et al. 2017), the use of liraglutide in over 2000 patients only 2% of the liraglutide group progressed to diabetes over 160 weeks, versus 6% of the placebo group, with a longer delay of progression (2.7 times longer) in the liraglutide group. However, the dropout rate was high in this study and further clinical evidence from other trials is lacking.

There is no evidence that the patient has tried and failed lifestyle modifications or metformin for prediabetes. Wegovy is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute cervical fractures

Treatment: Continued care in a Skilled Nursing Facility (SNF)

The insurer denied coverage for continued care in a Skilled Nursing Facility (SNF)
The denial is upheld.

This is a male with hypertension and alcohol dependence. He presented to the hospital emergency department "intoxicated after an altercation that day."  Cervical spine X-rays demonstrated multiple chronic and acute cervical fractures.  He was transferred to a SNF for subacute rehabilitation. He was approved for skilled services including physical therapy, occupational therapy and speech therapy. Under review is the medical necessity for continued care at a skilled nursing facility (SNF).

The patient was initially appropriate for the SNF subacute rehabilitation level of care (1, 2, 3). He had functional deficits that were amenable to comprehensive rehabilitation. He participated in physical and occupational therapy with demonstrated gradual improvement. According to the occupational therapy progress notes, the patient was at the "supervision" level for activities of daily living including dressing, hygiene and grooming. According to the physical therapy notes the patient was independent with bed mobility and transfer activities. He was able to ambulate "unlimited distances." According to the case notes, the patient was scheduled for discharge from the SNF. However, placement was difficult due to being homeless. A friend was willing to take him, and he was subsequently discharged. Given his functional level, skilled therapy services were no longer medically necessary. In addition, there were no acute medical or complicated nursing issues that required continued stay at the SNF for the time period under review.  

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, continued care in an SNF was not medically necessary.

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

The insurer's denial of coverage for the continued stay in a skilled nursing facility is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Depressive Disorder.
Treatment: Inpatient hospital admission.
The insurer denied coverage for inpatient hospital admission.
The denial is overturned.

This patient was admitted to this hospital due to worsened depressive symptoms including suicidal thoughts as she wrote a suicide note which was found by the school staff. She reportedly was brought by EMS (emergency medical services) to the hospital. She reportedly had trauma issues and victimization issues including reports that she was sexually molested at an early age by a family friend and reported being sexually molested by her sister's boyfriend. She also reported that an ex-boyfriend tried to rape her. She reported nightmares regarding the trauma. She reported feeling hopeless, depressed in mood, tearful, guarded, and was impulsive. She reportedly had 3 past suicide attempts including 2 by overdose and one by cutting. She reportedly had 2 past hospitalizations including a 6 week stay for a serious suicide attempt by overdose. She reportedly had a cutting suicide attempt a few months prior to admission. She reportedly had a history of eloping. She reportedly had a diagnosis of Depressive Disorder. She reportedly continued to express suicidal thoughts with plan that she would not reveal and had a few self-injurious behavior episodes by cutting even on the unit. She reportedly took Prozac for depression and anxiety. She reportedly was on 1:1 observation for suicidality. She eventually improved enough for discharge.

The Interqual  Child and Adolescent Psychiatry guidelines report that  if symptoms were present it included at least one of the following: assaultive behavior, catatonia, command auditory hallucinations, destruction of property, disorganized behavior, unstable eating disorder symptoms, endangering behavior, fire setting, suicidal or homicidal attempt, homicidal ideation with a high risk of an attempt, mania, non-suicidal self-injury with continued danger to self, positive psychotic symptoms with risk of harm to self or others, mania and associated symptoms, psychomotor agitation or retardation, suicidal ideation with high risk of attempt, or support unavailable or unable to provide needed care or supervision. Also, if symptoms improved but the patient was not clinically stable for discharge or was a high risk for rehospitalization or a high risk of harm to self or others then criteria would have still been met. In this case this patient had severe psychiatric symptoms including suicidal ideation with plans which she would not reveal, self-injurious behavior while in the hospital and on 1:1 observation for suicidality, continued to have depressive symptoms, and was considered a high risk for suicide due to past suicide attempts including a serious one and attempts at self-injurious behavior even while in this hospital.  

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

The insurer's denial of coverage for the inpatient hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cholecystitis
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is overturned.

The patient is a female at 36.3 weeks of gestation who presented to the emergency room (ER) with complaints of abdominal pain. Imaging revealed evidence of cholelithiasis. The patient was admitted with a diagnosis of cholelithiasis. She was kept on nothing by mouth (NPO). External fetal monitoring (EFM) and nonstress tests (NST) were done. She was given intravenous (IV) Zosyn and pain medications as needed (PRN). Her condition did improve. She was discharged.

The patient was pregnant and was diagnosed with cholecystitis. Cholecystitis should be considered in the evaluation of any pregnant woman with abdominal complaints. Acute cholecystitis can mimic many other intra-abdominal problems, both obstetric and non-obstetric. Most patients respond to conservative management, with minimal increase in maternal or fetal morbidity and mortality. A few will not respond to therapy or will have severe complications requiring more aggressive management, including surgery.

The initial management of pregnant patients with gallstone disease is supportive and includes pain control, intravenous fluid therapy, and, for patients with acute cholecystitis, antibiotic therapy. Additional imaging and repeat laboratory studies are indicated to assess for potential complications if symptoms worsen.

This patient was pregnant and was diagnosed with cholecystitis. Admission for intravenous fluid, antibiotics and pain management and close monitoring for worsening condition that could put the patient and the fetus at risk was medically necessary. 

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

The insurer's denial of coverage for the inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: CVA (cerebrovascular accident). 
Treatment: Continued Inpatient Rehabilitation Admission. 

The insurer denied: Continued Inpatient Rehabilitation Admission.  
The denial is upheld. 

The patient is an adult male with recent medical history of a cerebrovascular accident resulting in deficits with mobility and ADLs (activities of daily living). 

The patient was admitted to a facility to receive inpatient rehabilitation, and his mobility improved and he was able to ambulate 50 feet. However, the patient continued his stay to maximize as many of his deficits with ADLs (activities of daily living) and mobility as possible. 

The additional stay was declined coverage by the health plan for not being medically necessary. The denial is being appealed. 

The Continued Inpatient Rehabilitation Admission was not medically necessary. 

The patient's functional status and medical status had improved enough to where he no longer needed inpatient rehabilitation. The patient was able to perform activities of daily living (ADLs) at a supervision to minimum assistance level. The patient was also able to ambulate over 150 feet with a single point cane according to the medical records. In addition, the patient was medically stable enough to not require 24-hour skilled nursing care. Lastly, the patient was able to receive his care at a lower level of care. 

Therefore, given the above, the Continued Inpatient Rehabilitation Admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis.
Treatment: Power operated vehicle (three or four wheel non highway) specify brand name and model, number 1 unit.
The insurer denied coverage for power operated vehicle (three or four wheel non highway) specify brand name and model, number 1 unit.
The denial is upheld.

The patient is an adult with chronic bilateral knee pain and underlying osteoarthritis.  She uses a cane for ambulation. Her treating physician requested a motorized scooter.  According to the enclosed records, the patient was scheduled for an elective left total knee arthroplasty. However, more recent office visit notes document that the surgery was performed, and post-operative status was not enclosed for review. Currently under review is the requested power operated vehicle (three or four wheel non highway) specify brand name and model, number 1 unit.
 
From a physical medicine & rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, based on the clinical information made available for review, the requested motorized wheel scooter is not medically necessary.  Proper patient selection is crucial for determining medical/functional benefits and medical necessity of a power operated vehicle, such as the requested motorized scooter. The premature provision of such a device can actually lead to decreased medical and functional status. This is particularly the case for an individual who has reportedly undergone an elective left knee arthroplasty, with no subsequent office visit notes discussing her post-operative course.

The premature provision of a passive mobility device, such as a motorized scooter, places individuals at risk of de-conditioning and cardiovascular morbidity (1). Unfortunately, there are limited rigorous research available for review that evaluates specific outcomes for particular demographic groups utilizing motorized scooters (2).   This physician would agree the provision of a mobility scooter provides a viable means of transport to facilitate access to physical activity situations. However, the over-reliance on a mobility scooter has the potential to decrease health-related physical activity; specifically for individuals participating in a physical rehabilitation program post elective surgical knee replacement.

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

The insurer's denial of coverage for a power operated vehicle (three or four wheel non highway) specify brand name and model, number 1 unit is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class III Malocclusion.
Treatment: Braces and monthly visits.
The insurer denied: Braces and monthly visits.
The denial is: Upheld.

The patient is a male with Class III malocclusion. He has mild maxillary crowding and mild mandibular spacing. He has a mild overjet and mild overbite with a posterior crossbite on the left. He has mild mandibular deviation to the left. The subject under review is the medical necessity for braces and monthly visits.

The health plan's determination is upheld.

Braces and monthly visits are not medically necessary for this patient. Using the Handicapping Labio-Lingual Deviation (HLD) index, a tool which is consistent with the standard of care, the malocclusion would score a 9 with no auto qualifiers. Auto qualifiers include cleft palate deformity or cranio-facial anomaly, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9 millimeters (mm) or greater and underbite 3.5 mm or greater. The malocclusion in question does not meet criteria which is consistent with the standard of care, to be classified as handicapping and treatment would not be considered medically necessary.
Thus, according to the standard of care, the treatment with braces and monthly visits are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis
Treatment: Personal Care Aide (PCA) Level 2 Services: 168 Hours per Week (7 Days per Week, 24 Hours per Day +(plus) 7 Days per Week, 24 Hours per Day), Split Shift.
The insurer denied Personal Care Aide (PCA) Level 2 Services: 168 Hours per Week (7 Days per Week, 24 Hours per Day + 7 Days per Week, 24 Hours per Day), Split Shift. The health plan's determination is upheld. 

The patient is a female with past medical history of osteoarthritis, congestive heart failure, urinary incontinence, atrial fibrillation, chronic anticoagulation, aortic stenosis, hypothyroidism, hypertension, hyperlipidemia, anxiety, and depression who had been assigned PCA (personal care aide) services based on assessment performed assessing the patient at total assistance with tasks of ordinary housework while maximum assistance with tasks of meal preparation, managing finances, managing medication, stairs, shopping, transportation, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, and toilet use. The patient was assessed at extensive assistance with task of bed mobility while limited assistance with task of eating. With task of phone use the patient was assessed at set up only.

Personal Care Aide (PCA) Level 2 Services: 168 Hours per Week (7 Days per Week, 24 Hours per Day + 7 Days per Week, 24 Hours per Day), Split Shift are not medically necessary for this patient.
There is no documentation from the patient's medical provider of medical necessity of turning and repositioning every 2 hours. There is no documentation of overnight assistance needs that would not allow a PCA 5 hours of uninterrupted sleep. There is no specific documentation in the form of overnight care logs of the patient's personal care assistance needs. There is no documentation that the patient's living space could not accommodate a PCA to sleep.
Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 168 Hours per Week (7 Days per Week, 24 Hours per Day + 7 Days per Week, 24 Hours per Day), Split Shift are not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a female with moderate persistent asthma who presented with shortness of breath. She was well until the week prior to presentation when she developed upper respiratory symptoms. She then developed wheezing and shortness of breath. She was using her albuterol inhaler twice a day with some improvement. However the morning of presentation she awoke with worse shortness of breath. She used her albuterol nebulizer at that time but did not experience relief, so she went to the emergency department for care.

Her past history was significant for several prior admissions for asthma. She had one prior intensive care admission. She uses albuterol at least once a day. In the emergency department she had a blood pressure of 148/88 and a respiratory rate of 22 with an oxygen saturation of 96%. On examination she had diffuse expiratory wheezes and decreased air entry. She received 3 Albuterol/Atrovent nebulized treatments as well as dexamethasone and magnesium. She also received a bolus of normal saline. After these treatments she continued to have inspiratory and expiratory wheezes throughout and still had decreased air entry. She was therefore admitted to the hospital for further care.

In the hospital she was placed on the asthma pathway and was initially given every 2 hour albuterol treatments. She was also continued on intravenous corticosteroids. Her treatments were weaned over time, and by hospital day 2 were spaced to every 4 hours. She was then felt to be stable for discharge to home with follow-up as an outpatient.
The hospitalization is under review.

The health plan's determination is overturned.

The inpatient admission was medically necessary for this patient; she required ongoing intensive treatments and monitoring in an inpatient setting.

This is a patient with moderate persistent asthma who presented with status asthmaticus. She was receiving albuterol treatments at home with no relief. She received appropriate and intensive treatment in the emergency department, but continued to have diffuse wheezing and decreased air entry. She therefore required hospital admission for ongoing intensive treatments as well as careful monitoring. She initially required bronchodilator treatment every 2 hours, which requires an inpatient setting.

The decision making at the time of admission for this patient was consistent with her age, the presence of status asthmaticus with continued significant wheeze despite appropriate treatment, and the need for continued frequent bronchodilators along with close monitoring for potential deterioration of clinical status.