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

Diagnosis: Dementia
 
Treatment: Personal Care Services, 24 hours per day, 7 days per week (live-in)

The insurer denied the Personal Care Services, 24 hours per day, 7 days per week (live-in). The denial was reversed. 

This is an elderly male patient with a significant history of multiple medical conditions and functional impairments including dementia, hypertension, hyperlipidemia, hypothyroidism, muscle weakness, gait abnormality; open wound left lower leg, urge incontinence, benign neoplasm of prostate, falling, and malignant neoplasm of skin. He currently has personal care services 12 hours per day, 7 days per week. Due to the ongoing safety ricks in light of the patient's recent history of falls a request has been made for an increase in services to 24 hours per day 7 days a week.  
 
Dementia: The patient has diagnosis of dementia, (type not noted).  UAS describes cognition as follows: memory is impaired (short term, procedural, situational); disoriented to time and place; decision making is poor/unsafe; needs constant supervision.  He needs extensive to maximal assistance for managing medications and finances.  As dementia progresses, decline of ability to perform IADLs and ADLs is an expected consequence of the disease; and so it is likely that the patient's functional limitations with daily activities is at least partly due to dementia.  At the patient's current level of cognition (as per UAS), it is likely that he is unable to asses safety risk during daily activity, and makes unsafe choices which can lead to falls and household accidents when he is alone.

Based on review of the available records, the patient has substantial functional impairment due to his medical conditions, and requires a high level of assistance for daily activities, including those ADLs that occur at unscheduled and unpredictable times, i.e. transfers, walking, toileting/incontinence care.  Therefore, it is medically necessary and in the patient's best interest for a caregiver to be present in the patient's home throughout the day and night.  The patient's son is the only informal caregiver identified in the UAS.  Assistance from informal caregivers is voluntary, as per NYS regulations for personal care services.  Considering the son is requesting PCS 24 hours live-in for his father, it is reasonable to conclude that the son (or any other informal caregiver) is not able to provide consistent and extended hours of care for the patient. When there are no informal caregivers available to provide the necessary care, then personal care services are indicated to provide assistance.

Personal Care Services 24 hours live-in, 7 days per week is medically necessary. 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 Personal Care Services, 24 hours per day, 7 days per week (live-in) is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diabetes
Nursing Services (including Private Duty Nursing)

The patient is a male with a past medical history significant for thyroid disease, diabetes, lower body weakness, and ambulatory dysfunction. He has been approved for 15 hours a week, 3 hours a day 5 days a week. The provider is requesting an increase of hours in consumer directed personal assistance services.

The health plan's determination is upheld. The Increase of hours in consumer directed personal assistance services is not medically necessary for this patient. The services being provided are adequate to meet the patient's need in the allotted time. Additional hours are not medically necessary. Services such as bathing, personal hygiene, dressing, toilet use, toilet transfer, eating, managing medicines, walking, locomotion, meal preparation, shopping ordinary housework should not require additional service hours since the last evaluation since the services such as housework and shopping and meal preparation, remain relatively the same regardless of the patient's condition. No bowel or bladder incontinence is noted.
The amount of services already being provided are adequate to meet the patient's medical needs in the time noted. Additional services for "prevention of falls" for "monitoring" without services being provided are typically not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Pain
 
Treatment: Inpatient Admission

The insurer denied the Inpatient Admission.  The denial was reversed.  

This is a female patient with a medical history of ischemic heart disease, diabetes mellitus (DM), hypertension (HTN), seizure disorder and drug abuse.  She presented to the hospital with complaints of severe chest pain.  An electrocardiogram (EKG) was performed that revealed active ischemia T-wave inversions inferiorly and ST depressions.  Her HEART score was 6.  A computed tomography (CT) angiography was negative for an aortic dissection.  Cardiac enzymes were drawn that were negative.  A toxicology screen for cocaine was performed which was positive for cocaine.  She had a presenting fever of 101.2.  Pulmonology consulted on the patient; she was treated for pneumonia with Azithromycin.  While in the hospital she was noted to have seizure activity; she was consulted by neurology.  She was hemodynamically stable and discharged home. 

Based on her intermediate risk score using both the HEART and thrombosis in myocardial infarction (TIMI) risk stratification, admission for observation and work-up of an acute ischemic syndrome was indicated.  Risk assessment of patients presenting with chest pain and ST changes on ECG as well as negative cardiac enzymes was performed by Sanchis, et al.(2)  Using their risk stratification schema, this patient would have a moderate risk of future myocardial infarction or death within one year.  Admission to the hospital for further testing and treatment was indicated.  This patient's multiple medical problems and history of active drug abuse all contributed to the possible risk of future myocardial infarction (MI) or death.  In conclusion, it was appropriate to manage this patient at a higher level of care.  Inpatient hospital services at the acute level of care were appropriate. 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 inpatient hospital services at the acute level of care is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multiple Sclerosis Exacerbation 
 
Treatment: Inpatient Admission 

The insurer denied the inpatient admission. The denial was reversed. 

This is a female patient with a history of multiple sclerosis and congenital hypothyroidism. She presented to the emergency department with complaints of difficulty swallowing. The patient upon arrival had normal vital signs which included an oxygen saturation of 98% on room air. She reported that her dysphagia had worsened over the past months due to her multiple sclerosis. She had a magnetic resonance imaging (MRI) of the central nervous system and the brain. The MRI of the brain showed multiple lesions in the corpus callosum white matter region and also throughout the cervical/thoracic spine region, including the proximal cervical spine region--C2-3-4. It was recommended that the patient be admitted for further treatment due to the inability to swallow and concern for an acute multiple sclerosis flare. The patient did undergo a neurological evaluation and was recommended to undergo a speech evaluation and swallow study. She was treated with intravenous (IV) steroids for her multiple sclerosis exacerbation. Her symptoms improved and she was discharged home with outpatient follow up instructions. 

The patient underwent IV steroid therapy for a multiple sclerosis exacerbation during her hospital stay. While this therapy can also be given on an outpatient basis, in this case--with a severe pattern of white matter findings in the brain (and proximal spinal cord)--and in the context of dysphagia, it would be reasonable to admit the patient for immediate therapy and speech therapy. Therefore, the entire hospital admission was medically necessary. The insurer did not act reasonably, or with sound medical judgment, or in the patient's best interest. 

The carrier's denial of coverage for the inpatient hospital services at the acute inpatient level of care is reversed. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prior stroke, VP shunt, anxiety 
Treatment: PCA 56 hours/week 

The proposed health treatment of an increase in personal care aide services to 56 hours/week is not deemed medically necessary. 

The patient is a male with a history of prior stroke, VP (Ventriculo-Peritoneal) shunt, dizziness and anxiety disorder. For these reasons, he requires assistance with many of his activities of daily living (ADLs). An appeal review requested for potential approval of an increase in personal care aide (PCA) services to 56 hours/week for increased assistance with completion of the patient's ADLs. 

In recent in home assessment of the patient's ability to complete ADLs revealed that the currently approved plan of 36 hours/week personal care services is sufficient to meet the patient's current needs. There are no additional medical records that demonstrate that the patient has had further clinical decline since this last assessment. For these reasons, the proposed health treatment of an increase in personal care aide services to 56 hours/week is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Altered mental status, drowsiness, vomiting, and fever
Treatment: Inpatient admission

The Inpatient admission was medically necessary.

The patient is a male with history of diabetes mellitus, BPH (benign prostatic hyperplasia), depression, and hypertension. He presented to ED with altered mental status, drowsiness, vomiting and fever. It was noted that patient urinated on himself at home, and he was unable to engage in conversation. 

The patient's vitals in ED were as follows: BP (blood pressure) 118/26, Temperature 101, Pulse 96, Respiratory rate 20, SPO2 (pulse oximetry) 94. 

On physical exam, the patient was alert and oriented times one (x1); He had a normal cardiopulmonary exam. 

The patient's laboratory studies were as follows: HB (hemoglobin) 11.8, HCT (hematocrit) 36.8, platelets 127, sodium 135, potassium 3.2, BUN (blood urea nitrogen) 22, CR (Creatinine) 1.6, lactate 3.0, WBC (white blood count) 10.3.

The patient's urinalysis showed red, turbid urine, protein 300, large hemoglobin, and large leukocyte esterase. 

The patient's radiological studies revealed the following: CT Abdomen, and Pelvis showed no hydronephrosis, 7 mm hyperdense focus within the mid right kidney which may represent a tiny hemorrhagic cyst or parenchymal calcification; hepatomegaly, hepatic steatosis and sigmoid colonic diverticulosis. CT head did not show any acute intracranial pathology. Chest x-ray was negative for opacities. 

The patient's admitting diagnosis was metabolic encephalopathy secondary to sepsis from UTI (urinary tract infection). Management plan included insertion of Foley catheter, IV fluid, and IV antibiotics. Follow-up hospital records notes that blood culture grew coagulase negative staph, felt to be a contaminant. 

The patient was discharged home in stable condition. 

The decision to admit patients with acute complicated UTI should be individualized. This decision is typically clear in septic patients.  Sepsis has a high mortality rate; estimates range from 10 to 52 percent. This patient clearly meets sepsis criteria; hence inpatient admission, and management is medically necessary and reasonable. Laboratory data notes elevated lactate level, fever, and infectious source (urinary tract infection). He had change in mental status from his baseline. He needed IV fluid, and broad spectrum antibiotics. 

In view of the foregoing, the Inpatient admission was medically necessary, because the care rendered could not have been performed at a lower level of care without adversely affecting the patient's health.
Appeal type: Medical necessity
Decision: Upheld

Digestive System/ Gastrointestinal - Abdominal/Stomach Pain
Inpatient Hospital

The patient is a man who presented to the hospital ED with a complaint of abdominal pain. At the time of presentation, the patient was without fever and vital signs identified hypertension. He was tender in the right upper abdomen. The white blood cell (WBC) count was normal. Alkaline phosphatase was slightly elevated with normal serum transaminases. An ultrasound identified gallstones. A magnetic resonance cholangiopancreatography (MRCP) was performed on the day of admission  that showed no ductal pathology. He was treated with laparoscopic cholecystectomy the following day. The records indicate an uncomplicated cholecystectomy procedure. He was discharged the following day. At issue is the medical necessity of the inpatient admission. 

The health plan's determination is upheld. The submitted records document that this patient was clinically and hemodynamically stable at the time of presentation. Surgery was performed and the perioperative period was uncomplicated. Inpatient stay may be needed for failure to achieve discharge status criteria, conversion to open surgery, systemic infection, care for active comorbidities, complications of procedure. In this case none of these conditions existed to warrant an inpatient level of care.

Inpatient care is indicated when there is right upper quadrant pain, AND systemic signs of inflammation (fever, C-reactive protein > 10, WBC count > 10 K). Inpatient admission is also indicated for acute cholangitis, common bile duct obstruction, vomiting that is severe or persistent, dehydration that is severe or persistent, hemodynamic instability, severe pain requiring acute inpatient management, signs of intestinal obstruction, bacteremia, need for percutaneous or open procedures, or other condition that requires inpatient admission. In this case, none of these indications existed to justify an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Cancer
Radiation Therapy

The patient is a male with a history of a T4N2c oropharynx squamous cell carcinoma right base of the tongue, status post chemotherapy and then concurrent chemotherapy and radiation therapy to this region three years ago. He now has right chest wall recurrence where radiation therapy is recommended to attempt control of this disease and proton beam approach is requested.

The health plan's determination is upheld.

The requested proton beam radiation therapy for this patient with metastatic disease is not considered medically necessary as 3D conformal photon beam radiation therapy can be safely used to deliver a palliative dose of radiation to this patient's metastatic disease. There are no significant trials published in peer reviewed literature supporting the use of proton beam radiation over photon beam radiation for this clinical scenario. The requested proton beam radiation is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic eosinophilic pneumonia (CEP)

Treatment: Nucala 

The insurer denied coverage for Nucala. The denial is reversed. 

This patient is a male with a rare condition, chronic eosinophilic pneumonia (CEP), which had been treated and responded to an anti-eosinophil medication (Cinqair) in the past.  With recurring symptoms and increased eosinophils in the blood, the provider is requesting approval for another anti-eosinophil(anti-IL5) medication, Nucala(mepolizumab).  Since this is a rare disease, no controlled studies have been published on biologic treatments for CEP.  Never-the-less, several case reports and series have reported apparent efficacy, particularly with mepolizumab.  The provider has provided 3 such references.  The standard treatment is using oral corticosteroids (not inhaled corticosteroids) which is associated with significantly more side effects that the biologics. Neither Cinqair nor Nucala are FDA approved for use in CEP. It should be noted that in the UpToDate chapter on CEP, mepolizumab is the only anti-eosinophil biologic treatment mentioned. "Mepolizumab, a monoclonal antibody that binds interleukin (IL)-5 and prevents it from binding to its surface receptor on eosinophils, is used for eosinophilic asthma and has been tested in eosinophilic phenotypes of COPD [chronic obstructive pulmonary disease]. At least one patient with a clinical diagnosis of CEP, whose disease had relapsed after tapering off oral prednisolone, remained in remission for at least 13 months on mepolizumab (100 mg once a month) without further prednisolone [36]."

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 Nucala is reversed.  The medical necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Gastroesophageal reflux disease (GERD).
Treatment:  LINX procedure.

The insurer denied the LINX procedure.  The denial is overturned.

This female with a history of gastroesophageal reflux disease (GERD) has requested surgical correction with LINX.  She had an esophagram revealing small hiatal hernia and an asymmetrical B ring.  She had upper endoscopy revealing a normal esophagus and erythematous mucosa in the antrum.  Biopsies were obtained revealing reactive gastropathy.  Esophageal pH monitor revealed an abnormally high DeMeester Score of 70 indicating severe esophageal acid exposure consistent with GERD.  Esophageal manometry was performed revealing a normal exam.  The patient has chest pain due to GERD despite being on maximal medical therapy consisting of omeprazole 40 milligrams (MG) daily, pantoprazole 40MG daily, and ranitidine 300MG daily. 

Yes, the health plan should cover the proposed LINX procedure.

Yes, the requested LINX procedure is likely to be more beneficial than any standard treatment(s) for the insured's condition or disease.

This patient suffers from GERD as evidenced objectively by the esophageal pH monitor.  Even with a proton pump inhibitor (PPI) and H2 blocker, there is refluxing gastric contents.  Surgical therapies exist that resolve this very well.  Without LINX procedure, a Laparoscopic Nissen Fundoplication (LNF) would have been recommended.  Other techniques have been studied endoscopically and otherwise, but none have been able to demonstrate long term efficacy and safety.  The side effects of LNF make it a less than ideal operation.  Linx is an operation that is less disruptive to the normal anatomy, has been shown to be effective at reducing reflux episodes to a physiologic level, and has been shown to dramatically improve patient satisfaction long term.  It is approved by the FDA.  There is published data on patients who have had the device for six years, showing a very low complication rate and a high resolution of GERD.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Gastroesophageal reflux disease (GERD).
Treatment:  LINX procedure.

The insurer denied the LINX procedure.  The denial is overturned.

This patient is a female with a body mass index (BMI) of 24.1 kg/m2 with long
standing gastroesophageal reflux disease (GERD) refractory to medication.  Twenty-four-hour pH study had an elevated DeMeester score consistent with GERD.  Esophagogastroduodenoscopy (EGD) did not document Barrett's
esophagus.  Esophageal motility testing is normal.  The patient has no history of
prior gastric or bariatric surgery.

Yes, the LINX procedure is likely to be more beneficial than any standard
treatment(s) for the insured's condition or disease.

This patient has GERD refractory to medical management.  Surgical treatment
options that are considered standard today include laparoscopic Nissen
fundoplication and LINX procedure.  Both of these treatments have been shown in
published studies to be more effective than medical management.  LINX is
comparable for mid-long-term studies to be as effective and durable as
laparoscopic Nissen fundoplication with less risk of mortality and major morbidity.  It
has been recommended, based on the available published literature, to be a
standard surgical treatment for GERD in newly updated nationally published
guidelines from the Society for Gastrointestinal and Endoscopic Surgeons.  The
exclusions to LINX and Nissen fundoplication include BMI >35 kg/m2, in which case
treatment of obesity is thought to be important for treatment of GERD.  Other
exclusions for LINX include Barrett's esophagus with dysplasia, age less than (<)
18 and prior gastric or bariatric surgery.  This patient documents no exclusion to
LINX treatment at this time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gout, Pain

Treatment: Inpatient admission

The insurer denied the inpatient admission.

The denial was overturned.    

This is a male patient with a history of gout, hypertension (HTN), chronic kidney disease (CKD), obstructive pulmonary disease (COPD), seizures and drug abuse.  He presented to the Emergency Department with complaints of multiple joint pains and swelling affecting functional ability.  He had chronic joint pain but it had worsened.  He normally uses a walker.  He was also experiencing several days of dyspnea with worsening pedal edema.  A chest x-ray and an electrocardiogram were performed with no acute changes.  His Sp02 was 98%.  The patient was admitted to Observation because of concern about congestive heart failure (CHF).  He was treated for gout.  There were no cardio-respiratory signs.  While in observation he received prednisone and pain medication but his pain continued.  He required two-person assistance to get out of bed.  He was admitted to the hospital for pain management.  He received intravenous morphine, Colchicine, Percocet, and prednisone which was tapered accordingly. His pain improved and he was discharged home.

Flares of gout are normally treated as an outpatient.  Anti-inflammatory therapy reduces pain by reducing inflammation.  In this case there was the complicating concern for CHF.  There was pedal edema and high BNP although chest x-ray, exam, vital signs (VS) and EKG only showed pedal edema.  He was admitted to Observation fulfilling criteria in MCG General Criteria: Observation Care. It was clear that CHF was not significant, and admission was changed to acute for further treatment of gout.  He still had polyarticular arthritis despite treatment and needed assistance x2 to get out of bed.  In this case the patient did meet the severity criteria on using MCG Musculoskeletal Disease guidelines.  

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 inpatient admission is overturned.  The medical necessity is substantiated.