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

Diagnosis:  Chronic obstructive pulmonary disease (COPD) exacerbation.
Treatment:  Inpatient stay.

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

This is a case of a male admitted for a diagnosis of chronic obstructive pulmonary disease (COPD) exacerbation. The patient presented with chief complaint of shortness of breath for one week. He was previously diagnosed with pneumonia and treated with Levaquin. Vital signs demonstrated blood pressure 112/70, pulse 94, temperature 36.8C (degrees Celsius), respiratory rate 18, and O2 (oxygen) saturation 95% (percent). Physical exam showed no acute distress or altered mental status. There were bilateral rhonchi but no wheezing. Pulmonary effort was normal. White blood cell count was 12.9 with hemoglobin 10.7. Venous blood gas showed potential hydrogen (pH) 7.37 with pC02 (partial pressure of carbon dioxide) 45. Chest x-ray was unremarkable. 

The inpatient hospital admission was not medically necessary. 

The patient was admitted for a COPD exacerbation, but it does not appear that the COPD exacerbation was life-threatening. He did not require ventilatory support for hypoxemia or hypercapnic respiratory failure. He did not have an inadequate response to emergency department management, cyanosis, altered mental status, increase oxygen requirement, respiratory distress, heart failure, hemodynamic instability or insufficient home support. His chest x-ray was unremarkable. Venous blood gas was unremarkable. He was treated with oral steroids which can typically be done on an outpatient basis.
Although the patient required services in the hospital setting, the monitoring, diagnostic testing and therapeutic interventions prescribed could have been rendered at a lower level of care. Therefore, inpatient hospital admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient admission
The insurer denied coverage for: Inpatient admission
The denial is: Upheld
The patient presented with abdominal pain and vomiting. The patient was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. There was no leukocytosis. The liver enzymes were normal. A computed tomography (CT) scan showed a distended thick-walled gallbladder. A magnetic resonance cholangiopancreatography (MRCP) showed normal bile ducts. A hepatobiliary iminodiacetic acid (HIDA) scan was normal. The patient's symptoms resolved and the patient was able to tolerate a diet. 

Clinical indications for admission for Undiagnosed Abdominal Pain (MCG M-05) include hemodynamic instability, peritoneal signs, bowel obstruction or perforation, bacteremia, and an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

Clinical indications for admission for Gallbladder or Bile Duct Inflammation or Obstruction (MCG M-555) include having acute cholecystitis or acute cholangitis with systemic signs of inflammation. The patient did not have either acute cholecystitis or acute cholangitis during this admission. The patient also did not have hemodynamic instability, common bile duct obstruction, severe vomiting not responsive to treatment, or bacteremia. 

The hospital has referenced Milliman Care Guidelines (MCG) guideline for Gastroenterology MG-GAS. A suspected acute intra-abdominal process is an indication for admission if there is hemodynamic instability, peritoneal signs, mesenteric ischemia, gastrointestinal obstruction or perforation, or free air. The patient did not have these conditions. 

This patient needed a work-up of the gallbladder in view of the abdominal pain and the finding of a distended gallbladder. This work-up could have been done with observation care. The HIDA scan was negative for acute cholecystitis and the MRCP showed normal bile ducts. The patient did not need any acute interventions. There was no evidence of sepsis or a severe systemic infection. The patient did not meet MCG criteria for admission for Undiagnosed Abdominal Pain, Gallbladder or Bile Duct Inflammation or Stone, or Gastroenterology. 

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: Decompensated heart failure
Treatment: Inpatient admission
The insurer denied coverage for: Inpatient admission
The denial is: Overturned
Asked to review the case of an adult that presented to the hospital complaining of  shortness of breath and chest pain. The patient noted that dyspnea has progressed over the past three months. Past medical history was significant for hypertension, diabetes mellitus, morbid obesity (Body mass index {BMI} 45 kilogram/square meter {kg/m2}) and left ventricular systolic dysfunction. On arrival, Blood pressure (BP) was elevated (151/88 millimeters of mercury {mmHg}) pulse was regular at 72 beats per minute (bpm). Physical exam revealed decreased breath sounds at both lung bases and 3+ pedal edema. 12 lead electrocardiogram (EKG) revealed normal sinus rhythm (NSR) with T wave inversions in leads I and aVL. B type natriuretic peptide (BNP) was elevated (320), serum troponin was elevated (31.6 nanograms per liter {ng/L}). Chest radiographic image (x-ray) revealed pulmonary vascular congestion. The patient was admitted to the hospital for treatment of decompensated heart failure. The patient was treated with intravenous (IV) diuretic therapy and noted an improvement in symptoms. Echocardiogram revealed a depressed left ventricular (LV) ejection fraction of 35-45%. Previously performed nuclear perfusion testing demonstrated small areas of ischemia in the anteroseptal and inferolateral regions extending to the apex with an left ventricular ejection fraction (LVEF) of 43%. The patient was discharged the following day after insisting on leaving the hospital.

This patient presented with complaints of dyspnea and chest pain. Upon presentation, physical exam and laboratory testing confirmed fluid overload due to systolic congestive heart failure. Troponin was positive consistent with type II myocardial infarction. The patient required treatment with intravenous diuretic therapy and was ultimately discharged on oral guideline directed medical therapy. Failure to admit and treat this patient would have resulted in excess morbidity or even mortality.  Patients with chronic congestive heart failure have a high risk of adverse outcomes warranting a higher level of care. (Reference 1) In one study, patients presenting with congestive heart failure and an elevated BNP level were found to have an increased morbidity and mortality in the subsequent 90 days. (Reference 2)  In conclusion this patient had decompensated congestive heart failure and an elevated BNP level. Inpatient hospital admission was medically necessary.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for inpatient hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Panniculitis

Treatment: Panniculectomy

The insurer denied coverage for panniculectomy.

The denial is upheld.

The patient has excess skin due to major weight loss and is requesting removal of excess skin.
 
The medical records do not provide documentation in the form of primary care physician (PCP) or dermatology progress notes that describe ongoing clinically significant dermatologic problems that have either 1) never responded to physician directed topical therapy or 2) despite initial response, have recurred and caused significant functional impairment. According to the American Society of Plastic Surgeons guidelines, "Patients considered for panniculectomy should document the type and duration of symptoms/treatment for panniculitis and photographs should confirm the patient's medical condition." Supervised medical management for rashes is not documented in any of the progress notes. The patient is not sick from her excess skin, and has not had ulcerations, panniculitis or sepsis from her infections.  A dermatologist has not evaluated the rashes.  The patient has not required hospitalization or treatment with intravenous (IV) or oral antifungal or antibiotic medications.  The excess skin has not jeopardized health.  Physician supervised treatment is the simplest, safest and most cost-effective method of managing this patient's problems, and conservative treatment with appropriate hygiene and topical medications has a reasonable likelihood of correcting the condition. 

In a multiple regression analysis of postoperative complications after body-contouring surgery, the authors found that the overall rate for major complications that required operative revision and/or antibiotics was 10.2% (percent). In addition, 41% (percent) had minor complications, such as seromas, hematomas, wound healing problems, and wound dehiscence. Therefore, conservative, non-operative treatment would be recommended, such as improved hygiene, topical creams or powders, and watchful waiting.  Surgical lipectomy should be reserved for patients that have failed optimal medical management for intertrigo, which is not documented to be the case for this patient. Summary treatment letters and member appeal testimonies in the absence of physician office note documentation of specific dates of treatments and medications prescribed do not provide sufficient documentation to confirm the failure of medically supervised care.

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 panniculectomy is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity
Treatment: Wegovy 1mg (milligrams) /0.5 mL (milliliters) SC (subcutaneously) SOAJ (solution prefilled syringe/ solution auto-injector)
The insurer denied Wegovy 1mg (milligrams) /0.5 mL (milliliters) SC (subcutaneously) SOAJ (solution prefilled syringe).
The denial is overturned.

The patient is an adult female patient for whom the provider requested the provision of Wegovy 1 milligram per 0.5 milliliter subcutaneous as treatment for the patient's condition. The patient had not lost more than 5% (percent) of their pre-treatment body weight to meet the plan guidelines for continuation of this medication. The plan stated that "documentation of current weight showing at least 5 percent weight loss from baseline body weight within the last month" is required for continuation.

The requested health service is medically necessary.

The patient has obesity with a body mass index (BMI) exceeding 30. The plan agreed that the initiation of this medication was medically necessary. The plan mandate for a 5% (percent) weight loss after a month of use of this medication has no basis in the Food and Drug Administration (FDA) package insert or the medical literature. As such, the use of Wegovy for this patient remains medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, Alzheimer's dementia. 

Treatment: consumer directed personal assistance program (CDPAP): 9 hours per day - 7 days per week - for a total of 63 hours per week. 

The insurer denied coverage for consumer directed personal assistance program (CDPAP): 9 hours per day - 7 days per week - for a total of 63 hours per week. 

The denial is overturned. 

 
This case involves an elderly female with a request for review for the Denial of coverage for consumer directed personal assistance program (CDPAP): 9 hours per day - 7 days per week - for a total of 63 hours per week. 

In this case, an elderly female lives with her grandson in a two bedroom private house. Patient is alert and oriented to person, place and disoriented to time. She is unable to choose weather appropriate clothes and confused day and night, and unable to verbalize emergency plan. Grandson stated patient cannot be left alone and she required supervision at all times. According to the assessment, the patient is totally dependent on meal preparation, Ordinary housework, and Managing medications. She required maximal assistance with Phone use, Stairs and is totally dependent with shopping. Furthermore, she required maximal assistance with Bathing, Dressing Lower Body, Walking. Extensive assistance with Personal hygiene, Dressing Upper Body, Toilet use, and Bed mobility. She is totally dependent with locomotion. In addition, she is Frequently incontinent with bladder and occasionally incontinent with bowel. As per grandson, patient's daughter and grandson assist patient daily as needed after 6-7pm. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for consumer directed personal assistance program (CDPAP): 9 hours per day - 7 days per week - for a total of 63 hours per week is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia. 
Treatment: Consumer directed personal assistance services (CDPAS) 24 hrs a day, 7 days a week (split-shift). 
The insurer denied Consumer directed personal assistance services (CDPAS) 24 hrs a day, 7 days a week (split-shift). 
The determination is upheld. 

This is a male patient with a past medical history of anemia, diabetes mellitus type 2, hypertension, dementia, blindness, bipolar disorder, human immunodeficiency virus (HIV), urinary incontinence, fecal incontinence, anxiety, and schizophrenia who had been assigned Consumer Directed Personal Assistance Program (CDPAP) services 84 hours/week. There was a request to increase CDPAP services and the patient underwent a video assessment. 
The patient's primary care physician (or provider) (PCP) provided a letter requesting an urgent increase in hours of home care for the patient due to his rapidly deteriorating mental state, physical health, and functional status based upon their clinical findings. The provider noted the patient suffered from physical and cognitive decline with progressive memory deficit secondary to head trauma and dementia. In addition, the provider noted the patient was legally blind due to a macular hole in right eye and an old retinal detachment of the left eye. The provider also stated the patient had chronic insomnia and urinary and fecal incontinence and required frequent multiple daytime and nighttime changes of soiled diapers and linens to prevent skin irritation and rash. The provider noted the patient lived by himself and was unable to call for help in an emergency and the patient did not sleep at night and suffered from sun downing. Lastly, the provider stated they believed it was very important and medically necessary for the patient to have 2 split shifts of 12 hours of home care daily and nightly 7 days/week. 
The insurer sent final adverse determination denial notice continuing to deny request to increase CDPAP services. At issue is the medical necessity of Consumer directed personal assistance services (CDPAS) 24 hrs a day, 7 days a week (split shift). 
The requested services are not medically necessary. 
There was a request for split shift services, however, there is no documentation from the patient's medical provider of the medical necessity of activities of daily living (ADL) needs in the overnight hours that would not allow a CDPAP service aide 5 hours of uninterrupted sleep. There is no documentation of medical necessity of turning and repositioning every 2 hours. There are no overnight care logs specifically documenting assistance needs in the overnight hours. There is no documentation that the patient does not have adequate space in his home to accommodate a live-in aide. 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, CDPAP services 24 hours/day, 7 days/week, split-shift, are not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nasal lacerations

Treatment: codes 14060 adjacent tissue transfer or rearrangement eyelids, nose, ears, and/or lips; defect 10 square centimeter (sq cm) or less and 14060-51 adjacent tissue transfer or rearrangement, eyelids, nose, ears, and/or lips; defect 10 sq cm or less

The insurer denied coverage for codes 14060 adjacent tissue transfer or rearrangement eyelids, nose, ears, and/or lips; defect 10 square centimeter (sq cm) or less and 14060-51 adjacent tissue transfer or rearrangement, eyelids, nose, ears, and/or lips; defect 10 sq cm or less

The denial is upheld 

This patient sustained nasal lacerations from a fall. The surgeon has submitted advancement flap codes. The operative note describes wide undermining and wound closure. According to the American Academy of Dermatology coding guidelines: "Complex repair (Current Procedural Terminology (CPT) codes 13100 - 13153) is defined as a repair that requires more than layered closure, such as scar revision, debridement (as of traumatic lacerations), extensive undermining, stents, or retention sutures. In dermatology the overriding use of the code is for repairs of surgical excisions of malignant and benign tumors. Such repairs may require extensive undermining or retention sutures." The surgeon performed wide undermining and a layered wound closure.  The surgeon did not perform code 14000.  The complex wound closure code is correct.

The American Society of Plastic Surgeons coding corner specifically states, Simple undermining to loosen tissues prior to primary closure is not considered a flap by CPT definitions. It requires less expertise and surgical effort than does an adjacent tissue transfer. Although "adjacent" tissues are "advanced" after undermining, this is not considered undermining to create "bilateral advancement flaps" and therefore does not constitute an adjacent tissue transfer. 

Per Centers for Medicare and Medicaid Services (CMS) guidelines: "Extensively undermining of adjacent tissue to achieve closure of a wound or defect may constitute complex repair, not tissue transfer and rearrangement. Tissue transfer and rearrangement requires that adjacent tissue be incised and carried over to close a wound or defect."

The surgeon performed undermining to close the nasal wounds. The surgeon should submit the appropriate complex wound closure codes to describe the procedure.

The coding is incorrect. Adjacent tissue transfer is not the correct way to code wound closure with wide subcutaneous undermining.

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 codes 14060 adjacent tissue transfer or rearrangement eyelids, nose, ears, and/or lips; defect 10 square centimeter (sq cm) or less and 14060-51 adjacent tissue transfer or rearrangement, eyelids, nose, ears, and/or lips; defect 10 sq cm or less is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: osteoarthritis, allergies, dizziness and giddiness, essential hypertension

Treatment: Personal Care Services, per 15 minutes increase to 49 hours per week

The insurer denied coverage for Personal Care Services, per 15 minutes increase to 49 hours per week

The denial is upheld

 
The patient is an elderly female who lives in a rented private house room on the 3rd floor with walkup access. She has diagnosis of bilateral knee osteoarthritis, allergies, dizziness and giddiness, essential hypertension, functional urinary incontinence, neuralgia and neuritis, abnormalities of gait and mobility, chest pain, constipation, fatigue, insomnia, low back pain, and glaucoma. Her medications include Meclizine, Meloxicam, Aspirin, Celecoxib, Levocetirizine, Zolpidem, Alendronate, Diclofenac, Docusate, Gralise, Latanoprost, Vitamin D, Exforge, Hydralazine, Nitroglycerin, and Synthroid. 

There are 40 steps from the entrance of the home to the patient's room. She is cognitively and physically able to press her personal emergency response system. She is alert and oriented but does have frequent forgetfulness due to age related cognitive decline. She is totally dependent for meal preparation, housework, She requires maximal assistance with shopping. She requires extensive assistance with stairs, and bathing. She requires limited assistance with personal hygiene, dressing, toileting, and ambulation. She reports that she has chronic fatigue, muscle weakness, and an unsteady gait due to osteoarthritis. She is occasionally incontinent for bladder. She is continent for bowel. She denies any falls within the 90 days preceding her assessment. The record indicates that she attends adult day care three days a week, Tuesday, Thursday, and Saturdays. 

According to the tasking tool, the patient requires 20 hours per week of personal assistance services four days per week.  She lives in one room in a house. The tasking tool allotted 2 hours per week of housework. The awarded 24 hours per week is sufficient to meet the needs of this patient. The decision to deny the increase to 49 hours per week is upheld. 

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 home care/personal care Home Health Care (HHC)- Level 2 Personal Care Services, per 15 minutes increase to 49 hours per week is not substantiated.