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

Diagnosis: Cardiac/Circulatory Problems
Treatment: Inpatient Hospital. 

The insurer denied inpatient admission.  The denial is upheld.

The patient is a male who presented to his physician's office complaining of dyspnea, lightheadedness and heart racing. The night prior he had a 30 minute episode of chest pain. An electrocardiogram showed supraventricular tachycardia. Three doses of adenosine were given without termination of the tachycardia. He was then transported to the emergency department via Emergency Medical Services (EMS). Electrical cardioversion with 50 joules was attempted and was unsuccessful. Intravenous amiodarone was given without conversion.

The patient's serum troponin level was elevated at .99 nanograms per milliliter (ng/ml). Heparin infusion was started. Chest x-ray showed possible mild pulmonary vascular congestion. The patient was admitted to the hospital and treated with oral metoprolol. A repeat troponin level was 1.5 ng/ml. An echocardiogram showed normal left ventricular systolic function. He was seen by a cardiologist who opined that acute coronary syndrome was unlikely and the troponin elevation was likely due to the rapid heart rate. Antibiotics were started for possible urinary tract infection then discontinued per the infectious disease consultant. The patient's troponin level fell to .63 ng/ml. He remained in sinus rhythm. He was discharged. Medical necessity for an inpatient admission is at issue.

The health plan's determination is upheld in whole.

An inpatient admission was not medically necessary for this patient.
This patient presented with paroxysmal supraventricular tachycardia (PSVT) that was terminated in the emergency department. The subsequent electrocardiogram showed was no evidence of ischemia. While his serum troponin level was elevated, this is common after episodes of PSVT, even in the absence of coronary stenosis. Per the cardiology consultant, this patient's troponin elevation was likely due to the PSVT and not acute coronary syndrome. For patients presenting to the emergency department with PSVT, most authors suggest that in the absence of serious comorbidities, syncope, or rapid pre-excited atrial fibrillation or flutter, inpatient admission is not necessary for adults whose PSVT is converted to sinus rhythm without complications. Given this patient's troponin elevation, it was reasonable to monitor him until serial measurements could be made. However, this did not require an inpatient level of care. The patient could have been managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain. 
Treatment: Inpatient admission. 

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

The patient is a female who had undergone a previous hysterectomy and bilateral salpingo-oophorectomy (BSO) and then a hernia repair with mesh. The patient presented for evaluation of abdominal pain. 

The patient had stable vital signs, a non focal exam, and a computed tomography (CT) showing stool in the colon with no other notable findings. She was able to ambulate, void, and take oral medications and an oral diet. She was admitted to the hospital and discharged.

No, the proposed inpatient admission was not medically necessary. 

The patient did not have any medical conditions that would justify admission and inpatient level of care. The patient had stable vital signs, a non focal exam, normal blood tests and a CT (computed tomography) showing constipation. She was able to ambulate, void, take oral medications and an oral diet and did not have any conditions that would justify inpatient level of care. Inpatient level of care in this case is not supported by peer reviewed literature, it is not standard of care, and it is not supported by professional organizations. 

Given that the patient had stable vital signs, a non focal exam, normal labs, and a normal CT (computed tomography), and that she was able to void, ambulate, and take oral medications and an oral diet means that she did not have any conditions that would necessitate inpatient level of care and that the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary Artery Disease, Hypertension, Congestive Heart Failure, Depression, Insomnia and Gait Ataxia.
Treatment: Increase Personal Care Aide Hours From 7 Days A Week 8 Hours A Day To 7 Days A Week 12 Hours A Day (84 hours/week).
The insurer denied the Increase Personal Care Aide Hours From 7 Days A Week 8 Hours A Day To 7 Days A Week 12 Hours A Day (84 hours/week).
The denial is overturned. 

The patient is a female with a history of Coronary Artery Disease, Hypertension, Congestive Heart Failure, Depression, Insomnia and Gait Ataxia. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Appeal review requested for potential approval of 84 hours/week Personal Assistance Services to offer increased ADL (activities of daily living) support.

Yes, the proposed treatment of 84 hours/week Personal Assistance Services is deemed medically necessary.

The patient is a female with a history of Coronary Artery Disease, Hypertension, Congestive Heart Failure, Depression, Insomnia and Gait Ataxia. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Despite assessments of the patient's functionality and ability to perform ADLs (activities of daily living) having been completed twice revealing that the currently approved plan of 63 hours/week Personal Assistance Services is sufficient to meet the patient's current needs, these assessments do not adequately address the patient's recent functional decline due to worsening medical conditions.

Specifically, the recent medical records indicate that the patient is status post recent bone marrow biopsy, which revealed evidence of myelodysplastic syndrome for which she will require intravenous chemotherapy. In addition, she has recently been diagnosed with chronic kidney disease and impending failure. These two conditions have rendered her with more weakness, immobility and worsening gait ataxia, which warrants additional ADL (activities of daily living) support. For these reasons, the proposed treatment 84 hours/week Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Supraventricular arrhythmia (Brugada syndrome). 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 

The denial is upheld. 

The patient is a female.  At the time of admission to the hospital she had a past medical history significant for hypertension, diabetes and Brugada pattern on electrocardiogram (ECG).  The patient presented for evaluation of abdominal pain, heartburn, epigastric pain and palpitations, lasting several seconds on the day of admission, which resolved spontaneously. The patient was hemodynamically stable. Electrocardiogram (ECG) revealed no arrhythmia and no acute ischemic changes. Cardiac troponin was negative. 

The patient was admitted for monitoring. No inpatient ischemic work-up was planned. There were no events on telemetry. The patient was discharged home the next day with a plan for outpatient follow-up with cardiology and electrophysiology specialists. 

No, the proposed inpatient admission was not medically necessary. 

This patient presented for evaluation of palpitations. The diagnosis of an acute myocardial infarct (MI) was ruled out by cardiac enzymes, which were negative. No further inpatient ischemic work-up was planned.  There were no arrhythmic events on electrocardiogram (ECG) or telemetry. There was no evidence of acute myocardial infarction, acute coronary syndrome (ACS), decompensated congestive heart failure (CHF), malignant arrhythmia or hemodynamic instability. The patient was discharged after a period of monitoring with a plan for outpatient follow-up.  Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission and the care required could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Pain and Shortness of Breath
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a male. At the time of admission to the hospital, he had a past medical history significant for hypertension (HTN), dyslipidemia, diabetes mellitus type II, coronary artery disease (CAD), congestive heart failure (CHF) status post (s/p) automatic implantable cardioverter defibrillator (AICD) placement, chronic obstructive pulmonary disease (COPD), and cocaine abuse.  

The patient presented to the emergency room (ER) with complaints of chest pain, which was new onset, associated with shortness of breath and exacerbated by exertion. The patient was hemodynamically stable. The electrocardiogram (ECG) revealed left bundle branch block (LBBB) pattern due to paced rhythm. Troponin was negative. Brain natriuretic peptide (BNP) was elevated. Urine toxicology was positive for cocaine. Serum creatinine was elevated, consistent with renal insufficiency. 

The patient was initially monitored in the ER, but subsequently a decision was made to admit him for further management, given ongoing symptoms and multiple comorbidities and risk factors. The patient was treated with intravenous (IV) diuretics for CHF. Serial troponins were obtained. The patient had uncontrolled diabetes and insulin therapy was started. Sleep apnea was managed with biventricular positive airway pressure (BiPAP). The patient was seen by social work to arrange for safe discharge. He was discharged from the hospital.

Yes, the proposed 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 patient presented with new onset chest pain, and was suspected to have unstable angina and CHF exacerbation. The patient had multiple risk factors for CAD, including diabetes, cocaine use, as well as a known prior history of coronary artery disease and CHF s/p AICD. The ECG was unrevealing for ACS, but was abnormal with LBBB pattern due to pacing. Given this presentation, suspicion for an ACS, as well as risk factors and known CAD, CHF, ongoing cocaine use, renal insufficiency, it would be consistent with the current standard of care that this patient be managed in an inpatient setting, and therefore the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status post (s/p) Surgery
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned. 

This is a female who sustained injury to her left wrist. Her past medical history was significant for hypertension. She fell from a step stool. She was found to have decreased range of motion and deformity. There were no neurovascular deficits. She was diagnosed with a severely comminuted fracture to distal radius and dislocation dorsal of carpus. It was reported to be open.

Yes, the records show the woman sustained a complex and serious orthopedic injury. She was found to have multiple fractures with associated carpal dislocation. She was found to have an open wound. She was elderly with an ASA (American Society of Anesthesiologists) score of 3. She required operative intervention to include 2 irrigations debridement, reduction of dislocation and open reduction internal fixation of fractures. She required IV (intravenous) antibiotics of greater than 24 hours. She was at risk for complications secondary to the nature of injury and underlying medical status. The Milliman Care Guidelines (MCG) criteria submitted were for "wrist fracture" which were for carpal bones. She sustained an open fracture dislocation to her distal radius. There were no guidelines referenced for the injury sustained. This type of injury is not managed in an acute surgical unit (ASU). Her condition was emergent with high risk for complication.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Recurrent pressure sores, Urinary incontinence, Dementia. 
Treatment: Personal care assistant (PCA) services 7 days per week live in (24 hours per day). 

The insurer denied coverage for PCA services 7 days per week live in (24 hours per day).

The denial is overturned. 

This is a female patient with a medical history that includes atrial fibrillation, osteoarthritis, heart disease, hypothyroidism, celiac disease, chronic obstructive pulmonary disorder (COPD), urinary incontinence, muscle weakness, chronic pain, sacral pressure ulcer, recurrent syncope, dementia, right eye blindness and left ear deafness. The patient is reportedly mostly non-ambulatory. 

According to the Uniform Assessment System (UAS) - New York, the patient lives alone in a 2-bedroom, second floor apartment with a chair lift. The patient has some impaired cognitive skills with forgetfulness, and her daughter reports a decline in cognitive function. The patient can make her needs known and her children assist her, but she requires oversight with medication and daily planning. The patient requires maximal assistance with meal preparation, finances, managing medication, and requires total assistance with housework. 

Due to multiple co-morbidities, the patient needs extensive-maximum assistance with activities of daily living (ADLs). This includes transfers, ambulating, toileting and bed positioning. The patient has had pressure sores and preventing these is an important goal. The patient uses pull-overs which make clean-up easier but still leaves the area prone to breakdown potentially wet and contaminated. The patient has unpredictable needs for toileting and cleaning several times at night and needs turning and positioning. 

In a patient with documented recurrent pressure sores, the need for assistance, cleanliness and positioning support the request for 24/7 aides. Thus, the requested service is considered medically necessary for this patient. 

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

The medical necessity for personal care assistant (PCA) services 7 days per week live in (24 hours per day) is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe bronchopulmonary dysplasia, pulmonary
hypertension, seizure disorder, and feeding
intolerance
Treatment: Continued stay in acute inpatient rehab
The insurer denied the Continued stay in acute inpatient rehab.
The denial is overturned. 

The patient is a male child born extremely prematurely with severe bronchopulmonary dysplasia, pulmonary hypertension, seizure disorder, and feeding intolerance. He is tracheostomy- and ventilator-dependent, as well as gastrostomy-dependent.

Since discharging from the NICU (neonatal intensive care unit), the patient has been able to transition from an ICU (intensive care unit) ventilator to a portable ventilator and continues to slowly wean from mechanical ventilatory support. The clinical specifics of his stay have not been included, but in generalities, he receives 35 to 40 doses of medication daily, respiratory and/or nursing bedside care on average every two hours, and active physician involvement five to ten times weekly. In addition, he receives comprehensive rehabilitation services that address his functional and global deficits to optimize his growth and development. His weight is monitored as he makes progress with ventilator weaning to optimize his long-term outcome.

Yes, the Continued stay in acute inpatient rehab is medically necessary.

Ongoing acute rehabilitation level of care is medically necessary and appropriate.

This medically fragile child was transferred from acute intensive care in the NICU (neonatal intensive care unit) in an effort to manage his severe chronic lung disease and optimize his functional developmental potential with appropriate rehabilitative services. The level of care that he continues to require, with administration of numerous medications, frequent bedside nursing and respiratory therapy interventions (e.g., ventilator management, tracheostomy care, suctioning, airway clearance, medication administration, feedings, gastrostomy care, maintenance of skin integrity), frequent physician oversight and intervention, and rehabilitative services consistent with his current developmental and functional level, is most consistent with acute rehabilitation level of care. His management is too complex and labor intensive for lower level of care such as subacute, and he is not currently clinically appropriate for discharge home. Decrease in level of care at this time places him at risk of morbidity and does not provide adequately for his developmental or functional needs. The requested acute rehabilitation level of care remains medically necessary and appropriate.

Looking to the future, given the expected rate of progress for this child, it would be most reasonable to re-evaluate in six months' time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Duchene Muscular Dystrophy.
Treatment: Emflaza 18-Milligram Tabs.
The insurer denied the Emflaza 18-Milligram Tabs.
The denial is overturned. 

The patient is a male with Duchene muscular dystrophy (DMD), which was genetically confirmed. Motor delays were initially noticed by the parents and diagnosis was made just 3 years later. The patient was on a prednisone treatment plan; however, he did not tolerate prednisone due to side effects of daily stomach pain and nausea, as well as severe behavioral dysregulation such that he caused disturbances at school. He also struggled with focusing. This behavior did not occur prior to the patient receiving prednisone.

The patient's neurologist recommended that the patient be started on a new treatment plan to include Emflaza. The patient is a candidate for gene therapy trial and he needs to be on a stable corticosteroid dosing for at least 12 weeks prior to enrolling for the trial.

Yes, the treatment with Emflaza is medically necessary.

Medically necessary services are those that are provided for the diagnosis, treatment, cure, or relief of a health condition and are necessary and appropriate to the diagnosis, cure, or relief from a health condition. Medically necessary services must be within the generally accepted standards of medical care and not administered solely for the convenience of the patient or provider.

According to the treatment guidelines published in Lancet (3), as well as the practice parameter by the American Academy of Neurology (4), deflazacort (Emflaza) is indicated and is medically necessary in cases of Duchene muscular dystrophy. Subsequent publications (1, 2) indicate that deflazacort causes lesser weight gain comparing to prednisone, and preserves motor strength for longer. Therefore, in the patient's case, the requested drug, deflazacort (Emflaza), is being used for a medically necessary indication as supported by the current medical literature and by treatment guidelines. As such, this treatment is medically necessary.

The patient has progressive muscular dystrophy, at the risk of losing ambulation. The patient has failed prednisone due to intolerable side effects. Deflazacort (Emflaza) is an FDA (United States Food and Drug Administration)-approved treatment for the patient's diagnosis. This medicine is supported by the practice guidelines and peer-reviewed medical literature, as indicated above.

The patient has documented motor performance scales North Star ambulatory assessment, the Brook scale for upper extremity, and Vigno scale for lower extremity. These scales are equivalent to the scales listed in the insurance policy. Therefore, the treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left ankle trimalleolar fracture malunion.
Treatment: Continued Skilled Nursing Facility.
The insurer denied the Continued Skilled Nursing Facility.
The denial is upheld. 

The patient is a female with history of left ankle trimalleolar fracture malunion. She had an elective left ankle arthrodesis. Her relevant past medical history includes meningioma status post resection x2 and still growing and with left hemiplegia, unsteady gait, seizures, and PT (physical therapy). Prior to admission, she was limited in activities with modified independence using cane and rollator after she sustained the left ankle fracture. She was living in a disability accessible apartment with daughter and autistic son.

Evaluation stated that the patient is still NWB (non-weight bearing) left LE (lower extremity) and requiring maximum assistance for ADLs (activities of daily living), with recommendation for SNF (skilled nursing facility) or AIRF (acute inpatient rehabilitation facility). She was transferred to SNF (skilled nursing facility).

The patient required moderate assistance for sit-to-stand using rolling walker, required minimum assistance x2 with standing using RW (rolling walker), and most other ADL (activities of daily living) with moderate assistance. She has not shown any tangible progress in rehabilitation since admission to SNF (skilled nursing facility).

No, the Continued Skilled Nursing Facility is not medically necessary.

The patient has not met all the criteria for subacute/SNF (skilled nursing facility) care INTERQUAL Criteria for Sub-Acute SNF (skilled nursing facility) Rehabilitation in a patient with General Debility and with no major ongoing clinical issues. She required moderate assistance for sit-to-stand using rolling walker, required minimum assistance x2 with standing using RW (rolling walker), and most other ADL (activities of daily living) with moderate assistance. She has not shown any tangible progress in rehabilitation since admission to SNF (skilled nursing facility).

The proposed continued SNF (skilled nursing facility) care is not medically necessary and should not be covered by the health plan, because the patient has not met all the criteria for sub-acute rehabilitation care under the Internal SNF (skilled nursing facility) Criteria as stated above. She has not shown tangible progress in SNF (skilled nursing facility), and her rehabilitation goals can be met at a lower level of care.

Therefore, the plan did act reasonably, with sound medical judgment, and in the best interest of the patient, and the patient will be better served continuing at a lower level of care.