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

Diagnosis: Parkinson's disease.
Treatment: Consumer Directed Personal Assistance Services (CDPAS): 7 Days per Week, 10 Hours per Day [Total of 70 Hours per Week]. 
The insurer denied Consumer Directed Personal Assistance Services (CDPAS): 7 Days per Week, 10 Hours per Day [Total of 70 Hours per Week]. 
The health plan's determination is overturned. 

The patient is a male with a past medical history of Parkinson's disease, hypertension, coronary artery disease, cerebrovascular disease, osteoarthritis of the knee, degenerative disc disease (DDD) / degenerative joint disease (DJD) of the lumbar spine with chronic low back pain, benign prostatic hyperplasia (BPH), urinary incontinence, and occasional bowel incontinence who had been assigned CDPAS (Consumer Directed Personal Assistance Services) with a request to increase services. The family and PCP (primary care provider) appealed the denial decision to increase CDPAS hours resulting in an increase of CDPAS services to 10 hours/day, 7 days/week, to a total of 70 hours/week. 

Consumer Directed Personal Assistance Services (CDPAS): 7 Days per Week, 10 Hours per Day [Total of 70 Hours per Week] are medically necessary for this patient.
There is documentation from the patient's neurologist of functional and cognitive decline related to his Parkinson's disease, cerebrovascular disease, and chronic back pain. The tasking tool indicated that the patient needed at least limited assistance with all activities of daily living (ADL) and Instrumental activities of daily living (IADL). The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The tasking tool which estimated 5.1 hours/day of assistance needs did not take into account time for transfer toilet, toilet use, and bed mobility for his unpredictable and unscheduled care needs but instead stated he would have 1 episode per day for the task of walking and locomotion and 2 episodes per day of transfer toilet and toilet use. The patient's care needs cannot be met solely with adaptive equipment and medical supplies as the plan suggested. The requested increase in CDPAS services was not solely for safety and supervision but to assist the patient with the safe completion of ADLs and IADLs. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAS services 10 hours/day, 7 days/week, to a total of 70 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support functions is essential to the maintenance of the patient's health and safety in his own home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease.
Treatment: Consumer Directed Personal Assistance Services (CDPAS): 7 Days per Week, 10 Hours per Day [Total of 70 Hours per Week]. 
The insurer denied Consumer Directed Personal Assistance Services (CDPAS): 7 Days per Week, 10 Hours per Day [Total of 70 Hours per Week]. 
The health plan's determination is overturned. 

The patient is a male with past medical history of Parkinson's disease, hypertension, coronary artery disease, cerebrovascular disease, osteoarthritis of the knee, degenerative disc disease (DDD) / degenerative joint disease (DJD) of the lumbar spine with chronic low back pain, benign prostatic hyperplasia (BPH), urinary incontinence, and occasional bowel incontinence who had been assigned CDPAS (Consumer Directed Personal Assistance Services) with a request to increase services. The family and PCP (primary care provider) appealed denial decision to increase CDPAS hours resulting in an increase of CDPAS services to 10 hours/day, 7 days/week, to total 70 hours/week. 

Consumer Directed Personal Assistance Services (CDPAS): 7 Days per Week, 10 Hours per Day [Total of 70 Hours per Week] are medically necessary for this patient.
There is documentation from the patient's neurologist of functional and cognitive decline related to his Parkinson's disease, cerebrovascular disease, and chronic back pain. The tasking tool indicated that the patient needed at least limited assistance with all activities of daily living (ADL) and Instrumental activities of daily living (IADL). The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The tasking tool which estimated 5.1 hours/day of assistance needs did not take into account time for transfer toilet, toilet use, and bed mobility for his unpredictable and unscheduled care needs but instead stated he would have 1 episode per day for the task of walking and locomotion and 2 episodes per day of transfer toilet and toilet use. The patient's care needs cannot be met solely with adaptive equipment and medical supplies as the plan suggested. The requested increase in CDPAS services was not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAS services 10 hours/day, 7 days/week, to total 70 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in his own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis

Treatment is an inpatient admission 

The insurer denied coverage for an inpatient admission 
 
The denial is upheld

This is a patient with past medical history significant for hypertension, hyperlipidemia, diabetes mellitus, retinopathy, and end stage renal disease who presented to the emergency room with complaints of right upper extremity cellulitis. 

Vitals on presentation included: Temperature 99.2 F (Fahrenheit) , Blood Pressure 118/64, Pulse 81, Respiratory Rate 18, oxygen (O2) saturation 100% on Room Air. Laboratory values were notable for the following: white blood cell count (WBC) 12, Hgb (hemoglobin) -7.9, Hct (hematocrit) -24, creatinine-3.74, and glucose-213. 

The patient was empirically started on intravenous antibiotics (Vancomycin and Zosyn) for a right arm infection. A computed tomography (CT) scan of the upper extremity showed diffuse subcutaneous edema, no evidence of soft tissue gas. A Duplex ultrasound was negative for deep vein thrombosis; right AVF (arteriovenous fistula) was patent. Vascular surgery evaluated the patient and determined no surgical intervention was required. The patient remained afebrile, hemodynamically stable and clinically improved. The patient was discharged to continue oral antibiotics (doxycycline and cephalexin) as an outpatient. 

According to documentation, the patient was admitted for a right arm cellulitis close to the AV (arteriovenous) fistula site. Otherwise, the patient was afebrile and hemodynamically stable. Laboratory results were only notable for a mildly elevated WBC, with other chronic findings related to underlying conditions. An ultrasound revealed that the AV fistula was patent, and no surgical intervention was required. Based on above findings, the patient met criteria for observation level of care.  

Prior determination of the denial of an inpatient stay is upheld.

The insurer's denial of coverage for the full hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Suicidal ideation

Treatment is an inpatient admission 

The insurer denied coverage for an inpatient admission 
 
The denial is overturned

This patient reportedly was admitted to this inpatient hospital after presenting with suicidal ideation, depressive symptoms, and abdominal pain. She reportedly had depressed mood, hopelessness, anhedonia, low energy, poor sleep and appetite, poor concentration, poor self-care, and suicidal thoughts. She reportedly was hospitalized 3 weeks prior to this admission. She reportedly was seen by the psychiatric consultant who recommended 1:1 observation and an inpatient psychiatric hospital treatment, and Sertraline was started. 
   
This reviewer disagrees with the decision to deny coverage for an inpatient hospital treatment as the medical records provided enough specific evidence to support that she required an inpatient hospital treatment then. The MCG (Milliman Care Guidelines) Behavioral Health Inpatient Level of Care Adult criteria reports that a patient needs to present as an imminent danger to self, imminent danger to others, with severe psychiatric or behavioral symptoms, have a severely dysfunctional living including an inability to care for self, unwillingness to participate voluntarily, or a less restrictive level of care is not feasible to meet criteria for inpatient behavioral health level of care. Also, the American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports that patients with suicidal intent or plan or suicide attempts are candidates for inpatient hospital treatment. It also reports that patients with hopelessness are at increased risk for suicide. This patient reportedly had severe psychiatric symptoms during the denial period as she had reports of severe psychiatric symptoms including suicidal ideation, depressed mood, hopelessness, anhedonia, low energy, poor sleep and appetite, poor concentration, poor self-care, and suicidal thoughts. She reported a suicidal plan. 

As a result, the recommendation is to overturn the previous decision and approve coverage for inpatient hospital treatment. 

The health plan did not act reasonably, with good medical judgment, or in the best interests of the patient.

The insurer's denial of coverage for the inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Supraventricular tachycardia (SVT)

Treatment inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is upheld

This is a patient with a past medical history which includes dermatomyositis, throat surgery for thrush, herpes with shingles, arthritis, autoimmune disease, palpitations, and anxiety. She presented with chest discomfort that was sharp, burning in nature radiating to the left shoulder, left leg. She was seen a year ago and diagnosed with tachycardia and started on metoprolol which she takes only when symptomatic. In the emergency department (ED), vital signs (VS) were initially noted as blood pressure (BP) of 160/78, heart rate (HR) 105, pulse oximetry 98% (percent). On exam, she appeared well, cardiac exam was unremarkable, her lungs were clear, abdominal exam was benign and neurological exam was all noted as normal. Initial labs included a normal troponin. Computed tomography (CT) scan of the head showed no acute findings.

A note indicates VS were normal with HR of 67 beats per minute (bpm). She was still complaining of a headache, but the chest pain had resolved.

A "rapid response" was called for tachycardia, with heart rates up to 174 bpm, improving with Valsalva maneuver (no diagnosis was initially recorded, but this is consistent with supraventricular tachycardia (SVT), which was later added to her problem list). No strip showing the rhythm was apparently obtained or preserved for the record. The working diagnosis was SVT.  A nuclear stress test was normal.  She was discharged to home.

This patient presented with highly atypical chest pain with no evidence of an acute ischemic event based on ECG (electrocardiogram) and troponin. She had a history of tachycardia and use of metoprolol on an adhoc basis. The notes are suggestive of a run of SVT that resolved with Valsalva. Regardless, SVT is treated as an outpatient, and, in fact, the patient underwent stress testing within hours of the event indicating a lack of any significant concern for the event.

In sum, this patient could have been evaluated during a period of observation. There was no indication for an acute inpatient admission.  In summary, the insurer acted appropriately in denying the admission. This is consistent with the documentation submitted for review.

The insurer's denial of coverage for the inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left hip fracture.
Treatment is continued stay in a SNF (skilled nursing facility) .
The insurer denied coverage for continued stay in a SNF.
The denial is overturned.

This is a patient with cerebral palsy who sustained a hip fracture after a fall at home. He underwent surgical hip fracture repair and transferred to a skilled nursing facility (SNF) for subacute rehabilitation. Under review is the medical necessity for continued SNF services.

The patient was appropriate for the SNF subacute rehabilitation level of care (1, 2, 3).  His clinical condition and functional deficits were amenable to medical intervention and comprehensive rehabilitation. He participated in physical and occupational therapy (OT) with demonstrated gradual improvement.  According to the OT (occupational therapy) the patient's ability to perform activities of daily living improved from poor to fair. Similar functional improvement was noted by the physical therapist. The patient's initial inability to ambulate improved to moderate assistance for approximately 50 feet. More recent therapy notes were not included for review. However, the available therapy notes support the medical necessity of continuing subacute rehabilitation. Based on the available records, this physician recommends an additional 10-day length of stay, in order for the patient (who has underlying cerebral palsy) to obtain his pre-injury functional ability.

From a physical medicine and rehabilitation perspective, SNF services provided were medically necessary.

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

The insurer's denial of coverage for the continued skilled nursing facility services is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malignant ascites and continued abdominal pain
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is overturned.

The patient had a history of endometrial carcinoma and presented with abdominal pain. A previous magnetic resonance imaging (MRI) scan showed a liver mass and she had received chemotherapy and radiation. There was a recent course of treatment with antibiotics for diverticulitis. She had persistent diffuse abdominal tenderness, but there was no rebound or guarding. A computed axial tomography (CAT) scan revealed ascites, but did not show acute diverticulitis. There was no leukocytosis. She was able to tolerate a diet and intravenous (IV) pain control was given. She was felt to have peritoneal carcinomatosis with malignant ascites. 

Milliman Care Guidelines (MCG) clinical indications for admission for Medical Oncology (MCG GRG: PG-ONC) include having a high-risk infection, gastrointestinal complications such as uncontrollable diarrhea, and malignant ascites which is complicated by respiratory compromise, vomiting, or abdominal pain or discomfort. 

This patient had malignant ascites and continued abdominal pain. Tramadol, gabapentin and IV Tylenol were ordered. Since the MCG lists malignant ascites with abdominal pain as an indication for admission, the health care plan did not act reasonably or with sound medical judgment. An inpatient hospital admission was medically necessary. 

The insurer's denial of coverage for inpatient hospital admission is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain 
Treatment is an inpatient admission 
The insurer denied coverage for an inpatient admission 
The denial is upheld

This patient was admitted for abdominal pain, he was found to have an elevated creatinine, likely secondary to prerenal azotemia and rhabdomyolysis. He was started on IV (intravenous) fluids and was evaluated by infectious disease services and started on antibiotics. His condition responded well, and he was discharged.

The patient was hemodynamically stable, with normal oxygenation and negative cultures, he did not have significant electrolyte disturbances. He did not have cardiac arrhythmias, no altered mental status, or persistent nausea and vomiting with dehydration.

There is no evidence-based literature supporting an inpatient level of care was medically necessary. Analysis of a database including 6710 adults (69% female, 80% age 18 to 55 years) evaluated in emergency departments for acute abdominal pain found that 85% did not require an inpatient admission.

[1] A retrospective analysis of 6633 consecutive adults evaluated in an urban academic medical center emergency department for acute abdominal pain found that 64% did not require admission.

[2] Analysis of 327 patients admitted to an observation unit for abdominal pain found that 91% were discharged within 24 hours.

[3] Analysis of national hospital discharge data shows 33% of hospitalized adult patients with the various principal diagnoses for abdominal pain discharged in 1 day [4]

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the inpatient stay is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class I Occlusion
Treatment: Braces (Comprehensive Orthodontic Treatment)
The insurer denied Braces (Comprehensive Orthodontic Treatment).
The health plan's determination is upheld.

The patient in question is a female with a Class I occlusion with 1 millimeter (mm) overbite and 2 mm overjet. She has minor maxillary and mandibular crowing. The narrative states she has an anterior crossbite of teeth 6 and 22. She is treatment planned for 24-39 months of orthodontics with extraction of teeth 5, 12, 21 and 28 to correct her malocclusion.

Braces (Comprehensive Orthodontic Treatment) are not medically necessary for this patient. There is no medical reason to correct her malocclusion with braces. While the patient is crowding, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. This patient presents with none of those conditions. Aligning her teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a skeletal Class I occlusion. If her teeth were aligned it would provide an aesthetic improvement but it would not create a medically significant improvement to the patient's health. Therefore, the requested Orthodontic treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Craniopharyngioma
Treatment: Bevacizumab (Mvasi)
The insurer denied Bevacizumab (Mvasi).
The health plan's determination is overturned.

The patient is a woman who is diagnosed with craniopharyngioma. The patient has undergone resection approximately one year prior to appeal followed by radiation therapy. The patient developed neurologic symptoms including slurred speech, somnolence, and diabetes insipidus. Repeat imaging of the brain showed reappearance of a 0.8 centimeter (cm) suprasellar lesion consistent with radiation necrosis versus progression of tumor. The patient was treated with bevacizumab for radiation necrosis. 

Bevacizumab (Mvasi) is medically necessary for this patient.

The patient is diagnosed with radiation necrosis following resection and radiation of a craniopharyngioma. The patient had significant neurologic symptoms including slurred speech, somnolence, and cerebral edema. The patient required a ventriculoperitoneal shunt.

In a double-blind clinical trial, 14 patients with radiographic- or biopsy-confirmed cerebral radiation necrosis were randomly assigned to bevacizumab (dose of 7.5 mg/kg [milligrams/kilogram] every three weeks for four doses) or a saline placebo. All patients assigned to bevacizumab had improvement in neurologic symptoms or imaging findings based upon magnetic resonance imaging (MRI) criteria. No responses were seen in those initially treated with placebo, but all patients who progressed on placebo did respond to bevacizumab during treatment crossover. A larger open-label trial compared bevacizumab (dose of 5 mg/kg every two weeks for four doses) with glucocorticoids (methylprednisolone 500 mg intravenously daily for three days followed by gradual prednisone taper) in 112 patients with mostly temporal lobe radiation necrosis after nasopharyngeal cancer therapy. Compared with glucocorticoids, bevacizumab resulted in higher rates of radiographic response (66 versus 32 percent) and clinical improvement (62 versus 43 percent) at 60 days, although the recurrence rate at six months was similar (29 versus 27 percent).

The optimal dose and duration of bevacizumab for treatment of brain tissue necrosis have not been established. Half of patients in the available studies have responded durably to a four-dose course of bevacizumab (either 7.5 mg/kg every three weeks or 5 mg/kg every two weeks).

As such, Bevacizumab (Mvasi) is medically necessary for this patient.