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

Diagnosis: Alzheimer's dementia.

Treatment CDPAS (Consumer Directed Personal Assistance Service) 24 hours a day, 7 days a week (live in).

The insurer denied coverage for CDPAS 24 hours a day, 7 days a week (live in).

The denial is overturned .

This is a female with chronic medical problems including Alzheimer's dementia with behavioral disturbance.  She lives alone in a 2-bedroom apartment.  She currently has 52 hours of Consumer Directed Personal Assistance Service (CDPAS) a week.  Under review is the medical necessity of CDPAS 24 hours a day, 7 days/week (live in).

The patient has moderate to severe cognitive deficits that according to her treating physician is "progressively worsening."   She also has multiple functional deficits which support the medical necessity of Directed Personal Assistance Service (CDPAS) to 24 hours a day, 7 days a week (live in).  According to the Uniform Assessment System (UAS) report, the patient is totally dependent for activities such as meal preparation, housework and shopping.  She requires extensive assistance for activities of daily living tasks such as bathing, personal hygiene and dressing.  She is bladder incontinent, and toileting also requires extensive assistance.  The patient reportedly "wakes up in the middle of the night confused, taking off pull-ups and pees/voids in random areas of the house."  The requested CDPAS 24 hours a day, 7 days a week (live in) will allow the patient to continue to safely live at home for a medical condition that is unfortunately progressive.   

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 Consumer Directed Personal Assistance Service (CDPAS) 24 hours a day, 7 days a week (live in) is medically necessary.

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 Consumer Directed Personal Assistance Service (CDPAS) 24 hours a day, 7 days a week (live in) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebral vascular accident (CVA) with hemiplegia, cognitive deficits, macular degeneration and rheumatoid arthritis.
Treatment: PCW (personal care worker) services for 7 days per week, 12 hours per day.

The insurer denied coverage for PCW services for 7 days per week, 12 hours per day.
The denial is overturned.

This patient has multiple medical problems including cerebral vascular accident (CVA) with hemiplegia, cognitive deficits, macular degeneration and rheumatoid arthritis.   Under review is the medical necessity of requested PCW services for 7 days per week, 12 hours/day.

According to the Uniform Assessment System (UAS) report, the patient requires maximal assistance to total dependence for meal preparation, housework and shopping.  Her condition has reportedly declined over the prior 90 days.  She also requires extensive to maximal assistance for activities of daily living tasks such as bathing, personal hygiene and dressing.  She is bladder incontinent, and toileting also requires extensive assistance.  The requested PCW services for 7 days per week, 12 hours/day, will allow the patient to continue to safely live at home in order to best manage her progressive functional decline.    

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

The insurer's denial of coverage for personal care worker (PCW) services for 7 days per week, 12 hours per day is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Amaurosis Fugax
Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.
The denial is overturned.

This is a patient with a history of hypertension, polycystic kidney disease, and gastric bypass surgery who presented to the emergency department (ED) with complaints of chest pain, loss of vision in the left eye for 15 minutes, and blurry vision. His blood pressure was 142/99 and body mass index (BMI) was 38.09. Computed tomography (CT) and magnetic resonance imaging (MRI) of the head were both negative. An electrocardiogram (EKG) showed sinus bradycardia. The patient was diagnosed with amaurosis fugax and admitted to the hospital. He was evaluated by Neurology and Ophthalmology. His blood pressure was monitored, and he received medication management. He was deemed stable for discharge to home with instructions for outpatient follow-up.

The health care plan did not act reasonably and with sound medical judgement and in the best interest of the patient.  The patient had transient vision loss with a strong cardiovascular risk factor history (including hypertension and history of gastric bypass).  If the presentation is within 72 hours, the American Heart Association recommends admission to a hospital setting based on age, blood pressure, clinical features and duration of symptoms (Easton).  The patient met these recommendations for admission. Thus, inpatient admission was reasonable.

The inpatient hospital admission was considered medically necessary for the patient.  The patient presented with transient vision loss within 72 hours.  Hospital admission is recommended in patients presenting with transient symptoms within 72 hours who meet certain high-risk criteria (Pula).  The patient's history put him at high-risk for life-threatening etiologies, including thromboembolic vascular etiologies, cardioembolic sources, ocular ischemic syndrome, giant cell arteritis, and hypercoagulable state.  Thus, the admission is considered medically necessary for this patient.

The insurer's denial of coverage for inpatient hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Peripheral vascular disease and claudication

Treatment: Inpatient hospital stay

The insurer denied coverage for inpatient hospital stay

The denial is overturned.

The patient is an adult male with a past medical history of hypertension, hyperlipidemia, gastroesophageal reflux disease, peripheral vascular disease, and claudication. The patient presented for a left femoral endarterectomy with iliac stent placement. The procedure was uncomplicated. The patient remained in the post-anesthesia care unit for 4 hours and then was transferred to the floor. On the day of discharge the patient's vitals were stable and he was tolerating a regular diet. 

While an isolated iliac stent procedure is an outpatient procedure, the combination of an open surgical femoral endarterectomy means it is not an outpatient surgery and this case needs at least one night of inpatient stay. This is well within the usual and customary care for this type of procedure.

Although the medical records given for this patient were very limited and there was no operative note from the surgeon of record available for review, it appears that the patient had a hybrid revascularization on the left lower extremity consisting of a femoral endarterectomy and iliac stents.  The inpatient hospital stay is considered medically necessary for this patient.

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

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

Diagnosis: Febrile seizure

Treatment: Inpatient hospital admission 

The insurer denied coverage for an inpatient hospital admission

The denial is upheld.

This case involves a child with a history of asthma and speech delay. The patient was admitted to the hospital with the diagnosis of febrile seizure. During the emergency department evaluation, the patient became progressively more alert and on reevaluation was fully alert and oriented. The patient was last seen in the emergency room over a year ago for simple febrile seizure and was discharged. The patient was admitted for management of first attack of febrile convulsion. Per the hospital record, as the patient had speech delay, he was more likely to have recurrence of seizures or complicated seizure and was admitted for further observation and management. The patient was discharged the following day.

The current literature indicates a patient may be admitted when there is evidence of a metabolic disorder persisting despite observation, recurrent seizure, increased intracranial pressure, new focal neurologic deficits, altered mental status that is severe and persistent or there is evidence of hemodynamic instability. According to the guidelines provided by the InterQual, the acuity of this case is considered to have required observation as a patient with a transient neurologic concern for febrile seizures. 

Within the documentation it was noted the patient presented for evaluation of a complex febrile seizure. However, the submitted documentation does not detail the patient had a trial and failure of care at a lower level such as observation. Upon arrival the patient had stopped seizing and he did not require any escalated intervention. No events requiring intervention were captured or treated during that stay. The patient was described as interactive; he was admitted at his baseline, and he was discharged on the following day. 

The requested inpatient admission would not be the most appropriate level of care and therefore, the prior denial remains upheld.

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

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

Diagnosis: Gender dysphoria.
Treatment: Bilateral Breast Augmentation with Implant (19325).
The insurer denied the Bilateral Breast Augmentation with Implant (19325).
The denial is overturned.

This is an individual assigned female at birth who identifies as gender queer and desires revision of gender affirming chest reconstruction. The patient underwent double incision with free nipple graft. They had the surgery elsewhere with another surgeon. This was the only option offered to them at the time. They identify as nonbinary, and they are completely flat, masculinized chest triggers gender dysphoria. This has been supported with a letter from their therapist. The surgeon is requesting the option of placing a small breast implant to give the patient a small breast mound which would be better aligned with their gender identity. Per the surgeon: "This patient is not transitioning. They have always identified as nonbinary, and it is my clinical impression that they were offered the wrong surgery at the time of their chest reconstruction. If this patient was seen in my clinic today, they would be offered inverted T mastectomy, which leaves behind a small amount of breast tissue. This procedure is often chosen in my practice by nonbinary patients who are seeking to maintain a small breast mound, and to achieve a chest that is in line with their gender identity. As I can no longer offer this type of surgery to [the patient], the best alternative would be placement of a very small breast implant."

Yes, the proposed treatment is medically necessary.
The treatment is medically necessary. This patient has already had top surgery but has had an unfavorable outcome (chest is overly masculinized for a non-binary individual).  Two therapists have submitted documentation indicating that the patient's gender dysphoria has worsened due to the poor outcome from the previous gender affirming surgery. Per the surgeon, an older technique that is now no longer used for the management of non-binary chest was used on this patient. In conclusion, this patient (per the surgeon and two mental health professionals) requires surgical treatment to better manage the medical diagnosis of gender dysphoria.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
As noted above, the health plan has not acted with sound medical judgment.  Per the patient's medical providers, this treatment is essential to the management of the patient's diagnosis of gender dysphoria.
Appeal type: Medical necessity
Decision: Upheld

Respiratory
Inpatient Hospital

Diagnosis: Pneumonia
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

This patient is a male with history of human immunodeficiency virus (HIV) and hyperlipidemia who presented to the hospital with a complaint of chest pain and productive cough. Vital signs were temp 101.0 F, pulse 94, respirations 28, blood pressure (BP) 105/77 and pulse oximetry 97% on room air. Physical examination revealed course bilateral breath sounds and abdominal distension from obesity. Abnormal laboratory values included white blood cell count (WBC) 13.84. Electrocardiogram (EKG) showed a normal sinus rhythm. Computed tomography (CT) Chest showed pulmonary consolidation in the medical left upper lobe compatible with pneumonia. The patient was admitted and treated with intravenous antibiotics and fluids. 

The inpatient hospital stay was not medically necessary.
This patient presented to the hospital with chest pain and cough. He was tachypneic with normal pulse oximetry. Imaging showed pneumonia. There was no evidence of hemodynamic instability. There was no evidence of altered mental status. There was no evidence of hypoxemia. There was no evidence of an immunocompromised state. There was no evidence of failure of outpatient therapy. The CURB-65 score was 0 (low risk). The Pneumonia Severity Index (PSI) score was 60 (risk class II with 0.6-0.9% mortality). There were no clinical needs that would have required an inpatient hospital stay.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Orthopedic/Musculoskeletal/other/Spinal Stenosis
Treatment: Inpatient Hospital
The health plan denied the requested inpatient hospital stay as not medically necessary. 
The health plan's determination is overturned, in part.

This is a male with a history of lumbar stenosis. He underwent a lumbar laminectomy L2-3 and L4-5. There were no complications noted on the operative note, specifically no dural tear. The patient ambulated 80 feet unassisted.  The hemovac was removed. The patient was discharged to home. 
At issue is the medical necessity of the inpatient stay.

The health plan's determination of medical necessity is overturned, in part. 

The inpatient stay was medically necessary, in part. The patient was ambulating well unassisted There were no perioperative medical or surgical issues documented. The patient had a hemovac drain that was removed, and it was medically necessary for the patient to be inpatient until this was removed.  The inpatient stay was medically necessary, in part.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Weakness. 
Treatment: Inpatient Admission. 

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

The patient is a woman. She was admitted for weakness following a bug bite. She presented with proximal weakness and had fallen. She was unable to ambulate. 

The patient's CK (creatine kinase) was mildly elevated, and potassium was low. She was treated with IV (intravenous) fluids as well as repletion. She was also evaluated by PT (physical therapy), who recommended outpatient PT (physical therapy). She was discharged the next day. 

No, the Inpatient admission was not medically necessary. 

The patient could have been treated on an observation status, and switched to inpatient status if indicated. She did have laboratory abnormalities and this was able to be treated. There was concern for rhabdomyolysis, however her CK (creatine kinase) was in the 300-400 range, which is not considered rhabdomyolysis, which is an indication for admission for weakness. 

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

The patient could have been monitored on an observation basis and switched to an inpatient basis only if indicated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertensive Emergency.

Treatment inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.

The denial is overturned.

This is the case of a female that was sent to the hospital for treatment of poorly controlled hypertension and hypertensive emergency. Past medical history was significant for chronic kidney disease, hypertension, and stroke. Upon arrival to the hospital blood pressure (BP) was 259/140mmHg (millimeters of mercury). Physical examination was within normal limits. A 12-lead electrocardiogram (EKG) revealed normal sinus rhythm with left ventricular hypertrophy and T (Interval on EKG) wave inversions in precordial leads V3-V6 (leads 3-6). Serum troponin was not elevated (high sensitivity 11.2ng/L (nanogram per liter)) serum creatinine was 1.67mg/dl (milligram per deciliter) and toxicology screen was negative. Following treatment with intravenous (IV) labetalol, repeat blood pressure remained markedly elevated 253/124 mmHg. The patient was admitted to the hospital for observation and treatment. Computed tomography (CT) scan of the chest was performed and was unrevealing. The patient required treatment with two IV medications (labetalol and hydralazine) over several days in order to achieve adequate blood pressure control. She was ultimately discharged home with follow up. 

Hypertensive emergency is defined as BP>180/120 with target organ damage (1). In this patient, precordial T wave abnormalities and acute on chronic renal insufficiency were noted. The goals of treatment for hypertensive emergency are to minimize progressive or additional target organ damage while preventing the consequences of rapid BP correction (2). Given this patient's failure to respond to initial medical therapy, admission to the hospital for aggressive blood pressure management was necessary. In fact, American Heart Association guidelines recommend admission to the intensive care unit (ICU) for management of hypertensive emergencies (1). In conclusion, this patient should have been managed at a higher level of care. Inpatient admission was medically necessary.

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 the inpatient hospital admission overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 
The insurer denied Inpatient Stay for medical necessity. 
The denial was overturned. 

This is a female patient, with a past medical history significant for multiple sclerosis. She presented to the emergency department (ED) a week prior with acute gastrointestinal (GI) symptoms and was diagnosed with cholelithiasis in the setting of a magnetic resonance cholangiopancreatography (MRCP) finding of pancreatic divisum and branch duct intraductal papillary mucinous neoplasm (IPMN). She was advised to follow up outpatient with surgery. She presented with recurrent abdominal pain in the epigastric region and right upper quadrant (RUQ) associated with nausea and decreased oral intake.
Her labs on admission revealed nonobstructive transaminitis, ultrasound significant for gallstones but no evidence of cholecystitis. The patient was admitted to the inpatient floor and received intravenous (IV) fluids, anti-emetics, and analgesics. Surgical consultation recommended against surgical intervention but recommended serial laboratory monitoring during this hospitalization and repeat MRCP that the patient refused. She was advised to follow up as an outpatient for a cholecystectomy.
At issue is the medical necessity of Inpatient Stay.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of Inpatient Stay is medically necessary for this patient.
This is a female with recently diagnosed pancreatic divisum and branched duct IPMN, who presented with abdominal pain (RUQ and epigastric pain), nausea, and decreased appetite in the setting of nonobstructive transaminitis, and ultrasound findings suggestive of cholelithiasis/choledocholithiasis. The patient had risk factors for Hepatobiliary dysfunction due to gender, age, recent diagnosis of pancreatic divisum, and IPMN. Secondly, this is her second admission for recurrent abdominal pain, and her clinical presentation required IV fluids, IV analgesic, IV anti-emetics, and surgical consultation. Surgery argued against surgical intervention but recommended serial laboratory monitoring and liver function tests. This detailed inpatient care of IV analgesics, IV anti-emetics, IV fluid, serial labs, and surgical consultation for prompt diagnostic workup and acute management of her GI symptoms including recurrent abdominal pain, nausea and abnormal liver function test (LFT)'s, could not be prudently provided as an outpatient level of care for this patient. She had risk factors for gallbladder disease including gallstone pancreatitis/cholecystitis/choledocholithiasis which can cause a life threatening intrabdominal infection leading to sepsis related mortality.
Therefore, the requested health service/treatment of Inpatient Stay was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis.
Treatment: Otezla 30 milligrams (mg).

The insurer denied coverage for Otezla 30 milligrams.
The denial is overturned.

The patient is a female with a diagnosis of psoriasis. The patient has failed topical steroids (ultravate) and Vitamin D analogues (Calcipotriene). The patient has been successfully treated with control of her psoriasis with Otezla 30 mg twice a day (bid). The physician is requesting continuation of therapy with Otezla for treatment of the patients' psoriasis.  

The patient has a documented diagnosis of psoriasis that is moderate-severe in affected area. The patient has failed appropriate topical steroid and non-steroidal treatment options. Although other medications may provide relief of her psoriasis symptoms, the patient has been successfully treated with Otezla with excellent clinical result and no documented adverse events. As such, the continuation of therapy for this patient would be medically appropriate. The decision is reversed and the use of Otezla to treat the patient's psoriasis is approved under the medical supervision of the treating physician.

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 Otezla 30 milligrams is overturned. Medical Necessity is substantiated.