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

Diagnosis: Tooth 4 and 5 without decay
Treatment: Root Canal Therapy Teeth 4 and 5
The insurer denied Root Canal Therapy Teeth 4 and 5
The denial is: Upheld

The patient is a female who presented to the office of her dental provider for evaluation and treatment of teeth # (number) 4 and 5. Included for review are previous letters of appeal and denial, full mouth panoramic radiographic image, a periapical radiographic image and health plan documents. 
The subject under review is the medical necessity for the root canal therapy for teeth 4 and 5. Previous denials have been on the basis that the patient will have enough (ten according to the health plan) teeth to chew with and therefore the patient does not need these teeth and can have them extracted instead of treated for root canal therapy.

The health plan's determination is upheld

The requested Root Canal therapy (teeth 4 & 5) is not medically necessary for this patient as there is no evidence of any disease activity affecting teeth 4 or 5 and no indication of any pulpal pathology provided in the documentation. There currently is no pulpal diagnosis, evidence of decay, periapical pathology, nor any indication that there is anything wrong with teeth 4 and 5 to warrant any therapy let alone root canal therapy. None of the documentation supports the treatment requested by the requesting provider.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Metastatic breast cancer
Treatment: Inpatient Hospital Admission
The insurer denied the Inpatient Hospital Admission.
The denial is upheld.

The patient is an adult female with metastatic breast cancer. She was under treatment for metastatic lymph nodes status post right mastectomy. A new, right, supraclavicular node was identified. A fine needle aspiration was performed that showed metastatic carcinoma. A surgical biopsy was recommended for additional tissue examination. The patient underwent the procedure. The patient was admitted from the post-anesthesia care unit (PACU) and discharged approximately five hours later.

The reason for denial was that there was no clinical indication for acute inpatient admission. The reason for appeal was due to an increased risk for severe infection and rapid deterioration, inpatient admission was appropriate for this immunocompromised patient.

Inpatient admission was not medically necessary.

The anesthesia start time was 13:45. The anesthesia end time was 15:05. The patient left the post-anesthesia care unit (PACU) at 16:37. The patient was discharged to home at 18:35.

Review of the records show that the patient was hemodynamically stable throughout her entire stay. Any risk of infection, even in an immunocompromised patient, would not occur in the short period of time between the end of surgery and her discharge to home - 3.5 hours. Any rapid deterioration would have occurred in the post-anesthesia care unit (PACU).

In the immediate post operative note, the disposition was to home. No events are documented after this to indicate a reason for acute inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status post robotic low anterior resection and diverting loop Ileostomy
Treatment: Full Hospital Admission
The insurer denied coverage for the full hospital admission.
The denial is upheld.

This is an adult who presented emergently with weakness, fever (102 degrees Fahrenheit), chills, nausea, and diffuse abdominal pain. The patient took ibuprofen prior to arrival. The patient had colorectal cancer treated with neoadjuvant chemotherapy. The patient was status post robotic low anterior resection and diverting loop ileostomy, one week prior to this presentation. The patient also had a history of obesity (body mass index [BMI] 37.6), hypothyroidism, and ex-tobacco use. Additional surgical history included ovarian cystectomy, Cesarean section, and knee surgery. Medications prior to the admission included levothyroxine, oxycodone, and Xanax. The patient evidenced leukocytosis and was admitted with fever and leukocytosis. Orders included intravenous (IV) lactated ringer's, Zosyn intravenous piggyback (IVPB) every eight hours (q8hr), Zofran intravenous push (IVP) as needed, levothyroxine, acetaminophen, Lovenox, sequential compression device (SCD), strict intake and output (I&O) monitoring, soft low fiber diet, and labs. The patient's appetite was fair-to-poor (25% [percent]). Serial abdominal exams were performed. Ibuprofen was administered for abdominal pain. The patient was voiding, and Ileostomy was functioning. At the time of discharge, the patient reported feeling better.

The care as provided could have been rendered in its entirety at a lower level of care. The patient had an infection; yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for 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.

"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).

"Observation was meant to be a short period of time for providers to assess whether patients required admission for inpatient care or could be discharged. Typically, this was meant to last fewer than 24 hours and only rarely spanned more than 48 hours." (Society of Hospital Medicine, 2021).

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.      

Medical necessity of the hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Heart Palpitations, Shortness of Breath and Left Arm Numbness
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult female with a past medical history of hypertension and cerebral aneurysm who presented to the emergency department for evaluation of palpitations, chest tightness, and left arm numbness.  

On presentation to the emergency department (ED), the patient was afebrile, heart rate was 73 beats per minute (bpm), respiratory rate was 18, blood pressure was 143/83, and she was saturating well on room air.  Initial work-up included a twelve-lead electrocardiogram (EKG) which demonstrated normal sinus rhythm.  Chest x-ray did not demonstrate any acute cardiopulmonary abnormalities and labs were notable for a white blood cell (WBC) count of 5.1, hemoglobin of 12.1, platelet count of 316, sodium of 141, potassium of 4.7, blood urea nitrogen (BUN) of 15, creatinine of 0.75.  Brain natriuretic peptide (BNP) was 49 and troponin was within normal limits. 

The patient was admitted to the inpatient unit and was hydrated with intravenous fluids. A head computed tomography (CT) was obtained and did not demonstrate any acute intracranial abnormalities. The patient's symptoms were attributed to a panic attack, and she was discharged with outpatient follow up.

The proposed inpatient hospital admission was not medically necessary.

The patient was hemodynamically stable and was not hypoxic. There was no evidence of end organ malperfusion and no mental status changes. There was no acute coronary syndrome, no heart failure, and no sustained arrhythmias. The care the patient received, including intravenous fluids and computed tomography of the head, can be performed at a lower level of care.  Consequently, based on the provided documentation, the clinical data do not support medical necessity for inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left Knee Pain

Treatment: Inpatient hospital admission

The insurer denied coverage for the inpatient hospital admission.

The denial is overturned.

This is the case of an adult with a history of asthma, fibromyalgia, and lupus (in remission). The patient presented the emergency department with complaints of atraumatic left knee pain that progressed to severe pain, inability to walk on left leg or bend the knee due to pain. A musculoskeletal physical exam revealed mild swelling in the left knee, thrombotic thrombocytopenic purpura (TTP) over the knee, and inability to flex the left knee. Diagnostic imaging revealed small to moderate effusion and slight pretibial dystrophic calcifications. Left knee aspiration was positive for calcium pyrophosphate deposition disease (CPPD). The patient was admitted for management of left knee pain with Orthopedic, Rheumatology, Physical Therapy, and Occupational Therapy services. The patient had a syncopal episode and a computed tomography (CT) and electroencephalogram (EEG) were performed. The patient's condition improved. The patient was discharged.

The medical records substantiate the need for admission and level of service. The pertinent clinical factors were unremitting knee pain to require multiple dosages (4) of intravenous (IV) narcotics. The physician record stated the medication of Morphine and Dilaudid was not enough and had to be increased. Pain management was recommended to aid in providing sufficient relief. 

The patient also had an episode of syncope which required a full diagnostic work up. The etiology was unclear. She was found to have a new medical condition which was not stable. Telemetry, diagnostic studies and subspecialty consultations were required. 

Based upon the above, observation status was not applicable. She could not likely be attended to a lower level of service. 

Based on the above, the insurer's denial must be overturned. 

The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. The medical necessity for the inpatient hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Crohn's Disease.
Treatment: Stelara.
The insurer denied: Stelara.
The denial is upheld.

This patient is an adult female with Crohn's disease for whom the provider has requested Stelara. There is an appeal letter describing the patient to have severe Crohn's disease. The medical records indicate that the patient has Crohn's ileitis and enteropathic arthritis. 

The proposed treatment is not medically necessary.

The medical records indicate that the patient has Crohn's ileitis and enteropathic arthritis. However, there are no medical records detailing the disease severity. There is no reason documented why the patient cannot try and fail conventional therapy. Therefore, at this time, medical necessity is not established.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Patent foramen ovale, stroke
Treatment: Implantation of an implantable loop recorder
The insurer denied implantation of an implantable loop recorder.
The determination is overturned.

This is a male patient with a history of hypertension, hyperlipidemia and myocardial infarction. The patient had acute left frontal lobe stroke while on dual antiplatelet therapy. Echocardiography revealed a patent foramen ovale. Four weeks of external ambulatory electrocardiographic monitoring did not reveal any episodes of atrial fibrillation (AF). The etiology of the patient's stroke remains unclear. The medical necessity for implantation of an implantable loop recorder (ILR) is at issue.

Based on the documentation provided, implantation of an ILR is medically necessary.

This patient had an unexplained stroke. Four weeks of external ambulatory monitoring revealed no episodes of atrial fibrillation. Implantation of an ILR has been recommended for further rhythm monitoring. AF is the most common cardioembolic source of ischemic stroke. Diagnosing occult AF in patients with an unexplained stroke is important since an effective medical intervention, i.e. (that is), chronic oral anticoagulation, decreases the risk of subsequent events and disability.

The CRYSTAL AF study enrolled 447 patients with unexplained stroke, 221 of whom received an implantable monitor and 220 of whom were monitored externally. By 6 months, AF had been detected in 8.9 percent (%) of patients in the ILR group versus 1.4% of patients in the externally monitored group. By 12 months, AF had been detected in 12.4% of patients in the ILR group versus 2.0% of patients in the externally monitored group. Given that prolonged external monitoring in this patient has not revealed any episodes of AF, and that ILR monitoring has been shown to have a higher diagnostic yield, it is medically necessary in this instance and its use is supported by the medical literature.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Hypertension, hyperlipidemia, diabetes, peripheral arterial disease (PAD), hypothyroidism, anemia, glaucoma, and spinal stenosis

Treatment: Personal care assistance (PCA) two 12 hour split shifts per day, 7 days a week

The insurer denied coverage for PCA two 12 hour split shifts per day, 7 days a week

The denial is modified

 
This is an elderly patient with diabetes, PAD and Alzheimer's dementia. She lives with her sister and daughter in a private residence. The insurer approved PCA 8 hours/day, 7 days/week. The request is for PCA 2-12 hour shifts, 7 days/week.

The recent Uniform Assessment System (UAS) was reviewed. The patient's cognition is described as severely impaired. She is totally dependent for much of her Instrumental Activities of Daily Living (IADL) tasks including ordinary housework, meal preparation and shopping. She requires maximal assistance for bathing, lower body dressing and toilet use. She is frequently incontinent of bladder and continent of bowel. Extensive assistance is needed for personal hygiene, upper body dressing, toilet transfer, locomotion and ambulation. She reportedly wanders (unescorted) in the hallway of the building. She is independent with eating and bed mobility.  Her cognitive status and functional ability have declined compared to the prior UAS report. 

The patient is waking up at night, getting out of bed and potential falls risk as well as wandering are of particular concern. However, her need for level 1 or 2 services during nighttime hours are not at a level or unpredictable as to require the requested PCA services, 2-12 hour shifts per day, 7 days a week. This physician would agree due to safety concerns the patient may require additional monitoring for her own safety; particularly at night. Unfortunately, safety monitoring under PCA services does not include monitoring an individual (e.g. with dementia) when no other Level 1 or Level 2 personal care services task is being provided. Based on the documents reviewed the currently approved PCA services 8 hours/day, 7 days/week are inadequate to meet the patient' functional needs. Based on the documents reviewed, increasing PCA services to 12 hours/day, 7 days/week is more appropriate to meet the patient's functional needs. 

Based on the above, the insurer's denial must be modified. The health care plan acted reasonably in part. 

The medical necessity for personal care assistance services (PCA) two 12-hour split shifts per day, 7 days a week services is not substantiated. However, increasing PCA services to 12 hours/day, 7 days/week is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer: Prostate Cancer
Treatment: Radiation Therapy/Proton Radiation Therapy
The health plan denied the requested proton radiation therapy as not medically necessary. The health plan's determination is upheld.

This is a male with a history of clinically localized intermediate risk adenocarcinoma of his prostate gland. He opted to proceed with definitive radiotherapy with a curative intent.
At issue is the medical necessity for the requested Proton Beam Radiation Therapy.

I uphold, in whole, the health plan's determination of medical necessity.

No, the requested proton beam radiation therapy is not medically necessary in the patient's setting. 
Proton radiation is not proven to yield superior outcomes as compared to standard treatment options (e.g., intensity modulated radiation therapy (IMRT) or prostatectomy). The treating provider did not supply a proton/photon plan comparison to show that photon radiation is unable to provide adequate safety/precision (the provided plan comparison was for a case control patient and not specific to the patient in question). The patient has not received prior pelvic radiation in the past, nor does he have a genetic/comorbid condition that increases his risk for normal tissue toxicity. Proton radiation is the subject of ongoing clinical trials and there is a lack of expert consensus regarding its role in the patient's setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shoulder Pain. 
Treatment: Inpatient Stay. 

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

The patient is a male with a medical history of seizure disorder and alcohol abuse who was brought in from home by Emergency Medical Services (EMS) because he was unable to function with his mom being in the hospital. The patient has had recent falls resulting in a scapular fracture and now reports his pain level as 10 out of 10. The patient had multiple visits to the emergency room (ER) with examinations. The patient has multiple social problems (no cell phone and does not know where his mom is hospitalized). His vital signs are within normal limits. The laboratory studies are remarkable for an aspartate aminotransferase (AST) of 311 and an alanine aminotransferase (ALT) of 186. 

The patient was admitted for shoulder pain. The patient's mother has an order of protection against the patient and is currently hospitalized at a psychiatric hospital but has been communicating with the patient via phone. The patient was agitated and going to other patient's rooms and behavioral health was consulted and the patient's antipsychotic medications were adjusted. The patient was discharged to subacute rehabilitation. 

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

The inpatient level of care was not medically necessary. The patient presented for his inability to care for himself and had a scapular fracture from multiple recent falls. His scapular fracture did not require surgery based on prior evaluation. A patient such as this one, who lives alone is more likely to be admitted to the hospital by the ER than those who do not live alone which may have played a role in this case (Choi et al 2019). If the family (patient's mother) cannot care for the patient or he comes and says he cannot care for himself, the ER does not have any choice but to admit the patient to the hospital. This is a social work issue that does not require a high level of medical management. A transition to a nursing facility should have occurred at the community level as the patient has a community case worker and has an extensive history of the inability to care for himself and this inability to care for himself is not a new finding (Naylor et al 2008). The patient does not require a complex level of medical management for his medical conditions and thus does not meet the criteria for the inpatient level of care by Centers for Medicare and Medicaid Services (CMS) guidelines and can be observed until placement could occur as there is not any active medical management occurring (CMS guidelines).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: heart failure
Treatment: inpatient stay
The insurer denied an inpatient stay. The health plan's determination is overturned. 

The patient is a male with a medical history of diabetes mellitus, cerebrovascular accident status post mechanical embolectomy and craniectomy, coronary artery disease status post percutaneous intervention, hypertension, and heart failure with a reduced ejection fraction status post implantable cardioverter-defibrillator. He was admitted for acutely decompensated heart failure secondary to COVID-19 infection with symptoms of shortness of breath, significant weight gain, bilateral lower extremity swelling, orthopnea and non-productive cough.

Inpatient Hospital Stay was medically necessary for this patient.
This patient was admitted for acutely decompensated heart failure secondary to COVID-19 infection with symptoms of shortness of breath, significant weight gain, bilateral lower extremity swelling, orthopnea and non-productive cough that began two days prior to admission. On admission and during the hospitalization, the patient was hemodynamically stable without need for invasive monitoring, he did not have any documented cardiac arrhythmias or signs of acute peripheral ischemia, did not have documented hypoxia and he did not have any documented severe electrolyte abnormalities.
However, he did have evidence for acute kidney injury with an elevated serum creatinine (1.34), he had an elevated BNP (B-type natriuretic peptide) of 6601, significant weight gain and bilateral lower extremity 2+ pitting edema on physical exam. He was treated with intravenous diuretics (Lasix) twice daily along with Coreg, Entresto and Aldactone for the heart failure. He required treatment with large volume diuresis with intravenous diuretics (Lasix), while monitoring his renal function and electrolytes. Therefore, due to the elevated BNP with acute kidney injury and weight gain with lower extremity edema requiring treatment with diuresis, and monitoring of his renal function along with electrolytes, the inpatient level of care was appropriate.