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

The patient has a past medical history of metastatic breast cancer - further complicated by recurrent right sided pleural effusion. The patient's effusion had been removed approximately 1 month prior and she had some relief. On this admission, the patient presents with worsening shortness of breath - presumably due to the re-accumulation of the malignant effusion.

The health plan's determination is overturned. The inpatient stay is medically necessary. The inpatient stay was medically after the patient got the pleurex catheter placed for two main reasons. First of all, the patient's mean arterial pressure was below 60 - a level (if sustained) would normally require an Intensive Care Unit (ICU) admission. Second, she required significant pain control with intravenous (IV) pain medications. With regards to her initial admission - that was warranted because she was progressively short of breath and intervention was necessary to ameliorate her condition. According to the MCG criteria for pleural effusion, the patient does meet criteria for admission. She has a recurrent malignant pleural effusion that required a chest tube placement; there were respiratory findings of dyspnea that persisted beyond her time in the ED (until she had the pleurex placed); and the complication of pain and hypotension after the procedure warranted inpatient/telemetry care.
Appeal type: Medical necessity
Decision: Upheld

This patient with no relevant past medical history, who presented to the emergency department by ambulance  after the patient  collided with a car while riding a bicycle. Workup in the emergency department revealed significant swelling of the left elbow, with a possible non-displaced fracture of the left elbow. The health plans determination of medical necessity is upheld in whole .The fracture did not require further intervention there was no evidence of hematoma expansion. Therefore an inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This patient with a history of hypertension who presented to the hospital with an acute complaint of double vision. Her past medical history also included diabetes and hyperlipidemia. She reported double vision for the past one week. She also reported a frontal headache and the feeling of intermittent dizziness along with difficulty with balance.  The health plan's determination if medical necessity is upheld in whole. The patient was hemodynamically stable and had stable chronic diplopia. This is normally evaluated as an outpatient. In addition, the patient did have a negative head CT scan in the emergency department.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: incontinence, advanced age, musculoskeletal
Treatment: Home health care
The insurer denied Home Care/Personal Care HHC - level 2 Personal Care Services (PCS), 80 hours per week. The denial was reversed. 

This elderly patient has multiple medical problems and extensive functional impairments. It appears that most of the patient's disability resulted from a previous stroke that occurred in 2018. The patient is bedbound as per the UAS, physician's letter and M11Q.  

PCS hours are currently approved for 40 per week. This amount of time is insufficient to address all the patient's daily. 

It is unlikely that the patient eats all her meals within such a limited time (5-6 hours); and since she cannot prepare her meals, someone must be present to prepare and serve her meals, even if she can eat independently.
 
It is noted the patient needs extensive/maximal assistance for dressing.  It is not clear whether she is in sleepwear all day or if she is dressed in day clothes part of the day and changes to sleepwear in the evening.  For the latter situation, she would need assistance to change her clothes late in the day.  It is also likely she needs clothing changes at times due to incontinence. 

The UAS indicates the patient is incontinent with no control (bladder and bowel).  The tasking tool includes allocation of time for toilet use, but it is not clear whether this means the patient is actually sitting on the toilet (or commode), or if this indicates incontinence care in bed (i.e. changing pads/diapers, hygiene, applying clean incontinence supplies, change of clothes/bed linens as needed).  Regardless of where the patient's care is provided (bathroom, commode or bed), she is totally dependent on a caregiver for toileting needs.  Episodes of incontinence occur at various and unpredictable times throughout the day and night.  This aspect of the patient's daily care cannot be completely managed by the aide within 5-6 hours per day. 

Another aspect of daily care which is especially important for this patient is bed mobility, as she spends most or all of her time in bed.  Bed mobility requires movement of upper and lower extremities.  The patient has limited mobility on her left side, and decreased range of motion of her left shoulder. The patient needs a caregiver (paid or voluntary) for most of the day and night to promptly address episodes of incontinence (occurring at unpredictable times), assist with proper positioning in bed (every two hours per physician recommendation), as well as other possible needs for a person who is bedbound (e.g. food, fluids, PRN medications).  Therefore, of PCS 80  hours is medically necessary and in the patient's best interest in order to manage the patient's Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) needs during hours previously managed by the daughter.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Blood Disorder (Sickle cell disease)
Treatment: Inpatient Hospital

Summary: This patient with known sickle cell (SC) disease (not sickle trait, but hemoglobin sickle cell (Hgb SC) disease), was transferred from the Psychiatric ward with complaints of abdominal pain that was 9/10 in intensity and was similar to a prior SC crises. The medical record indicated that the patient had an enlarged spleen on ultrasound, elevated reticulocyte count and an elevated lactate dehydrogenase (LDH). In addition, the platelet count was 175 (normal for that lab 180). All of these labs are consistent with SC hemolysis, and the combination of splenic enlargement and thrombocytopenia are consistent with SC crisis and splenic sequestration (which at this age is more common in patients with Hgb SC disease). The admission note stated that the patient was not taking adequate oral hydration, and as such, prolonged intravenous (IV) hydration was indicated both for the ongoing sickling hemolysis and possible splenic sequestration.

The insurer has denied coverage for the inpatient hospital admission as not medically necessary. The denial was reversed.

The inpatient Psychiatric ward is not suited to manage such a medical issue as SC pain and crisis. Given the lab findings and clinical complaints concerning for SC crisis, hemolysis and possible splenic sequestration in this patient with psychiatric concerns, inpatient management was appropriate. It is commonly understood and widely published that in children and young adults with SC disease the description of pain is often the only sign of SC crisis. As such, for a patient in whom ambulatory analgesia has not been sufficient, hospitalization for management of pain is standard of care. Hospitalization for management of pain with IV analgesia (ketorolac), IV hydration and to monitor for escalation of care as needed was within standard of care. The patient had significant pain consistent with SC crisis, and labs and imaging findings were concerning for splenic sequestration. Hospitalization for management of pain with IV analgesia and to monitor for escalation of care as needed was within standard of care. Her length of stay was justified by the interventions she received and the need to ensure her pain would be adequately controlled upon discharge. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

The is is a patient with a history of an anaphylactic reaction to peanuts at age three who was brought to the emergency department (ED) with lower lip swelling after eating Chinese food that was in peanut sauce. She had no systemic symptoms-no problems breathing, no abdominal complaints, no rash and did not have tongue swelling or a sensation of throat swelling. She was given intramuscular dexamethasone and oral Benadryl and observed for two hours in the ED. She did not worsen at all, but her lower lip remained swollen, so she was admitted to the hospital. The health plan's determination of medical necessity is upheld.
Th patient did not have anaphylaxis. Her vital signs were always normal. She did not have any respiratory signs or symptoms. She did not have any systemic symptoms.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fever and Rash
Treatment: Inpatient admission
The inpatient admission was medically necessary.
The patient was admitted for FUO after not responding to outpatient treatment and work-up, as is standard-of-care. To complete this work-up as an outpatient could take one to two months, and if the diagnosis is a cancer (what was ultimately suspected in this patient), that time lost could easily translate into worse outcomes or even death. For this reason, the health plan did not act in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain and abdominal pain, past medical history of hypertension 
Treatment: Inpatient admission, diagnostic testing, and medication management

The insurer denied the inpatient admission. The denial was upheld

The patient was brought to the ED, by ambulance, with a complaint of sudden onset of left chest pain and left abdominal pain radiating through the back this morning. The pain was described as a pressure sensation which worsened while walking, and was associated with dyspnea which resolved. Aspirin x2 were taken at home and the patient was given nitroglycerin by Emergency Medical Services (EMS). At arrival to the hospital the patient was symptom-free. He has a past surgical history of an appendectomy. His review of systems was negative except for what has been mentioned above. He reported having a gastrointestinal viral type syndrome with vomiting and diarrhea one week prior. He has a positive family
history for coronary artery disease (CAD). His vital signs included temperature 98.1, heart rate 60, BP
147/86, respirations 20 and oxygen saturation 100%. On physical exam he was described as being in no acute distress. Examination of his abdomen revealed mild left upper quadrant tenderness with no rebound or guarding. There was mild left thoracic spine tenderness and no other abnormalities
were noted. The patient was judged to have a Thrombolysis in Myocardial Infarction (TIMI) high score of 3 because of aspirin use, risk factors of CAD and chest pain in the past 24 hours. An echocardiogram revealed no valvular abnormalities and no evidence of pericardial effusion. The patient had a coronary angiogram revealed the left anterior descending (LAD) artery was a large vessel and there was a 20%
stenosis in the proximal LAD and there was mild atherosclerosis in the mid LAD with no flow limiting lesions. The impression was non-obstructive CAD with normal left ventricular (LV) systolic function. The recommendation was to continue medical therapy for mild coronary artery disease (CAD) including
aspirin and statins. Observation units have been developed to improve care of patients who do not
have an obvious clinical condition after their ED evaluation. Selected people with chest pain are one of the most prominent groups of such patients. They benefit from observation unit care with standardizing timely and accurate risk assessment, implementation of clinical decision rules, and use of accelerated
diagnostic protocols. They are a modern structure for cost-effective, high-quality outpatient/in-hospital patient care. (5) This patient presented to the hospital with a complaint of chest and abdominal pain. troponin was within normal limits and his EKG did not show any evidence of ST segment elevation or T-wave inversion consistent with acute myocardial injury or ischemia. The literature cited makes it clear that acute hospital admission for this type patient is not medically necessary
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pregnancy- shortened cervix seen on sonogram
Treatment: Inpatient Hospital

Summary: This patient was referred at 28.2 weeks gestation to the Emergency Department (ED) because of a shortened cervix seen on sonogram. The patient's evaluation revealed a 2 cm long closed cervix. There was no bleeding, ruptured membranes or fever. The patient was admitted and hydrated. She was started on magnesium sulfate. She received two doses of steroids for fetal lung maturity. The progress notes do not document any cervical changes or problems. 

The insurer has denied coverage for the inpatient hospital admission as not medically necessary. The denial was upheld. 

Preterm labor is an indication for admission and tocolysis. Preterm labor is defined as uterine contractions with cervical changes. Did this patient have preterm labor? During this admission, there was no documentation of any cervical changes. So the patient was not in preterm labor. Ideally, this patient could have been observed in Labor and Delivery, received intravenous (IV) fluid and then re-evaluated a few hours later. If upon re-evaluation no cervical changes occurred then, she could be sent home. If cervical changes did occur, then she would be admitted for tocolysis and further management. Neither the patient nor the fetus was in any jeopardy. There was no bleeding or fever. There was no evidence of ruptured membranes. The fetal heart rate tracing was reassuring and an ultrasound did not show any anomaly. The management that this patient received during her admission could have been easily done in a less acute setting: Once the provider ascertained that there was no evidence of preterm labor (no change in cervical status after few hours of observation), the patient could have been sent home after being hydrated. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back pain
Treatment: Lumbar fusion at L4-5
The proposed lumbar fusion was not medically necessary.
Based on the medical records supplied, the surgery was not medically necessary as documentation of a sufficient trial of conservative care, including physical therapy, was not present.  The patient only went to nine sessions of four weeks and was showing some improvement. 
This patient does have spondylolisthesis and significant neural compression but there was not a progressive motor deficit that would make surgery urgent.  A complete trial of physical therapy would be medically appropriate before considering surgery.  Therefore, the lumbar fusion was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

This is a patient who presented for evaluation and treatment of tooth #28. Based on the documentation, tooth #28 has recurrent decay around a failed restoration along with pulpal involvement. In question is the medical necessity of the planned treatment of (3320) root canal treatment of a pre molar #28, and full metal cast base metal crown (2791) for tooth #28.

The health plan's determination is overturned. The requested procedures will allow the patient to maintain the tooth in the mouth and use it toward chewing. The patient does not have this tooth as the single tooth remaining in the dentition which would be the only numerical tooth based rationale for not completing the therapy and instead extracting the tooth as it would not serve purpose for a removable partial denture (RPD). As the tooth has recurrent decay involving the pulp, and as the failed restoration will result in loss of substantial tooth structure, the therapy of (3320) root canal treatment of a pre molar #28, and full metal cast base metal crown (2791) for tooth #28 is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

The patient presented to the emergency department (ED) with right hemiparesis and aphasia.  A computed tomography angiography (CTA) showed a thrombus within the left internal carotid artery (ICA) terminus extending throughout the interior left M1 segment, with extension into the proximal left M2 posterior segment with loss of gray white differentiation in the anterior left temporal lobe and posterior insula and large ischemic penumbra.

The health plan's determination is overturned.  The inpatient stay is medically necessary.  Patients following IV tPA or mechanical thrombectomy are at an increased risk of post treatment hemorrhage in the brain and require close monitoring in the inpatient setting.  This particular patient did sustain a post reperfusion hemorrhage following thrombectomy; therefore, continued inpatient care was reasonable and medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back and Leg Pain
Treatment: Removal of Tarlov's cysts and reconstruction of the sacrum
The removal of Tarlov's cysts and reconstruction of the sacrum is not medically necessary.
The documentation does not support the proposed surgery. The literature included below describes a 20% complication rate associated with this procedure and only 32% rate of complete resolution of symptoms. Surgical treatment for Tarlov cysts are associated with a very high complication risk as noted in large reviews of the literature, and do not demonstrate adequate resolution rates for the surgery to be considered within the standard of care or medically necessary for this patient. For this reason, this proposed surgery would not be considered medically necessary for this patient's symptoms.
Based upon the high rate of complication, the decreased likelihood of complete resolution, the surgery proposed would not be considered medically necessary and the health plan's denial is reasonable in this situation considering the poor success rates and high complication rates associated with the procedure.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who was brought to the emergency department (ED) with a three day history of upper respiratory infection (URI) symptoms and wheezing.  At triage, the patient had normal vital signs and an oxygen saturation of 96% on room air. He is described as in no acute distress with diffuse wheezing on lung exam, but no accessory muscle use, good respiratory effort, and good air entry. He was given systemic steroids and three duoneb treatments in the ED, and still had some wheezing, so he was also given magnesium. The patient was admitted to the hospital for further management. The health plan's determination of medical necessity is upheld. The patient did not have any respiratory distress (retractions, increased work of breathing), tachypnea, or hypoxemia. The patient  did not have a prior history of severe asthma exacerbations resulting in acute hospitalization or any other issue that would lead to increased concern in a patient who had wheezing alone without any other problems as part of his asthma exacerbation.
Appeal type: Medical necessity
Decision: Overturned

The patient is young boy who had a dental cleaning and developed facial swelling and a fever. He was admitted to the hospital. The health plan denied the inpatient admission as not medically necessary. The health plan's determination is overturned. The inpatient stay was medically necessary as his symptoms were progressing quickly with an increased amount of swelling and pain. He was also dehydrated due to difficulty tolerating oral fluids. He required parenteral antibiotic treatment to treat the infection and prevent the spread as well as intravenous fluids to maintain hydration.
Appeal type: Experimental/Investigational
Decision: Overturned

Reviewer #3:

Per the progress note written by the General Surgeon, the patient was seen for her complaint of gastroesophageal reflux disease (GERD) and hiatal hernia.  He noted a prior endoscopy performed that showed the esophagogastric junction was normal with small erosions in the antrum.  The patient underwent an esophagram which showed moderate GERD up to mid esophagus.  No evidence of a stricture was noted.  Esophagogastroduodenoscopy (EGD) performed did not reveal a hiatal hernia.  Ambulatory pH monitoring showed a DeMeester score of 38.1.  A high resolution esophageal motility study was normal 

Schwaitzberg6 noted that eligible patients for the procedure include those with all of the following: Typical GERD symptoms; abnormal pH study; Partial response to daily PPI therapy; Absence of a large hiatal hernia (>3 cm) or severe esophagitis.

There is scientific evidence in peer reviewed literature to support and substantiate the LINX system's improvement in health outcomes as well as its safety and effectiveness.  It is approved by the FDA. It has been recognized by the Society of American Gastrointestinal and Endoscopic Surgeons [SAGES] and the American Society of General Surgeons [ASGS] as an option for treating GERD.  There are long term results out to 5 years with improvement in the health outcomes for patients undergoing the LINX procedure. Smith5 reported that "during a 4-year period in more than 3000 patients, no unanticipated magnetic sphincter augmentation device [MSAD] complications have emerged, and there is no data to suggest a trend of increased events over time.  The presentation and management of device-related issues have been less complicated than revisions for laparoscopic fundoplication or other interventions for GERD.  MSAD is considered safe for the widespread treatment of GERD." Therefore, the LINX procedure does improve health outcomes. 

The requested service is indicated in the case at hand as the patient has longstanding reflux and does have proven GERD with a positive pH study with a DeMeester score of 38. She meets all the criteria as set forth in UpToDate by Schwaitzberg. Thus, the patient is a good candidate for this procedure.
Appeal type: Experimental/Investigational
Decision: Overturned

Reviewer #2:

The LINX Reflux Management System (a sphincter augmentation device) (Torax Medical, Shoreview, MN) is used, according to the FDA, "to treat gastroesophageal reflux disease (GERD) in patients who continue to have GERD symptoms despite the use of maximum medical therapy for the treatment of their reflux. 

There is growing sufficient published peer-reviewed data from well-constructed clinical studies to permit a scientific conclusion regarding the benefit of laparoscopic magnetic sphincter augmentation procedure for the treatment of GERD using the (CPT) code 43284 (laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device) as an alternative to the Heller surgical approach. 

Position statement from the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) noted the implementation of the LINX device requires minimal dissection and relatively few technical steps when compared to Nissen fundoplication and that the LINX device may provide an option currently lacking in clinical practice for patients with medically refractory GERD who have not yet progressed to end-stage reflux disease with associated complications. The conclusion was that "on the basis of the available evidence, the LINX device should be an option available to patients and providers for the management of medically refractory GERD."