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

Diagnosis: Fusion of spine, lumbar region 
Treatment: Continued stay in subacute rehabilitation
The health plan denied the requested continued stay in subacute rehabilitation as not medically necessary.
The health plan's determination is upheld.

This is a case review for a male admitted to subacute rehabilitation for the diagnosis of lumbar spinal fusion, acute and subacute endocarditis, unspecified mycoses, protein calorie malnutrition, neuromuscular dysfunction of the bladder, anxiety and hypertension. 
The patient was admitted to the hospital for (lumbar) L3-L4 osteomyelitis. A transesophageal echocardiogram (TEE) was performed and showed mitral and aortic valvular vegetations. He had an L4/L5 laminectomy, bilateral foraminotomy, and bilateral neural lysis. He developed a postoperative ileus during his recovery. He completed a six-week course of intravenous (IV) antibiotics for endocarditis. He was deemed stable for discharge and was admitted to the subacute rehabilitation facility. They planned to do an interval surgery for aortic valve replacement following his recovery.

The patient progressed well in the subacute rehabilitation facility and received regular physical therapy. He was notified that his approval for the stay at the rehabilitation facility would be ending. The patient was not compliant with providing financial information to the social workers and care managers to allow them to find alternative placement options. He stated he could not return home due to incontinence and wound care needs. He was offered assistance with home health and obtaining personal care assistance but declined. He was ultimately referred to some Medicaid accepting facilities.
At issue is the medical necessity for the requested health service/treatment of continued stay in subacute rehabilitation.

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

The requested health service/treatment of continued stay in subacute rehabilitation has not been demonstrated to be medically necessary for this patient.

The patient had a prolonged hospitalization and is expected to need an extended period of therapy and rehabilitation. However, he showed good progression toward his goals over six weeks of subacute rehabilitation and appears to meet criteria for discharge to a lower level of care. He was not yet functioning at the same level as he was prior to admission, but assistance with wound care and personal care could be arranged on an outpatient basis.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Upper extremity contractures, spastic quadriplegia

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This is an adult with a history of upper extremity contractures related to traumatic brain injury (TBI), spastic quadriplegia, deep vein thrombosis (DVT), and seizures. The patient presented to the hospital for a scheduled elective right shoulder/elbow/wrist tenotomies, capsular releases, bicep tendon lengthening, flexor pronator slide, hand intrinsic releases, proximal row carpectomy, wrist arthrodesis, recurrent radial perforator flap. The patient was placed in a long arm fiber glass cast. The patient tolerated the procedure well. The patient was discharged after a period of hemodynamic stability. 

The medical records show a complex, unique and extensive surgical procedure was performed. The physician reported at the very least thirty procedures. The anesthesia time was nearly eight hours and surgical time was six hours. The physician placed three drains with documentation of close wound care. This person would be at extremely high risk for bleeding and possible compartment syndrome post operatively. These procedures would be very painful as they included the entire upper extremity including shoulder, elbow and wrist. 

This type of operation cannot be performed in an ambulatory surgical unit (ASU) or lower level of care. Considering the overall medical condition and associated comorbidities, a higher level of service would be imperative.

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: Overturned

Diagnosis: Morbid obesity

Treatment: Surgical procedure on the stomach

The insurer denied coverage for surgical procedure on the stomach

The denial is overturned

According to the documentation provided by the provider, the patient has a Body Mass Index (BMI) of 39 and has a history of sleep apnea as well as fatty liver. She has been actively participating in efforts to lose weight non surgically and has been following up monthly. The medical workup has been completed. The provider reviewed with the patient the expectation pre and post-surgery and risks and benefits. The patient was felt to be a good candidate for bariatric surgery. The patient was seen previously by the provider for a follow up appointment for bariatric surgery. The note indicated the patient has been compliant with workup. The patient was seen previously by this provider who noted the BMI of 38.6 and noted that the patient had a long-standing history of morbid obesity and presented for discussion of bariatric surgery. As per the note she has failed attempts with weight loss and exercise programs. The plan was a workup including endocrine screening, sonogram of the abdomen, Thyroid Stimulating hormone (TSH) and hemoglobin A1c (HBA1c).

The patient was found to be psychiatrically cleared for bariatric surgery. The patient was seen for nutrition visits where her BMI was noted to be 39, 38.6, respectively. Weight loss history questionnaire was completed. The note recommended the team should proceed with surgery. 

The patient was seen by provider for pulmonary clearance and noted no pulmonary contraindication to proceed with surgery. Sleep study done showed severe obstructive sleep apnea (OSA).

Abdominal sonogram revealed a fatty liver without gallstones.

Based upon the records provided and Milliman Care Guidelines (MCG) guidelines, the patient does meet the criteria and indications for bariatric surgery. 

Thus, the patient meets the current revised guidelines as her BMI was greater than 35 and she also has severe apnea. In terms of the insurer denying based upon thyroid evaluation the patient's TSH level was normal and therefore no further evaluation should have been required. Therefore, the patent does meet the guidelines for bariatric surgery.
	
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 a surgical procedure on the stomach is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Thyroidectomy

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld
 

According to the patient's medical record, this is the case of a patient with the history of hypertension, neoplasm of the thyroid gland and sleep apnea who was admitted for elective thyroidectomy. The patient was seen preoperatively for medical clearance and was found to be medically stable for surgical procedure. As per the brief operative note right lobe thyroidectomy was performed. Surgery was uneventful. Postoperatively the patient was stable and was discharged from the post anesthesia care unit (PACU). 

Progress notes indicated that the patient's voice was clear and not hoarse and at baseline. The RN did report that patient desaturated to 89-90% while asleep. The vitals were reviewed and oxygen saturation was 95-97% with patient awake and when asleep desaturates consistent with sleep apnea. The provider spoke to the patient's daughter who confirmed the history of sleep apnea. The decision was made to keep the patient overnight for respiratory monitoring due to sleep apnea history.

She was cleared for discharge when she was tolerating diet, her pain was well controlled, and her vital signs were stable.

Based upon the information provided, the inpatient admission  was not medically necessary as the patient should have been managed with a 23-hour observation. The patient should have been monitored with a short stay 23-hour monitoring which would have included appropriate postop monitoring and care. According to Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care 27th Edition Thyroidectomy ORG: S-1090 (ISC) the operative status goal is ambulatory.  Extended Stay as defined by Minimal (a few hours to 1 day), Brief (1 to 3 days), Moderate (4 to 7 days), and Prolonged (more than 7 days) is indicated for select situations.  Inpatient stay may be needed for selected patient factors, which include: 1) extensive thyroid carcinoma requiring lymph node dissection; Large substernal extension of goiter; Graves' disease with large goiter and marked elevation of thyroid hormone; Severe co morbidities (e.g., heart failure, chronic obstructive pulmonary disease (COPD), diabetes mellitus); or 2) Complications of procedure including: Postoperative hematoma or neck swelling requiring close observation; Recurrent laryngeal nerve injury or edema sufficient to cause respiratory compromise or bilateral vocal cord palsy; Postoperative hypocalcemia not easily stabilized with oral calcium supplementation; or Thyroid storm; or 3) Failure to achieve discharge status criteria. 

The patient did not meet any of these criteria and therefore could have been safely monitored in a 23-hour setting and discharged without having an acute inpatient admission.  

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: Diabetes, low back pain, anxiety, asthma, depression, and hypertension
Treatment: Consumer Directed Personal Assistance (CDPAS) (CPT T1019)
The insurer denied: Consumer Directed Personal Assistance (CDPAS) (CPT T1019)
The denial is Upheld

The patient is an adult male. His conditions include diabetes, low back pain, anxiety, asthma, depression, and hypertension. He reportedly has difficulty with cleaning and organizing his apartment. The patient's provider reports that the patient's chronic conditions affect his ability to perform ADLs (activities of daily living) and housekeeping. Denial of Consumer Directed Personal Assistance (CDPAS) is being appealed. Uniform Assessment System (UAS) evaluation completed last year shows independent cognition and functional status. The patient is independent with all ADLs (activities of daily living), except limited assistance with housework. He is continent of bowel and bladder.

The requested Consumer Directed Personal Assistance is not medically necessary. 

Personal Assistance Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. This patient has multiple chronic conditions. Denial of Consumer Directed Personal Assistance (CDPAS) is being appealed. The health plan denied CDPAS (consumer directed personal assistance services) because the UAS (Uniform Assessment System) evaluation did not show that the patient needs assistance with ADLs (activities of daily living). Uniform Assessment System (UAS) evaluation completed last year shows independent cognition and independent functional with ADLs (activities of daily living), except housekeeping. CDPAS (consumer directed personal assistance service) is not indicated for housekeeping and when no tasks are being performed. The requested CDPAS (consumer directed personal assistance service) is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hemoptysis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

 
This is the case of an adult patient with a history of hypertension, ankylosing spondylitis, kidney transplant. He has a history of renal artery stenosis in transplant renal artery. He now presented as a direct admit complaining of spitting up blood for a few weeks. He had discussed this with his provider who suggested he have a dental check. This was done and the patient was told all is good. The patient also reported an episode of blood from his penis during intercourse which made him nervous and again called his provider who told him to go to the hospital for further workup. Medications included aspirin (ASA) and Plavix as well as immunosuppressants. Exam was unremarkable. He was admitted to transplant surgery.  Labs included Hematocrit 40.4 and platelet count of 150. The Plavix and ASA were held.

Computed tomography (CT) of the chest was performed and was found to be unremarkable. Interventional Radiology (IR)  was consulted regarding the single agent anti platelet given the patient that was 6 months post stent placement. The plan was not to restart either ASA or Plavix today.

IR saw the patient and recommended that they can stop the Plavix but continue ASA.

Progress note indicted vital signs were stable. The patient was found to be stable and was discharged to home after a period of hemodynamic stability.

Based upon the records provided, the patient did not require acute inpatient admission since he could have been managed in an observation status. He did not require an acute inpatient admission but rather observation status. 

Based upon  guidelines the patient does not need to be in an inpatient stay but rather observation. All that was needed was to hold the Plavix and to document that there was no significant pathology causing the hemoptysis. This could have all been done in an observation setting.

The patient was admitted and had his Plavix held. He had a computed tomography (CT) of the chest which was unremarkable. Bleeding is a known complication of Plavix and he did not need to be acutely admitted but rather observed. Furthermore his Hematocrit was stable- thus showing that he was not having significant 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 the inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Breathing Problem.
Treatment: Inpatient emergency admission.
The health plan denied: Inpatient emergency admission.
The determination is: Overturned.

The patient is a female with a past medical history significant for chronic heart failure due to ischemic cardiomyopathy, prior myocardial infarction (MI) with percutaneous coronary intervention (PCI), prior cocaine and tobacco use, hypertension, chronic obstructive pulmonary disease (COPD) with chronic hypoxic respiratory failure on 2 liters per minute (LPM) via nasal cannula (NC) oxygen, and advanced chronic kidney disease (CKD), who was brought by Emergency Medical Services (EMS) to the emergency department (ED) for evaluation of worsening shortness of breath, paroxysmal nocturnal dyspnea (PND), orthopnea, and leg swelling. She admitted to noncompliance with medical therapy and fluid restriction. In the ED, the patient appeared to be in respiratory distress requiring uptritraton of her home oxygen to 5 LPM, and she refused bi-level positive airway pressure (BiPAP). The brain (or B-type) natriuretic peptide (BNP) was high. A chest x-ray (CXR) showed pulmonary vascular congestion. The patient was admitted to the inpatient level of care for evaluation and treatment of acute on chronic heart failure with volume overload and COPD exacerbation. The patient was initiated on treatment with intravenous (IV) Lasix twice daily, IV solumedrol, and DuoNebs with plans for an echocardiogram and renal evaluation with a urinalysis (UA)/renal ultrasound (US); however, the patient left the hospital the following day against medical advice (AMA).
At issue is the medical necessity of the inpatient emergency admission.
The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of inpatient emergency admission is medically necessary for this patient. This medically complex patient presented with respiratory distress and acute on chronic respiratory failure due to acute heart failure/COPD exacerbations and severe renal failure. She required an increase in the level of supplemental oxygen to help relieve dyspnea with plans for aggressive IV diuresis and evaluation for renal failure. There was an anticipated need that inpatient hospital care services would be necessary for at least 2 midnights. Furthermore, the combination of acute on chronic hypoxic respiratory failure, high BNP, and renal failure is indicative of increased risk for progressive end-organ failure including respiratory failure, need for intubation, and mortality, supporting the inpatient level of care in this case. Due to the high-risk features of this patient's acute heart failure exacerbation with associated high level of medical complexity, the inpatient level of care would be supported by peer reviewed medical literature and expert consensus guidelines on acute heart failure management [1-5].
Appeal type: Medical necessity
Decision: Upheld

Cardiac
inpatient hospital

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

This case involves a 62-year-old a woman admitted to the hospital for low back pain and elevated blood pressure. She has chronic hypertension and chronic back pain, ambulated with a cane, and was referred to the hospital due to elevated blood pressure. The emergency room (ER) measured her blood pressure, which was elevated over 200 systolic. The previous day, at the PCP (primary care provider) office, the patient's blood pressure was reportedly 140/90. She takes lisinopril, hydrochlorothiazide, and metoprolol for blood pressure. She denied headache or vision changes, and the head computed tomography (CT) in the ER was unremarkable. 

The inpatient hospital stay was not medically necessary. The patient presented with elevated blood pressure and an appropriate response to medical therapy. At no point in time was there evidence of end-organ damage caused by a hypertensive emergency. The patient has no symptoms of elevated blood pressure, as documented in the progress notes, including no chest pain, shortness of breath, lightheadedness, or headache. The imaging of the head was unremarkable, and the laboratory studies were undeniably normal. There was no clear reason to pursue evaluation for secondary causes of hypertension in the hospital setting when the patient had relatively controlled blood pressure. This can be done at a lower level of care. There were significant delays, and obtaining the echocardiogram, and a renal artery ultrasound, further prolonged the patient's hospital stay without clear indication. The entire evaluation and treatment could have been completed under a lower level of care, with subsequent follow-up in the outpatient setting to complete the workup.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic low back pain 
Treatment: Nerve treatment in the spine (Intracept Procedure for intraosseous ablation of basivertebral nerve, code 64628)
The insurer denied coverage for Nerve treatment in the spine (Intracept Procedure for intraosseous ablation of basivertebral nerve, code 64628). 
The denial is upheld. 

This adult has chronic low back pain. His medication trials have included Mobic, Methocarbamol, and Gabapentin. He has done Physical Therapy and a Home Exercise Program. He had Transforaminal Epidural Steroid Injections with good effect. His magnetic resonance imaging (MRI) shows at lumbar (L)4-L5 a Posterior Disc Herniation and Annular Fissure which displaces the sacral (S)1 nerve root. And at L5-S1 there is a posterior midline disc herniation displacing the S1 nerve roots bilaterally. The physical exam does not document Achilles Tendon reflexes. The physician documents L5 and S1 Modic type II changes but this is not documented in the official radiology report. There is no documentation of a surgical consult to address the disc herniations.

The publications to date have been company sponsored and had methodology flaws. There are no published data on long term complication rates. There are other evidence- based interventions available to this patient. This procedure is unlikely to be more beneficial than the standard approaches. 

Similarly, a clinical practice guideline (4) while favorable pointed out the limitations of the current literature:

- Industry funding is a potential source of study bias for the available data reviewed.
- Limited number of studies.
- Short-term follow up for the majority of studied patients.
- Unknown effect on the primary degenerative process

Urits et al (5) also commented on the need for more research on this promising technique:  "reproducible large RCTs are still needed for clinicians to gain full confidence in utilizing this treatment in practice. Additionally, further research is needed on the anatomy of the vertebrae to optimize the method of treatment. These studies can help to elucidate the role of RF ablation in the management of chronic low back pain (CLBP) and improve the quality of life of CLBP patients in the near future."

In sum, this procedure is NOT likely to be more beneficial than the standard of care.

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 Intracept Procedure for intraosseous ablation of basivertebral nerve, code 64628 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumomediastinum and Subcutaneous Air in the Neck.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is overturned.

The patient is a toddler male with presentation of respiratory syncytial virus (RSV) bronchiolitis. The patient was followed by their general pediatrician and was found to have respiratory syncytial virus (RSV+). The patient had increased work of breathing, and other respiratory symptoms indicative of increased respiratory effort when patient had a chest x-ray done which showed a pneumomediastinum. The patient, on exam in the emergency department, had crackles, wheezing, continued respiratory distress symptoms on physical exam indicative of 
a concern for respiratory decompensation. The patient received intravenous steroids, nebulizer treatments, and required serial exams to ensure he was not developing a pneumothorax or any cardiac symptoms from a worsening pneumomediastinum. The patient required a trauma assessment after falling off of a stretcher while in the emergency room.

The treatment was medically necessary.

As per the assessment of the physician, the patient had multiple exam signs of respiratory distress on auscultation as well as on exam. The patient had wheezing, crackles and retractions.
The patient had developed pneumomediastinum in the presence of increased respiratory effort that was worsened with respiratory syncytial virus (RSV). With the increased respiratory effort and distress noted as well as the developed pneumomediastinum, the patient was at a higher risk for clinical deterioration that could have been rapid and thus required the inpatient stay for close observation and access to immediate care.