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

Diagnosis: chronic leukemia, diabetes type 2, morbid obesity, cerebral vascular accident (CVA)

Treatment: Personal Care Services (PCS) 24 hours a day, 7 days a week, (split-shift) for a total of 168 hours per week

The insurer denied coverage for Personal Care Services (PCS) 24 hours a day, 7 days a week, (split-shift) for a total of 168 hours per week

The denial is overturned


This is an elderly female with diagnoses of chronic leukemia, diabetes type 2, morbid obesity, cerebral vascular accident (CVA), edema, spinal stenosis, hypertension, hypothyroidism, arthritis and severe hearing loss.  The patient also has chronic leg pain and several other chronic health conditions. The patient lives alone in an apartment with family support.  The patient was noted as alert and oriented to person, place and time but is forgetful.  She can direct her care, but her son directs major decisions about her care. The patient ambulates with a walker or wheelchair and uses a personal emergency response system. The patient needs help with bathing, grooming, dressing, eating, bathroom and toileting. The patient is at risk for skin breakdown and uses a gel mattress to help repositioning and reduce pressure points. She needs Instrumental Activities of Daily Living (IADL) assistance with meal preparation, housekeeping, shopping and laundry.  

The patient also requires assistance for all Activities of daily living (ADLs), transfer, mobility locomotion, bathroom/ toileting, night incontinence of bowel and bladder, medication and is a fall risk. Considering the patient's age, diagnoses and functional deficits, the patient requires continuous care.  

Per the NYS Department of Health: Office of Health Insurance Programs; Personal Care Guidelines, the scope of the Personal Care Services (PCS) benefit includes continuous personal care services, which means the provision of uninterrupted care, by more than one person, for more than 16 hours per day for a patient who, because of the patient s medical condition and disabilities, requires total assistance with toileting, walking, transferring or feeding at times that cannot be predicted. Based on the patient's assessments, and medical documentation and family member letter, the patient's level of functioning, diagnoses and functional deficits and continuous maximum assisted needs, the approved 91 hours per week / 7 days a week is not sufficient to meet the assisted care needs and safety. 

The clinical records support night care needs based on total assistance needs or toileting, walking, transferring and multiple night incontinence episodes. The documentation does support unpredictable, frequent nighttime needs and that prevents a care aide attaining at least 5 hours of sleep. 

Based on the above, the insurer's denial must be overturned. 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 Personal Care Services (PCS) 24 hours a day, 7 days a week, (split-shift) for a total of 168 hours per week services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: rectal bleeding

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

This is an adult patient with a history of cirrhosis and presented with rectal bleeding. The patient had a history of previous colon resection for a large hepatic flexure mass. There was a history of chronic anemia, and the patient has received multiple previous transfusions. At presentation he was afebrile, and the vital signs were stable. The abdominal examination was benign. The hemoglobin (Hgb) was 8.3 which was similar to his baseline hemoglobin and there was pancytopenia. The international normalized ratio (INR) was 1.47. Clinically it was determined at presentation, that he did not need a colonoscopy, and he was referred for outpatient follow up. One unit of packed red blood cells (PRBC) was given. There was no further bleeding seen. 

Medical necessity was determined based on Milliman Care Guideline (MCG) M-182 for Lower Gastrointestinal Bleeding. Clinical indications for admission include hemodynamic instability, ongoing active bleeding, failure to control bleeding after a colonoscopy, severe coagulopathy that is not reversible, severe anemia with signs of cardiac ischemia, and peritoneal signs. The patient did not have these conditions. 

This patient has cirrhosis and chronic anemia. He was not actively bleeding and did not need an urgent colonoscopy. The transfusion could have been given with observation care. He did not meet Milliman Care Guideline (MCG) criteria for admission for Lower Gastrointestinal Bleeding. 

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 inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: gastroesophageal reflux disease (GERD)
Treatment: Diagnostic Esophagogastroduodenoscopy (EGD)
The insurer denied Diagnostic Esophagogastroduodenoscopy (EGD).
The health plan's determination is upheld. 

The patient is a female with gastroesophageal reflux disease (GERD). She presented with medical history of gastroesophageal reflux disease, and two weeks of sharp epigastric pain, sometimes after eating, bloating, and occasional rectal bleeding; she was suspected to have peptic ulcer disease. She had esophagogastroduodenoscopy for the indication of functional dyspepsia, with finding of esophagitis, irregular squamocolumnar junction, and diffuse gastritis while on H2(Histamine Type-2)receptor antagonist therapy. 

Diagnostic Esophagogastroduodenoscopy (EGD) is not medically necessary. Clinical guidelines (including the American College of Gastroenterology guidelines for the treatment of gastroesophageal reflux disease, and guidelines for dyspepsia) recommend endoscopy for investigation of upper gastrointestinal symptoms when those symptoms are refractory to proton pump inhibitor taken properly for 4-8 weeks without response. The most recent American Society for Gastrointestinal Endoscopy (ASGE) guidelines for appropriate use of endoscopy state that endoscopy is warranted if an appropriate empirical trial of therapy for a suspected benign digestive disorder has been unsuccessful. Current medical literature continues to support these recommendations. In this case, there is no documented proton pump inhibitor therapy for at least 4 weeks before the endoscopy. No other guideline-supported indication for esophagogastroduodenoscopy is documented.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: atrial fibrillation with rapid ventricular rate

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned


 
Asked to review the case of an adult female that presented to her doctor complaining of palpitations and dyspnea for two weeks.  Past history was significant for a recent viral respiratory infection. Electrocardiogram (ECG) demonstrated atrial fibrillation with rapid ventricular rate of 180. She was sent to the hospital. On arrival vital signs were stable (Blood Pressure 152/98, pulse 96 ).  Physical examination revealed an irregularly irregular heart rhythm without other abnormality.  12 lead ECG revealed atrial fibrillation.  Serum blood testing was significant for elevated white blood cell count. Echocardiogram demonstrated a moderate pericardial effusion without tamponade physiology and a reduced left ventricular ejection fraction of 40%. The patient was admitted to the hospital for treatment of new onset atrial fibrillation and reduced ejection fraction and pericardial effusion.  Anticoagulant therapy was initiated along with intravenous (IV) diltiazem.  Computed tomography (CT) angiogram demonstrated a left atrial appendage thrombus.  Trans esophageal echocardiogram (TEE) confirmed the same finding, and a rate control treatment strategy was required.  Following treatment with beta blockers and afterload reduction agents, the patient was discharged with plans for repeat TEE and cardioversion following resolution of thrombus.

Admission for monitoring and treatment was medically necessary.  Patients presenting with atrial arrhythmia with rapid ventricular rates require acute therapy and further monitoring to ensure that medications control heart rate and rhythm without producing significant bradycardia.(Reference 1) An analysis of 68 million Medicare patients admitted to the hospital for atrial fibrillation over a fifteen-year period demonstrated an average length of stay of 3 days. (Reference 2)  This analysis also demonstrated decreased mortality and readmission rates following admission to the hospital.  The current standard of care is consistent with hospital admission when patients present with symptomatic rapidly conducted atrial fibrillation. This patient presented to the hospital with new onset atrial fibrillation, new onset reduced ejection fraction and a moderate pericardial effusion. In conclusion, inpatient admission was medically necessary.

Based on the above, the insurer's denial must be overturned. 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 the inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diarrhea

Treatment: Polymerase Chain Reaction (PCR) testing - Code 87507

The insurer denied coverage for Polymerase Chain Reaction (PCR) testing - Code 87507

The denial is upheld 

The patient has been having ongoing diarrhea attacks for several months. Previously the patient was told that they likely has irritable bowel syndrome (IBS) and was having predominantly constipation. The patient's symptoms are associated with bloating and dizziness. The abdominal exam was benign. A gastroenterology (GI) workup was ordered including colonoscopy, celiac serologies, and GI Polymerase Chain Reaction (PCR) testing. 

UpToDate has an article titled "Approach to the adult with acute diarrhea in resource-rich settings." Stool testing with stool cultures is a recommended test if a patient continues to have diarrhea for more than 1 week. The article also addresses multi-pathogen molecular panels. It states that a high degree of clinical correlation is necessary when interpreting results of molecular testing since these assays detect genetic material which does not always indicate 
infection with a viable organism. Any specimens that test positive for a bacterial pathogen on a multiplex molecular panel, should be submitted for confirmatory culture. 

Gastroenterology and Hepatology 2018 Nov; 14 ( 11 ): 646-652 has an article titled "Use and Interpretation of Enteropathogen Multiplex Nucleic Acid Amplification Tests in Patients with Suspected Infectious Diarrhea." The article states that this testing cannot differentiate between true infection and carrier states. The interpretation of the test requires acknowledging the limitations of the tests and exercising clinical judgment. More studies are needed to establish the cost effectiveness and their impact on antibiotic stewardship and clinical outcomes. 

The stool testing for infectious disease by PCR has been denied by the insurance company. The medical literature has shown that this test has limitations in its clinical use. If there was a concern about an active bowel infection, stool culture and testing for ova and parasites could have been done. The health care plan acted reasonably and with sound medical judgment. Stool PCR testing was not medically necessary for this patient. The denial is upheld.

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 Polymerase Chain Reaction (PCR) testing - Code 87507 services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right lower quadrant pain 
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.


This is a male patient who presented to the emergency department (ED) for right lower quadrant pain and vomiting. The review of systems was negative for additional clinical symptoms. The patient was afebrile (temperature of 36 degrees Celsius). He was described as alert.  The physical examination was remarkable for abdominal tenderness.
 A computed tomography (CT) scan of the abdomen showed status/post (s/p) appendectomy, small calcification near posterior bladder.
The patient was admitted for possible renal colic. The patient was treated with intravenous (IV) fluids and pain medication. The patient was evaluated by a urologist who stated that a stone was not confirmed. A trial of passage was recommended, and the patient was discharged on Cipro and Flomax. An inpatient stay is under review for medical necessity.

The requested health service/treatment of inpatient hospital admission was not medically necessary.
The care could have been safely rendered at a lower level for IV hydration and pain control. The patient was admitted for a possible renal stone that was not confirmed. Additionally, the patient did not have sepsis, acute kidney injury or hydronephrosis. There was no clinical evidence of obstructive uropathy. As such, the care could have been rendered at a lower level of care for IV hydration, pain medication and short-term monitoring for improvement.
Renal stones are common problems that result in emergency department (ED) admissions, and many cases may end up requiring only conservative therapy and outpatient management. However, there are certain cases where nephrolithiasis can result in renal obstruction, which could cause permanent renal damage if treated inadequately. The patient presented with clinical symptoms of possible renal colic. Imaging and laboratory studies did not show acute kidney injury or hydronephrosis in the setting of a ureteral stone. Urologic procedural intervention was not warranted. Therefore, close observation or conservative treatment would have been optimal.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male who presented to the hospital for scheduled percutaneous coronary intervention. His medical history was remarkable for hypertension, hyperlipidemia, type 2 diabetes, obstructive sleep apnea and coronary artery disease. Coronary angiography performed had shown three vessel disease including a chronic total occlusion of the distal left circumflex coronary artery that filled via left to left collaterals. Coronary artery bypass graft surgery had been recommended, but the patient declined. 

The inpatient hospital admission was not medically necessary.
This patient presented for elective percutaneous coronary intervention (PCI). He was stable upon presentation, without acute chest pain. While some period of observation immediately following percutaneous coronary intervention is needed to ensure hemodynamic and access site stability, as well as recovery from sedation, inpatient admission is not generally required for most patients. The 2009 Expert Consensus Document from the Society for Cardiovascular Angiography and Interventions recommends inpatient admission in patients with acute ST segment elevation or non-ST segment elevation myocardial infarction, and unstable acute coronary syndrome with hemodynamic instability or dynamic electrocardiographic changes. Additionally, inpatient admission is recommended for patients whose procedures are associated with significant access site or other complications. This patient met none of these criteria. Per the 2018 update to this document, with the exception of patients with ST segment elevation myocardial infarction, most stable patients can be discharged post- percutaneous coronary intervention (PCI) on the day of the procedure provided they are at their baseline functional and mental status and all of their baseline comorbidities are stable. However, it is recommended that certain patients remain in the hospital for overnight observation following PCI, including those who undergo atherectomy.
Thus, in this instance, admission for overnight observation post-procedure was appropriate. However, it did not require an inpatient level of care. A lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia
Treatment: Inpatient admission 
The insurer denied coverage for: Inpatient admission. 
The denial is: Upheld. 
The patient is an adult who has a history of coronary artery disease (CAD). Presented to the hospital with complaints of chest pain and cough. Chest pain was pleuritic in type. The patient also complained of some myalgia, chills, and respiratory tract infection symptoms.

Vital signs at presentation: Temperature 97.7 degrees Fahrenheit , Heart Rate 98, Respirations 18, Blood Pressure 156/78, oxygen (O2) saturation 97% on room air. The patient was in no acute distress. Lungs were clear. Reproducible tenderness of the anterior chest wall. Normal heart sounds. Abdomen was soft. The patient was alert and oriented X 3.

Labs were within normal limits. Troponin negative. Electrocardiogram (EKG) showed no acute changes. Chest x-ray notable for infiltrates consistent with pneumonia. Patient was started on Ceftriaxone and Azithromycin. The patient improved with treatment. The patient remained afebrile and hemodynamically stable. Was switched to oral antibiotics the next day and discharged home.

This patient did not need acute inpatient hospitalization. The patient could have been placed in observation and discharged home after a brief stay. Observation could be for up to 48 hours.
The patient was discharged home the next day. The patient was stable, white blood cells (WBC) were normal. The patient was not hypoxic. There was no evidence of myocardial infarction (MI) or any cardiac event.

The patients' pneumonia was mild. The patient was stable to be placed in observation while diagnostic testing and treatment were initiated and once stable could have been discharged home on oral medications with close follow-up in an outpatient setting.

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: Cerebrovascular accident (CVA)
Treatment: Personal Care Assistance services, a total of 18 to 26 hours per week
The insurer denied Personal Care Assistance services, a total of 18 to 26 hours per week.
The determination is upheld.

This is a male patient with a medical history notable for a cerebrovascular accident and hypertension. The patient is approved for 15 hours per week of personal care assistance. The patient and his care team requested an increase to 18 to 26 hours per week, and this request was denied by the health plan.
A Uniform Assessment System was completed. The patient lives in an apartment with his significant other. The patient showed modified independence for cognition, and he is able to direct his own care. For his instrumental activities of daily living the patient requires maximal assistance for transportation, shopping, finances, and meal preparation. He requires total dependence for housework. He requires extensive assistance for medications and stairs. For his activities of daily living, he requires extensive assistance for bathing, hygiene, dressing, toilet transfer, and toilet use. He is independent for other activities of daily living. He has right arm pain and stiffness, right leg swelling, and inability to move the right side of his body as a result of his prior stroke. His significant other provides a great deal of support for his activities of daily living. His continent of urine and stool. There was no pressure ulcer present. A task tool associated with the assessment recommended 14.38 hours per week to address his personal care needs. There were no medical records, letters of medical necessity, or other letters provided as part of this appeal. At issue is the medical necessity of Personal Care Assistance services, a total of 18 to 26 hours per week.

The requested health service of Personal Care Assistance services, a total of 18 to 26 hours per week has not been demonstrated to be medically necessary for this patient.
The patient has functional deficits as a result of his stroke. These deficits are outlined in the assessment. The assessment task tool recommended 14.38 hours per week to address his personal care needs. The patient is approved for 15 hours per week. It is unclear what personal care needs, if any, are not being met by his current allotment of hours. Therefore, the requested increase has not been demonstrated to be medically necessary for the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cough and Shortness of Breath (pneumonia)
Treatment: Inpatient Hospital Admission
The insurer denied Inpatient Hospital Admission.
The denial is upheld.

This patient is an adult female with history of asthma, who presented to the emergency room with complaints of cough and shortness of breath. The patient was found to have pneumonia on chest X-ray, and was started on intravenous antibiotics, as well as intravenous steroids for asthma exacerbation. The patient was admitted to acute hospitalization for the management of asthma exacerbation as well as pneumonia. The patient was continued with intravenous steroids, and frequent nebulization treatment, as well as intravenous antibiotics in the hospital. Coverage for the acute hospitalization was denied due to a lack of medical necessity. This denial is being appealed. 

The requested health service of an Inpatient Hospital Admission is not considered medically necessary. 

This patient was admitted to acute hospitalization for the management of pneumonia and asthma exacerbation. By day (number) #2, the patient was not reported to be in any distress. The patient was reportedly tolerating an oral diet. The patient's intravenous steroids were switched to oral Prednisone, and she was not on any supplemental oxygen. The patient was expected to be discharged home by day (number) #3. The patient did not receive any treatment that could not have been safely and effectively provided at a lower level of care. Therefore, the requested health service is not considered medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes mellitus type 2; hypertension; dementia; cardiac arrhythmia
Treatment: Personal Care Aide (PCA) 12 Hours Per Day, 7 Days Per Week
The insurer denied: Personal Care Aide (PCA) 12 Hours Per Day, 7 Days Per Week
The denial is upheld.

This patient is an elderly female with a history of diabetes mellitus type 2 (two), hypertension, dementia, and cardiac arrhythmia. The patient reportedly requires assistance with insulin injections, cleaning, cooking, ambulating, and using the bathroom. The request is to increase hours to 12 hours a day for seven days a week. This request is under review. 

The requested health service of a Personal Care Aide (PCA) 12 (twelve) Hours per Day, 7 (seven) days per week, is not considered medically necessary. 

The patient's family is requesting someone to oversee insulin injections twice daily, managing insulin is out of the scope of practice for a personal care aide (PCA). This patient has a straight cane, rollator walker, handheld shower, shower chair, wall grab bar, and incontinence supplies, for use during patient's activities of daily living. The patient is alert and oriented but forgetful at times. The need for assistance with toilet transfer, walking, eating, bed mobility, bathing, toileting, hygiene, dressing, and locomotion have remained the same since the patient's last assessment last year. As such, the requested health service would not be considered medically necessary.