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

Diagnosis: Pelvic inflammatory disease.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned. 

The patient is a female. She presented with a chief complaint of pelvic pain.

The patient's vital signs were stable. Physical examination was normal except for cervical motion tenderness. The patient was diagnosed previously with endometriosis.

The patient was admitted with the diagnosis of PID (pelvic inflammatory disease) complicated by a history of endometriosis and suspected pelvic myofascial pain syndrome. She received IV (intravenous) antibiotics for 24 hours and was discharged on progestin to treat her endometriosis, Gabapentin, and Tylenol for pain, and Sertraline for depression anxiety. She was discharged.

Yes, the Inpatient admission was medically necessary.

The presumptive clinical diagnosis of PID is made in sexually active young women, especially women at high risk for sexually transmitted infections (STIs), who present with pelvic or lower abdominal pain and have evidence of cervical motion, uterine, or adnexal tenderness on exam.

The sensitivity of this clinical diagnosis is only 65 to 90 percent but because of the potential for serious reproductive sequelae if PID treatment is delayed or not given, this presumptive diagnosis is sufficient to warrant empiric antimicrobial therapy for PID. Even patients with minimal or subtle findings should be treated since the potential consequences of withholding therapy are great.

So even though this patient did not have the typical PID presentation (no fever, no abnormal cervical or vaginal mucopurulent discharge or cervical friability), treating her for possible PID was warranted.

There has been a persistent trend toward outpatient treatment of PID with only 15 percent of women now being hospitalized. Clinical trial data support such an approach in patients with mild or moderate PID.

Recommended indications for hospitalization and parenteral antibiotics include the following:

1) Pregnancy 2) Lack of response or tolerance to oral medications 3) Nonadherence to therapy 4) Inability to take oral medications due to nausea and vomiting 5) Severe clinical illness (high fever, nausea, vomiting, severe abdominal pain) 6) Complicated PID with pelvic abscess (including tubo-ovarian abscess) 7) Possible need for surgical intervention or diagnostic exploration for alternative etiology (e.g., appendicitis)

This patient had severe pain. While PID was suspected, she also had a history of endometriosis complicating her presentation. In addition, she had elevated white count, nausea and vomiting and has a history of poor adherence to antibiotics. The pain was severe, necessitating IV morphine.

Based on the above, the inpatient care from was medically necessary.

The health Plan should allow admission as the admission was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Endocrine/metabolic/nutritional. 
Surgical Services  (All). 

Diagnosis: Morbid Obesity. 
Treatment: Reoperative Bariatric Surgery. 
 
The insurer denied Reoperative Bariatric Surgery. The health plan's determination is overturned. 

This patient is a woman under consideration for revisional bariatric surgery. She underwent the sleeve gastrectomy procedure. 

The patient consulted for the condition of weight gain and gastroesophageal reflux disease (GERD). At this time, she was 57 inches tall and weighed 173 lbs. This corresponds to a body mass index (BMI) of 37.5 kg/m2. The patient has obesity-related comorbid diseases of GERD, type 2 diabetes and hypertension. The patient has consulted with a dietician for this condition. Upper endoscopy showed a normal esophagus, an irregular Z-line(squamocolumnar mucosal line), and a 1-cm hiatal hernia. The gastric sleeve was described to have a moderate degree of axial torsion at the level of the incisura. A mental health evaluation was performed with clearance for the proposed revisional operation. She has been cleared for surgery from a cardiology standpoint. The records reference a pH study that recorded a normal DeMeester score of 4.4 (normal < 14.7). Her listed medications do not include any antacid medications per the surgical consultation. The provider has proposed conversion of the sleeve gastrectomy to roux en Y gastric bypass as a tool to augment weight loss, treat comorbid health conditions and divert gastric acid away from the gastroesophageal junction.

Given this patient's diagnosis, her current health condition and medical standards in the field of bariatric and metabolic surgery, the proposed revision of sleeve gastrectomy to roux en Y gastric bypass (RYGB) is medically necessary for this patient. The patient has a body mass index (BMI) in excess of 35 kg/m2 with weight related comorbid health conditions that include GERD, diabetes, and hypertension. She has successfully completed a multidisciplinary bariatric evaluation. She has had appropriate dietary counseling and has been cleared for bariatric surgery from a mental health standpoint. Finally, she has participated with a supervised weight loss program over a period of 6-months as detailed. She has refractory medically complicated morbid obesity despite her participation with this program. 

Revisional surgery as is proposed in this case is a reasonable clinical consideration for this patient. This patient underwent sleeve gastrectomy. While he initially lost weight following surgery, she regained weight as is sometimes experienced with restrictive bariatric operations. She has weight related comorbid health conditions that will respond favorably to both weight loss and anatomic changes of roux en Y gastric bypass. She has actively participated in a post-surgical program and has completed the prerequisite evaluation with mental health and nutritional consultations.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic bilateral knee pain. 
Treatment: Synvisc J7325 - 48 mg injected intra-articular into bilateral knees one
time - 48 units per dose for a total of 96 units. 

The insurer denied the Synvisc J7325 - 48 mg injected intra-articular into bilateral
knees one time - 48 units per dose for a total of 96 units. 

The denial is upheld. 

The patient is a male with chronic bilateral knee pain. He had received multiple
injections of cortisone, which did not help. He was interested in receiving
viscosupplementation. 

The physical examination was significant for BMI (body mass index) 58, joint
tenderness, bilateral pitting edema. X-ray report was that of severe
tricompartmental disease. He was diagnosed with osteoarthritis. 
Viscosupplementation was recommended. 

The patient was not using his braces, nor was he taking a medication. He had not
had PT (physical therapy). 

No, the treatment with J7325 - 48 mg injected intra-articular into bilateral knees one
time - 48 units per dose for a total of 96 units is not medically necessary. 

Viscosupplementation is an additional modality to treat knee osteoarthritis. It is
applicable if a full course of conservative treatment had been provided. 
Conservative treatment includes pharmacologic and non-pharmacologic modes. 
The facts are that the patient has not received the "full" course of conservative
management. He was not taking any medications, nor was he using a brace. There
was no documentation to an attempt of weight reduction or visits to PT (physical
therapy). 

The basis for the health plan's denial is consistent with the standard of care in the
orthopedic community. It is not unreasonable to have the patient trial more
conservative therapy before considering the issue under review. 
Based upon the above, the use of viscosupplementation would not be applicable at
this time. Therefore, it is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal-Abdominal pain
Treatment: Inpatient stay
The health plan denied the inpatient stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

The patient was admitted with left lower abdominal pain. She has chronic obstructive pulmonary disease (COPD) and is on home oxygen(O2). Other medical history includes diverticulosis, hypertension (HTN), chronic back pain, urinary incontinence, Anemia, depression, and diastolic congestive heart failure (CHF). The patient had been experiencing these symptoms for 3 days prior to admission. The patient had associated nausea with decreased appetite. In addition the patient endorsed black stools for 3 days. On exam in the emergency room (ER) the patient was afebrile and hemodynamically stable and had mild palpation tenderness in the left lower quadrant(LLQ) without guarding or rebound. Initial complete blood count (CBC) was without leukocytosis. Hemoglobin (Hgb) 9.1 and normocytic. Underwent a computed tomography (CT)scan of the abdomen which demonstrated diverticulosis but no evidence of diverticulitis. Patient had no problems overnight after discharge from the ER to inpatient bed. Patient was started on MiraLAX as some discomfort was thought to be from a large fecal burden. The patient was discharged uneventfully.

The requested inpatient stay was not medically necessary for this patient. The patient presented with abdominal pain and mild dehydration. The patient endorsed dark stool but was not having a significant gastrointestinal (GI) bleed. The patient's CT ruled out diverticulitis and the final diagnosis was likely constipation. During the hospitalization there were no adverse events such as life threatening bleeding or infection. No inpatient procedures were indicated. Based on her age and co-morbidities it was reasonable to admit her for a lower level of care, but she did not require inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer- Breast Cancer
Treatment: Inpatient stay
The health plan denied the inpatient stay as not medically necessary. 
The reviewer has upheld in whole the health plan determination.

The patient presented to the hospital with the diagnosis of right breast cancer and a left breast lesion. At the time of presentation the patient was without fever and vital signs were normal. She was treated with right simple mastectomy with right axillary sentinel node biopsy and left breast needle localized excisional biopsy. The operative dictation and the anesthetic record describe an uncomplicated procedure. A surgical drain was placed in the area of the operative field.
The patient was treated with post-surgical monitoring, intravenous (IV) fluid, analgesia, and antiemetics. The immediate post-surgical recovery was uncomplicated. Following surgery, the patient had stable vital signs. Pain was controlled. The diet was advanced. The patient remained clinically stable and was discharged from the inpatient setting the next day.

An inpatient hospital admission was not medically necessary. There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care. The records support that this patient could have been appropriately treated with a lower level of care. A lower level of care would have provided for perioperative care and monitoring, provision of post-surgical monitoring, and overnight care. The records do not document hemodynamic instability, sepsis or toxicity, significant electrolyte imbalance, bleeding, or surgical complications of the procedure that required inpatient care. In this case the patient tolerated oral hydration, diet, and medication, and her pain was well controlled following surgery. Inpatient care was not required or medically necessary in this case as this level of care was not in accordance with generally accepted standards.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Right ankle pain and swelling.
Treatment:  MRI of leg without contrast.

The insurer denied the MRI of leg without contrast.  The denial is overturned. 

The patient is a female.  She had an MRI (magnetic resonance image) of the right ankle after having right ankle pain and swelling.  This showed edema that was nonspecific, effusion of the ankle.  No tendon tear and mild tenosynovitis of the posterior tibial tendon.

The patient had presented with ankle pain that had been present for two months.  On exam she was found to have swelling and weakness.  X-rays were done in the office, which were negative and showed swelling only.  Examination showed weakness of the mid-foot and pain in the mid-foot.  An Unna boot was applied to reduce edema.  The MRI (magnetic resonance image) was ordered to assess for Lisfranc fracture dislocation.

Yes, the MRI (magnetic resonance image) of leg without contrast (73718) is medically necessary.

The MRI (magnetic resonance image) was ordered to assess for a Lisfranc injury.  A Lisfranc injury is a soft tissue injury of the midfoot often caused by a twisting type injury to the midfoot.  This is an easily missed injury in that it typically involves a tear of a midfoot ligament, sometimes without bony abnormality.  It is commonly missed because practitioners are often looking for a fracture and when none is found, patients are treated inappropriately.  An MRI (magnetic resonance image) is indicated, as when there is a Lisfranc tear, surgery is required.  It may also be treated with prolonged nonweightbearing and casting.  The MRI (magnetic resonance image) in this case was necessary to assess for a Lisfranc injury, as that was the diagnosis that was suspected.

The office notes show that the MRI (magnetic resonance image) was ordered to rule out a Lisfranc injury.  An MRI (magnetic resonance image) is needed to assess for this injury, as it is a soft tissue injury and not present on x-rays, which were negative.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: s/p (status post) Hysterectomy
Treatment: Inpatient admission
The insure denied the inpatient admission.
The denial is upheld. 

The patient is a female. She was admitted to the hospital for a
laparoscopic assisted vaginal hysterectomy. She has a medical history of hypertension.

The procedure was performed without complications with minimal blood loss. The patient recovered in the PACU (post anesthesia care unit) without incident. She was then admitted to the inpatient service. The patient recovered uneventfully on the inpatient service.

The patient was resting comfortably, with good pain control, normal vital signs, afebrile and tolerating a clear liquid diet resting comfortably, ambulating, with good pain control, normal vital signs, afebrile and tolerating a normal diet. She was discharged.

No, the Inpatient admission was not medically necessary.

The medical records and peer-reviewed medical literature were thoroughly reviewed. The patient had an uncomplicated laparoscopic hysterectomy and was admitted postoperatively as an inpatient. There is no evidence to support an inpatient admission based on her intraoperative and immediate postoperative conditions.

A review of the physician progress notes and associated inpatient records does not reveal any evidence that the patient's preoperative or postoperative condition required acute inpatient admission. The patient did not have co-morbidities indicating the need for an inpatient postoperative admission. There is no evidence that her pain was uncontrolled, and in fact was controlled by oral pain medications. She was tolerating normal PO (by mouth) intake overnight and through the first postoperative day. Her bowel function demonstrated normal progression.

It is not within the standard of care for a laparoscopic hysterectomy to be an ambulatory procedure with a same day discharge. The patient required postoperative care. However, given her intraoperative condition and uncomplicated postoperative recovery she could have been reliably discharged from the recovery room to a unit providing a lesser level of care, rather than as an acute inpatient admission. Therefore the treatment was within the standard of care to be provided in a less than acute level of care setting, and not in an inpatient setting. Therefore the services were not medically necessary.

Given the patient's intraoperative condition and uncomplicated postoperative recovery, she could have been reliably discharged from the recovery room to a unit providing a lesser level of care, rather than as an acute inpatient admission. Therefore the treatment was within the standard of care to be provided in a less than acute level of care setting, and not in an inpatient setting. Therefore the services were not medically necessary. Therefore the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic low back pain with sciatica.
Treatment: Personal Care Assistance Services; 5 hours per day, 5 days per week.

The insurer denied personal care assistance services of 5 hours per day, 5 days per week.  The denial was overturned.   

This female patient has medical conditions including chronic low back pain with sciatica, supraventricular tachycardia (SVT), bilateral shoulder pain, diabetes mellitus, hypertension, asthma, hyperlipidemia, hypothyroidism, osteoarthritis, depression, dizziness, and obesity. Due to constant pain, her ambulation with a rollator has been limited; her ability to participate in activities of daily living (ADLs) has been significantly impacted; and she requires much more assistance at home.  Pain also impacts her ability to stand or sit.  She has difficulty bending from the waist, putting on clothes, especially to lower extremities.  She needs assistance with housekeeping, meal preparation, shopping, laundry. Her physical functioning has declined. The patient has been receiving personal care assistance (PCA) services 18 hours per week, Monday - Friday. The patient requested increase of PCA services to 25 hours per week which was denied.  

Uniform Assessment System (UAS) showed the functional status report for independent activities of daily living (IADLs) indicates the patient needs maximal assistance for housework, extensive assistance for meal preparation, shopping and stairs. For the other IADLs the patient needs supervision or limited assistance (phone use is independent).  For ADLs, the patient needs limited assistance for bathing, dressing, and personal hygiene; for the other ADLs, only setup help is needed.

At the current approved hours, the PCA helps for a few hours, but it appears the patient is alone for a period of time until her son returns home. The patient is requesting increase of PCA services to 5 hours per day Monday - Friday. Therefore, it is reasonable to conclude that neither her son nor any other informal caregiver is available for additional time on weekdays when she needs assistance after the PCA departs. 

Assistance from informal caregivers is voluntary as per NYS regulations for personal care services. In the absence of informal caregivers who can provide assistance for daily activities when needed, then personal care services are indicated to provide the necessary care.

The patient's medical history and functional impairments support the need for caregiver assistance with most daily activities; including ADLs and household related tasks.  The patient's request for additional PCA hours when informal caregiver help is unavailable appears reasonable, and is consistent with her functional needs.

Personal Care Assistance services 5 hours per day, 5 days per week, total of 25 hours per week (Monday - Friday) is medically necessary.

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

Based on the above, the medical necessity for the requested PCA services at 5 hours per day, 5 days per week is substantiated. The insurer's denial is overturned.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Migraine headache disorder, chronic daily headache and "transformed migraine".
Treatment: Formulary exception for Reyvow 100mg (milligrams) Tablet.

The insurer denied the Formulary exception for Reyvow 100mg Tablet.  The denial is upheld. 

The member is a female with migraine headache disorder, chronic daily headache and "transformed migraine".  She has tried and failed sumatriptan for abortive therapy.

No, the health plan should not cover the proposed treatment, formulary exception for Reyvow 100mg Tablet.

There is no reason the patient cannot be treated with the preferred formulary agents. She has only tried and failed one acute treatment for migraine. All of the preferred agents are considered first line, standard of care, migraine abortive agents. There are no high quality clinical trials or standard of care guidelines supporting the preferential use or superiority of Reyvow relative to the preferred oral agents.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Impacted upper right canine. 
Treatment: Braces. 

The insurer denied the braces.  The denial is overturned. 

The patient is a female.  The request is for orthodontic benefits. 

Yes, the proposed treatment with braces is medically necessary. 

The patient has an impacted upper right canine, tooth #6. This tooth needs to be pulled down orthodontically so it is in its proper position.  When there is an impacted anterior tooth, where extraction is not indicated, (like this one), there is an "automatic qualification" for orthodontic benefits according to the handicapping index scale. This case has medical necessity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastrointestinal-Abdominal Pain. 
Treatment: Inpatient stay. 

The health plan denied the inpatient hospital admission as not medically necessary for this patient.  The reviewer has upheld in whole the health plan's determination. 

The patient presented to the emergency room (ER) with 2 days of abdominal pain associated with nausea and vomiting. On exam she appeared in no acute distress (NAD). The patient was afebrile without tachycardia. She had a normal white blood cell count (WBC) and liver function tests (LFT's). The patient was tender in the right upper quadrant (RUQ) without guarding or rebound. A computed tomography (CT) scan demonstrated gallstones but no signs of acute cholecystitis. The patient also underwent ER ultrasound which confirmed the same findings as the CT scan. She was seen by surgery consults. On the first day of hospitalization the patient was without events. Cholecystectomy was not indicated per their consult. Exam was still with RUQ tenderness without guarding or rebound. Later the patient denied abdominal pain in the nursing report. The patient had a hepatobiliary iminodiacetic acid (HIDA) scan which was negative for cystic duct obstruction but showed delayed ejection fraction. In the hospital the patient was found to be Helicobacter pylori (H. pylori) positive (+) and was discharged on antibiotic therapy with Flagyl and Tetracycline, and Bismuth, and proton pump inhibitor (PPI). 

No, the requested inpatient hospital admission was not medically necessary for this patient. The patient had RUQ tenderness of unclear etiology; however, this was not due to a biliary tract abnormality. The findings on radiographic studies in conjunction with normal LFT's support this statement. She did not have to stay in the hospital at the inpatient level of care for the diagnostic testing and management she received. Rather, a lower level of care was appropriate, and she could have been safely followed as an outpatient thereafter. This would have allowed time to complete the HIDA scan, find H pylori, and assure that her clinical course was not worsening.