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

Diagnosis: Alzheimer's dementia, hypertension, stage 3 chronic kidney disease (CKD), osteoarthritis (OA), asthma, and rectal adenocarcinoma.

Treatment PCA (personal care aide) hours, 7 days per week 2-12 split shift (168 hours per week).

The insurer denied coverage for PCA hours, 7 days per week 2-12 split shift (168 hours per week).

The denial is overturned.

This is a patient with multiple medical problems including Alzheimer's dementia, stroke and rectal adenocarcinoma.  She lives alone in a 1-bedroom apartment.  According to the treating physician's office visit note, "Patient's daughter had to resign from work to take care of mother for 2 years and needs to go back to work to support her own family. She will start working CDPAP (consumer directed personal assistance program) 10 hours for 2 days for patient and aide from agency for 5 days."  The patient is receiving PCA services 7 days/week, 10 hours/day for a total of 70 hours.  Under review is the request for increase in PCA hours to 7 days per week 2-12 split shift (168 hours per week).

According to the Uniform Assessment System (UAS), the patient is totally dependent for activities of daily living including bathing, dressing, and personal hygiene.  She is reportedly "bed bound" and totally dependent for bed mobility.  Feeding is via an NG (nasogastric) tube.  She is bowel and bladder incontinent.  The patient is unable to verbally respond to questions or instructions.  Cognition is described as "severely impaired."  The patient's functional incapacity and dementia renders the current PCA services 7 days/week, 10 hours/day for a total of 70 hours, insufficient.  The requested increase in PCA hours to 7 days per week 2-12 split shift (168 hours per week) is clinically appropriate; allowing the patient the ability 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 increase in personal care aide (PCA) hours to 7 days per week 2-12 split shift (168 hours per week) is medically necessary for this patient.  

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 7 days per week 2-12 split shift (168 hours per week is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Memory problems, OA (osteoarthritis), and decreased mobility.
Treatment: Increase Consumer Directed Personal Assistance Program (CDPAP) Services to 6 Hours/Day - 7 day(s) per week For A Total Amount of 42 Hours Per Week.

The insurer denied the Increase Consumer Directed Personal Assistance Program (CDPAP) Services to 6 Hours/Day - 7 day(s) per week For A Total Amount of 42 Hours Per Week.
The denial is overturned.

The patient is a female. She reportedly has memory problems, OA (osteoarthritis) and decreased mobility. She lives alone in a one-bedroom apartment located on the third floor. She cannot perform her own tasks.

The patient needs extended hours of home services. The patient needs assistance with personal hygiene, meal preparations and medications. Her self-sufficiency has declined significantly.

An Increase in Consumer Directed Personal Assistance Program (CDAP) Services to 6 Hours/Day - 7 day(s) per week For A Total Amount of 42 Hours Per Week is requested.

The health plan's reason for denial of coverage was that they deemed the service not medically necessary.

Yes, the increase in consumer directed personal assistance program to 42 hours/week is medically necessary.
The patient needs help with ADLs (activities of daily living). She needs help with personal hygiene, bathing and meal preparations. The patient has weakness and dizziness. She needs daily reminders with medications.

Extended hours services are medically necessary. The previously-approved 28 hours per week are insufficient, because the patient's functional status has significantly deteriorated, and she needs additional hours.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension and nonischemic cardiomyopathy;left total hip arthroscopy.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a female with past medical history (PMH) / co-morbidities of hypertension and non-ischemic cardiomyopathy (NICM). Past surgical history was significant for mitral and aortic valve replacement, atrial fibrillation, and gout. The patient underwent a left total hip arthroplasty through an outpatient surgical admission. Post-operative course was remarkable for post-operative blood loss anemia which manifested as orthostatic hypotension which negatively impacted her ability to participate in and complete the activity milestones in the pre-admission anticipated timeline. Her failure to meet the criteria necessitated a change in status to inpatient until the Discharge Readiness criteria were met.

Yes, the proposed inpatient admission was medically necessary.
Inpatient status is required only if a patient's safety or health would be significantly and directly threatened if care were provided in a less intensive setting.

In this clinical scenario the health system has established a best practices algorithm for outpatient arthroplasty and in this algorithm specific clinical benchmarks must be achieved to transition from each care unit ultimately arriving at a safe discharge condition or Discharge Readiness.

This patient underwent a left total hip arthroplasty through an outpatient surgical admission. The patient's post-operative course was remarkable for post-operative blood loss anemia which manifested as orthostatic hypotension.  This negatively impacted the patient's ability to participate in and complete the activity milestones in the pre-admission anticipated timeline. Her failure to meet the criteria necessitated a change in status to inpatient until the Discharge Readiness criteria were met.

This patient transitioned from the pre-operative area to inpatient floor thru the oversight of the Interdisciplinary team, however safe criteria for Physical Therapy to approve Discharge Readiness was not met due to in large part to post-operative blood loss anemia, until the afternoon of the third hospital day.

No, the health plan act did not reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis. 
Treatment: Personal care aide services (84 hours per week). 

The insurer denied Personal Care Aide (PCA) services: 12 hours per day/7 days a week, total amount of 84 hours per week. 
The health plan's determination is overturned. 

The patient is male with past medical history of hypertension, hyperlipidemia, dementia, benign prostatic hyperplasia (BPH), gastroesophageal reflux disease (GERD), anxiety, depression, heart failure and osteoarthritis who had been assigned PCA (personal care aide) services based on assessment performed that assessed the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, and shopping while maximum assistance with tasks of managing medication, stairs, transportation, bathing, dressing lower body, walking, locomotion, transfer toilet, and toilet use. The patient was assessed at extensive assistance with task of phone use, personal hygiene, dressing upper body, and bed mobility while limited assistance with task of eating. 

PCA Services: 12 hours per day/7 days a week, total amount of 84 hours per week is medically necessary for this patient. 

There is documentation in the assessment of worsening cognitive and physical functioning despite no change in activities of daily living (ADLs) or Instrumental activities of daily living (IADLs) status. The recent assessment underestimated the patient's care needs. The patient does need at least maximum assistance with walking, locomotion, transfer toilet, and toilet use all of which are unpredictable care needs. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of IADLs and ADLs. The patient will require PCA assistance outside of all of the hours that he has informal help.

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: 12 hours per day/7 days a week, total amount of 84 hours per week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in his own home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Below knee amputation
Treatment: Durable Medical Equipment (replacement socket prosthesis)
The insurer denied the Durable Medical Equipment (replacement socket prosthesis)
The denial is overturned

The patient is a male with history of Right Below-Knee-Amputation secondary to trauma. The request is for replacement of components of a BKA (below knee amputation) prosthetic mostly Right Transtibial replacement Socket, prosthetic socks, etc.

The patient had a new socket based on measurement and has since then had a significant decrease in the BKA (below knee amputation) volume with reductions in all dimensions with 1.7-4.5 cm (centimeter) difference from that measurement compared to a new one and the reason for a new in less than a year, thereby exceeding the limit within the stated period.

Yes, the replacement socket prosthesis is medically necessary.
The replacement below knee socket is medically necessary because the patient has met the generally accepted criteria for the replacement of a previously approved external prosthetic device or one or more of its components (parts) or supplies.

The replacement device is provided by an eligible ancillary provider. The continued use of the device remains medically necessary for the individual and appropriate for the individual's condition. The replacement is not an additional device (e.g., for use when traveling or for an additional residence) but rather a replacement of an ineffective component. The replacement is equivalent to a previously approved external prosthetic device/component. The device itself is not under a manufacturer's warranty. The replacement device is for an individual who has either one of the following: A change in condition that impacts the fit or function of the device and, therefore, requires its replacement which in this case is due to the significant loss of volume of the limb making it not to fit; A device that does not function properly due to lack of proper fitting.

Therefore, based on the above, the requested health service is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.

The essence of the prosthetics is to enable the patient to have a limb device that will allow him to ambulate as near-normal as possible as part of his functionality.

A non-fitting or badly-fitting socket makes the entire prosthetics useless and unusable and therefore not providing the necessary purpose for it. An attempt to use a non-fitting socket can also lead to a bad gait-pattern that will inevitably lead to more serious injuries.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Balanitis and Balanoposthitis. 
Treatment: Inpatient Hospital Admission. 

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

The patient is a male child. He presented to the ED (emergency department) with one day history of pain and swelling of the penis. He had been prescribed cephalexin, bacitracin ointment, and ibuprofen by his pediatrician. He had no other symptoms (fever, abdominal pain, nausea, poor appetite, voiding issues). 

The patient's vital signs included temperature 36.9, heart rate 97, respiratory rate 20, and blood pressure 97/69. Examination was significant for no acute distress with non-toxic appearance, moist mucous membranes, benign abdomen, phimosis, erythema and tenderness and swelling of the penis with no lesions or discharge, and no palpable inguinal adenopathy. He was diagnosed with balanitis and balanoposthitis. Urology was consulted, and IV (intravenous) antibiotics were changed to clindamycin. 

The patient was subsequently admitted for further care. On hospital day 1, the phimosis was reduced at the bedside. On hospital day 2, cultures returned positive for Enterococcus, so antibiotics were changed to Unasyn. Redness, swelling, and pain improved rapidly and significantly. He was subsequently deemed safe for discharge, with plans for outpatient circumcision. 

No, the inpatient hospital admission was not medically necessary in this case. 

Balanitis is an inflammation of the glans penis, balanoposthitis is an inflammation of the prepuce. Phimosis occurs when the foreskin cannot be retracted, either physiologically from naturally-formed adhesions or secondary to scarring of the prepuce. Inflammation may result from infection, trauma, or irritations, often resulting from poor hygiene. If phimosis is severe enough, a catheter may need to be placed to allow for urination. Infection, usually secondary to Candida, Strep, or Staph, usually resolves after topical treatment, but bacterial infection can be treated with enteral antibiotics such as cephalexin. Other causes have etiology-specific treatment recommendations. 

This young male child presented to the emergency department (ED) with signs and symptoms consistent with balanitis and balanoposthitis. He had initiated treatment in the outpatient setting, but because of worsening pain was admitted for parenteral therapy. While it was not unreasonable to monitor treatment in the hospital for improvement, he was overall stable, with no urinary complaints, no constitutional complaints (e.g. [for example], fever). He did not require acute inpatient admission and could have been safely managed at a lower level of care. 

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 in Part

Diagnosis: Flat Foot Deformity. 
Treatment: Procedure code 27899-RT-59 (unlisted procedure-right side-distinct procedure service) and 28899-RT-59 (unlisted procedure foot and toes-right side-distinct procedure service). 

The insurer denied coverage for procedure code 27899-RT-59 and 28899-RT-59. 

The denial is modified. 

The patient is a female with long history of being treated under the care of her physician. After failed conservative measures, the patient underwent flat foot reconstruction including both an Evans and a Cotton osteotomy. 

The literature has extensive evidence of the long-term positive outcomes in the use of these procedures for severe flat foot deformity. "The combination of these joint-preserving osteotomies with additional soft-tissue procedures allows realignment of the hindfoot with the goal of preventing further deformity or degenerative joint disease." (1) Patients tend to have high levels of satisfaction when it comes to correction of their flatfoot deformity with these types of osteotomies. Studies show a "high patient satisfaction based on the American Orthopedic Foot and Ankle Score (AOFAS) ankle-hindfoot scale and radiographic measurements demonstrate maintenance of correction of the adult acquired flatfoot." (2) When compared to a subtalar arthroereisis, a lateral column lengthening procedure results in no loss of correction and great results. (3) 

In the case of this denial, the fact remains that the procedures were the correct choice, however, it appears that the billing was done improperly and there are CPT (Current Procedural Terminology) codes that better encompass the procedures done, rather than the unlisted procedures that were billed. As such, there should be resubmission of the claim with the correct codes. 

The health plan acted reasonably in part. 

The insurer's denial of coverage for procedure code 27899-RT-59 and 28899-R  is modified. Medical Necessity is substantiated for the procedure that was performed; however, the coding must be corrected and resubmitted.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back pain
Treatment: Spinal Cord Stimulator
The insurer denied the Spinal Cord Stimulator
The denial is overturned

The patient is a female with low back pain. She has a history of spinal tumor that was resected, which caused postoperative kyphosis at L1-L2 (first lumbar spine vertebra-second lumbar spine vertebra). MRI (magnetic resonance imaging) shows scoliosis with multilevel degenerative changes and moderate to severe stenosis. Exam reveals no focal deficit. The patient takes opioids for pain. She has attempted PT (physical therapy) in the past.

The patient was recommended SCS (spinal cord stimulator) trial. Psychological evaluation demonstrates the patient is safe for SCS (spinal cord stimulator).

Yes, the Spinal Cord Stimulator is medically necessary.
The patient has prior spine surgery for benign tumor resection. The patient has postoperative failed back surgery/post-laminectomy syndrome causing chronic pain. The patient has failed multimodal therapies. The proposed use of a SCS (spinal cord stimulator) trial is the most appropriate treatment in the setting of continued chronic pain and no imaging findings on MRI (magnetic resonance imaging) that would support any other surgical intervention. Therefore, this is the most appropriate option and is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
This surgery is medically necessary due to the patient's current condition, the failed surgery in the past, and continued chronic pain without evidence of significant findings on MRI (magnetic resonance imaging) that warrants surgical intervention. Therefore, SCS (spinal cord stimulation) is the most appropriate treatment for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain.
Treatment inpatient admission.
The insurer denied coverage for inpatient admission.
The denial is upheld.

This patient presented to the hospital complaining of chest pain radiating to his jaw.  Associated symptoms included diaphoresis, nausea, and dyspnea.  Past medical history was significant for hypertension, diabetes mellitus and schizophrenia.  The patient reported a similar episode several months earlier where work up was negative.  Upon arrival to the hospital vital signs were stable (blood pressure (BP) 119/77, pulse 80).  Physical examination was significant for epigastric tenderness and rales over the lower lung fields.  A 12-lead electrocardiogram (EKG) revealed no ischemic ST (interval on EKG) or T (interval on EKG) wave changes and a mildly prolonged QTc(interval on EKG) interval (483msec) consistent with Haldol use.  Serum blood testing revealed no elevation in troponin (< [less than] 0.012ng/ml [nanogram per milliliter]) or BNP (brain natriuretic peptide tests) (133).  Previously performed echocardiogram revealed preserved LVEF (left ventricular ejection fraction) 55-60% (percent).  The patient was admitted to the hospital and ultimately underwent perfusion stress testing that revealed no evidence of ischemia. 

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.  This patient presented with chest pain and a past medical history of hypertension and diabetes. A previous work up performed months earlier was unrevealing. His pretest probability of coronary artery disease was moderate. (Reference 1) Utilizing the HEART (history, EKG, age, risk factors, troponin) score, he was considered low risk.(Reference 2)  Utilizing the TIMI (thrombolysis in myocardial infarction) risk score he also had a low risk of developing major adverse cardiac events in the subsequent 30 days .  (Reference 3) Risk assessment of patients presenting with chest pain and no significant ST changes on EKG was reviewed by Hedayati et al. (Reference 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. In conclusion, this patient could have been treated at a lower level of care.

The health plan acted reasonably with sound medical judgment 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: Upheld

Diagnosis: s/p (status post) Surgery. 
Treatment: Inpatient admission. 

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

The patient is a female. She underwent a robotic assisted total laparoscopic hysterectomy, bilateral salpingectomy, bilateral ovarian cystectomy, anterior colporhhaphy, and injection of a keloid. The procedure was uncomplicated but there were dense adhesions. Blood loss was 2-300ml (milliliters). She was transferred to recovery with a Foley catheter. She was given IV (intravenous) dilaudid and IV (intravenous) toradol. She was admitted overnight for pain control. She was given IV (intravenous) morphine as needed, IV (intravenous) toradol every 6 hours. She was also given lovenox. 

By day two, the Foley was removed. The patient passed her voiding trial. She was ambulating, tolerating diet. She was discharged home with follow up as an outpatient. 

No, the Inpatient admission was not medically necessary. 

In review of the medical record, the procedure was uncomplicated and without a high level of blood loss. The patient did not have any hemodynamic instability. She was able to meet discharge criteria within 24 hours of admission. She was voiding, ambulating, tolerating diet, and pain controlled. There is no evidence that the care required acute inpatient level of care. The same care could have been provided with the same safety and efficacy at an observation level of care. 

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

There was no evidence that inpatient level of care was needed. Therefore the health plan reasonably denied coverage for the inpatient stay.