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

Diagnosis: Acquired absence of left leg below the knee (BKA), muscle weakness

Treatment: Skilled inpatient rehabilitation and nursing

The insurer denied coverage for skilled inpatient rehabilitation and nursing. The denial was reversed.

This patient is a male diagnosed with the following conditions; post- cholecystectomy syndrome, acquired absence of left leg below the knee (BKA), Type 2 Diabetes, acute kidney failure, anemia, alcohol abuse, hyperlipidemia, anxiety disorder and muscle weakness. The speech therapy report noted that the patient requires constant supervision 24 hours/day. The skilled nursing treatment interventions include: instructing and training the patient and attention processing techniques, cognitive communicative strategies, compensatory strategies, functional memory techniques and safe sequencing techniques in order to increase independence, and safety participation in activities daily living. Physical therapy noted that the patient had a left leg below the knee amputation. The left lower extremity range of motion was impaired. The right and left lower extremity strength was impaired as well as hip strength. The static sitting was fair and dynamic sitting, was poor. The static standing was unable and dynamic standing was not attempted.

The patient had ongoing significant medical issues just prior to a specified date as well as limited mobility and ability to take care of himself. He had a recent left below the knee amputation with uncontrolled diabetes as well as poorly controlled hypotension and high risk of infection s/p cholecystostomy drain; the drain was recently placed. Social work notes indicate that patient "has not been caring for himself properly." On a specified date therapy notes indicated that patient needs 2 assistants for ADLs. On another specified date Lantus was increased due to poor glycemic control.  On yet another specified date, the physician was called for uncontrolled hypotension. The patient was clearly not stabilized prior and recent post of date specified. The patient also needed to be properly trained in safely and mobility related to left below the knee amputation (BKA). 

Therefore, continued skilled nursing was medically necessary past a specified date. The patient was not medically stable and could not take care of himself at home. Although he had help from a friend, he does live alone and was not able to perform his activities of daily living (ADL's) on his own.  He needed assistance for mobility and was not properly trained post left BKA. Therefore, the previous denial was inappropriate. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

Based on the above, the medical necessity for skilled inpatient rehabilitation and nursing to discharge is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Spontaneous rupture of the amniotic membranes; abdominal pain 
Treatment: Inpatient stay

Summary:
The patient is a G2P0100 female.  She presented to the hospital at 30 weeks two days for lower abdominal cramping every five minutes.  A cerclage had been placed for a prior history of a previable spontaneous preterm delivery.  Her pregnancy was also complicated by diabetes and hypothyroidism, and it was conceived by IVF (in vitro fertilization) with donor eggs. 

The inpatient admission was medically necessary.  The patient met diagnostic criteria for the diagnosis of prelabor preterm spontaneous rupture of membranes after observation in the hospital for one day.  The standard of care for this condition is continuous hospitalization for prolonged monitoring until development of complications such as chorioamnionitis, labor, significantly abnormal fetal heart rate tracing, or the achievement of 34 weeks of gestation; delivery is then indicated for any of these conditions.  In addition, intravenous followed by oral antibiotics, antenatal steroids, and fetal heart rate monitoring are indicated as were given to this patient.  

In this case, the patient developed clinical evidence of chorioamnionitis at 33 weeks, at which time she was delivered.  Therefore, the hospitalization was medically necessary, as it is the standard of care for prelabor preterm spontaneous rupture of membranes as recommended by the American College of Obstetricians and Gynecologists.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cognitive impairment, CHF, gait ataxia
Treatment: Increase in personal care assistance hours from 56 hours per week to 84 hours per week

The proposed treatment of an increase in personal care assistance hours from 56 hours per week to 84 hours per week is deemed medically necessary. 

This is a female with a history of cognitive impairment, congestive heart failure, gait ataxia and malignant hypertension. Due to these conditions, she requires assistance with the majority of her activities of daily living (ADLs). Per documentation from the patient's Attending Physician, the currently approved plan of 56 hours of PCA per week is not sufficient to meet the patient's needs as she lives alone and is dependent on assistance with all of her major ADLs. For these reasons, the proposed treatment of an increase in personal care assistance hours from 56 hours per week to 84 hours per week is deemed medically necessary for improved assistance with the patient's ADLs.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Issue under review: Increase in PCA services

Determination:
The Increase in PCA services is medically necessary.

The patient is an elderly female with a history of dementia. Due to impairments related to these conditions, she does require assistance with the majority of her activities of daily living. Recent documentation from the patient's health care providers indicates that this patient sustained a traumatic fall injury, sustaining a left arm fracture. Although she requires surgery to be able to use that arm and bear weight, due to her advanced age and issues with general anesthesia, she is not considered a good candidate for surgical repair. Since sustaining this fracture, the patient has been unable to raise herself from a prone position or seated position, as her left arm is unable to support her weight. In addition, without the ability to put weight on that arm, her ability to ambulate has also decreased. Hence, the currently approved plan is not sufficient to meet the patient's needs. For these reasons, the proposed treatment of an increase in PCA services is deemed medically necessary for increased assistance with the patient's ADLs.
Appeal type: Medical necessity
Decision: Upheld

Headache
Nursing Services (including Private Duty Nursing)

The patient is a female with multiple medical problems. She requests continuation of personal care service hours, 40 hours per week. The services were decreased as per her health insurance plan stating that the original 40 hours a week were noted in error. Currently, she is approved for 25 hours per week in transition.

The health plan's determination is upheld. The Increase in Consumer Directed Personal Assistance Services (CDPAS) from 25 Hours per Week to 40 Hours per Week is not medically necessary for this patient. The 25 hours per week of consumer directed personal care services are adequate to meet the patient's needs. Additional service hours are not medically necessary. The Uniform Assessment System (UAS) State of New York noted following: The patient is independent with grooming, toileting, walking, moving around in bed and changing positions and eating. The patient is noted to be safe at home and has not had any falls or emergency room visits. The patient is able to walk independently without an assistive device. She has rare urinary incontinence. Service hours are mainly for housekeeping, meal preparation and transport. The patient lives with her husband and children. No one works outside the home. The assessment noted that the patient was independent with personal hygiene. Cognitive assessment showed patient decisions are consistent and reasonable.
It is not unreasonable to expect the patient's husband assist with normal daily tasks, IADLs (Instrumental Activities of Daily Living) which any other typical spouse would assist with. The requested services are not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Glioma
Issue under review: Mekinist

Determination:
The treatment with Mekinist is medically necessary.

The patient is a teen-aged female with a diagnosis of neurofibromatosis type I who was diagnosed with a low grade glioma of the cerebellum. She had a tumor biopsy and has had progression of the tumor.

Neurofibromatosis I (NF1) is an autosomal dominant tumor predisposition disorder that affects about one in 3,000 people. The NF1 gene is located on chromosome 17q11.2. It encodes for neurofibromin, a cytoplasmic protein that is expressed in the nervous system. Neurofibromin negatively regulates proto-oncogene RAS and acts as a tumor suppressor through the reduction of cell proliferation and differentiation by preventing the activation of downstream signaling pathways such as PI3K/AKT/mTOR and Raf/Mapk/MEK/ERK. As a result, an individual with NF1 has a predisposition to develop both benign and malignant tumors. Patients with brain tumors have limited options for treatment as radiation therapy is contraindicated due to the risk of secondary malignancy. Low grade gliomas are sometimes characterized as a chronic disease as the ten-year survival is greater than 95%. Gross-total resection is reported in 94% of cerebellar tumors but only 3.2% of hypothalamic and/or chiasmatic tumors. The rate of progression ranges from 50% to 80% in tumors for which gross-total resection is not achievable. 

Increasing sophistication in genetic testing has allowed for the detection of specific mutations within tumor subtypes that could represent targets for individualized tumor treatment. The MAPK pathway and, more specifically, BRAF mutations have been shown to be prevalent in pediatric astrocytomas and could represent important areas to target. Pathways identified in tumorigenesis are the targets for many inhibiting or altering agents. However, as the MAPK pathway is involved in development, inhibition of this pathway could lead to widespread unintended results. Therefore, identifying and targeting specific anomalies in the pathway have become goals in treating tumors with these mutations. Due to the rarity of these tumors there are no large phase III clinical trials to guide therapy in recurrent disease. Several case reports and case series have demonstrated the effectiveness and safely in young children with low grade glioma. In one study of six patients, two partial responses and three minor responses as best response were noted; three of these patients are still on therapy. 

The use of Mekinist for the treatment of low grade glioma in this patient is medically necessary.

This patient with neurofibromatosis with a low grade glioma has no other treatment options. The use of Mekinist for this indication has been shown to be safe and effect and its use in this patient would be considered medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of hypertension, hyperlipidemia, gastritis and a stroke. He presented to the emergency department complaining of one week of intermittent palpitations and chest heaviness. His blood pressure was 101/63 millimeters of mercury (mmHg) with a heart rate of 164 beats/minute. Other than tachycardia, his cardiovascular exam was unremarkable. His electrocardiogram showed a narrow complex tachycardia. His serum sodium was low at 128 milliequivalents per liter (mEq/L); his creatinine was mildly elevated at 1.22 milligrams per deciliter (mg/dl). His troponin level was normal. His chest x-ray was unremarkable. His rhythm converted to sinus with a dose of intravenous adenosine. He was treated with intravenous saline and admitted to the hospital. He remained in sinus rhythm. An echocardiogram showed hyperdynamic left ventricular systolic function. He was to be transferred to another institution for catheter ablation, which was recommended. The health plan's determination is upheld.
This patient presented with paroxysmal supraventricular tachycardia (PSVT). He was hemodynamically stable and the tachycardia was terminated with a single dose of intravenous adenosine. While there are no clear guidelines regarding disposition for patients presenting to the emergency department with PSVT, most authors suggest that, in the absence of serious comorbidities, syncope, or rapid pre-excited atrial fibrillation or flutter, hospital admission is not necessary for adults whose PSVT is converted to sinus rhythm without complications. One single-center, retrospective study of patients presenting to emergency department with PSVT found that 71% were discharged home after an average stay of four hours. The 24-hour recurrence rate in those patients was less than 5%. Likewise, data from the National Hospital Ambulatory Medical Care Survey 1993-2003 database revealed a 76% discharge rate for PSVT after evaluation in the emergency department. While this patient complained of chest pain, this is common in PSVT, even in the absence of coronary artery disease. His serum troponin level was normal.
In summary, this episode of hemodynamically stable PSVT that was terminated with intravenous adenosine did not require an inpatient admission. Given the patient's hyponatremia, overnight observation and intravenous hydration was a reasonable approach. However, his mental status was normal, he did not require treatment with hypertonic saline, and this did not require an inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Chest pain syndrome
Treatment:  Cardiac positron emission tomography scan
The cardiac positron emission tomography (PET) scan is medically necessary.

The patient had chest pain syndrome with cardiac risk factors of dyslipidemia, overweight, hypertension, current smoking, sedentary lifestyle, and a family history of cardiovascular disease.  The stress test and myocardial perfusion SPECT (single photon emission computed tomography) test were both positive for coronary artery disease, and an inferior, inferoseptal, and apical scar, but peri-infarct ischemia could not be excluded, as they were suboptimal.  A cardiac PET scan was ordered to determine if revascularization would be beneficial.  A coronary artery angiogram would not provide this information.  

A paper by Bober in 2019: "Revascularization targeted to regions with reduced CFC and relative perfusion abnormalities on baseline PET yielded significant improvements in sMBF.  When revascularization was performed in regions without reduced CFC, sMBF did not improve."  A review paper by Chen, in 2019, states that "PET-based cardiac nuclear imaging plays a large role in the management of ischemic heart disease.  Compared with conventional single-photon emission CT myocardial perfusion imaging, PET provides superior accuracy in diagnosis of coronary artery disease and, with the incorporation of myocardial blood flow and coronary flow reserve, adds value in assessing prognosis for established coronary and microvascular disease."
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Relapsing remitting multiple sclerosis

Treatment: Gammagard Liquid

The insurer denied coverage for Gammagard Liquid. The denial was reversed.

This patient is a female who has previously been diagnosed with relapsing remitting multiple sclerosis almost 2 decades prior. The submitted documentation detailed that this patient has been on intravenous immunoglobulin (IVIG) monthly for a couple of years with concurrent Ocrevus. She continues with persistent lymphopenia with a history of infectious complications and IVIG has been helpful in limiting infections according to the physician.  In mid-2019 this patient was seen for a follow-up.  It was noted that the patient's last Ocrevus infusion was in early 2019.  She was seen in mid-2019 for a worsening right-sided tremor and was given low-dose Topamax which did not have significant benefit.  The patient stated walking continued to be an issue.  She continued to be limited significantly by tremor and finds it socially embarrassing.  She also continued to complain of headaches.  She was given a trial of lidocaine injections which was helpful for approximately two weeks.  She continued with nortriptyline which did not provide much benefit.  

She has been treated with Tysabri which she discontinued due to being John Cunningham virus (JCV) positive. A couple years ago she received half doses of Ocrevus due to persistent leukopenia.  She has been on monthly IVIG since late 2017 and it is recommended that this patient continue with IVIG treatment and infusions of Ocrevus.

The medication Gammagard Liquid for the patient's multiple sclerosis is considered medically necessary for this patient.  As noted above, IVIG therapy is typically reserved for more severe cases of relapsing/refractory MS, such as this case. A 2017 review stated "IVIG should be considered a potentially effective second-line treatment in relapsing-remitting MS."

The healthcare plan did not act reasonably or with sound medical judgment or in the best interest of the patient.

The carrier's denial of coverage for the medication Gammagard Liquid for multiple sclerosis is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: M54.16 (Radiculopathy, Lumbar Region), M54.5 (Low Back Pain), and M99.03 (Segmental and Somatic Dysfunction of Lumbar Region)
Treatment: Continued chiropractic services

The medical necessity for the ongoing course of chiropractic therapy is not established upon review of the documentation made available.

The records indicate that the patient presented to the office of the attending chiropractic provider as an established patient on with a reported new complaint of low back pain. The records made available for review fail to identify what treatment had transpired prior to this date and similarly, what progress had been documented in the dates of service leading up to this date. However more importantly, the records made available for review do not unequivocally document that the patient had made measurable objective progress in the protracted course of care from the date of presentation to the date of service under review.  

As of the date of service under review, the patient had participated in a course of care of nearly six months. The records do not establish that the patient's condition was of such complexity to require the administration of a course of chiropractic care six months in duration. Moreover, the records fail to establish through regular and timely collections of measurable objective data at the time of the initial evaluation  and throughout the course of care lasting until the date of service under review to document that the patient was continuing to measurably and objectively improve in response to the ongoing course of chiropractic intervention. Moreover, the case notes report that the patient's subjective pain levels were improved in the beginning, however, the case notes indicate that the patient's subjective pain levels did not improve or progress from that point and forward. 

Absent documented evidence that the patient was continuing to measurably progress from a subjective and/or objective standpoint, the records would not support the medical necessity for ongoing similar chiropractic intervention for the same/similar condition as effective for the patient's condition during the dates of service in question.

As noted above, the records fail to establish that the patient was continuing to measurably and objectively progressed in response to the ongoing course of chiropractic intervention. The documentation made available for review would not establish any reasonable expectations that continued chiropractic care forward would likely result in ongoing measurable medical benefit from an objective standpoint to the patient. As such, the records would support that the health plan acted reasonably in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Deconditioning and H.pylori infection
Treatment: Skilled nursing facility 
The proposed skilled nursing facility stay is not medically necessary. 

The member is a male with history of headache, abdominal pain and vomiting with loss of consciousness and admitted for deconditioning and treatment for Helicobacter Pylori infection.

The patient's relevant past medical history includes human immunodeficiency virus (HIV), hypertension, bipolar disorder, post-traumatic stress disorder (PTSD), benign prostatic hyperplasia (BPH), gastritis, duodenitis, proctitis, etc.

The continued stay in skilled nursing facility is not medically necessary because the patient was admitted to SNF and as of 41 days later, he was totally dependent for stairs with muscle strength of 3-/5 in lower extremities, required moderate assistance with toileting, bathing, lower body dressing, bed-mobility, pivot stand, sit-to-stand, requiring minimum assistance for 40 feet of ambulation, toilet/commode transfer, requiring contact-guard with upper body dressing, etc. This is the same level of functioning since 27 days prior, showing no tangible improvement.  The plan is to discharge him home. 

Therefore, continued stay in SNF from is not medically necessary as the patient has not shown any tangible improvement for almost a month and his needs can be met at a lower level of care.

The continued stay in SNF was not medically necessary with clinical evidence as stated above showing no tangible improvement that further stay in SNF is not reasonably expected to be health beneficial for the patient and/or withholding it in whole or in part be reasonably expected to affect the patient's health adversely as the patient's needs can be met at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Emesis
Treatment: Inpatient Stay
The Inpatient admission was not medically necessary.

Summary:
The patient is a male patient who had a history of depression as well as anxiety. The patient presented not having eaten for five days, having emesis after meals with associated nausea, having streaks of blood at times, and noting weight loss for the prior three months. He noted watery diarrhea two to three times a day, and his last bowel movement was two days prior to presentation. He had not been compliant with his psychiatric medications but was taking OTC (over-the-counter) preparations for his body aches. He reported 8/10 pain. 

Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had volitional anorexia as a result of non-compliance with his psychiatric medications, yet he did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for NPO (nothing by mouth) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission.  As such, the care could have been rendered at a lesser level.