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

Diagnosis: Genetic Diseases/CHARGE Syndrome
Treatment: Physical Therapy/6 visits 
The health plan denied the requested physical therapy visits as not medically necessary. The health plan's determination is overturned. 

The patient is a female with CHARGE Syndrome and spastic quadriplegic cerebral palsy with severe scoliosis with pulmonary compromise. She is a poor candidate for the surgical correction of her scoliosis. Her orthopedic surgeon also notes supination and plantar flexion foot deformity for which they recommend intensive physical therapy to improve range of motion, gait and obtain bracing. Documentation notes that despite some pulmonary illnesses including COVID (coronavirus disease) and a pneumonia, there have been no plateaus in her progress with physical therapy. 

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

The requested treatment of 6 physical therapy visits are medically necessary for this patient.
There is a significant amount of research and peer reviewed literature that supports that exercise based physical therapies can be used to maintain and reverse the signs and symptoms of scoliosis in adolescents and adults. In this patient, who is not a surgical candidate for correction of neuromuscular scoliosis, intensive physical therapy directed at mobility, range of motion and positioning, and pulmonary rehabilitation is appropriate and fits medical necessity by preventing further deterioration of patient's condition. It is further documented that the patient was benefiting and progressing with 2x/week physical therapy, which further meets the medical necessity of helping the patient keep and improve skills of functioning for daily living.
Further, this patient is noted to have a supination and limited dorsiflexion deformity of her foot for which her orthopedic surgeon recommends intensive physical therapy, and this is also supported in the literature. Proper treatment of this foot deformity with physical therapy, bracing and gait training would improve patient's mobility and quality of life, again meeting medical necessity of her insurance plan.
I support 6 physical therapy visits additional, total of 12 physical therapy visits as medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

The patient is a male with a history of seizure disorder. He presented to the emergency ward after a seizure.

The patient's CT (computed tomography) at presentation showed orbital fracture. At presentation, the patient's neurological examination was normal. He was noted to be non-compliant with anticonvulsant regimen. He was started on parenteral Keppra and Dilantin and admitted for further evaluation.

No, the Inpatient admission was not medically necessary.
The patient has an established diagnosis of seizure disorder. The etiology of the breakthrough seizure was considered to be medication non-compliance. He was restarted on an anticonvulsant regimen and he did not have any further seizures. The clinical evaluation, monitoring and treatment could have been safely and effectively 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: Upheld

Diagnosis: Multiple sclerosis (MS)

Treatment is an inpatient admission 

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

The patient was seen in the emergency room (ER) for trouble walking. It was noted that the patient had a prior diagnosis of multiple sclerosis (MS) and that the last MS relapse was more than 30 years earlier. The patient's symptoms happened when he got out of bed and lasted for 30 minutes and was associated with feeling weak and unsteady and vision zooming in and out. It was noted that the patient had no symptoms at the time of evaluation in the ER. On examination the NIH (National Institute of Health) Stroke Scale/Score (NIHSS) was 0.

There was a history and physical documentation which noted that the patient complained of difficulty speaking and difficulty concentrating and had vision issues upon presentation. It was noted that the patient denied weakness. The patient's symptoms lasted for 30 minutes while at home. The neurological exam was non focal. In the assessment it was noted the possibility of transient ischaemic attack (TIA) and that the plan was to admit the patient to obtain an Magnetic resonance imaging (MRI) and monitor the patient on the stroke unit.

There was an MRI of the brain which showed evidence supporting extensive long-standing multiple sclerosis but no acute infarction.

The health care plan did act reasonably and with sound medical judgement and in the best interest of the patient. The patient had an atypical presentation for a transient ischemic attack (TIA) as she had symptoms of speech difficulty, vision changes and gait problems which would not localize to one area of the brain. The patient was also asymptomatic in the emergency room (ER) and the workup could have been done as outpatient.

"Transient ischemic attack (TIA) and minor ischemic stroke are associated with brain dysfunction in a circumscribed area caused by a regional reduction in blood flow (i.e., ischemia), resulting in either transient or minor observable clinical symptoms." (Coutts S. B. 2017).

The inpatient admission is not considered medically necessary for this patient. The patient had an atypical presentation for a transient ischemic attack (TIA) as she had symptoms of speech difficulty, vision changes and gait problems which would not localize to one area of the brain. The patient was also asymptomatic in the emergency room (ER) and the workup could have been done as outpatient. Therefore, the request is not medically necessary and cannot be approved.         
                                                
The insurer's denial of coverage for an inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope.
Treatment: Inpatient admission.

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

This case involves a patient with history of hypertension who presented to the hospital with complains of a syncopal episode. She reported that she was at work when her legs became heavy, and she leaned against the wall. The patient reported that she had passed out. She reported that she had difficulty speaking for short period of time. Laboratory testing was remarkable for elevated D-dimer, hemoglobin, and hematocrit. Vital signs noted heart rate of 100, respiratory rate of 18, oxygen saturation 98% on room air, and blood pressure of 134/98. On exam, her speech was clear, and there was no facial droop noted. Her pupils were equal and reactive to light. She was able to move all extremities. She reported that she had congestion, body aches, chills, sweats, and a cough for the past 2 weeks. She was seen by her primary care provider and had been placed on steroids and a Zithromax (azithromycin) (Z-Pak). She reported aching low back pain, for which her primary care provider had started her on pain medication. A few days later, she started to have cramping intermittently in her legs. She endorsed generalized weakness and feeling tired. It was noted that she had persistent weakness and decreased sensation to the right side while in the emergency department. The patient was admitted for further evaluation. Magnetic resonance imaging (MRI) and electroencephalogram (EEG) were completed. The imaging was unremarkable. The patient's hemoglobin and hematocrit normalized after intravenous fluids. The patient was deemed stable for discharge.

In an appeal, it was stated that the patient's full hospital admission was substantiated by the clinical documentation provided for review. Excerpts from medical record and medical guidelines were referenced.  

Per the cited sources, admission for syncope is indicated when there is hemodynamic instability, altered mental status that is severe or persistent, and cardiac disease or findings that indicates necessity of immediate intervention. However, the documentation did not reveal hemodynamic instability that persisted despite appropriate treatment, altered mental status that was severe or persistent, or cardiac disease or findings that required immediate intervention. The patient's care could have been completed at an observation level. As such, the denial of coverage for the full hospital was appropriate and is upheld.

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

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

Diagnosis: Bndness/glaucoma. 
Treatment: Home health care. 

The insurer denied Personal Care Aide (PCA) Services: Total of 84 Hours per Week. The health plan's determination is overturned. 

The patient is a female with past medical history of breast cancer, osteoarthritis, blindness, glaucoma, anxiety, depression, urinary incontinence, coronary artery disease, atrial fibrillation, and seizure disorder who had been assigned PCA (personal care aide) services. 

Personal Care Aide (PCA) Services: Total of 84 Hours per Week is medically necessary for this patient. 

There is documentation from the patient's medical provider of medical necessity for increased PCA services. There is documentation from the plan's own assessment of a decline in activities of daily living (ADL) status and a deterioration of overall self-sufficiency in the last 90 days. The patient requires at least maximum assistance with walking, locomotion, transfer toilet, and toilet use, therefore, 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 plan assumed the patient had informal help outside of the hours presently approved which was not the case as the patient's daughter has her own chronic medical conditions and is not physically able to assist the patient. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. 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, PCA services: 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

Vision
Home health care

Diagnosis: blindness/glaucoma
Treatment: Home health care
The insurer denied Personal Care Aide (PCA) Services: Total of 84 Hours per Week. The health plan's determination is .

The patient is a  female with past medical history of breast cancer, osteoarthritis, blindness, glaucoma, anxiety, depression, urinary incontinence, coronary artery disease, atrial fibrillation, and seizure disorder who had been assigned PCA (personal care aide) services.

Personal Care Aide (PCA) Services: Total of 84 Hours per Week is medically necessary for this patient. .
There is documentation from the patient's medical provider of medical necessity for increased PCA services. There is documentation from the plan's own assessment of a decline in activities of daily living (ADL) status and a deterioration of overall self-sufficiency in the last 90 days. The patient requires at least maximum assistance with walking, locomotion, transfer toilet, and toilet use, therefore, 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 plan assumed the patient had informal help outside of the hours presently approved which was not the case as the patient's daughter has her own chronic medical conditions and is not physically able to assist the patient. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. 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, PCA services: 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: Experimental/Investigational
Decision: Overturned

Diagnosis: Left sided scrotal varicocele

Treatment: Vein embolization to treat a varicocele, procedure code 37241

The insurer denied coverage for vein embolization to treat a varicocele, procedure code 37241

The denial is overturned

This is a male patient with painful left-sided scrotal varicocele confirmed by scrotal ultrasound. Provider wishes to perform left gonadal vein embolization, which plan is denying as experimental treatment.

There is ample scientific evidence supporting an improved clinical outcome with the proposed varicocele embolization procedure. The scientific evidence in peer-reviewed literature does support a result of improvement in health outcome.

Puche-Sanz, et al. note "Percutaneous retrograde embolization as a primary treatment for painful varicocoele is a clinically effective option with a high success rate that can be maintained in the long term, especially in patients with high pre-operative pain."

Lomboy, J. R., & Coward, R. M. state, "The goal of treatment for varicocele is preventing retrograde flow within the internal spermatic veins. This is performed either by percutaneous selective embolization, sclerotherapy, or surgical correction, commonly known as varicocelectomy (although this is a misnomer, as varicocele veins are not surgically removed as the term implies)."

Per Talaie et al. "Percutaneous embolization is a viable option for this group of patients, particularly given the inflammation and pain associated with surgery.10 A retrospective review of 154 patients demonstrated that 86.9% of patients were pain free at 39 months after percutaneous retrograde embolization.11"      

Vein embolization to treat a varicocele, procedure code 37241 does have final approval from the appropriate regulatory bodies for this diagnosis. There is a significant body of literature over many years supporting this type of treatment. There are no regulatory issues.     

Based upon the ultrasound findings and the age of the patient with no significant comorbid conditions he is a good candidate for the proposed embolization procedure.     

Although alternative treatments exist such as traditional surgery, there is no literature suggesting an improved clinical outcome with either treatment (embolization verses surgery).      

Both surgery and embolization have similar risks.     

The requested service is not inferior to the standard surgical procedure and has similar results, and recovery time. Thus, the request for vein embolization to treat a varicocele, procedure code 37241 is medically necessary for this patient.

The carrier's denial of vein embolization to treat a varicocele, procedure code 37241 should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: left sided scrotal varicocele

Treatment: vein embolization to treat a varicocele, procedure code 37241

The insurer denied coverage for vein embolization to treat a varicocele, procedure code 37241

The denial is overturned

This is a male with history of left scrotal varicocele, revealed by imaging. The patient presented to the doctor's office for evaluation treatment of this left varicocele, with constant pain. The physician recommended a trans jugular left gonadal vein coil embolization to treat the left scrotal pain. The insurer has denied coverage for vein embolization to treat the varicocele, procedure code 37241. They stated there was not enough proof that this procedure improves health. The requested procedure is denied based on medical policy. The appeal on behalf of the patient is noted and read in detail. Vein embolization to treat a symptomatic varicocele is FDA (food and drug administration) approved and constitutes a standard of care option. While embolization does have a recurrence rate of 4-5%, there is a minimal risk of hydrocoele post procedure. To answer the relevant question:

Scientific evidence in peer reviewed literature supports a result of improvement in health outcome after this procedure.

Procedure code 37241 has final approval from the appropriate regulatory bodies for this diagnosis.

This patient is a good candidate for procedure code 37241

Code 37241 is an option to treat the varicocele. There is no "best treatment". Patients can choose between open surgery, radiographic embolization, or laparoscopic treatment. Each has its own risks, benefits, potential side effects. Younger patients often prefer the embolization procedure as it appear to be the least invasive has low recurrence rate varicocele and low risk of post-op active hydrocoele. The adverse risks of vein embolization are not increased over the standard treatment options (see above). The embolization procedure does have risks of exposure to radiation (fluoroscopy) which the other procedure does not have, and 10-15 % risk of technical failure.

The requested treatment has a low risk of recurrence (4-5%) low risk of post op (operative) hydrocoele and it is likely to be as beneficial as other standard treatments, although the recurrence rate is slightly higher than the microsurgical approach to varicocele repair (4-5% vs 1%). Younger patients often prefer to stay out of the operating room and choose to have the least invasive approach, so the vein embolization is often chosen as first treatment. Embolization of vein has 10-15 % risk of technical failure, higher than the other treatments.

The carrier's denial of vein embolization to treat a varicocele, procedure code 37241 should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Increase Consumer Directed Personal Assistance Services to 100 Hours A Week
The insurer denied the Increase Consumer Directed Personal Assistance Services to 100 Hours A Week
The denial is overturned

The patient is a female with cognitive impairment. The request is for increase Consumer Directed Personal Assistance Services to 100 Hours a Week for personal assistance service to ensure the patient eats and bathes, as well as ensuring a safe environment. The request is also for toileting and medication administration. The patient refuses  to shower, and cannot make food. She has trouble remembering to keep her life alert device nearby.

The request for increasing Consumer Directed Personal Assistance Services to 100 Hours was because, per the family-submitted note, the patient has Alzheimer and sundowning. The family are requesting 100 hours because the patient is fall risk at night.

Yes , the requested Consumer Directed Personal Assistance Services to 100 Hours A Week is medically necessary.
The patient does have severe dementia. She needs assistance with food and activities of daily living. The patient does have multiple awakenings at night. She does not know how to use life alert. She has history of falls at night. She does not have self-awareness.

Therefore, given the above, the requested Consumer Directed Personal Assistance Services to 100 Hours/week is medically necessary.

No, The health plan  did not act reasonably, with sound medical judgment and in the best interest of the patient.
The requested Consumer Directed Personal Assistance Services to 100 Hours/week is appropriate.

The patient needs assistance preparing food and showering, and monitoring at night. The patient has severe dementia. She needs assistance with food and activities of daily living. The patient has multiple awakenings at night. She does not know how to use life alert. She has history of falls at night. She does not have self-awareness.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of Breath/Pneumonia
Treatment: Inpatient admission

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

The patient is a male with depression and schizophrenia. He presented to the ER (emergency room) with worsening SOB (shortness of breath), nausea and vomiting.

The patient was found to be tachycardiac in the ER (emergency room). The patient was found to have pneumonia. He was started on IV (intravenous) antibiotics and IV (intravenous) fluids, as well as Tylenol. The patient was admitted to acute inpatient level of care for further management.

The acute inpatient level of care was denied coverage by the health plan due to lack of medical necessity. This denial is being appealed.

No, the Inpatient admission was not medically necessary.
The patient was admitted for the management of pneumonia. The patient had a CURB-65 (confusion, blood urea nitrogen, respiration rate, blood pressure, Age 65+) score of 0, which suggests that the patient could have been safely and effectively treated at a lower level of care. The patient's condition improved significantly with ER (emergency room) care and within 24 hours of hospitalization. The acute inpatient level of care was not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Since the patient was hemodynamically stable, and the treatment included antibiotics and IV (intravenous) fluids for the first 24 hours with significant symptoms improvement, it would have been reasonable to expect the patient's treatment course would have been safe and effective at a lower level of care.