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

Diagnosis: Pneumonia 
Treatment: Inpatient hospital 
The insurer is denied coverage for the inpatient hospital stay.
The denial is overturned.

The is a male patient with a history of attention deficit hyperactivity disorder (ADHD), traumatic brain injury (TBI), anxiety, depression and substance abuse (Opiates). The patient was brought to emergency department (ED) with complaint of homicidal ideation - (had threatened his father) and delusional ideation. Vital signs in ED temperature 97.5 F, respiratory rate 16, blood pressure 137/82 mm Hg, oxygen (O2) saturations 95 %. Laboratory work up was performed that revealed White Blood Cell Count (WBC) was 18.3 K, Hb 17.6, BUN/ Creatinine and electrolytes (Lytes) within normal limits (WNL). A chest x-ray was done that revealed (CXR) Possible RML infiltrate. This patient was admitted for treatment of pneumonia. 

This patient did not need acute hospitalization for pneumonia. He was awake, alert, afebrile and hemodynamically (HD) stable. Was not hypoxic, lungs were clear, was tolerating oral (PO), and was treated with PO Levaquin. This patient had mild community acquired pneumonia (CAP) and did not need inpatient stay. His CURB 65 score was Zero.

Admission for pneumonia was not medically necessary; however patient was consulted by Psychiatry. Their opinion was that this patient has overall deteriorating symptoms over the past one year and patient also exhibiting signs of withdrawal and negative symptoms, irritability, bizarre behavior and at that time significant aggression.

As per Psychiatry the patient met criteria for involuntary commitment given combination of possible active psychosis and dangerous behavior. An inpatient psychiatry admission was recommended. Inpatient hospital treatment was medically necessary for this psychiatrically compromised patient; this was an acutely psychotic patient with homicidal ideation and aggression who presented as an imminent danger to others and required police escort to the hospital and required involuntary psychiatric hospitalization after his medical evaluation.

The health plan did not act reasonably with sound medical judgment it the best interest of the patient. He could not be treated in a less restrictive level of care as he required involuntary psychiatric hospitalization and was discharged to a psychiatric hospital.

Based on the above, the medical necessity for the inpatient hospital stay is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Near syncope
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The proposed treatment was not medically necessary.

The patient is a woman that presented to the hospital with near syncope.  She noted lightheadedness and near syncope while unloading packages from her car. (Of note - she reported a previous episode of near syncope several days prior to presentation and was evaluated in the emergency department at another hospital.) 

Upon presentation, vital signs were stable and physical examination was unremarkable.  Serum blood testing revealed no significant abnormality.  Electrocardiogram (ECG) revealed sinus rhythm with normal axis, no ST or T wave abnormalities and normal intervals.  Head up tilt table testing was negative and implantable loop recorder was placed.  The patient was subsequently discharged.

This patient presented with near syncope that occurred while unloading her car.  No significant cardiac findings were noted on serum blood testing, ECG or tilt table testing.  The patient was discharged the following day.  According to the European Society of Cardiology, this patient was a low risk patient for future morbidity and mortality. (Reference 1) In a study of individuals presenting to the emergency room, patients that were low risk for cardiac events (no significant cardiac history of acute cardiac findings on initial evaluation) had an excellent prognosis and did not require admission to the hospital for further testing. (Reference 2)  In this case, the patient falls into a low risk category and could be managed a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Slurred speech and left facial droop
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

The Inpatient admission was not medically necessary.

The patient is a female with a history of stroke, hypertension and anxiety disorder. She presented to the emergency ward with the complaint of confusion, slurred speech and left facial droop.

At presentation, the patient's NIH (National Institutes of Health) stroke scale score was zero. Her CT brain was negative. She was admitted for stroke work-up. MRI was negative for acute stroke, and she was discharged. 

The patient presented with slurred speech. At presentation, her examination was normal.  Based on her clinical history and examination at presentation, the monitoring, diagnostic studies and treatments could have been safely and effectively completed at a lower level of care. Inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory Distress
Treatment Inpatient Hospital.  The insurer denied the Inpatient Hospital Stay,
The determination is upheld.

The patient was brought to the emergency department (ED) with upper respiratory infection (URI) symptoms that started the day before. She was previously well, with a history of bronchiolitis once. She did not have a fever or problems taking by mouth (PO). On arrival to the ED, at triage , her vital signs were normal including an oxygen saturation of 100%. The ED physician noted retractions and moderate expiratory wheeze bilaterally, with normal hydration and perfusion. She was given oral prednisolone and two albuterol nebulizer treatments. Flu and respiratory syncytial virus (RSV) swabs were negative and a chest x-ray (CXR) was normal. Afterward, she was noted to have "mild retractions and expiratory wheeze" and she was admitted to the hospital. The admission history and physical (H&P) documents mild intercostal retractions and "massive" wheezing with upper airway noises. She was treated with further nebulizer treatments and azithromycin. The next morning, she was described as "alert and active, comfortable in room air." Her vital signs continued to be normal. She had "scattered wheezing" and harsh breath sounds and the plan was to continue treatments and discharge when improved. At issue is the medical necessity of an inpatient stay.
The inpatient stay was not medically necessary. The patient did not have an oxygen requirement, signs of dehydration, trouble taking PO, or problems with perfusion. The respiratory distress was mild with mild retractions and expiratory wheezes that did not fully resolve after nebulizer treatments in the ED. In reviewing the Milliman Guidelines, the patient met none of them. For bronchiolitis, the patient did not have tachypnea and significant compromise, a high respiratory assessment score, an oxygen saturation less than 90% on room air, cyanosis, history of apnea, compromising chronic lung condition, significant wheezing or distress that persisted despite the breathing treatments, or need to be in an inpatient unit to continue to receive the breathing treatments. The patient clearly did not have respiratory failure. She did not need mechanical ventilation, she did not have pulmonary edema, she did not have severe respiratory distress or respiratory deficit, and she did not have airway obstruction. The pneumonia guideline did not apply. She did not have clinical or radiographic evidence of pneumonia. She did not have a fever, she did not have crackles (rales), she did not have any findings on chest x-ray.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute gouty arthritis

Treatment: inpatient admission

The insurer denied coverage for inpatient admission. The denial is upheld. 

This patient is a male with several medical conditions. The patient was evaluated in the Emergency Department (ED) with the complaint of left knee pain and swelling for several days. The patient denied trauma. The patient reported taking Tylenol and Prednisone. The patient's primary physician had aspirated 20cc of fluid from the knee prior to this patient's arrival to the ED. The patient was advised to seek further medical care in the ED. The patient reported his pain level as 10 out of 10 in severity. The patient's vital signs were stable. On exam, the patient's knee was hot to the touch. The patient's labs showed ESR of 14 and uric acid of 8. Consultation was completed by Orthopedics who recommended conservative treatment and possible additional aspiration. The patient was unable to bear weight on his knees, and was unable to ambulate. The patient was admitted to the hospital and several medications were provided, including Morphine and intravenous steroids. The patient's diagnosis was acute gouty arthritis. The patient received Colchicine and Prednisone. The patient was discharged.

Based on the review of the medical record, this patient had chronic gout with frequent episodes acute flares. The patient reported having an attack on the right knee several weeks prior. The patient reported that these current symptoms felt the same as his previous attack. The diagnosis of acute gout was established. According to this patient's orthopedic evaluation, this patient did not require any invasive management or specialized diagnostic studies that required inpatient level of care. The patient was recommended to weight bear as possible and physical therapy. The steroid taper and additional analgesia that was provided during this patient's inpatient stay did not require an acute admission status. The patient could have been prescribed oral analgesic agents. The patient also did not have any underlying medical conditions or extenuating circumstances to substantiate this patient's inpatient admission and hospital length of stay. Thus, the inpatient admission was not medically necessary for this patient. This patient could have been managed at the observation level of care.

The health care 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 admission from is upheld. The medical necessity is not substantiated
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Gastroesophageal reflux disease (GERD)

Treatment: Laparoscopic surgery 

The insurer is denied coverage for laparoscopic surgery (43284) for placement of the LINX Reflux Management System. 

The denial is reversed.  

The patient was then a male with medically refractory gastroesophageal reflux disease (GERD). The patient had an esophagogastroduodenoscopy (EGD) showing LA Grade B esophagitis and possible hiatal hernia. The patient's manometry showed ineffective motility. The patient's DeMeester score was 48.5. The patient's esophagram did not show achalasia.

According to Asti et al (2018), the magnetic sphincter augmentation (MSA) procedure is a minimally invasive and highly standardized surgical option for patients who are partially responders to proton-pump inhibitors, which have troublesome regurgitation or develop progressive symptoms despite continuous medical therapy. The procedure has proven to be highly effective in improving typical reflux symptoms, reducing the use of proton-pump inhibitors, and decreasing esophageal acid exposure. Observational cohort studies have shown that MSA compares well with fundoplication in selected patients and has an acceptable safety profile. The device can be easily removed if necessary, thereby preserving the option of fundoplication in the future. As per Kuckelman, Barron & Martin (2017), "This [magnetic sphincter augmentation] procedure offers a new option that is anatomically and physiologically unique compared to standard fundoplication, and that offers highly effective control of GERD with a less invasive approach."

Upon review of the peer reviewed medical literature, LINX [magnetic sphincter augmentation device] procedure is safe and effective for patients with small hiatal hernias, no Barrett's esophagus, and no left anterior (LA) grade C or D esophagitis. LINX is FDA approved treatment option for gastroesophageal reflux disease (GERD). Results of current medical literature show that LINX is an acceptable alternative to Nissen Fundoplication and may have fewer side effects. As this patient has medically refractory GERD, no esophagitis and has a small hiatal hernia, this patient is a good candidate for this LINX procedure. Thus, it is considered that the requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of coverage for laparoscopic surgery (43284) for placement of the LINX Reflux Management System should be reversed.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Gastroesophageal reflux disease (GERD)

Treatment: Laparoscopic surgery

The insurer is denied coverage for laparoscopic surgery (43284) for placement of LINX Reflux Management System

The denial is reversed. 

According to the patient's medical chart, this was then a male with a history of gastroesophageal reflux disease (GERD). As per progress note the patient had extensive work-up including upper endoscopy, upper gastrointestinal (GI) series with barium swallow, timed barium swallow, esophageal pH study and esophageal manometryx2 as well as Endoflip evaluation. The patient had a reported DeMeester score of 48.5. It was noted that the patient had significantly disordered esophageal motility with weakened peristalsis and low distal contractile integral (DCI) score by manometry that did not improve with proton pump inhibitors (PPI). Given that this patient's esophageal pressurization and compliance are normal on Endoflip, the consensus was that it was reasonable to consider offering magnetic sphincter augmentation (LINX procedure) in this setting although there was a higher risk of dysphagia related issues. The patient's esophageal manometry with impedance catheter placed showed normal upper esophageal sphincter (UES) resting and relaxation pressures with a 1.5 cm hiatal hernia, and normal resting and relaxation pressure at the lower esophageal sphincter (LES). The patient's upper gastrointestinal (GI) study was done which showed normal caliber esophagus. The patient's esophageal Biopsy did not show any metaplasia. The patient's ambulatory pH monitoring was done and showed a DeMeester score of 48.5 with a 95.6 symptom association probability.

It appears that this patient is a good candidate for this device given the fact that the patient has esophagitis on endoscopy and a DeMeester score of 48 and 95% symptom association probability on ambulatory pH monitoring. Schwaitzberg noted in surgical management of gastro esophageal reflux in adults, in UpToDate, that eligible patients for the procedure include those with all of the following: typical GERD symptoms; abnormal pH study; partial response to daily proton pump inhibitor (PPI) therapy; absence of a large hiatal hernia (>3 cm) or severe esophagitis. In this case, this patient had significant reflux and his symptoms were supported by his pH study. 

The LINX offers several advantages over the fundoplication approach. While the fundus wrap is extremely invasive and is non-reversible, and often leaves the patient with the inability to vomit and vent their stomach, the LINX procedure is less invasive and is potentially reversible. Thus, it is considered that the requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient. 

The carrier's denial of coverage for laparoscopic surgery (43284) for placement of LINX Reflux Management System should be reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart Failure, Sepsis.
Treatment: Inpatient admission.
The insurer is denied coverage for inpatient admission. 
The denial is overturned.

This is a male patient with history of metastatic lung cancer with metastases to the brain, atrial fibrillation on Eliquis, congestive heart failure (CHF), and pulmonary hypertension (PHTN). The patient presented to the Emergency Department (ED) with shortness of breath (SOB)/dyspnea on exertion (DOE), palpitations, bilateral lower extremity swelling, and chills. The patient's vital signs on presentation were; temperature of 100.9F, heart rate (HR) of 156 ; irregular, respiratory rate (RR) of 31 and oxygen (O2) saturations in the 80's. On exam, the patient's lung revealed bilateral rales and bilateral lower extremity edema. Laboratory work up was performed that revealed a white blood cell (WBC) count to 16.3 K, BUN/Creatinine 30/0.9 and hemoglobin (Hb) 11.5, brain natriuretic peptide (BNP) 2046, troponin 0.49 and lactate was 3.5. The patient received intravenous (IV) metoprolol and Digioxin for heart rate control, intravenous (IV) Lasix and IV antibiotics. Oxygen was administered at 6L nasal cannula (NC). The patient was pan-cultured. A computed tomography (CT) angiogram was done that was negative for a pulmonary embolism (PE). The patient had progression of disease with worsening left lower lobe (LLL) mass and adenopathy. The patient's lungs had bilateral ground glass opacity and patchy bilateral opacities; thickening of interlobular septa and small right pleural effusion. The patient was admitted to the hospital with a differential diagnosis that included infectious etiology vs. drug reaction vs. lymphangitic spread. The patient was continued on beta blocker. The patient expired.

The patient was admitted for possible pneumonia and sepsis, decompensated heart failure (HF) and atrial fibrillation with rapid ventricular response (RVR). The patient remained hypoxic, tachycardic, and had atrial fibrillation with RVR. The patient's lactate was elevated, and the patient had leukocytosis and elevated troponin. This patient remained in hypoxic respiratory failure requiring supplemental oxygen (O2) 6 Liters nasal cannula (NC). The patient continued to be tachycardic requiring beta blockers. The patient became hypotensive after treatment. The patient was not stable to be placed under observation. After admission to the floor, the patient's condition further deteriorated. The rapid response team (RRT) was called. The patient went into cardiac arrest. Despite advanced cardiac life support (ACLS), the patient could not be revived. The patient was critically ill with sepsis/pneumonia/atrial fibrillation with rapid ventricular response and decompensated heart failure (HF). Literature review supports that inpatient admission was medically necessary for this patient.

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

The carrier's denial of coverage for the inpatient admission should be overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Pain, Shortness of breath .
Treatment: Acute inpatient hospital.
The insurer is denied coverage for acute inpatient hospital. 
The denial is reversed.

The patient is a male who presented to the Emergency Department (ED) with complaints of shortness of breath one day prior to presentation with associated chest pain, leg swelling and a non productive cough. He reported having a past medical history of heart failure with a reduced ejection fraction (EF); EF 12% with grade 3 diastolic dysfunction and diabetes mellitus type 2, smoking cigarettes and using crack cocaine.  A physical exam revealed that he had 3+ lower extremity edema and that his shortness of breath worse when he spoke. The patient was admitted to the hospital and treated in the ICU. The ICU treatment including aggressively diuresing the patient and a dobutamine intravenous (IV) drip. Vital signs recorded included a blood pressure of 106/74, a pulse of 84, a temperature of 98, respirations of 20 and an oxygen saturation of 100%. The patient was transferred to another medical facility for further medical treatment.

The insurer did not act reasonably, or with sound medical judgment, or in the patient's best interest.

The carrier's denial of coverage for the acute inpatient hospital stay is reversed. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lewy Body Dementia, Severe Cognitive Apraxia.
Treatment: Personal Care Worker services to 2 x 12 x 7, Split Shift Mutual Case.
The insurer is denied coverage for Personal Care Worker services to 2 x 12 x 7, Split Shift Mutual Case.
The denial is reversed. 
This is a female has had worsening of Lewy body dementia, with severe cognitive apraxia, worsening insomnia, ataxia, imbalance, increased risk for falls. The patient needs help with ADLs, IADLs, housework, psychosocial support, safety concerns. The patient can benefit from HHA 8-12 hours/day.

The patient requested approval for Personal Care Worker services 2 x 12 x 7 split shift mutual case. The patient was approved for 2 hours of Personal Care Worker x 7 days a week. An appeal was requested. The final decision upheld the denial for Personal Care
Worker services 2 x 12 x 7 split shift mutual case because it is not medically necessary. Plan approval stays at 2 hours of Personal Care Worker x 7 days a week. The reason for the decision is note d as follows: The patient's assessment did not show a need for more hours. The patient can be left alone safely; she can talk; she needs help with most of her daily activities. She has not had any changes in her condition. The patient's daughter requested an external appeal as designee on behalf of the patient.

Notes from the previous UAS include diagnoses: dementia (MMSE 22/30); arthritis with chronic pain in back and joints. It was also noted that patient was observed walking without assistive device; and transfers with assist of nearby furniture. All ADLs were independent set up help; but patient needs cueing for bathing, dressing, grooming due to confusion. The patient sleeps through the night. Nurse educated patient on fall precautions; advised to use assistive device for ambulation.

The determination in this review is based on available medical information, the home situation of the patient, risk/benefit assessment and best interest standard for the patient's health and safety. The patient has physical and mental impairment that limits her ability to properly and safely perform most daily activities. It is in the best interest of the patient to have personal care services as two 12 hour shifts per day as a mutual case with her husband to provide adequate assistance for the patient's personal care needs and household related tasks. It is not clear whether live-in services would be satisfactory; but at this time with the information that is available, two 12 hour shifts per day is medically necessary to ensure the patient has sufficient assistance to manage her daily activities effectively and safely through the day and night.

Personal Care Worker services 2 x 12 x 7 split shift mutual case is medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the requested increase in Personal Care Worker services to 2 x 12 x 7, Split Shift Mutual Case is substantiated. The insurer's denial is reversed.