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

Diagnosis:  Type II diabetes mellitus with hyperglycemia, COPD, fibromyalgia.
Treatment:  Additional hours for consumer directed personal assistance services.
The insurer denied the Additional hours for consumer directed personal assistance services.  The denial is upheld.

The proposed treatment of an increase in consumer directed personal assistance services to 24 hours/week is not deemed medically necessary. 

The patient is a female with a history of hypertension, diabetes mellitus, COPD (chronic obstructive pulmonary disease), fibromyalgia and depression/anxiety.  Due to restrictions/limitations related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs).  An appeal review requested for potential approval of an in increase in consumer directed personal assistance services to 24 hours/week to offer increased assistance with completion of the patient's ADLs.

The patient is a female with a history of hypertension, diabetes mellitus, COPD, fibromyalgia and depression/anxiety.  Due to restrictions/limitations related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs).  An in-home assessment of the patient's overall functionality and ability to complete ADLs was performed and indicated that the currently approved plan of 11 hours/week consumer directed personal assistance services is sufficient to meet the patient's current needs.  There is no additional documentation since the date of this last assessment which demonstrates that the patient has sustained additional functional decline which would warrant increased consumer directed personal assistance services.  For these reasons, the proposed treatment of an increase in consumer directed personal assistance services to 24 hours/week is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Abdominal pain and diarrhea.
Treatment:  Inpatient admission.

The insurer denied the inpatient admission.  The denial is upheld. 

The patient is a male, who presented to the emergency department of the facility filing the appeal.  The patient reported four days of emesis and watery diarrhea.  The patient had generalized abdominal pain.  The patient reported his last alcohol consumption was a half-bottle of whisky the night prior.  The patient had been unable to eat for the preceding four days.  The patient also had a recent trip to India.  The patient had a history of hyperlipidemia, alcoholism, hypertension and pancreatitis.  The alcohol level was 103.  The lipase was mildly elevated at 189.  An ultrasound and CT scan showed hepatic steatosis.  A stool PCR (polymerase chain reaction) evaluation showed pathogenic E coli species.  The patient was admitted for a CIWA (Clinical Institute Withdrawal Assessment) protocol, management of acute pancreatitis, and supportive care including antibiotics.  The patient was discharged when deemed stable.

No, the proposed Inpatient admission is not medically necessary.

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 a mild alcohol-induced acute pancreatitis episode and diarrhea from travel; yet he did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for a prolonged 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.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia

Treatment: Inpatient admission

The insurer denied the inpatient admission.

The denial was upheld.

This is a female patient with history of anemia, anxiety, asthma, depression, dyspnea on exertion, status post gastric bypass in 2002. She presented to the hospital for scheduled cardiac catheterization, but the surgery was canceled due to severe anemia. The initial lab findings showed low hemoglobin of 3.8, hematocrit of 16.8, white blood cells of 3.39, red blood cells of 2.65, alanine aminotransferase (ALT) of 6, B12 of <150, iron of 28, ferritin of 2. The patient was admitted to inpatient for anemia. The repeat lab findings showed low ferritin of 2, iron of 28, % saturation of 7, calcium of 8.0, red blood cells of 3.54, hemoglobin of 6.9, hematocrit of 24.6. The hospital course of treatment included blood transfusions (packed red blood cells (PRBC)), Lexapro, and aspirin. The patient was consulted by Gastrointestinal and Cardiology. After treatment and once medically stable, the patient was cleared for discharged to home with follow-up with the primary care physician.	
As noted in Up to Date "All patients should be assessed clinically when transfusion is considered. If the patient is stable, transfusion may not be needed even when the hemoglobin level is 7 to 8 g/dL."

The patient had chronic co-morbidities; however, this was long standing. There was no issue of a sudden loss of blood or hemorrhagic shock. Even though she needed several PRBC, she did not have risk factors for developing potential transfusion associated overload syndrome. The risk factors for transfusion associated overload are presence of chronic renal failure, heart failure, or presence of hemorrhagic shock. This patient did not have these risk factors. If one were to assign a MEWS core (modified early warning score), this is a score that incorporates, systolic blood pressure, heart rate, respiratory rate, temperature, and mental status. Patients score was 0 all the time and this is the perfect score which portends normal hospitalization course. Also during the hospitalization there were no perturbations in the clinical status nor laboratory values. Hence the necessary evaluation could have been done in the observational status. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for inpatient admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Induced labor

Treatment: inpatient hospital admission 

The insurer denied coverage for inpatient hospital admission. The denial is overturned.

This patient is a female who was admitted at 22.3 weeks gestation for a termination of pregnancy due to a deletion of chromosome 7 discovered on amniocentesis. The patient's labor was induced. The patient required Cytotec, Fentanyl, epidural anesthesia. She delivered vaginally She was discharged later that day.

It has always been the standard of care to admit patients for delivery. This patient was pregnant in her late second trimester. Admission was medically necessary to deliver the patient. The admission is primarily to induce labor, observe for the progression of labor, monitor the patient for any complication (uterine rupture) and for delivery and postpartum management (retained placenta, bleeding).  

According to ACOG coding guidelines, the following services are included in the delivery services: 
1)	Admission to the hospital 
2)	The admission history and physical examination 
3)	Management of uncomplicated labor, vaginal delivery (with or without episiotomy, with or without forceps, with or without vacuum extraction), or cesarean delivery, external and internal fetal monitoring provided by the attending physician 
4)	Intravenous (IV) induction of labor via oxytocin (CPT codes 96365 - 96367) or misoprostol.
5)	Delivery of the placenta; any method 
6)	Repair of first or second degree lacerations.

Milliman Care Guidelines, also states clearly that admission is medically necessary for delivery. 

According to the progress note the patient delivered and was discharged a few hours later. In other words the patient was kept for a minimal amount of time in the hospital. There was no delay in discharging the patient.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The inpatient hospital admission is considered medically necessary for this patient.

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

Diagnosis:  Endocrine/adrenal Glands.
Treatment:  Inpatient hospital stay.

The insurer denied the inpatient hospital stay.  The denial is overturned in whole. 

This patient who was admitted to the hospital.  The patient had been diagnosed with a right, 6.5-centimeter (cm), adrenal pheochromocytoma.  The patient underwent laparoscopic right adrenalectomy. 

Yes, the inpatient stay was medically necessary for this patient.  This patient had a biochemically active right sided adrenal mass (Pheochromocytoma).  These lesions produce and release vasoactive substances that can result in profound and acute hypertensive episodes.  As stated in the appeal letter, the patient was prescribed medication preoperatively to block the catecholamines produced by the tumor.  The surgical treatment of these patients requires coordinated treatment between the surgeon and anesthesiologist with intensive hemodynamic monitoring.  The records do support that this patient was monitored in the post-surgical period with intensive hemodynamic monitoring (every one-hour vital sign monitoring).  While the operation was performed without adverse incident, the intensity of service (pre-surgical, intra-operative and post-surgical monitoring) did justify a higher level of care.  The patient did manifest reactive hypotension in the post-surgical period and had the potential to require more intensive care.  An inpatient level of care was most appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis Back and leg pain.
Treatment: Spine surgery for posterior or posterior lateral fusion at L5-L6 and decompression at L5-6 and L6-S1.
The insurer denied the Spine surgery for posterior or posterior lateral fusion at L5-L6 and decompression at L5-6 and L6-S1. 
The denial is upheld. 

The patient is a female with history of back and leg pain.  It is stated that the patient has attempted conservative therapy in the past including physical therapy (PT), home exercise program (HEP), medications and epidural steroid injection (ESI); however, there are no documents provided that demonstrate this. Exam reveals no focal deficit. Magnetic resonance image (MRI) shows grade I spondylolisthesis L6-S1 with moderate foraminal narrowing. X-ray shows no dynamic instability. The patient was recommended for L5-L6 transforaminal lumbar interbody fusion (TLIF).

No, the proposed treatment, spine surgery for posterior or posterior lateral fusion at L5-L6 and decompression at L5-6 and L6-S1, is not medically necessary.

There is insufficient evidence provided of an adequate trial of conservative multimodal therapies employed or duration of these therapies. An adequate trial of nonsurgical therapy should consist of multimodal therapies including PT, injections, pain management and an appropriate length of duration (usually six weeks to three months) and should have been performed recently (within the last year). There is no dynamic instability, fracture or other pathology that would warrant a fusion at this time. Because the imaging does not support the proposed surgery and there is insufficient evidence of adequate trial of nonsurgical therapy, the surgery and all CPT codes are not deemed medically necessary for this patient based upon standard of care and medical necessity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal
Treatment: Inpatient stay
The insurer denied the medical necessity of the inpatient stay. The denial is upheld in whole.

At the time of service, the patient had an 8-month history of a right Cervical (C)7 radiculopathy. A preoperative neurological exam was documented to be non-focal. A magnetic resonance imaging  scan of the cervical spine reported a right C6-7 disc herniation, and the patient underwent a C6-7 ACDF (anterior cervical discectomy and fusion). This was uncomplicated according to the operative report and the anesthesia record is uneventful. After surgery the patient was admitted as an inpatient for postoperative monitoring. There are no documented episodes of respiratory or cardiovascular instability in the medical records provided for review. The patient was ordered intravenous (IV) Decadron, which was discontinued upon discharge the next morning when the patient was noted to be in stable condition.
It is very common to admit ACDF patients to a lower level of care in order to monitor them overnight, as the complications of respiratory distress from either tissue swelling or a postoperative hematoma usually occur the night of surgery and frequently require emergent attention. If ever any significant complications or vascular instability arises then the patient can always be reclassified as an inpatient as needed. Postoperative intravenous steroids and pain medications can be administered in a lower level of care admission. In healthy selective patients this procedure is frequently carried out in a completely outpatient setting but that is within the purview and judgment of the operating surgeon. There is nothing in the health records of this patient that would have required an inpatient status for this admission. The patient could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Respiratory system /Breathing problems 
Treatment: Inpatient hospital 
The insurer denied the entire  inpatient stay
The denial is overturned in part 

The patient with hypertension (HTN), emphysema, nut allergy, and gastroesophageal reflux disease (GERD). The patient presented to the emergency department (ED) with tongue swelling and dyspnea 2 hours after eating almonds.

Yes, the inpatient admission was medically necessary in part for the first 2 days. The admission was not medically necessary on the last 2 days.  He required an inpatient admission on the first two days  because of his increased risk of respiratory failure and late response. The patient did not require inpatient admission after the last 2 days  because his condition had improved, and his risk of recurrence was low.

The inpatient admission was reasonable for the first 2 days . He had anaphylaxis with upper airway symptoms and required more than one round of intramuscular (IM) epinephrine. This does suggest a higher risk of respiratory failure and a bi-phasic/late recurrence. These patients do need close monitoring to monitor airway status as they can decompensate quickly and require advanced airway management.

However, by the 3rd day, the patient had improved and there was no longer a need for ongoing observation. He was improved and feeling better, the endocrine physician's recommendations were to continue low dose sliding scale while an inpatient, start an oral agent on discharge, and follow-up with endocrinology. These are all things that can be done at a lower level of care as they do not require close inpatient monitoring or inpatient only testing or treatment. This largely represents a chronic problem. Typical recommendation for a lower level of care, as in literature cited below, is 24-48 hours. The patient had improved within 24-48 hours, and therefore an ongoing admission was not needed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer/Prostate cancer 
Treatment:Lab work 
The insurer denied  Oncotype Dx testing 
The denial is uphled in whole

The patient  who underwent a prostate biopsy for an elevated prostate-specific antigen (PSA). The biopsy showed Gleason 6 adenocarcinoma in 1 out of 12 cores. The clinical stage was T1c. An OncotypeDx test was ordered on the biopsy specimens.
No, the Oncotype Dx testing is not medically necessary.

The Oncotype DX Prostate Cancer Assay is a real time polymerase chain reaction (RT-PCR) assay designed for analysis of prostate core needle biopsies. The assay measures the expression of 17 genes to calculate a Genomic Prostate Score (GPS). A lower GPS score more favorable biology and less aggressive disease. This test may be utilized to counsel men regarding the best course of therapy (active surveillance vs. treatment) in newly diagnosed low or low-intermediate prostate cancer.

Recent studies have suggested that Oncotype Dx can predict adverse pathology and unfavorable outcomes after radical prostatectomy. These studies have financial conflicts of interest, are recently published and need continued validation from a widespread clinical use. In addition, it is difficult to ascribe clinical utility of Oncotype Dx Prostate in patients planning to undergo active surveillance as all patients in the above studies, regardless of clinical criteria, elected radical prostatectomy within 6 months of diagnostic biopsy. Moreover, the validity of using different degrees of tumor pathology as "markers" to extrapolate the risk of progression of a tumor in vivo is unclear.

National Comprehensive Cancer Network (NCCN) guidelines for prostate cancer 2020 states, "Several tissue-based molecular assays have been developed in an effort to improve decision-making in newly diagnosed men considering active surveillance and in treated men considering adjuvant therapy or treatment for recurrence. No randomized controlled trials have studied the utility of these tests. These molecular biomarker tests have been developed with extensive industry support, guidance, and involvement,and have been marketed under the less rigorous Food and Drug Administration (FDA) regulatory pathway for biomarkers. Although full assessment of their clinical utility requires prospective randomized clinical trials, which are unlikely to be done, the panel believes that men with low or favorable intermediate disease may consider the use of Decipher, Oncotype DX Prostate, Prolaris, or ProMark during initial risk stratification. Men with unfavorable intermediate-and high-risk disease and life expectancy >=10 y may consider the use of Decipher and Prolaris tumor-based molecular assays."
While Oncotype dx may eventually have a role in making treatment decision about patients with prostate cancer, there is limited data on clinical outcomes to currently support routine use. Hence, it is not considered a generally acceptable standard of care for management of patients with a diagnosis of prostate cancer.and therefore not medically necessary in this case .
Appeal type: Medical necessity
Decision: Upheld

Respiratory System
Inpatient Hospital

Diagnosis: Shortness of Breath
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a past medical history (PMH) of hypertension (HTN), benign prostatic enlargement (BPE), diverticulosis, obstructive sleep apnea (OSA) and atrial fibrillation status/post (s/p) ablation who was admitted with complaints of (c/o) shortness of breath (SOB) associated with chest pain (CP), pressure, tightness and dyspnea on exertion (DOE). Vital signs were unremarkable. The physical exam showed no apparent distress (NAD) and was notable for rales. Lab work was notable for leukocytosis. A chest x-ray (CXR) showed interstitial prominence bilaterally and atelectasis, a transthoracic echocardiogram (TTE) showed right ventricular dilation, a computed tomography (CT) scan showed likely atelectasis, and a venous duplex showed no deep vein thrombosis (DVT). An electrocardiogram (EKG) showed sinus bradycardia with incomplete right bundle branch block (RBBB). The patient did have an episode of self-limited lip swelling. He was diagnosed with interstitial lung disease (ILD) versus bronchitis/viral upper respiratory infection (URI) and treated with a biochemical work-up, CT of the chest, TTE, infectious work-up, cough suppressants, bronchodilators, incentive spirometry and pulmonary consultation.  At issue is the medical necessity of an inpatient stay.
The inpatient stay was not medically necessary. This patient with a PMH of HTN, BPE, diverticulosis, OSA and atrial fibrillations s/p ablation presented to the ED with c/o SOB associated with a productive cough. There was no requirement for intubation, carbon dioxide (CO2) narcosis with oxygen saturation less than (<) 90%, severe acidosis, concomitant cardiac disease, acute coronary syndrome, new arrhythmia, congestive heart failure exacerbation, pulmonary embolism, pneumonia, lobar collapse, cyanosis, depressed mental status or altered level of consciousness (LOC), impending respiratory failure, or new ischemic ECG changes. This patient was treated with a biochemical work-up, CT scan of the chest, TTE, infectious work-up, cough suppressants, bronchodilators, incentive spirometry and pulmonary consultation and this could have been safely provided at a lower level of care. The patient did not have impending respiratory distress, severe airflow abnormalities, severe respiratory findings, severe chronic lung disease deterioration, tuberculosis, high-risk pulmonary infection, severe pulmonary arterial hypertension (PAH), cystic fibrosis (CF), bronchiectasis, sarcoidosis, ILD with severe exacerbation and respiratory distress, allergic pneumonitis, or transplanted lung complications.