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

Diagnosis: Transient ischemic attack (TIA) versus seizure.

Treatment: Inpatient admission.

The insurer denied coverage for the inpatient admission.

The denial is overturned. 

This is a female patient who presented to the Emergency Department (ED) complaining of left arm weakness as well as left-sided facial droop. The documentation indicated she has a history of a prior cerebral vascular accident (CVA) with residual upper left-sided weakness. She also has a history of brain cancer with surgical removal. She had a resolution of symptoms while in route to the ED. The physical examination revealed a blood pressure of 156/74. The patient had facial asymmetry with a left-hand tremor and left hand weakness. There was minimal left-sided facial droop noted. She was recommended to undergo laboratory and diagnostic studies. 

The documentation detailed the patient had 4/5 left upper extremity weakness which she reported was her baseline. Imaging included a computed tomography (CT) scan of the head revealing no acute intracranial abnormalities. There was no intracranial hemorrhage or stroke. The laboratory studies did not reveal any significant abnormalities. The patient was recommended to undergo a Neurology consultation. Neurology recommended she be admitted for transient ischemic attack (TIA) versus seizure. The patient was admitted to the floor as an inpatient and it was recommended she be treated with Keppra as well as labetalol. She also started Lipitor and Lovenox. She continued to improve and denied any significant abnormalities while hospitalized. She remained stable and was discharged with instruction to follow-up.

The submitted documentation indicated this patient presented with a history of prior stroke as well as a history of brain cancer. The documentation does indicate this was an appropriate admission in order to thoroughly evaluate and monitor this patient. She required hospitalization due to stroke versus seizure and the need for continued monitoring and possible timely intervention. Therefore, treating this patient in a lower level was not appropriate.  

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

The insurer's denial of coverage for the inpatient admission is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiovascular Accident

Treatment: Hospital Admission

The insurer denied coverage for hospital admission

The denial is upheld

This case involves a female who presented to the Emergency Department with complaints of left-sided weakness.  The documentation indicated while in the emergency department she was stable.  She was recommended to undergo a computed tomography scan as well as multiple laboratory studies.  Computed tomography scan of the head did not show any acute abnormality.  There was no stenosis or occlusion on Computed Tomography Angiogram.  The patient was noted to be alert and oriented.  She was in moderate distress and had anxiety related to her condition.  The patient reported continued left-sided numbness to the face as well as lower extremity.  The submitted documentation indicated it was recommended she undergo a consultation with neurology and follow-up with a brain magnetic resonance imaging.  The patient was also recommended to be admitted for further evaluation.  The patient did undergo an evaluation by Neurology where it was determined that ischemia was a less likely cause.  She was noted to have a possible psychiatric component.  She was evaluated by psychiatry and was noted to have ongoing depression.  The patient was noted to have complaints of stress.  She did indicate she was motivated to continue care and participate in additional services.  The patient was treated with multiple medications while hospitalized which included benzodiazepines.  The patient was also recommended to undergo a physical/occupational therapy evaluation.  She continued with treatment and had no further significant adverse events.  She did undergo a physical therapy consultation.  The recommendation was made for restorative physical therapy services.  The documentation indicated the patient was alert and oriented however in moderate distress and continued multiple questions about her anxiety.  The documentation detailed she did continue with treatment and given there was a period of stability without further decline, the patient was discharged.

Admission for possible cardiovascular accident was not clinically appropriate as the needed evaluation due to her presenting symptoms could have been done during a period of observation.   Given no significant findings and stability the inpatient stay was not appropriate.  She could have followed up with a lower level of care as she was stable. 

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

The insurer's denial of coverage is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Prostate adenocarcinoma

Treatment: Radiation therapy

The insurer is denied coverage for radiation therapy

The denial is overturned. 

This male patient has a history of prostate cancer, pre-op Prostate-Specific Antigen (PSA) of 15.3, who was treated with radical prostatectomy, revealing pT3Bn0, Gleason Score 4+3 prostate cancer, negative surgical margins, 0/9 lymph nodes involved, and a post-op PSA initially detectable at 4.496.  The patient was found to have a right pelvic sidewall lymph node that was treated using Cyberknife Stereotactic Body Radiation Therapy (SBRT) using a regimen of 36.25 gray units (Gy) in 5 fractions.  The patient had successful local control after oligometastasis-directed SBRT for the pelvic lymph node.  The physician is requesting coverage for radiation therapy for the patient's prostate adenocarcinoma.

The patient has had a prostatectomy, pelvic radiation and SBRT to a right pelvic lymph nodes and para-aortic nodes. He now has thoracic and ribs mets for which the AP intends to deliver SBRT. Palliative RT can be delivered in either 3D or SBRT techniques. The ASTRO Model Policy for SBRT 2020 indicates that SBRT is appropriate for patients with recurrent disease that cannot be treated as effectively or safely by other methods due to requiring a high level of accuracy and precision to minimize the risk of injury to surrounding normal tissues. The patient has three areas of disease all in reasonably proximity. Standard treatment would expose unnecessary amounts of normal tissue to excess radiation. The patient has also had prior radiation, thus using SBRT will minimize normal tissue volumes radiated, which will also protect him from unnecessary overall treatment side effects. National Comprehensive Cancer Network (NCCN) Guidelines for Prostate Cancer V 2.2021 also notes that "SBRT to metastases can be considered in patients with oligometastatic progression where progression-free survival is the goal". The patient does fit the criteria for this situation. He has good performance status and limited metastatic disease that can be treated with SBRT fields. The intention is to improve progression free survival." Per Guidelines noted above, the patient is a candidate for SBRT treatment for his clinical situation.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the radiation therapy is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle Cell Vaso-occlusive Crisis.
Treatment: Inpatient admission. 
The insurer is denied coverage for inpatient admission.  
The denial is upheld. 

This female with a history of sickle cell disease and asthma.  She presented to the Emergency Room (ER) with complaints of 10 out of 10 back pain, chest pain, and leg pain.  A chest x-ray (CXR) revealed no significant findings.  An x-ray of the lumbar spine revealed mild scoliosis with slight curvature to the left. An electrocardiogram (EKG) revealed normal sinus rhythm (NSR). White blood cell (WBC) count and reticulocytes were elevated.  Heart rate, respiratory rate, and oxygen saturation levels were within normal limits (WNL). In the ER the patient was given intravenous (IV) fluids, IV Diphenhydramine, and IV hydromorphone.  She was admitted to medicine with a sickle cell vaso-occlusive crisis.  During the admission the patient was given 40 milligrams (mg) of subcutaneous (SC) Enoxaparin a day (QD), 4 mg of oral (PO) folic acid QD, 2 mg of IV hydromorphone every 3 hours (Q3H), 500 mg of PO hydroxyurea twice a day (BID), and insulin as ordered. Hematology consulted over the case.  Hemoglobin (Hgb), reticulocytes, and lactate dehydrogenase (LDH) were stable.  They recommended starting the patient on 3 mg of Dilaudid Q3H and obtaining Hgb electrophoresis.  The care plan was implemented and the patient's symptoms improved.  She was discharged with instructions to follow up with the primary care physician (PCP) within 1 week of discharge.  

"Generally a person is considered to be in inpatient status if officially admitted as an inpatient with the expectation that he or she will remain at least overnight.  The severity of the patient's illness and the intensity of services to be provided should justify the need for an acute level of care.  An inpatient admission solely because the patient has been kept in observation status over 23 hours would not be considered medically necessary." (American Health Information Management Association, 2018)
	
"Observation was meant to be a short period of time for providers to assess whether patients required admission for inpatient care, or could be discharged.  Typically, this was meant to last fewer than 24 hours and only rarely spanned more than 48 hours." (Society of Hospital Medicine, 2021)                                                        

Uncomplicated sickle cell pain crisis can typically be managed in alternative levels of care and do not require acute level hospitalization.   As this patient had a condition that could reasonably be expected to be stabilized within 24 hours, observational status would be appropriate. Therefore, the inpatient hospital admission is not considered medically necessary for this patient.

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems/Congestive Heart Failure/CHF
Treatment: Home Health Care
The health plan denied the requested increase in personal care hours as not medically necessary. 
The health plan's determination is overturned.

The patient is a female with past medical history of dementia, osteoarthritis, osteoporosis, congestive heart failure, aortic stenosis with procedure and resultant aortic insufficiency, urinary incontinence, hearing loss, hyperthyroidism, anxiety, depression, vitamin B12 deficiency, hypertension, and hyperlipidemia who had been assigned personal care assistance (PCA) hours 8 hours/day, 7 days/week, to total 56 hours/week following an assessment  over the phone. The patient was assessed at total assistance with tasks of meal preparation, ordinary housework, managing finances, stairs, shopping, and bathing while maximum assistance with tasks of managing medication, phone use, transportation, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, toilet use, and bed mobility. The patient was assessed at extensive assistance with eating. The daughter provided a letter stating the patient was unable to perform daily activities and she was not able to get dressed or clean herself, could not get off the toilet by herself, had minimal to no bed mobility, could not prepare meals or even eat by herself, could not manage her medication on her own, and could not perform ordinary housework. The letter also stated the patient was not able to walk without the assistance of an aide. Lastly, the letter stated the patient had fallen out of bed several times and required overnight assistance. At issue is the medical necessity of the requested increase in personal care assistance hours to 129.5 hours per week.

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

Yes. The patient has documented progressive chronic medical conditions of dementia, osteoporosis, and severe aortic insufficiency with congestive heart failure. The patient has documented worsening physical and cognitive functioning. The increase in PCA hours to 129.5 hours per week is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADLs)/instrumental activities of daily living (IADLs). Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle Cell Disease.
Treatment: Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

The patient has a past medical history (PMH) of sickle cell disease, scoliosis and transient ischemic attacks (TIAs) and was admitted with complaints of (c/o) back and bilateral knee pain typical of her sickle cell crises. Her vital signs were notable for a pulse of 102, and peripheral capillary oxygen saturation (SpO2) 98%. The physical exam was notable for no apparent distress (NAD), right scapula tenderness to palpation (TTP). Lab work was notable for a hemoglobin (hgb) of 6.7 (believed to be near patient's baseline). A chest x-ray (CXR) showed no acute disease. The patient was diagnosed with a sickle cell crisis and treated with intravenous (IV) fluids, Tylenol, Benadryl, Hydrea, and intramuscular (IM) pain medication. The patient was discharged per her request, 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 c/o diffuse body pain, both back and knees, and was diagnosed with a sickle cell crisis. The patient did not have any concerning qualities that would make a lower level of care inappropriate, including fevers or clinical suspicion of infection, hypoxia, hypotension, acute chest syndrome, stroke, refractory priapism, or other serious co-morbid condition. The patient was admitted, was given IM and oral pain medications, and she was discharged on a home oral pain regimen at the request of the patient. Overall, this clinically stable patient was admitted for a non-complicated sickle cell crisis, treated with IV fluids, Tylenol, Benadryl, Hydrea, and IM pain medication, and discharged in stable condition, all of which could have been safely and appropriate provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse/Addiction. 
Treatment: Substance Abuse Inpatient. 

The insurer denied inpatient substance abuse treatment. 
The denial is overturned in whole. 

The patient is a male who was admitted to acute inpatient level services for monitoring and detoxification and withdrawal management of cannabis, sedative-hypnotic-anxiolytic (benzodiazepine), and opioid (heroin) use disorders. 

The patient was admitted to acute inpatient level care and placed on a detoxification regimen with a methadone and Valium taper, vitamin replacement therapy, and medical monitoring; the patient was tobacco dependent and offered smoking cessation treatment and received nicotine replacement. Following his third day of treatment, the patient began to participate actively in counseling and educational sessions, as his withdrawal symptoms diminished, and he was feeling better. The subject under review is the medical necessity for the inpatient substance abuse treatment. 

The health plan's determination is overturned. 

The presenting clinical features and history and risk for withdrawal seizures and other complications of benzodiazepine and opioid/heroin use did warrant the admission and the continued structure of an inpatient level setting and 24-hour monitoring in view of the severity of the substance use disorders with multiple substances of abuse, and the associated psychosocial stressors and impairment of functioning. The patient did require a safe and effective detoxification with withdrawal management during the time frame under review with associated substance use disorder treatments, as it was reasonable that the patient would have been unable to abstain from the substances of abuse if detoxification and treatment were to be attempted at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute coronary syndrome. 
Treatment: Acute inpatient hospitalization. 

The insurer denied coverage for the acute inpatient hospitalization. 

The denial is overturned. 

This is a female patient who presented to the hospital with chest pain radiating to her left arm.  Her past medical history was significant for coronary artery disease with previous percutaneous coronary intervention (PCI), atrial fibrillation, peripheral vascular disease status post toe amputation, psoriasis, diabetes mellitus (DM), and hypertension (HTN).  Upon arrival to the Emergency Department (ED), her vital signs were stable.  Electrocardiogram (ECG) revealed atrial fibrillation with a ventricular rate of 110 beats per minute (bpm) with inferior T wave inversions.  Serial troponin values were elevated and reached 0.10.  The patient was taken to the cardiac catheterization laboratory where right radial artery was not palpable and left radial arterial access was attempted.  Following failure to access the left radial artery the procedure was aborted with plans to perform cardiac catheterization the following day via femoral access.  Right coronary artery stenosis was noted on diagnostic catheterization and the patient refused further intervention.  A trial of medical therapy was prescribed and the patient was ultimately discharged. 

The acute inpatient admission was necessary for this patient.  This patient presented with 10/10 chest pain, ECG changes and elevated serum troponin.  She had an acute coronary syndrome.  Her pretest probability of coronary artery disease is high.(1)  Utilizing the HEART (History, Electrocardiogram, Age, Risk factors, Troponin) score she was considered high risk.(2) Risk assessment of patients presenting with chest pain and no significant ST segment changes on ECG was reviewed by Hedayati et al.(3)  Using the HEART score risk stratification schema, this patient would have a high risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation. These findings are concerning and warrant management and evaluation at a higher level of care.  This patient had a history of atrial fibrillation (AF) and was on oral anticoagulant therapy.  Attempts to perform cardiac catheterization via radial artery approach were not successful and her procedure had to be rescheduled for a femoral access approach the following day.  Given her multiple medical problems and presentation, outpatient management or observation would not have been appropriate.  In conclusion, admission to the hospital to treat an acute cardiac event was medically necessary. 

The health plan did not act reasonably with sound medical judgment in the best interest on the patient. 

The insurer's denial of coverage for the acute inpatient hospitalization is overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Proctitis. 
Treatment: Inpatient admission. 

The insurer denied coverage for the inpatient admission. 

The denial is upheld. 

This is a male patient with a past medical history of immunocompromised status who presented to the Emergency Department (ED) with rectal pain.  The patient was afebrile and his vital signs were stable.  The patient had been compliant with his home medication and treatment.  On exam, there was no abdominal rebound or guarding.  The patient had a history of syphilis and there was now a concern that he could have gonorrhea.  Stool cultures were ordered.  The patient's computed tomography (CT) scan revealed proctitis.  The patient was requesting narcotics but then insisted on leaving the hospital.  The Infectious Disease (ID) consult advised that the patient takes doxycycline and have a sigmoidoscopy as an outpatient. 

Based in Milliman Care Guidelines (MCG), the clinical indications for admission for Gastroenterology include having a suspected acute intra-abdominal process, severe diarrhea, severe dysphagia, ascites requiring acute treatment, and severe gastroparesis.  In this case, the patient did not have any of these conditions. 

Based on MCG, the clinical indications for admission for Gastroenteritis include having a suspected severe infection such as bloody diarrhea, severe abdominal pain, peritoneal signs, hemodynamic instability, severe vomiting, severe electrolyte abnormalities, and an inability to maintain oral hydration after observation care. 

Based on the review of the medical record and literature, inpatient admission was not medically necessary for this patient. This patient had rectal pain and proctitis. The patient's stool testing and pain control could have been done in the Emergency Room (ER).  The patient could then have been discharged on oral antibiotics.  There was no evidence of an acute intra-abdominal process.  The patient did not meet the MCG criteria for admission for either Gastroenterology or Gastroenteritis.  

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

The insurer's denial of coverage for the inpatient admission should be upheld.