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

Diagnosis: Attention deficit hyperactivity disorder (ADHD)

Treatment: service codes 97110 (therapeutic exercise) x 35 (1 unit for each service date listed) and therapeutic activity (97530) x 35 (1 unit for each service date listed)

The insurer denied coverage for service codes 97110 (therapeutic exercise) x 35 (1 unit for each service date listed) and therapeutic activity (97530) x 35 (1 unit for each service date listed)

The denial is upheld 

This is a male with reported history of attention deficit hyperactivity disorder (ADHD). He received occupational therapy (OT) services. 

The OT treatment notes provide insufficient objective clinical information to support the medical necessity for the services under review. The treatment notes for each visit usually consist of 2-3 sentences documenting general areas of concentration, which are non-specific and woefully inadequate. There was limited if any, quantitative or verifiable measures of improvement. There was no evidence the treatment was expected to result in significant therapeutic improvement over a clearly defined period of time. The treatment plan is not individualized or appropriately correlated with any specific physical examination findings.  

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, based on the treatment records, services were not medically necessary.

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

The insurer's denial of coverage for service codes 97110 (therapeutic exercise) x 35 (1 unit for each service date listed) and therapeutic activity (97530) x 35 (1 unit for each service date listed) is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lung transplant
Treatment: Prevymis
The insurer denied Prevymis. 
The health plan's determination is overturned. 

The patient is a female status post a bilateral lung transplant. The patient was cytomegalovirus (CMV) positive while the donor was CMV negative and she was initially started on valganciclovir prophylaxis for CMV. However, she developed leukopenia, most notably neutropenia due to the valganciclovir treatment for CMV prophylaxis. She now requires CMV prophylaxis due to the high-risk of developing CMV viremia secondary to the patient being CMV positive.

Prevymis is medically necessary for this patient.
Prevymis (Letermovir), a viral terminase inhibitor, is approved by the Food and Drug Administration (FDA) for CMV prevention in allogeneic hematopoietic stem cell transplant (HSCT) recipients. However, letermovir has been reported to successfully treat CMV disease lung transplantation recipients. Kaul et al. demonstrated that letermovir was well tolerated with only minor side effects. In addition, Veit et al. concluded that CMV-infection and -disease were successfully managed with letermovir. It was well tolerated and effective in treating CMV-infections in lung transplant recipients failing on currently available antiviral agents. As there are no other current options and this would be last line therapy, it would be in accordance with generally accepted standards of medical practice in the United States, clinically appropriate, in terms of type, frequency, extent, site, and duration; and considered effective for the patient's illness, disease and symptoms. Therefore, Prevymis is medically necessary for this individual under these specific circumstances.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left renal colic.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

This male was admitted through the emergency room with left renal colic.  His vitals signs were as follows: temperature 97.8, blood pressure 126/61, and pulse 61.  The white blood cell count was normal.  The creatinine was 1.81.  The patient's ultrasound imaging demonstrated a five millimeter left mid-ureteral calculus with hydronephrosis.  Intravenous pain medications, nausea medications, intravenous antibiotics and intravenous fluids were administered.   

Day two, the patient had a cystoscopy and stent placement. He was discharged home.  He was afebrile and hemodynamically stable throughout the stay.

No, the proposed inpatient hospital admission was not medically necessary.
An acute inpatient level of care was not medically necessary.  The care could have been provided at a lower level of care.  The patient was afebrile and hemodynamically stable throughout the hospitalization. There was no significant evidence for sepsis.  

Following admission, there were no unstable vital signs reported.  The patient did not have a documented infection or kidney failure, solitary kidney or a kidney transplant, or need for an open surgery. He did not have bilateral obstruction, acute renal failure, severe vomiting.  Pain control, intravenous antibiotics and intravenous fluids followed by stent placement in a non-toxic patient can be provided at a lower level of care.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left foot sarcoma.
Treatment: Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is overturned.

This is a patient who presented for surgical management of a left foot mass that had been present for approximately two years, slowly increasing in size over time, and becoming painful approximately 2-3 months prior. The provider reported that the patient underwent a biopsy for this mass with findings concerning for a malignant spindle neoplasm. They noted that pathology was confident that this represents a sarcoma.
An operative report indicated that the patient underwent wide excision of a fungating sarcoma from the left lateral foot followed by wound vacuum-assisted closure (VAC) placement. The surgeon indicates a plastic surgeon was able to view the defect after tumor excision and will wait for final margins before making any soft tissue coverage preparation.

An orthopedic postoperative progress report indicated that the patient tolerated the surgical procedure well. The patient had no complaints of pain. They had not yet voided. The physical examination of the left foot revealed a wound VAC in place, mild tenderness, intact sensation and motor function, and brisk capillary refill in all five digits. There were recommendations for pain control, non-weightbearing to the left lower extremity, completing perioperative antibiotics for 24 hours, deep vein thrombosis (DVT) prophylaxis, advancing the diet as tolerated, physical/occupational therapy, follow-up morning labs, incentive spirometry, and follow-up wound VAC output.

The inpatient stay was medically necessary. The provided documentation indicates the patient presented to the hospital for surgical management of a left foot mass that had been present for approximately two years, slowly increasing in size over time, and becoming painful approximately 2-3 months ago. A preoperative biopsy was concerning for a sarcoma. As noted in the referenced article from Foot, soft tissue sarcoma patients are complex patients that require early appropriate management, including surgical treatment. As noted in the referenced article from Surgical Oncology, wound complications after soft tissue sarcomas of the extremities are associated with worse local oncological outcome and survival. The patient underwent surgical excision of the soft tissue mass with removal of tissue measuring 7.9 x 7.2 x 0.5-1.7 cm (centimeters) followed by wound VAC placement over the large wound. This is a complex surgical procedure that is performed on an inpatient basis. The patient was kept in the hospital for monitoring and a wound VAC change. She was then discharged home with services. Given the complexity of the condition, nature of the surgery, and type of postoperative care required to ensure appropriate wound management, the inpatient hospital stay was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems - Congestive Heart Failure. Treatment: Home Health Care. 
The insurer denied Personal Care Aide (PCA) Level 2: 12 hours per day - 7 day(s) per week - for a total of 84 hours per week. The denial is overturned.

The patient is a female with past medical history of coronary artery disease, congestive heart failure (CHF), osteoarthritis, chronic obstructive pulmonary disease (COPD), urinary incontinence, hyperlipidemia, atrial fibrillation, gastroesophageal reflux disease (GERD), oxygen dependence, and hypothyroidism who had been assigned Personal Care Assistance (PCA) services 7.5 hours/day, 7 days/week, to total 52.5 hours/week based on telephonic assessment performed assessing the patient at maximum assistance with all tasks except for eating for which she was assessed at extensive assistance and phone use for which she was assessed at limited assistance. The subject under review is the medical necessity for an increase in personal care aide services level 2, 12 hours per day, 7 days per week for a total of 84 hours per week.

The health plan's determination is overturned.

The requested increase in services is medically necessary for this patient.
There is documentation of worsening physical functioning following admission. There is documentation by the patient's medical provider of medical necessity of increased PCA services. The health plan's own assessments documented an increased need for assistance with tasks of ordinary housework, managing finances, phone use, and equipment management when comparing the assessment to the prior assessment. In addition, the assessment documented a decline in activities of daily living (ADL) status and overall self-sufficiency, yet the tasking tool did not increase hours compared to the last assessment despite the patient having documented increased need for assistance. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and instrumental activities of daily living (IADLs). The patient has unpredictable and unscheduled care needs that span a continuum of time and the health plan failed to document a plan to meet these unpredictable and unscheduled care needs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies.
Taking into account, 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, to total 84 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 her own home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Duchenne Muscular Dystrophy

Treatment: power wheelchair

The insurer denied coverage for a power wheelchair
 
The denial is overturned

This is a male with diagnosed Duchenne Muscular Dystrophy.  He is unable to maneuver a manual wheelchair. Power mobility was requested secondary to a decrease in function and decreased ability to independently access his environment. During an evaluation, it was determined he could properly utilize a power wheelchair. Under review is the requested power wheelchair.

This physician agrees with the treating providers. The requested power wheelchair is clinically appropriate and medically necessary. This individual with diagnosed Duchenne Muscular Dystrophy is an appropriate candidate for a power wheelchair. The requested power wheelchair with power tilt, recline, power stander and seat elevator functions are integral components that assist the patient for daily living activities. The power stander/seat elevator functions are particularly beneficial in this case; specifically for activities such as transfer tasks, hygiene and reducing the caregiving burden of others. In addition, the power tilt/recline, and stander/seat elevator functions also allow for improved positional changes, weight bearing ability, and decreases the risk of skin breakdown/pressure ulcers.  

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

From a physical medicine & Rehabilitation/Pain Management perspective, as well as within a reasonable degree of medical certainty, based on the documentation available for review, the requested power wheelchair is medically necessary.  

The insurer's denial of coverage for a power wheelchair is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Endocrine/Metabolic/Nutritional. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.

The patient is a female with pre-diabetes, hypertension and peripheral vascular disease who presented with urinary frequency, blurred vision, dry mouth, and fatigue for 3 weeks. Her potential hydrogen (pH) was 7.385, glucose was greater than (>) 600 milligrams per deciliter (mg/dL), positive ketones. Blood pressure (BP) 167/77, heart rate 91, temperature 98.1. She was noted to be in no acute distress with normal neurological exam. She was admitted and treated with intravenous hydration and Glucommander. She was transitioned to subcutaneous insulin. She was tolerating her diet well without nausea/vomiting or abdominal pain. Glucose was 170 mg/dL. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld.

The requested inpatient stay was not medically necessary for this patient.
This patient presented with hyperglycemia and dehydration in the setting of newly diagnosed type 2 diabetes. She was hemodynamically stable. She had a normal pH, which does not support a diagnosis of diabetic ketoacidosis. She did not have altered mental status to support a diagnosis of hyperglycemic hyperosmolar syndrome. She had dehydration and an elevated creatinine that responded to intravenous fluids. Her hyperglycemia responded to insulin therapy, and she was transitioned to subcutaneous insulin therapy. The documentation does not support that she failed management under a lower level of care. Therefore, no, the proposed inpatient stay was not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endocrine/Metabolic/Nutritional/Abdominal pain.
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is overturned.

The patient is a female who presented to the emergency department with abdominal pain. Pertinent history included asthma, gastroesophageal reflux disease, and diabetes mellitus.
Initial vital signs were a temperature of 99.4 Fahrenheit (F), heart rate (HR) 106, blood pressure (BP) 126/83, respiratory rate (RR) 18, and peripheral capillary oxygen saturation (SpO2) was 98%. Initial examination documented the patient as tender in the epigastric area. Initial laboratory findings revealed a glucose (Glu) 326, carbon dioxide (CO2) less than (<) 10, and potential hydrogen (pH) 7.23, Ketones were markedly elevated. Electrocardiogram (EKG) revealed a prolonged QT interval. Intravenous fluids were administered, and an insulin infusion was initiated. The patient was admitted with an impression of diabetic ketoacidosis likely due to medication non-compliance. Insulin infusion and intravenous fluids were continued. The anion gap was closed, CO2 improved to 15, and the insulin infusion was transitioned to a subcutaneous regimen. The patient was discharged with a diagnosis of diabetic ketoacidosis. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is overturned.

Based on the clinical documentation provided, evidence-based literature and standards of care, acute inpatient level of care was indicated as medically necessary for the entire admission.
Savage et al. note that diabetic ketoacidosis is defined by the biochemical triad of ketonemia, hyperglycemia and acidemia. It remains a life-threatening condition despite improvements in diabetes care. The diagnostic criteria for diabetic ketoacidosis are ketonemia 3 millimoles per liter (mmol/L) and/or significant ketonuria (more than 2+ on standard urine sticks); blood glucose over 11 mmol/l (greater than [>] 180 milligrams per deciliter [mg/dl]) or known diabetes mellitus; venous bicarbonate (bicarbonate [HCO3-]) below 15 mmol/l and/or venous pH less than 7.3.[1] In this particular case, the criteria was met for the diagnosis of diabetic ketoacidosis.
Westerberg notes that diabetic ketoacidosis (DKA) is characterized by a serum glucose level greater than 250 mg/dL, a pH less than 7.3, a serum bicarbonate level less than 18 milliequivalents per liter (mEq/L), an elevated serum ketone level, and dehydration. DKA has a case fatality rate of 1 to 5 percent. Although the highest rate of mortality is in older adults and persons with comorbid conditions, DKA is the leading cause of death in persons younger than 24 years with diabetes, most often because of cerebral edema.[2] In this particular case, the criteria were met for the diagnosis of diabetic ketoacidosis.
Moreover, clinical indications for admission to inpatient care were met. The patient presented with diabetic ketoacidosis requiring inpatient services that could not have safely been performed at a lower level of care.[3]
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Breast cancer.
Treatment: inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

This is a female with triple negative breast cancer that is widely metastatic. The patient was admitted for inpatient care with progressive lower extremity weakness and paresthesias and was found to have imaging findings content with leptomeningeal disease. An imaging evaluation and lumbar puncture were unremarkable for disease. The patient underwent a neurologic evaluation and ultimately initiated therapy with TDM1 (Trastuzumab emtansine), as had been planned as an outpatient. The patient was discharged. 

The inpatient hospital admission was not medically necessary. 
This patient was admitted with stable vital signs and subacute neurologic complaints. The patient underwent neurologic testing and received supportive care. The patient did not require emergent surgery or intensive nursing. The patient did not have major organ failure, severe metabolic abnormalities, nor other services that require inpatient care. None of the criteria in the supplied inpatient guidelines have been satisfied. For these reasons, the inpatient hospital admission is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back Pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a female. She presented to the emergency room for severe low back pain with radiation to the abdomen for about 3 weeks. The pain had continued to increase despite prior ER (emergency room) visits and medication management.  She developed difficulty ambulating, and required an assistive device to ambulate.

The patient was seen and evaluated in the ER (emergency room).  A CT (computed tomography) of the Lumbar-spine was ordered that showed an L1 (first lumbar spine vertebra) and L3 (third lumbar spine vertebra) vertebral body compression fracture.

On evaluation, the patient's physical exam findings included tenderness to palpation of the low back and weakness in the bilateral lower extremities on manual muscle testing (right hip flexion - 2/5, left hip flexion - 3/5, right knee extension - 4/5, and left knee extension 4/5).  Pain medication management, Q4h (every-four-hours) neurological checks, consult to Pain Medicine, and outpatient follow up for a Kyphoplasty minimally invasive surgery were recommended.

The patient was hospitalized, but the hospitalization was not approved coverage by the health plan, because it was deemed not medically necessary. This denial is being appealed.

Yes, the Inpatient admission was medically necessary.
The Neurosurgical recommendation was for Q4h (every-four-hours) neurological exam checks and medication management of pain with the recommendations from Pain Medicine.  These recommendations were made in the setting of a CT (computed tomography) Lumbar spine confirmed L1 (first lumbar spine vertebra) and L3 (third lumbar spine vertebra) vertebral compression fractures with pain induced bilateral lower extremity weakness documented on physical exam by the neurosurgical team. Every-four-hour neurological examinations cannot be done unless the patient is in the facility/inpatient. Therefore, the 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, as the admission was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tachycardia

Treatment: Inpatient admission

The insurer denied coverage for an inpatient admission

The denial is upheld. 

This is a woman with a history of EtOH (ethanol alcohol) abuse that presented to the hospital complaining of palpitations, chest pain, dyspnea and lightheadedness. She called EMS (emergency medical services) and was found to have a heart rate of 160bpm (beats per minute). An ECG (electrocardiogram) revealed narrow complex tachycardia (short RP (interval on an ECG) type). She was treated with adenosine and transported to the hospital. Upon arrival, vital signs were stable Pulse 112bpm and Blood Pressure 110/65mmHg (millimeters of mercury). Physical examination was remarkable for obesity (BMI (body mass index) 47kg (kilograms)/m2 (square meter)) and abdominal distension without tenderness or guarding. 12 lead electrocardiogram revealed sinus tachycardia at a rate of 111bpm without ischemic abnormalities. Serum blood testing revealed anemia with a hemoglobin of 9.5mg (milligram) /dl (deciliter) and no elevation in troponin (< [less than] 0.012). An echocardiogram demonstrated normal LV (left ventricle) wall motion and ejection fraction (55-65%[percent]). The patient was treated with beta blocker therapy and discharged the following day.

The health care plan acted reasonably with sound medical judgment and in the best interest of the patient. This patient presented with narrow complex tachycardia that responded to adenosine therapy. There were no significant abnormal findings on physical examination or subsequent ECG to warrant acute inpatient hospital admission.  Treatment of short RP tachycardia can be performed with AV (atrioventricular) nodal blocking medications in the outpatient setting. Most patients with palpitations can be evaluated in the outpatient setting. (Reference 1-2). In conclusion, acute inpatient admission was not medically necessary in this case. 

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

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

Diagnosis: Cataract
Treatment: Cataract surgery
The insurer denied Extracapsular Cataract Removal with Insertion of Intraocular Lens Prosthesis (CPT 66984-RT). 
The health plan's determination is overturned.

The patient is a male with history of diminished vision of the right eye who underwent cataract surgery. 

Extracapsular Cataract Removal with Insertion of Intraocular Lens Prosthesis (CPT 66984-RT) is medically necessary for this patient. The patient had a visually significant cataract that required surgery to improve his visual outcome. The requested procedure was indicated in order to improve vision due to a progressive decrease in vision.
The cataract surgery would be necessary to remove the old cloudy lens and to allow a new intraocular lens prosthesis to be placed to restore vision.