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

Diagnosis: Cardiac/Circulatory Problems/Heart Attack
Treatment: Inpatient Hospital
The health plan denied the requested inpatient stay as not medically necessary. 
The health plan's determination is overturned.

This case involves a female with a history of hypertension (HTN), diabetes mellitus (DM), multi-vessel coronary artery disease (CAD), and chronic heart failure who presented to the emergency department (ED) for evaluation of chest pain and new onset of atrial fibrillation with a rapid ventricular response (RVR). She was hypoxic to 88% (percent). Initial electrocardiogram (ECG) showed anterior ST elevation, cardiac troponin was high and up-trended. The patient was admitted under the inpatient level of care to the coronary care unit (CCU) for evaluation and management of a non-ST elevation myocardial infarction (NSTEMI). A coronary angiogram was performed the following day showing severe 3 vessel CAD including left main disease, and a left ventricular ejection fraction (LVEF) of 30%. Due to hemodynamic compromise, an intra-aortic balloon pump (IABP) was placed, and patient was urgently transferred to another medical center for high-risk percutaneous coronary intervention (PCI) with an Impella device support.
At issue is the medical necessity for the inpatient stay.

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

Yes, inpatient level of care was medically necessary and in the best interest for the safety of this patient. Inpatient level of care is considered standard of care in this case and is supported by peer reviewed medical literature and expert consensus guidelines on NSTEMI syndromes [1-3].
This patient presented with signs and symptoms of acute coronary syndrome (ACS) secondary to NSTEMI with associated acute hypoxic respiratory failure and new onset atrial fibrillation with rapid ventricular response needing CCU level of care. She was subsequently determined to have severe multivessel CAD needing urgent high-risk revascularization with hemodynamic support device requiring transfer to another medical facility. This patient's high-risk presentation of ACS associated with significantly increased risk of short-term mortality, respiratory failure and cardiogenic shock, inpatient level of care (CCU level) was medically necessary and in the best interest for the safety of this patient. 
I recommend that the health plan's determination be overturned, and coverage be granted for inpatient level of care, given this patient presented with acute coronary syndrome, NSTEMI, acute hypoxic respiratory failure due to severe multi-vessel CAD and systolic heart failure.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Home Health Care. 
The insurer denied 40 hours of consumer directed personal assistance service. 
The denial is upheld.

The patient is a female with past medical history significant for hypertension, hyperlipidemia, psoriasis and chronic pain mainly located in her lower back and feet. The patient is currently approved for 23 hours a week consumer directed personal assistance services. The subject under review is the medical necessity for 40 hours per week.

The health plan's determination is upheld.

The requested 40 hours a week of consumer directed personal assistance services is not medically necessary for this patient.
The patient requested the increased hours stating that it is very hard to walk or stand for more than 10 minutes due to foot spurs on both feet. The patient indicates she is becoming forgetful and loses her balance causing her to get dizzy. She is not able to bathe herself or do laundry or clean around the house because she cannot bend, go down and up or stand for too long. She indicates she also has severe back pain.
Services were denied by the health plan stating that the patient does not meet criteria. Uniform Assessment System (UAS) state of NY assessment showed that the patient needed help with meals, housekeeping, laundry, shopping and bathing. The patient needs limited help with toileting, dressing and walking. It indicates that the patient can feed herself and perform personal hygiene. She can turn herself in bed. She has a cane to move about in her environment. She has intermittent incontinence. Currently the patient lives with her daughter.
The tasking tool noted 4 days a week of services for a total of 18 hours a week of services was needed.
The increase in services is not necessary. She requires extensive assistance for many Instrumental activities of daily living (IADLs). She is independent or needs limited assistance for most activities of daily living (ADLs). The patient is able to walk with the assistance of a cane.
The patient is currently allotted is 23 hours a week services. The most recent nursing assessment along with physician assessment and personal statement do not support the medical necessity for additional requested services beyond 23 hours a week. Additional services are not medically necessary. With the patient's complaint of foot pain and back pain it does not specifically necessitate additional services beyond 23 hours a week. There were no specific functional needs that could not be addressed or that were requested by the patient that could not be performed in the 23 hours allocated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gynecological. 
Treatment: Infertility Treatment. 
The insurer denied infertility services (IVF cycle).  
The denial is upheld.

The patient is a female gravida (G) 0 who has no history of infertility and presents wanting to pursue in vitro fertilization (IVF) with preimplantation genetic testing (PGT-M) to screen for breast cancer (BRCA1) and BRCA2 mutations. These mutations are autosomal dominant and carried by her partner. Per the records, spouse has a normal semen analysis. Anti-Mullerian hormone (AMH) 2.09 with antral follicle count (AFC) 10-14.
She has undergone 2 cycles of IVF: # (number) 1 resulted in a single embryo that was a carrier for BRCA 1. #2 resulted in two embryos that each were carriers for one of the BRCA genes.
The couple does not wish to conceive naturally as they do not want to conceive a child that is positive for either of the BRCA genes that her partner is positive for. They have family members that have suffered through cancer diagnosis and treatment and wish to avoid this if possible. The subject under review is the medical necessity for an IVF cycle.

The health plan's determination is upheld.

An IVF cycle is not medically necessary for this patient. This patient does not meet criteria for either PGT-M or IVF based on her history Therefore, IVF is not medically necessary.
The patient does not have a diagnosis of infertility and therefore based on this there is no medical necessity for this treatment. The use of PGT-M to diagnose which embryos are carriers for recessive and autosomal mutations is well documented. The presence/carrier status of BRCA genes does not guarantee with certainty that the carrier will get cancer but significantly increases the risk of developing such cancers. There are many people with these genes that do not ever get diagnosed with cancer. Unlike in cases of Huntington's disease where the carrier is 100% (percent) guaranteed to develop the disease in later life, carriers for BRCA may never develop cancer for reasons not completely understood. Therefore, the patient does not meet the requirements for PGT-M.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Spinal stenosis, osteoporosis status compression fractures and right eye macular degeneration

Treatment increase in Personal Care Aide (PCA) Level 2 hours to 12 hours per day, 7 days per week (split shift)- for a total of 168 hours per week 

The insurer denied coverage for increase in PCA Level 2 hours to 12 hours per day, 7 days per week (split shift)- for a total of 168

The denial is modified

This is a patient with spinal stenosis, osteoporosis status compression fractures and right eye macular degeneration. She lives alone in a 4-bedroom house.
The patient requires extensive assistance for activities of daily including bathing, lower body dressing and toilet use. She requires limited assistance for personal hygiene, upper body dressing and walking in home. Cognition is reported as moderately impaired.  She is frequently incontinent of bladder and infrequently incontinent of bowel.  

The office visit notes from the patient primary care physician were also reviewed. The patient was seen by her primary care physician, feeling well without complaint. Musculoskeletal Review of Systems was documented as negative for arthralgias, myalgias and neck stiffness. Psychiatric/Behavioral Review of Systems was documented as negative for confusion and decreased concentration. She was in no acute distress and described as alert and oriented to person, place, and time. There were no focal (neurological) deficits present.   

Review of the Uniform Assessment System (UAS) combined with primary care physician office visit notes do not support cognitive and functional impairments that support the requested PCA level 2 services- a total of 168 hours per week. However, the records do support an overall decline; particularly her cognitive status and to a lesser extent her functional status. PCA Services Level 2; of 12 hours per day, 7 days per week for a total of 84 hours per week is medically necessary. The increased PCA services will allow the patient to continue living safely at home.   

The health care acted reasonably in part.

The requested PCA level 2 services, 12 hours per day- 7 days a week; 12 hours per day- 7 days a week (split shift) - for a total of 168 hours per week, is not considered medically necessary for this patient. However, increasing PCA services to level 2; 12 hours per day, 7 days per week for a total of 84 hours per week is medically necessary.  

The insurer's denial of coverage for personal care aide (PCA) level 2 services, 12 hours per day- 7 days a week; 12 hours per day- 7 days a week (split shift)- a total of 168 hours per week is modified as noted above.
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 with a history of obesity, breast cancer, bipolar disorder, GERD (gastroesophageal reflux disease), anemia, and a history of pulmonary embolisms. She was admitted for elective total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and cystoscopy. 

The procedure was uncomplicated. The patient was in PACU (post anesthesia care unit) and required IV (intravenous) Dilaudid for pain. She was admitted overnight where she received Tylenol, IV (intravenous) Toradol. Her vitals were stable. On day two, she was ambulating, voiding, tolerating diet. Her pain was well controlled. She was discharged home with follow up. 

Coverage for the inpatient hospital stay was denied by the health plan as not medically necessary. This is being appealed.

No, the Inpatient admission was not medically necessary. 

In review of the medical record, the patient underwent an uncomplicated procedure. Despite having a high risk assessment for anesthesia, surgically things went well. She had some post-operative pain, but stable vital signs. Although an overnight stay was needed to manage her pain and continued monitoring after surgery, an inpatient stay was not needed. The same care could have been provided at a lower level of care, such as observation. 

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

The health plan reasonably denied the inpatient stay, as it was not necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer
Treatment: Proton Beam Therapy (77370,77387,77470,77520)
The insurer denied the Proton Beam Therapy (77370,77387,77470,77520)
The denial is overturned

The patient is a female with history of stage IV breast cancer with leptomeningeal disease.  The request is for approval of proton beam radiation therapy.

Yes, the requested proton beam therapy is medically necessary.
Proton radiation is standard of care and required in the patient's setting, as it is proven to minimize the risk for high grade toxicity as compared to photon-based radiotherapy. Proton radiation will significantly minimize the patient's bone marrow, heart, esophagus, stomach, bowel, thyroid, oral cavity, laryngeal, and pharyngeal exposure. There are numerous high quality prospective clinical outcomes reported in the peer reviewed medical literature that support the role of proton radiation therapy for management of the patient's life-threatening malignancy. Proton radiation therapy is widely utilized throughout the oncology community for similar patients in the patient's setting.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient
Proton radiation should be approved and it is medically necessary as previously discussed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Severe Constipation.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male. He has severe chronic constipation and has been tried on multiple medications including Miralax, senna, motegrity and dulcolax. His doctor requested inpatient care for two to three days for bowel cleanout and colon motility study.

Day 1: NG (nasogastric) tube cleanout with GoLytely.

No, the requested in hospital care is not medically necessary.
This patient was evaluated by a pediatric gastroenterologist, who recommended bowel cleanout 1-2 days prior to colonic motility study (1-2). Since the patient would only stay in the hospital for bowel cleanout and recording, and there is no documentation of any acute treatment or intervention, the requested services could be provided at the observational level of care, not as In Hospital Care stay. Thus, the requested In Hospital Care is not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
This patient has severe constipation and has failed multiple medications. Thus colonic manometry study is indicated (1-2). The plan approved the requested colonic manometry study. The patient would be in the hospital for 2-3 days to have bowel cleanout by NG (nasogastric) tube and then manometry study. Since the patient would not require any other acute treatment or intervention, the care can be achieved at observational level of care.
Day 2: NG (nasogastric) tube cleanout with GoLytely
Day 3: Colon motility study and then discharge home.

The health plan's reason for prior denial of coverage was that the requested care may be provided at an observation level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Infectious Disease. 
Treatment: Inpatient Hospital. 
The insurer denied Inpatient Stay. 
The denial is overturned. 

The patient is a female infant, born at gestation that presented to the emergency department (ED) with fever to 101 Fahrenheit (F), sleepiness, and decreased feeding. The mother had been diagnosed with coronavirus 2019 (Covid-19) the week prior and recently streptococcal (strep) for which she was taking amoxicillin. The infant's vital signs included a temperature at 38.4, heart rate was 176, and respiratory rate was 38. Examination was significant for sleepy and dehydrated appearance, moist oral mucosa, clear lungs with no retractions, and prolonged capillary refill. Full septic work-up including lumbar puncture was planned followed by ampicillin and ceftazidime and admission. 
Her laboratory evaluation was unremarkable except for rapid testing positive for Covid-19. Blood, urine, and spinal fluid cultures were all pending. In addition to the antibiotics, she was treated with a normal saline bolus and Tylenol. She was admitted for further work-up. Admitting diagnosis was acute febrile illness in a neonate rule out sepsis, and Covid-19 positive. Admission orders included Tylenol as needed, follow up cultures, continue antibiotics pending culture results, and consult Infectious Diseases. She did well, with improved feeding, improved fever curve, and negative cultures. She was deemed stable for discharge home with close outpatient follow-up.
At issue is the medical necessity of the Inpatient Stay.

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

The requested health service/treatment of Inpatient Stay was medically necessary for this patient.
The requested acute inpatient admission was medically necessary for this neonatal patient admitted with fever and possible sepsis. Acute febrile illnesses are common in infants and young children, and represent the gamut of pathology, from self-limited viral infections including Covid-19 to serious bacterial infections such as pneumonia, pyelonephritis, and meningitis. Neonates less than 28 days of life represent a special group of patients because of difficulties assessing behavioral state, decreased immunologic function, and a higher frequency of serious bacterial infections in this age group. Neonates that present with fever require a full sepsis evaluation including blood, urine, and cerebral spinal fluid (CSF) cultures, followed by hospitalization with or without antibiotics pending culture results. This infant presented with a high fever and minor congestion, sleepiness and decreased oral intake. A full septic work-up was appropriately completed and the baby was treated with antibiotics pending culture results. While the baby was overall hemodynamically stable with no evidence of impending septic shock, the level of care necessary in this instance was most consistent with the acute inpatient level of care. 
Therefore, the requested health service/treatment of Inpatient Stay was medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

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

The patient a male. He sustained a gunshot wound to his left posterior thigh. He was evaluated in the ED (emergency department). His X-ray showed an impacted fracture to the distal femoral shaft with fragmentation. He underwent irrigation and debridement to the wound.

No, the Inpatient admission was not medically necessary.
The records show the patient's diagnosis was established and managed in a timely and appropriate manner. There were no other conditions to require treatment. Surgery had been completed without problem. This type of procedure is not complex or extensive. A CT (computed tomography) scan was recommended and completed. There was no change in the overall plan.

The young man was able to tolerate oral pain medications. His vital signs were stable. There was no infection nor bleeding. He was able to weight-bear with crutches. There were no extenuating circumstances to warrant inpatient admission.

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


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

The patient is a male with a past medical history remarkable for hypertension, and hyperlipidemia, who was presented for a dental abscess. The patient completed a course of Amoxicillin but reported increase in swelling, discomfort and decrease range of motion of the jaw. Review of system was negative for additional clinical symptoms. The patient was admitted for dental abscess. 

The requested inpatient hospital admission was not medically necessary. The care could have been safely rendered at a lower level of care for incision and drainage of a tooth abscess.
The patient was admitted for a dental abscess. Although the patient failed a course of outpatient antibiotics, full admission was not necessary since the patient had no systemic signs of infection (systemic inflammatory response syndrome (SIRS) or sepsis) and did not have comorbid conditions (such as immunocompromised status or diabetes) that would predict treatment failure. Observation would have been most appropriate for short-term antibiotics and incision and drainage.
Localized dental abscesses can be managed in an outpatient setting. Patients who require hospitalizations usually have evidence of systemic symptoms from infection spread regionally and haematogenously, causing serious disseminated infections, especially in patients who are medically compromised. In this case, the patient was not immunocompromised and did not have evidence of systemic infection.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Binge Eating Disorder

Treatment: 97803, medical nutrition therapy- 104 units

The insurer denied coverage for 97803, medical nutrition therapy- 104 units

The denial is overturned.

The patient has an eating disorder manifested by binge eating. A nutritional note states that her weight was 358 pounds. Various food groups were recommended by the nutritionist, and she has resumed physical activity. Attempts are being made to reduce emotional eating tendencies. She has been advised to eat healthier fats and to incorporate fruits and vegetables into her meals. The nutritionist has been following the American Association of Clinical Endocrinologists Obesity guidelines which include recommendations for meal plans, physical activity, and behavior modifications.

UpToDate has an article titled "Eating Disorders: Overview of prevention and treatment." The introduction states that binge eating disorder can be life threatening. Treatment of the eating disorder involves an interdisciplinary team that includes a mental health clinician, dietician, and a general medical clinician. The role of the dietician and nutritional support staff is to direct nutritional rehabilitation, discuss available dietary options, and provide nutritional education regarding changes in eating behaviors. The dietician along with the general medical clinician set appropriate weight goals.

This patient has morbid obesity with a weight of 358 pounds. She has a diagnosis of a binge eating disorder. The recommendation from UpToDate is that a nutritionist needs to be a part of the health care team. The health care plan did not act reasonably or in the best interest of the patient. Medical nutrition therapy 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 97803, medical nutrition therapy- 104 units is overturned. Medical Necessity is substantiated.