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

Diagnosis: Cardiac/Circulatory Problems/Stroke/CVA
Treatment: Skilled Nursing Facility

Diagnosis: Cardiac/Circulatory Problems/Stroke/CVA.
Treatment: Skilled Nursing Facility.
The health plan denied the requested Skilled Nursing Facility stay as not medically necessary. 
The health plan's determination is overturned.

This is a case of a female admitted to inpatient rehab after a hospital stay for an acute right intracranial hemorrhage and subdural hematoma. At the time of discharge from the hospital, it was noted that the patient was tolerating bedside rehabilitation and had achieved some functional gains. Given her complex and severe history of stroke, she had significant functional deficits and was noted to be admitted to acute inpatient rehabilitation to address some of the functional deficits. Prior to her hospitalization she was independent with all levels of function. Her current level of function is complete dependency with ambulation, transferring, toileting, bathing and dressing. She had difficulties speaking and needed assistance with feeding.

At issue is the medical necessity of the Skilled Nursing Facility stay.

The health plan's determination of medical necessity has been overturned, in whole.

The medical necessity of inpatient rehab has been established.
According to Up-to-date, 2021:
"Types of care facilities - The severity of functional impairments and the need for assistance with activities of daily living (ADLs) often determine whether a patient can be safely managed at home or requires care at a skilled nursing facility (SNF) or extended care facility (ECF). In making this determination, particular attention is paid to the need for supervision in activities of daily living (ADLs) and safety awareness.
Medicare in the United States identifies three categories of health facilities:
1) Acute care hospitals
2)Exempt hospitals (inpatient rehabilitation hospitals [IRFs] and long-term acute care hospitals [LTACs])
3)Nursing facilities (SNFs and ECFs)
Functional capabilities of each of these facilities are shown in a table and outlined briefly here:
4) Inpatient rehabilitation facilities - To meet certification criteria, IRFs must admit 75 percent of patients for 1 of 13 specified diagnoses such as stroke or major trauma. Patients must require multidisciplinary therapy (e.g., physical therapy, occupational therapy, speech therapy, orthotic or prosthetic services) and be able to participate in intensive treatment. Physician supervision is provided at least three days per week.
The patient's stay at the IRF may continue as long as there is continued progress and the ability to participate in and benefit from at least three hours of therapy per day."
The patient in this case had one of the 13 specified diagnoses (Stroke) recognized to qualify for inpatient rehabilitation facility. The patient also required multidisciplinary therapy and it was noted that the patient was tolerating therapy and showing functional progress. Therefore, the medical necessity of skilled nursing facility subacute rehabilitation has been established.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Triple negative metastatic breast cancer. 
Treatment: Intensity modulated radiation therapy (IMRT). 

The insurer denied coverage for IMRT. 

The denial is upheld. 

This is a female patient who has a medical history including triple negative breast cancer. She was noted to be status post bilateral mastectomy with reconstructive surgery. She did undergo chemotherapy. She was found to have metastasis to the bone and axillary subpectoral adenopathy. She was noted to be treated with intensity modulated radiation therapy (IMRT). 

The patient's physician indicated the patient has a history of triple negative breast carcinoma with disease in the chest. Biopsies have been obtained and they were awaiting pathology. The physician detailed if the pathology results returned triple negative breast cancer, they will coordinate care for further treatment. 

The patient had a diagnosis of triple negative metastatic breast cancer with disease involving the ribs, spine, sternum, axillary and subpectoral nodes. The physician was considering palliative radiation therapy to these areas. The physician's intention is to deliver 3000 centi-gray (cGy) to sites of disease. The physician is considering the use of IMRT. The dose of 3,000 cGy is an acceptable palliative dose that in general will not exceed tissue tolerances. Per American Society for Radiation Oncology (ASTRO) Model policy for IMRT, its use can be considered when treatment of tumors involving the spine will exceed spinal cord tolerance by conventional techniques; re-irradiation cases where treatment can exceed tolerances. The physician has not shown that these conditions are met for this patient. The ASTRO Guidelines for Palliative radiation therapy for bone metastases would also suggest that the clinical situation be complex enough to warrant complex treatment. The physician has not shown that normal tissue tolerances are exceeded nor is there a comparison of 3-dimensional conformal radiation therapy (3DCRT) versus IMRT to show that IMRT is the necessary plan to meet constraints. A comparison plan may show that IMRT is needed, but one was not provided. Given the clinical situation, the patient could likely be treated with 3DCRT, and the IMRT, without additional supporting data, is 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 intensity modulated radiation therapy (IMRT) is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rashes and skin breakdown under the pannus fold. 

Treatment: Panniculectomy (15830 x 1).

The insurer denied coverage for a panniculectomy (15830 x 1).

The denial is overturned. 

This is a female patient with a history of vertical sleeve gastrectomy surgery and intertrigo. The patient has had a recurrent rash on her left lower abdomen below the pannus. The patient reports that medications have helped but the rash recurs, and is described as itchy and painful. She has missed work due to her symptoms. The patient has been evaluated and a panniculectomy has been requested.

According to the American Society of Plastic Surgeons Position Paper "Treatment of Skin Redundancy for Obese and Massive Weight Loss Patients", "When surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patient's appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature and not a compensable procedure.  For example, a panniculectomy to eliminate a large hanging abdominal panniculus and its associated symptoms would be considered reconstructive.  In situations where a circumferential treatment approach is utilized to also treat the residual back and hip rolls or the ptotic buttock tissue, only the anterior portion of the procedures would be considered reconstructive, the remaining portion of the procedure would be considered cosmetic.  Only in rare circumstances will buttock, thigh or arm lifts be needed to treat functional abnormalities.  Typically, these procedures are performed to improve appearance and are therefore cosmetic in nature." 

The patient has failed conservative treatment for her longstanding rashes, including treatment by her primary care physician and Dermatologist.  Photos show rashes and skin breakdown under the pannus fold.  A panniculectomy will eliminate her rashes. The patient's condition meets the InterQual guidelines for a panniculectomy, and the Milliman Care Guidelines (MCG), 25th Edition for panniculectomy.  

The patient has chronic maceration, recurrent skin infections and an inability to maintain hygiene of the lower abdominal and genital areas. She has been treated for months with over the counter and prescription topical medications. The patient has persistent rashes despite medical treatment including prescription topical medications. The records confirm problems with activities of daily living. She has missed work due to her rashes. Photos show a heavy pannus with excoriations and rashes under the pannus. Her weight is stable based on the clinical notes. 

Based on the American Society of Plastic Surgeons Position Paper, MCG, and InterQual guidelines, a panniculectomy is medically necessary for this patient. 

The health plan has not acted reasonably. 

The insurer's denial of coverage for the requested surgical procedure, panniculectomy (15830 x 1) is overturned.  Medical necessity substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis.

Treatment: Repair of Knee Joint Using an Endoscope, CPT code 29879, and Removal of One Knee Cartilage Using an Endoscope, CPT code 29881.

The insurer denied coverage for the pre-service request for Repair of Knee Joint Using an Endoscope, CPT code 29879, and Removal of One Knee Cartilage Using an Endoscope, CPT code 29881.

The denial is upheld. 

This female patient has a history of osteoarthritis (OA). She presented to the orthopedic surgeon's office for a follow up visit on left knee arthritis. The physical examination revealed good alignment of the left knee. It was tender around the medial joint line. There was a positive McMurray's sign. Range of motion (ROM) was fair. The patient reported ongoing tenderness in the right Achilles' distally. The patient had a desire to avoid total knee replacement (TKR) as long as possible. The physician discussed an arthroscopy. He explained the risks of the procedure and noted that it might not help at all. The physician also recommended Magnetic Resonance Imaging (MRI) of the left knee. The MRI revealed a complex tear of the posterior medial meniscus root and body with severe medial compartment arthritis. There is debris, possible loose chondral bodies, an osteochondral body, and a moderate sized popliteal cyst. The physician recommended a repair of knee joint using an endoscope, Current Procedural Terminology (CPT) code 29879 and removal of one knee cartilage using an endoscope, CPT code 29881. 

There is no indication for arthroscopic surgery to the left knee. The records demonstrate the patient has long standing chronic pain to both knees. She had received extensive treatment including medications, corticoid injection and viscosupplementation. Imaging demonstrated "fairly significant disease, degenerative joint disease (DJD)". She was seen several times over a period of approximately 6 months with no report of mechanical dysfunction. Most recently, her physician reported evidence of locking and giving way. 

These findings support the diagnosis of severe OA. The scientific literature does not recommend arthroscopic surgery for this condition. Patient outcome has been found to worsen after the procedure. 

On occasion if documentation shows mechanical dysfunction (i.e. locked knee, giving way), the operation would be considered. The facts were the patient was seen on multiple occasions (nine) and no report of such was found. One would expect if a torn meniscus was present, a more timely description of the problem would have been made. Imaging studies failed to show evidence of flap tear or bucket handle tear which can cause mechanical problems. There were no extenuating circumstances to substantiate left knee surgery. 

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

The medical necessity for the pre-service request for Repair of Knee Joint Using an Endoscope, CPT code 29879, and Removal of One Knee Cartilage Using an Endoscope, CPT code 29881 is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hiccups and Vomiting. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a male with history of hiccups in the past. He presented to the ED (emergency department) with a three-day history of hiccups, and two episodes of vomiting. He stated that he had hiccups off and on for the prior nine months. He had a GI (gastroenterology) work up in another hospital, and his EGD (esophagogastroduodenoscopy) and Colonoscopy were normal three to four months prior. 

In the ED (emergency department), the patient was found to be hypokalemic with 3.3 and hyponatremic with serum Na (sodium) of 128, and lipase of 886. He also had mild renal insufficiency with creatinine 1.4. 

In the ED (emergency department), the patient was given IV (intravenous) K (potassium) supplements (100 mEq [milliequivalent] IV [intravenous]), and given 1 liter of NS (normal saline) bolus, and given IM (intramuscular) Benadryl and Chlorpromazine, and IV (intravenous) Reglan. The chest x-ray was done, and it was normal. The abdominal ultrasound was done, which revealed increased echogenicity of the liver consistent with fatty liver. 

In the ED (emergency department), the patient was hemodynamically stable and afebrile. He was admitted to the general medicine service for further management. He was continued on IV (intravenous) fluids and K (potassium) supplement, and Chlorpromazine 10 mg(milligrams) PO (by mouth) TID (three times daily) PRN (as needed), and Nexium 40mg (milligrams) PO (by mouth) daily. 

The patient had one episode of vomiting. The GI (gastroenterology) consult was requested, and no further intervention was recommended. 

The patient's labs revealed serum Na (sodium) 130, K (potassium) 3.6, and creatinine of 0.8. The patient was discharged home on Nexium, Chlorpromazine and multivitamin, and advised to follow up with his PCP (primary care provider) and GI (gastroenterologist). 

No, the inpatient admission was not medically necessary for the management of this patient's condition. 

The patient presented with hiccups and abdominal pain of three days duration, and two episodes of vomiting. He had a prior history of hiccups for the prior nine months. He had had a GI (gastroenterology) work up done in the past, and it was unremarkable. His hiccups were attributed to electrolyte imbalance. He was treated with IV (intravenous) fluids and IV (intravenous) K (potassium) supplements. His hiccups were treated with Reglan, Benadryl and Compazine. The chest x-ray was normal, and ultrasound of the abdomen revealed mild fatty liver disease and no other abnormalities. During his 48 hours in the hospital, the patient's electrolytes and renal functions normalized, and his hiccups resolved. Given this clinical scenario, his condition could have been safely managed under lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lower Extremity Edema

Treatment: Continued Stay at Skilled Nursing Facility

The insurer denied coverage for continued stay at Skilled Nursing Facility

The denial is upheld

This is a male with multiple chronic medical problems including diabetes mellitus, hypertension and congestive heart failure.  He was hospitalized for lower extremity edema and subsequently transferred to a skilled nursing facility (SNF).  He received physical, occupational and speech therapy.  Under review is the medical necessity of continued stay at an SNF.

From a physical medicine and rehabilitation perspective, the patient was initially an appropriate candidate for subacute rehabilitation at the skilled nursing facility. (1, 2, 3)   The patient's multiple comorbidities and frailty impairing functional improvement were taken into consideration.  However, there was a plateau in the patient functional progress.  According to the physical therapy notes, for the time period under review, the patient remained at the dependent level for transfer activities and ambulation.  There was "no change in functional status noted."  A similar lack of improvement was noted by the Occupational Therapist.  The patient was essentially at the moderate to maximal assistance level for hygiene, grooming and lower body dressing.  In addition, there were no acute medical or complicated nursing issues to support continued stay at the SNF level.

The health plan acted reasonably, with medical judgment and in the best interest of the patient in this particular case.  
  
From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, continued stay at an SNF was not medically necessary.

The insurer's denial of coverage for the Continued Stay at a Skilled Nursing Facility is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back Pain. 
Treatment: Outpatient Spinal Procedure (Minimally Invasive Lumbar Compression [MILD procedure]), Pre-service. 

The insurer denied the Outpatient Spinal Procedure (Minimally Invasive Lumbar Compression [MILD procedure]), Pre-service. 

The denial is overturned. 

The patient is a female with severe spinal stenosis and neurogenic claudication. She has failed conservative treatment. The Minimally Invasive Lumbar Compression (MILD) procedure has been offered. 

Yes, the proposed MILD procedure is medically necessary. 

The patient is a female with a history of chronic low back pain, neurogenic claudication. She has failed physical therapy (PT), medications and epidural steroid injections. She has symptoms consistent with neurogenic claudication. Magnetic resonance image shows severe spinal stenosis, primarily at L (lumbar) 3-4, and L4-5, due to ligamentum flavum thickening. MILD is a minimally invasive lumbar decompression procedure that is Food and Drug Administration (FDA) approved and has been shown to be effective in the setting of symptomatic lumbar spinal stenosis, especially in patients where the spinal stenosis is caused by ligamental flavum thickening. 

Given the severity of spinal stenosis, and the presence of neurogenic claudication, the recommended procedure is indicated. The patient was seen by a spine surgeon and an extensive surgical option was offered, a laminectomy from L2-S (sacral) 1. Randomized controlled trials (RCTs) have shown the effectiveness of MILD for spinal stenosis; the morbidity and rate of complications are low. Given that the options are limited, the patient has failed conservative treatment, open surgery carries a higher risk, MILD is FDA approved with two year evidence of safe and effective outcomes for spinal stenosis, the requested MILD is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Kidney stone. 
Treatment: Inpatient admission. 

The insurer is denied coverage for inpatient admission. 

The denial is upheld. 

This male patient has a medical history of  hypertension and recent COVID infection. The patient presented to the Emergency Department (ED) for evaluation of recurrent abdominal pain, left flank pain, dysuria, urinary frequency and diarrhea.  This was his third ED visit over 1.5 weeks and he had been treated with antibiotics, pain medication and Flomax.  On arrival, the patient's blood pressure was 171/112.  The patient was admitted for further management and evaluation by urology.  The patient's pain and urgency resolved, and the impression was that the patient may have passed a kidney stone.  The patient was discharged home. 

Per the MCG Health (24th Edition) Renal Colic and Kidney Stones RRG, the patient fails to meet the clinical indications for admission to inpatient care. The criteria include hemodynamic instability, acute renal failure, bilateral obstruction, urinary tract infection (UTI), and severe pain requiring acute inpatient management. 

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

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

Diagnosis: Diverticulitis.

Treatment: Full Hospital Admission.

The insurer denied coverage for the Full Hospital Admission.

The denial is upheld.

This is a female patient with a history of diverticulitis, diverticulosis, and hypothyroidism who presented with abdominal pain.  The patient was afebrile and her vital signs were stable.  On exam, there was no abdominal rebound or guarding.  The patient's computed tomography (CT) scan revealed acute diverticulitis but no fluid collection.  The patient had previously been on oral antibiotics and was now given intravenous (IV) Levaquin and Flagyl.  The patient was placed on a liquid diet.  By the next day, the patient's diet was able to be advanced, and her pain had improved.

Based on Milliman Care Guidelines (MCG), the clinical indications for admission for Diverticulitis include hemodynamic instability, peritoneal signs, persistent gross bleeding, and a significant complication seen on imaging.  This can be a fistula, obstruction, or free perforation.  In this case, the patient did not have these conditions.  The patient also did not need a surgical intervention or have severe vomiting, severe pain that was not responsive to treatment, or an inability to maintain oral hydration after observation care.

Based on the review of the medical record and literature, the full hospital admission was not medically necessary for this patient. This patient had diverticulitis that was not complicated by an abscess or perforation.  After a day of intravenous (IV) antibiotics, the patient's symptoms were much improved.  The patient did not meet the MCG criteria for admission for diverticulitis.  The patient could have been treated with observation care.  

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

The insurer's denial of coverage for the Full Hospital Admission should be upheld.