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

Diagnosis: weakness, inability to ambulate
Treatment: inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is overturned in part. 

The patient is a male with an unremarkable past medical history who presented with complaints of progressively increasing lower extremity weakness and inability to ambulate. The patient stated that his issues initially started with left upper extremity weakness that was associated with decreased grip strength. The patient said that it had been going on for at least a year or so. The patient stated that he left his job due to his left upper extremity weakness and progressive lower extremity weakness.

The inpatient stay was medically necessary for 24 days. 
Based on the nationally accepted standards of care, admission at the acute inpatient level of care is indicated in cases of severe myopathy, neuropathy, or another neuromuscular disease associated with a severe functional disability that interferes with the patient's ability to perform activities of daily living, safety concerns.
The results of the physical exam and imaging studies revealed that the patient had progressive generalized weakness and inability to perform activities of daily living requiring immediate workup and surgical intervention, which was performed during the hospital stay and described in detail in the previous section of this report.
This type of workup and surgical intervention could not have been performed at any other level of care rather than the acute inpatient level.
Having said that, the entire hospitalization was not indicated at the acute inpatient level of care. Based on the review of the medical records, the patient could have been safely discharged to a rehabilitation facility on day 24. At that time the patient was afebrile, hemodynamically stable, and did not require admission at the acute inpatient level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Cellulitis.
Treatment:  Inpatient stay.

The insurer denied the inpatient stay. The health plan's determination is upheld. 

This case involves man with asthma and human immunodeficiency virus (HIV), who was admitted to the hospital with a laceration to the left hand over the fourth digit causing pain. A laceration occurred three days before this presentation, while he was involved in an altercation. He denied any fever or chills. He complained of malaise, fatigue, diaphoresis, and myalgias. The temperature was normal at 98 degrees, heart rate 85, and blood pressure 109/71. The cardiopulmonary exam was fairly unremarkable. Skin and musculoskeletal exam showed swelling, with exudates in the left fourth digit and normal range of motion. There was a laceration in the dorsal aspect of the first and fourth digits with erythema and edema. 

The inpatient hospital admission was not medically necessary.

The patient has lacerations of the digits of the hand, which he suffered in an altercation, with the appearance of erythema and edema. However, there is no evidence of systemic illness, as noted by normal white count, negative blood cultures, fairly normal inflammatory markers, and an x-ray of the hand showed no evidence of abscess, gangrene, or fractures. The patient was empirically treated with intravenous antibiotics. There is no evidence of a failure of outpatient treatment with an appropriate antibiotic regimen to require inpatient hospitalization with broad-spectrum antibiotics. There is no evidence of sirs, sepsis, or severe sepsis. There is no documentation of lymphangitis or compartment syndrome to consider this a limb-threatening infection. The lacerations did not require surgical closure or debridement. The patient's condition improved within 48 hours with empiric antibiotics, and he was transitioned to an oral regimen before being released from the hospital. Based on these facts, the patient did not require an inpatient admission.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Sinusitis. 
Treatment: Sinus Surgery. 

The insurer denied the Sinus surgery. 
The determination is upheld. 

The patient has a history of recurrent acute sinusitis, requiring multiple treatment courses with oral antibiotics (including Ceftin and Antibiotics), intranasal corticosteroids, and chronic pansinusitis with significant opacification of the sinuses based on a computed tomography (CT) scan report (pansinusitis with opacification, thought secondary to nasal/sinus polyposis). The patient underwent nasal swell/septum reduction (current procedural terminology (CPT) 30117), bilateral maxillary balloon antrostomy dilation (current procedural terminology (CPT) 31295), bilateral anterior ethmoidectomy, bilateral sphenoid balloon dilation (current procedural terminology (CPT) 31298). 

At issue is whether the requested health service or treatment is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. 

The proposed health service/treatment of balloon sinuplasty and nasal swell reduction is not standard of treatment for the patient's disabling condition or disease (chronic sinusitis with nasal/sinus polyposis) and is likely not more beneficial. 

The American Academy of Otolaryngology clinical consensus statement (last published in 2018) states that balloon sinus dilation is appropriate as a standalone procedure in patients with chronic sinusitis without polyposis, but only as an adjunct procedure along with functional endoscopic sinus surgery in patients with polyposis. 

There is a paucity of data regarding surgery to reduce nasal/septal swelling to improve nasal congestion.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Sinusitis. 
Treatment: Sinus Surgery. 

The insurer denied the Sinus surgery. 
The determination is upheld. 

The patient has chronic sinusitis with nasal polyps. Medical management included multiple antibiotic courses, nasal steroids, oral antihistamines. The exam revealed nasal polyps. A computed tomography (CT) scan revealed chronic sinusitis with nasal polyps Balloon sinuplasty of the maxillary, frontal, sphenoid was carried out along with ethmoidectomy. 

At issue is whether the sinus surgery is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. 

The requested sinus surgery is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. 

Balloon sinuplasty is not indicated for treatment of nasal polyps. Balloon sinuplasty has not been shown in well-designed studied to be more beneficial than standard sinus surgery for the management of nasal polyps. Balloon sinuplasty is not Food and Drug Administration (FDA) approved for treatment of nasal polyps. Studies have not shown balloon sinuplasty to be an effective treatment of nasal polyps.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Colitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient is an adult female who underwent an acute hospitalization. The patient has a history of polycystic ovarian syndrome (PCOS), endometriosis, helicobacter (H.) pylori, cholelithiasis and irritable bowel syndrome (IBS). The patient had presented to the emergency room (ER) with complaints of nausea, vomiting, and abdominal pain. Radiology imaging revealed colitis. The patient was admitted with acute segmental colitis. The patient was given intravenous (IV) Ciprofloxacin, IV Metronidazole, mesalamine, and IV pain medications. The patient's condition improved, and she was discharged. 

The patient did not require inpatient hospitalization based on a detailed review of the provided records. The diagnosis and treatment of colitis could have been rendered in its entirety at a lower level of care. There was no documentation to support a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for prolonged nothing by mouth (NPO) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission. Further, there was no documentation to support the patient would be unable to be safely cared for at an observational level of care. 

"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)
                                                     
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 inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ptosis.
Treatment: Eyelid surgery (15823).
The insurer denied: Eyelid surgery (15823).
The denial is: Overturned.

The patient is a female with history of ptosis due to excessive eyelid skin of her upper eyelids. The patient complains of problems of heavy upper eyelids as well as difficulty with her distance vision. Visual field demonstrates loss of superior visual field that is improved with tapping of the eyelid skin up. Photographs also demonstrate excessive eyelid skin on the upper eyelid to the lash margin. Patient is seeking ptosis repair to improve visual function and symptomatology. The medical necessity for eyelid surgery is the subject under review.

The requested eyelid surgery (15823) is medically necessary for this patient. Based on the clinical exam, visual field tapped and untapped, photographs, and the patients complaints related to her diagnosis surgery would be considered medically necessary to improve this patient's condition.

The patient complains of heavy upper eyelids as well as difficulty seeing at distance. On physical exam she has redundant upper eyelid skin which encroaches upon the lash line. Visual field testing demonstrates loss of superior visual field. The visual field can be improved with tapping of the eyelid up. This demonstrates the improvement that can be made with surgical repair. Photographs demonstrate excessive skin of the upper eyelids that encroach the lash line. Based on the clinical exam as well as the patients complaints, this case would be considered medically necessary for surgical repair.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholelithiasis/cholecystitis
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient is a female who presented to the emergency department (ED) with new onset right upper abdominal pain, nausea and vomiting of 2-days duration. At the time of presentation, the patient was without fever and vital signs were normal. She was tender in the right upper quadrant. The white blood cell (WBC) count was 11.5 thousand (K). The complete metabolic panel identified normal liver enzymes and bilirubin of 1.8. Abdominal ultrasound showed gallstones within the gallbladder without gallbladder wall thickening. The common duct was of normal caliber. The subject under review is the medical necessity for the inpatient admission.

Inpatient hospital admission was not medically necessary for this patient.

A lower level of care would have permitted for the surgical assessment, the surgical procedure and perioperative intravenous (IV) fluid, IV antibiotics, IV antiemetics, and overnight monitoring. The submitted records document that this patient was clinically and hemodynamically stable at the time of presentation. The patient was clinically stable throughout the period of monitoring as supported by the corresponding medical records.
Inpatient care may be indicated when there is right upper quadrant pain, and systemic signs of inflammation (fever, C-reactive protein greater than [>] 10, WBC count > 10 K). Inpatient hospital admission may also be indicated for acute cholangitis, common bile duct obstruction, vomiting that is severe or persistent, dehydration that is severe or persistent, hemodynamic instability, severe pain requiring acute inpatient management, signs of intestinal obstruction, bacteremia, need for percutaneous or open procedures, or other condition that requires inpatient hospital admission.

In this case, the lab and imaging data in conjunction with the history and physical exam established the diagnosis of cholelithiasis/cholecystitis. The patient was clinically stable at presentation. The indication for cholecystectomy was established and the patient underwent an uncomplicated cholecystectomy procedure. Though the WBC count was elevated at 11.5 K, she responded promptly to the provided therapy. The post-surgical course was uneventful, and the patient was able to be discharged from the hospital.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia
Treatment: Personal Care Aide (PCA) services: 12 hours/day, 7 days/week; 12 hours/day, 7 days/week (split shift) for a total of 168 hours/week
The insurer denied PCA services: 12 hours/day, 7 days/week; 12 hours/day, 7 days/week (split shift) for a total of 168 hours/week.
The health plan's determination is upheld. 

The patient is a female with past medical history of traumatic brain injury following a fall, dementia, anemia, chronic/recurrent urinary tract infection (UTI), osteoarthritis, urinary incontinence, hypertension, hyperlipidemia, and osteoporosis who had been assigned PCA (personal care aide) services.

PCA services: 12 hours/day, 7 days/week; 12 hours/day, 7 days/week (split shift) for a total of 168 hours/week are not medically necessary for this patient.

There is no documentation of medical necessity of turning and repositioning every 2 hours nor are there overnight care logs provided to show activities of daily living (ADLs) care needs that would not allow a PCA 5 hours of uninterrupted sleep.

Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 12 hours/day, 7 days/week; 12 hours/day, 7 days/week (split-shift) are not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Blurry Vision, Abnormal Vision.
Treatment: Inpatient Stay.
The insurer denied the inpatient stay. 
The health plan's determination is upheld.

The patient is a female who presented to the emergency room after an episode of blurred vision. The patient has a medical history significant for hypertension and vertigo. The patient was admitted to the hospital for evaluation of a stroke/transient ischemic attack. In the hospital, the patient underwent an evaluation with magnetic resonance imaging (MRI) of the brain and MRI of the head and neck. These studies were unremarkable. The patient was evaluated by neurology. Treatment with an Aspirin and a statin drug was recommended. The patient was discharged with outpatient follow-up.

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

The inpatient hospitalization was not medically necessary for the patient. The patient presented to the hospital with a transient visual disturbance. Upon admission to the hospital, the patient had a normal neurologic examination without any significant abnormal vital signs or other diagnostic testing. After admission to the hospital, the patient underwent an MRI of the brain and cerebral blood vessels. These studies were normal. The patient was treated with oral medication consisting of an Aspirin and a statin drug. The patient did not have any significant neurologic deficits. The patient was not treated with thrombolytic therapy. The patient did not require acute rehabilitation. Admission to the hospital for evaluation of a transient ischemic attack is not the standard of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central precocious puberty
Treatment: Lupron Depot-PED 30 mg (milligrams)
The insurer denied: Lupron Depot-PED 30 mg.
The denial is overturned.

The patient is a female child diagnosed with CPP (central precocious puberty). This request is for Lupron Depot. As reported, the patient was noted to have breast buds last summer. Last year her breasts were at tanner 2 and her pubic hair was at tanner 1; Thelarche was at tanner 3. Her MRI (magnetic resonance imaging) was normal.

The patient's bone age on earlier this year was advanced compared to CA (chronological age); last year it was also advanced compared to CA. Last year her estradiol was 27.5 (6-27); LH (luteinizing hormone) was 0.4; FSH (follicle stimulating hormone) was 1.6.

The requested Lupron Depot is medically necessary.

The definition of precocious puberty is children who have the onset of secondary sexual characteristics younger than age 8 in girls and younger than age 9 in boys [1-3]. CPP is diagnosed using a basal LH of greater than 0.3 or stimulation testing 
with a GnRH (gonadotropin-releasing hormone) analog such as luprolide showing a pubertal response defined as an LH greater than 5 or estradiol greater than 40 [4]. CPP is treated with GnRH agonists [5-10] such as lupron [11] and supprelin [12]. The FDA (United States Food and Drug Administration) indication for GnRH agonists is for use in CPP. In addition, when used for CPP the FDA recommends discontinuation of GnRH agonists before age 11 for females and before age 12 for males [11]. This is consistent with accepted recommendations for discontinuation of GnRH agonist therapy at a bone age of 12 in girls and 13 in boys [2, 4-7].

The patient has a diagnosis of CPP. This is based on a basal LH greater than 0.3 and breast development consistent with central puberty as well as onset of secondary sexual characteristics before age 8. The patient meets accepted criteria for the diagnosis of CPP. Bone age is not a recognized criterion. The requested treatment is therefore medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Gastroesophageal Reflux Disease without Esophagitis.
Treatment:  Esophageal Sphincter Augmentation Device.

The insurer denied Esophageal Sphincter Augmentation Device. The health plan's determination is upheld. 

This is a case of a male, who has gastroesophageal reflux disease (GERD), which is controlled with medications, but the patient is concerned about the long term side effects of the medications. His body mass index (BMI) is 33. An esophagogastroduodenoscopy (EGD) showed Barrett's esophagus. A ph (potential hydrogen) study showed a Demeester score of 31.

The Esophageal Sphincter Augmentation Device is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

This patient has gastroesophageal reflux disease (GERD) that is controlled with medication. Also, he has Barrett's esophagus. As per Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), the safety and effectiveness of the LINX device has not been evaluated in patients with Barrett's esophagus.

The Following is from SAGES:
The LINX device has not been evaluated in patients with a hiatal hernia larger than 3- centimeter (cm). The Use of LINX device in patients with a hiatal hernia larger than 3-cm should be considered on the basis of each patient's medical history and severity of symptoms.
The safety and effectiveness of the LINX device has not been evaluated in patients with Barrett's esophagus or Grade C or D esophagitis.
The safety and effectiveness of the LINX device has not been evaluated in patients with major motility disorders.
The safety and effectiveness of the LINX Reflux Management System has not been established for the following conditions:  1)  Scleroderma, 2)  Suspected or confirmed esophageal or gastric cancer, 3)  Prior esophageal or gastric surgery or endoscopic intervention, 4)  Distal esophageal motility less than 35-mmHg peristaltic amplitude on wet swallows or < 70% (propulsive) peristaltic sequences or a known motility disorder (such as Achalasia, Nutcracker Esophagus, and Diffuse Esophageal Spasm or Hypertensive lower esophageal sphincter (LES)), 5)  Symptoms of dysphagia more than once per week within the last 3 months, 6)  Esophageal stricture or gross esophageal anatomic abnormalities (Schatzki's ring, obstructive lesions, etc.), 7)  Esophageal or gastric varices, 8)  Morbid obesity (BMI >35), or 9)  Age < 21.

Based on the above, the patient would not qualify for the requested procedure.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Gastroesophageal Reflux Disease without Esophagitis.
Treatment:  Esophageal Sphincter Augmentation Device.

The insurer denied Esophageal Sphincter Augmentation Device. The health plan's determination is overturned. 

This patient is a male with a body mass index (BMI) 32.8, who presents with long standing gastroesophageal reflux disease (GERD) controlled with medication. A 24 hour potential hydrogen (pH) study revealed an elevated DeMeester score consistent with GERD. Esophageal motility evaluation was within normal limits (WNL). An esophagogastroduodenoscopy (EGD) did not reveal any evidence of Barrett's esophagus. No hiatal hernia was noted.

The Esophageal Sphincter Augmentation Device is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

This patient has GERD with breakthrough symptoms despite medication. Surgical treatment options that are considered standard today include: laparoscopic Nissen fundoplication and the LINX procedure. Both of these treatments have been shown in published studies to be more effective than medical management. LINX is comparable for mid-long-term studies to be as effective and durable as laparoscopic Nissen fundoplication with less risk of mortality and major morbidity. It has been recommended based on the available published literature to be a standard surgical treatment for GERD in newly updated nationally published guidelines from the Society for Gastrointestinal and Endoscopic Surgeons. The exclusions to LINX and Nissen fundoplication include BMI > (greater than) 35, in which case treatment of obesity is thought to be important for treatment of GERD. Other exclusions for LINX include Barrett's esophagus with dysplasia, poor esophageal motility, > 3 centimeter (cm) hiatal hernia, age <  (less than) 18 and prior gastric or bariatric surgery. This patient does not document any clinical exclusion to LINX. Therefore, the requested Esophageal Sphincter Augmentation Device is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.