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

Diagnosis: Abnormal stress echocardiogram
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld

This adult male presented for elective outpatient left heart catheterization (LHC) and underwent successful percutaneous coronary intervention (PCI) with drug eluting stent (DES) to the mid left anterior descending (LAD) on the same day. His past medical history (PMH) was significant for worsening effort angina and abnormal stress echocardiogram remarkable for stress-induced apical hypokinesis, hyperlipidemia (HLP) and hypertension (HTN). There were no procedural complications and the patient was admitted to the hospital for overnight observation for post-procedure care. There were no acute changes and the patient was discharged to home. This is an appeal of the denied claim that the requested inpatient hospital admission: was medically necessary for this patient.

The proposed inpatient hospital admission was not medically necessary.
In this particular case, the patient underwent planned left heart catherization followed by successful and uncomplicated percutaneous coronary intervention (PCI) with stenting to the left anterior descending on the same day. The information provided does not support the medical necessity for admission after his successful and uncomplicated coronary intervention. Percutaneous coronary intervention (PCI) procedures are routinely performed in the ambulatory setting with a period of observation. There is no documentation of unstable medical conditions like acute coronary syndrome (ACS)/acute myocardial infarction (AMI), cerebral vascular accident (CVA), contrast nephropathy, acutely decompensated congestive heart failure (CHF), 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. The care he received is routinely provided safely and effectively at a lower level of care. Therefore, based on the submitted information and the current published medical literature, the proposed treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Symptoms of a Stroke. 
Treatment: Inpatient Admission. 

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

The patient is a woman. She had a recent stroke (left occipital infarction) approximately two weeks prior, leading to headache, right sided sensory symptoms and visual deficit prior, and subsequently returned back to normal. She presented again. She returned due to worsening visual deficit. 

She was admitted overnight for close monitoring, MRI (magnetic resonance) brain and MRA (magnetic resonance angiography) head and neck, and for neurological consultation. She was subsequently discharged. 

The plan denied coverage of the inpatient admission on the basis of medical necessity. This denial is being appealed. 

Yes, the Inpatient admission was medically necessary. 

The patient had a significant stroke approximately two weeks prior, and she was having a return of the symptoms. A history of prior recent stroke with new or worsening symptoms is an emergency and requires inpatient hospitalization for potential progression of stroke or new symptoms. This requires frequent neurological checks and expedited imaging, which cannot be done in the outpatient setting. 

Therefore, given the above, the Inpatient admission was medically necessary. 

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient. 

The health plan should cover the inpatient admission, as the patient is at high risk for further strokes. To not cover the admission when it was medically necessary is not reasonable, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Seizure (epilepsy)
Treatment: MRI guided laser treatment (laser interstitial thermal therapy), pre-service
The insurer denied the MRI guided laser treatment (laser interstitial thermal therapy), pre-service
The denial is overturned

The patient is a female with medically refractory epilpesy who underwent extensive epilepsy workup including stereoelectroencephalography (SEEG) and her seizures were localized to the left posterior cingulate and precuneus region. The patient is recommended for laser interstitial thermal therapy (LITT) therapy to these areas.

Yes, the use of laser ablation for epilepsy surgery is medically necessary and appropriate.
The literature supports the use of laser ablation as one method to treat patients with epilepsy. There are many studies that have demonstrated the efficacy of this and has been well discussed in the literature.

"In recent years, new practices and technologies have emerged that dramatically expand the scope of interventions performed: stereoelectroencephalography has become widely adopted for seizure localization; stereotactic laser ablation has enabled more focal, less-invasive, destructive interventions; and new brain stimulation devices have unlocked treatment of eloquent foci and multifocal-onset etiologies." (3)

"This case highlights the role of the cingulate cortex (CC) in regulating anxiety. Ablation of the epileptic focus resolved both epilepsy-related anxiety and baseline features. Future studies assessing the role of the cingulate cortex (CC) in anxiety disorders may enable improvements in surgical treatments for anxiety disorders." (2)

"Applications of MRgLITT (Magnetic resonance-guided laser interstitial thermal therapy) in mesial temporal lobe epilepsy and hypothalamic hamartoma, along with its contraindications in the treatment of epilepsy, are discussed based on current evidence. To put this position statement in perspective, we detail the evidence and authority on which this ASSFN (American Society for Stereotactic and Functional Neurosurgery) position statement is based." (1)

The need for inpatient surgery is medically necessary and appropriate as there is risk for postoperative complication such as bleeding or stroke, and the patient requires neurochecks and observation in an acute inpatient level of care to treat any issues that might arise after surgery. Therefore, the acute inpatient hospitalization is also medically necessary.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
The use of laser ablation for medically refractory epilepsy is well accepted and part of the treatment of patients with epilepsy. This is standard of care and appropriate and should be approved for this patient. All major centers perform this procedure and this is an excellent treatment option for patients such as this one with deep ictal onset zones; therefore, this denial should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congestive Heart Failure
Treatment: Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 24 Hours per Day (Split Shift)
The insurer denied: Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 24 Hours per Day (Split Shift) 
The health plan's determination is overturned.

The patient is a male with medical history notable for congestive heart failure (mixed systolic and diastolic), dementia, diabetes, coronary artery disease, hypertension, insomnia, cataracts, and glaucoma. He resides alone in an apartment. He recently had a prolonged hospitalization related to a fall at home and is now functionally bed bound. He currently receives 24 hours per day (live-in) level 2 personal care assistance. His care team requested an increase to 24 hours per day split-shift, and this request was denied by the insurance company. This denial is the subject of this review.

The health plan's determination is overturned.

The requested health service/treatment of Home Care / Personal Care Home Health Care (HHC) - Level 2 Personal Care Services, per 15 minutes Increase to 24 Hours per Day (Split Shift) is medically necessary for this patient.
If the aide is unable to achieve five hours of uninterrupted sleep the patient would qualify for continuous personal care services (split-shift). Therefore, the question at hand is whether it is appropriate for this patient to go through a minimum of five hours nightly without personal care services.
The Uniform Assessment System (UAS) and physician appeal letter indicate that the patient is no longer capable of turning and positioning in bed after the functional decline from his recent hospitalization. This is to be completed every 2 hours. Therefore, the patient requires around-the-clock level 2 personal care services which would only be accommodated by split-shift services.
The patient has bowel and bladder incontinence which has been occasional in the past, but which may worsen after his recent functional decline. He may also require level 2 services throughout the night for unscheduled toileting needs.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Break in the Lower Back (L1 vertebral fracture)
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

The patient is a female. The patient sustained an L1 (first lumbar spine vertebra) compression fracture. She was admitted to an inpatient level of care.

The patient had a fall off of a step stool and was complaining of lower back pain. The patient was unable to sit or stand due to the pain. The patient was brought by EMS (emergency medical services) to the emergency department.

The patient was diagnosed with an L1 (first lumbar spine vertebra) vertebral body fracture after orthopedic consultation. The patient was not recommended for any acute orthopedic intervention. The patient was prescribed a lumbar brace and given pain medications. The patient was discharged home the following day.

This is a review for the inpatient level of care.

No, the Inpatient admission  was not medically necessary.
The patient did not require the acute inpatient level of care for this injury. The patient sustained a compression fracture of L1 (first lumbar spine vertebra), which was stable and required external bracing. The patient did not require any surgical intervention or advanced interventions. There is no evidence of severe instability or neurologic deficits that would require emergent care. The patient did not require an inpatient level of care, since the same services could have been safely and effectively provided to the patient at the observational level. Thus, the inpatient hospital care was medically necessary, since it was not standard of care or clinically appropriate based upon the information provided.

Yes, the health plan did act reasonably and with sound medical judgment and in the best interest of the patient.
The patient was recommended for a lower level of hospital care. The patient could have received the same services at a lower level of hospital care and did not require an inpatient level of care. The decision was appropriate and medically sound. This treatment is in the best interest of the patient, since the patient would have received the same services, but just at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension, congestive heart failure and fibromyalgia
Treatment is (PCA) level 2: 12 hours per day - 7 days per week; 12 hours per day- 7 days per week (split shift) - for a total of 168 hours per week
The insurer denied coverage for (PCA) level 2: 12 hours per day - 7 days per week; 12 hours per day- 7 days per week (split shift) - for a total of 168 hours per week
The denial is upheld

This is a morbidly obese patient with chronic medical problems including hypertension, congestive heart failure and fibromyalgia. She lives alone in a 1-bedroom apartment in the basement of a 2-story building. She is currently approved for PCA (patient care assistant) level 2: 12 hours per day - 7 days per week - for a total of 84 hours per week.  She is requesting (PCA) level 2: 12 hours per day - 7 days per week; 12 hours per day- 7 days per week (split shift) - for a total of 168 hours per week, which is currently under review.  

The Uniform Assessment System (UAS) report was reviewed.  The patient's cognition is described as modified independent with good short- and long-term memory. She is totally dependent for bathing, lower body dressing and toilet use.  The patient requires maximal assistance for upper body dressing, personal hygiene and bed mobility. She is frequently incontinent of bladder and occasionally incontinent of bowel. She is able to contact a relative in case of an emergency and speaks with a social worker on a weekly basis.   

The patient's significant functional impairments support the medical necessity of a personal care aide. However, her condition and functional needs are not at a level or as unpredictable as to require the requested PCA level 2: 12 hours per day - 7 days per week; 12 hours per day- 7 days per week (split shift) - for a total of 168 hours per week. This physician would also agree that the patient may require 24-hour monitoring. However, safety monitoring under personal care services does not include monitoring an individual when no other Level I or Level II personal care services task is being provided. Based on the enclosed documents reviewed, the patient health and safety can be appropriately provided and maintained by the authorized PCA services 12 hours/day, 7 days/week. 

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

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, the requested personal care aide (PCA) level 2: 12 hours per day - 7 days per week; 12 hours per day- 7 days per week (split shift) - for a total of 168 hours per week is not medically necessary.  

The insurer's denial of coverage for personal care aide (PCA) level 2: 12 hours per day - 7 days per week; 12 hours per day- 7 days per week (split shift) - for a total of 168 hours per week is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female with no significant history. She was admitted to the hospital with abdominal pain, lethargy and decreased appetite.

The patient was noted with urinary tract infection and fevers, possible peri-nephritic abscess. She was admitted and started on IV (intravenous) antibiotics.

The health plan denied coverage of the inpatient admission on the basis of medical necessity. The denial is being appealed.

No, the Inpatient admission was not medically necessary.
The patient was admitted and started on intravenous antibiotics and intravenous fluids for a urinary tract infection, pyelonephritis and possible perinephric abscess. Based on available data, there was no documentation of hemodynamic instability, vomiting that was severe or persistent, altered mental status that is severe or persistent, persistence or worsening of clinical findings or urinary system findings. There was no documentation of acute renal failure or need for continued IV (intravenous) hydration support or other condition, treatment, or monitoring requiring inpatient admission. Based on available data inpatient level of care was not medically necessary.

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: Diabetes, peripheral neuropathy and congestive heart failure.
Treatment: Increase in CDPAP (consumer directed personal assistance program) services to 8 hours per day 7 days per week for a total of 56 hours per week.
The insurer denied coverage for an increase in CDPAP services to 8 hours per day 7 days per week for a total of 56 hours per week.
The denial is upheld.

This is a patient with chronic medical problems including diabetes, peripheral neuropathy and congestive heart failure. She is currently authorized for 6 hours/day, 7 days/week for a total of 42 CDPAP hours/week. She is requesting an increase in CDPAP services to 8 hours/day 7 days/week for a total of 56 hours/week, which is currently under review.

The Uniform Assessment System (UAS) report was reviewed. The patient's cognition is described as "minimally impaired." She is self-directing and able to verbalize an emergency plan. The patient requires extensive assistance for bathing, lower body dressing, ambulating and toilet transfers/use. She is frequently incontinent of bladder and continent of bowel. Limited assistance is needed for personal hygiene and upper body dressing. She is independent for bed mobility and supervision for eating/drinking. There has not been a significant functional decline compared to the prior assessment. This physician agrees with the insurer; the patient's health and safety can be appropriately provided and maintained by the currently approved CDPAP for 6 hours/day, 7 days/week for a total of 42 CDPAP hours/week.

The healthcare plan acted reasonably, with sound medical judgment and in the best interest of the patient. (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board, and associations. All decisions are evidence-based).

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, the requested increase CDPAP services to 8 hours per day, 7 days per week for a total of 56 hours per week is not medically necessary.

The insurer's denial of coverage for an increase in CDPAP services to 8 hours per day 7 days per week for a total of 56 hours per week is upheld. Medical Necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Irritable Bowel Syndrome (IBS).
Treatment: Hyoscyamine Sulfate 0.125 milligrams (mg) sublingual tablet.
The insurer denied: Hyoscyamine Sulfate 0.125 milligrams (mg) sublingual tablet.
The denial is: Upheld

The patient is a female with Irritable Bowel Syndrome (IBS) without diarrhea manifesting with abdominal pain. She has responded to hyoscyamine. Therefore, the attending provider would like to use hyoscyamine sublingual tablets to treat her patients symptoms.

This patient has not tried and failed dicyclomine which is also an antispasmodic agent and is likely to be as effective as the non-formulary drug (Hyoscyamine Sulfate 0.125mg sublingual tablet).
Hyoscyamine side effects include drowsiness, dizziness or lightheadedness, headache, blurred vision, flushing (feeling of warmth), dry mouth, constipation, difficulty urinating,
Dicyclomine side effects include dry mouth, upset stomach, vomiting, constipation, stomach pain, gas or bloating, loss of appetite, dizziness.
Thus, the side effects of the formulary drug dicyclomine would not be different or more severe than the non-formulary hyoscyamine.
Irritable bowel syndrome (IBS) is a common gastrointestinal disease characterized by abdominal pain and change in bowel habits. IBS diarrhea predominant (IBS-D), which is arguably the most common subset of IBS, is also associated with rectal urgency, increased frequency, abdominal bloating, and loose to watery stools. Current treatments for diarrhea include mu-opioid agonists (i.e., loperamide, Lomotil) and bile acid sequestrants (i.e., cholestyramine) while treatments for abdominal pain include antispasmodics (i.e., hyoscyamine, dicyclomine) and tricyclic antidepressants (i.e., amitriptyline). Abnormal contraction of smooth muscle within the gastrointestinal (GI) tract may underlie some IBS symptoms, especially pain; therefore, agents that relax smooth muscles such as antispasmodics and peppermint oil have been evaluated in patients with IBS. A 2014 systematic review of available randomized, placebo- or 'no treatment'-controlled trials for various antispasmodics (23 trials; 2154 patients) demonstrated that antispasmodics significantly improved IBS symptoms to a greater extent than placebo (number needed to treat [NNT]) for antispasmodics 5 (95% confidence interval [CI]). However Hyoscyamine is not superior to the antispasmodic (dicyclomine) available on the plan.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: congestive heart failure, cerebral infarction (unspecified), schizoaffective disorder, iron deficiency anemia.
Treatment: Custodial Care (long term care).
The insurer denied the Custodial Care (long term care). 
The denial is overturned.

The patient is a male with an extensive past medical and psychiatric history including
congestive heart failure, cerebral infarction (unspecified), schizoaffective disorder, iron deficiency anemia, among others. Due to altered mental status and a functional decline he was admitted to skilled nursing facility for physical therapy, occupational therapy, and skilled nursing from
for several months. He was then kept at the same facility for long term care for several more months.

Coverage for his long-term care at the facility was denied by the health plan, because per the health plan, it did not meet medical necessity criteria. This is being appealed.

Yes, the Custodial Care (long term care) was medically necessary.

The provided care could not have been attained at a lower level of care. According to the supporting documentation provided by the patient's physical and occupational therapist he requires at least supervision with all ADLs (activities of daily living) and mobility, therefore, the patient requires long term care at a nursing home, and not home health nursing.

Therefore, given the above, the Custodial Care (long term care) was medically necessary.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.