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

Diagnosis: Chest Pain.

Treatment: inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

This patient presented to the emergency department (ED) with chest pain and dyspnea on exertion over a period of weeks. Symptoms were accompanied by pedal edema.  Past medical history was significant for obesity. Physical examination revealed stable vital signs: the patient was afebrile with respiratory rate (RR) of 17 beats per minute (bpm), blood pressure (BP) 148/93 and a pulse of 107bpm.  Lungs were clear and no cardiac murmurs were noted.  2+ pitting edema of the lower extremities was present.  Electrocardiogram (ECG) revealed sinus rhythm with non-specific T (intervals) wave changes in the inferior leads. Serum blood testing revealed an elevated D dimer, elevated glucose (197mg/dl [milligrams per deciliter]), elevated  BNP (Brain natriuretic peptide) (314), (elevated ALT/AST [alanine aminotransferase /Aspartate transaminase] (176/104) and a normal troponin level x2.  Computed tomography (CT) angiogram ruled out pulmonary embolism.  Echocardiogram revealed a normal left ventricular ejection fraction (LVEF).  CT chest revealed a mild nodular infiltrate and he was treated for both pneumonia and fluid overload.  He was ultimately discharged home on antibiotic therapy with follow up. 
 
The health plan did act in the best interest of the patient. This patient did not have a myocardial infarction.  No other abnormalities or findings consistent with an acute coronary syndrome were noted.  Based on history and presentation alone, this patient had a low short-term risk of death and nonfatal cardiac ischemia (Reference1).  

Sudden onset shortness of breath is concerning for pulmonary embolism and this was ruled out with a CT angiographic study.  This finding is consistent with a low risk of future morbidity and mortality in three months following presentation (Reference 2). 

Of note, the CT study revealed a nodular infiltrate and possible pneumonia, correlating with the patient symptoms of chest pain. He was not hypoxic and did not have fever or an elevated white blood cell count. He would be considered low risk and appropriate for treatment at a lower level of care (Reference 3). 

In conclusion, it was appropriate to treat this patient at a lower level of care. Acute inpatient admission was not medically necessary for this individual.

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

Diagnosis: Cancer 
Treatment: Inpatient Hospital 
The insurer denied inpatient hospital admission for medical necessity. 
The denial was overturned.

This patient is a female without a significant past medical history, with left estrogen receptor (ER) negative, progesterone receptor (PR) negative, Her2Neu (a certain protein involved in cell growth) positive intraductal breast cancer. She presented with left axillary lymph node disease without a recognized primary tumor after a magnetic resonance imaging (MRI) scan and two radiographic breast biopsies. After neoadjuvant chemotherapy treatment, she underwent an uncomplicated left modified radical mastectomy and reconstruction (left tissue expander and AlloDerm placement). After monitoring in the post-anesthesia care unit (PACU), she was transferred to the hospital floor. Pathology from the operation showed metastatic high-grade apocrine mammary carcinoma in five of nine lymph nodes with a single focus of high-grade ductal carcinoma in situ in the left breast, ER negative, PR negative, Her2Neu positive, KI-67 protein at 95%.

At issue is the medical necessity of inpatient stay.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of inpatient stay was medically necessary for this patient.

Several organizations recognize the need for inpatient care after modified radical mastectomy. Moreover, large United States (US) studies demonstrate that both modified radical mastectomy (as opposed to a simple mastectomy) and simultaneous tissue expander placement were risk factors that indicate an inpatient admission after breast surgery. The uncomplicated outcome after surgery in this patient does not change the medical necessity of the inpatient admission. Thus, the inpatient stay after modified radical mastectomy and tissue expander placement is reasonable and in the best interest of this patient.

Therefore, the requested Inpatient stay is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis. 
Treatment: Full hospital admission. 

The insurer denied coverage for full hospital admission. 
The denial is upheld. 

This is the case of an adult male with a benign past medical history who presented to the emergency room (ER) with complaints of right lower extremity swelling and erythema. Vital signs on presentation included: temperature 97.5, blood pressure 156/102, pulse 98, respiratory rate 16 and oxygen saturation 99% (percent) on room air. Laboratory results included the following: white blood cell (WBC) 9.0, hemoglobin 15.1, hematocrit 45.8, creatinine 1.17, and glucose 95.  The patient was started empirically on intravenous antibiotics (Ancef) for possible lower extremity cellulitis. A chest x-ray was negative, and cultures remained negative. Infectious Diseases was consulted. No surgical intervention was deemed necessary. The patient remained afebrile, and clinically and hemodynamically stable. He was discharged to continue oral antibiotics (doxycycline) as an outpatient. 
 
According to the documentation, the patient presented with possible right lower extremity cellulitis. Otherwise, he remained afebrile and hemodynamically stable. Laboratory results were unremarkable including a normal white blood count (WBC). The patient had a localized infection, and no surgical intervention was necessary. All cultures remained negative. Based on above findings, the patient met criteria for an observation level of management. Acute hospital admission was not considered medically necessary treatment for the patient's condition. 

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

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

Diagnosis: Abdominal Pain. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a female who underwent an acute hospitalization.  The patient had recently undergone a laparascopic cholecystectomy for gallstones. The patient then presented with bilateral alternating shoulder pain. The pain then went to the chest and upper abdomen. The pain was not relieved with ibuprofen or Tylenol. The patient also reported bright red blood with a bowel movement. 

Right upper abdominal pain and epigastric pain with rebound tenderness was noted. A magnetic resonance cholangiopancreatography (MRCP) was performed with no retained stones. The alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were 101 and 133. The alkaline phosphatase was 228. As the liver function tests (LFTs) rose to less than 200, the patient was admitted for further evaluation.  The patient received supportive care and the gastroenterologist (GI) consultant declined performing an endoscopic retrograde cholangiopancreatography (ERCP).  The patient's pain improved and she was discharged. 

No, the proposed inpatient hospital admission was not medically necessary. 

While the care was medically appropriate, the level at which the care was provided was not medically necessary. 
Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had pain and a mild increase in her liver enzymes; 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.  The elevation of liver enzymes is in part expected given the recent manipulation of the liver and biliary duct with the cholecystectomy.  As such, the care could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Varicose Veins. 

Treatment: Vein treatment services (Procedure code 36478). 

The insurer denied coverage for vein treatment services (Procedure code 36478). 

The denial is overturned. 

This case involves a patient who has a history of hypertrophic obstructive cardiomyopathy, hypothyroidism, and migraine headaches.  She was seen via telemedicine to complain of ongoing painful varicose veins to the lower extremities.  She indicated her treatment has been present for several years.  She has had a prior venous duplex performed with evidence of an incompetent great saphenous vein (GSV) on the right.  Distal augmentation maneuvers resulted in retrograde flow for a time duration of greater than 500.  The sapheno-femoral junction (SFJ) reflux was also noted to be 4.17.  The right anterior accessory saphenous vein (AASV) also had a retrograde flow of greater than 500 with SFJ reflux of 4.17.  The physician indicated the patient continues with painful lower extremity varicose veins with evidence of superficial venous incompetency despite a trial and failure of conservative care. 

This is a female with long-standing chronic venous insufficiency of the lower extremities, and with previous history of left GSV ablation. This ablation occurred some time ago and involved the GSV from the SFJ to the mid-thigh. 

She presented to a vascular specialist with recurrent symptomatic left greater than right  venous insufficiency marked by edema, pain, fullness and enlarged varicosities in the bilateral lower extremities.  In particular, the varices on the left involved the thigh veins attributable to the remnant GSV which was incompetent at a level below the previous ablation. The patient also failed conservative management with elevation, daily/regular compression stocking use and avoiding prolonged standing. 

Non-invasive imaging revealed right GSV and AASV reflux and left GSV remnant reflux. 

Thus, given the patient's symptomatology and venous reflux study, the above requested procedures are medically necessary and standard of care.  One does not need SFJ or saphenopopliteal junction (SPJ) reflux to justify ablation, especially in this case where the left leg has recurrent symptoms and evidence of reflux below the original index ablation. 

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 vein treatment services (Procedure code 36478) is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute Respiratory Failure. 
Treatment: Emergent Admission. 

The insurer denied coverage for emergent admission. 

The denial is overturned. 

The patient is an adult male who has history of schizophrenia, morbid obesity, chronic obstructive pulmonary disease (COPD), and obstructive sleep apnea (OSA). He has been non-compliant with continuous positive airway pressure (CPAP). The patient presented to the Emergency Department (ED) with complaints of shortness of breath (SOB) for about 3 months and worse for 2 weeks. 

Vital signs at presentation included a temperature of 99 degrees Fahrenheit, heart rate (HR) 93 beats per minute (bpm), respiratory rate (RR) 20, blood pressure (BP) 133/76 millimeters of mercury (mmHg), and oxygen (O2) saturations 84 % [percent] on room air. The patient was morbidly obese and lung exam revealed rales. Decreased air entry. Labs revealed white blood cell (WBC) count of 12.3 thousand (K), hemoglobin (Hgb) 14.3, and liver function tests (LFTs) were elevated. B-type natriuretic peptide (BNP) was 558. D-dimer was 2094. 

Chest X-ray revealed (CXR) bilateral opacities. Differential diagnosis was congestive heart failure (CHF) versus pneumonia (PNA) versus Covid. Initial arterial blood gases (ABG) on non-rebreather mask (NRB) revealed respiratory acidosis with pH (potential of hydrogen) 7.26/ partial pressure of carbon dioxide (PaCO2) 89. The patient was placed on bilevel positive airway pressure (BIPAP) 14/7 with fraction of inspired oxygen (FIO2) 40 %. Repeat ABG revealed pH 7.34/ PCO2 (partial pressure of carbon dioxide) 76. 

The patient was given intravenous (IV) Lasix, steroids, and bronchodilators. A computed tomography angiography (CTA) was done to rule out pulmonary embolism (PE). PE was negative. The patient had bilateral air space disease. He was admitted to the intermediate care unit. 

Given multiple medical problems and presentation with hypercapnic and hypoxic respiratory failure, it was appropriate to admit this patient to a monitored bed. This patient was not appropriate for observation level of care due to his unstable respiratory situation. He was being treated with IV Lasix twice per day for decompensated heart failure and needed to be monitored closely. The patient felt better after treatment and decided to sign out against medical advice (AMA) by the evening. This patient was not stable to have been managed in observation given multiple medical issues. 

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

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

Diagnosis: Viral syndrome

Treatment inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

This patient is a female with no significant past medical history who presented to the Emergency Room (ER) with two days of fever and abdominal pain. On examination, and as documented in multiple nurse notes, the patient was not in any acute distress. The patient's abdomen was noted to be tender to palpation all over, but the patient was not otherwise ill- appearing or toxic. The patient was observed to be sitting upright and engaged in activity (coloring).

The patient's fever was documented as 102 Fahrenheit, but the patient was otherwise hemodynamically stable, including a cardiac evaluation with troponin and an electrocardiogram (EKG) within normal limits. The patient's white blood cell (WBC) count was slightly above the upper limit of normal at 16,000, but the differential count was unremarkable with only two band-form neutrophil and an elevated C-reactive protein (CRP). The patient's abdominal ultrasound and chest X-ray were normal.

Based on the review of the medical record, the patient presented with a viral syndrome, which can be accompanied by abdominal pain. The justification for admission given is systemic inflammatory response syndrome (SIRS), based upon fever and elevated inflammatory markers. However, the patient did not exhibit signs of sepsis, and while she may have met the SIRS criteria, this should not have been a criterion for admission since fever and elevated inflammatory markers are a hallmark of any viral infection. The patient's SIRS criteria could be reassessed after anti-pyretic administration.

Moreover, collecting the patient's blood and urine cultures were unnecessary. Sherman & Sood (2021) details the rationale for lack of need for a workup other than urinalysis in a non-toxic-appearing infant older than 2 months of age. The patient's clinical picture was consistent with a viral infection and not with septicemia, sepsis, or bacteremia. Moreover, there was no evidence of dehydration. Clinical prediction rules exist for identifying febrile infants 60 days and younger at high risk for serious bacterial infections, but in older children, serious bacterial infections are to be suspected and empirically treated only if there are signs of sepsis or evidence of a source of infection. 

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

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

Diagnosis: Heart disease, osteoarthritis and depression.
Treatment: Personal Care Services 24 hours a day, 7 days a week (live-in).
The insurer denied coverage for personal Care Services 24 hours a day, 7 days a week (live-in).
The denial is overturned.

This is a geriatric patient with medical problems including heart disease, osteoarthritis and depression. The patient lives alone. The insurer approved Personal Care Services (PCS) 10 hours per day, 7 days per week, 70 hours total and the request is for Personal Care Services 24 hours a day, 7 days a week (live-in).

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as "Moderately impaired, decisions consistently poor or unsafe; cues/supervision are required at all times." The patient requires total dependence for much of the Instrument Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient also requires total dependence for bathing and lower body dressing. Maximal assistance is reportedly needed for personal hygiene, upper body dressing, bed mobility, locomotion, ambulation and toilet transfer/use. The patient is occasionally incontinent of bladder and continent of bowel. The Activities of Daily Living status have declined over the past 90 days. The patient was also found on the floor with various bruises and cuts on the right eye. The patient's medical condition, cognitive deficits and physical limitations are at the level or unpredictable as to require the requested PCS 24 hours/day (live-in). 

The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient. Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. All decisions are evidence-based.   

From a physical medicine and rehabilitation perspective, Personal Care Services (PCS) 24 hours a day, 7 days a week (live-in) is medically necessary.

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 Personal Care Services 24 hours a day, 7 days a week (live-in) is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Macular degeneration, gait ataxia, depression and dementia. 
Treatment: Increase Personal Care Services from 38 Hours per Week to 24 Hours per Day (Live-In). 

The insurer denied the Increase Personal Care Services from 38 Hours per Week to 24 Hours per Day (Live-In). 

The denial is overturned. 

The patient is a female with a history of macular degeneration, gait ataxia, depression and dementia. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). 

Appeal review requested for potential approval of 24 hours per day (live in) personal assistance services to offer increased activities of daily living (ADLs) support. 

Yes, the proposed treatment of 24 hours per day (live-in) personal assistance services is deemed medically necessary. 

This is a female with a history of  macular degeneration, gait ataxia, depression and dementia.  Although an assessment of the patient's functionality and ability to perform activities of daily living (ADLs) was completed and revealed that the currently approved plan of 38 hours per week personal assistance services is sufficient to meet the patient's current needs; the patient relates this reduced schedule leaves her alone, completely unassisted for numerous hours per day. This is problematic as she has a history of significant cognitive impairment, gait ataxia with repeated falls and hallucinations. 

At current, the beneficiary requires assistance for meal preparation, household chores, shopping, transportation, attending medical appointments, ambulation, personal hygiene, toileting, showering and dressing. She is unable to get the assistance she requires for all of these activities with the currently approved plan of 38 hours per week personal assistance services. 

Hence, provision of 24 hours per day personal assistance services can reasonably be expected to be beneficial for the patient and withholding these services, in whole or in part, can reasonably be expected to affect the patient's health adversely. For these reasons, the proposed treatment 24 hours per day (live-in) personal assistance services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Genetic Diseases/Cystic Fibrosis
Treatment: Durable Medical Equipment (DME)
The health plan denied the requested durable medical equipment (Vest Airway Clearance System) as not medically necessary. 
The health plan's determination is overturned.

This is a female patient with Cystic Fibrosis (CF) and pancreatic insufficiency. She was prescribed the alternative modes of airway clearance; however she was not cooperative. She also has some obstructive pulmonary function tests. She is receiving pancreatic enzyme supplements. The pediatric pulmonology prescribed high frequency chest wall oscillation airway clearance and it has changed the volume of sputum production and improved the quality of life.
At issue is the medical necessity of the requested Vest Airway Clearance System.

The health plan's determination of medical necessity is overturned, in whole.

Yes. The Vest Airway Clearance System is medically necessary for this patient.
High-frequency airway clearance (HFCWC) assist devices generate either positive or negative trans-respiratory pressure excursions to produce high-frequency, small-volume oscillations in the airways. Hence, it is clearly medically necessary.
HFCWC can lead to changes in volume of 15-57 milliliters and in flow up to 1.6 Liters, which generate minimal coughing to mobilize secretions. The typical treatment lasts 20-30 minutes and consists of short periods of compression at different frequencies, separated by coughing.
Airway clearance with Vest or HFCWC is a mainstay of CF therapy. Several studies showed that HFCWC produced an improvement in several lung function parameters such as higher forced expiratory volume (FEV), lower sputum volume, less days sick, compared to traditional chest physiotherapy. Our clinical experience also is a testament for the benefits of high frequency Vest therapy.