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

Diagnosis: Atrial fibrillation
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

The patient is a male. He was hospitalized for atrial fibrillation.

The patient presented to the ED (emergency department) for evaluation of chest discomfort and palpitation, and he was found to be in atrial fibrillation with a rapid ventricular response of 170. His pertinent past medical history is remarkable for known CAD (coronary artery disease), NSTEMI (non-ST-elevation myocardial infarction) treated with PCI (percutaneous coronary intervention), HTN (hypertension), HLP (hyperlipidemia), DM2 (diabetes mellitus type 2), GERD (gastroesophageal reflux disease), sleep apnea and obesity.

The patient's treatment included IV (intravenous) Cardizem and anticoagulation. LVEF (left ventricle ejection fraction) was 55% (percent). Troponin panel reflected Type 2 MI (myocardial infarction) from demand ischemia and not Type 1 thrombotic MI (myocardial infarction). Chest x-ray showed NAD (no active disease).

By day two, the patient's BP (blood pressure) remained stable. His rhythm spontaneously reverted to sinus, and he was discharged home.

This is an appeal of the denied claim the requested Acute Inpatient Hospital Stay was medically necessary for this patient.

No, the Inpatient admission was not medically necessary.
Based on the peer reviewed medical literature, including the MCG (Milliman Care Guidelines) guideline for Atrial Fibrillation ORG: M 505 (ISC), the documentation submitted for review does not establish the requested Acute Inpatient Hospital Stay was medically necessary for this patient. Criteria are not met, including hemodynamic instability, myocardial ischemia, syncope, altered mental status, dyspnea or hypoxemia, pulmonary edema, continuous cardiac monitoring is required for condition causing arrhythmia, such as, serious electrolyte abnormality, any underlying medical condition requiring inpatient care like thyrotoxicosis or pneumonia, recent systemic embolic event like CVA (cerebrovascular accident), initiation of antiarrhythmic drug (AAD) therapy for patient at high risk for adverse effects like use of AAD (antiarrhythmic drug) with proarrhythmic potential, low ejection fraction, congenital heart disease, valvular heart disease, prolonged QT interval, significant sinus or AV (atrioventricular) node conduction disease, intolerable symptoms despite optimal OP (outpatient) treatment or elective or urgent cardioversion which cannot be done on an OP (outpatient) basis or during observation care.

In this case, the care the patient received, including medication for ventricular rate control in hemodynamically stable patients like this patient, is routinely provided safely and effectively at a lower level of care. Therefore, based on the submitted information and the standard of care, the requested inpatient level of care is not medically necessary.

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

Diagnosis: hypertension, hyperlipidemia, diabetes and peripheral vascular disease.
Treatment: Increase Personal Care Aide Level II Basic 15 Minutes from Twenty Five (25) Hours Per Week To Forty (40) Hours Per Week.
The insurer denied the Increase Personal Care Aide Level II Basic 15 Minutes from Twenty Five (25) Hours Per Week To Forty (40) Hours Per Week.
The denial is overturned.

The patient is a male. He is documented to have hypertension, hyperlipidemia, diabetes and peripheral vascular disease. The request is to Increase Personal Care Aide Level II Basic 15 Minutes from Twenty Five (25) Hours Per Week To Forty (40) Hours Per Week.

The health plan approved an increase to 28 hours per week, and denied the remaining increase as not medically necessary. This is being appealed.

Yes, the requested increase in personal care aide services to 40 hours/week is medically necessary.
The patient lives alone. His clinical condition has significantly worsened after recent hospitalization for toe infection. He has limited mobility. He requires more assistance with completing ADLs (activities of daily living). He needs help with preparing meals and other house work. The request is medically appropriate and necessary.

The health plan increase in hours to 28 hours/week is not sufficient, as the patient is homebound and needs help throughout the day. Because of his toe amputation, mobility is difficult. The patient needs help with getting out of the bed, toileting, preparing meals, etc.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
The patient has significant decline and has limited mobility. He needs more help.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Salmonella infection.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient presented to the hospital with acute onset diarrhea, dizziness, fever, and vomiting. He was diagnosed with a salmonella infection and received intravenous fluids and antibiotics.
At issue is the medical necessity of an inpatient admission.

The requested inpatient stay was medically necessary.
This patient presented with the acute onset of diarrhea, vomiting, dehydration and dizziness. He had already been seen at the emergency room the day before and discharged home. He was unable to maintain oral hydration and started having dizziness. His vital signs were concerning for a low blood pressure and tachycardia. He was also febrile.
His blood culture was positive for a salmonella infection. He had a low sodium level which supports the impression of severe dehydration. His clinical picture was consistent with a severe systemic infection and sepsis, which can be life threatening. He had already failed outpatient management. Therefore, inpatient management was necessary at that point.
His care at the hospital was complex and included intravenous antibiotics, intravenous fluids, close monitoring of his electrolytes, gradual diet advancement, repeat blood culture and sub-specialty consultation (infectious disease). His care was not possible at a lower level of care.
According to et al : "Management of sepsis in children first requires prompt recognition. Attention needs to be paid to education and training of healthcare staff in the recognition of warning or adverse signs of sepsis in children and neonates to enable appropriate triage and rapid treatment. Child death reviews suggest failure to recognize severe sepsis and septic shock with delayed or inappropriate treatment at first contact with healthcare services.".
According to Marchello, Christian S., et al :"Non-typhoidal salmonella typically causes acute enterocolitis that is mild and self-limiting in most people. (1) The illness can also present as a febrile invasive disease often in the absence of diarrhoea, with bacteraemia, meningitis, or focal infections that, if untreated or improperly treated, can be fatal".
Therefore, the hospital stay at inpatient level of care was appropriate and medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe Renal Failure

Treatment surgical procedure on the kidney (transplant)

The insurer denied coverage for surgical procedure on the kidney (transplant)

The denial is overturned

The patient with severe renal failure which appears to be secondary to irreversible etiology and currently without contraindication to surgical procedure.
 
A systematic review of 110 studies encompassing almost 2 million patients concluded that kidney transplant was associated with better quality of life, fewer cardiovascular events, and lower long-term all-cause mortality than was chronic dialysis [1]
 
A subsequent study comparing 173 patients receiving intensive home dialysis (more than 16 hours per week) with 1517 kidney transplant recipients found, after multivariate adjustment, that receipt of kidney transplant was independently associated with a lower mortality risk and a higher 1-year hospitalization risk[2]. 
 
"In summary, our study shows that kidney transplantation is associated with superior treatment and patient survival compared with IHHD [intensive home hemodialysis]. By contrast, IHHD patients have a lower early hospitalization rate compared with kidney transplant recipients. Overall, this study emphasizes the relative benefit of kidney transplantation over IHHD." (Tennankore, K. K., et al. 2014).
 
Cadaveric and expanded criteria donor kidneys are appropriate when living donors are not available and for the elderly in whom the graft may last the lifetime of the recipient.

Results were consistent across different types of kidney donors and subgroups divided according to various recipient characteristics. Elderly adults with ESRD [end stage renal disease] who receive a KTx [kidney transplant] have greater survival than those who undergo home HD." (Molnar, M. Z., et al. 2016). "Several studies have shown that renal transplantation (RT) is safe and provides better survival, compared with dialysis, in patients of advanced age." (Segall, L., et al. 2016).

The insurer's denial of coverage for a surgical procedure on the kidney is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Immune thrombocytopenia purpura
Treatment: Nplate
The insurer denied Nplate.
The determination is overturned.

The patient has a diagnosis of immune thrombocytopenia purpura (ITP). She was diagnosed with ITP and was started on intravenous immune globulin (IVIG), with pulse dose steroids given. She had a platelet count of 12 thousand (K) and was given IVIG and dexamethasone. She has had significant menstrual bleeding due to her thrombocytopenia and requires iron supplementation due to the blood loss. She has continued to have issues with ITP (her platelet count was 18K) and her provider is now recommending Nplate therapy as treatment of her condition. Nplate was denied as she had not been treated with Ruxience, Truxima, or Riabni (rituximab formulations). The use of Nplate is under review.

The requested health service / treatment of Nplate is medically necessary for this patient.
This patient has chronic ITP that has failed treatment with both steroids and IVIG. The provider has recommended treatment with Nplate. As per the American Society of Hematology (ASH), the first-line therapies for children with newly diagnosed ITP are to be treated with corticosteroids, intravenous immunoglobulin, or anti-D immunoglobulin. Second-line therapies for those children with ITP lasting for 3 or more months include thrombopoietin receptor agonist (such as romiplostim), rituximab, or splenectomy, given in preferential order. The provider is recommending the top recommended treatment for chronic ITP issues.
As per Kim et al, second line agents are indicated for those children who do not respond or relapse after first-line agents. Medications such as Nplate are being used as the initial second line agent for pediatric ITP in preference over either rituximab or splenectomy. This information is echoed by DeSouza et al in their recent review.
This patient is being treated with the current standard of care, which per ASH is preferred over rituximab. Therefore, based on the clinical information provided for review, the current standards of care, and the peer-reviewed medical literature, the request for Nplate is medically necessary at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bronchiolitis.
Treatment: Full hospital admission.

The insurer denied coverage for full hospital admission.
The denial is upheld.

According to the documentation submitted, this is a male with no significant past medical history. He presented to the emergency room (ER) with complaints of a cough and fever. Heart rate was 153 beats per minute, respiratory rate was 45 breaths per minute, and temperature was 100.9 Fahrenheit. The physical examination revealed retractions and abdominal breathing. He was admitted with bronchiolitis. During the admission the patient was saturating well on room air. He was given intravenous (IV) fluids, nebulizers, nasal drops, and Tylenol as needed (PRN). He was discharged after a period of hemodynamic stability. 

American Academy of Pediatrics (AAP) guidelines for bronchiolitis is relaxed, and there is no requirement of supplemental oxygen unless there is oxygen saturation (SpO2) less than 90 and no need for even continuous pulse oximetry. 

The patient could have been managed at a lower level. There was no need for Magsulfate, no need for continuous nebulizer, no need for terbutaline drip or continuous steroids. The patient's lowest SpO2 was 90 percent. If one were to assess the asthma severity such as Pediatric Asthma Severity Score (PASS) or Pediatric Respiratory Assessment Measure (PRAM), the score would indicate that patient needed only a lower level of care such as observational status or outpatient. Furthermore, the chest x-ray was normal which is expected. Also, there was no underlying medical conditions such as chronic lung disease or congenital heart disease. There was also no need for bilevel positive airway pressure (BiPAP). The Hospital course was suggestive of rapidly improving clinical picture. Due to all the above reasons, the patient only required observational status care. 

There was no need for pressors and no need for positive pressure ventilation. The Pediatric Early Warning Score (PEWS) documented by nursing was always 0 which is a perfect score and predicted uneventful course. If one were to examine the Pediatric Risk of Mortality (PRISM) score, that would be low and desirable too; the PRISM score incorporates various clinical parameters and lab parameters [Glasgow Coma Scale (GCS) score, systolic blood pressure (BP), acid base values etc.] to synthesize a score system used in Pediatric Intensive Care Units (ICUs) to control for severity of illness or injury when comparing patients within and between ICUs.

The health plan acted reasonably with sound medical judgment 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: Overturned

Diagnosis: Fevers, chills, cough and Shortness of Breath
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a male with uncontrolled diabetes, hypertension, hyperlipidemia, and obesity. He presented to ER (emergency room) with fevers, chills, cough and SOB (shortness of breath).

The patient was in moderate respiratory distress, along with severe metabolic acidosis, hyperglycemia and had multifocal pneumonia due to COVID 19. The patient was admitted to acute inpatient level of care for the management of acute respiratory failure due to COVID 19 and severe sepsis due to COVID 19 as well as diabetic ketoacidosis due to sepsis.

The patient was treated with IV (intravenous) antibiotics, IV (intravenous) steroids, supplemental oxygen, remdesivir, and insulin. 

Yes, the Inpatient admission was medically necessary.
The patient was admitted with the diagnosis of acute respiratory failure due to COVID-19 pneumonia, severe sepsis due to COVID-19 pneumonia and uncontrolled diabetes. The patient was started on IV (intravenous) antiboitcs, IV (intravenous) remdesivir, IV (intravenous) steroids, as well as supplemental oxygen. The insulin dosage was adjusted for DM (diabetes mellitus) treatment. Despite ER (emergency room) care, the patient was in respiratory distress and had severe sepsis that would require inpatient level of care. The patient continued to have SOB (shortness of breath) and cough. The patient was seen by Infectious disease as well as pulmonary consultation. The patient remained on IV (intravenous) remdesivir, IV (intravenous) antibiotics, IV (intravenous) steroids and supplemental oxygen.

The entire admission was medically necessary, as the patient had acute respiratory failure due to COVID-19, DKA (diabetic ketoacidosis), and severe sepsis. He needed to be on IV (intravenous) antibiotics, IV (intravenous) remdesivir and IV (intravenous) steroids as well as supplemental oxygen.  The proposed treatment is medically necessary, as it is the current standard of clinical practice.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Myelodysplastic syndrome.
Treatment: 81455 - Comprehensive Genomic Profile.
The insurer denied the 81455 - Comprehensive Genomic Profile.
The denial is overturned.

The patient is a female with myelodysplastic syndrome. Attending physician performed genomic testing.

Yes, the health plan cover the proposed treatment.

Yes, the requested health service is more beneficial than any standard treatment for this insured's condition.

At this time, the National Comprehensive Cancer Network supports the use of molecular diagnostics in the evaluation and management of MDS (myelodysplastic syndrome). This testing can help further prognosis and help to guide therapy decision independent of conventional cytogenetics. This approach is now condensed standard of care and would be warranted.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Myelodysplastic syndrome.
Treatment: 81455 - Comprehensive Genomic Profile.
The insurer denied the 81455 - Comprehensive Genomic Profile.
The denial is overturned.

The patient in this case was diagnosed with myelodysplastic syndrome after presenting with leukopenia and anemia. Conventional cytogenetics were performed and were normal. Molecular testing was done using a panel.

Yes, the health plan should cover the proposed treatment.

Many different gene mutations can be identified in patients diagnosed with myelodysplastic syndrome. It is currently considered standard of care to perform molecular profiling in all cases of myelodysplastic syndromes. This information is important in assigning prognosis, which has a direct impact on treatment decisions. National Comprehensive Cancer Network (NCCN) guidelines recommend routinely testing for gene mutations in many different genes based on their documented impact on prognosis assessment and thereby recommendations for treatment. Given NCCN endorsement of this type of testing it should be covered by the health plan.

Yes, the requested health service is more beneficial than any standard treatment for the insured condition.

Molecular testing such as was done in this case is currently considered a standard test for patients diagnosed with myelodysplastic syndromes, as noted above.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity.
Treatment: Wegovy.
The insurer denied the Wegovy.
The denial is overturned.

The patient is a female. She reportedly has obesity and needs Wegovy.

The health plan denied coverage because coverage is provided if patient has lost at least 5% of baseline weight using Wegovy. Documentation of baseline weight and after Wegovy use is required.

The physician is appealing the decision, as the patient has lost > [greater than] 5% weight in 3 months since starting Wegovy.

Yes, the requested Wegovy is medically necessary.
The patient has lost more than 5% of her baseline weight while on Wegovy. Her baseline weight was 173 pounds. Her weight is now 156 pounds while on Wegovy for less than 3 months.

Wegovy is FDA (United States Food and Drug Administration)-approved for weight loss and is already working for this patient.

Therefore, given the above, the requested Wegovy is medically necessary and appropriate for weight loss for this patient, and is supported by current literature.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Non-Hodgkin's lymphoma.
Treatment: Laboratory Test (86152).
The insurer denied the Laboratory Test (86152).
The denial is upheld.

The patient is a male. The patient in this case has non-Hodgkin lymphoma. According to an appeal letter he was diagnosed with a pulmonary embolism and had been advised to delay biopsy of a known mass.  An oncologist caring for him obtained a BIOFOCUS test.  This is a blood test done to perform molecular analysis to determine which chemotherapy drugs should be used in the treatment of his disease.

No, the health plan should not cover the Laboratory Test (86152).
Testing of circulating tumor DNA (deoxyribose nucleic acid) to help determine sensitivity to specific chemotherapy agents for the purpose of aiding treatment decision making in patients with non-Hodgkin lymphoma is not currently considered a standard of care intervention and has not been shown to improve overall health outcomes.  This type of testing is not endorsed as a standard test by NCCN (National Comprehensive Cancer Network) guidelines under any circumstance and has not been shown in any prospective clinical trial to improve overall health outcomes in comparison to standard of care treatment.

No, the requested health service is not more beneficial.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Non-Hodgkin's lymphoma.
Treatment: Laboratory Test (86152).
The insurer denied the Laboratory Test (86152).
The denial is upheld.

The patient is a male with NHL (non-Hodgkin's lymphoma). His provider performed a CTC (circulating tumor cell) assay for chemosenstivity.

No, the health plan should not cover the Laboratory Test (86152).

No, the Laboratory Test (86152) is not more beneficial.
In vitro assays of chemosensitivity or resistance, such as the ChemoFX assay, or the extreme drug resistance (EDR) assay, are laboratory tests that have been developed as a method to select the optimal chemotherapy regimen (sensitivity assays) or identify those agents least likely to be effective (resistance assays). However, the utility of these assays has not been prospectively validated, and benefits have not been clearly demonstrated. ASCO (American Society of Clinical Oncology) guidelines continue to state that this testing is not supported or recommended in management of cancer patients. The NCCN (National Comprehensive Cancer Network) does not list any therapeutic role for this testing.