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

Diagnosis: Low Back Pain.
Treatment: Nerve treatment in the spine.
The insurer denied Nerve treatment in the spine.
The determination is upheld.

This is a female patient with complaints of chronic low back pain.  Prior treatment has included injections and medications, as well as physical therapy. The pain impacts the activities of daily living. Magnetic resonance imaging (MRI) of the lumbar spine demonstrated Modic type II changes at disc spaces lumbar (L) 4, L5, and sacral (S)1. At issue is the medical necessity of intraosseous basivertebral nerve ablation.

No. The requested procedure, intraosseous basivertebral nerve ablation, is not medically necessary. This procedure is not recommended. Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. A Food and Drug Administration (FDA) investigational device exemption trial examined 225 chronic low back pain patients with type I or II Modic changes who were randomized to the requested procedure or sham treatment, resulting in decreased Oswestry disability index (ODI) of 20.5 and 15.2 points, respectively. The authors noted that these marginally clinically meaningful improvements suggested some potential as a minimally invasive treatment, however, there is lack of data to recommend this procedure as treatment modality. In general, there is lack of substantial support for this procedure, and it is currently not considered standard of care. As such, the requested health service/treatment of nerve treatment in the spine is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute ischemic right middle cerebral artery stroke
Treatment: Outpatient surgery (internal cardiac monitor 
placement - 33285 x 1)
The insurer denied: Outpatient surgery (internal cardiac monitor 
placement - 33285 x 1)
The denial is Upheld

This adult male patient with a history of acute ischemic right middle cerebral artery (MCA) stroke with hemorrhagic conversion last year was referred for an implantable loop recorder (ILR). His past medical history is pertinent for aortic root dilation, chest pain with negative stress test, type II diabetes, hyperlipidemia (HLP), hypertension (HTN) and right eye (OD) ischemic optic neuropathy. Echocardiography Doppler (ECD) was suboptimal. There was no transesophageal echocardiogram (TEE). The patient's 30-day mobile cardiac outpatient telemetry (MCOT) study from 5 months ago was negative for occult paroxysmal atrial fibrillation. The requested coverage for outpatient surgery (internal cardiac monitor placement - 33285 x 1) has been denied, based on the patient's policy and the patient is appealing the decision.

The proposed treatment with outpatient surgery (internal cardiac monitor placement - 33285 x 1) is not medically necessary.

Based on the current published medical literature, medical necessity criteria for mobile cardiac outpatient telemetry are not met, including suspected cardiac arrhythmia is not detected with standard cardiac event monitoring, for cryptogenic stroke with suspected occult atrial fibrillation as the cause of the stroke and for monitoring arrhythmia status following an ablation procedure. 
Mobile cardiac outpatient telemetry for the evaluation of arrhythmias for all other indications continues to be considered unproven, since efficacy has not been established, as is in this patient's particular case. The physician has not submitted any clinical evidence to demonstrate improved patient health outcomes by use of mobile cardiac outpatient telemetry in the proposed manner for this patient's medical condition, palpitation syndrome, or that the information gained is only possible with mobile cardiac outpatient telemetry or why standard cardiac monitoring techniques, like a Holter monitor or patient-activated or auto-triggered cardiac event monitor (EM) without the real-time telemetry could not have been utilized instead. Mobile cardiac outpatient telemetry under these circumstances has not been shown to be of additional benefit. Therefore, the proposed treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity
Treatment: Weight loss surgery (43775 x 1, 43659 x 1)
The insurer denied the weight loss surgery (43775 x 1, 43659 x 1).
The health plan's determination is overturned. 

This patient is a woman under consideration for bariatric surgery. She was 70 inches tall and weighed 256 lbs (pounds). This corresponds to a body mass index (BMI) of 36.8. She has comorbid health conditions of hyperlipidemia and hypertension. She is prescribed atorvastatin, hydrochlorothiazide, and metoprolol for these conditions. The patient has attempted weight loss with conventional exercise programs. Unfortunately, she has not been successful with significant sustained weight loss.

Given this patient's diagnosis, her current health conditions and generally accepted guidelines for patient selection, the proposed procedure is medically necessary for this patient.

This patient has a BMI in excess of 35 with weight related comorbid health conditions that include hyperlipidemia and hypertension. She is prescribed atorvastatin, hydrochlorothiazide, and metoprolol for these conditions. These weight-related health conditions will respond favorably to the sustained weight loss associated with laparoscopic sleeve gastrectomy. She has successfully completed a multidisciplinary bariatric evaluation. She has had appropriate dietary counseling and has been cleared for bariatric surgery from a mental health standpoint. She has been granted medical clearance.

Laparoscopic sleeve gastrectomy is medically necessary for this patient per widely accepted guidelines as her BMI is in excess of 35 in association with weight related illness of hyperlipidemia and hypertension. The patient has undergone evaluation by a multidisciplinary bariatric program. The patient has been cleared for the proposed surgery from a mental health standpoint per the enclosed psychological consultation and clearance.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Depression, hearing loss and chronic pain.

Treatment: Consumer directed personal assistance services (CDPAS) 8 hours per day, 6 days per week, a total of 48 hours per week.

The insurer denied coverage for consumer directed personal assistance services (CDPAS) 8 hours per day, 6 days per week, a total of 48 hours per week.

The denial is upheld.
 

The patient is an elderly patient with chronic medical problems including depression, hearing loss and chronic pain.  She lives with her daughter in a private residence.  The insurer approved 20 consumer directed personal assistance services (CDPAS) hours/week and the request is for CDPAS 8 hours/day, 6 days/week, for a total of 48 hours/week.  

The most recent Uniform Assessment System (UAS) report was reviewed.  The patient's cognitive skills are described as minimally impaired.   She is reportedly totally dependent to extensive assistance for completing much of her Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.  The patient reportedly requires extensive assistance for bathing.  Limited assistance is reportedly needed for locomotion and ambulation.  The patient is otherwise at the supervision or independent level for personal hygiene, dressing, bed mobility, eating and toilet transfer/use.  The patient is also fully continent of bladder and bowel.  There have been no reported falls over the prior 90 days. The patient may benefit from monitoring for safety; particularly due to her reported cognitive deficits.  However, CDPAS for companion care or safety supervision without the direct provision of activities of daily living (ADL) task assistance is not a covered service.  Based on the enclosed documents reviewed, The patient's health and safety are appropriately provided and maintained by the currently approved CDPAS 20 hours/week, shared household responsibilities with the other adult living in the home and informal care from family.  

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 consumer directed personal assistance services (CDPAS) 8 hours per day, 6 days per week, a total of 48 hours per week is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

This is a male child that presented to the emergency department (ED) with a four-day history of a fever to 100.2 degrees Fahrenheit and a cough and one-day history of noisy breathing. He initially was taken to urgent care and referred from there to the ED for evaluation with an oxygen saturation of 94 percent (%). The examination was significant for no acute distress, moist mucous membranes, a clear oropharynx, strong peripheral pulses, mild respiratory distress with no retractions or nasal flaring and able to speak in full sentences, with no wheezing, a benign abdomen, and non-focal neurology exam. Laboratory evaluation was significant for a white blood cell count (WBC) of 16.1 thousand (K) and negative rapid viral screening. A chest x-ray revealed a large right lower lobe infiltrate consistent with pneumonia. A repeat oxygen saturation was 92% on room air so he was placed on 2 liters (L) of supplemental oxygen via nasal cannula. He was treated with ceftriaxone per the admitting hospitalist while awaiting bed availability. He was also treated with nebulized albuterol, an anti-pyretic, and prednisolone.
Admission orders included supplemental oxygen to wean as tolerated, continued ceftriaxone with consideration to transition to amoxicillin, and vital signs every four hours. He was able to wean from the supplemental oxygen overnight. He tolerated his regular diet. He was subsequently deemed stable for discharge to complete a course of antibiotics with Augmentin. At issue is the medical necessity of an inpatient stay.

No. An acute inpatient admission was not medically necessary.

This young male child with an unremarkable medical history presented with a fever and cough. A chest x-ray revealed a large right-sided infiltrate consistent with pneumonia. He was treated with parenteral antibiotics in the emergency department (ED) pending bed availability. His oxygen saturation dipped to the low 90s prompting initiation of supplemental oxygen. He was admitted for further management. Overnight, he was successfully weaned from supplemental oxygen. While it was not unreasonable to monitor him in the hospital pending successful transition back to room air, he was overall hemodynamically stable with no chronic underlying medical condition, no evidence of impending respiratory failure, able to tolerate a regular diet. He did not require acute inpatient admission and could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

The patient is an adult with past medical history of peripheral arterial disease and diabetes mellitus, who presented to the emergency department with complaints of left lower extremity erythema and swelling. 

Vitals on presentation included: Temperature 97.5 degrees Fahrenheit, Blood Pressure 126/73, Pulse 100, Respiratory Rate 18, oxygen (O2) saturation 99% (percent) on Room Air. Laboratory results included the following: White blood cell (WBC) count 10.31, hemoglobin (Hgb) 16.9, hematocrit (Hct) 48.7, creatinine 0.56, glucose 240.

The patient was started empirically on intravenous antibiotics (Zosyn) for possible lower extremity cellulitis. Infectious Diseases consulted and recommended adjustments in antibiotics. X-ray of tibia/fibula showed no acute radiographic osseous pathology. She remained afebrile and clinically and hemodynamically stable. The patient was discharged to continue oral antibiotics (Cefadroxil) as outpatient.

According to documentation, the patient presented with lower extremity cellulitis. Otherwise, the patient remained afebrile and hemodynamically stable. Laboratory results showed normal WBC. Cultures remained negative. The patient had no evidence of a disseminated infection and no surgical intervention was required. Based on above findings, the patient did meet criteria for observation level of management. She did not fulfill criteria for acute hospital admission. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, 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: Upheld

Diagnosis: Atrial Fibrillation
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The determination is upheld.

This is a male patient who presented to the hospital for a scheduled catheter ablation of persistent atrial fibrillation. The procedure was uncomplicated. Post-procedure the patient was admitted to the hospital. He remained stable overnight. His rhythm converted from sinus to atrial fibrillation with a controlled ventricular rate. He denied associated chest pain, dyspnea or palpitation. His rhythm was electrically cardioverted to sinus and the patient was discharged. The medical necessity for an inpatient admission is at issue.

Based on the documentation provided, an inpatient level of care was not medically necessary.

This patient underwent a transcatheter pulmonary vein isolation (PVI) procedure for persistent atrial fibrillation. Given the complexity of the procedure, with transseptal punctures, catheter manipulation and ablation within the left atrium, full dose anticoagulation, and the proximity of the ablation lines to the esophagus, the complication rate is higher than that of catheter ablations for other supraventricular arrhythmias. Accordingly, despite at least two reports demonstrating the safety of same day discharge after PVI, most electrophysiologists admit patients for overnight observation post-procedure. This patient's procedure was uncomplicated, and he was hemodynamically stable. He had an episode of atrial fibrillation with a controlled ventricular rate the morning after the procedure that was electrically converted to sinus without complications. While overnight observation was reasonable in this situation, the records provided do not indicate that an inpatient level of care was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Dementia.
Treatment:  Personal Care Worker (PCW) services 7 days per week, 10 hours per day; 70 hours per week.

The insurer denied Personal Care Worker (PCW) services 7 days per week, 10 hours per day; 70 hours per week.  The determination is overturned.

This is a female patient with a medical history notable for dementia, obesity, and gait dysfunction. The patient is approved for 7 hours per day, 7 days per week (49 hours per week) of personal care worker services. The patient and her care team requested an increase to 10 hours per day, 7 days per week (70 hours per week) and this request was denied by the health plan.

The patient's physician provided a letter of support for this appeal. The letter states that her chronic conditions result in her requiring assistance with activities of daily living (ADLs) and Instrumental activities of daily living (IADLs). She also needs "frequent care management on a daily basis."

A letter of support for this appeal was provided by the patient's advocacy team. The letter states that she had a fall with a resulting shoulder fracture. Since that time, she has had difficulty with mobility and requires assistance when using the toilet, standing, and preparing food.

A Uniform Assessment System (UAS) was completed and was provided for review. The patient's cognition was minimally impaired and had shown a decline since previous assessment. A Mini-Mental State Examination (MMSE) score was 20/30 which is consistent with mild to moderate cognitive impairment. For her IADLs, she requires maximal assistance with meal preparation, housework, and shopping. She requires extensive assistance for finances and medications. For her ADLs, she requires maximal assistance for bathing, dressing lower body, and toilet use. She requires extensive assistance for dressing upper body and toilet transfer. She requires limited assistance for hygiene, bed mobility, and eating. She was described as bed-bound. She is frequently incontinent of urine and continent of stool. A task tool associated with the assessment recommended 3.8 hours per day to address her personal care needs. At issue is the medical necessity of Personal Care Worker (PCW) services 7 days per week, 10 hours per day; 70 hours per week.

The requested health service of 7 days per week, 10 hours per day; 70 hours per week, personal care worker (PCW) is medically necessary for this patient.

The patient has had a functional decline following a fall. Her UAS now demonstrates that she requires maximal assistance with toileting and is incontinent of urine. Although her task tool only recommends 3.8 hours per day, her personal care needs can be expected to be of a continuous and unscheduled nature and thus, the task tool cannot adequately reflect her true level of need. In order to prevent additional falls, she will require more assistance with her ADLs and IADLs. She will also need prompt incontinence care to prevent skin breakdown and/or infection.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Deep vein thrombosis
Treatment: Inpatient stay
The insurer denied the inpatient stay.
The health plan's determination is upheld. 

The patient is a male who presented to his physician's office complaining of left leg pain and swelling. Recently, he had traveled by plane from Greece to the U.S. He developed pain in his left leg. Several months prior to presentation, he had a near syncopal episode. His family called Emergency Medical Services (EMS); however, the patient had recovered by the time they arrived and declined transport to the emergency department. His leg pain continued and he developed associated swelling. He had an episode of lightheadedness prior to seeing his physician. He reported that his blood pressure was 77/64 at that time. The patient's past medical history was remarkable for coronary artery disease, coronary artery bypass graft surgery, percutaneous coronary intervention, chronic anemia, mild thrombocytopenia, chronic kidney disease, paroxysmal atrial fibrillation and permanent pacemaker implantation. He took apixaban chronically for thromboprophylaxis.

Based on the documentation provided, an inpatient level of care was not medically necessary.

This patient was admitted to the hospital with suspected deep vein thrombosis (DVT). The safety and effectiveness of outpatient treatment with enoxaparin for the majority of patients with DVT has long been recognized. After the publication of two landmark trials in 1996, outpatient treatment became the standard of care. Indications for inpatient admission include pulmonary embolism; significant active cardiovascular or pulmonary comorbidity; iliofemoral DVT; contraindication to anticoagulation; inherited thrombophilia; familial bleeding disorder; pregnancy; morbid obesity and renal failure. This patient met none of these criteria. Thus, a lower level of care would have been appropriate.
Appeal type: Medical necessity
Decision: Upheld

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

This is a male patient with a past medical history (PMH) of diabetes mellitus type 2 (DM2), alcohol abuse, gout, hypertension (HTN), and a seizure disorder (d/o) who was admitted from the psychiatry floor with complaints of (c/o) dizziness on standing and right hand/ankle pain. His vital signs were notable for negative orthostatics. The physical exam was notable for negative Dix-Hallpike, no apparent distress (NAD), right knee swelling and tenderness to palpation (TTP). Lab work was notable for anemia. Imaging studies included a computed tomography (CT) scan of the abdomen/pelvis (A/P) which showed no acute pathology. An electrocardiogram (EKG) showed normal sinus rhythm (NSR), no evidence of acute ischemia. The patient was diagnosed with acute gout and treated with colchicine, allopurinol, and prednisone. Orthopedics evaluated the patient and recommended physical therapy (PT). 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.
The patient presented to the emergency department (ED) with c/o dizziness and right hand/ankle pain. The patient was afebrile, did not appear toxic, had no unstable comorbidities, did not have a limb-threatening infection, there was no septicemia, life-threatening infection, necrotizing fasciitis, did not meet systemic inflammatory response syndrome (SIRS) criteria, there was no animal or human bite with extensive damage, pain out of proportion to clinical findings, neutropenia, immune-suppression, marked systemic toxicity or worsening symptoms, or inability to take oral medications. For the dizziness, the patient did not have any acute hearing loss, double vision, fixed neurologic deficits, severe headache, associated head trauma, fever, cerebellar infarct or hemorrhage, vertebrobasilar insufficiency, acute suppurative labyrinthitis, intractable nausea/vomiting, or inability to ambulate. All imaging performed showed no acute intracranial pathology. This patient was treated with prednisone, physical therapy, and pain control, and this could have been safely provided at a lower level of care. A lower level of care would allow frequent reevaluation to assess the response to therapy while avoiding inpatient admission in this stable patient.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: seizure
Treatment: inpatient stay
The insurer denied the inpatient stay. 

The health plan's determination is upheld. 

This case involves a woman with asthma, and seizure disorder, who was admitted to the hospital with a seizure event. Before arrival, the patient did not take her Keppra for three days and had breakthrough seizures. This has happened before when the patient runs out of her medications and experiences immediate breakthrough seizures. Keppra was initiated six months prior to this presentation. On further questioning, the patient reported drinking 1 L (liter) of vodka every other day, with the last alcohol intake 1.5 days before this presentation. She denies any falls or trauma to the head. The ethanol level was checked and was elevated at 175. A head computed tomography (CT) was completed in the emergency department (ED), showing no acute intracranial hemorrhage. The patient has a known epidermoid cyst and medial left temporal, occipital cyst, unchanged from previous magnetic resonance imaging (MRI).

The inpatient hospital admission was not medically necessary. Based on the provided documentation, the clinical conclusion is that the seizure was caused by noncompliance with antiepileptic therapy and not an alcohol withdrawal seizure. The patient reported never experiencing alcohol withdrawal seizures, and at the same time, similar episodes of breakthrough seizure events were reported when off of Keppra for a few days. Concurrent acute medical problems were contributing to breakthrough seizures. The patient did not have intractable epilepsy. There are no documented barriers to continuing the current antiepileptic treatment with Keppra in the outpatient setting. The patient was monitored for 24 hours after reloading with intravenous Keppra, had no breakthrough seizures, and was released home. A lower level of care is appropriate for this stay.