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

Diagnosis: hypertension, depression and anxiety

Treatment: increase in personal care worker (PCW) services to 7 days per week, 12 hours per day; 84 hours per week

The insurer denied coverage for increase in personal care worker (PCW) services to 7 days per week, 12 hours per day; 84 hours per week

The denial is upheld

This is an elderly female with chronic medical problems including hypertension, depression and anxiety.  She lives alone in a private residence.  The insurer approved an increase in personal care worker (PCW) services from 4 to 5 hours per day; 7 days per week for a total of 35 hours per week and the request is for PCW 12 hours/day, 7 days/week (total 84 hours/week), leading to an external review. 

The Uniform Assessment System (UAS) report was reviewed.  The patient's cognition was described as moderately impaired.  She reportedly requires extensive to maximal assistance for Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.   The patient reportedly requires extensive assistance for bathing, lower body dressing and toilet use.  Limited assistance is reportedly needed for personal hygiene, upper body dressing, eating, bed mobility, toilet transfer, locomotion and ambulation.  She was observed by the nurse assessor ambulating with a walker and contact guard assistance.   The patient reports being occasionally incontinent of bladder and infrequently incontinent of bowel.   There has been no reported change regarding her ability to perform activities of daily living (ADL) or self-sufficiency over the prior 90 days.  There has been 1 reported fall over the prior 90 days.  The patient's cognitive status has modestly declined, and her functional ability is much the same when compared to the prior UAS report.

Based on the case notes, the patient does not have functional needs at a level or unpredictable as to require the requested personal care worker (PCW) services 7 days per week, 12 hours per day; 84 hours per week.  This physician would agree the patient may benefit from additional monitoring for safety; particularly upon her reported weakness and falls risk.  However, safety monitoring under PCW does not include monitoring an individual when no other Level I or Level II personal care services task is being provided.   The insurer's approval for a modest increase PCW hours from 4 to 5 hours/day was appropriate, given the slight cognitive decline.  Based on the submitted clinical records, the patient's health and safety are appropriately provided and maintained at home by the approved PCW services to 5 hours per day; 7 days per week for a total of 35 hours per week.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an increase in personal care worker (PCW) services to 7 days per week, 12 hours per day; 84 hours per week services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic low back pain

Treatment: Inpatient hospital

The insurer denied coverage for inpatient hospital

The denial is upheld
 

This adult female has chronic low back pain and then had an acute episode of pain which was localized to her lower back and some radiation.  She stated she was unable to ambulate. She was constipated and was able to feed herself. A computed tomography (CT) scan did not reveal pathology. A magnetic resonance imaging scan (MRI) showed a disc herniation.

The only valid reason for hospitalizing this patient is that she cannot manage basic activities of daily living (ADLs) at home. As per Milliman Care Guidelines (MCG) if necessary, patient can be admitted to observation care E.g. for pain management.  When the patient is stabilized and evaluation is negative for an acute process such as an acute fracture, the patient can be discharged.

In this case, the patient lived with another adult at home who could assist her with activities of daily living as necessary. She was able to stand but had pain with ambulation.  She did not meet criteria for inpatient hospital admission.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

This is a female patient who has a history of malrotation treated with Ladd's procedure. She presented to the hospital for vomiting and fatigue. She was admitted for further management and was started on intravenous fluids. She had normal upper gastrointestinal series imaging. Her diet was advanced and she was discharged home in a stable medical condition. The medical necessity of an inpatient stay is under review.
The admission to acute inpatient level of care was not medically necessary.
Most gastroenteritis cases do not require inpatient care. However, a small percentage of patients develop severe dehydration and require intravenous rehydration and hospital care. Per Banyai, K., et al. (2018) "For treatment of dehydration caused by gastroenteritis viruses, the administration of reduced-osmolality oral-rehydration solutions (50-60 millimoles per liter (mmol/L) sodium) is the first line of therapy. Profuse vomiting, worsening dehydration with altered consciousness, or severe acidosis, hypovolemic shock, abdominal distension, and ileus are indications for intravenous rehydration".
This patient presented to the emergency room for vomiting and fatigue. She was unable to take adequate oral hydration, therefore, continued outpatient management was not appropriate.
However, she was hemodynamically stable and did not have mental status changes or severe electrolyte abnormalities. There was no evidence of bowel obstruction or ileus. She did not have evidence of a renal injury or other organ damage.
The provided care included intravenous fluids, antiemetics and monitoring. The upper gastrointestinal series is a simple test that can be done at a lower level of care. The patient did not require invasive procedures or surgical interventions. She did not require a complex treatment regimen or respiratory support. Therefore, the patient's condition and care were manageable at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory distress
Treatment: Inpatient admission
The insurer denied Inpatient admission.
The determination is overturned. 

The patient is a female with hypertension (HTN) and asthma who presented with dyspnea and chest tightness that had persisted despite a course of outpatient steroids. In the emergency department (ED), her temperature was 37.4, blood pressure (BP) was 157/99, heart rate (HR) was 112, respiratory rate (RR) was 22, and pulse oxygen saturation (spo2) was 100% on room air (RA). She was in acute distress, heart was regular, in respiratory distress with tachypnea, decreased breath sounds, and wheeze. Her white blood cell count (WBC) was 15.7, sodium (Na) was 136, bicarbonate was 21, blood urea nitrogen (BUN)/creatinine (Cr) was 18/1.2
She was diagnosed with status asthmaticus, given intravenous (IV) magnesium, nebulized bronchodilators, IV steroids, ceftriaxone, and azithromycin; she did not respond and was placed on bilevel positive airway pressure (BiPAP) while in the ED. She was admitted, diagnosed with asthma exacerbation, and started on IV steroids and nebulized bronchodilators.
By the next day, she had improved somewhat and was weaned off BiPAP. She still felt tight and was wheezy on exam. She desaturated while ambulating. The patient then left against medical advice (AMA).
At issue is the medical necessity of an inpatient admission.

The requested health service/treatment of Inpatient admission was medically necessary for this patient.
An inpatient admission was medically necessary. She had respiratory distress, requiring intensive treatments only performable in an inpatient setting. She presented with an acute asthma exacerbation. She was at a higher risk having been intubated previously. She had also just failed an outpatient course of oral steroids, making further outpatient care an unreasonable option. Finally, she was in severe respiratory distress requiring non-invasive ventilation which requires close, inpatient monitoring during and after to watch for deterioration and the need for non-invasive ventilation (NIV) suggests a higher severity of illness and a higher risk of poor outcome (e.g., requiring invasive mechanical ventilation). Given failure of outpatient treatment, high risk historical features (prior intubation), and severe disease at presentation, an inpatient admission was needed for close monitoring and inpatient only treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Myo-pericarditis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned.

This is the case of a patient with no significant past medical history that presented to the hospital complaining of sharp chest pain for three days duration.  Upon arrival to the hospital the patient was tachycardic with a pulse of 108 and blood pressure (BP) 115/67. No abnormal findings were noted on physical exam. A 12 lead electrocardiogram revealed ST segment elevation in lead II and the anterior lateral precordial leads V3-V6.  High sensitivity troponin was markedly elevated (15,000 - 17,100). Serum C-reactive protein (CRP) was 71. The patient was admitted to the hospital for treatment of myo-pericarditis.  A computed tomography (CT) chest demonstrated no evidence of pulmonary embolism. Cardiac magnetic resonance imaging (MRI) demonstrated delayed gadolinium enhancement of the epicardium with a nodular pattern.  Left ventricular ejection fraction (LVEF) was 54% (percent).  The patient was monitored and discharged with instructions to avoid strenuous physical activity and follow up with cardiology.

Acute inpatient admission was medically necessary in this case.  This patient presented with chest pain, abnormal electrocardiogram and markedly elevated serum troponin levels. The patient's pretest probability of coronary artery disease was low (Reference 1). Despite this, clinical presentation and initial evaluation supported a diagnosis of acute myocarditis. The patient was appropriately admitted for diagnostic testing and treatment.  Cardiac MRI revealed delayed myocardial enhancement consistent with myo-pericarditis.  Following resolution of chest pain the patient was discharged with cardiology follow up.

Patients with myocarditis require observation and treatment. Up to 9% of patients presenting with myocarditis can develop fulminant myocarditis resulting in lethal ventricular arrhythmia and cardiogenic shock (Reference 2). The European Society of Cardiology (ESC) guidelines recommend hospital admission for patients presenting with myocarditis and note that 12-25% of patients may acutely deteriorate, develop progressive heart failure and die (Reference 3). In conclusion, acute inpatient admission was medically necessary.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pain of the muscles of the left anterior thigh
Treatment: MRI Lumbar Spine without contrast
The insurer denied MRI Lumbar Spine without contrast.
The determination is upheld.

This is a male patient who is requesting coverage of a magnetic resonance imaging (MRI) scan of the lumbar spine. He presented for an evaluation of needle-like burning pain of the muscles of the left anterior thigh. The musculoskeletal and neurologic exams were normal. Lumbar exercises were recommended. There are no further medical records or communications from his providers found in the materials supplied for review. At issue is the medical necessity of MRI Lumbar Spine without contrast.
The requested health service/treatment of MRI Lumbar Spine without contrast was not medically necessary for this patient. Based on a review of the information provided, the requested MRI of the lumbar spine was not medically necessary. There is no provider documentation indicating that the patient tried and failed a 6-week course of medication, physical therapy, and activity modification. There were no physical exam findings raising the suspicion of a serious or life-threatening cause of the patient's symptoms. Therefore, based on the standard of care, as well as the peer reviewed literature cited in the references, MRI of the lumbar spine was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left Knee Multiple Myeloma

Treatment: Current procedural terminology (CPT) code 13160/LT [secondary closure of surgical wound or dehiscence, extensive or complicated] and CPT code 20245/51/LT [biopsy, bone, open; deep (e.g., humeral shaft, ischium, femoral shaft)]

The insurer denied coverage for current procedural terminology (CPT) code 13160/LT [secondary closure of surgical wound or dehiscence, extensive or complicated] and CPT code 20245/51/LT [biopsy, bone, open; deep (e.g., humeral shaft, ischium, femoral shaft)]

The denial is upheld  

The patient has a history of a pathological fracture of the left femur and multiple myeloma of the left femur.  At the time of the procedure, there was suspicion that the patient's cancer was relapsing.  The medical records (including operative report) show the procedure completed was removal of hardware and biopsy. No arthrotomy was performed. Nevertheless, charges were submitted for a biopsy which was necessary and appropriate. It would be important to define if recurrence of disease was present. The records showed presence of plasma cells. 

The biopsy charge should be submitted only once. It was submitted twice. 27331-51 as charged would be the only biopsy code applicable.

There were charges submitted for secondary closure. This service was not performed. A secondary closure is applicable when return to the operating room (OR) is necessary after a wound being left open. The records show the surgical incision and primary closure. There would be no extenuating circumstances to report a secondary closure. It should not be reimbursed. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for current procedural terminology (CPT) code 13160/LT [secondary closure of surgical wound or dehiscence, extensive or complicated] and CPT code 20245/51/LT [biopsy, bone, open; deep (e.g., humeral shaft, ischium, femoral shaft)] is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Obstructive Pulmonary Disease

Treatment: Skilled Nursing Facility Subacute Rehabilitation Level 1

The insurer denied coverage for Skilled Nursing Facility Subacute Rehabilitation Level 1.

The denial is upheld.

This is a patient with chronic medical problems including chronic obstructive pulmonary disease (COPD) (2-liter portable oxygen), hypertension and anxiety.  The patient presented to the hospital with shortness of breath and chest pain.  The patient was subsequently admitted to an subacute nursing facility (SNF) for subacute rehabilitation.  Under review is the medical necessity for SNF subacute rehabilitation.

According to the Final Adverse Determination Denial Notice letter, the insurer denied the SNF stay.  The submitted SNF records do not support that the patient continued to be an appropriate candidate for the SNF subacute rehabilitation level of care during the time period under review (1, 2, 3).   The physical therapy records indicate the patient required only supervision for bed mobility, transfers and ambulating.  According to the occupational therapy notes, the patient required only supervision to setup assistance for activities of daily living, including toilet transfer/hygiene, bathing and upper body dressing.  Treatment could have been safely provided at a lower level of care.  In addition, there were no acute medical or complicated nursing issues that warranted SNF subacute rehabilitation level of care for the time period under review.  

The healthcare plan acted reasonably, with sound medical judgment and 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, as well as within a reasonable degree of medical certainty, skilled nursing facility subacute rehabilitation was not medically necessary.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Skilled Nursing Facility Subacute Rehabilitation Level 1 services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary Tract Infection (UTI)
Treatment: Inpatient admission
The insurer denied Inpatient admission.
The denial is upheld.

The patient is an adult male. He presented to the Emergency Department (ED) for an emergency evaluation of worsening abdominal pain with associated acute fever. His past medical history is significant for alcohol abuse, inguinal hernia, urinary tract infection (UTI), and morbid obesity (body mass index 41.14). The patient's exam suggested abdominal distension and left lower quadrant abdominal tenderness. US (ultrasound) showed medical renal disease. Labs revealed a creatinine of 1.39 and WBC (white blood count) of 12.1. He was admitted for AKI (acute kidney injury) and UTI (urinary tract infection). He was admitted for observation and managed with antibiotics, IV (intravenous) fluids and nephrology consultation. He was discharged on day (number) #5. The medical necessity of the inpatient stay is under review.

The inpatient admission was not medically necessary.

The majority of patients who present with AKI (acute kidney injury) and UTI (urinary tract infection) can be discharged within 24 to 48 hours of the presentation. This patient did not present with hemodynamic instability, renal failure, severe obstruction, sepsis or unstable medical problems requiring inpatient management. The hospital course was essentially normal without any significant complications or major issues with pain control. There was no procedure performed. The information provided and the patient's clinical status does not suggest the need for acute inpatient care. Observation status for this patient's clinical presentation and hospital course was the safe, effective, generally accepted standard and the most appropriate treatment option. Admission status may be changed anytime during observation if the patient requires continuing services and monitoring, and if the patient's condition is severe enough to require inpatient treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fibromyalgia, Osteoarthritis
Treatment:  Consumer Directed Personal Assistance Services (CDPAS) 70 hours per week
The insurer denied:  Consumer Directed Personal Assistance Services (CDPAS) 70 hours per week.
The determination is overturned.

This is a female patient with a medical history notable for fibromyalgia, chronic obstructive pulmonary disease (COPD), and osteoarthritis. The patient is approved for 5 hours per day, 7 days per week for a total of 35 hours per week consumer directed personal assistant services. The patient and her care team requested an increase to 10 hours per day, 7 days per week for a total of 70 hours per week and this request was denied by the health plan.
A Uniform Assessment System (UAS) was completed. The assessment was conducted via video teleconference. The patient lives alone in an apartment. As previously noted, she had a fall in her home which resulted in a hospitalization and subsequent discharge to a skilled nursing facility (where she is currently residing). The patient is hoping to return home if adequate help can be put in place. The patient was alert and oriented with periods of forgetfulness. Her recall was two out of five on a short-term memory test. She is able to make her needs known. For her instrumental activities of daily living, the patient requires total dependence for meal preparation, housework, finances, stairs, and shopping. She requires maximal assistance for medications and transportation. For her activities of daily living, the patient requires maximal assistance for bathing, dressing lower body, walking, locomotion, toilet transfer, and toilet use. She requires extensive assistance for hygiene, dressing upper body, and bed mobility. She requires weight bearing and balance support to toilet and for transfers. She is frequently incontinent of urine and is continent of stool. She uses 3 to 4 diapers daily which require changing by an assistant due to weakness. She had no fall in the previous 30 days. There was no pressure ulcer present.
A community advocacy report was provided on behalf of the patient. This report was reviewed in detail as part of this case review. At issue is the medical necessity of Consumer Directed Personal Assistance Services (CDPAS) 70 hours per week. 

The requested health service of Consumer Directed Personal Assistance Services (CDPAS) 70 hours per week is medically necessary for this patient.
The patient requires extensive or maximal assistance with essentially all activities of daily living. She is unable to toilet, transfer, ambulate, or change incontinence care products without assistance. Her personal care needs are expected to be continuous and unscheduled throughout the day. 5 hours a day would not be sufficient for the patient. She will need assistance during mealtimes, with toileting, and after episodes of incontinence. Therefore, the requested increase to 10 hours per day, for a total of 70 hours per week is medically necessary for the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: alcohol withdrawal
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is overturned. 

This case involves a man with alcohol use disorder, who was admitted to the hospital after a witnessed seizure with associated tongue biting and urinary incontinence. The patient drinks 1.5 bottles of bourbon daily and has experienced previous seizure events when abstaining from alcohol. Temperature was normal, pulse rate of 66, and blood pressure 113/69 on assessment. The exam was unremarkable. Laboratory studies showed mild leukocytosis of 11.7, with hemoglobin 12.6, creatinine 1.4, and sodium 133. The patient was admitted to the hospital with concern for an alcohol withdrawal seizure. 

The inpatient hospital stay was medically necessary. The patient has an acute seizure, presumed due to alcohol withdrawal. He was placed on seizure precautions and treated with antiepileptics and benzodiazepines. Alcohol withdrawal seizure is a life-threatening condition that can recur, leading to status epilepticus and death.
More importantly, the patient has a new onset of systolic heart failure with an ejection fraction of 20-25%, with hypotension. Serial vital signs show low systolic blood pressure 82, with concurrent tachycardia of 100 beats per minute (bpm). The patient was in the process of being evaluated for ischemic cardiomyopathy when he left Against Medical Advice. Hemodynamic instability, in the setting of acute heart failure with concurrent acute kidney injury, is our clinical indication for inpatient admission.