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

Diagnosis: Liver cirrhosis, Ascites
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a past medical history (PMH) of liver cirrhosis, portal hypertension, ascites, chronic obstructive pulmonary disease (COPD), end stage renal disease (ESRD) on hemodialysis (HD), hypertension (HTN), and diabetes mellitus type 2 (DM2) who was admitted with complaints of (c/o) increasing abdominal distention and abdominal pain after missing an interventional radiology (IR) appointment for paracentesis. Vital signs were notable for HTN. The physical exam was notable for a markedly distended abdomen with generalized tenderness to palpation (TTP), no apparent distress (NAD), comfortable, with bilateral expiratory wheezes. Lab work was significant for pancytopenia, positive troponin at patient's baseline, ascitic fluid work-up negative for spontaneous bacterial peritonitis (SBP). A computed tomography (CT) scan of the abdomen showed no acute intra-abdominal or pelvic pathology. An electrocardiogram (EKG) showed no acute ischemia. The patient was diagnosed with symptomatic ascites and was treated with a bedside paracentesis in the emergency department (ED) of 1.7 liters (L) and further 4L was removed after admission. The patient was discharged 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 ED with c/o increasing abdominal distention and abdominal pain after missing an IR appointment for paracentesis. The patient did not have associated high-risk features, such as congestive heart failure or acute liver failure, nor did the patient have any hemodynamic instability. In addition, while the patient had ascites, it was not new-onset, had a readily identifiable cause (missing appointment), and there was no associated SBP, nor did the patient have bowel obstruction, diabetic ketoacidosis, or appendicitis. The patient was hemodynamically stable, he did not require urgent dialysis, and there was no pyelonephritis, ascending infection, toxic appearance, unstable vital signs, or immunosuppression. The patient presented with increasing ascites after missing an IR appointment, was treated and responded to paracentesis without complications, and these interventions could have been safely and appropriately provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath
Treatment: Hospital admission
The insurer denied coverage for an inpatient admission.
The denial is upheld.

This is a patient with a history of Asthma presented to the emergency department (ED) with complaint of (C/O) shortness of breath (SOB) with productive cough and wheezing. The patient had used her inhalers at home but did not feel better so came to the ED.

Vital signs at presentation included: Temperature 98.1 degrees F (Fahrenheit) , Heart Rate 99, Respiratory Rate 18, Blood Pressure 126/72, oxygen (O2) saturation 98 % on Room Air. White blood cell count (WBC) was 9.7 K (thousand) Hb (hemoglobin) 14.3, electrolytes were within normal limits (WNL), oxygen saturation was 92-93 % on room Air, chest x-ray was negative. COVID-19 (coronavirus disease 2019) and Influenza were negative.

The patient was noted to have bilateral (B/L) wheezing and was given Decadron intravenous (IV) 10 mg (milligrams), Magnesium sulfate, and DuoNebs. She did show improvement but as she was still wheezing, she was admitted to the hospital with acute exacerbation of asthma. Per the history and physical (H&P), the patient was in no acute distress (NAD), was afebrile, and hemodynamically stable. A lung exam showed a bilateral wheeze. The patient was switched to Solumedrol 60 mg and continued on nebulizers and Doxycycline. 

The patient was in no distress with stable vital signs: Temperature 98 degrees F (Fahrenheit), Heart Rate 91, Respiratory Rate 17, Blood Pressure 113/65, oxygen (O2) saturation 98% on Room Air. No evidence of CO2 (carbon dioxide) retention.

The patient was not hypoxic, was hemodynamically stable, not using accessory muscles and was speaking in full sentences. No pneumonia (PNA) on the CXR (chest x-ray). The patient was stable to be switched to oral steroids and other medications. The patient could have been treated under observation status for up to 48 hours. She remained stable after admission and did not need acute inpatient hospitalization.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the hospital admission is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Gastroesophageal reflux disease (GERD).
Treatment: Outpatient Surgery (43284 x 1) (LINX reflux management system).

The insurer denied Outpatient Surgery (43284 x 1) (LINX reflux management system).
The denial is upheld.

The patient is a male, who has been having gastroesophageal reflux disease (GERD). According to the surgeon's initial consult the patient is not on any medication to control GERD. Esophagogastroduodenoscopy (EGD) showed small hiatal hernia. DeMeester score is 9.3 The subject under review is whether treatment with the LINX reflux management system is likely to be more beneficial for this patient's condition than any standard treatment.

The health plan's determination is upheld.

The proposed LINX reflux management system is not likely to be more beneficial for this patient than any standard treatment. The patient has not been on any medication to control the GERD. Surgery should be last resort, if the medical treatment is not effective. This patient has a very low DeMeester score, and the EGD does not show any evidence of esophagitis and there is no biopsy to prove esophagitis.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Gastroesophageal reflux disease (GERD).
Treatment: Outpatient Surgery (43284 x 1) (LINX reflux management system).

The insurer denied Outpatient Surgery (43284 x 1) (LINX reflux management system).
The denial is upheld.

The patient is a male with history of symptomatic gastroesophageal reflux disease (GERD) that has resulted in nausea and abdominal pain. Esophagogastroduodenoscopy (EGD) revealed a small hiatal hernia without evidence of Barrett's esophagus or esophagitis. 24 hour potential hydrogen (pH) study revealed a normal DeMeester score of 9.3 (less than [<] 14) and normal acid exposure time of < 4% (2.1%). Esophageal manometry was normal. Upper gastrointestinal (UGI) revealed GERD. It is unclear from the medical records whether the patient have been previously treated with any medical management such as proton pump inhibitor (PPI) or histamine 2 (H2) blocker. There is no reported indication of prior medical management failure.

The proposed LINX reflux management system is not likely to be more beneficial for this patient than any standard treatment. This patient has equivocal findings for GERD. EGD did not reveal evidence of esophagitis and the 24 hour pH study showed a normal DeMeester score and acid exposure percentage. It is also unclear whether the patient had any symptomatic improvement from medical management or had ever been treated with PPI or H2 blockers. Failure to respond to any medical management treatment for GERD would also suggest atypical symptoms that may not respond as well to an anti-reflux procedure. Given the equivocal findings for GERD based on 24 hour pH, which is the gold standard evaluation, the requested LINX anti-reflux treatment LINX is not determined to be more beneficial for the patient than standard treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Gastroesophageal reflux disease (GERD).
Treatment: Outpatient Surgery (43284 x 1) (LINX reflux management system).

The insurer denied Outpatient Surgery (43284 x 1) (LINX reflux management system).
The denial is upheld.

This patient is a male (body mass index [BMI] 28 kilograms per square meter [kg/m2]) who is seeking coverage for LINX as treatment of gastroesophageal reflux disease (GERD). He has complaint of constant chest pain that is worse after meals and laying down. The submitted records do not indicate that he is treated with any medicinal therapy for gastroesophageal reflux disease (GERD). He was evaluated with upper endoscopy that showed a small hiatal hernia and mild gastritis. There was no mention of esophagitis.  A potential hydrogen (pH) study was performed that identified a DeMeester score of 9.3 (normal less than [<] 14.7). A barium upper gastrointestinal (UGI) showed reflux during the study when recumbent. Esophageal motility testing was normal.

The treating surgeon has proposed the LINX procedure as treatment of chronic GERD. The material sent for review also includes selected literature regarding the LINX procedure.

The health plan's determination is upheld.

Considering the submitted documentation, the published literature, and the clinical details of this case, the requested LINX procedure is not known to be more beneficial than any standard treatment for the condition being treated in this case.

LINX (Magnetic Sphincter Augmentation [MSA]) has been approved by the U.S. Food and Drug Administration (FDA) to be lawfully marketed for the treatment of GERD since 2012. LINX is not subject to review and approval by any institutional review board for the proposed use. LINX is not the subject of an ongoing clinical trial that meets the definition of a Phase 1, 2 or 3 clinical trial set forth in the FDA regulations. There is sufficient long-term data to support that this therapy is as efficacious as the established alternative (laparoscopic fundoplication) for the treatment of GERD.

However, in this case, the records do not include documentation of the prerequisite data to support the diagnosis of surgically amenable GERD. This patient has had complaints of constant chest pain that is worse after meals and laying down. He is not treated with any anti-acid medications, as are typically prescribed for GERD. He has completed a pH test; however, there is not confirmation of pathological esophageal acid exposure. The DeMeester score was within the normal range of less than 14.7. In the absence of confirmatory testing and in the absence of pathologic esophageal acid exposure, LINX is not known to be more beneficial than any standard treatment for the condition being treated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tooth pain
Treatment: D2750, white glass with high gold content crown tooth 13
The insurer denied coverage for D2750, white glass with high gold content crown tooth 13.
The denial is upheld.

Upon review of the documentation provided which includes a copy of bitewing and periapical radiographs and insurer correspondence, it appears that this patient presented to the dentist for care involving tooth 13. The treating dentist recommended a full coverage crown for 13 after completion of endodontic therapy on this tooth. It appears there was a preexisting crown on 13. The insurer has denied these services stating the there is no clinical/ radiographic evidence, such as traumatic injury or decay, provided to support the necessity of this service, there is incomplete fill of the root canal, and the documentation is insufficient to approve treatment, and therefore the service does not meet medical necessity criteria. 

The objective documentation provided for review is a copy of bitewing and select periapical radiographs. There are no other dental treatment records provided for review. It appears that there is no evidence of fracture or other pathology specifically affecting 13 based on the images provided for review. Further there is no periapical radiograph submitted of tooth 13. There does not appear to be any radiographic evidence of caries. The radiographs do not substantiate the requested dental services as enumerated above and therefore the crown is deemed not medically necessary.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for D2750, white glass with high gold content crown tooth 13 services is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Syncope
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is overturned.

This is a patient with a history of hypertension, hyperlipidemia, type II diabetes mellitus (DM), gastroesophageal reflux disease (GERD), obesity, psoriasis and alcohol (ETOH) use. He presented with an episode of syncope and convulsive episodes of the lower extremities bilaterally. He had one drink of liquor before his admission, and he was in the car when this happened. He was afebrile and hemodynamically stable. He was started on intravenous (IV) hydration and was placed on telemetry for arrhythmia monitoring. He was tachycardic and remained tachycardic for a number of hours after admission. A computed tomography (CT) scan of the chest, abdomen and pelvis showed patchy ground glass opacities. The patient subsequently developed hypoxia and required 2 liters per minute (LPM) of oxygen (O2). He was given intravenous (IV) Lasix for a concern for fluid overload. His orthostatic vital signs were monitored as well. They were negative. Due to a concern for pneumonia, based on the computed tomography (CT) scan he was started on intravenous (IV) antibiotics as well. He was slowly improving. He requested to be discharged and continue treatment in the outpatient settings. He was overall feeling better.
The medical necessity of an inpatient admission is under review.

The request for inpatient stay was appropriate and medically necessary for this patient.
The patient presented with an episode of syncope and convulsive episodes of lower extremities bilaterally. He was afebrile and hemodynamically stable. He was started on IV hydration and placed on telemetry for arrhythmia monitoring. He was continued on IV hydration. He was suspected to have pneumonia based on a CT scan and was started on IV antibiotics. He also developed hypoxia that was treated with IV Lasix. The patient gradually improved and requested to be discharged home. The patient was seen by neurology, nephrology and cardiology as well during his stay. The patient met criteria for an inpatient admission. He had confusion, tachycardia, possible dehydration, electrolyte abnormalities and acidosis on admission. Per the Milliman Care Guidelines (MCG) Health, Inpatient and Surgical Care 26th edition Syncope ORG: M-340 (ISC) the inpatient admission was indicated due to associated severe dehydration and persistent tachycardia. He required IV hydration beyond a period of observation. He had an acute kidney injury, stage 2, had associated acidosis and electrolyte imbalance [1]. He had a serum creatinine (Cr) close to 4, with associated acidosis and dehydration, that made him a high risk patient [2,3]. He also had a concern for infection/sepsis and later on developed hypoxia. He had too many active issues that were not suitable to manage at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Anemia.
Treatment: Inpatient Admission.
The insurer denied the hospital stay.
The determination is partially overturned.

The patient is a female with severe anemia for which she presented to the hospital. Her admitting hemoglobin was 4.8 grams per deciliter (g/dL). The patient also was noted to exhibit profound leukopenia with a decreased white blood cell count and a decreased absolute neutrophil count. Transfusion support was provided to the patient and the patient was admitted for further evaluation. Her work-up revealed a vitamin B12 deficiency, evidence of alpha thalassemia trait, possible hemolysis, severe hypokalemia and considerations were made for possible bone marrow disease. With respect to treatment, in addition to red blood cell transfusion support, the patient received electrolyte repletion. She was eventually discharged 4 days later. The patient's healthcare plan has denied coverage for the patient's inpatient admission.

The patient's healthcare plan, in its determination of medical necessity and denial of coverage for the patient's hospitalization did not act in the best interest of the patient.
The patient exhibited profound anemia and thrombocytopenia. The acuity of such findings was not evident from the provided medical records however, such a severe degree of anemia is the major predisposition for cardiovascular and cerebrovascular events and would mandate for the patient to have transfusion support. An inpatient evaluation can exclude potential bleeding or overt hemolytic anemia. Either of these potential scenarios would mandate inpatient medical management. This opinion is further supported by consensus recommendations to evaluate severe anemia in an inpatient setting.
However, once the patient's hemoglobin and hematocrit stabilized and it was demonstrated the patient did not exhibit overt hemolytic anemia or gastrointestinal bleeding, a more expeditious discharge would have been appropriate.

I believe the medical service requested of an inpatient admission was medically necessary in this case. However, I do not believe a 4 day hospitalization was required. Upon stabilization of the patient's hemoglobin and hematocrit which was noted 48 hours post admission, the patient could have been discharged.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Consumer Directed Personal Assistance Program (CDPAP) 10 hours/day, 7 days/week, a total of 70 hours/week
The insurer denied CDPAP 10 hours/day, 7 days/week, a total of 70 hours/week.
The denial is overturned.

The patient is a female with medical history notable for frontotemporal dementia, anxiety, incontinence, chronic pain, gait disturbance, and generalized weakness. The patient was receiving 5 hours/day, 7 days/week (total 35 hours/week) of Consumer Directed Personal Assistance Program (CDPAP) hours. The patient and her care team requested an increase to 10 hours/day, 7 days/week (70 hours/week) of CDPAP. This request was partially denied by the insurance company, who authorized an increase to 6.5 hours/day, 7 days/week (total of 45.5 hours/week). This denial is the subject under review.

A letter of support for this appeal was provided by the patient's physician. The letter states that the patient has had difficulty with performing activities of daily living (ADLs) independently due to her functional status. Additionally, she was seen in the hospital recently due to a fall with laceration to the head while bathing. She is "unable to be left alone at all due to her unsteady gait, confusion of where she is, and even had instances of lighting items on fire in her home when left unattended. I strongly advise the patient be granted the assistance of Home Health Aide (HHA) for more hours than the daily 5 hours allotted." The physician feels that the patient can reach her fullest functional capacity only with additional hours. The subject under review is the medical necessity for the increase in hours. 

The health plan's determination is overturned.

The requested CDPAP 10 hours/day, 7 days/week, a total of 70 hours/week is medically necessary for this patient. The patient has had a functional and cognitive decline over the past year due to her multiple medical problems compounded with worsening dementia. She requires assistance for most ADLs. It is unlikely that she can complete any of her ADLs without assistance at this point due to her cognitive issues. Furthermore, she has developed worsening incontinence, which often comes alone with worsening dementia. She will have ongoing unscheduled personal care needs. Her family has been filling in to cover the shortage of hours to cover her needs, but she appears to have medical necessity for 10 hours/day to address her needs. The tasking tool associated with the Uniform Assessment System can be useful as a guideline for minimum hours but cannot be relied on for the final determination of hours allotted to the patient when their needs become complex and compounded by cognitive issues. The additional hours would not be meant only for safety and security monitoring but would be used to complete her personal care activities which may take longer than usual due to her condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Atrial Flutter.
Treatment:  Implantable heart monitor.

The insurer denied the implantable heart monitor.  The health plan's determination has been upheld.

The patient is a female with a history of mitral of prolapse with a mitral and tricuspid valve repair and postoperative atrial flutter. She subsequently reverted to normal sinus rhythm. A loop monitor is under review.

There are multiple types of portable cardiac monitors to evaluate for the presence of an arrhythmia. They vary in types and extent of data acquired, being auto triggered or patient activated, continuous versus intermittent acquisition, external vs. (versus) implanted, as well as monitoring duration capabilities. The implanted monitor is considered not medically necessary in this case.

More elaborate systems tend to provide more data on a more continuous feedback basis. Despite these differences, more elaborate systems, such as an implanted monitor as in this case, have not been established as standard of care, compared to simpler systems such as an event or Holter monitor, towards improved diagnostic capabilities or improved cardiac outcomes.