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

Diagnosis: Varicose veins

Treatment: outpatient surgery (36475 x 1, 37766 x 1, 37765 x 1)

The insurer denied coverage for outpatient surgery (36475 x 1, 37766 x 1, 37765 x 1)

The denial is upheld

 
The patient is an adult female seeking coverage for outpatient surgery (36475 [Endovenous ablation therapy of incompetent vein] x 1, 37766 [Stab phlebectomy of varicose veins] x 1, and 37765 [Stab phlebectomy of varicose veins] x 1).  

The patient presented for bilateral varicose vein insufficiency ultrasound.  The patient had edema in the bilateral lower extremities with the right being worse than the left.  The legs felt heavy and tired, and the symptoms worsened at the end of a long day.  The varicosities produced a throbbing pain and had become pruritic.  The patient had worn compression stockings without sufficient relief.  The ultrasound showed no intraluminal thrombus in the right and left great saphenous vein/small saphenous vein.  Deep varicose vein insufficiency was observed in the right common femoral vein, femoral, and left common femoral veins.  There was superficial varicose vein insufficiency.  The patient tried conservative treatment without significant improvement in symptoms.  There was a plan to proceed with right leg great saphenous vein ablation and phlebectomies.

A venous duplex study of the patient's bilateral lower extremities noted right saphenofemoral junction diameter of 0.676 centimeters (cm), mid-thigh diameter of 0.650 cm, knee diameter of 0.512 cm, mid-calf diameter of 1.485 cm, and ankle diameter of 0.471 cm.

In this case, the patient had symptomatic venous insufficiency of the right lower extremity.  The patient had been treated conservatively without significant symptom improvement.  The patient's symptoms were worsening.  The provider clarified that there was no severe swelling or infection.  The patient reportedly had evidence of sufficient arterial perfusion given palpable pulses on exam.  The provider recommended greater saphenous vein ablation with phlebectomies.  While increased vein diameter is a common consequence of vein reflux, the provided duplex study did not report on valve closure time to identify if there was greater than 500 milliseconds (ms) of reflux in the symptomatic veins to support the requested ablation (36475).  Additionally, while the treating provider indicated that there was sufficient arterial perfusion, the exam findings found within the clinical records did not specify palpable pulses to support the stab phlebectomy.  As such, the denial of coverage for outpatient surgery (36475 x 1, 37766 x 1, 37765 x 1) is upheld.

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 outpatient surgery (36475 x 1, 37766 x 1, 37765 x 1) is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

This woman presented to the emergency department (ED) complaining of a 15 minute episode of chest pain associated with palpitations that persisted upon arrival in the ED. Her medical history was remarkable for type 2 diabetes, hypertension, hyperlipidemia and recent COVID-19 infection. She reported noncompliance with her prescribed medical regimen. In the ED, her blood pressure was 182/112 with a heart rate of 116 beats/minute. Her room air oxygen saturation was 98%. An electrocardiogram showed sinus tachycardia without acute changes. Her troponin I level was mildly elevated at 0.07. Chest X-ray showed no acute pathology. Her blood glucose was 524. Her serum creatinine level was 0.61. Her arterial potential hydrogen (pH) was normal at 7.44. Her anion gap was normal. Her D-dimer level was elevated. Chest computed tomography (CT) angiography showed no evidence of pulmonary embolism. The patient was treated with intravenous fluid, insulin, aspirin and amlodipine. She was admitted to the hospital. 

Based on the documentation provided an inpatient hospital admission was not medically necessary.
This woman presented with chest pain and marked hypertension. Her serum troponin level was minimally elevated and there was concern for acute coronary syndrome (ACS). Accordingly, observation until ACS could be ruled out was a reasonable approach. However, she was hemodynamically stable, with no ischemic electrocardiographic changes and no significant delta troponin. She did not require intensive monitoring, infusion of intravenous cardioactive medications or urgent cardiac catheterization. The care this patient received for her chest pain did not require an inpatient admission and could have been provided at a lower level.
Appeal type: Medical necessity
Decision: Overturned

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

This is a female patient with a medical history notable for dementia, incontinence, mobility issues, diabetes, hypertension, and chronic pain. The patient is approved for 8 hours per day, 6 days per week (48 hours per week) of consumer directed personal assistance program (CDPAP). The patient and her care team requested an increase to 12 hours per day, 7 days per week (84 hours per week) and the request was denied by the health plan.
The request for additional hours states that the patient has become very confused lately. She has been taking off her diaper at inappropriate times and having falls. The additional aide hours are intended for assistance with transfer to the commode, toileting, changing soiled linens, and supervision at night. The patient lives with her daughter who assists with her care.
A Uniform Assessment System (UAS) was completed and was available for review. The patient lives with her daughter. She was alert and oriented to person only. Her procedural and short-term memory was not intact. She showed confusion with wandering and unsafe behaviors. For her Instrumental activities of daily living (IADLs), she requires total dependence for meal preparation, housework, finances, medications, phone use, and shopping. She requires extensive assistance for transportation. For her activities of daily living (ADLs), she requires maximal assistance for bathing. She requires extensive assistance for dressing, walking, locomotion, toilet transfer, toilet use, and bed mobility. She requires limited assistance for all others. She is incontinent of urine and stool with no control present. She wears diapers, pull-ups, and liners for incontinence care. There was no pressure ulcer present. Compared to a prior UAS , the patient showed a cognitive and functional decline. At issue is the medical necessity of Consumer Directed Personal Assistance Program (CDPAP) Services: Total of 84 Hours per Week (12 Hours per Day / 7 Days per Week).

The requested health service of Consumer Directed Personal Assistance Program (CDPAP) Services: Total of 84 Hours per Week (12 Hours per Day / 7 Days per Week) is medically necessary for this patient.
The patient requires hands-on assistance with all personal care tasks, including ambulating, transfers, toileting, and incontinence care. She is incontinent of urine and stool with no control present and lacks the ability to direct her own incontinence care. Her physician documented recent falls when attempting personal care tasks which are evidence of unmet personal care needs. Her personal care needs are expected to be continuous and unscheduled throughout the day and night. Her daughter provides much of her care, but her care needs are expected to be extensive. Therefore, the requested increase to 12 hours per day is medically necessary and reasonable for the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Palpitations
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient recently treated for helicobacter (H) pylori gastritis who presented to the emergency department (ED) for evaluation of palpitations. In the emergency department (ED), the patient was tachycardic, heart rate (HR) was 150 beats per minute (bpm). An electrocardiogram (ECG) demonstrated atrial fibrillation (afib) with rapid ventricular response (RVR). The patient was administered Cardizem 20 milligrams (mg) intravenous (IV) then 60 mg orally. She was admitted to the telemetry service under an inpatient level of care for evaluation and management of new onset atrial fibrillation. She was started on metoprolol 25 milligrams (mg) twice daily and therapeutic Lovenox for stroke prevention. The patient spontaneously converted to normal sinus rhythm the day of admission and remained in normal rhythm during her hospitalization. Cardiology was consulted and recommended changing anticoagulant to a direct-acting oral anticoagulant (DOAC), add Multaq 400 mg twice daily (BID), obtain an echocardiogram and stress test for evaluation of structural heart disease. Both the echocardiogram and Regadenoson stress tests were normal. The patient was discharged home in stable condition. At issue is the medical necessity of an inpatient stay.

An inpatient level of care was not medically necessary for evaluation and management of this patient presenting with new onset atrial fibrillation to the ED. There was no evidence of acute coronary syndrome (ACS). The patient clinically improved with medical treatment she had received in the ED (atrioventricular (AV) nodal blockade) and spontaneously converted to normal sinus rhythm the day of admission. Overall, she responded well to medical management for the treatment of new onset atrial fibrillation within the observation level of care time frame. A lower level of care would have been medically appropriate and safe for evaluation and management of new onset atrial fibrillation supported by peer reviewed medical literature on the management of patients presenting with atrial fibrillation to the emergency department (1-3).
Appeal type: Medical necessity
Decision: Upheld

Digestive System/Gastrointestinal
Inpatient Hospital

Diagnosis: Gastroenteritis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient with a past medical history (PMH) of asthma, chronic kidney disease (CKD) stage 3 status/post (s/p) renal transplant on immunosuppressants, diabetes mellitus type 2 (DM2), hyperlipidemia (HL), and hypertension (HTN) who was admitted with complaints of (c/o) watery diarrhea associated with recent sick contacts, fever, nausea, and vomiting. Her vital signs were notable for temperature (T) 101 degrees Fahrenheit, pulse 100.  The patient was diagnosed with gastroenteritis and dehydration and treated with intravenous fluids (IVF) and electrolyte repletion. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with complaints of (c/o) watery diarrhea associated with recent sick contacts, fever, nausea, and vomiting. The patient did not have associated high-risk features, such as severe acute renal failure, congestive heart failure, or liver failure, nor did the patient have any hemodynamic instability, bowel obstruction, diabetic ketoacidosis, appendicitis, pyelonephritis, ascending infection, toxic appearance, or unstable vital signs. The patient did have a small increase in creatinine, which resolved quickly with the administration of intravenous fluids (IVF) and was at baseline, per nephrology. The patient presented with acute gastroenteritis with dehydration, was treated and responded to IVF, anti-emetics, and pain control, and these interventions could have been safely and appropriately provided at a lower level of care.
The patient did not have suspected severe infection ( eg, bloody diarrhea), severe abdominal pain, peritoneal signs, toxic megacolon, hemodynamic instability, severe vomiting, severe dehydration, metabolic abnormality that persisted beyond observation, hemolytic uremic syndrome (HUS), bacteremia, hypoxemia, altered mental status (AMS), failure of outpatient treatment, new coagulopathy, evidence of end-organ dysfunction that persists despite observation care, pyelonephritis, or antimicrobial regiment hat must be implemented on an inpatient basis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Blindness.
Treatment: 31 Hours/Week, Consumer Direct, 1 Client Personal Care Aide.
The health plan denied: 31 Hours/Week, Consumer Direct, 1 Client Personal Care Aide
The determination is Upheld.

The patient is a male with a medical history notable for hypertension, stroke, and macular dystrophy blindness. The patient is approved for 10.5 hours per week of consumer-directed personal care assistance. The patient and his care team requested an increase of 31 hours per week, and this request was denied by the health plan.
The patient's primary care physician provided a letter for this appeal. The letter lists his medical history as noted above. It states that he would "benefit from an extension of home care hours because he needs support with activities of daily living (ADLs) including shopping and meal preparation. He needs support with medication preparation and visits to medical appointments." No further detail was provided.
A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted via teleconference. The patient lives alone in a private home. The patient was requesting additional help at home with daily activities due to vision issues and back and leg pain. He was not receiving any home care services at the time. The patient's cognitive testing was normal, and he was independent in daily decision-making. For his instrumental activities of daily living, the patient requires extensive assistance with housework. He is otherwise independent or requires supervision only for his instrumental activities of daily living. For his activities of daily living, the patient is independent for all. He is occasionally incontinent of urine and does not use any incontinence supplies. He toilets independently. A task tool associated with the assessment recommended 9.81 hours per week to address the patient's personal care needs.
At issue is the medical necessity of 31 hours/week, consumer direct, 1 client personal care aide.
The health plan's determination of medical necessity is upheld as a whole.
The requested health service of 31 Hours/Week, Consumer Direct, 1 Client Personal Care Aide is not medically necessary for this patient.
The patient is currently receiving 10.5 hours per week of consumer-directed personal care assistance. This is more than the amount which was recommended by the task-based assessment tool. It is unclear which personal care needs, if any, are not being met at this current allowance. According to the UAS, the patient is fairly independent with most activities. His physician provided a letter that stated that he needs assistance with meal preparation, medication preparation, and shopping. The task tool has denoted an appropriate amount of time for these activities. The requested increase has not been demonstrated to be medically necessary for the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left foot ulcer. 
Treatment: Inpatient hospital admission. 
The insurer denied the inpatient hospital admission. 
The denial is overturned. 

The patient is an adult male. He has a history of asthma, arthritis, poorly controlled diabetes mellitus, hyperlipidemia, and gout. He presented to the emergency department upon recommendation of his primary care physician for a left foot ulcer. The patient had a new onset prior to admission of nausea; vomiting; chills; and redness, pain, and swelling to his right foot. The patient's labs demonstrated an elevated white blood cell count suggestive of infection. His glucose level was 420, demonstrating uncontrolled diabetes mellitus. Concern for osteomyelitis was present. The attending physician in the emergency department judged that admission with intravenous antibiotics was appropriate, and the patient was admitted on that basis. He was discharged days later when his clinical picture improved. The health plan's denial of coverage was based upon MCG (Milliman Care Guidelines) citing that the severity of the patient's condition was such that inpatient emergency admission was not indicated and that the patient could have been treated at an observation level of care. The denial is being appealed. 

The inpatient admission was medically necessary. 

The patient was a poorly controlled diabetic with an open ulcer on the left foot. He had a history of three prior toe amputations and evidence of cellulitis on the right. He had new onset nausea, vomiting, and chills with an elevated white count, all of which indicated a significant infection. Without admission and intravenous antibiotic treatment, the patient may have developed sepsis and progressive ulceration leading to possible further amputation or worse. Admission as deemed by the emergency department physician was clearly indicated. The inpatient admission was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever; congestion
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This patient is a toddler female presenting with fevers, congestion and decreased oral intake for four days due to the parainfluenza virus. The patient was admitted for IV intravenous) hydration and IV (intravenous) antibiotics. The request for the inpatient admission is under review. The reason for denial stated that an inpatient stay was not considered medically necessary as clinical criteria has not been met.

The requested health service of an Inpatient Hospital Admission is not considered medically necessary. 

This patient was reportedly ill for four days and was seen in the ED (emergency department) the day prior to admission and was discharged with anticipatory guidance. The patient then returned and was diagnosed with a pneumonia and had a fever. She could have been given Ibuprofen in addition to Tylenol to reduce fevers and trialed on outpatient antibiotic therapy. There is no documentation of an IV (intravenous) fluid bolus given in the ED (emergency department), nor was there excessive vomiting that caused the patient to be intolerant to oral antibiotics. Documentation shows that this patient was able to tolerate fluids and meals, which further proves that she could have received Ibuprofen, fluid bolus, as well as outpatient antibiotics to avoid inpatient admission. As such, the requested health service is not considered medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fatigue and Diarrhea
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is an adult female with diabetes mellitus type 2, hyperlipidemia, deep vein thrombosis (DVT) several years ago and on Xarelto indefinitely. Per the appeal letter, she presented to the emergency department with five days of fatigue and malaise, and one day of diarrhea. The patient had been recently admitted for left-sided abdominal pain. On the day of admission, she had six to eight episodes of watery stools with no blood. She had lower abdominal cramping pain. In the emergency department, the blood pressure was 83/61. White blood cell count was 2.6. 
Computed tomography (CT) scan of the abdomen / pelvis with intravenous contact showed decrease in size of slightly complex cystic lesion in the left renal upper pole presumed to be an 
infected cyst. She received ceftriaxone intravenous, vancomycin orally, lactated Ringer's (LR) 2.5 liter bolus then continuous fluids, acetaminophen 650 milligrams x1, and famotidine 20 milligrams intravenous. Infectious and urology were consulted.
The patient was continued on ceftriaxone 1 gram intravenous every 24 hours per infectious disease recommendations. The patient was noted to have just completed a course of cefuroxime. She was found to be Clostridium difficile positive on day # (number) 2 and was started on oral vancomycin to complete a 10-day course per infectious disease. Per infectious disease, considering that antibiotic therapy had caused Clostridium difficile infection, and that the patient's renal cyst might not be infected, antibiotics targeting the urinary tract infection were stopped. Symptoms of urinary tract infection resolved. The patient was discharged on the next day.

The Inpatient admission was not medically necessary.

An inpatient level of stay was not medically necessary since the patient did not require any procedural or surgical intervention, did not require to be nothing by mouth for a prolonged duration of time, did not require prolonged treatment with intravenous hydration or intravenous medications, did not have acute kidney injury, did not have electrolyte derangement needing intravenous replacement, and did not have any complications such as intra-abdominal abscess or a surgical abdomen. The patient did not have hemodynamic instability, severe pain requiring acute inpatient management, or peritoneal signs. The patient did not require identification of etiology or finding; or evaluation requiring the patient to not eat or drink for extended period (e.g., more than 24 hours). The patient did not have inability to maintain oral hydration (e.g., needs intravenous fluid support) that persists after observation care; and did not have suspected toxic megacolon. The patient did not have bacteremia.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Knee Pain
Treatment: Magnetic resonance imaging of the left knee
The insurer denied Magnetic resonance imaging of the left knee.
The determination is overturned.

This is a male patient with a history of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), obstructive sleep apnea (OSA) (unable to tolerate continuous positive airway pressure (CPAP)), depression, pre-diabetes mellitus (DM), alopecia, Epstein-Barr virus (EBV) and long-standing left knee pain. Magnetic resonance imaging (MRI) of the left knee is being denied by the health plan as the patient has not tried and failed physician directed therapy. However, the patient has tried and failed multiple prescription nonsteroidal anti-inflammatory drugs (NSAIDs) as well as Cymbalta (stopped due to excessive somnolence). X-rays (XRs) of the knees were normal. Per a letter from the patient's provider, due to ME/CFS, the patient is mostly homebound and therefore unable to participate in physical therapy (PT). Per an office visit note, the patient is now 80 percent (%) bedridden due to fatigue. At issue is the medical necessity of MRI of the left knee.
The MRI of the left knee is medically necessary. Under normal circumstances, a trial of PT would be warranted before obtaining an MRI of the knee to evaluate his knee pain. However, this is a unique case where it is clearly documented that the patient has debilitating fatigue and somnolence and is mostly bedbound, thus cannot participate in a trial of PT. Thus, an MRI of the left knee is medically necessary at this time. As per UpToDate (Approach to the adult with knee pain likely of musculoskeletal origin), 'MRI and CT are most useful for suspected intra-articular problems. In most medical centers, MRI is the standard technique used to diagnose anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), and meniscal injuries.