Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems/Congestive Heart Failure/CHF
Treatment: Durable Medical Equipment (DME) 
The health plan denied the requested DME (Wearable Defibrillator) as not medically necessary. 
The health plan's determination is overturned.

This case is a male with a history of hypertension, hyperlipidemia, diabetes mellitus who presented to the emergency room (ER) with chest pain due to a non-ST elevation myocardial infarction (MI). The patient underwent a coronary angiogram showing multivessel coronary artery disease (CAD) and an echocardiogram showed severely reduced left ventricular ejection fraction (LVEF). The patient was referred to coronary artery bypass graft (CABG) undergoing left internal mammary artery (LIMA) to left anterior descending (LAD) and vein graft to patent ductus arteriosus (PDA). Post CABG, the patient developed cardiogenic shock requiring urgent Impella CP placement which was able to be explanted. The patient was started on guideline-directed medical therapy for his newly diagnosed ischemic cardiomyopathy and was discharged home with a ZOLL LifeVest for sudden death protection. Repeat echocardiogram was performed showing recovered LVEF to 50% and the LifeVest was discontinued. The patient's health plan has denied coverage for a ZOLL LifeVest due to the experimental/investigational indication for the device.

I would recommend that the health plan's determination regarding denial for coverage of the LifeVest in this case be overturned.

Yes, treatment with the ZOLL LifeVest would be beneficial for this patient for the following reasons. The clinical effectiveness of the LifeVest to terminate ventricular tachycardia (VT) / ventricular fibrillation (VF) has been demonstrated in prospective registry data demonstrating first shock efficacy of 99% with a very high post shock survival. In the prospective Wearable Cardioverter Defibrillator (WEARIT-II Registry) that evaluated 2000 patients with both ischemic and nonischemic cardiomyopathies, over 50% of the sustained ventricular arrhythmias were terminated by an appropriate shock by the LifeVest, there was a low incidence of inappropriate shocks, and the rate of ventricular arrhythmias remained high at 3 months (3%) in patients with known cardiomyopathy due to CAD [1].

Given the currently published literature on the effectiveness of the LifeVest, favorable safety profile, and clinical trial evidence demonstrating reduction in all-cause mortality in post-MI patients during the 90-day waiting period post revascularization, the recommendation for LifeVest  was medically appropriate and should not have been viewed as experimental or investigational. Given this patient's high risk of death due to ventricular arrhythmias and established effectiveness of the LifeVest to terminate sustained ventricular arrhythmias resulting in lower all-cause mortality, coverage for the LifeVest should be granted.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems/Congestive Heart Failure/CHF
Treatment: Durable Medical Equipment (DME) 
The health plan denied the requested DME (Wearable Defibrillator) as not medically necessary. 
The health plan's determination is upheld.

This patient is a male with who was admitted to the hospital with chest pain and non- ST-Elevation Myocardial Infarction (STEMI). The patient was found to have poor systolic function and a non-STEMI. He was admitted to the hospital. Coronary angiography showed three-vessel coronary arterial disease. The patient underwent coronary artery bypass surgery. Post-surgery the patient developed cardiogenic shock and therefore he had a percutaneous left ventricular assist device placed. He was weaned off the ventilator and the patient was weaned off hemodynamic support and he was discharged home in a stable condition. His postoperative course was uncomplicated. He was discharged home with a follow-up with cardiology as an outpatient. A wearable external cardioverter was provided.

Based on my review of the medical literature and the standard of care, I do uphold, in whole, the health plan's determination regarding the proposed health service/treatment.

No, the proposed health service of treatment with a Zoll LifeVest is not likely to be more beneficial than any standard treatment. Based on the policy criteria as well as the peer-reviewed literature, the use of wearable cardioverter defibrillator is considered medically appropriate for patients who require explantation of an implantable cardioverter defibrillator due to infection or reactive displacement, experience contraindication as systemic infection that temporary delay implantable cardioverter defibrillator (ICD) implantation or patients that are waiting for heart transplantation. The use of a wearable cardioverter defibrillator for other indications is considered investigational. This patient has ischemic cardiomyopathy. He was well revascularized during that admission, therefore a wearable cardioverter defibrillator will not provide any more benefit than any standard medical therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems/Congestive Heart Failure/CHF
Treatment: Durable Medical Equipment (DME) 
The health plan denied the requested DME (Wearable Defibrillator) as not medically necessary. 
The health plan's determination is overturned.

The patient is a man with a history of hypertension, hyperlipidemia and diabetes who presented to the emergency department with congestive heart failure and an acute non-ST segment elevation myocardial infarction. A cardiac catheterization showed severe two vessel disease. The patient underwent coronary artery bypass graft surgery. His course was complicated by cardiogenic shock requiring temporary support with an Impella left ventricular assist device. His left ventricular ejection fraction (LVEF) by echocardiogram was 20-29%. On guideline directed medical therapy, an echocardiogram showed a LVEF of 50-54%. Coverage for use of a LifeVest wearable cardioverter defibrillator for three months  is at issue.

I overturn, in whole, the health plan's determination.

Yes. Depressed left ventricular systolic function is a risk factor for, and powerful predictor of, sudden arrhythmic death. Consequently, implantation of an implantable cardioverter defibrillator (ICD) for the primary prevention of sudden cardiac death is a widespread practice, proven to be beneficial to heart failure patients with a variety of cardiac diagnoses. Current guidelines support ICD implantation in patients, such as this man, with ischemic cardiomyopathy, and left ventricular ejection fractions of 35% or less. However, due to the possibility that left ventricular function may improve with revascularization, it is recommended that device implantation be delayed for at least 90 days following coronary artery bypass graft surgery or percutaneous coronary intervention. If, 90 days post-revascularization, the LVEF remains less than or equal to 35%, ICD implantation is then recommended. However, the degree to which revascularization mitigates the risk for serious ventricular arrhythmias during this 90-day period is unclear. Accordingly, many physicians prescribe the LifeVest wearable cardioverter defibrillator (WCD) as a "bridge" to ICD implantation in these patients. The efficacy of the WCD in terminating serious ventricular arrhythmias compares favorably to that of the implanted device. In one large retrospective study of patients with left ventricular ejection fractions of 35% or less after coronary artery bypass graft surgery (CABG) or percutaneous intervention, the WCD was associated with a lower 90-day mortality in patients after CABG (no WCD: 7% vs WCD: 3%) and after percutaneous coronary intervention (PCI) (no WCD: 10% vs WCD: 2%). There are no other treatments that have proven successful in reducing the risk for sudden cardiac death in this patient population.
Appeal type: Medical necessity
Decision: Overturned

The patient who was 33 weeks present pregnant and had a history of lupus, lupus nephritis, and immune thrombocytopenic purpura (ITP), presented for care. The patient was referred by the treating hematologist. The patient reported spontaneous nose bleeding and gingival bleeding for the past two days while brushing teeth and was found to have a platelet count of 33 in the hematologist office. The patient was referred for management of thrombocytopenia. 
The health plan's determination is overturned.
The reason is because the patient presented with evidence of bleeding in the setting of thrombocytopenia, and was pregnant, which increases the risk of having a thrombocytopenia-related complication. Had the patient gone into labor while having thrombocytopenia, the risk of hemorrhage and hemorrhagic shock and death would be markedly increased. The treating physicians explicitly stated that the platelets needed to be monitored as an inpatient while the patient was receiving IVIG and dexamethasone to ensure that the patient had an adequate response, given the demonstrated bleeding and the risk of hemorrhage during labor. The patient was at markedly increased risk of having an adverse event because of the thrombocytopenia and her comorbidities. An inpatient level of care was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who has been receiving ongoing physical therapy treatment for the neck, low back, knee and shoulder pain starting in 2018. Records indicate that previously 15 visits of physical therapy were found to be medically necessary for the shoulder pain and the provider requested additional sessions for the shoulder. The health plan's determination of medical necessity is upheld.There is no documentation showing any significant or sustained improvement and outcomes following the initial 15 visits. There was a lack of objective measures showing ongoing progress made and no clear indication as to why the patient would continue requiring supervised physical therapy sessions rather than transitioning into an independent home exercise program based on exercises and instruction received in the initial 15 visits of therapy. It is standard of care to provide this education and transition the patient into a home program.
Appeal type: Medical necessity
Decision: Upheld

The patient was admitted to skilled care with diagnosis of a right upper extremity deep vein thrombosis (DVT) with a history of fall fracture the same arm.  The patient is requesting admission to long-term care facility. 

The health plan's determination is upheld.  The Admission to Long-Term Care Facility is not medically necessary for this patient.  The patient was able to walk with contact guard for distance of 175 feet.  The patient lives in a 1 bedroom apartment with others.  It is reasonable to think that if the patient could ambulate 175 feet this would be more than sufficient enough to ambulate with inside a 1 bedroom apartment.  Other services including home physical or occupational therapy and home health aide could support the patient.
Appeal type: Medical necessity
Decision: Overturned

The patient was admitted with dehydration, bronchiolitis, and anemia. The patient had been ill with a runny nose for one week, and then developed increased work of breathing for one day. He was seen by the PCP (primary care provider) on for cough and increased work of breathing and was started on albuterol via nebulizer every six hours. The patient did not improve and developed poor by mouth (PO) intake. 

The health plan's determination is overturned. The inpatient stay was medically necessary. The patient's constellation of findings and abnormal lab studies warranted an inpatient hospitalization. The patient's diagnosis of dehydration was evidenced by a physical exam documenting sunken eyes and mottling of the skin. It would not have been reasonable or safe to manage this as an outpatient, particularly while the child was afflicted by two other acute illnesses.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial fibrillation and atrial flutter.

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld. 

This is a male patient with a history of palpitations that was referred for elective electrophysiologic (EP) study and ablation of atrial fibrillation and atrial flutter. The patient had a past medical history of immune compromise and atrial septal defect. He underwent successful pulmonary vein electrical isolation and cavotricuspid isthmus ablation and was monitored overnight on telemetry.  His post-operative course was uncomplicated and the patient was discharged the following day.

The health plan acted reasonably and in the best interest of the patient. This patient presented to the hospital for an elective electrophysiologic study and ablation. According to hospital records, the ablation was successfully performed without complication. Observation following ablation was unremarkable and no post-operative issues were noted. The patient was discharged home the following day. In this case, there were no clinical reasons for hospital admission and the patient could safely be managed at a lower level of care.

In two multi-center registry studies looking at healthcare utilization after EP study with catheter ablation, more than 80% of patients undergoing ablation were hospitalized for a single day, regardless of age or co-morbidity. (Reference 1) Other studies have demonstrated that patients undergoing ablation procedures could be safely discharged on the same day. (Reference 2-3) The current standard of care in an uncomplicated atrial fibrillation ablation is to manage patients at a lower level of care. In conclusion, inpatient hospital admission was not medically necessary.

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: Malocclusion.
Treatment: D8080 Braces and D8670 Monthly Visit.
The insurer denied the D8080 Braces and D8670 Monthly Visit.
The denial is overturned. 

The patient is a male. The request is for orthodontic benefits. He has Class I malocclusion.

The braces and monthly visits are medically necessary.
The patient has multiple lower anterior teeth in crossbite (reverse bite), with gingival attachment loss. This is an automatic qualifier for treatment according to the handicapping index scale.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gallbladder dysfunction. 
Treatment: Full hospital admission. 

The insurer denied coverage for the full hospital admission. 

The denial is upheld. 

This is a female patient with no significant past medical history. She presented to the Emergency Department (ED) with a one-day history of abdominal pain with associated nausea. Her vital signs were within normal limits. Her liver function tests were within normal limits. Her white blood cell count was 8.26. Her blood urea nitrogen (BUN)/creatinine ratio was 12.3, and there was no indication of acute kidney injury. An ultrasound demonstrated a mildly thickened gallbladder wall without evidence of gallstones or sludge. A hepatobiliary iminodiacetic acid (HIDA) scan was performed and demonstrated gallbladder dysfunction with an ejection fraction of 10%. The patient was taken to the Operating Room for a laparoscopic cholecystectomy. There were no reported complications. The patient was noted to have adequate pain control and was tolerating a regular diet. 

Per Milliman Care Guidelines (MCG) criteria, admission is necessary for acute cholangitis, acute cholecystitis, or calculus or obstruction of the gallbladder or bile duct. According to clinical documentation, there was no indication of acute cholangitis and/or cholecystitis. The cystic duct was noted to be patent on HIDA scan. Although the laparoscopic cholecystectomy was medically necessary, outpatient work-up and management would have been reasonable. Therefore, the requested full hospital admission was not medically necessary. 

Studies have shown that ambulatory laparoscopic cholecystectomy is safe and avoids an overnight hospital stay.[2, 4, 5] Factors that contribute to admission after laparoscopic cholecystectomy include drain placement, conversion to open surgery, persistent abdominal pain, nausea, and vomiting.[3] In patients without abnormalities of the bile duct or abnormal liver function tests, ambulatory laparoscopic cholecystectomy is safe and feasible. [5] 

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. 

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

Diagnosis: Ulcer of right lower extremity.

Treatment: Inpatient admission.

The insurer denied coverage for the inpatient admission.

The denial is upheld. 

This male patient has a history of asthma, Buerger's disease, and bilateral below knee amputations (BKA).  He was to have had a skin graft performed that day, but had missed his COVID pre-admission testing and did not go to the appointment.  He was also unable to get a wound vacuum assisted closure (VAC) device due to scheduling issues with nursing services and needed a wound VAC change.  The patient presented via ambulance to the Emergency Department (ED) for evaluation of an open wound on his right BKA stump and 10/10 pain, and to see if they could help get the graft organized.  He also had a new ulcer forming on the left knee due to prosthesis irritation.  Vascular and surgery were consulted for evaluation of chronic right lower extremity ulcer needing skin graft, and the patient was admitted to vascular surgery.  The wound was debrided and a wound VAC was placed on; a split-thickness skin graft on the right BKA was performed.  The patient was deemed stable for discharge on and the patient was transferred to Lenox Respite.

This patient had been having right BKA stump chronic open wounds and was already scheduled for an outpatient debridement procedure, but missed his pre-operative COVID testing.  He was seen on his scheduled operative day, and deemed on the medical record not to be emergent.  He had no elevated inflammatory markers, no physical exam evidence of cellulitis or sepsis, and was afebrile.  Thus, the procedure could have been rescheduled, as this was elective.  Next, after the debridement and wound VAC placement, which was and is an outpatient procedure, the patient could have been discharged to a skilled nursing facility, to home with home health nursing protocols, and had his wound VAC changed purely as an outpatient.  When the wound was then sufficiently appropriate to have a split thickness skin graft, the patient could have been brought in again as an outpatient to have the split-thickness skin graft (STSG), procedure performed and discharged the same day.

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

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

Diagnosis: Cardiac/Circulatory System. 
Treatment: Inpatient Hospital. 
The insurer denied the inpatient stay. 
The denial is upheld.

The patient is a male who presented to the emergency department complaining of palpitations. His medical history was remarkable for hypertrophic cardiomyopathy and atrial fibrillation treated with hybrid ablation. His blood pressure was 126/75 millimeters of mercury (mmHg), with a heart rate of 92 beats/minute. His room air oxygen saturation was 96%. An electrocardiogram showed atrial flutter with variable atrioventricular (AV) conduction. Chest x-ray showed no acute pathology. The patient was treated with metoprolol and heparin and admitted to the hospital. He had no complaints. His heart rate ranged from 67-111 beats/minute. Oral metoprolol was continued. He was discharged. Medical necessity for an inpatient admission is at issue.

The health plan's determination is upheld.

This patient presented with atrial flutter. He was hemodynamically stable, there was no evidence of acute ischemia, he was not in heart failure, and was not at high short-term risk for thromboembolism. For patients presenting with acute atrial fibrillation (AF) or flutter, the safety of discharge to home with close follow-up has been well demonstrated. As stated by Lin, et al, "There is growing evidence to suggest that outpatient management is a safe and effective alternative to hospital admission for the management of many patients with acute AF or atrial flutter. Protocols for early rhythm control, clinical decision rules to guide the decision to initiate antithrombotic therapy, and low molecular weight heparin and direct oral anticoagulants have reduced the need for acute inpatient hospitalization." 

The patient could have been managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems/Decay/Cavities.
Treatment: Dental/Orthodontic Procedure,
The health plan denied the requested dental treatment as not medically necessary. 
The health plan's determination is upheld.

The patient is a female who presents with decay on teeth #10 and #11. Root canal, post-core, and crowns are being requested at this time.
At issue is the medical necessity of the requested dental treatment.

I uphold the health plan's determination of medical necessity, in whole.

The need for root canals, post-core, and crowns is based on the prognosis of the tooth and size and location of the decay. When the prognosis of the tooth is not favorable, extraction is the recommended choice for treatment.
According to the submitted radiographs, teeth #10 and #11 have large caries where the majority of the tooth structure is missing. Due to the size of the caries and the amount of tooth structure remaining, the prognosis of these teeth is either questionable or poor. In this case, treatment with a root canal, post-core, and crown would not result in long-term success. Therefore, the request for root canal treatment, crown with post-core on teeth #10 and #11 is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right knee pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female with right knee pain. She had been diagnosed with osteoarthritis. She was admitted to hospital for an elective TKR (total knee replacement). Her past medical history was significant for hypertension, ASHD (arteriosclerotic heart disease) and metabolic syndrome. Her BMI (body mass index) was 38.51. Her ASA (American Society of Anesthesiologists) score was 2.

A review of the operative report showed EBL (estimated blood loss) of 250cc (cubic centimeters) and duration of procedure 3:38 (including anesthesia time). The patient's post-surgical course was non-complicated. The attorney's letter reported drainage to wound and inadequate pain control.

No, the Inpatient admission was not medically necessary.
The records show a non-complicated post-surgical course. There was no evidence of bleeding or fever. The patient's wound was clean and dry. The patient was able to tolerate oral pain medication and required some adjustment to dosage. She did not require treatment for an underlying medical condition. She did not require additional testing or imaging.

The records showed that the patient's pain level was manageable. She was seen on several occasions by many physicians who reported the need for "disposition planning" and discharge. 

There were no extenuating circumstances to warrant the inpatient admission.