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

Diagnosis: Shortness Of Breath and Chest Pressure (heart failure)
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

The patient is a male. He was hospitalized for management of acute on chronic systolic heart failure. He presented to the ED (emergency department) for evaluation of Shortness of Breath and Chest Pressure after consuming Asian food the prior evening. His PMH (past medical history) is pertinent for HTN (hypertension), chronic kidney disease (CKD) and gout.

The patient's vital signs revealed BP (blood pressure) 153/97, HR (heart rate) 91-122, RR (respiration rate) 24-30, and O2 (oxygen) saturation was 93% (percent) on RA (room air). There were no arrhythmias reported. Chest x-ray reported vascular congestion. BNP (brain natriuretic peptide) was 5817. Troponin was negative. Cr (creatinine) was 1.78. Treatment included IV (intravenous) Lasix.

The health plan denied coverage of the inpatient admission. This is being appealed.

No, the Inpatient admission was not medically necessary.
Based on the peer-reviewed medical literature and this reviewer's expert medical opinion, the documentation submitted for review do not establish the requested Acute Inpatient Hospital Stay was medically necessary for this patient. According to the MCG (Milliman care guidelines) Guidelines titled: Heart Failure (ORG: M-190), the inpatient admission was not medically necessary, because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay per the guideline. Criteria for inpatient stay are not met, including documentation of hemodynamic instability, respiratory distress, hypoxia, change in mental status, severe heart failure, cardiac arrhythmias of immediate concern, myocardial ischemia or myocardial infarction, positive troponin not explained by CKD (chronic kidney disease) and CHF (congestive heart failure), hypertension requiring inpatient hospitalization, CVA (cerebrovascular accident), pulmonary embolism (PE), aortic dissection, pneumonia, severe electrolyte abnormalities or any other medical condition or other medical instability or acute care needs for which a lower level of care has failed or is not considered appropriate and that would require acute inpatient management. The care he received for mildly decompensated chronic LV (left ventricle) systolic HF (heart failure) is routinely provided safely and effectively at a lower level of care.

Therefore, the Inpatient admission was not medically necessary, based on the submitted information and the current published medical literature evidence-based standards.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Corticobasal degeneration
Treatment: Increase Consumer Directed Personal Assistance To 84 Hours Per Week
The insurer denied the Increase Consumer Directed Personal Assistance To 84 Hours Per Week
The denial is overturned.

The patient is a female with a history of corticobasal degeneration resulting in dysarthria and right sided hemiparesis. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). An appeal review was requested for potential approval of 84 hours/week Personal Assistance Services to offer increased ADL (activities of daily living) support.

Yes, the requested  84 hours/week Personal Assistance Services is deemed medically necessary.
This is female with a history of corticobasal degeneration resulting in dysarthria and right sided hemiparesis. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs).

Although an assessment of the patient's functionality and ability to perform ADLs (activities of daily living) was completed and revealed that the currently approved plan of 63 hours/week Personal Assistance Services is sufficient to meet the patient's current needs, the patient's daughter relates this reduced schedule leaves her home alone, completely unassisted for at numerous hours/day. This is problematic as she is fully dependent on assistance from others for completion of personal hygiene, dressing upper/lower body, toileting, transfers, bed mobility, locomotion, eating, shopping, laundry, meal preparation and house cleaning.

Hence, provision of 84 hours/week Personal Assistance Services can reasonably be expected to be beneficial for the patient and withholding these services, in whole or in part, can reasonably be expected to affect the patient's health adversely. For these reasons, the proposed treatment 84 hours/week Personal Assistance Services is deemed medically necessary.

No, the health plan did not act reasonably, with sound medical judgment or in the best interest of the patient
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Morbid Obesity

Treatment: Requested weight loss surgery (procedure code 43775)

The insurer denied coverage for requested weight loss surgery (procedure code 43775).

The denial is overturned.

As per the medical records, this is a female patient with a history of morbid obesity, sleep apnea, and gastroesophageal reflux disorder (GERD). Her doctor is requesting authorization for lap sleeve gastrectomy and hiatal hernia repair as a matter of medical necessity to be performed inpatient. The patient has a body mass index (BMI) of 38.8 and has sleep apnea but does not wear continuous positive airway pressure (CPAP). She joined their multidisciplinary program and she has undergone a supervised program including surgical evaluation, nutritional and exercise counseling. 

The provider noted in terms of obstructive sleep apnea (OSA) he will defer recommending CPAP given hypopnea predominant disease and only minimal desaturation. The provider noted that the patient may proceed with proposed surgery with moderate pulmonary risk and no contraindication to using Low molecular weight heparin (LMWH) for venous thromboembolism (VTE) prophylaxis.

Notes indicated that the patient has struggled with obesity for most of her life and was evaluated by this provider from a psychiatric perspective and found to be an appropriate candidate for bariatric surgery with the patient not displaying any untreated major depression psychosis, binge eating disorder or current substance/alcohol use disorder.

Documentation noted in a letter that the patient was seen for nutrition consultation in preparation for bariatric surgery. She noted that the patient has been overweight for more than five years and has made significant attempts at non-surgical weight loss including trying Weight watchers, intermittent fasting, Whole 30, low calorie diets and Beach Body without lasting success. Dietary instruction and pre and post nutritional implications of bariatric surgery were reviewed with the patient.

Based upon the records provided and Milliman Care Guideline (MCG) Health Inpatient and Surgical Care 25th Edition Gastric Restrictive Procedure, sleeve gastrectomy by laparoscopy, the patient does meet the criteria and indications for bariatric surgery.  This patient has a BMI greater than 35 (currently approximately 38.8) and does have co morbidities in the form of sleep apnea which would justify bariatric surgery.  Thus, the patient does meet MCG criteria and should have bariatric surgery.

The denial is overturned. The health care plan did not act reasonably and with sound medical judgment as the patient has a BMI of approximately 38.8 and has the co morbidity of OSA. 

The insurer's denial of coverage for the requested gastric sleeve weight loss surgery (procedure code 43775) and hospital admission is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Angina
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

The patient is a male with chronic stable angina. He was hospitalized for elective LHC (left heart catheterization) for PCI (percutaneous coronary intervention) to CTO-LAD (chronic total occlusion-left anterior descending artery).

The patient underwent an uncomplicated PCI (percutaneous coronary intervention) with stenting to the chronically occluded LAD (left anterior descending artery). He became ambulatory and was discharged to home.

No, the Inpatient admission was not medically necessary.
In this particular case, the patient underwent planned LHC (left heart catheterization) followed by successful and uncomplicated PCI (percutaneous coronary intervention) with stenting of the CTO LAD (chronic total occlusion-left anterior descending artery) on the same day. The information provided does not support the medical necessity for admission after his successful and uncomplicated coronary intervention. PCI (percutaneous coronary intervention) procedures are routinely performed now in the ambulatory setting with overnight observation. There is no documentation of unstable medical conditions like ACS/AMI (acute coronary syndrome/acute myocardial infarction), CVA (cerebrovascular accident), contrast nephropathy, acutely decompensated CHF (congestive heart failure), life-threatening cardiac arrhythmia, procedural complications like acute coronary perforation or vascular access complication requiring surgery, or other medical instability or acute care needs that would require acute inpatient management. Since hospitalization for patient, physician or hospital convenience does not establish medical necessity, the denial for care in the acute setting when the same care can be provided in a lesser intense setting is upheld.

Yes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sleep disordered breathing.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male child with a history of snoring and sleep disordered breathing.  Tonsil and adenoid hypertrophy was present. The patient underwent a tonsillectomy and adenoidectomy (T and A) and was admitted as an inpatient for dates of service.  The inpatient stay was denied previously as not been medically necessary and the provider is appealing the denial.

No, the proposed inpatient admission was not medically necessary.
All records were reviewed.  The patient underwent a tonsillectomy and adenoidectomy for sleep disordered breathing.  The tonsils and adenoids were enlarged.   There were no intraoperative or postoperative complications.  The patient's vital signs were stable and the postop diet was advanced.  Based on the above, the medical necessity of the inpatient stay cannot be confirmed as the patient could have been cared for at a lower level of care, observation.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shoulder pain.
Treatment: Shoulder Surgery (arthroscopy) (29827).
 
The insurer denied the Shoulder Surgery (arthroscopy) (29827).  The denial is upheld.

The patient is a female with chronic left shoulder pain. She had participated in PT (physical therapy) and took Ibuprofen. She sustained a fall and noted worsening right shoulder pain. Her physical examination showed 4/5 strength, + (positive) Hawkins and Need. She was able to flex to 170.

An MRI (magnetic resonance image) showed partial thickness tear to rotator cuff, tendonosis to biceps and labral fraying. Her physician recommended arthroscopic rotator cuff repair. He performed several procedures including use of REgenen implant and open biceps tenodesis.

No, the Shoulder Surgery (arthroscopy) (29827) was not medically necessary.  

The indications for surgery require identification of the pain generator and likelihood that improvement will result with operative intervention. There should be consistency of subjective complaints, objective findings on physical examination, imaging studies and a diagnosis. The whole person's clinical condition should be taken into consideration including medical comorbidities and psychological aspects. These factors will also have an effect on response to management. There should be a course of conservative management that has not provided benefit.

The facts in this case are that an insufficient course of conservative treatment was provided. There was no evidence that a course of PT (physical therapy) was completed. The PT (physical therapy) records were for the lumbar condition. No physical therapy, nor injections were provided for a shoulder condition. Prior treatment was directed to the lumbar and cervical spine.

Current practice guidelines and Criteria recommend a full course of conservative treatment prior to surgical intervention. There would thus be no indication for surgery as completed.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Home Health Care. 
The insurer denied an increase in Personal care Assistance Services. 
The denial is upheld in whole.

The patient is a female. She has a medical history of hypertension, arthritis, dizziness, and fatigue. The assessment noted extensive assistance needed for meal preparation, ordinary housework and limited assistance is needed with managing finances, medications and maximal assistance is needed with shopping. The patient is on Advil, chlorthalidone, Plavix, Meclizine, Metoprolol, Nexlizet, and Verapamil.
At issue is the medical necessity of an Increase in Personal Care Assistance Services to 6 hours per day, 6 days per week, for a total of 36 hours per week.

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

The requested health service/treatment of Increase in Personal Care Assistance Services (PCAS) to 6 hours per day, 6 days per week, for a total of 36 hours per week is not medically necessary for this patient.
Increasing Personal Care Assistance Services to 36 hours per week does not appear to be medically necessary for the patient. There was no supporting documentation other than the community assessment to support the medical necessity for the requested PCAS hours. There is no physician documentation supporting the requested hours. There are no physician notes stating or justifying the increased hours and there is insufficient evidence to support this.
Therefore, the requested health service/treatment of Increase in Personal Care Assistance Services (PCAS) to 6 hours per day, 6 days per week, for a total of 36 hours per week is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Genitourinary/Kidney Disorder. 
Treatment: Inpatient Hospital. 
The insurer denied Inpatient Stay. 
The denial is upheld in whole. 

This patient is a male, who was admitted through the emergency room (ER) with left renal colic. His vital signs were a temperature of 36.9 Celsius, blood pressure was 136/87 and heart rate was 81. The white blood cell (WBC) count was 13,000. The creatinine was 1.22 The computed tomography (CT) imaging demonstrated a 13, 7, and 6 millimeter (mm) left distal ureteral calculi with hydronephrosis. The urinalysis was concerning for an infection. Intravenous (IV) pain medications, nausea medications, IV antibiotics and intravenous fluids (IVF) were administered.
A left ureteral stent was placed by urology. IV pain medications, IV antibiotics and IVF were administered. He was discharged home. He was afebrile and hemodynamically stable throughout the stay.
At issue is the medical necessity of the Inpatient Stay.

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

The requested health service/treatment of Inpatient Stay was not medically necessary for this patient.
An acute inpatient level of care was not medically necessary. The patient was afebrile and hemodynamically stable throughout the hospitalization. There was no evidence for sepsis. Following admission, there were no unstable vital signs reported. He did not have a documented infection or kidney failure, solitary kidney, or a kidney transplant, or need for an open surgery. He did not have bilateral obstruction, acute renal failure, or severe vomiting. Pain control, IV antibiotics and IVF followed by stent placement in a non-toxic patient does not require an inpatient stay.
Therefore, the requested health service/treatment of Inpatient Stay was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Screening Chromosomal Anomalies.

Treatment genetic testing (81220 x1, 81329 x 1, 81243 x 1) diagnostic testing.

The insurer denied coverage for genetic testing (81220 x1, 81329 x 1, 81243 x 1) diagnostic testing.

The denial is modified.

The patient has no significant medical history. The provider ordered carrier screening for cystic fibrosis (CF), Fragile X and spinal muscular atrophy (SMA). There is no documentation that the patient has a personal or family history of inherited genetic disorders. 

As per the American College of Obstetricians and Gynecologists (ACOG), "All patients who are considering pregnancy or are already pregnant, regardless of screening strategy and ethnicity, should be offered carrier screening for cystic fibrosis (81220) and spinal muscular atrophy SMA (81329). All other genetic carrier screening in the absence of a positive family history or personal history and in the absence of an ethnic background at high risk for these conditions is considered not medically necessary". ACOG based their recommendation on the fact that there is insufficient scientific evidence that the requested gene panel will have a significant impact on treatment planning or outcome. 

Current consensus guidelines from professional genetics organizations recommend carrier screening only for women with a family history of fragile X syndrome or undiagnosed mental retardation, developmental delay, or autism or for those with ovarian insufficiency. 

The American College of Obstetricians and Gynecologists Committee on Genetics recommends testing for fragile X syndrome as follows: 

Women with a family history of fragile X-related disorders, unexplained mental retardation or developmental delay, autism, or premature ovarian insufficiency are candidates for genetic counseling and fragile X premutation carrier screening. 

If a woman has ovarian insufficiency or failure or an elevated follicle-stimulating hormone level before certain age without a known cause, fragile X carrier screening should be considered to determine whether she has an FMR1 (fragile X mental retardation 1) premutation. 

This patient does not have any of the above conditions. Testing for Fragile X (81243) was not medically necessary. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.

Genetic testing (81220 x1, 81329 x) diagnostic testing is considered medically necessary for this patient. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The insurer's denial of coverage for genetic testing (81220 x1, 81329 x 1, 81243 x 1) diagnostic testing is modified. Approve genetic testing (81220 and 81329) but uphold denial of 81243.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Essential (primary) hypertension
Treatment: Formulary exception for Carvedilol ER
The insurer denied the Formulary exception for Carvedilol ER
The denial is upheld

The patient is a female with a past medical history of HTN (hypertension), cardiomyopathy, who was maintained on Carvedilol ER. Continuation of Carevdilol ER was requested. There is no documentation of failure of formulary b-blocker alternatives.

No, the health plan should not cover the Formulary exception for Carvedilol ER (extended release).
There is no documentation of failure of formulary b-blocker alternatives. There is no documented evidence that a formulary drug, such as carvedilol, would be less effective that the requested carvedilol ER (extended release) or would have an adverse effect. A trial of a formulary medication would be a reasonable alternative to the requested medication.

Therefore, given the above, the health plan should not cover the Formulary exception for Carvedilol ER (extended release).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Need for contraception
Treatment: Phexxi 1.8-1-0.4% VA GEL
The insurer denied the Phexxi 1.8-1-0.4% VA GEL.
The denial is overturned.

The patient is a female who needs contraception. She has tried multiple oral contraceptives. The provider letter states that she has failed Gynol II, Shur Seal and diaphragm. The request is for Phexxi.

The health plan denied the request as not medically necessary. This is being appealed

Yes, the requested Phexxi is medically necessary.
American College of Obstetricians and Gynecologists supports patient or clinician requests for branded OCs (oral contraceptives) or continuation of the same generic or branded OC (oral contraceptive) if the request is based on clinical experience or concerns regarding packaging or compliance, or if the branded product is considered a better choice for that individual patient.

In review of the information provided, the patient requires birth control.  She has failed the formulary alternatives per the provider letter.  She has an intolerance to hormones and requires a non-hormonal method of birth control.  Therefore, this is a medically appropriate and necessary option for this patient.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
In review of the information provided, the patient has failed the formulary options, so this would be considered necessary.