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

Diagnosis: Vaginal abscess.
Treatment: Inpatient stay.

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

The patient is a  female with a past medical history significant for recurrent abscesses who presented to the emergency department with complaints of abscess in the left groin that extended to the vagina. Her symptoms had been going on for one week. The patient stated that she used to get abscesses in the past. Due to the abscess, the patient was unable to walk or wear her underwear. At the same time, she denied fever, chills, chest pain, shortness of breath, palpitations, cough, sore throat, nausea, vomiting, or any other symptoms.

The inpatient hospital admission was not medically necessary. In general, admission at the acute inpatient level of care is indicated for patients with cellulitis or soft tissue infection such as abscess when patients need a surgical procedure not amenable to the outpatient, emergency department, or observation care treatment. In this clinical case, the patient had a large abscess that was not amenable for outpatient or emergency department care.
However, considering overall clinical stability, the care could have been provided at a lower level. There was no evidence that the patient was immunocompromised or hemodynamically unstable. There was no mention of outpatient therapy failure. There were no indications that the patient had high-risk comorbid conditions necessitating admission to the hospital. The postoperative period was unremarkable. There was no indication that the patient's pain was so severe that she required admission at the acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pain Crisis

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

This is a female with sickle cell anemia with a history of acute chest syndrome who presented to the hospital with a pain crisis. The patient was placed on intravenous (IV) narcotics. She was afebrile with stable labs and no evidence of aplastic crisis. The patient was admitted to the hospital. Pain improved, and she was discharged.

The patient was noted to be sitting in a chair comfortably with no pain. She was seen by hematology later that day, who recommended increasing hydroxyurea and outpatient crizanlizumab.

A denial letter states the hospital admission is denied. The patient's heart rate, breathing, and oxygen were normal. There was anemia, and pain medicine was given. There were no notes of an unstable heart rate, respiratory rate, or blood pressure. It was not noted that the patient was in pain after treatment, had a fever, or did not get better after observational treatment. There were no notes of chest pain, lung infection, seizures, and/or confusion. There is no computed tomography (CT) or magnetic resonance imaging (MRI) showing new bleeding or stroke. There were no notes of blood build up in spleen or liver sequestration crisis. There was no indication of poor oral intake, metabolic acidosis, cyanotic extremity, ischemic bowel, or kidney issues. Based on medical notes provided, care could have been given in the ER (emergency room) or in observation, and instead of admission, follow-up care could have occurred at the patient's doctor's office.

This individual could have been managed at a lower level of care. On arrival to the ER, the patient was hemodynamically stable with no fever. A chest x-ray (CXR) was negative. The patient was given pain medications and was noted to be improved the following morning.

"Generally, a person is considered to be in inpatient status if officially admitted as an inpatient with the expectation that he or she will remain at least overnight. The severity of the patient's illness and the intensity of services to be provided should justify the need for an acute level of care. An inpatient admission solely because the patient has been kept in observation status over 23 hours would not be considered medically necessary." (American Health Information Management Association)

"Observation was meant to be a short period of time for providers to assess whether patients required admission for inpatient care or could be discharged. Typically, this was meant to last fewer than 24 hours and only rarely spanned more than 48 hours." (Society of Hospital Medicine)

As this patient had a condition that could reasonably be expected to be stabilized within 24 hours, observational status would be appropriate.

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

The insurer's denial of coverage for an inpatient admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Myocarditis. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for inpatient hospital admission. 

The denial is overturned. 

This patient has no significant past medical history. He presented to the emergency room with complaints of chest pain and a fever after having a second coronavirus (COVID) vaccine. As per Emergency Medical Services (EMS), the patient had an abnormal electrocardiogram (EKG) two days after second dose of COVID vaccine, reportedly with nonspecific ST (interval on EKG) elevations. In the emergency department (ED), he was febrile 100.5, and had a HR (heart rate) of 92 beats per minute. History and physical note by ED physician describe the chest pain as midline, non-radiating, decision to admit for trending of cardiac enzymes (troponin in reported as 22 (normal range less than 0.02), and creatinine phosphokinase (CPK) level was elevated at 1237 (normal range less than 367). Both these elevated values signify muscle tissue injury which includes myocardial tissue. He was treated with ketorolac intravenously in the ED. 

Cardiology consult note states consult is for post-COVID vaccination hypersensitivity myocarditis. 

Post COVID vaccine myocarditis in young adolescent and adult males had only recently been reported. Subsequently, there has been extensive nationwide surveillance and published literature in large numbers of patients and although the course is usually benign, this was not known at the time. Treatment involving non-steroidal anti-inflammatory drugs (NSAID), careful monitoring for worsening of myocarditis as well as trending cardiac enzyme levels is recommended to prevent adverse outcomes, which can include myocardial depression and sudden death. It was appropriate to admit for close monitoring in the event that inotropic support for the myocardium became necessary. In the review by Oster, et al (JAMA), about 96% (percent) of patients were hospitalized, and cardiac MRI (magnetic resonance image) was abnormal in 72% of cases. MRI was not performed on the patient at the time, but ST elevations reported by EMS was another reason for concern for myocardial injury being present. 

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

The inpatient hospital admission is considered medically necessary for this patient. 

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

Diagnosis: Cardiac/Circulatory Problems/Arrhythmia/ Irregular Heart Rhythm. 
Treatment: Pharmacy/Prescription Drugs. 

The health plan denied the requested prescription medication, Eliquis as a formulary exception. 

The health plan's determination is upheld. 

This case involves a male with a history of atrial fibrillation anticoagulated with Apixaban, prior direct current cardioversion (DCCV) and an atrial fibrillation ablation, hypertension, obstructive sleep apnea (OSA) on continuous positive airway pressure (CPAP), mitral regurgitation, and chronic systolic heart failure due to hypertensive cardiomyopathy. 

At issue is whether the formulary drugs (Warfarin, Xarelto), will be or have been ineffective, would not be as effective as the non-formulary drug (Eliquis), or would have adverse effects. 

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

Based on published medical literature comparing new oral anticoagulants (NOACs) to Warfarin and as reflected in the 2019 American Heart Association (AHA)/American College of Cardiology (ACC)/Heart Rhythm Society (HRS) focused update on the management of patients with atrial fibrillation, overall NOACs are generally considered to be superior in efficacy in reducing the risk of stroke and systemic embolism with a lower risks of serious bleeding [1]. For these reasons, NOACs would be recommended over Warfarin for this patient. Because there is no documentation that this patient has failed or would have an anticipated adverse outcome to Xarelto, Xarelto is an acceptable formulary anticoagulant for this patient. 

I recommend that the health plan's determination is upheld; based on the documentation provided for review of this case, Xarelto would be a medically appropriate anticoagulant to reduce the risk of stroke and systemic embolism for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hyperlipidemia, breast cancer, nicotine dependence, and atrial fibrillation.

Treatment:  PCS (personal care services) 24 hours a day, 7 days a week (split shift) for a total of 168 hours of PCS.

The insurer denied coverage for PCS 24 hours a day, 7 days a week (split shift) for a total of 168 hours of PCS.

The denial is overturned.

This elderly female has significant functional decline associated with various medical conditions. The patient lives alone. She receives personal care services (PCS) 9 hours per day, 7 days per week. The UAS (Uniform Assessment System) Social Supports indicates no informal helpers, but in another section Psychosocial Well-Being, comments indicate the patient's daughter pays privately for someone to provide care after the aide leaves at 6pm until the daughter arrives; daughter helps patient go to bed, then daughter returns to her own home. Request was made for increase of PCS to 24 hours per day, 7 days per week (split shift), which was denied. An external appeal was requested.

Based on the patient's medical history and functional status, it is medically necessary for the patient to have assistance with all daily activities. This includes preparation and service of all 3 meals per day and assistance with eating. She needs ADL assistance for bathing daily; personal hygiene and dressing morning and evening; toileting/incontinence care which occurs at various unscheduled times of the day and night. The patient's mobility is substantially impaired, and she needs help for transfers to and from bed/chair/toilet, walking in her home, and bed mobility (repositioning). MLTC Managed Long-Term Care) policy 16.07 states that plans must assure that the plan of care can meet any unscheduled or recurring daytime or nighttime need for assistance. Therefore, all the patient's care needs must be considered in the determination of the patient's PCS hours. Without assistance for all daily activities as they occur through the day and night, the patient is at risk for multiple adverse health and safety events including: skin damage (due to incontinence and pressure), malnutrition, dehydration, falls/injuries.

The information provided for review supports medical necessity for PCS 24-hour continuous services (i.e., split shift). Live-in services would not be adequate, as the patient's care needs are not compatible with the schedule of a live-in aide, which includes 5 uninterrupted hours of sleep per day (within 8 total hours of sleep per day), as per NYS (New York State) regulations for live-in aides. As described in this report, it appears the patient's care needs (including toileting/incontinence care, repositioning) could not be properly met by an aide who is unavailable for 5 continuous hours per day; therefore, 24-hour continuous personal care services are indicated.

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 personal care services (PCS) 24 hours a day, 7 days a week (split shift) for a total of 168 hours of PCS is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prostate Cancer. 
Treatment: OncotypeDx Testing. 

The insurer denied OncotypeDx testing. The health plan's determination is upheld. 

The patient is a male who underwent a prostate biopsy for an elevated prostate-specific antigen (PSA). The biopsy showed Gleason 6 adenocarcinoma in 2 out of 12 cores. The clinical stage was T1c. An OncotypeDx test was ordered on the biopsy specimens. 

OncotypeDx testing is not medically necessary for this patient. The American Society for Clinical Oncology Guideline on Molecular Biomarkers in Localized Prostate Cancer, 2019 states "Tissue-based molecular biomarkers (evaluating the sample with the highest volume of the highest Gleason pattern) may improve risk stratification when added to standard clinical parameters, but the Expert Panel endorses their use only in situations in which the assay results, when considered as a whole with routine clinical factors, are likely to affect a clinical decision. These assays are not recommended for routine use as they have not been prospectively tested or shown to improve long-term outcomes-for example, quality of life, need for treatment, or survival." 
While OncotypeDX may eventually have a role in making treatment decision about patients with prostate cancer, there is limited data on clinical outcomes to currently support routine use. Hence, it is not considered a generally acceptable standard of care for management of patients with a diagnosis of prostate cancer.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Benign prostatic hypertrophy, hypertension, gastroesophageal reflux disease (GERD), hyperlipidemia, hypokalemia, multiple sclerosis (MS), cerebrovascular accident (CVA), obstructive sleep apnea (OSA), diabetes, and vertigo

Treatment: PCA (Personal Care Aide) level 2: 12 hours per day- 7 days per week; 12 hours per day- 7 days per week (split shift)- for a total of 168 hours per week

The insurer denied coverage for PCA level 2: 12 hours per day- 7 days per week; 12 hours per day- 7 days per week (split shift)- for a total of 168 hours per week.

The denial is overturned.

This is a patient with multiple medical problems including multiple sclerosis, stroke, macular degeneration, and vertigo. He lives with his spouse (who is reportedly also impaired) in a 3-bedroom home. Under review is the medical necessity of requested PCA level 2: 12 hours/day- 7 days/week; 12 hours/day- 7 days per week (split shift) - for a total of 168 hours/week.

According to the New York State Department of Health's Uniform Assessment System (UAS-NY), the patient is totally dependent for all activities of daily living including bathing, dressing, personal hygiene, and toilet use. He is bowel and bladder incontinent. The patient is also totally dependent for bed mobility and requires a Hoyer lift for transfer to his motorized wheelchair. He is non-ambulatory. He is visually impaired and has vertigo. The patient has quadriplegia, vertigo, and macular degeneration as well as underlying multiple sclerosis and 2 stokes over the prior years. His severe functional impairments are progressive and require the requested Personal Care Aide (PCA) level 2: 12 hours/day- 7 days/week; 12 hours/day- 7 days per week (split shift) - for a total of 168 hours/week, in order for him to continue living safely at home. 

The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient. Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. All decisions are evidence-based.  

From a physical medicine and rehabilitation perspective, the requested Personal Care Aide (PCA) level 2: 12 hours/day- 7 days/week; 12 hours/day- 7 days per week (split shift) - for a total of 168 hours/week is medically necessary.

The insurer's denial of coverage for personal care aide (PCA) level 2: 12 hours per day- 7 days per week; 12 hours per day- 7 days per week (split shift)- for a total of 168 hours per week is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shoulder Pain
Treatment: Shoulder Surgery (29827, 29824, 29823, 29826)
The insurer denied the Shoulder Surgery (29827, 29824, 29823, 29826)
The denial is upheld

The patient is a male with left shoulder pain. His physical examination was significant for weakness, tenderness and decreased motion. His MRI (magnetic resonance imaging) report was significant for full thickness rotator cuff tear, tendinitis, AC (acromioclavicular) arthrosis and disruption to biceps.

The patient's physician recommended several arthroscopic procedures. He performed surgery and could not repair the cuff. He debrided several structures and resected a portion of the acromion.

No, the Shoulder Surgery (29827, 29824, 29823, 29826) is not medically necessary.
Surgery is recommended if a pain generator has been defined and there is no improvement with conservative management. The records show initial complaints were made to right shoulder. The patient then reported left shoulder pain and had an MRI (magnetic resonance imaging). There was pathology reported but no documented course of conservative management prior to surgical intervention. Surgery would thus not be indicated at that time.

While the patient experienced gradual onset of shoulder pain, without a significant traumatic event, evidenced pain level of 4 on the VAS (Visual Analogue Scale) scale, which interferes with age-appropriate activities of daily living, experiences weakness of rotator cuff muscle(s) (less than grade 4/5 on manual muscle testing), had a painful arc test full/empty can test, had weakness of external rotation, and recent advanced imaging confirms features of a degenerative full thickness tear, his physical exam did not demonstrate a positive response to drop arm test, and he is not documented to have had a failure of at least 6 weeks of conservative management.

Therefore, given the above, the shoulder surgery is not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis; Alopecia. 
Treatment: Dupixent. 

The insurer denied Dupixent. The health plan's determination is overturned. 

The patient is a male with alopecia universalis, treated with Xeljanz and minoxidil. He has not responded to Xeljanz. The provider is requesting Dupixent. The health plan denied the request as the medication is not FDA (Food and Drug Administration) approved for this diagnosis. 

Dupixent is medically necessary for this patient. There is substantial support in current peer reviewed literature for potential use of Dupixent in refractory alopecia areata. It has been hypothesized that IL-4 results in the production of inflammatory mediators (ie, IgE, mast cells, and eosinophils) implicated in both AA (alopecia areata) and AD (atopic dermatitis). Dupilumab, by inhibiting IL-4 and IL (interleukin)-13, dampens the downstream effect of these inflammatory mediators, potentially leading to concomitant improvement in AA (alopecia areata) and AD (atopic dermatitis). Given that this patient has tried and failed other standard therapies and Dupixent has been shown to be beneficial in alopecia areata, it is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient presented to the emergency department with complaints of abdominal pain for one day. The pain was located in the lower abdomen and epigastric region and radiated through to the back. The patient noted associated nausea. Her vital signs were without significant abnormalities. The examination demonstrated tenderness in the right lower quadrant (RLQ) and epigastric region. The white blood cell count (WBC) was 8.4. Other lab results were unremarkable. The patient underwent a pelvic ultrasound. She underwent a computed tomography (CT) scan which demonstrated acute appendicitis without other evidence of significant pathology. The patient was hospitalized on the surgery service. She was scheduled for a laparoscopic appendectomy the next day. The patient underwent a laparoscopic appendectomy with lysis of adhesions without significant complications. She was noted to have had a urinary tract infection (UTI) and a dose of ceftriaxone was given postoperatively. The patient met discharge criteria and was discharged later that day. The pathology demonstrated acute appendicitis and peri-appendicitis and a focal serrated lesion suggestive of sessile serrated adenoma.
At issue is the medical necessity of an inpatient stay.

No, an inpatient stay was not medically necessary for this patient.
The patient had acute appendicitis, but did not have evidence of other complications. She did very well after surgery and was able to be discharged home later on the day after surgery. The patient achieved discharge criteria in a reasonable amount of time. She did not have any evidence of complicated appendicitis. She did not have any evidence of active comorbidities requiring inpatient management. There were no complications such as a wound infection, wound dehiscence, enterocutaneous fistula or continued ileus. There is no evidence that additional complex testing or therapy other than the surgery was performed. There is no evidence that a complicating event occurred before, during, or after the procedure that required a higher level of care. There is no documentation that the treating team identified conditions or problems specific to the patient that would have required inpatient care. The patient did not have significant dehydration, hemodynamic instability, severe pain requiring frequent or high doses of narcotics, signs of intestinal obstruction, peritonitis, or bacteremia. The provided documentation does not support the medical necessity of an inpatient level of care.